**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 2 residents (Resident #12) reviewed for bowel and bladder incontinence. This failed practice created the potential for Resident #12 to experience bowel obstruction when her medications were not administered according to the physician's order. Findings include: Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues). A physician's order, documented Resident #12 was to receive the following medications: - Colace capsule 100 mg (milligrams), one capsule by mouth every 12 hours as needed for constipation, ordered 2/24/25. -Milk of Magnesia (MOM) Suspension 400 mg/5 ml (milliliter), give 30 ml by mouth every 24 hours as needed for bowel care if no bowel movement for 3 days, ordered 7/1/24. - Dulcolax suppository 10 mg, insert one suppository rectally every 24 hours as needed for bowel care if no results from MOM, ordered 7/1/24. - Fleet Enema 7-19 gm/118 ml, insert one application rectally every 24 hours as needed for bowel care if no results from Dulcolax, ordered 7/1/24. Resident #12's Bowel Movement Records, dated 2/5/25 through 3/6/25, documented she did not have a bowel movement from: - 2/15/25 through 2/19/25 (5 days). - 2/25/25 through 2/27/25 (3 days). There was no documentation in Resident #12's record that she was administered MOM suspension when she did not have a bowel movement for 3 days. On 3/3/25 at 1:06 PM, Resident #12 stated she was experiencing constipation. On 3/5/25 at 12:06 PM, the DON reviewed Resident #12's record and stated Resident #12 should have been given MOM suspension when she did not have a bowel movement for 3 days.

Based on observation, policy and record review, it was determined the facility failed to ensure that prior to placement of bed rails, residents were thoroughly assessed for the risk of entrapment. This was true for 1 of 1 resident (Resident #115) reviewed for bed rails. This deficient practice created the potential for harm from entrapment or injury related to use of bed rails. The facility's Bed Rails policy and procedure, revised 12/2023 documented the following: - The facility would attempt to use appropriate alternatives prior to installing a side or bed rail. - If it was determined that these alternatives failed to meet the resident's assessed needs, the interdisciplinary team would assess the resident for risk of entrapment. - The risks and benefits regarding the use of bed rails would be considered for each resident. - The facility would obtain an informed consent form from the resident, or if applicable, the resident representative for the use of bed rails prior to installation or use. On 3/3/25 at 3:36 PM and 3/6/25 at 9:00 AM, Resident #115 was observed in his bed in his room with two mobility bars in an upright position. Resident #115's record did not include documentation that he was assessed for the use of the mobility bars. On 3/6/25 at 10:15 AM, the DON stated Resident #115 was not assessed for the use of his mobility bars. The DON stated Resident #115 should have been assessed prior to installation of his mobility bars.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policy and procedure, review of Incidents and Accidents (I&As) reports, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 2 of 2 residents (#116 and #117) reviewed for medication errors. The facility's Six Rights of Medication Administration, revised May 2024, documented the following in order to ensure safety and accuracy of medication administration. - Right resident - Right time - Right medication - Right dose - Right route - Right documentation The facility's Medication Errors and Adverse Reactions policy and procedure, revised January 2025 documented resident's condition must be monitored for 72 hours or as may be directed and detailed account of the incident must be recorded on an incident report. Clinically relevant information about follow-up of the resident should be recorded in the chart including: - The kind of medication error or adverse reaction. - The date and time the physician was contacted. - The physician orders. The policy also stated resident's condition and response to treatment must be recorded during the monitoring period. 1. Resident #116 was admitted to the facility on [DATE], with multiple diagnoses including diabetes. Resident #116's physician's orders included the following: - Insulin Lispro (rapid acting insulin) solution 100 unit/ml (milliliter), inject 18 units subcutaneously with meals for diabetes, ordered 4/4/24. - Insulin Glargine (long acting insulin) solution 100 unit/ml, inject 33 units subcutaneously two times a day for diabetes, ordered 4/14/24. - Glucose gel 40%, 15 mg orally as needed for blood sugar below 70. Recheck blood sugar in 15 minutes and notify the physician. If blood sugar remains below 70 may repeat for a total of three doses. If blood glucose is below 70 after glucose gel, provide snack/meal and recheck in one hour, ordered 4/1/24. An I&A report, dated 5/10/24 at 7:05 AM, documented Resident #116 was administered 33 units of Novolog (a rapid acting insulin) instead of Lantus. Immediate action taken documented Resident #116 was given glucose gel and OJ (orange juice) x2 along with peanut butter and cottage cheese, and her blood glucose was taken every 15 - 30 minutes for four hours. The I&A report documented Resident #116's blood glucose became stable. The report documented Resident #116's initial blood glucose was 171 and ending blood glucose was 152. Resident's representative and physician were notified of the medication error. The I&A report did not include documentation of how and why the medication error occurred, and what Resident #116's signs and symptoms were before she was given glucose gel and OJ x2 along with peanut butter and cottage cheese. Resident #116's record did not include documentation her blood glucose was monitored every 15 - 30 minutes, as stated on the I&A. On 3/6/25 at 12:19 PM, the DON together with UM #1, stated LPN #1 was training MAC #1(Medication Assistant Certified) on how to prepare the insulin injection. When asked why Resident #116 was given glucose gel and OJ x2 along with peanut butter and cottage cheese, the DON stated, I would say it was a nursing judgment not wanting her blood glucose to drop. When asked about what it meant, Resident #116's blood glucose became stable as stated in the I&A, the DON stated Resident #116 was placed on alert charting for 72-hours and she did not show signs and symptoms of hypoglycemia. When asked about documentation of blood glucose monitoring every 15-30 minutes, the DON stated it was monitored but it was not documented, and it should have been documented. The DON stated LPN #1 was provided education regarding medication administration. Documentation of education provided to LPN #1 was requested from the DON. A nurse practitioner progress note, dated 6/3/24 at 4:45 PM, documented Resident #116 had . with one episode of low blood sugar several weeks ago that she is fearful of repeating. The nurse practitioner's assessment and plan documented, Hypoglycemia, unspecified: Patient had an episode of hypoglycemia due to missed meal after administering short-acting insuli[n] several weeks ago, plan to adjust only long acting insulin at this time. Documentation of LPN #1's education regarding medication administration after this incident was not received prior to the exit conference on 3/7/25. 2. Resident #117 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including diabetes and schizophrenia (a diagnosis categorized as a major mental illness). An I&A report, dated 10/26/24 at 6:50 PM, documented Resident #117 received a medication error. The provider was notified and ordered to put Resident #117 on alert charting and to hold her scheduled Seroquel (antipsychotic medication) for possible side effects with incorrect medications. Resident #117 denied any signs and symptoms. The I&A report did not include documentation how and why the medication error occurred, and what medication was administered to Resident #117 which resulted in a medication error. On 3/6/25 at 11:56 AM, the DON together with UM #1, stated LPN #1 self-reported the medication error. When asked what medication was administered to Resident #117, the DON stated it was oxycodone (narcotic pain medication) 5 mg. The DON stated LPN #1 was preparing Resident #117's medication when another resident requested her pain medication. The DON stated LPN #1 discovered the medication error during reconciliation of narcotic medication. The DON provided documentation LPN #1 was educated of the six rights of medication administration, and random medication audits were conducted by the nurse manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including schizoaffective disorder, bipolar type (a mental health condition characterized by bouts of hypomania [stated of heightened or irritable mood and unusually increased energy or activity that is similar to but less intense than mania] or mania and sometimes depression). Resident #27's record documented a PASRR Level II, dated 1/19/23, was completed. An annual MDS assessment, section A1500, dated 7/17/24, documented, No Resident #27 did not have a completed PASRR Level II. On 3/4/25 at 1:20 PM, the MDS Coordinator stated Resident #27's MDS was coded No on his annual MDS section A1500 because his PASRR Level II documented, no further evaluation was required. 4. Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including bipolar disorder (a chronic mental condition characterized by extreme shifts in mood, energy, and behavior), depression, and problems with communication due to difficulties of thinking clearly. The annual MDS assessment, section A1500, dated 9/20/24, documented Resident #8 did not have a PASRR Level II. A PASRR Level II, dated 9/19/24, was completed for Resident #8, and provided to the facility. On 3/5/25 at 2:00 PM, the MDS Coordinator stated, she did not code the MDS assessment a PASRR Level II had been completed for Resident #8. At 3:27 PM, the Social Worker confirmed a PASRR Level II had been completed for Resident #8, and the MDS Coordinator should have coded the MDS assessment appropriately. Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 4 of 16 residents (#1, #8, #25, and #27) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The RAI, revised 10/1/2024, documents section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determines a resident has a serious mental illness and/or mental retardation, or related condition. 1. Resident #1 was admitted to the facility on [DATE], with a diagnosis of bipolar disorder (a major mental mood disorder), depression, anxiety opioid dependence, and tobacco use. Resident #1's PASRR Level II dated 6/6/23, and PASRR Level II dated 8/23/24, documented she had a diagnosis of bipolar disorder, depression, anxiety, opioid dependence and tobacco dependence. Resident #1's annual MDS assessment, dated 3/11/24, and significant change MDS dated [DATE], documented under A1500 in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there were two PASRR Level II's found in her electronic medical record dated 6/6/23, and 8/23/24. On 3/5/25 at 3:30 PM the MDS Coordinator stated Resident #1's MDS assessments were coded that the resident did not receive a PASRR Level II screening because she believed the form HW0090 Abbreviated Level II PASRR screening form was not considered a true level 2 screening. 2. Resident #25 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, severe with psychotic symptoms, paranoid schizophrenia (mental disorder involving chronic or recurrent psychosis), and anxiety. Resident #25's admission MDS assessment, dated 2/4/25, documented under A1500 in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR Level II found in her electronic medical record dated 1/29/25, which documented she had a diagnosis of schizophrenia (a diagnosis categorized as a major mental illness). On 3/5/25 at 3:35 PM the MDS Coordinator stated Resident #25's MDS assessments were coded that the resident did not receive a PASRR Level II screening because she believed the form HW0090 Abbreviated Level II PASRR screening form was not considered a true PASRR Level II screening.

Based on observation and staff interview, it was determined the facility failed to ensure the cleaning and sanitation of kitchen cookware. This deficiency had the potential to affect the 64 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food services equipment. Findings include: The Food Drug Administration (FDA) Code Section 4-602.12 Cooking and Baking Equipment documented: Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. On 3/6/25 at 3:34 PM, baking sheets and frying pans were observed with the Certified Dietary Manager (CDM) and Registered Dietitian to have a crusted black residue. They stated the cookware was cleaned and sanitized using appropriate food service methods; however, it was not cleaned thoroughly as the CDM was able to scratch off the crusted black residue with her fingernail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to promote and facilitate a resident's ability to make food choices. This was true for 1 of 3 residents (Resident #4) reviewed for accommodation of food choices. This deficient practice placed Resident #4 at risk of continued weight loss, a decreased sense of well-being and self-worth, and frustration when he was not asked what foods he would like to eat and was not provided with menu choices. Findings include: The facility's menu policy, dated 9/2017, documented menus were developed and prepared to meet the nutritional needs of the residents and resident choices. It further stated prepared menus would reflect reasonable efforts to include input received from residents regarding diet choices. This policy was not followed. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including spastic quadriplegic cerebral palsy (damage to a child's brain or nervous system which does not cause paralysis but result in difficulty in controlling movements in the arms and the legs, facial muscles may also twitch or become tight and interfere with speech and eating ability), muscle wasting, and severe protein-calorie malnutrition (when you are not consuming enough protein and calories, which can lead to muscle loss, fat loss, and your body not working as it usually would). A quarterly MDS assessment, dated 10/8/21, documented a cognitive assessment could not be completed for Resident #4. A physician note, dated 11/29/21, documented Resident #4 answered to yes and no questions by shaking his head. On 1/21/22 at 8:40 AM, CNA #3 stated Resident #4 communicated with staff by nodding yes or no to their questions. CNA #3 said Resident #4 would stick out his tongue when he thought something was funny and would bump elbows when he wanted to agree with an opinion expressed by staff. CNA #3 said the question and answer sessions guided his daily care regarding eating. CNA #3 said Resident #4 nodded yes or no when asked if he wanted to eat a meal or food item. CNA #3 stated Resident #4's menu was determined by dietary services and he ate whatever was delivered. A physician note, dated 12/9/21, documented Resident #4's diet was to be modified to his favorite foods. There was no documentation in Resident #4's medical record he was asked about his diet preferences. On 1/20/22 at 12:45 PM, Resident #4 was observed eating lunch. When asked if he chose his lunch, he shook his head no. When CNA #2 was asked if Resident #4 chose his food, she said, No. CNA #2 stated dietary services sent him a meal, and he could eat it or refuse to eat it. Resident #4 nodded his head yes to this statement. On 1/21/22 at 1:51 PM, Resident #4 nodded yes, when asked if he had eaten lunch. When asked if he ate everything brought to him, he shook his head no. When asked if he liked his lunch, he shook his head no. When asked if his lunch tasted good to him, he shook his head no. When asked if he wanted more food choices, he nodded his head yes. When asked if he would eat more if he could choose what he ate, he nodded his head yes. When asked if staff asked him what he wanted to eat, he shook his head no. When asked if he had input into what food he was offered, he shook his head no. On 1/21/22 at 2:22 PM, the Dietician was interviewed regarding nutrition choices for Resident #4. When asked if she asked Resident #4 about his diet choices, she stated she had talked to his Power of Attorney about dietary choices, but not him. The dietician said she tried to interview Resident #4 but did not get any responses to her questions. Resident #4's record did not include documentation staff who Resident #4 did communicate with were included in assessing his favorite foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (stroke) and diabetes. Resident #35's quarterly MDS assessment, dated 12/8/21, documented he was moderately cognitively impaired. He did not walk, depended on a wheelchair, was totally dependent, and required the assistance of two people for bed mobility and transfers, and extensive assistance from one person for dressing, toileting, and hygiene. Resident #35 had a Foley catheter (indwelling urinary catheter) and was always incontinent with bowel function. On 1/18/22 at 10:01 AM, Resident #35 said CNA #4 acted like a doctor. Resident #35 said CNA #4 was rough during peri care and grabbed his testicles and told him it was for his own good. Resident #35 said CNA #4 told him he needed to get his leg amputated. Resident #35 said he would like to know which medical school CNA #4 went to. On 1/19/22 at 8:53 AM, when asked, Resident #35 said the incident happened a long time ago. He said he talked to RCM #1, and RCM #1 made it so CNA #4 would not provide care to him again. Resident #35 said CNA #4 had not cared for him since, and he was not afraid or worried about retaliation by CNA #4. On 1/21/22 at 3:30 PM, RCM #1 said Resident #35 told her he felt CNA #4 was too rough when providing peri care to him, and she did not remember what date it was, maybe a few months ago. RMC #1 said after Resident #35 reported the incident she asked him if he wanted CNA #4 to stop providing care for him and Resident #35 answered no. RCM #1 said Resident #35 returned to her about a week later and asked that CNA #4 no longer provide care for him. RCM #1 said CNA #4 still worked in the same hall where Resident #35's room is located, but he did not provide care for Resident #35. During the same interview, RCM #1 said Resident #35 was incontinent of bowel and sometimes refused to lay down for incontinent care during the day. Instead he sat in his electric wheelchair all day long. Staff usually offered incontinence care to him again after a refusal. RCM #1 said CNA #4 told her the night he performed peri care for Resident #35, it was difficult to clean him because the stool was left there all day and was dried to his skin. CNA #4 said he had been very careful and was not rough, but it took a long time to clean Resident #35. On 1/21/22 at 3:30 PM, RCM #1 said an Incident and Accident report was not completed for this event. RMC #1 said she investigated the incident, but she did not document it. RCM #1 said the event was considered a suspected staff to resident abuse. RCM #1 said an Incident and Accident report was not completed for this event. RCM #1 said the event was considered a suspected staff to resident abuse and should have been reported to the Administrator and the State Survey Agency Long Term Care reporting portal. Based on policy review, record review, review of grievances, and staff and resident interview, it was determined the facility failed to report allegations of potential abuse and misappropriation of resident property were reported to the State Survey Agency within two to 24 hours. This affected 2 of 15 residents (#8 and #35) who were reviewed for abuse/neglect/misappropriation of resident property. This deficient practice created the potential for adverse outcomes to residents whose abuse, neglect and misappropriation of resident property was not reported and investigated thoroughly. Findings include: The facility's Abuse Investigation policy, revised April 2021, documented all staff who witnessed abuse or had knowledge of potential or actual abuse, were to report the abuse to the Administrator and/or designee immediately. This policy was not followed. 1. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses, including depression and neurogenic bladder urinary bladder (difficulty controling urination due to disease or injury of the central nervous system or peripheral nerves). A quarterly MDS assessment, dated 10/13/21, documented Resident #8 was cognitively intact. A Grievance Communication form, dated 4/5/21, documented Resident #8 called and reported to the Business office her bank card was missing. The Grievance Communication form documented Resident #8's bank card was in her lock box. Resident #8's room was searched but the bank card was not found. Resident #8 was very concerned and called her bank to cancel her bank card. The Grievance Communication form documented Resident #8 was educated on proper use of her lock box. Documentation Resident #8's missing bank card was reported to the administrator was not found and was not noted in the State Survey Agency LTC reporting portal . On 1/20/22 at 4:54 PM, the Administrator stated the facility started under new administration in October 2021, and he was unable to find documentation Resident #8's missing bank card was reported to the previous administrator. The Administrator reviewed the grievance report and said it was a potential misappropriation of resident property and should have been reported to the previous Administrator and State Survey Agency. The Administrator said Resident #8's grievance was not in the State Survey Agency's Long Term Care reporting portal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of grievances, and resident and staff interview, it was determined the facility failed to ensure allegations of abuse, neglect, and misappropriation of resident's property were investigated for 2 of 15 residents (#8 and #35) reviewed for abuse, neglect and/or misappropriation of personal property. This failure created the potential for residents to be subjected to ongoing abuse and misappropriation of resident property without detection. Findings include: The facility's Abuse Investigation policy, revised April 2021, documented the facility would promptly and thoroughly investigate reports of abuse, neglect and misappropriation of property. This policy was not followed: 1. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including depression and neurogenic bladder urinary bladder (difficulty controlling urination due to disease or injury of the central nervous system or peripheral nerves). A Grievance Communication form, dated 4/5/21, documented Resident #8 called and reported to the Business office her bank card was missing. The Grievance form documented Resident #8's bank card was in her lock box. Resident #8's room was searched but the bank card was not found. Resident #8 was very concerned and called her bank to cancel her bank card. The Grievance form documented Resident #8 was educated on proper use of her lock box. There was no documentation found on Resident #8's record her missing bank card was investigated for possible misappropriation of property. On 1/20/22 at 4:54 PM, the Administrator stated the facility started under new administration in October 2021, and he was unable to find documentation of Resident #8's missing bank card was investigated by the previous administration. The Administrator then reviewed Resident #8's grievance and said Resident #8's grievance should have been investigated for possible misappropriation of resident property. The facility failed to ensure an investigation was conducted for Resident #8's missing bank card for possible misappropriation of resident property. 2. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (stroke) and diabetes. Resident #35's quarterly MDS assessment, dated 12/8/21, documented he was moderately cognitively impaired. He did not walk, depended on a wheelchair, was totally dependent, and required the assistance of two people for bed mobility and transfers, and extensive assistance from one person for dressing, toileting, and hygiene. Resident #35 had a Foley catheter (indwelling urinary catheter) and was always incontinent with bowel function. On 1/18/22 at 10:01 AM, Resident #35 said CNA #4 acted like a doctor. Resident #35 said CNA #4 was rough during peri care and grabbed his testicles and told him it was for my own good. Resident #35 said CNA #4 told him he needed to get his leg amputated. Resident #35 said he would like to know which medical school CNA #4 went to. On 1/19/22 at 8:53 AM, when asked, Resident #35 said the incident happened a long time ago. He said he talked to RCM #1, and RCM #1 made it so CNA #4 would not provide care to him again. Resident #35 said CNA #4 had not cared for him since, and he was not afraid or worried about retaliation by CNA #4. On 1/21/22 at 3:30 PM, RCM #1 said Resident #35 told her he felt CNA #4 was too rough when providing peri care to him, and she did not remember what date it was, maybe a few months ago. RMC #1 said after Resident #35 reported the incident she asked him if he wanted CNA #4 to stop providing care for him and Resident #35 answered no. RCM #1 said Resident #35 returned to her about a week later and asked that CNA #4 no longer provide care for him. RCM #1 said CNA #4 still worked in the same hall where Resident #35's room is located, but he did not provide care for Resident #35. During the same interview, RCM #1 said Resident #35 was incontinent of bowel and sometimes refused to lay down for incontinent care during the day. Instead he sat in his electric wheelchair all day long. Staff usually offered incontinence care to him again after a refusal. RCM #1 said CNA #4 told her the night he performed peri care for Resident #35, it was difficult to clean him because the stool was left there all day and was dried to his skin. CNA #4 said he had been very careful and was not rough, but it took a long time to clean Resident #35. On 1/21/22 at 3:30 PM, RCM #1 said an Incident and Accident report was not completed for this event. RMC #1 said she investigated the incident, but she did not document it. RCM #1 said the event was considered a suspected staff to resident abuse. There was no documentation a thorough investigation into the allegation of potential staff to resident abuse, to include interview with other residents who received care from CNA #4, interview with Resident #35 to determine the reason he decided a week later he did not want CNA #4 providing care for him, and applicable staff interviews, was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected a resident's status. This was true for 1 of 15 residents (Resident #12) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and/or monitored due to inaccurate assessments. Findings include: Resident #12 was admitted to the facility on [DATE] with multiple diagnoses, including a Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) of the sacral region (the upper-middle portion of the pelvic cavity). Resident #12's annual MDS assessment, dated 8/2/21, documented she was at risk of developing pressure ulcers, and she had one or more unhealed pressure ulcers at Stage 1 or higher. The MDS assessment did not document the number of Resident #12's current pressure ulcers, staging, or how many pressure ulcers were present upon admission. Resident #12's pressure ulcer weekly reports, dated 12/2/21 to 1/5/22, included documentation she had two Stage 4 pressure ulcers; one of which was on the sacrum region and was present upon admission. The report documented Resident #12 developed a new pressure ulcer on her IT (ischial tuberosity: the part of the pelvis that supports a person while sitting) while she resided in the facility on 2/21/21. The annual MDS assessment did not include documentation of these pressure ulcers. On 1/24/22 at 1:20 PM, CRN #1 said she called and asked the MDS nurse about the 8/2/21 MDS assessment. CRN #1 stated the MDS nurse said Resident #12's annual MDS assessment, dated 8/2/21, should have documented Resident #12 had two Stage 4 pressure ulcers, and one of them was present upon admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a resident's care plan included individualized, resident-centered interventions and goals related to treatment of his insomnia and related medication. This was true for 1 of 15 residents (Resident #35) whose care plans were reviewed. This placed the resident at risk of adverse outcomes if cares and/or services were not provided appropriately due to a lack of information in the care plan. Findings include: The facility's policy, Comprehensive Person-Centered Care Planning, revised 8/2017, documented healthcare information necessary to care for each resident properly would be documented to provide effective and person-centered care and meet professional standards of care. This policy was not followed. Resident #35 was admitted to the facility on [DATE] with multiple diagnoses, including cerebral infarction (a type of stroke which occurs when the blood supply to part of the brain is interrupted or reduced), and insomnia (a sleep disorder in which you have trouble falling or staying asleep.) Resident #35's annual MDS assessment, dated 6/9/21, and quarterly MDS assessments, dated 9/9/21 and 12/8/21, documented he was receiving an antidepressent medication Resident #35's active physician orders included the following: * Trazodone (an antidepressant drug) tablet 150 mg, give one tablet by mouth at bedtime for insomnia, restart date 10/28/21. * Document sedative, hypnotic medication side effects every shift for syncope, dizziness, confusion, hallucinations, nightmares, fatigue, anxiety, headache, sedation, mania, gastrointestinal upset, restart date 9/30/21. * Monitor hours of sleep every shift, start date 11/10/21. Resident #35's IDT psychoactive medication review note, dated 11/2/21, stated the IDT reviewed the use of the medication Trazodone and documented it was prescribed for his medical condition of insomnia. Resident #35's care plan and care plan history did not include documentation of insomnia, or the use of the Trazodone. On 1/21/21 at 3:30 PM, RCM #1 confirmed there was no care plan for Resident #35's insomnia and Trazodone use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident and staff interview, it was determined the facility failed to ensure a resident was given the appropriate treatment and services to maintain or improve communication ability to carry out the activities of daily living. This was true for 1 of 15 residents (Resident #23) reviewed for activities of daily living. This failure placed Resident #23 at risk for decreased quality of life and psychosocial distress, depression, and negative behavior related to the inability to communicate her needs and choices. Findings include: 1. Resident #23 was admitted to the facility on [DATE] with multiple diagnoses, including stroke, the loss of ability to express speech, apraxia (when a person loses the ability to carry out skilled movements such as writing), paralysis of the right side of her body, and diabetes. Resident #23's Annual MDS assessment, dated 11/11/21, documented she had normal cognitive functioning, was usually understood, and could make herself understood to others, but had no verbal communication. Resident #23's care plan for communication, dated 12/01/21, documented she would be able to make her basic needs known on a daily basis and staff were to assist with word finding as needed. Under the focus of ineffective coping related to loss of speech, the intervention was to encourage Resident #23 to make choices and participate in planning of care and scheduled activities. A speech and language pathology note, dated 11/5/20, documented Resident #23 would have a communication book to increase her ability to communicate with others. On 1/19/22 at 2:30 PM, Resident #23 nodded yes when asked if she had been in the facility for 14 months. She shook her head no when asked if she had a communication device. She shook her head no when asked if she had ever had a communication device. She shook her head no when asked if she could file a grievance, write, or communicate her wants to facility staff. When asked if people understood her and met her needs, she shook her head no. When asked if she had pushed her call light for staff and they were unable to understand her needs and left without helping her, she nodded yes. When asked if her lack of ability to communicate made her feel frustrated, she nodded yes. When asked if she was frustrated with staff because she could not communicate, she nodded yes. When asked if she started feeling depressed because she could not communicate, she nodded yes. On 1/21/21 at 8:35 AM, CNA #3 stated Resident #23 was smiling and interacting less and less with staff. Additionally, she stated she would often not nod yes or no to staff when asked questions. On 1/24/22 at 11:35 AM, the DON stated if a resident was assessed for a communication assistive device and it was recommended, they hould have one. The facility failed to ensure Resident #23 was given the appropriate treatment and services to improve her communication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure there was an ongoing activity program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was true for 3 of 3 residents (Resident #4, #23, and #24) reviewed for activities. This failure created the potential for harm if residents experienced boredom and lacked meaningful activities throughout the day. Findings include: 1. Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including traumatic brain injury and quadriplegia (paralysis of both arms and legs). Resident #24's annual MDS assessment, dated 2/20/21, documented she was severely cognitively impaired. The MDS assessment also documented it was very important to her to listen to music, to be around animals such as pets, and to do things with groups of people. Resident #24's care plan, initiated on 11/13/21, documented she enjoyed certain activities such as music, special events, watching television, 1:1 with her roommate and going outdoors when it was warm. The care plan directed staff to ensure Resident #24's activities were age appropriate and adapted as needed with her needs and abilities. The care plan also directed staff to ensure that adaptive equipment was provided and functional. A SSD progress note, dated 11/23/21 at 11:28 AM, documented Resident #24 had traumatic brain injury and could not communicate except through her eyes. Resident #24 stayed active in activities with the assistance from the staff. The SSD progress note also documented Resident #24 enjoyed watching television and spending time with her roommate. On 1/18/22 at 10:27 AM, Resident #24 was observed sitting in her wheelchair in her room watching television. On 1/19/22 at 9:10 AM, CNA #2 and CNA #3 provided perineal care to Resident #24. CNA #2 and CNA #3 left Resident #24's room after they completed her perineal care. The CNAs did not turn the television on before leaving Resident #24's room. On 1/19/22 at 10:26 AM and 11:30 AM, Resident #24 was awake in her bed in her room. The privacy curtain between Resident #24 and her roommate was drawn. There was no music playing and the television was turned off. On 1/20/22 at 10:09 AM, Resident #24 was in bed and awake with the TV on. On 1/21/22 at 10:11 AM, the SSD was asked what adaptive equipment Resident #24 had. The SSD stated Resident #24's adaptive equipment was her wheelchair. The SSD stated Resident #24's social time was being with the other residents in the common area. The SSD stated a one-to-one (1:1 - one staff and one resident) staff was also provided for 1:1 activities. When asked what kind of 1:1 activities were being provided to Resident #24, the SSD stated examples included applying lotion, massaging her arms and legs, combing her hair, providing hygiene such as cleaning her hands and trimming her nails, and talking to her. On 1/21/22 at 1:50 PM, the Activity Director (AD) stated touch activity, such as applying lotion and massaging her arms and legs were provided to Resident #24 and she liked her stuff toys to be next to her. The AD also stated Resident #24 enjoyed sitting by the fish tank. When asked when the last time Resident #24 was brought next to the fish tank, the AD said Resident #24 was brought next to the fish tank three days ago. 2. Resident #23 was admitted to the facility on [DATE] with multiple diagnoses, including stroke, the loss of ability to express speech, apraxia (difficulty initiating and executing voluntary movement patterns necessary to produce speech when there is no paralysis or weakness of speech muscles. It may cause difficulty producing the desired speech sound and using the correct rhythm and rate of speaking), paralysis of the right side of her body, and diabetes. A speech and language pathology evaluation, dated 11/5/20, documented Resident #23 would have a communication book to increase her ability to communicate with others. Resident #23's annual MDS assessment, dated 11/11/21, documented she had normal cognitive functioning, was usually understood, and could make herself understood to others, but had no verbal communication. Resident #23's care plan for communication, dated 12/1/21, documented she was able to make her basic needs known on a daily basis and staff were to assist with word finding as needed. Under the focus of ineffective coping related to loss of speech, the intervention was to encourage Resident #23 to make choices and participate in planning of care and scheduled activities. On 1/19/22 at 2:30 PM, Resident #23 nodded yes when asked if she had been in the facility for 14 months. She shook her head no when asked if she had a communication device. She shook her head no when asked if she had ever had a communication device. She shook her head no when asked if she could write or communicate her wants to facility staff. When asked if people understood her and met her needs, she shook her head no. When asked if she had pushed her call light for staff and they were unable to understand her needs and left without helping her, she nodded yes. When asked if her lack of ability to communicate made her feel frustrated, she nodded yes. When asked if she was frustrated with staff because she could not communicate, she nodded yes. When asked if she started feeling depressed because she could not communicate, she nodded yes. On 1/21/21 at 8:35 AM, CNA #3 stated Resident #23 was smiling and interacting less and less with staff. Additionally, she stated she would often not nod yes or no to staff when asked questions. She stated Resident #3 had lost the ability to write. On 1/21/22 at 10:11 AM, the SSD was asked what 1:1 activities with staff looked like for Resident #23. The SSD stated Resident #23 was very active and loved to hang out with others. When asked what activities Resident #23 did with others, she stated she liked to observe people playing games. When asked what individualized 1:1 activities the staff did with Resident #23, the SSD stated staff put on lotion and completed hygiene and grooming tasks. When asked how that differed from providing ADL care services, the SSD stated Resident #23 was very independent and it was not a care service because it was based on her preference for an activity. 3. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including spastic quadriplegic cerebral palsy (a medical condition where people have difficulty controlling movements of the arms and legs), muscle wasting, and severe protein-calorie malnutrition. Resident #4's care plan for psychosocial well-being, dated 10/1/21, documented the facility would help increase communication between Resident #4 and the facility about his care and living environment. During observations in the facility, from 1/18/22 through 1/21/22, Resident #4 was noted to be in his room in his bed. A physician note, dated 11/29/21, documented Resident #4 answered to yes/no questions by shaking his head. On 1/21/22 at 10:11 AM, the SSD was asked what 1:1 activities with staff looked like for Resident #4. The SSD stated Resident #4 used an iPad and liked to listen to music and watch videos. When asked what individualized 1:1 activities the staff did with Resident #4, the SSD stated staff put on lotion and completed hygiene and grooming tasks. When asked how that differed from providing ADL care services, the SSD stated no not when the individuals cannot leave their rooms independently. They need the extra 1:1 care. She stated it was not a care service because it was based on the resident's preference for an activity. On 1/21/22 at 1:51 PM, Resident #4 nodded yes, when asked if he had eaten lunch. When asked if he ate his meals in his room, he shook his head yes. When asked if he ate his meals in the dining room, he shook his head no. When asked if he would like to eat his meals in the dining room, he shook his head yes. The facility failed to ensure there was an ongoing activity program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents were provided a therapeutic diet that took into account the resident's clinical condition and preferences. This was true for 1 of 15 residents (#4) reviewed for nutrition concerns. This failure created the potential for harm if Resident #4 failed to eat because his nutritional preferences were not considered. Findings include: The facility menu policy, dated 9/2017, documented menus were developed and prepared to meet the nutritional needs of the residents and resident choices. It further stated prepared menus would reflect reasonable efforts to include input received from residents regarding diet choices. The facility's undated weight loss/gain policy documented that it was the facility policy to maintain resident weight within 10 percent plus or minus their ideal body weight. These policies were not followed. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including spastic quadriplegic cerebral palsy (damage to a child's brain or nervous system which does not cause paralysis but result in difficulty in controlling movements in the arms and the legs, facial muscles may also twitch or become tight and interfere with speech and eating ability), muscle wasting (loss of muscle mass), and severe protein-calorie malnutrition (when you are not consuming enough protein and calories, which can lead to muscle loss, fat loss, and your body not working as it usually would). Resident #4's care plan for nutrition, initiated 10/1/21, documented he was to receive the diet ordered by the physician and staff were to honor Resident #4's right to make personal dietary choices. On 1/19/22 at 9:48 AM, Resident #4 was observed seated in a BRODA chair (tilt-in-space positioning wheelchair) and subsequently being assisted to bed. Resident #4 appeared emaciated. Resident #4's legs, abdomen, face, and arms consisted of skin and bones and did not include muscle mass. He had contractures of both arms and legs. Resident #4's weight summary for the date range of 8/1/21 - 1/2/22, documented his height as 57 inches. Using the [NAME] formula (a math equation for estimating ideal body weight using a height measurement) to calculate ideal body weight, Resident #4 was to weigh 110 pounds. A Physician Progress note, dated 11/29/21, documented Resident #4 previously had a J-tube (feeding tube) which was found lying in his bed on 4/17/21 and had apparently been self-dislodged. The note documented the gastroenterologist decided not to replace it as Resident #4 was having good oral intake on pureed food. Resident #4's weight record documented he weighed 72.6 pounds on 4/21/21. Resident #4's weight summary documented his weight was 72 pounds on 12/2/21. An IDT review to address Resident #4's nutritional status, dated 12/6/21, documented his average meal intake was variable with most at greater than 49 percent. The review documented Resident #4's POA said he enjoyed applesauce and macaroni and cheese. The review documented applesauce would be added to all Resident #4's meals. A social service note, dated 12/8/21, documented Resident #4's nutritional status was discussed with his Power of Attorney (POA), including the potential complications of decline in weight, skin impairment, infection, and death. The possibility of placing another feeding tube was discussed with the POA. The note documented based on past experience the POA did not want a feeding tube placed. The note documented Resident #4's POA wanted to keep him comfortable and reported the favorite foods he liked to eat. A Physician Progress note, dated 12/9/21, documented Resident #4's diet was to be modified to a diet of his favorite foods. An IDT review to address Resident #4's nutritional status, dated 12/20/21, documented his average meal intake was variable with most at greater than 50 percent. An IDT review to address Resident #4's nutritional status, dated 12/28/21, documented his average meal intake was variable with most at greater than 76 percent. The review also documented an appetite stimulant was added to Resident #4's medication regimen on 12/10/21. A Physician Progress note, dated 12/30/21, documented Resident #4 continued to have problems maintaining his weight due to often declining meals. The note stated Resident #4's antidepressant medication had been increased in hopes that may help. The note documented his POA did not want a feeding tube placed and Resident #4 was to continue to be offered frequent snacks of his favorite foods to boost his caloric intake. An IDT care plan review, dated 1/10/22, did not include a review of Resident #4's nutritional status by the dietician. There was no documentation Resident #4 was asked about his diet preferences in the IDT review. Resident #4's weight summary documented on 7/19/21, he weighed 76.8 pounds. On 1/17/22, six months later, it documented he weighed 66.6 pounds, a 13.28 percent weight loss. On 1/21/22 at 8:40 AM, CNA #3 stated Resident #4 communicated with staff by nodding yes or no to their questions. She said he would stick out his tongue when he thought something was funny and would bump elbows when he wanted to agree with an opinion expressed by staff. She stated his head nods are appropriate answers to the questions being asked of him. She said the question/answer sessions guided his daily care regarding getting out of bed, bathing, eating, watching TV, and interacting on his iPad. On 1/21/22 at 1:51 PM, Resident #4 nodded yes, when asked if he had eaten lunch. When asked if he ate everything brought to him, he shook his head no. When asked if he liked his lunch, he shook his head no. When asked if his lunch tasted good to him, he shook his head no. When asked if he wanted more food choices, he nodded his head yes. When asked if he would eat more if he could choose what he ate, he nodded his head yes. When asked if staff asked him what he wanted to eat, he shook his head no. When asked if he had input into what food he was offered, he shook his head no. On 1/21/22 at 2:22 PM, the Dietician was interviewed regarding nutrition choices for Resident #4. She stated she had talked to Resident #4's POA about his dietary choices, but not Resident #4. She said she had tried to interview him but Resident #4 did not respond to her questions. When asked how the facility addressed Resident #4's weight loss, the Dietician stated he was on a fortified diet, and they offered him supplements. The Dietician stated they changed the type of supplements offered to increase Resident #4's acceptance of them. The Dietician stated Resident #4 was on a fortified diet and received extra butter for his food and extra cream on his oatmeal. Resident #4's record did not include documentation the assistance of staff who Resident #4 communicated well with, was elicited to assess his favorite foods. Resident #4's food preferences were not fully assessed to potentially improve his intake and promote weight gain. On 1/21/22 at 2:48 PM, the DON was interviewed regarding Resident #4's diet choices. She stated she was aware of the need for the nutrition at risk team to be reevaluated because the interventions seemed to be lacking for residents, including Resident #4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure actions were taken in a timely manner to address drug regimen review irregularities identified by the consultant pharmacist for 1 of 15 residents (Resident #35) reviewed for medication administration. This failure put Resident #35 at risk to experience adverse effects from medications that were not compatible or administered as recommended. Findings include: The facility's policy for medication regimen review (MRR), revised August 2017, stated the pharmacist reviewed each resident's medication regimen at least once a month to identify irregularities, clinically significant risks, and adverse consequences resulting from or associated with medication. The procedures included the following: * The MRR report was provided to the responsible physician and the DON within seven working days of review. * The attending physician would document in the resident's medical record that the identified irregularity was reviewed and if any action was taken to address it. * Nursing personnel provided a written response to the review, and nursing staff response to the updated report to the pharmacist. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses, including cerebral infarction (stroke), and hypothyroidism (thyroid gland doesn't produce enough of certain crucial hormones.) A physician order, dated 9/29/21, stated Resident #35 was to receive the following medications: * Fibercon tablet (medication to treat constipation) 625 mg, give 2 tablets by mouth two times a day at 7 AM and 4 PM to bulk up stool, give 30 minutes prior to food or other medications. * Levothyroxine Sodium (a thyroid hormone) tablet give 225 micrograms (mcg) by mouth at 8 PM bedtime related to hypothyroidism. Resident's #35's MRR report, dated 4/3/21 and 11/3/21, documented the consultant pharmacist alerted the attending physician two times with the same significant drug to drug interaction notifications as follows: * This resident is receiving the following medication which interacts in a significant way: Fibercon, Levothyroxine. * Please note that Fibercon contains calcium which will impair the absorption of Levothyroxine. Recommend to administer Levothyroxine on an empty stomach at least 30 minutes prior to food or other medications. Bedtime administration is only appropriate if there are no interacting medications or food consumed at the same time. Resident's #35's MRR report, dated 4/3/21, documented the physician and RCM #1 signed the report on 4/12/21. The physician marked Agree on the report. Resident's #35's MRR report, dated 11/3/21, was signed by the Nurse Practitioner on 11/15/21 and RCM #1 on 11/17/21. The Nurse Practitioner documented on the MRR report that she changed the timing for the Fibercon in the facility's electronic medical software system. Resident's #35's MARs, dated 10/1/21 to 1/20/22, documented there were no changes made to Resident #35's Fibercon and Levothyroxine medication orders and administration. The MARs documented Fibercon was to be given two times a day at 7:00 AM and 4:00 PM, and the Levothyroxine was given at 8:00 PM with multiple other medications. On 1/21/22 at 9:35 AM, RCM #1 said the MRR reports were sent to the physician and the facility at the same time. RCM #1 stated she was responsible to carry out the physician's instructions documented on the MRR. RCM #1 said based on the physician's comment on the 4/12/21 MRR report, she would not change the Fibercon's administration time. Instead, she would change the Levothyroxine administration time from bedtime to administer 30 minutes before meals. The facility failed to ensure actions were taken in a timely manner to address the physician's response to Resident #35's drug regimen review irregularities identified by the consultant pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, review of facility menus, and resident and staff interview, it was determined the facility failed to follow a resident's gluten-free meal preference or provide appropriate meal alternatives. This was true for 1 of 15 residents (Resident #8) reviewed for food preferences. This failure put Resident #8 at risk if she experienced hunger or weight loss for not having meals provided according to her needs or preference. Findings include: The facility's policy for Food and Nutrition Services, revised September 2017, documented the menus were developed and prepared to meet residents' nutritional needs and choices. This policy was not followed: Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including depression and disease of stomach and duodenum (a part of the small intestine). Resident #8's quarterly MDS, dated [DATE], documented she was cognitively intact. Resident #8's physician order, dated 7/1/19, documented to Resident #8 was to be provided a a regular texture, thin liquids consistency diet. A Nutrition Quarterly Review, dated 10/13/21, documented Resident #8 preferred gluten-free dietary items (a diet that excludes foods containing gluten; a protein found in wheat, barley, and rye). A Nutrition Risk Review assessment, dated 1/17/22, documented Resident #8's diet order was regular, regular texture, thin liquids, prefers gluten-free. Resident #8's Nutritional care plan, initiated 12/30/21, and revised 1/17/22, included the physician ordered dietary interventions as follows: Regular diet, regular texture, thin liquids, small portions, and Resident 8 preferred gluten-free items and meals. The interventions documented Resident #8 ordered some items that contained wheat, such as canned tomato soup. The interventions documented Resident #8 was educated about items that contained wheat and Resident #8 reported she did not have any negative effects from them. On 1/18/22 at 3:48 PM, Resident #8 said sometimes food was okay, sometimes it was junk. For example, Resident #8 said a few days ago, the facility served soup and ham and cheese sandwiches for dinner. She said she could not eat it because she was gluten-free. Resident #8 said the facility gave her two bowls of soup instead. Resident #8 said she was offered a plate of ribs which she did not order. She said she told the facility she did not like ribs and did not order them, and the facility sent her some chicken strips. Resident #8 said the facility did not have many choices for replacement meals. On 1/20/22 at 12:10 PM, Resident #8's lunch tray card documented the following: * Diet order: regular. * Allergies: Latex. * Note: No sticky foods. * Dislikes: Bananas, bread, broccoli. The tray card did not include Resident #8's gluten-free preference. The facility's menu for Alternate Choices for Lunch and Dinner, changed once every quarter, documented residents had the same four choices for lunch and dinner each day as follows: a. Hot dog, fries, and steamed vegetables. b. Barbeque ribs, mashed potatoes, and steamed vegetables. c. Chicken strips, fries, and steamed vegetables. d. Bread fish, rice, and steamed vegetables. The whole meal is the alternate, not pick and choose On 1/20/22 at 12:10 PM, the RD said she documented in nutrition notes when residents requested textures such as chopped meat or a gluten-free diet. The Dietician said she then contacted the dietary manager either verbally or wrote a communication slip for the dietary manager to update the preference in the tray card system. She said barbeque ribs, mashed potatoes, and steamed vegetables were the only gluten-free dish in the facility's Alternate Choices for Lunch and Dinner menu. When asked, the Dietician said if the facility did not update the tray card system with Resident #8's gluten-free preference, Resident #8 would have the same alternate choice of barbeque ribs for lunch and dinner for three months.

Based on observation, resident and staff interviews, and policy review, it was determined the facility failed to ensure a safe environment was provided for residents, staff and the public. This was true for 1 of 45 residents (Resident #39) observed using an extension cord with a power strip. This failure placed a resident at risk of physical harm if his extension cord power strip caught on fire due to being covered with pillows. Findings include: The facility's policy for Electrical Equipment Power Cords and Extension Cords, documented the following: * Power strips in patient care areas are only used for movable Patient-Care-Related- Electrical-Equipment (PCREE), such as beds, air mattresses, feeding pumps, etc. * For all electronics (TVs, computers, cell phones, etc.) in resident areas, use only UL (underwriters laboratories certified) 1363. * For PCREE, use UL1363A or UL60601-1. It is prohibited to use PCREE outlets for any type of personal electronics. * All power strips are used with general precautions. * Extension cords were for use on a temporary basis and were to be removed after use. This policy was not followed. On 1/18/22 at 1:58 PM, Resident #39 was observed in bed in his room. There was a black extension cord with a power strip connected to the wall outlet and was draped over his bedside table. When asked about the power strip, Resident #39 said he brought the power strip into the facility, and the facility was aware he had it and used it to charge his i-Pod. On 1/19/22 at 9:31 AM, Resident #39 was observed in bed in his room. The extension cord with a power strip was still connected to the wall outlet and draped over his bed side table but was now located in the open top drawer. A large white pillow and a small blue pillow were placed on top of the power strip which had Resident #39's hospital bed and i-Pod plugged into the power strip. On 1/20/22 at 9:59 AM, Resident #39's i-Pod and hospital bed were still plugged into the power strip located in the top drawer of his bedside table and covered with a small blue pillow. During an interview on 1/20/22 at 5:00 PM and continuing on 1/24/22 at 12:10 PM, the Plant Manager was asked about the use and placement of power strips in the facility. The Plant Manager stated when he started this position about four months ago, he noticed about 50% of the residents were using personal power strips. The plant manager said the facility currently had about 60% of the power strips in use by residents were not UL certified but the prior company that managed the facility allowed them. He said the new facility management did not allow residents to bring in their own power strips. The Plant Manager said the facility was in the process of switching out the non-UL certified power strips the residents were using with UL 1363, UL1363A, or UL 6060-1 certified strips but it was a process and taking time. The plant manager said placing pillows on top of a power strip was considered a fire hazard and pillows should not be on top of power cords that were in use. The facility failed to ensure a safe environment for residents, staff and the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, policy review, review of grievances, and record review, it was determined the facility failed to ensure: * Residents were notified individually or through postings in the facility of how to file a grievance * A functional process for filing a grievance anonymously was in place * Residents received written responses to grievances which included the date the grievance was received, steps taken to investigate the grievance, and corrective action taken to resolve the grievance. This was true for 4 of 13 residents interviewed regarding grievances (Residents #8, #9, #23, and #51) and had the potential to impact all of the other 53 residents in the facility, or their representatives, who may want to file a grievance. These failures impeded the ability of residents and their representative to file grievances and to receive resolution. Findings include: The facility's Grievance policy, dated 10/2021, documented residents and their representatives had the right to file grievances orally or in writing and the right to file grievances anonymously. This policy was not followed. 1. The facility's processes impeded the ability of residents to file grievances, as follows: a. Resident #23 was admitted to the facility on [DATE] with multiple diagnoses, including stroke, the loss of ability to express speech, apraxia (loss of the ability to carry out skilled movements such as writing), paralysis of the right side of her body, and diabetes. Resident #23's Annual MDS assessment, dated 11/11/21, documented she had normal cognitive functioning, was usually understood, and could make herself understood to others, but had no verbal communication. On 1/19/22 at 2:30 PM, Resident #23 was interviewed regarding her process for filing a grievance. When asked if she could write or speak, she shook her head no. When asked if she was having difficulty filing a grievance, Resident #23 nodded her head yes. When asked if she could file a grievance, she shook her head no. When asked if she could ask staff to help her file a grievance, she shook her head no. b. On 1/21/22 at 3:35 PM, Resident #9 and Resident #51 were in the common area by the nurse's station. When asked where grievance forms were located, they stated the forms were behind the nurse's counter in a drawer. When asked if they could get the grievance form themselves, they stated no, they had to ask staff for them. When asked if they could make a grievance anonymously, both residents replied No. On 1/21/22 at 3:58 PM, CNA #1 stated he did not know how to help a resident file a grievance. He said if a resident wanted to file a grievance, he would let the nurse know. On 1/21/22 at 4:05 PM, LPN #4 stated she thought the posting for filing a grievance was in the front office. When asked how a resident would file a grievance, she said she would tell the administrator or nurse about the request. On 1/21/22 at 4:08 PM, LPN #5 stated she did not know how to file a grievance, but she would tell her supervisor. When asked if she knew where the posting of how to file a grievance was, she stated she did not know. On 1/21/22 at 4:12 PM, RN #1 stated she did not know where the posting for how to file a grievance was. She said she thought it was at the nurse's station. When asked how she would help a resident file a grievance, she stated she would ask the RCM how to do it. She said if a resident wanted to file a grievance she would document it in the resident's record. Throughout the survey, a posting of how to file a grievance was not observed in any common area in the facility. On 1/24/22 at 11:15 PM, the DON stated the facility expected open communication through the grievance process, and residents should be able to file a grievance anonymously. 2. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including depression and neurogenic bladder (inability to control urination due to disease or injury of the central nervous system or peripheral nerves). A Grievance Communication form, dated 4/5/21, documented Resident #8 called the Business Office reported her bank card was missing. The Grievance Communication form documented Resident #8's bank card was in her lock box. Resident #8's room was searched and the bank card was not found in her lock box or elsewhere. Resident #8 was very concerned and called her bank to cancel the bank card. The Grievance Communication form documented Resident #8 was educated on proper use of her lock box. There was no documentation in Resident #8's record or elsewhere of actions taken to investigate the cause of her missing bank card, the results of the investigation, and resolution of her grievance. On 1/20/22 at 4:54 PM, the Administrator stated the facility started under new administration in October 2021. The Administrator stated he requested documentation of the investigation regarding Resident #8's missing bank card from the previous administration. The Administrator stated the previous administration was unable to provide him documentation an investigation was conducted. The Administrator then reviewed Resident #8's grievance and said Resident #8's grievance should have been investigated for possible misappropriation of resident property. The facility failed to ensure Resident #8 was provided a written response to her grievance documenting the steps taken to investigate the grievance, results of the investigation, and resolution of the grievance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as needs changed and included residents' representative in the development of the care plan. This was true for 4 of 15 residents (#3, #12, #24, and #35) whose care plans were reviewed. This deficient practice placed residents at risk for adverse outcomes if care and services were not provided appropriately due to a lack of information in the care plans. Findings include: The facility's Comprehensive Person-Centered Care Planning policy, revised August 2017, documented the care plan would be reviewed by the IDT after each assessment. 1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including diabetes mellitus, vascular dementia (caused by the lack of blood that carries oxygen and nutrients to the brain and can result in problems with reasoning, planning, judgment, and memory), and depression. Resident #3's care plan, initiated 10/21/21, documented Resident #3 was at risk for falls and had a history of falls due to impaired mobility. The care plan stated Resident #3's bed was to be in lowest position. On 1/18/22 at 11:03 AM, on 1/18/22 at 1:55 PM, on 1/19/22 at 9:02 AM, on 1/20/22 at 10:56 AM, and on 1/20/22 at 5:09 PM, Resident #3 was observed in her bed. During those observation times, her bed was not in its lowest position. On 1/24/22 at 11:26 AM, RCM #3 stated it was standard protocol to put the bed in the lowest position if residents were high risk for falls. When asked if Resident #3 was at high risk for falls and if her bed should be in lowest position, RCM #2 stated she did not think so. RCM #2 said Resident #3 did not try to get out of her bed and her bed did not need to be in the lowest position. 2. Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including traumatic brain injury and quadriplegia (paralysis of both arms and legs). A quarterly MDS assessment, dated 11/19/21, documented Resident #24 had severe cognitive impairment. Care conference notes, dated 2/18/21 and 8/19/21, documented Resident #24's representative was informed of the care conference but did not attend the care conference. On 1/19/22 at 11:09 AM, Resident #24's representative stated during a telephone interview, she received mail or a phone call from the facility previously regarding care plan meetings but had not received any since the COVID-19 pandemic. Resident #24's representative stated she was unable to attend the care plan meeting due to her work but would like to be informed of the outcome of the meeting. An IDT care plan review, dated 11/10/21, documented Resident #24's representative participated in the development of and review of her care plan. On 1/20/22 at 11:10 AM, the SSD stated Resident #24's representative was last present for her care conference about 6 to 8 months ago but was in constant communication with the RCM. On 1/24/22 at 11:26 AM, RCM #2 stated Resident #24's representative was notified of the care conference but did not attend the meeting. When asked if Resident #24's representative was informed of the outcome of the meeting, RCM #2 said Yes. RCM #2 stated she would look for the documentation Resident #24's representative was informed of the outcome of the care conference meeting. On 1/26/22, a hand-written note was received from RCM #2. RCM #2's note stated she could not find documentation regarding calling Resident #24's representative about her care conference. 3. Resident #35 was admitted to the facility on [DATE] with multiple diagnoses, including cerebral infarction (stroke), and insomnia. On 1/18/22 at 10:01 AM, Resident #35 said, I feel depressed, and seems like nobody cares. Resident #35 said sometimes he told the staff he was depressed, and they just walked away. Resident #35 said he was on medication for Parkinson's disease (a progressive disease of the nervous system that affects movement) and did not know if he was on medication for depression. He said, I don't think they take good care of my health; I have been sicker since I am here. On 1/19/22 at 9:00 AM, when asked how he was doing, Resident #35 said he felt depressed. Resident #35's care plan, dated 12/9/21, did not include a plan and interventions for his depression as identified in his annual and quarterly MDS assessments. On 1/21/21 at 9:10 AM and at 3:30 PM, RCM #1 said Resident #35 had been depressed since December 2021. RCM #1 said the facility offered Resident #35 to speak to the psychologist or the in-house counselor and Resident #35 refused. RCM #1 said there was no care plan for Resident #35's onset of depression. She said Resident #35 was very depressed, and the care plan should be updated. 4. The facility's policy for Skin Management System, revised December 2019, stated a plan of care was initiated to address areas of actual skin breakdown. The policy also stated the plan of care was reviewed and revised as needed. This policy was not followed: The National Pressure Injury Advisory Panel website, accessed on 1/31/22, defined pressure ulcer Stage 3 and Stage 4 follows: Stage 3 - Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), and epibole (rolled edges) are often present. Slough (non-viable yellow, tan, gray, green, or brown tissue), and/or eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber, and muscle in place), muscle, tendon, ligament, cartilage, or bone is not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 - Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses, including left-sided hemiplegia (weakness of one entire side of the body that can affect the arms, legs, and facial muscle due to neurological damage). At admission, she had a Stage 4 pressure ulcer of the sacral region (tailbone). Resident #12's quarterly MDS assessment, dated 2/1/21, documented she had acquired 2 new pressure ulcers, one Stage 3 and one Stage 4. The MDS did not include documentation where the new pressure ulcers were located. Resident #12's weekly pressure ulcer report, dated 2/21/21, documented she had developed a new pressure ulcer on her IT (ischial tuberosity: the part of the pelvis that supports a person while sitting) while residing in the facility. Resident #12's care plan was not revised to address her newly acquired Stage 3 pressure ulcer and Stage 4 pressure ulcer documented in her quarterly MDS assessment, dated 2/2/21, or her newly acquired IT pressure ulcer documented in her weekly pressure ulcer report dated 2/21/21. A weekly pressure ulcer report, dated 1/5/22 at 12:19 PM, documented the Treatment Nurse noted that Resident #12's wound was currently being impacted by the removal of Resident #12's Foley catheter due to incontinence and her resistance care. This resulted in more frequent dressing changes and removing the fragile epithelial tissue. The note did not include which wound was impacted by the removal of the Foley catheter. Resident #12's record did not include updated care plan interventions or revisions to reflect her wound decline related to incontinence after removing her Foley catheter as documented in the 1/5/22 weekly pressure ulcer report. On 1/24/22 beginning at 1:00 PM, the Treatment Nurse said the care plan should be updated as soon as there was a change in a resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 5 of 15 residents (#3, #10, #17, #33, and #35) reviewed for standards of practice. Specifically: *Resident #3 was at risk for ongoing constipation or fecal impaction when physician orders for bowel care were not followed. Resident #3 was also at risk for side effects of a narcotic given contrary to parameters ordered by the physician. *Resident #3, #10, #17, #33 and #35 were at risk of abnormally high or low blood sugar when their insulin medication was administered late, *Resident #35 was at risk for adverse outcomes such as altered sleep, increased pain, pressure injuries, and respiratory infection when monitoring for sleep, pain, air mattress pressure, screening for COVID-19 signs and symptoms, and cleaning of his CPAP machine (a device connected to a mask or nose piece to deliver constant and steady air pressure to help breathing when sleeping) were not consistently completed. * Resident #35 was at risk for development of urinary tract infections when his catheter care and treatment ordered by the physician was not followed. Findings include: 1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including diabetes mellitus and depression. a. A physician order, dated 9/30/21, included the following medications for Resident #3 to promote bowel movements: * Docusate Sodium (stool softener), two capsules by mouth two times a day, * Miralax (laxative) mixed in 6-8 ounces of fluid of choice, two times a day by mouth as needed, hold for loose stools, * Senna tablet (laxative), one tablet by mouth at bedtime, * Dulcolax suppository, insert one suppository rectally as needed for constipation if no bowel movement for 2 or more days, Resident #3's Bowel Movement Records, dated 12/22/21 through 1/20/22, documented she did not have a bowel movement between 12/28/21 and 1/1/22 (5 days) and between 1/7/22, and 1/10/22 (4 days). Resident #3's MARs, dated 12/1/21 through 1/11/22, documented the Dulcolax suppository was not administered as ordered when she did not have a bowel movement from 12/28/21 to 1/1/22 (5 days) or 1/7/22 to 1/10/22 (4 days). The MARs also documented Resident #3 did not receive Miralax as needed. On 1/20/22 at 10:46 AM, the DON said the facility did not have a bowel protocol. The DON stated physician orders for bowel movement medications differed among residents. The DON reviewed Resident #3's record and said Resident #3 was not provided bowel medications as ordered. The facility did not follow Resident #3's physician orders for bowel care. b. Resident #3's quarterly MDS assessment, dated 1/5/21, documented she had moderate cognitive impairment, experienced occasional pain, and received PRN pain medications. The MDS assessment also documented Resident #3's pain did not limit her day to day activities. Resident #3's care plan, revised 10/21/21, documented Resident #3 had fibromyalgia (a chronic disorder that causes widespread muscle pain and tenderness, trouble sleeping, and overwhelming tiredness). The care plan directed staff to offer her non-pharmacological pain management such as repositioning, massage, ice, relaxation techniques, administer pain medication as ordered, and monitor/document side effects of her pain medications such as constipation, onset or increased agitation, etc. A physician order, dated 9/30/21, documented the following medications for Resident #3: * Tylenol Extra Strength (used to treat mild to moderate pain), give one tablet by mouth every 4 hours as needed for pain rating of 1 to 5 (a 0-10 scale used to rate level of pain, 0 for no pain, and 10 the highest level of pain). * Norco Tablet (opioid analgesic used to treat moderate to severe pain), give one tablet by mouth every 12 hours as needed for pain rating of greater than 6. Resident #3's MARs, dated 12/1/21 through 1/17/21, documented she rated her pain less than 6 and received Norco on 12/2/21, 12/8/21, 12/9/21, 12/13/21, 12/14/21, 12/16/21, 12/20/21, 12/16/22 and 12/17/21, instead of Extra Strength Tylenol as ordered for a pain rating of 1 to 5. On 1/24/22 at 11:26 AM, RCM #2 reviewed Resident #3's record and stated she could not answer for the nurse who administered the Norco to Resident #3. RCM #2 stated if Resident #3 rated her pain less than 6, Tylenol should have been administered and not Norco. The facility did not follow Resident #3's physician's order for her pain medications. 3. The Drugs.com website, accessed on 1/26/22, stated, Insulin glargine is a long-acting insulin that starts to work several hours after injection [to lower blood glucose] and keeps working evenly for 24 hours. The website stated insulin glargine may be given at any time of the day; however, once a time is chosen, it is best to inject it within three hours of that time every day. These professional guidelines were not followed. a. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including diabetes mellitus. A physician order, dated 9/30/21, documented Resident #3 was to receive 15 units of Lantus (insulin glargine) solution 100 units/ml subcutaneously (injection under the skin) in the morning and 10 units of Lantus solution 100 units/ml subcutaneously in the evening. Resident #3's December 2021 and January 2022 MARs documented her morning insulin glargine solution was scheduled to be given at 7:00 AM and her evening insulin glargine solution was scheduled to be given at 8:00 PM. Resident #3's insulin glargine was not documented as given at 7:00 AM, or within 1 hour before or 2 hours after the scheduled times on the following dates: - 12/2/21 at 11:46 AM, greater than 4 hours - 12/12/21 at 10:08 AM, greater than 3 hours - 12/15/21 at 1:18 PM, greater than 6 hours - 12/27/21 at 9:40 AM, greater than 2 hours - 12/28/21 at 9:25 AM, greater than 2 hours - 12/29/21 at 9:45 AM, greater than 2 hours - 12/30/21 at 9:50 AM, greater than 2 hours - 1/4/22 at 11:07 AM, greater than 4 hours - 1/5/22 at 12:13 PM, greater than 5 hours - 1/13/22 at 9:31 AM, greater than 2 hours b. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses including diabetes mellitus, osteoarthritis, and chronic ischemic heart disease (recurring chest pain or discomfort that occurs when a part of the heart does not receive enough blood). A physician's order, dated 9/29/21, documented Resident #10 was to receive 28 units of Lantus (insulin glargine) solution 100 units/ml subcutaneously (injection under the skin) in the morning. Resident #10's November 2021, December 2021, and January 2022 MARs documented her insulin glargine solution was scheduled to be given at 7:00 AM. Resident #10's insulin glargine was not documented as given at 7:00 AM, or within 1 hour before or 2 hours after the scheduled times on the following dates: - 11/2/21 at 9:26 AM, greater than 2 hours - 11/11/21 at 9:32 AM, greater than 2 hours - 11/19/21 at 9:25 AM, greater than 2 hours - 11/24/21 at 10:06 AM, greater than 3 hours - 11/25/21 at 9:47 AM, greater than 2 hours - 11/28/21 at 9:24 AM, greater than 2 hours - 12/1/21 at 9:38 AM, greater than 2 hours - 12/2/21 at 9:34 AM, greater than 2 hours - 12/7/21 at 9:38 AM, greater than 2 hours - 12/8/21 at 9:38 AM, greater than 2 hours - 12/10/21 at 9:45 AM, greater than 2 hours - 12/14/21 at 9:59 AM, greater than 2 hours - 12/18/21 at 9:39 AM, greater than 2 hours - 12/19/21 at 10:17 AM, greater than 3 hours - 12/20/21 at 9:58 AM, greater than 2 hours - 12/21/21 at 9:26 AM, greater than 2 hours - 12/25/21 at 9:42 AM, greater than 2 hours - 12/26/21 at 10:40 AM, greater than 3 hours - 12/27/21 at 9:58 AM, greater than 2 hours - 12/29/21 at 9:36 AM, greater than 2 hours - 12/30/21 at 9:26 AM, greater than 2 hours - 1/1/22 at 9:38 AM, greater than 2 hours - 1/2/22 at 10:48 AM, greater than 3 hours - 1/4/22 at 11:00 AM, 4 hours late - 1/5/22 at 10:27 AM, greater than 3 hours - 1/7/22 at 9:29 AM, greater than 2 hours - 1/8/22 at 9:42 AM, greater than 2 hours - 1/11/22 at 9:30 AM, greater than 2 hours - 1/12/22 at 10:13 AM, greater than 3 hours - 1/13/22 at 10:03 AM, greater than 3 hours - 1/14/22 at 10:22 AM, greater than 3 hours - 1/15/22 at 10:26 AM, greater than 3 hours - 1/20/22 at 9:34 AM, greater than 2 hours c. Resident #17 was admitted to the facility on [DATE] with multiple diagnoses including hypertensive kidney disease (kidney disease caused by high blood pressure), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and diabetes mellitus. A physician's order, dated 11/30/21, documented Resident #17 was to receive 30 units of Basaglar Kwik-Pen Solution (insulin glargine) 100 units/ml subcutaneously (injection under the skin) two times per day. Resident #17's November 2021, December 2021, and January 2022 MARs documented her insulin glargine solution was scheduled to be given in the morning at 7:00 AM and in the evening at 8:00 PM. Resident #17's insulin glargine was not documented as given at 7:00 AM, or within 1 hour before or 2 hours after the scheduled times on the following dates: - 11/2/21 at 10:00 AM, 3 hours late - 11/5/21 at 12:35 PM, greater than 4 hours - 11/6/21 at 10:12 AM, greater than 3 hours - 11/7/21 at 9:54 AM, greater than 2 hours - 11/8/21 at 9:31 AM, greater than 2 hours - 11/28/21 at 11:07 AM, greater than 4 hours - 12/3/21 at 9:21 AM, greater than 2 hours - 12/8/21 at 9:32 AM, greater than 2 hours - 12/9/21 at 9:44 AM, greater than 2 hours - 12/14/21 at 10:29 AM, greater than 3 hours - 12/19/21 at 12:37 PM, greater than 5 hours - 12/21/21 at 12:39 PM, greater than 5 hours - 12/24/21 at 9:46 AM, greater than 2 hours - 12/26/21 at 1:00 PM, 6 hours late - 12/31/21 at 10:47 AM, greater than 3 hours - 1/2/22 at 1:00 PM, 6 hours late - 1/3/22 at 10:55 AM, greater than 3 hours - 1/7/22 at 10:08 AM, greater than 3 hours - 1/8/22 at 10:02 AM, greater than 3 hours - 1/10/22 at 9:52 AM, greater than 2 hours - 1/12/22 at 10:37 AM, greater than 3 hours - 1/18/22 at 12:07 PM, greater than 5 hours - 1/19/22 at 10:41 AM, greater than 3 hours d. Resident #33 was admitted to the facility on [DATE] with multiple diagnoses including non-ST elevation myocardial infarction (heart attack), acute respiratory failure, and diabetes mellitus. A physician's order, dated 9/30/21, documented Resident #33 was to receive 25 units of insulin glargine 100 units/ml subcutaneously (injection under the skin) in the morning and 25 units of insulin glargine 100 units/ml subcutaneously at bedtime. Resident #33's November 2021, December 2021, and January 2022 MARs documented her insulin glargine solution was scheduled to be given in the morning at 7:00 AM and in the evening at 8:00 PM. Resident #33's insulin glargine was not documented as given at 7:00 AM, or within 1 hour before or 2 hours after the scheduled times, on the following dates: - 11/4/21 at 10:03 AM, greater than 3 hours - 11/11/21 at 11:48 AM, greater than 4 hours - 11/24/21 at 9:26 AM, greater than 2 hours - 11/25/21 at 9:28 AM, greater than 2 hours - 11/26/21 at 9:34 AM, greater than 2 hours - 11/29/21 at 9:35 AM, greater than 2 hours - 11/30/21 at 9:28 AM, greater than 2 hours - 12/1/21 at 9:53 AM, greater than 2 hours - 12/2/21 at 9:41 AM, greater than 2 hours - 12/4/21 at 9:57 AM, greater than 2 hours - 12/6/21 at 10:01 AM, greater than 3 hours - 12/7/21 at 9:44 AM, greater than 2 hours - 12/13/21 at 9:29 AM, greater than 2 hours - 12/14/21 at 10:27 AM, greater than 3 hours - 12/19/21 at 10:09 AM, greater than 3 hours - 12/23/21 at 11:17 AM, greater than 4 hours - 12/26/21 at 10:30 AM, greater than 3 hours - 12/28/21 at 11:58 AM, greater than 4 hours - 12/29/21 at 9:26 AM, greater than 2 hours - 1/4/22 at 10:03 AM, greater than 3 hours - 1/11/22 at 9:39 AM, greater than 2 hours - 1/18/22 at 9:41 AM, greater than 2 hours - 1/20/22 at 10:34 AM, greater than 3 hours e. Resident #35 was admitted to the facility on [DATE] with multiple diagnoses including cerebral infarction due to embolism (stroke due to blood clot), permanent atrial fibrillation (irregular and often very rapid heart rhythm that can lead to blood clots in the heart, increasing the risk of stroke, heart failure and other heart-related complications), essential (primary) hypertension (high blood pressure), and diabetes mellitus. A physician's order, dated 10/28/21, documented Resident #35 was to receive 26 units of insulin glargine 100 units/ml subcutaneously (injection under the skin) in the morning. Resident #35's November 2021, December 2021, and January 2022 MARs documented his insulin glargine solution was scheduled to be given in the morning at 7:00 AM. Resident #35's insulin glargine was not documented as given at 7:00 AM, or within 1 hour before or 2 hours after the scheduled times, on the following dates: - 11/1/21 at 10:06 AM, greater than 3 hours - 11/5/21 at 9:25 AM, greater than 2 hours - 11/7/21 at 12:03 PM, greater than 5 hours - 11/14/21 at 9:25 AM, greater than 2 hours - 11/20/21 at 10:08 AM, greater than 3 hours - 11/28/21 at 9:39 AM, greater than 2 hours - 12/7/21 at 10:14 AM, greater than 3 hours - 12/9/21 at 10:14 AM, greater than 3 hours - 12/10/21 at 9:29 AM, greater than 2 hours - 12/19/21 at 9:41 AM, greater than 2 hours - 12/21/21 at 9:59 AM, greater than 2 hours - 12/22/21 at 9:28 AM, greater than 2 hours - 12/23/21 at 9:40 AM, greater than 2 hours - 12/24/21 at 9:40 AM, greater than 2 hours - 12/25/21 at 9:59 AM, greater than 2 hours - 12/26/21 at 10:56 AM, greater than 3 hours - 12/27/21 at 9:39 AM, greater than 2 hours - 12/28/21 at 11:00 AM, 4 hours late - 12/29/21 at 10:38 AM, greater than 3 hours - 12/31/21 at 10:23 AM, greater than 3 hours - 1/2/22 at 10:41 AM, greater than 3 hours - 1/3/22 at 10:37 AM, greater than 3 hours - 1/4/22 at 10:25 AM, greater than 3 hours - 1/5/22 at 10:10 AM, greater than 3 hours - 1/6/22 at 10:01 AM, greater than 3 hours - 1/7/22 at 10:02 AM, greater than 3 hours - 1/8/22 at 9:46 AM, greater than 2 hours - 1/9/22 at 9:38 AM, greater than 2 hours - 1/12/22 at 9:35 AM, greater than 2 hours - 1/13/22 at 10:23 AM, greater than 3 hours - 1/14/22 at 10:48 AM, greater than 3 hours - 1/15/22 at 10:07 AM, greater than 3 hours - 1/18/22 at 10:17 AM, greater than 3 hours - 1/19/22 at 10:26 AM, greater than 3 hours On 1/21/22 at 3:45 PM, CRN #1 said the facility did not have a policy covering medication administration. She stated all medications should be given within the timeframe of 1 hour before to 1 hour after the scheduled time. 4. Resident #35 was admitted to the facility on [DATE] with multiple diagnoses, including cerebral infarction (stroke), and diabetes. Resident #35's monitoring for sleep, pain, and air mattress were not consistently completed. a. A physician order, dated 9/29/21, documented nursing was to assure Resident #35's air mattress was set as indicated every shift to maintain skin integrity. Resident #35's TAR did not include an entry for monitoring his air mattress on the following dates/shifts: 12/19/21 day shift, 12/21/21 day shift, 12/22/21 day shift, and 1/3/22 day shift. A physician order, dated 1/4/21, modified Resident #35's airbed mattress monitoring for nursing staff to assure his airbed mattress was set as indicated every day. Resident #35's TAR did not include an entry for monitoring his air mattress on 1/6/22, 1/7/22, 1/8/22, 1/9/22, and 1/12/22. b. A physician order, dated 9/29/21, documented nursing staff were to monitor Resident #35's hours of sleep every shift. Resident #35's TAR did not include an entry for monitoring his hours of sleep on the following days/shifts: 12/19/21 day shift, 12/21/21 day shift, and 12/22/21 day shift. c. A physician order, dated 12/22/21, documented nursing staff were to monitor his level of pain every shift. Resident #35's TAR did not include an entry for monitoring his pain on the following days/shifts: 1/3/22 day shift, 1/6/22 day shift, 1/8/22 day shift, 1/9/22 day shift, and 1/12/22 day shift. On 1/21/22 at 2:15 PM, CRN #1 said Resident #35's TAR was not filled out on certain days, which meant there was no documentation for those cares. She stated the care should be documented. On 1/24/21 at 12:24 PM, CRN #1 said she could not find documentation for the blank dates on the TARs. She stated if care could not be completed, there should be documentation regarding the reason care was not performed. 5. The facility's Catheter Care policy, revised July 2013, documented urinary catheter (a flexible tube inserted into the bladder and secured by a small inflatable balloon to hold the tube in place. The tube is used to empty the bladder and collect urine in a drainage bag) care was completed daily and as needed for each resident with a urinary catheter and the catheter care was documented. The policy also stated the catheter tubing and bag were to be kept below the bladder level, and the drainage bag was to be covered with a privacy bag. This policy was not followed. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses, including cerebral infarction (stroke) and diabetes. Resident #35's quarterly MDS assessment, dated 12/8/21, documented he was moderately cognitively impaired, and was totally dependent requiring the assistance of two staff for bed mobility and transfers. The MDS assessment documented Resident #35 had a urinary catheter and was incontinent with bowel function. Resident #35's care plan for his suprapubic urinary catheter (a urinary catheter inserted surgically through an incision in the abdomen directly into the bladder), revised 12/9/21, included the following interventions: * Provide catheter care every shift and as needed. * Position catheter bag and tubing below the bladder level and away from the entrance room door. * Secure catheter to facilitate urine flow, prevent tubing kinks and accidental removal. Resident #35's TAR included the following physician orders for his urinary catheter care: * Flush catheter with 60 ml normal saline every day shift, start date 9/29/21. Resident #35's TAR documented this was not completed on 12/19/21, 1/3/22, 1/6/22, 1/7/22,1/9/22, and 1/12/22. * Catheter care every shift, clean insert site with warm soapy water. Catheter patency to gravity drain, catheter cover over drainage bag at all times, and check for placement, start date 9/29/21. Resident #35's TAR documented this was not completed on day shift on 12/19/21, 12/21/21, 1/3/22, 1/6/22, 1/7/22, 1/8/22, 1/9/22, and 1/12/22. * Check the catheter leg strap to ensure it is in place every shift, start date 9/30/21. Resident #35's TAR documented this was not completed on day shift on 1/3/22, 1/6/22, 1/7/22, 1/8/22, 1/9/22, and 1/12/22. On 1/21/22 at 2:15 PM, CRN #1 said Resident #35's TAR was blank, which meant the catheter care was not documented. On 1/24/21 at 12: 24 PM, CRN #1 said she could not find documentation to support why Resident #35's TAR did not include documentation of completion. She said the TAR should be marked as completed or include documentation why it was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interviews, it was determined the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to properly date food items when they were received and stored and failed to monitor and discard outdated food items. This had the potential to affect the 58 residents residing in the facility who consumed food prepared by the facility and placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The facility's policy, Infection Control Policy/Procedure for Dietary Services, revised 5/2007, documented safe food services would be provided for residents and employees. Old stock was to be rotated and used first, and leftovers were to be dated, labeled, covered, cooled, and stored. The facility's policy, Resident/Personal Food Storage, stated refrigeration units were monitored by designated facility staff for food safety. FDA Food Code Section 3-501.17(A) documented food should be clearly marked to indicate the date by which the food should be consumed, sold, or discarded. FDA Food Code Section 3-701.11(A) documented food that was unsafe should be discarded. These policies, and guidelines were not followed. On 1/18/22 at 10:00 AM, the following observations were made in the kitchen: * Bacon fat was stored in the walk-in refrigerator, marked UB (use by) 1/4, * An open bottle of Sweet Baby Ray's barbeque sauce in the walk-in refrigerator was not marked with use by date. * An open bag of mozzarella cheese shreds in the walk-in refrigerator was not marked with the use by date. * An open bag of cheddar cheese shreds in the walk-in refrigerator was not marked with the use by date. * An open yogurt container in the walk-in refrigerator was marked 01/11/22. It was unclear if the date was the date the food was opened or the use by date. * An open bag of raw spinach was not marked with the use by date. * An open bag of lettuce mix was not marked with the use by date. * Cupped barbeque sauce was not marked with the use by date. * Canned goods and dried goods in the dry storage room were not marked with the received date. * An open bag of dried potato pearls was not marked with the use by date. * An open container of tomato juice in the reach-in refrigerator was marked UB 1/15. * Juice in a blue container in the reach-in refrigerator, marked Regular, was marked UB 1/17. * Iced tea in a blue container in the reach-in refrigerator was marked UB 1/17. * There was a yellow substance cupped in 1-ounce containers, one on a tray in dry storage and one on a condiment tray to take to residents, not labeled or dated. On 1/21/22 at 9:30 AM, the Dietary Manager (DM) stated food should be monitored for expiration dates. The DM stated all dietary staff members were responsible for ensuring expired foods were monitored and discarded. The DM stated the person storing or putting food away was responsible for ensuring food was properly labeled and dated. When asked about the unknown yellow substance, the DM stated it was turmeric, a special blend one resident asked to have provided with his meals. The DM stated he did not know which resident wanted the turmeric and stated it should be labeled. On 1/21/22 at 9:50 AM, the following items were present in the communal resident food refrigerator and freezer: * A container of almond milk, a sandwich, and a salad container were marked with a resident's name and dated 1/19. It was unclear if that was the date the items were put into the refrigerator or a use by date. * A Dutch Brothers orange smoothie with no name or date. * A box of Melona frozen juice bars in the freezer with no name or date. On 1/24/21 at 11:50 AM, the communal resident food refrigerator was observed to have leftovers in a container with a resident room number and marked U/B 1/23. The same sandwich and salad containers, dated 1/19 were in the refrigerator observed on 1/21/22. On 1/21/22 at 10:50 AM, the RD stated the communal resident food refrigerator was monitored by a tag team of both nursing and dietary staff. The RD stated nursing staff should mark resident food with the name or room number and expiration date when food is brought in by residents. The RD stated it was not clear whether the dates on food items were received dates or expiration dates. The RD threw out the unmarked Dutch [NAME]. smoothie, stating it was partially consumed and was not marked with anyone's name or date. The RD stated dietary staff should review the refrigerator contents for expired or unlabeled food each day when they stock the refrigerator.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents, their representatives, and families were updated regarding the number of new COVID-19 positive cases for residents and staff, the cumulative number of COVID-19 cases for residents and staff, and the mitigating factors the facility was used to help control/stop the spread of the virus by 5:00 PM the next day. This was true for all 58 residents who resided in the facility. This systemic failure had the potential to deprive the resident representatives and families of each of the residents in the facility of the extent of COVID-19 cases in the facility and the opportunity to advocate for the resident and assist the resident in choosing whether to remain in the facility. Findings include: The facility's policy for Notification and Reporting of Suspected or Positive COVID-19, dated June 2021, stated the facility electronically reported information about COVID-19 in a standard format, which included the following: * The facility electronically informed residents' representatives and families by 5:00 PM on the next calendar day following the occurrence of each single confirmed COVID-19 infection or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. * The notification must include information on mitigation actions implemented to prevent or reduce the risk of transmission, including if operations of the facility were altered. The notice must include any cumulative updates at least weekly. This policy was not followed. The facility's Residents' and Employees' COVID-19 positive test tracking report, dated 12/28/21 to 1/15/22, documented three staff members tested positive for COVID-19, as follows: * 12/28/21 - 1 housekeeper * 1/12/22 - 1 nurse * 1/15/21 - 1 CNA The Facility's Voice Broadcast Transcripts and residents' representatives and families' telephone logs, dated 12/28/21 to 1/15/22 included the following: * On 12/29/21, the Voice Broadcast Transcript documented the facility notified residents' representatives and families that one contract staff member tested positive for COVID-19 on 12/28/21. The staff member did not have symptoms and was sent home from the facility after working one shift. The staff wore a mask and eye protection the entire time when working in the facility. The Transcript documented the facility began COVID-19 testing protocols. The facility's Voice Broadcast Transcript did not include the COVID-19 cumulative updates. * On 1/12/22, the Voice Broadcast Transcripts documented the facility notified residents' representatives and families the facility had one staff member test positive for COVID-19 on 1/12/22. The staff member was not working at the time of the positive test and was not symptomatic on the last shift worked on 1/10/22. The staff member was removed from the schedule. The facility continued the outbreak protocols put in place. The facility's Voice Broadcast Transcript did not include the COVID-19 cumulative updates. * On 1/18/22, the Voice Broadcast Transcript documented the facility notified residents' representatives and families one more staff member tested positive on 1/15/22 for COVID-19. The Transcript documented the facility continued outbreak protocols. The facility did not notify residents' representatives and families by 5:00 PM the next calendar day after confirming one COVID-19 infection on 1/15/22. The facility's Voice Broadcast Transcripts also did not include information on mitigation actions implemented to prevent or reduce the risk of transmission and the COVID-19 cumulative updates. On 1/19/22 at 4:09 PM, the Administrator said he had the impression the facility was only required to notify residents' representatives and families weekly. The facility did not notify residents' representatives and families on 1/16/22 and 1/17/22. On 1/21/22 at 10:25 AM, the Administrator said the facility's policy required COVID-19 notification be completed by 5:00 PM the next calendar day. On 1/22/22 at 10:50 AM, CRN #2 said the Voice Broadcast Transcripts did not include the COVID 19 cumulative updates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a written notice of transfer was provided to a resident and/or their representative, and the local ombudsman was notified of residents being transferred out of the facility. This was true for 2 of 2 residents (#19 and #56) reviewed for transfers, and had the potential for harm if residents were not aware of or able to exercise their rights as members of a long-term care facility. Findings include: The facility's policy for Transfer or Discharge, Emergency, revised December 2012, documented if a resident was transferred emergently, a transfer form was sent with the resident, and the resident's representative or other family member was notified. The facility's policy for Transfer or Discharge Documentation, revised December 2012, documented an appropriate notice was provided to the resident and/or their representative. These policies were not followed. 1. Resident #19 was admitted to the facility on [DATE], with diagnoses which included multiple sclerosis (a potentially disabling disease of the brain and spinal cord) and neuromuscular dysfunction of the bladder (bladder problems due to disease or injury of the central nervous system or peripheral nerves). a. A Progress Note, dated 11/30/19 at 7:39 PM, stated Resident #19 was transferred to the hospital after experiencing blood in his urine, a change in level of consciousness, and murmured speech. There was no documentation in Resident #19's record which stated the facility provided written notification of the reason for the transfer to the hospital to Resident #19 and his respresentative. There was also no documentation in the record the Ombudsman was notified of Resident #19's transfer on 11/30/19. b. A Progress Note, dated 2/10/20 at 6:00 AM, documented Resident #19 was transferred to the hospital after experiencing increasing confusion, blood in his urine, and severe pain. There was no documentation in Resident #19's record which stated the facility provided written notification of the reason for transfer to the hospital to Resident #19 and his respresentative. There was also no documentation in the record the Ombudsman was notified of Resident #19's transfer on 2/10/20. c. A Progress Note, dated 2/14/20 at 4:09 PM, documented Resident #19 was transferred to the hospital after experiencing abdominal distention and abdominal pain. There was no documentation found in Resident #19's record which stated the facility provided written notification of the reason for the transfer to the hospitalto Resident #19 and his respresentative. There was also no documentation in the record the Ombudsman was notified of Resident #19's transfer on 2/14/20. On 3/5/20 at 10:11 AM, the Social Worker was interviewed. When asked if the facility had notified the Ombudsman regarding Resident #19's transfers to the hospital on [DATE], 2/10/20, and/or 2/14/20, she stated she did not know the Ombudsman was to be notified when a resident was transferred to the hospital. On 3/5/20 at 12:46 PM, the DON was asked if Resident #19 and/or his representative had been provided written notification of the reason for his transfer to the hospital on [DATE], 2/10/20, and/or 2/14/20. He stated the facility had not provided written notification of the reason for transfer for any of the transfers. 2. Resident #56 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses including acute and chronic respiratory failure with hypoxia (low oxygen level), end stage renal (kidney) disease, and obesity. Resident #56's discharge MDS assessment, dated 12/18/19, documented she had an unplanned discharge to the hospital. A Progress Note, dated 12/18/19 at 5:22 AM, documented Resident #56 became unresponsive when the CNAs were preparing to transfer her using the Hoyer (a mechanic lift). Her pulse was 168, blood pressure was 52/48, and temperature was 100.1 Fahrenheit. Resident #56's husband requested to transfer her to the hospital and 911 was called. Resident #56's record did not document the Ombudsman was notified of her transfer to the hospital. On 3/5/20 at 9:56 AM, the DON said the facility notified the Ombudsman monthly of transfer/discharges, and Social Services did that. On 3/5/20 at 10:02 AM, the Recreation Therapist, who also assisted with social service functions, said if there were concerns about a resident's discharge then she would call the Ombudsman, and otherwise she did not report it to the Ombudsman. The Recreation Therapist said she thought nursing staff reported transfer/discharges, and when she asked the DON about it he said he did not know anything about that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents upon transfer to the hospital. This was true for 2 of 2 residents (#19 and #56) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's admission Agreement, dated 5/27/17, contained a Bed Hold Policy, which stated A bed hold will be offered at the time of transfer to an acute hospital. If the bed hold is not completed upon discharge, Facility staff will contact the Resident regarding their decision to hold the bed. The Bed Hold Policy also documented the resident signed the admission Agreement, including the Bed Hold Policy, upon admission, and the Bed Hold Policy applied to all transfers and discharges. These policies were not followed. 1. Resident #19 was admitted to the facility on [DATE], with diagnoses which included multiple sclerosis (a potentially disabling disease of the brain and spinal cord) and neuromuscular dysfunction of the bladder (urinary bladder problems due disease or injury of the central nervous system or peripheral nerves involved in the control of urination). a. Resident #19's Progress Notes, dated 11/30/19 and 12/6/19, documented he was transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. There was no documentation in Resident #19's record which stated the facility provided written notification of the bed hold policy to him or his representative upon transfer to the hospital on [DATE]. b. Resident #19's Progress Notes, dated 2/10/20 and 2/13/20, documented Resident #19 was transferred to the hospital on 2/10/20 and re-admitted to the facility on [DATE]. There was no documentation in Resident #19's record which stated the facility provided written notification of the bed hold policy to Resident #19 or his representative upon transfer to the hospital on 2/10/20. c. Resident #19's Progress Notes, dated 2/14/19 and 2/19/20, documented Resident #19 was transferred to the hospital on 2/14/20 and re-admitted to the facility on [DATE]. There was no documentation in Resident #19's record which stated the facility provided written notification of the bed hold policy to him or his representative upon transfer to the hospital on 2/14/20. On 3/5/20 at 10:23 AM, the Administrator was interviewed. When asked if the facility provided written notification of the bed hold policy to Resident #19 or his representative when he was transferred to the hospital on [DATE], 2/10/20, and 2/14/20, the Administrator stated there was probably no documentation the facility's bed hold policy was provided to Resident #19 or his representative upon any of the transfers to the hospital. 2. Resident #56 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses including acute and chronic respiratory failure with hypoxia (low oxygen level), end stage renal (kidney) disease, and obesity. Resident #56's discharge MDS assessment, dated 12/18/19, documented she had an unplanned discharge to the hospital. Resident #56's Progress Note, dated 12/18/19 at 5:22 AM, documented she became unresponsive when the CNAs were preparing to transfer her using the Hoyer (a mechanic lift). Her pulse was 168, blood pressure was 52/48, and temperature was 100.1 Fahrenheit. Resident #56's husband requested to transfer her to the hospital and 911 was called. Resident #56's record did not document a bed hold notice was provided upon her transfer to the hospital. On 3/5/20 at 9:56 AM, the DON said residents were brought back to their same room in the facility if they were transferred to the hospital. The DON said he did not know where it would be documented the bed hold policy was provided to the resident. On 3/5/20 at 10:21 AM, the Administrator saidhe thought the bed hold notice was documented on the pink sheet that was sent to the hospital with the resident, and he was aware the bed hold notice was supposed to be provided to the resident upon transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure bathing was provided to meet residents' needs. This was true for 2 of 16 residents (#3 and #49) reviewed for ADL care. This created the potential for residents to experience skin breakdown and a negative effect to their psychosocial well-being when care was not provided as needed. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses which included stroke and dementia. A quarterly MDS assessment, dated 2/7/20, documented Resident #3 required extensive assistance with one staff member for bathing. Resident #3's ADL report for February 2020, documented there were no showers provided from 2/8/20 through 2/13/20 (6 days), and 2/15/20 through 2/23/20 (9 days). On 3/4/20 at 2:13 PM, RCM #1 stated Resident #3 did not receive a shower for 6 days from 2/8/20 through 2/13/20 and 9 days from 2/15/20 through 2/23/20. 2. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses which included diabetes mellitus and heart failure. A significant change MDS assessment, dated 2/4/20, documented Resident #49 received hospice services and required extensive assist with one staff member for bathing. Resident #49's care plan, revised on 1/31/20, documented she was to receive 2 showers per week from hospice health aides. Resident #49's ADL report for February 2020 documented there were no showers provided from 2/1/20 through 2/6/20 (6 days). There were no showers provided from 2/8/20 through 2/13/20 (6 days). The documentation showed no showers were provided from 2/18/20 through 2/28/20 (11 days). On 3/5/20 at 2:12 PM, RCM #1 stated Resident #49 did not receive a shower twice during the week of 2/3/20 and the week of 2/10/20. She stated Resident #49 did not receive 2 showers per week from 2/18/20 through 2/28/20 (11 days). She stated when hospice aides provided services they gave written documentation of resident cares to a licensed nurse and the documentation was either scanned into the resident's record or a progress note was completed in the resident's record. She was unable to find documentation hospice aides provided 2 showers per week as directed by the deliniation of cares. RCM #1 stated if hopsice aides do not complete resident cares, the facility was responsible to ensure the resident received ADL cares to meet their needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents received respiratory care as ordered by a physician. This was true for 2 of 2 residents (#51 and #107) reviewed for respiratory care. This failure created the potential for adverse outcomes related to low oxygen levels and infection from contaminants. Findings include: 1. Resident #51 was admitted to the facility on [DATE], with multiple diagnoses which included chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness) and obstructive sleep apnea (a sleep disorder that causes temporary stoppage of breathing during sleep). A quarterly MDS assessment, dated 2/6/20, documented Resident #51 was using oxygen therapy. A physician's order, dated 10/29/19, documented the following: * Check oxygen saturation every shift and as needed for acute respiratory failure. * Administer oxygen at 4 liters per minute via nasal cannula to maintain oxygen saturations equal to or greater than 90 percent for shortness of breath. On 3/2/20 at 10:50 AM, Resident #51's oxygen concentrator was set at 3 liters per minute, he was wearing a nasal cannula. On 3/3/20 at 3:16 PM, CNA #1 and CNA #2 stated during the evening shift, they set the oxygen liter flow to what the nurse told them to set it to. On 3/3/20 at 3:35 PM, the DON stated that CNAs were not to adjust oxygen settings. On 3/3/20 at 3:43 PM, Resident # 51's oxygen was set to 1 liter per minute. The DON came to the room and verified the setting was 1 liter per minute and stated that was not correct per his physician orders. 2. Resident #107 was admitted to the facility on [DATE], with multiple diagnoses including acute kidney failure. The facility's policy for Continuous Positive Airway Pressure (machine that uses mild air pressure to keep breathing airways open), undated, documented staff were to wash the mask in warm water and air dry, then store the mask and tubing in a plastic bag labeled with the resident's name and the date the tubing was pulled into use. This policy was not followed. A physician's order dated 2/28/20, documented the following for Resident #107's continuous positive airway pressure (CPAP) use: * CPAP with 2 liters of continuous oxygen at bedtime for obstructive sleep apnea. * CPAP-monitor every 2 hours during the night to assure equipment is in place. * CPAP-document oxygen liters per minute and saturations every night. *Oxygen CPAP tubing to be replaced every 3 months. * Empty water reservoir daily and wash mask one time a day A care plan, dated 2/28/20, directed staff to replace Resident #107's CPAP tubing every 3 months and to empty the water reservoir and wash the CPAP mask once a day. Resident #107's Treatment Administration Record (TAR), dated 3/1/20 through 3/4/20, directed staff to empty the water reservoir from her CPAP and wash the mask once daily. Resident #107's TAR did not include replacement of the CPAP tubing. On 3/2/20 at 9:50 AM, Resident #107's CPAP mask was observed attached to the CPAP tubing and the CPAP machine was laying on Resident #107's unmade bed. On 3/3/20 at 3:14 PM, Resident #107's CPAP mask was attached to the CPAP tubing and the CPAP machine was laying on the windowsill next to her bed. On 3/3/20 at 3:16 PM, CNA #1 and CNA #2 both stated they did not know who cleaned the CPAP masks. When asked if Resident #107's mask, which was sitting on the windowsill, was cleaned and they stated it was not. On 3/3/20 at 3:35 PM, the DON stated nurses or CNAs cleaned the masks. On 3/4/20 at 11:02 AM, RCM #1 stated CPAP masks should be cleaned when they were taken off residents in the morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents received appropriate monitoring while receiving psychotropic medications. This was true for 1 of 5 residents (Resident #22) reviewed for unnecessary medications when a resident received antidepressant medication without appropriate monitoring. This failure created the potential for harm if residents experienced adverse effects from unnecessary psychotropic medications. Findings include: The facility's policy for Psychotropic Management Guideline, dated October 2015, documented the following: * The facility routinely evaluated residents for behaviors and actively attempted to decrease or eliminate the use of psychoactive medications. * Residents were monitored daily for side effects and effectiveness of the medication. The facility's policy for Sleep Disorders, revised October 2010, documented the following: * Nursing staff described any sleep disturbance in detail. * Sedatives/hypnotics were prescribed judiciously, at the lowest possible dose for the shortest amount of time. * The physician and staff monitored the resident's progress with sleep, and adjusted interventions appropriately. These policies were not followed. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including stroke and insomnia (difficulty sleeping). Resident #22's quarterly MDS assessment, dated 12/21/19, documented he was cognitively intact, and he received antidepressant medication on 7 of the previous 7 days. Resident #22's physician orders documented trazodone (an antidepressant medication which may also help with sleep disorders) 150 mg (milligrams) at bedtime related to insomnia. The order started on 1/6/20. Resident #22's Medication Administration Records for January, February, and March 2020 documented the trazodone was administered as ordered. Resident #22's care plan documented he received a sedative/hypnotic medication and directed staff to monitor for side effects and effectiveness. The care plan directed staff to consult the appropriate medical provider if signs/symptoms of sleep deprivation persisted or became worse, and to determine Resident #22's usual sleep habits. Resident #22's record did not document his sleep was monitored prior to 3/4/20. On 3/4/20 at 2:41 PM, the DON said if a resident was taking trazodone for insomnia the resident's sleep should be monitored unless they had been taking it for a long time, then the monitoring might be discontinued if they were stable. The DON said there was no documentation Resident #22's sleep was being monitored. The facility was unable to provide documentation sleep monitoring was discontinued or not necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' records included an Advance Directive or documentation an Advance Directive was discussed or offered. This was true for 5 of 24 residents (#33, #47, #49, #51 and #107) whose records were reviewed for an Advance Directive. This failed practice created the potential for harm if residents' wishes regarding end of life or emergent care were not honored if they became incapacitated. Findings include: The State Operations Manual, Appendix PP, defines an Advance Directive as .a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. The State Operations Manual also states a Physician Orders for Life-Sustaining Treatment (POLST) is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an Advance Directive. The facility's Advance Directive policy, dated April 2008, documented the following: * Upon admission social services will provide written information to the resident concerning the right to formulate an Advance Directive. * Social Services will inquire about the existence of an Advance Directive. * Information about whether a resident has executed an Advance Directive shall be prominently displayed in the medical record. This policy was not followed. 1. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses which included diabetes mellitus Type 2 and heart failure. Resident #49's physician orders, dated 8/10/16, documented her code status was do not resuscitate. A care plan initiated on 6/6/17, documented Resident #49's Advance Directive would be reviewed quarterly, and as needed, with any changes to her condition. Resident #49's record did not include an Advance Directive, or documentation one was offered or discussed with her. On 3/3/20 at 1:53 PM, the Social Worker stated there was no documentation in Resident #49's record that an Advance Directive was discussed with her. 2. Resident #51 was admitted to the facility on [DATE], with multiple diagnoses which included chronic obstructive pulmonary disease (lung disease causing long term breathing problems and poor airflow) and congestive heart failure (a condition that affects the pumping power of heart muscles). Resident #51's physician order, dated 10/30/19, documented his resuscitation status was Full Code (a person will allow all interventions needed to get their heart started). A care plan, dated 2/5/20, documented Resident #51's Advance Directive would be reviewed quarterly, and as needed, with any changes to his condition. A Social Services progress note, dated 10/31/19, documented Resident # 51 did not have an Advance Directive. Resident #51's record did not include an Advance Directive, or documentation one was offered or discussed with him. On 3/3/20 at 1:53 PM, the Social Worker stated there was no documentation in Resident #51's record that an Advance Directive was discussed with him. 3. Resident #107 was admitted to the facility on [DATE], with multiple diagnoses including acute kidney failure. Resident #107's physician orders, dated 2/6/20, documented her code status was do not resuscitate. Resident #107's record did not include an Advance Directive, or documentation one was offered or discussed with her. On 3/3/20 at 1:53 PM, the Social Worker stated there was no documentation in Resident #107's record an Advance Directive was discussed with her. 4. Resident #33 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses including respiratory failure with hypoxia (low oxygen level) and hypertension (high blood pressure). Resident #33's physician orders documented his resuscitation code status was Full Code, and the order started on 1/6/20. Resident #33's quarterly MDS assessment, dated 1/10/20, documented he was cognitively intact. Resident #33's care plan documented his code status was Full Code. Resident #33's Physician Orders for Scope of Treatment (POST) documented he wished for his status to be Full Code with comfort measures, and it was signed by him on 11/1/19. The POST differed from the care plan, which documented Full Code with aggressive interventions. A Huddle Note, dated 11/4/19 at 9:11 AM, documented Resident #33 had an Advance Directive and a copy was to be obtained for his record. There was no documentation in Resident #33's record of an Advance Directive, or that one was discussed with him. On 3/3/20 at 2:33 PM, the Recreation Therapist, who also assisted with social service functions, said Resident #33 was on the list to have Advance Directives discussed with him, and only a POST was documented in his record. 5. Resident #47 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses including rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet). Resident #47's annual MDS assessment, dated 2/2/20, documented she was cognitively intact. Resident #47's physician orders documented her resuscitation code status was Full Code, and the order started on 9/8/15. Resident #47's care plan documented her status was Full Code, she had a POST, and directed staff to review her code status quarterly, and as needed, with her and her family. Resident #47's POST documented she wished for her status to be Full Code with aggressive interventions, and it was signed by her on 11/2/12. Resident #47's record did not contain an Advance Directive or documentation one was discussed with her. On 3/3/20 at 2:25 PM, the Recreation Therapist said Resident #47 was on the list to have Advance Directives discussed with her, and only a POST was documented in her record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised to accurately reflect toileting status and included related interventions, and quarterly care conferences were held. This was true for 3 of 16 residents (#3, #33, and #49) whose care plans were reviewed. This failure created the potential for harm if care was based on inaccurate care plan information. Findings include: The facility's policy for Care Plans-Comprehensive, revised October 2010, documented Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change[s]. The facility's policy for Care Plans, Goals and Objectives, dated April 2011, documented goals and objectives were reviewed or revised when the resident was readmitted to the facility and at least quarterly. These policies were not followed. 1. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses which included diabetes mellitus and heart failure. A significant change MDS assessment, dated 2/4/20, documented Resident #49 received hospice services and required extensive assistance of two staff members for bed mobility and toileting, Resident #49 was frequently incontinent, and was not on a urinary toileting program. Resident #49's care plan, initiated on 10/17/19, documented she was a candidate for scheduled toileting and was placed on an incontinent program to include toileting upon rising, before and after meals and at bedtime, and was to be continent at all times through the next care plan review date. Resident #49's record included documentation of her toileting, dated 2/1/20 to 2/29/20. A section for day shift, evening shifts, and a night shift included documentation of bladder function and type of toileting. Resident #49's toileting did not follow the interventions on her care plan for an incontinent program with specific times. On 2/3/20, 2/6/20 to 2/10/20, 2/13/20 to 2/16/20, 2/19/20, and 2/21/20 to 2/23/20, the documentation stated Resident #49 was incontinent and used briefs. Resident #49's care plan was not updated to reflect her current toileting status. On 3/5/20 at 2:24 PM, RCM #1 stated Resident #49's care plan should have been changed and was not. 2. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses which included stroke and dementia. Resident #3's care plan initiated on 12/4/19, documented she was on an incontinent program to include toileting upon rising, before and after meals, and at bedtime and to be continent at all times through the next care plan review date. A bowel and bladder evaluation, dated 2/7/20, documented Resident #3 was incontinent and pads and briefs were used daily. On 3/5/20 at 2:24 PM, RCM #1 stated Resident #3's care plan should have been changed to reflect her current toileting status and was not. 3. Resident #33 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses including aspiration pneumonia (pneumonia from inhaling food, liquid, or vomit into the lungs), respiratory failure with hypoxia (low oxygen level), and hypertension (high blood pressure). Resident #33's MDS assessments documented the following: * An admission MDS assessment, dated 11/8/19, documented he was admitted to the facility on [DATE] from the community. * A Discharge MDS assessment, dated 12/27/19, documented he was discharged to the hospital on [DATE]. * An Entry Tracking Record MDS assessment, dated 1/6/20, documented he re-entered the facility from the hospital on 1/6/20. A 72 Hour Huddle note, dated 11/4/19 at 9:11 AM, documented a care plan meeting was held with Resident #33, the Social Worker, and the MDS nurse. There was no documentation of other care plan meetings held with Resident #33 after 11/4/19. On 3/2/20 at 3:31 PM, Resident #33 said he never had care plan meetings with the facility. On 3/3/20 at 2:33 PM, the Recreation Therapist said Resident #33 was due for a care conference. On 3/4/20 at 10:03 AM, the DON said care plan meetings should be held at the 72 hour huddle (after admission) then quarterly, and the Interdisciplinary Team attended the care plan meetings. The facility did not provide documentation of other care conference meetings for Resident #33 other than the 72 hour huddle on 11/4/19.