Based on observation, interview, and record review, the facility failed to have a Dietary Manager available to ensure daily Dietary services were performed appropriately and efficiently resulting in residents not receiving meals according to their preferences, requests, needs, or the facility's menu; residents not being served in a timely and consistent manner; residents not receiving food at an appetizing temperature; and dry food not being stored under sanitary conditions. These failures applies to all 131 residents receiving food from the facility. Findings include: On 06/12/2025 at 9:51 AM, R1 stated, Yesterday, (Wednesday), they were serving fish for lunch. I asked for a cheeseburger instead and was still served the fish. I was told 'sorry we missed your nam'e, even though they have a list. R1 stated the food sometimes is served lukewarm. The facility's lunch menu for Wednesday (06/11/2025) of the week three menu cycle included: Fried Fish. On 06/12/2025 at 10:22 AM, R2 stated yesterday he requested a salad for lunch. They had him marked as no salad, although salad was not a part of the menu and he did not receive it. He requested a cheeseburger, and was told there were none, although they had cheese because they were making grilled cheeses and had burgers. He wanted the dinner being served, which was biscuits and gravy; they had him marked as wanting a burger, and the only reason he received the regular meal is because they were out of burgers. R2 stated, You never know what you'll be served until you receive it. R2 has asked them why even bother telling them what is being served. R2 stated food is sometimes warm and sometimes cold. R2 stated sometimes breakfast items are missing, such as being served cereal with no milk. On 06/12/2025 at 11:15, AM R3 stated the food served is not hot and is lukewarm. She was getting cold cereal for a while, but hasn't in the past week or so, she informed them she prefers yogurt for breakfast and was receiving it, but hasn't been getting yogurt because they're out of it. On 06/12/2025 at 12:39 PM, R3's lunch tray included a sloppy joe sandwich, fries, and sliced carrots. R3 had not touched her meal, and stated she was expecting pork for lunch and instead received her current meal. The facility's lunch menu for Thursday (06/12/2025) of the week three menu cycle includes Pork Chop with Gravy, Pinto Beans, Mixed Vegetables, and a Dinner Roll. On 06/12/2025 from 12:39 PM - 1:35 PM, eight meal trays were covered in plastic wrap with no lids on them, sitting on food carts that were covered in plastic covers. V10 (Certified Nursing Assistant) stated, Those trays are for residents who eat in their rooms, and the trays normally have lids on them. Three meal trays were covered in plastic wrap with no lids and no meal tickets sitting on food cart. A steam table in the dining room not in use. V10 stated, The steam table is fairly new, they used to serve food from the steam tables months ago. R1's meal tray arrived 20 minutes after meal service began, and two other residents sharing the table with him had already received their meals. V10 stated, (R1's) meal tray just arrived and confirmed dining service has had some challenges since the Dietary Manager left. R4's and R1's meal tickets stated cheeseburger, and they received a hamburger. R1 and R4 stated they were supposed to get a cheeseburger. V5 (Dietary Regional Consultant) stated they do have cheese in the kitchen, and she isn't sure why R1 and R4 did not get cheese on their burgers. At 1:14 PM, a test tray was delivered to the 2nd floor dining area by V5. The fries, carrots and sloppy joe on the test tray were not warm or hot, and were nearly cold, and therefore not appetizing. At 1:27 PM, V5 stated this week's menus are from the third week in the monthly menu cycle; they had to change the menu from the original pork based meal because the pork had just come in. On 06/16/2025 from 8:29 AM - 9:30 AM, V7 (Head Cook) stated the breakfast meal was supposed to include toast, however, they are out of toast and biscuits were served instead. Meal trays being prepared with biscuits. 3-4 plates at a time were prepared by V8 (Dietary Aide) with bacon, eggs, and a biscuit sitting on a side prep table for up to a minute before being covered and placed on a tray cart by V9 (Dietary Aide). V6 (Cook) and V8 stated, The trays without tickets last Thursday were for newly admitted residents, they didn't have anyone to enter the dietary information for those residents. V6, V8, and V9 stated Dietary duties have been challenging without a Dietary Manager, and there hasn't been one in two weeks, and all emphasized they really need the assistance of a Dietary Manager. V6 and V8 stated they ran out of tray lids last Thursday. V6 stated maintaining inventory has been more challenging without a Dietary Manager, and they have run out of items. V6 stated, There is only one hot box for meal trays which is used for the locked unit. Having a Dietary Manager helps ensure everything gets done efficiently and properly in the kitchen. V9 left the kitchen multiple times during tray prep. V6 stated, (V9) went to deliver the trays, there's usually another staff available to assist with that. V9 re-entered the kitchen with plastic cups and supplies during tray prep. V8 was waiting with multiple uncovered prepared plates for V9 to return to the kitchen. V8 stated a Dietary Manager helps ensure tickets are prepared and ready for meal service. V9 stated having a Dietary Manager ensures they have everything they need and don't have any disruptions in their duties, such as tray lids, silverware, coffee etc. V8 stated she believes they are about to run out of dish soap. V6, V8, and V9 all expressed the Dietary Manager typically ensures all of the Dietary supplies are available so they can perform their duties efficiently, and this has been difficult to maintain since no longer having a Dietary Manager. V8 stated the Dietary Manager also ensures other kitchen duties such as cleaning is done, so they can focus on other duties and make sure they are performed efficiently. V9 stated, Bread is stored on the bread rack; typically it comes in on Saturdays, however, we had not received a shipment this Saturday, which is why there is not really any bread on the bread rack. 4 loaves of bread and one large pack of hot dog buns were sitting on the bread rack. V8 stated when they had a Dietary Manager, everything was stocked. During tray preparation, the lid of the storage bin with oatmeal in it was left open when not in use. A scoop was lying in the sugar stored in the bulk bin. A scoop was left sitting on top of the rice storage bin. No holders for the scoops were near or inside the bulk bins. V5 (Dietary Regional Consultant) did not arrive to the kitchen at any time during tray preparation for breakfast. The facility's breakfast menu for Monday (06/14/2025) of the week four menu cycle includes Choice of Hot or Cold Cereal, Bacon, Scrambled Eggs, and Toast. On 06/16/2025 at 9:43 AM, R4's breakfast meal ticket notes included double portions at breakfast meal. R4's meal tray had one biscuit, two servings of eggs, multiple slices of bacon, and one bowl of grits. On 06/16/2025 at 9:31 AM, R3's Meal Ticket notes included two bowls of cold cereal/yogurt/fruit. R3's breakfast included one bowl of cold cereal, one bowl of hot super cereal/oatmeal, and no yogurt or fruit. R3 confirmed she was supposed to have two bowls of cold cereal. On 06/16/2025 at 9:45 AM, R2 was in the lobby area after breakfast waiting to be transported for an appointment. R2 stated during breakfast his bacon was cold, but it always is. On 06/16/2025 at 1:29 PM, V5 (Dietary Regional Consultant) stated she believes yogurt is served upon request, and confirmed yogurt is stored in the cooler and there was none currently. Observed there was no yogurt in the kitchen cooler. V8 (Dietary Aide) stated she noticed the scoops stored inside the sugar bulk bin and on top of the rice bulk bin; they shouldn't be there, everyone is just moving too fast. V8 confirmed staff are overwhelmed and overlooking things without a Dietary Manager. On 06/16/2025 at 2:51PM, V5 (Dietary Regional Consultant) stated she came in to the facility last Monday (06/09/2025) to assist since they let the Dietary Manager go. V5 stated V5 had concerns as well about the staff using plastic wrap to cover the meal trays; they were used because of the limited space on the top of the speed racks used for transporting meals. V5 stated she was only concerned about staff wasting plastic wrap, but didn't have any food safety concerns because the aides pass the trays very quickly. V5 stated a steam table is normally used for meal service ,however, the one in the dining area has the wrong voltage, so they are waiting for it to be replaced. V5 stated the steam table keeps the food nice and warm. V5 stated the speed racks don't hold temps as well as the hotbox, however they are passed out really quickly. V5 stated food temps should be palatable; it is subjective. V5 stated, If there is no holder inside the dry storage bins they should get a clean scoop every time. Technically, if the scoop handle is up, it's ok to store it inside the bulk bins, but it should not be sitting on top of the bin, and the bulk bin lid needs to be closed. When asked what might have contributed to staff making these errors in Dietary practices, V5 stated, I'm guessing they're in a hurry, not paying attention, and if the Dietary Manager observed these things, they would do in-services. V5 stated this last week has been kind of tumultuous because they lost a staff member and manager. V5 stated, I assume the Dietary meal tickets should be prepared right away after admission; this is done by nursing staff. If a resident was supposed to receive double portions for breakfast, this would include double portions of all meal items, so they should have had two biscuits, double the bacon portion, double the egg portion, and a double cereal portion of cereal, which includes two bowls. On 06/16/2025 at 3:55 PM, V1 (Administrator) informed that V14's (Former Dietary Manager) last working day was 06/04/2025. On 06/16/2025 at 5:47 PM, V1 (Administrator) reported the facility has total of 131 residents who are served food from the facility, and a total of 4 residents who do not receive foods orally. On 06/17/2025 at 2:33 PM, V5 (Dietary Regional Consultant) stated the notes section on a meal ticket is for general information such as double portions, likes and dislikes. V5 stated the Dietary staff needs the oversight of a Dietary Manager for kitchen operations, which is different from the medical side of signing diet orders. When asked what Dietary operations require the Dietary Manager's oversight, V5 replied, For example, I am filling in as a Dietary Manager, which includes ordering food supplies and dishware, monitor inventory and ordering these supplies as needed, making staff schedules, general day to day kitchen inspections including, ensuring general cleanliness is taken care of, food is stored correctly, menus and meal tickets are being followed, and making sure meals are served at an appropriate temperatures. V5 confirmed substitutions are listed on the meal tickets. The facility's Dietary Manager Job Description, received 06/17/2025, states: The CDM (Certified Dietary Manager) is responsible fore the daily operations of dietary department in accordance with facility policy and procedures as well as federal and sate regulations. They provide leadership and guidance to ensure that food quality, safety standards, and client expectations are satisfactorily met. They also maintain records of food, supplies, inventory levels, and equipment. These duties are also listed under the Essential Functions section of the Dietary Managers job duties. Food Service Management duties include: Inspect meals and ensure that standards for palatability, temperature, and serving times are met. Assure that foods are prepared according to menus. Sanitation and Food Safety duties include: Manage staff to ensure compliance with safety and sanitation regulations including safe storage of food. The Facility's Competency Check List for Dietary Manager, received 06/16/2025, includes: Ensures dietary staff are performing assigned tasks appropriately. Ensures dietary staff follow established infection control guidelines and food safety regulations. Ensures alternate meals are available upon request. Supervises the preparation and service of regular and therapeutic diets. Ensures foods served are palatable, and at the appropriate temperature. Ensures nutrition documentation/data collection is timely, accurate, appropriate, and in accordance with company guidelines and state requirements. The facility's Dry Food Storage Policy, received 06/16/2025, states: The purpose of the policy is To ensure dry food is stored in a safe, sanitary manner to provide the best food quality. Bins for food storage (flour, cornmeal, etc.) should be with tight fitting lids to prevent contaminations. No scoops are to be stored with food bins. The facility's Holding Foods Policy received, 06/16/2025, states: In part, Foods should be held at proper temperatures while remaining palatable. The facility's Resident Dining Services Policy, received 06/16/2025, states: The purpose of the policy is To ensure foods are appropriate temperatures, and meet the individual resident's needs. Residents seated together should receive meals at the same time (served by table) so that they may dine together.

Based on observation, interview, and record review, the facility failed to determine self-administration of medication was appropriate for a resident whose medication was left at the bedside for the resident to self-administer for one of one resident (R20) reviewed for self-administration of medications in sample of 26. Findings include: An order summary report, dated 12/3/2024, indicates R20 has diagnoses of atrial fibrillation, mood disorder, Hypertensive heart and chronic kidney disease, Cardiopulmonary disease, asthma, chronic respiratory failure, major depressive disorder, GERD, diabetes mellitus, and peripheral vascular disease. R20's has medication orders for sodium bicarbonate 650mg, tamsulosin cap 0.4mg, torsemide 20mg, tums chewable 500mg, omeprazole 20mg, citalopram hydrobromide 20mg, Eliquis 5mg, farxiga 10mg, finasteride 5mg, carvedilol 6.25mg, multivitamin with minerals. R20's care-plan, dated 7/18/2024, indicates an intervention to give medications as ordered by a physician and monitor and document for side effects and effectiveness. On 12/3/2024 at 11:00 AM, R20 said, I didn't take my medication because I do not want to take my water pill. I have some business to take care of this morning. I always ask them to leave it I'll take my medication as soon as my business is completed. On 12/3/2024 at 11:05 AM, V8 (Licensed Practical Nurse-LPN) said, I should have stayed until (R20) consumed his medication and (R20) should be assessed for medication-administration. On 12/3/2024 at 11:10 AM, V9 (Unit Manager) said R20's medication should not be at the bedside without a medication assessment completed indicating R20 can self-medicate. On 12/5/2024 at 10:30 AM, V2(Director of Nursing-DON) said, I expect all residents that have medication at the bedside to have a self-administration assessment completed. Facility Policy: Self-Administration of Medications - Effective 10/25/2014 Policy: To maintain the resident's highest level of independence residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is prescriber; s order to self-administer. Procedure: If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident call light was within reach. This deficiency affects two (R46, R72) of three residents in the sample for 26 reviewed for accommodation of needs. Findings include: 1. R72 was admitted on [DATE], with diagnoses listed in part but not limited to cerebral infarction, covid-19, unspecified asthma, history of falling. R72 has a focus care plan for at risk for falls related to cerebral infarction, asthma, congestive heart failure. Intervention dated 8/19/24 -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 12/03/24 at 10:23 AM, R72 observed in room, in bed, and call light observed on floor behind privacy curtain. On 12/03/24 at 10:29 AM, V16 (Certified Nurse Aide) verified the call light was not within reach, and said R72 should have it next to her in bed in case she needs assistance to call for help. 2. R46 was admitted on [DATE], with diagnoses listed in part but not limited to unspecified asthma, syncope and collapse, congestive heart failure. R46's has a focus care plan of falls related to lymphedema, congestive heart failure, asthma, headache, chronic kidney disease, syncope and collapse, renal failure impaired vision with intervention dated 7/29/24- Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 12/04/24 at 10:59 AM, R46 observed in bed, alert, able to communicate needs, observed call light was behind bed on the floor. On 12/04/24 at 11:04 AM, V6 (Licensed Practical Nurse) said, (R46) is totally dependent on staff, she is unable to ambulate. If she needs assistance then she can pull call light for assistance. V6 entered room and verified call light was not within reach of the resident. V6 said she will need call light within reach in case she needs help, since she is in her room and away from staff. On 12/04/24 at 1:07 PM, V2 (Director of Nursing) said all call lights should be placed within resident reach for assistance, and all call lights should be answered timely. Facility's policy on Answering the Call light revised 8/2008. Purpose: The purpose of this procedure is to respond to the resident's requests and needs. 4. Be sure that all call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 8. Answer the resident's call as soon as possible.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibits prevention of resident abuse. This deficient practice 3 of 5 residents (R29, R41, R123) reviewed for abuse prevention program in a sample of 26. Findings include: On 12/5/2024 at 11:45 AM, R29 was noted with admission date of 11/13/2024 and Criminal History Information Response Process was initiated on 11/20/2024. R41 was noted with admission date of 11/1/2024 and Criminal History Information Response Process was initiated on 11/4/2024. R123 was noted with admission date of 11/2/2024 and Criminal History Information Response Process was initiated on 11/4/2024. On 12/5/2024 at 12:24 PM, V18 (Admissions) stated Criminal History Information Response Process (Background check) is done within 72 hours of admission, and is impossible to do within 24 hours, because V18 does not work after hours and on weekends. V18 said they have no policy on running and checking Criminal History Information Response Process. On 12/5/2024 at 02:15 PM, V1 (Administrator) stated all new admissions need to have the Criminal History Information Response Process completed within 24 hours of admission. On 12/6/2024 at 12:10 PM, V1 stated Admissions is responsible for ensuring Criminal History Information Response Process (Background check) was done within 24 hours of admission. V1 also stated failure to complete screening on a timely manner on admission puts other residents at risk for danger. Review of undated policy and procedure, titled: Abuse Policy and Prevention Program indicated Pre-admission Screening of Potential Residents - Illinois only, This facility shall check the criminal history background for any resident seeking admission to the facility in order to identify previous criminal convictions. This facility will request a Criminal History background Check within 24 hours after admission of a new resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to submit information for preadmission screening and resident review for level l Preadmission screening and Resident Review (Preadmission screening resident review PASRR) and for a level ll evaluation for 1 of 4 resident's (R20) reviewed for PASRR in a sample of 26. Findings include: An order Summary Report indicates R20 has diagnoses of Post traumatic stress disorder, Unspecified Mood (Affective) Disorder, insomnia due to other mental disorder, major depressive disorder. On 12/5/2024 at 12:10 PM, V23 (Unit Manager) said, (R20) has very manipulative behavior. On 12/5/2024 V1 (Administrator) said, I do not have a Level 1 or a Level ll (PASRR) screening for (R20). I know all residents under [AGE] years of age should have a screening, and if indicated a level ll, but I do not have it. On 12/6/2024, V18 (Admissions Director) said, I am responsible for obtaining a preadmission screening and (R20) was grandfathered in. I was not aware I had to do a PASRR level ll (two). On 12/6/2024, V24 (Social Services Director-SSD) said, I did not know (R20) had a mental illness diagnosis. I will immediately request a PASRR ll (two) and provide the correct services needed. He does have very manipulative behavior and I will care plan and notify the staff to chart behaviors. Facility Policy: PAS Screening 1/20/2024 General: I n accordance with Illinois regulatory standards and recommended practices, this organization requests level l (one) and Level 2 (two, where applicable) Pre-admission screening documents prior to the individual's at the facility. Procedure: 1. A facility representative shall request the complete screening packet from appropriate screening agency/referral source.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow manufacturer's recommendation in using low air loss mattress to resident who has stage 4 pressure ulcer. This deficiency affects one (R6) of three resident in the sample of 26 reviewed for Pressure ulcer Management. Findings include: R6 was admitted on [DATE], with admitting diagnoses of Dementia, Type 2 Diabetes mellitus, Peripheral Vascular Disease, Acquired absence of left leg below knee. R6's active physician sheet indicated: Resident to have alternating pressure air mattresses to promote wound healing. Right hip- cleanse with normal saline, pat dry, apply xeroform and cover with a bordered gauze 3 times a week and PRN (as needed). Right buttocks- cleanse with normal saline, pat dry, apply xeroform and cover with a bordered gauze 3 times a week and PRN. R6's comprehensive care plan indicated: She has re-opened stage 4 pressure ulcer on right hip and right buttocks related to history of pressure ulcers and immobility. R6's admission Braden scale assessment for prediction of pressure sore risk, dated 8/4/24, and most recently done 10/2/24, indicates that she is at risk. R6's most recent wound assessment done by wound care physician, dated 12/3/24, indicated Stage 4 pressure wound of right hip full thickness and non-pressure wound of right lateral buttocks with partial thickness. On 12/4/24 at 9:59AM, R6 was lying in bed on low air loss (LAL) mattress. V17, Licensed Practical Nurse (LPN), said \R6 has pressure ulcers on Right buttocks and right hip. V17 lifted the top linen and observed a cloth pad and flat sheet over the LAL mattress. R6 was wearing disposable adult brief. V17 said R6 should only be on flat sheet over the LAL mattress. On 12/4/24 at 11:50AM, V4, Wound Care Nurse, performed wound care treatment to R6's stage 4 pressure ulcer on right hip and right buttocks. V4, WCN, said residents on low air loss mattress should only be on flat sheet over the mattress, as manufacturer's recommendation of avoiding multiple layers of linen of the mattress. The multilayers of linen will impede the purpose of the LAL mattress. On 12/4/24 at 1:00PM, V4, WCN, said they don't have manufacturer's literature recommendation for using low air loss mattress. On 12/5/24 at 9:28AM, V2, Director of Nursing (DON), said residents on LAL mattress should only have flat sheet over the mattress as manufacturer's recommendation. Facility's policy on Mattress use, reviewed January 2024, indicates: General: To provide a statement on the types of mattresses that are standard in the facility. Guideline: 3. Information regarding the mattresses is based on the manufacturer's literature. Facility's policy on Skin care prevention, reviewed January 2024, indicated: General : All residents will receive appropriate care to decrease the risk of skin breakdown. Guidelines: 15. For residents who are bed bound or chair bound, a chair cushion and pressure reducing mattress is needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R21's diagnosis indicates R21 has a history of repeated falls. R21's care plan focus, dated 7/22/2024, indicates R21 is at risk for falls related to pain, hemiplegia, and hemiparesis, seizures, and hypertension, and an intervention to provide a floor mat while in bed. On 12/3/2024 at 11:35 AM, R21 was in bed, and his fall mat was between the clothes cabinet, and not on the floor next to the bed. On 12/3/2024 at 11:37 AM, V8, LPN, said, (R21) is a fall risk and had a fall recently. (R21's) fall mat should be on the floor beside his bed. On 12/5/2024, V2 (Director of Nursing-DON) said R21 is a fall risk and should have a fall mat next to his bed, and she expects the staff to follow the fall interventions for each resident. Facility's policy on Managing Falls and Fall risk revised August 2008 indicated: Policy statement: Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Prioritizing approaches to managing falls and fall risk. 1. The staff with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. 6. Staff will identify and implement relevant interventions to try to minimize serous consequences of falling. Based on observation, interview, and record review ,the facility failed to implement fall preventive measures for a resident who has history of falls. This deficiency affects two (R21 and R56) of three residents in the sample of 26 reviewed for Fall prevention management. Findings include: 1. R56 was admitted on [DATE], with diagnoses listed in part but not limited to Chronic Obstructive pulmonary disease (COPD), Cognitive communication deficit, adult failure to thrive, Difficulty walking. R56's admission Fall assessment and most recent assessment dated [DATE], indicated she is at risk for fall. R56's comprehensive care plan indicated she is at risk for falls related to COPD, Respiratory failure. R56's unwitnessed fall incident, dated 11/26/24 at 6:50 PM, indicated: The resident was found lying on the floor on the side of her bed. She stated that she was getting up to use the bathroom. She was sent to the hospital for evaluation. Fall investigation/Root cause analysis was done. New care plan intervention in placed was applying bilateral floor mat when she is in bed to prevent from injury. On 12/3/24 at 11:20AM, R56 was lying in a side lying position, closer to the edge of right side of the bed. The bed was not in lowest position. The bed was approximately 30 inches from the floor. The left side of the bed was pushed to the wal,l and the right side of the bed has a floor mat. V17, Licensed Practical Nurse/LPN, said R56 is high risk for falls due to recent falls. V17 said R56's bed should be in the lowest position as part of fall prevention measures. V17 adjusted the bed to its lowest position using the bed control located at the foot part of the bed. On 12/4/24 at 9:37AM, V2 Director of Nursing (DON) said residents with floor mats should have their bed on the lowest position as part of fall prevention measures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to followa a physician's order for oxygen administration. This deficiency affects one (R96) of three residents in the sample of 26 reviewed for oxygen management. Findings include: R96 was admitted on [DATE], with diagnoses listed in part but not limited to chronic obstructive pulmonary disease, unspecified asthma, unspecified chronic bronchitis, hypoxemia, dependence on supplemental oxygen. Active physician order sheet indicates: Change oxygen tubing weekly every night shift, Oxygen @ 4LPM (liters per minute) per nasal cannula, continuously. On 12/03/24 at 10:42 AM, R96 was observed in dining area, sitting in wheelchair with oxygen concentrator @ 6LPM (liters per minute) via nasal cannula, and no date or label on oxygen tubing. On 12/03/24 at 10:45 AM, V13 (Registered Nurse) verified R96 was receiving oxygen at 6LPM (liters per minute) via nasal cannula. V13 verified R92's physician order states R96 should be receiving oxygen at 4LPM (liters per minute) via nasal cannula. V13 also said oxygen tubing should be changed weekly and dated to verify when the last time it was changed. On 12/05/24 at 1:07 PM, V2 (Director of Nursing) said R96 can potentially be at risk for carbon dioxide levels to be high when administering higher levels of oxygen. V2 said her expectations for all nurses is to follow physician's orders for oxygen administration, and to change oxygen tubing as ordered with date and label on tubing. Facility's policy on Oxygen Administration- Revised 3/2024. Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Steps in the Procedure 5. Start the flow of oxygen as ordered. 18. Make sure the oxygen humidifier jar is labeled properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to act upon and implement medication recommendations in a timely manner. This deficiency affects two (R56 and R114) in the sample of three residents in the sample of 26 reviewed for Pharmacy medication review. Findings include: 1. R114 was admitted on [DATE], with diagnoses listed in part but not limited to Alzheimer's disease, Fracture of right femur, Abnormality of gait and mobility, Repeated falls. R114's active physician order sheet indicated Aricept (Donepezil HCl) tablet 5mg give 1 tab by mouth one time a day for dementia ordered date 10/25/24. November 2024 indicated Aricept 5mg (Donepezil) 1 tablet by mouth given at 9AM daily. R114's Pharmacist drug regimen review, dated 11/11/24, indicated: Please take the following action described below. See report. R114's Pharmacist recommendation note to attending physician, dated 11/11/24, indicated, This resident has an order of Aricept (Donepezil) at 9am. Aricept should be dosed at bedtime per the manufacturer and can cause syncope, dizziness and fatigue which can contribute to falls as well as other adverse events. Please consider giving Aricept (donepezil) at bedtime. The physician response marked agreed, dated 12/4/24. On 12/3/24 at 11:08AM, R114 was observed up in wheelchair by the nursing station. R114 was closely supervised due to high risk for fall. 2. R56 was admitted on [DATE], with diagnoses listed in part but not limited to Chronic obstructive pulmonary disease, Cognitive communication deficit, adult failure to thrive, Unsteadiness on feet, Difficulty walking. R56's active physician order sheet indicated Aricept (Donepezil HCl) tablet 5mg give 1 tab by mouth one time a day for dementia, ordered 8/23/24. November 2024 indicated Aricept 5mg (Donepezil) 1 tablet by mouth given at 9AM daily. R56'sPharmacist drug regimen review, dated 11/11/24, indicated: Please take the following action described below. See report. R56's Pharmacist recommendation note to attending physician, dated 11/11/24, indicated, This resident has an order of Aricept (Donepezil) at 9am. Aricept should be dosed at bedtime per the manufacturer and can cause syncope, dizziness and fatigue which can contribute to falls as well as other adverse events. Please consider giving Aricept (donepezil) at bedtime. The physician response marked agreed, dated 12/4/24. On 12/3/24 at 11:16AM, R56 was observed lying in bed, not in lowest position. Floor mat on right side of the bed. On 12/4/24 at 9:37AM, V2, Director of Nursing (DON), said the Pharmacist comes on a monthly basis to conduct residents medication record review. The recommendations made were given to DON on the day the review was conducted. The DON then will give to the unit managers to notify resident's physician of pharmacist recommendation and implement as ordered. They should act upon it within the same day. Requested for Pharmacist recommendation response for R56 and R114, dated 11/12/24. On 12/4/24 at 1:00PM, V2, DON ,provided copy of pharmacist recommendation response for both R56 and R114. On 12/4/24 at 1:24PM, V2, DON, said, It was not acted upon immediately. Both (R56's) and (R114's) primary care physician were notified of pharmacist recommendation when surveyor follow up for the recommendation made last 11/11/24. Facility's policy on Documentation and communication of consultant pharmacist recommendations effective date 10/25/14 indicates: Policy: The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapy are communicated to those with authority and or responsibility to implement the recommendations and responded to an appropriate and timely fashion. Procedures: A. A record of the consultant pharmacist's observation and recommendations is made available in an easily retrievable form to nurses, physicians, and the care planning team. This should include: 1) Documentation of the date each medication regimen review is completed on appropriate form and notation of the findings in the medical record or other designated site. 3) The consultant pharmacist documents potential or actual medication-related problems, irregularities and other medication regiment review findings appropriate for prescriber and or nursing review. B. Comments and recommendations concerning medication therapy are communicated in a timely fashion. C. Recommendations are acted upon and documented by the facility staff and or the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have appropriate diagnosis for resident receiving anti-psychotic medications. This deficiency affects one (R110) of three residents reviewed for Psychotropic medication management. Findings include: R110 was admitted on [DATE], with diagnoses listed in part but not limited to Hemiplegia and hemiparesis following non traumatic intracerebral hemorrhage affecting right dominant side, Aphasia, Vascular dementia with agitation, Anxiety disorder, Depression. R110's active physician order sheet indicates Risperdal (Risperidone) oral tablet 0.5mg give 1 tablet by mouth one time a day for Vascular Dementia for agitation, ordered 10/11/24. R110's comprehensive care plan did not address the anti-psychotic medication R110 is receiving. No care plan formulated for usage of anti-psychotic (Risperdal). No qualifying diagnosis. R110's AIMS (Abnormal Involuntary Movement Scale) was completed by Unit Manager/Psychotropic Nurse dated 12/4/24, after surveyor requested documentation. No admission baseline AIMS assessment was done upon admission. R110's most recent Physician assistant psychotropic note, dated 9/19/24, indicated follow up for Depression and Anxiety. No indication of addressing usage of anti-psychotic medication (Risperdal) in the psychiatrist notes and no GDR (gradual dose reduction) documentation. No behavioral symptoms monitoring documented in medical records. On 12/3/24 at 11:30AM, R110 was lying in bed. He was alert and responsive, with slurred speech. V110 keeps verbalizing Ohio during conversation. V17, LPN ( Licensed Practical Nurse), said R110 is from Ohio, and was transferred here to Illinois closer to his family. On 12/4/24 at 12:46PM, V9, Unit Manager /Psychotropic Nurse, said she is responsible for residents on psychotropic medications. V9 said V21, MDS Coordinator, is responsible for the appropriate diagnosis for usage of specific anti-psychotropic medications and development of care plan. V9 said AIMS assessment is done for prior to start of resident on anti-psychotic as baseline assessment. On 12/4/24 at 1:31PM, V21, MDS/Resident Assessment Coordinator, said R110 does not have qualifying diagnoses for usage of anti-psychotic (Risperdal). The qualifying diagnoses for using Risperdal (anti-psychotic medication) are Schizophrenia and Psychosis. V21 said she just uses the diagnosis listed in R110's medical records and MDS/resident assessment, which is non-Alzheimer's dementia, Anxiety and Depression. On 12/5/24 at 12:05PM, requested behavioral symptoms monitoring for the usage of anti-psychotropic medication (Risperdal) as indicated in the policy. V2 said they just revised their policy last September, and it has not been implemented yet. Facility's policy on Behavior and Psychotropic Medication Management Guidelines revised 9/2024 indicates: Purpose: To promote and provide the highest practicable quality of life and a safe environment for residents and staff. Procedure: a. If psychotropic medications are needed when behaviors are harmful to self and others or interfere with function or care, complete a risk and benefits to review with the resident and or resident representative. b. Baseline assessment for abnormal involuntary movements, completed every 6 months and with each dose reduction and cessation of psychotherapeutic medication: AIMS c. If gradual dose reductions are not deemed clinically appropriate documentation regarding contraindication is completed and updates as required using this form in PCC 7. a. Complete behavior program review to document for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure hospice coordinated communication and plan of care are available and accessible to facility staff. This deficiency affects one (R177) of three residents in the sample of 26 reviewed for Hospice care services. Finding include: R177 was admitted on [DATE], with diagnoses listed in part but not limited to Alzheimer's disease, Malignant neoplasm of stomach. Active physician order sheet indicates that she is on hospice care upon admission. R177's comprehensive care plan indicates she is receiving end of life services with admitting diagnosis of Malignant neoplasm of stomach. No intervention was written in care plan. On 12/3/24 at 11:16AM, R177 was lying in bed, with oxygen via nasal cannula at 3 liters per minute (LPM). She has an indwelling catheter. She was confused, and needs total care with activity of daily living and transfers. V17, Licensed Practical Nurse, said she is on hospice care. On 12/4/24 at 10:12AM, V19, Social Service (SS), said Social Services, Admissions, and the clinical/nursing team coordinates with hospice services. V19 said they have hospice binder for R177. Review R177's hospice binder only had nursing. No other documents observed. V19 said she does not know why the hospice documentation was not available in R177's hospice binder. V19 said she will follow up with hospice services. On 12/4/24 at 10:20AM, V20, Medical records, said she has not uploaded any documents from hospice services for R177 to her electronic medical records. On 12/4/24 at 11:00AM, V1, Administrator, R177's hospice binder should have referral/admission packet, Hospice consent/agreement, Hospice certification, Plan of care, Level of care, and medication list. On 12/4/24 at 1:20PM, V2, Director of Nursing, provided copies of facility's hospice policy and hospice provider agreement contract to the facility. The hospice service provider representative did not sign the contract, only V1, Administrator, signed the contract, dated 12/1/24. Per facility's policy, both hospice representative and facility's representative should sign the contract before hospice care is provided. Facility's policy on Hospice Care, revision date 1/2024, indicates: General: To provide guidance on how hospice services will be administered within the facility. A written agreement with the hospice that is signed by an authorized representative of the hospice provider and an authorized representative of the LTC facility before hospice care is furnished. Purpose: Ensure that the hospice services meet the professional standards and principles that apply to individuals providing services in the facility and to the timeliness of the services. Protocol: 2. The hospice's responsibilities for determining the appropriate hospice plan of care 3. The Services the LTC facility will continue to provide based on each resident's plan of care. 4. A communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. Agreement to provide hospice services to facility residents, dated 12/1/24, indicates: I. Hospice Services: Hospice shall provide the following services in a safe and effective manner through qualified personnel to facility resident who are eligible for services in accordance with the IDT plan of care and CMS regulations and who elect to receive services from hospice, in accordance with the following: F. Hospice shall provide facility with a copy of Resident's plan of care and the hospice RN shall coordinate its implementation with the facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices, such as hand hygiene and used of personal protective equipment (PPE), were performed during enteral feeding assessment, and failed to ensure the urinary catheter tubing and drainage bag was not touching the floor for infection control. This deficient practice has the potential to affect 1 of 3 residents reviewed for enteral feeding procedure (R51) and 1 of 2 residents reviewed for urinary catheter management (R177) in a sample of 26. Findings include: 1. R1's records indicate: Order Summary Report: Diagnoses: Gastrostomy Status, Dysphagia, Oropharyngeal Phase Order date 6/20/2024: Enteral Feed order every shift. Care Plan: Focus: R51 requires Enhanced Barrier Precaution d/t G-tube. On 12/4/2024 at 9:47 AM, V9 (Licensed Practical Nurse) entered R51's room, which displayed signage for Enhanced Barrier Precautions (EBP). V9, without performing hand hygiene, put her gloves on and proceeded to the room without wearing the required PPE gown. V9 assessed R51's tube feeding stoma and its surrounding area, directly touching R51 skin. After the assessment, V9 removed her gloves then exited the room, without performing hand hygiene despite a hand sanitizer dispenser being available on the wall in the hallway. On 12/4/2024 at 10:35 AM, V2 (Director of Nursing/DON) stated, PPE should be worn in an EBP room and when providing direct care like enteral feeding (Gastrostomy/G-tube) assessment. Hand hygiene should be done before and after care. On 12/5/2024 at 10:32 AM, V3 (Infection Preventionist) stated, EBP is an extra precaution used for residents with invasive lines like G-tube. Staff need to wear PPE- gown and gloves and should perform hand hygiene before donning and after removing PPE. Policy and Procedure: Hand-Washing/Hand Hygiene Policy, Effective Date: March 2020 Policy: It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids. Policy Specifications: 4. When hands are not visibly soiled, employees may use an alcohol-based hand rub (foam, gel, liquid) containing at least 60% alcohol in all of the following situations: a. before direct contact with residents b. after direct contact with a resident but prior to direct contact with another resident c. before donning gloves h. before and after putting on and upon removal of PPE, including gloves i. after contact with resident's intact skin k. after contact with objects such as medical devices or equipment in the immediate vicinity of a resident that may be potentially contaminated m. after removing gloves. Review of the Centers for Disease Control, dated 7/12/22, titled Implementation of Personal Protective Equipment (PPE) Use in Nursing homes to prevent Spread of Multidrug-resistant organisms (MDROs) indicated Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities .Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. 2. R177 was admitted on [DATE], with diagnosis listed in part but not limited to Alzheimer's disease, Malignant neoplasm of stomach. R177's active physician order sheet indicates indwelling catheter Fr16 10cc balloon for Gastric Cancer. On 12/3/24 at 11:16AM, R177 was lying in bed, with indwelling catheter drainage bag and tubing touching the floor. V17, Licensed Practical Nurse/LPN said the urinary catheter tubing and drainage bag should not be touching the floor for infection control. On 12/4/24 at 9:37AM, V2, Director of Nursing, said,For infection control protocol, the urinary drainage bag and tubing should not be touching the floor. Facility's policy on Urinary Catheter Care, revised September 2005, indicates: Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract. General Guidelines: 11. Be sure the catheter tubing and drainage bag are kept off the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. R108 is a 61 year male admitted with diagnoses not limited to hypotension, pulmonary hypertension, anemia, major depression, psychotic disturbance, mood disturbance, and anxiety. Care Plan, dated 8/16/2024, indicated R108 was care planned for oxygen therapy administration. On 12/3/2024 at 10:45AM, R108 was lying in bed. R108 was on oxygen via nasal cannula at the rate of 3 liters per minute. On 12/4/2024 at 11:00 AM, V8 (Licensed Practical Nurse) noted R108 was on oxygen via nasal cannula at the rate of 3 liters per minute. On 12/4/2024 at 11:02 AM, reviewed R108's physician order sheet (POS) with V8, and no oxygen order was indicated. V8 said R108 should have oxygen order before R108 receives oxygen therapy. On 12/4/2024 at 12:22 PM, V2 (Director of Nursing/DON) said R108 should have order for oxygen administration. On 12/4/24 at 9:37AM, V2 Director of Nursing (DON) said they administer medication as prescribed by the physician according to professional standards. V2 added no medication is left at bedside unless ordered by physician. On 12/5/24 at 9:28AM, V2, DON, said residents on enhance barrier precaution and oxygen usage should have a written physician order as a standard of practice. Facility's policy on Storage of Medications effective, dated 10/25/14, indicates: Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Facility's policy on Medication Administration policy, effective date March 2014, indicated: Policy specification: 1. Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates. 2. All licensed nurses assigned the responsibility of administering and recording of medications must meet the requirements of the state in which the facility operates. Facility's policy on Medication and treatment order policy, effective date [DATE], indicates: Policy: To establish guidelines for ordering drugs and biologicals. Policy specifications: 6. Order of medications must include: a. Name of physician giving the order b. Date and time the order was received c. Signature of licensed personnel receiving/transcribing the order d. Name and strength of the drug e. Dosage and frequency of administration f. Form or route of administration Facility's Oxygen Administration, revised March 2024, indicates: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders of facility protocol for oxygen administration. Facility's policy on Enhanced barrier precautions, revised 3/21/24, indicated: Guideline: It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism. Enhanced Barrier precautions refer to the us of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) Based on observation, interview, and record review, the facility failed to obtain a physician order for the administration of medication, oxygen and enhance barrier precautions. This deficiency affects all five (R14, R41, R56, R108, and R177) residents in the sample of 26 reviewed for Professional Standards of Practice. Findings include: 1. R177 wass admitted on [DATE], with diagnoses listed in part but not limited to Alzheimer's disease, Malignant neoplasm of stomach. Active physician order sheet indicated EBP (Enhanced barrier precaution) due to urinary catheter, dated 12/3/24. Order was written after surveyor inquired. On 12/3/24 at 11:00AM, R177 was on enhanced barrier precaution (EBP) set up. V17, LPN (Licensed Practical Nurse), said R177 is on EBP due to indwelling catheter. On 12/4/24 at 10:06AM, R177 was lying in bed. She was confused. Observed medication ointment placed on 30ml medication cup, not labeled, at bedside. V17, LPN, said, It's probably barrier cream left by treatment nurse. No medication should be left at bedside. 2. R14 was admitted on [DATE], with diagnoses listed in part but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Contractures on left hand and elbow, Dysphagia, Dementia, Need for assistance with personal care. Active physician order sheet does not indicate order for Polyethylene glycol 400 1% lubricant eye drop solution. On 12/3/24 at 11:10AM, R14 was lying in bed with entire right arm brace/splint applied. Observed R14 with right periorbital edema. Observed eye medication at bedside tray table indicated Dry eye. Polyethylene glycol 400 1% lubricant eye drop solution. R14 said he used the medication for dryness and irritation. He called the nurse to apply the medication to his both eyes. V17, LPN, said they give the medication whenever R14 requests it. V17 also stated R14 does not have order for it, so they don't need to document it. V17 said, It is okay to have eye medication at bedside, but not oral medication. V17 said R14 has multiple glaucoma eye medications for his eye. They keep those medications with physician orders in the medication cart, and document when they give it. 3. R56 was admitted on [DATE], with diagnoses listed in part but not limited to Chronic obstructive pulmonary disease, Asthma with acute exacerbation, adult failure to thrive. Active physician order sheet indicated order for oxygen at 3LPM via nasal cannula as needed may be administered for SOB (Shortness of breath) or oxygen saturation below 92 % ordered on 12/3/24, after surveyor inquired. On 12/3/24 at 11:20AM, R56 was lying in bed with oxygen via nasal cannula at 3LPM (liters per minute). 4. R41 was admitted on [DATE], with admitting diagnoses listed in part but not limited to Cerebral infarction, Dysphagia, Dementia, Gastrostomy, Congestive heart failure, Acute Kidney failure. Active physician order sheet indicated order for enhanced barrier precaution related to gastric tube and oxygen at 2 LPM per nasal cannula, both ordered on 12/3/24, after surveyor inquired. On 12/3/24 at 11:30AM, R41 was observed on enhanced barrier precaution. He was lying in bed with enteral feeding of Nepro 1.8 at 55ml /hr. He was on oxygen via nasal cannula at 3 LPM (liters per minute). V17, LPN, said R41 was on EBP due to enteral/Gastric feeding.

Based on interview and record review, the facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program effectively identified quality deficiencies and described how the facility would evaluate the effectiveness of corrective actions and performance improvement activities to address repeated deficiencies regarding infection control. This deficient practice had the potential to affect all residents residing in the facility. Findings include: Review of the facility survey history, documented in Casper Report 003D Provider History Profile, updated on 11/19/2024, revealed repeated non-compliance at Federal tag F880, infection control for 11/2021, 10/2022, and 9/2023. The facility's corrective actions following these deficiencies included re-educating nursing staff on infection control, and requiring the Director of Nursing (DON) or designee to conduct facility-wide infection control audits to ensure staff adherence to proper practices. Further review of training and education documentation, dated 9/26/2023, indicated facility staff were provided education on infection control. Additionally, facility's Infection Control Report for QA October 2024 included an action plan to Continue to educate staff on hand hygiene and donning/doffing PPE upon hire and annually, with surveillance rounds implemented weekly. On 12/4/2024 at 9:47 AM, V9 (Licensed Practical Nurse) entered R51's room, which displayed signage for Enhanced Barrier Precautions (EBP). V9, without performing hand hygiene, put her gloves on and proceeded to the room without wearing the required PPE gown. V9 assessed R51's tube feeding stoma and its surrounding area, directly touching R51 skin. After the assessment, V9 removed her gloves then exited the room without performing hand hygiene, despite a hand sanitizer dispenser being available on the wall in the hallway. On 12/5/2024 at 10:32 AM, V3 (Infection Preventionist/IP) stated periodic spot checks are conducted to monitor staff adherence to hand hygiene protocols. On 12/5/2024 at 1:15 PM, V2 (Director of Nursing/DON) acknowledged her expectation was for staff to adhere to infection control practices. V2 explained ongoing education should be provided through in-service training, and monitoring and auditing staff compliance should be implemented, with results reported during QA meetings. V2 also indicated V3 should conduct regular surveillance rounds and educate staff on proper infection control practices, either in one-on-one or group settings. On 12/3/24 at 11:16AM, R177 was observed lying in bed with indwelling catheter drainage bag and tubing in contact with the floor. V17 (Licensed Practical Nurse) confirmed urinary drainage bags and tubing should not touch the floor as part of infection control protocols. On 12/5/2024 at 2:15 PM, V1 (Administrator) stated the QAPI Committee should review and evaluate the corrective actions related to infection control concerns. Review of the facility's undated policy, titled Quality Assurance Performance Improvement Program and Plan revealed Each LTC (Long-Term Care) facility .must develop, implement, and maintain an effective, comprehensive, data driven QAPI program .demonstrate evidence of its ongoing QAPI program .maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities .A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must (1) address all systems of care and management practices. (2) Include clinical care, quality of life, and resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's representative of a resident discharge from the facility, including the reasons for the move in writing, and failed to have a record that the local Ombudsman was notified of the discharge. This failure affected one (R3) of three residents reviewed for discharge. Findings include: R3 is a [AGE] year-old male admitted to the facility on [DATE], past medical history includes: Abdominal aortic aneurysm without rupture, essential primary hypertension, diabetes, other lack of coordination, need for assistance with personal care, alcohol abuse, history of falling, etc. Physician order. dated 6/11/2024. states: Discharge Home with Home Health, RN, Wound Care RN, Ok to Take Medication from facility. Progress note, dated 7/5/2024, states as follows: Resident discharged with belongings and medication. Transferred to community living home. Social service progress note, dated 7/2/2024, reads: (R3) is scheduled to discharge on [DATE] at 1PM. Staff from Independent living program will provide transportation. (R3) has a follow-up app (appointment) with his PCP (Primary Care Physician) in the community on 7/10/24 at 11AM, IDT (Interdisciplinary Team) made aware. There is no documentation any family member, POA (Power of Attorney) or Ombudsman was notified of R3's discharge. On 7/31/2024 at 3:56PM, V12 (Social Services) said when R3 was admitted to the facility from the hospital, R3 wanted to leave. The facility sent out referrals and resident was accepted in one community living place. V12 said she was not aware R3 had a State Guardian. V12 said they tried to reach family members of R3, but were unable. The staff from the community living that he went to came to pick him up, and R3 went with all his belongings. The facility has since not followed up with the resident; they don't usually do that. On 8/1/2024 at 12:05PM, V12 said, The place (R3) was discharged to does not provide any medical care. (R3) was appropriate because he does not need any medical care; the wounds he was admitted with were healed before he was discharged . (R3) was going to have a room and access to a kitchen. The facility was supposed to assist him with clothing and other needs in the community. On 8/01/2024 at 9:59AM, V17 (Social Service Director) said she recalls R3, but had just started working at the facility before he was discharged . V17 said she had a conversation with V16 (State Guardian), who called and asked about the resident; she told him that the resident discharged . V16 informed her the resident had a State Guardian. V17 looked through resident's documents and did not see any documentation of V16 being a State Guardian. V17 said that she brought it up in the morning meeting and no one was aware; the information may not be uploaded in the EMR (electronic medical record) and V17 does not have access to previous EMR system. On 8/1/2024 at 9:33AM, V16 (State Guardian) said R3 was appointed to Office of State Guardian (OSG) temporarily on 4/29/2024, then on 5/10/2024, the OSG guardianship became permanent. R3 was at the hospital and was transferred to the facility for placement, the hospital communicated to the facility through the social worker that resident was a ward of the State, the information was included in the referral packet. V16 added the resident is now in a different facility; he was discharged to a community setting that provided no medical care; resident cannot make his own decision. V16 added he visited the resident at the facility in May and introduced himself. On 8/3/2024 at 1:26PM, V32 (Hosp Social Worker) said the facility was aware R3 is a ward of the state because it was specified in the referral letter that was sent to the facility. V32 stated she spoke to the facility liaison who confirmed the facility is aware that resident has a state guardian. On 8/5/2024 at 9:00AM, V1 (Administrator) said she spoke to V16 (OSG) and she told the records department to look for any documentation of R3's guardianship when he was at the facility. V1 later presented documentation from the facility stating R3 was a ward of the state. V1 said OSG should have been notified of resident's discharge. Facility transfer and discharge policy, dated September 2016 ,states in its policy, to assure resident transfers and discharges will be conducted in accordance with residents' rights, physician orders, and in such a manner as to maintain continuity of care. Under policy specifications, the policy states in item 2, When the facility transfers or discharges a resident under any circumstance, the resident/authorized legal representative must be notified verbally and in writing at least thirty (30) days prior to the intended discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the environment in good repair and failed to maintain a clean and sanitary environment. These failures have the potential to affect all thirty residents residing on the fifth floor of the facility. Findings include: On 4/26/2024, V1 (Administrator) presented the facility's Daily Census document, which shows the resident census on the fifth floor was 30. On 4/26/2024 between 2:30 PM and 3:15 PM during facility rounds with V1, Administrator and V4, Maintenance Director, the following environmental conditions were observed: room [ROOM NUMBER] has some peeling paint on the wall; there are things all around the room that are in disarray; there are clean clothes and clean towels placed on top of the chair with other dirty clothes underneath; several disposable wipes are laying on top of the bedside table; the wall fan has a lot of dust and debris; the overbed light has a lot of dust and debris; there is a shoe horn and hanger in the middle of the room; the glass window is full of dust and sticky substance. Surveyor pointed out the glass window to V1, who stated, There's a film on it, it's dirty. room [ROOM NUMBER]'s door has some peeling wood on the lower part of the door room [ROOM NUMBER]'s door has some peeling wood on the lower part of the door room [ROOM NUMBER]'s door has some peeling wood on the lower part of the door room [ROOM NUMBER]'s door has some peeling wood on the lower part of the door room [ROOM NUMBER]'s door has some peeling wood on the lower part of the door room [ROOM NUMBER]'s door has some peeling wood on the lower part of the door On 4/26/2024 at 3:08 PM, inside the fifth floor dining room, an accumulated grayish black sticky substance covered parts of the dining room floor; there are scattered brownish liquid in other parts of the dining room floor. Shoes stuck to the floor when walked on. V1 stated, Housekeeping usually mops the floor after meals, but they didn't do a good job of cleaning the floors. I'll have them clean it right now. I'm not sure if they mop every day. All the residents are allowed to enter this dining room. V1 presented an undated policy titled Housekeeping Services Policy, which documents, It is the policy of this facility to maintain a clean, order free, comfortable and orderly environment in all healthcare and public areas, which meet the sanitation needs of the facility and residents' rights for a safe, clean, comfortable home-like environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and regularly assess a resident for arterial ulcers, who then developed necrosis to the right heel and right great toe. This failure applied to one (R3) of three residents reviewed for nursing care. Findings include: R3's Physician's Order Sheet, printed on 12/8/23, shows R3 was admitted to the facility on [DATE], with diagnoses including Right Femur Fracture, Dementia, and Peripheral Vascular Disease. R3's Nurse's Notes, dated 11/10/2,3 states, Writer informed per CNA (Certified Nursing Assistant) resident had drainage on his sock upon removal, assessment done resident had brown drainage note on resident his sock great toe area, great noted with thick toenail, dry skin no visible open area noted, observed small amount of brown drainage from right great toe, nail bed, denies any pain or discomfort, ROM WNL (Range of Motion within normal limits), first aid rendered, dry dressing applied . On 12/8/23 at 12:20 PM, V5 (LPN- Wound Care) was asked about the drainage on R3's right toe in November. V5 stated, There was never any drainage when I saw him. R3's Duplex Scan, lower extremity arteries/arterial bypass graft (Doppler), dated 11/9/23, states, Marked peripheral arterial disease, CT (Computed Tomography) recommended. R3's CT (Computed Tomography) of the right foot, dated 11/17/23, states, 1. Questionable posterior heel soft tissue ulceration versus bandage . 2 Chronic appearing erosions in the 1st metatarsal head medially are nonspecific . On 12/8/23 at 11:55 AM, V5 (LPN- Wound Nurse) stated, He has a vascular appointment on 12/13. We were rounding with the wound doctor (V19) and she found the wounds. He has a history of his feet being crusty and the CNAs wanted me to check them out. V5 proceeded with R3's dressing change. R3's right foot was extremely dry and with white/yellow thick calloused skin covering the heal and ball of his foot. There was a half-dollar sized black eschar (devitalized tissue) with yellow dry flaky- looking skin around the wound on the right posterior heel. There was also a small pen point black eschar area to the top of R3's right great toe. V5 stated, A doppler was done in the last month. On 12/8/23 at 2:45 PM, V19 (Wound Medical Doctor/MD) stated, I was not surprised at all that he developed the wounds. It could have gone unnoticed to the untrained eye. He has very dry and calloused feet and they may not have known that it was a wound. They may have thought that is was just part of his dry skin. Earlier intervention is always better, but the course of action would have been the same. He has no signs of active infection. May need an angiogram or stent. He needs to see the Vascular surgeon and I have no idea what they are going to say. R3's Progress Notes, dated 12/1/23 (2 weeks after the CT scan), states, Skin is warm and dry. There is a wound to resident's right posterior heel related to PVD (Peripheral Vascular Disease) measuring 3.0 cm 3.0 cm x und (Unable to determine), no drainage. R3's Progress Notes, dated 12/6/23, states, While rounding with In-House Wound Care MD resident was noted with an arterial wound to right 1st toe measuring 0.8 cm x 0.8 cm x und, no drainage. R3's Initial Wound Management Detail Report, dated 12/1/23, shows a wound assessment, dated 12/5/23, showing R3 has a 4 cm x 3 cm, 100% eschar, arterial wound to his right heel. This same document shows R3 also has an arterial wound to his right big toe measuring 0.8 cm x 0.8 cm and described as 100% Thick black necrotic tissue. R3's Wound Evaluation and Management Summary, dated 12/5/23, states, Patient LTC (Long Term Care) resident per chart review patient had dopplers done 11/9 that showed marked PAD (Peripheral Artery Disease). CT was recommended and completed 11/17/23 , no results found on chart. Vascular referral made 11/13/23 per NP (Nurse Practitioner), unclear if patient was evaluated by vascular at that time, per chart patient presented with drainage from 1st toe the resolved, presents now with heel wound, in house wound MD now requested to evaluate while in house. On exam patient with necrotic heel wound, also note crusting and callus debrided from right first toe revealing underlying wound . On 12/8/23 at 2:55 PM, V2 (Director of Nursing) stated, With 137 residents there is no way that (V5) can go around and check everyone's feet every night. I know he is higher risk, so maybe we could look at him a little more often. I think he has had bad feet for a long time- I don't think this is anything new. The girls just like to lather him up with lotion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promptly address a resident's urinary catheter care needs by allowing the resident to continue the use of the same catheter that was leaking, while the resident was experiencing adverse symptoms, for a resident with a history of urinary tract infection (UTI). This failure applied to one (R78) of five residents reviewed for catheter care/UTI. Findings include: R78 is [AGE] years old, admitted to the facility on [DATE] with past medical history of type two diabetes, recent left BKA, end stage renal disease, chronic kidney disease stage 3, atrial fibrillation, hypertension, hypokalemia, iron deficiency anemia, and history of falling. On 09/08/2023 at 1:07 PM, Nurse practitioner note documented the following: HPI (History of Present Illness): Resident is a [AGE] year-old male, being seen in a follow up for Bacteriuria. Seen s/p (status post) recent hospitalization for two amputations on left leg, with the 2nd being a left BKA (below knee amputation). He was stabilized and discharged back to the facility. Noted with urinary catheter for underlying fluid retention. UA (uninalysis) noted with cloudy urine, leuk, protein and many bacteria as well as dysuria. Culture on 8/12 was positive for E Coli - greater than 100,000 colonies/ml (milliliter)Patient was started on Bactrim. Wound care following. Resident completed Bactrim on 8/20. Urinalysis result, dated 9/12/2023, indicated a dark yellow cloudy urine with specific gravity of 1.013, PH 5.0, glucose 30, trace of ketones, large leukocytes, high white blood cells, and many bacteria. Result was initialed with a note to wait for culture. Urine culture, dated reported 9/14/2023, indicated 50-100,000 colonies of Escherichia coli, was initialed and no ABT (antibiotic) written on the result. On 9/18/23 at 12:10 PM, R78 was observed in his room, awake and alert, and stated he has been having problem with his urinary catheter for a while now; it was leaking since last week when he went for an appointment, and it is still leaking. Resident stated his penis is very painful, and this has been going on for some time now. Resident's urinary catheter was observed to be wet, with brownish colored liquid; some yellowish/cloudy urine noted draining into the urinary catheter bag via gravity. On 9/18/2023 at 12:28PM, this observation was presented to V16 (RN), the assigned nurse for R78, who also checked the incontinence brief and confirmed it was wet. V16 said she will ask the CNA (Certified Nursing Assistant) to change resident; she added the catheter was changed last Friday when resident returned from his appointment, due to the same complaint of urine leakage. V16 said she is not sure why the catheter is leaking, and it might be the wrong size, and she is not sure what size resident has right now. On 9/18/2023 at 1:52PM, V10 (Nurse Practitioner) said he just checked R78's urinary catheter, and it is not leaking, the wetness in the diaper appears to be a discharge from his penis, and that might be due to irritation. V10 confirmed the resident told him of his urinary catheter leaking, and he believed it was on Friday, because that was the same day they changed his urinary catheter. V10 is not sure what size resident had earlier because he got it at the hospital. Resident currently has a 10c /16 French, maybe he needs a bigger size, the plan is to make a follow up appointment with urology, get a culture of the discharge and take it from there. Resident had a urine culture recently and is not being treated because he has less than 100,000 microorganisms. V10 said that they are going to fix the problem. On 9/19/2023 at 1:50PM, V10 (Nurse practitioner) said he was not looking back in resident's record, another NP was following the resident, antibiotics were not started for the resident because the bacteria in his urine culture was 50,000 to 100,000 colonies, and resident was not having any symptoms. When V10 noticed the discharge from resident's penis, he contacted the nephrologist who recommend to increase resident's current antibiotic treatment for Left BKA to twice daily for an additional 5 days. V10 stated he did not initial the urine culture result and did not write no ABT on them. Residents are treated with antibiotics if they have 50,000 to 100,000 colonies of bacteria in their urine culture, but for residents who have a urinary catheter catheter and have issues with UTI (urinary tract infection), it will probably be better to start antibiotics right away to prevent the infection from getting worse. Resident's physician order shows an order for Augmentin (amoxicillin-pot-clavulanate) 500-125mg, 1 tablet twice a day for infection at LBKA x 10days and for UTI 5 days. Care plan, initiated 9/18/2023, stated: resident on antibiotic therapy related to urinary tract infection. Resident also has the following orders: urinary catheter catheter care every shift and as needed, change urinary catheter catheter system for blockage ad/or leakage, document procedure and urine characteristics under progress note, sign with date, time and initial on urinary drainage bag. Review of resident's medical record did not show any documentation of urinary catheter catheter care in resident's progress note as ordered. On 9/21/2023 at 8:20AM, V17 (Nurse Practitioner) said she recalls the resident, but must look in his records to recall all that happened. V17 stated she does not treat residents for UTI if they have only 50,000 to 100,000 colonies, even if they have a urinary catheter catheter. V17 said she was informed the resident's urinary catheter was leaking and nursing reported that they changed it; she cannot recall if resident complained of pain in his penis to her. On 9/19/2023 at 2:42PM, V3 (Infection Prevention Nurse) said R78 had a urinalysis and culture because he was complaining of fullness and retention; his antibiotics was daily initially for his left BKA wound, and now the doctor ordered for it to be given twice daily for additional 5 days for UTI. Urinary catheter care policy, revised September 2005, stated its purpose as to prevent infection of the resident's urinary tract. Under general guideline, it documents, to report to the supervisor any complaints the resident may have of burning, tenderness, or pain in the urethral area. Under documentation, the policy states that the following information should be recorded in the resident's medical record: the date and time that catheter care was given, the name and title of individual (s) giving the catheter care. Any problem noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting or pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedures for pain management by not regularly assessing and monitoring a resident's complaints of pain and by not communicating resident pain to a provider in a timely manner following a fracture. This failure applied to one (R7) of one resident reviewed for pain management. Findings include: R7 is a [AGE] year old male with a diagnoses history of Quadriplegia, Parkinson's Disease, Epilepsy, Anxiety Disorder, Major Depressive Disorder, Cognitive Communication Deficit, and Osteoarthritis, who was admitted to the facility 04/02/2019. R7's progress note dated 09/13/2023 02:46 PM documents during repositioning R7 complained pain. Relief received, will continue to monitor. R7's progress note, dated 09/17/2023 at 11:16 AM, documents he was received in bed quietly with eyes open. R7's lower left extremity shows swelling and is warm to touch. Pain meds administered and became effective at this time. Nurse Practitioner paged. Writer awaiting call back for further orders. R7's progress note, dated 09/17/2023 at 07:41 PM, documents R7 received x-ray of lower left extremity via in house x-ray. Results pending at this time. On 09/18/23 at 10:38 AM, R7 stated his left leg was in pain and he needed assistance. Call light pad pressed on dresser three feet from bed. R7 stated it could take a couple of hours for staff to respond. V25 (Certified Nursing Assistant) responded to the call light, and asked R7 what was wrong with his knee. V25 stated they are waiting on transportation to come and get him. R7 stated but they never do. V11 (Licensed Practical Nurse) stated R7 complained of pain over the weekend, and his Nurse Practitioner was notified, rather than the in house Nurse Practitioner. V11 stated R7 is being sent out due to an abnormal x-ray. R7's progress note, dated 09/18/2023 at 10:41 AM, documents writer reported x-ray results to V23 (Nurse Practitioner). V23 stated she will look over R7's history and physical to conclude if fractures are new, and to renew his previous pain medication order for pain in the meantime. R7's progress note, dated 09/18/2023 at 3:17 PM, documents received new orders from V23 (Nurse Practitioner) to send resident to (local) Hospital d/t fracture to LLE. (Ambulance) ETA is 60 minutes. R7's Hospital Discharge Summary Report, dated 09/18/2023, documents he was seen for ankle pain and injury with a diagnoses of closed fracture of left tibia and fibula initial encounter. R7's Hospital X Ray documents his bones appear diffusely demineralized, suggesting osteopenia/osteoporosis. Impression, nondisplaced distal tibial and fibular fractures. On 09/18/23 at 3:40 PM, V22 (Unit Manager/ Licensed Practical Nurse) stated, (R7's) Nurse Practitioner wanted to come in and examine him regarding his fractures. However, it was just decided (R7) would be sent out to the hospital based on discussion and decision by herself, V2 (Assistant Director of Nursing), and V1 (Administrator). (R7) was x-rayed Sunday because he had some swelling and pain to his left lower extremity. V22 stated she believes this was R7's ankle. V22 stated, All abnormal results are reported to Nurse Practitioner and physician, and we follow their instructions. Abnormal X rays must be reported immediately. X-ray results takes a few hours. I received (R7's) X-ray results when I arrived this morning, and she reported to work at 9AM. V22 stated she spoke with V23 (Nurse Practitioner) and informed her they felt it was in R7's best interest to send him to the hospital because it was reported that he has a fracture to his left lower extremity. V22 stated V23 agreed to this recommendation. On 09/19/23 at 09:46 AM, V23 (Nurse Practitioner) stated she saw R7 yesterday around 12:30 -1:00 PM. V23 stated she observed R7's left ankle with yellow discoloration suggesting the area was in the healing stages. V23 stated V26 (Family Member) contact number is disconnected, so since they were unable to update his plan of care and confirm she's ok with what they were doing, she just decided to send him to the hospital for his acute fractures. On 09/20/23 at 4:23 PM, V2 (Assistant Director of Nursing) stated, If new pain is presented such as with (R7) on 09/13/2023, staff should assess pain each shift or as needed for at least 72 hours and it should be documented whether the pain continues or is resolved. This information should be documented in the nurses notes. On 09/21/23 at 2:48 PM, V2 (Assistant Director of Nursing) stated, As soon as the results of an x-ray are received revealing a fracture, the physician would be notified. (R7')s x-ray results revealing he had a fracture were received in the morning. If the physician cannot be reached, we would do what's in the best interest of the resident. If (R7) complained of pain after his fracture was identified, the nurse would provide him with medication, call the doctor, and most likely the doctor would order for him to be sent out to the hospital. R7's September 2023 medication administration record does not document pain medication administration until 09/18/2023, and does not include pain levels on 09/13/2023. R7's medical records from 09/01/2023 to 09/13/2023 do not document complaints of pain, and his medical records from 09/13/2023 - 09/18/2023 do not document a 72-hour pain assessment, and do not document R7 was communicating pain to V25 on 09/18/2023, after a fracture was identified and reported to his physician. The facility's Pain Policy reviewed 09/21/2023 states: Identify individuals who have pain: This includes a review of know diagnoses or conditions that commonly cause or predispose residents to pain; It also includes a review for any treatments that the resident is currently receiving for pain; Such assessments should occur at any time pain is suspected. Evaluate how pain is affecting mood, activities of daily living, and sleep. The staff will reassess the individual's pain and consequences of pain at regular intervals. The staff will discuss significant changes in levels of comfort with the attending physician who will adjust interventions accordingly. Resident's physician should be notified of significant changes pertaining to resident's pain level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were available during medication administration per physician orders for one (R135) of five residents reviewed during medication administration observation. Findings include: R135 is [AGE] years of age. Current diagnoses include but are not limited to: Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, Essential (primary hypertension, Age related nuclear cataract, bilateral, Presbyopia, and Myopia, bilateral. On 09/19/23 at 8:26 PM, medication administration was observed with V5, RN/Registered Nurse, on unit 100. V5 prepared medications for R135, and the following medications were not available for administration per the physician's order: *Lubricant Eye drop (carboxymethylcellulose-glycerin) 0.5%-0.9% administer 2 drops to each eye twice a day due to dry eyes. V5, RN, stated, I'm not seeing it (eye drops) here, I'll have to reorder it. The medication was not administered. *Sertraline 25 mg give one tablet a day. (Depression/Anxiety medication). V5, RN, stated, I don't see this (Sertraline) here either, I'll have to reorder it. The medication was not administered. On 09/21/23 at 10:03 AM, V2, ADON Assistant Director of Nursing, was asked, During medication administration, what is the expectation when the nurse prepares to administer medications regarding medication availability? V2 stated, Medication should be available for medication pass. We also have a pyxis (medication storage system) it has a list of additional medications. The Medication Administration Policy, dated March 2014, states: Policy: To authorize licensed nursing personnel (RN, LPN) and Qualified Medication Aides (QMA) to prepare and administer drugs and biologicals. 1. Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were three medication errors out of 25 medication opportunities resulting in a 12% medication error rate. This failure applied to two (R110, R135) residents reviewed during the medication administration task. Findings include: R135 is [AGE] years of age. Current diagnoses include but are not limited to: Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, Essential (primary hypertension, Age related nuclear cataract, bilateral, Presbyopia, and Myopia, bilateral. R110 is [AGE] years of age. Current diagnoses include but are not limited to: Glaucoma and Type 2 diabetes mellitus with other diabetic ophthalmic complication. On 09/19/23 at 8:26 PM, medication administration was observed with V5, RN/Registered Nurse, on unit 100. V5 prepared medications for R135 and the following medications were not available for administration per the physician's order. *Lubricant Eye drop (carboxymethylcellulose-glycerin) 0.5%-0.9% administer 2 drops to each eye twice a day due to dry eyes. V5, RN, stated, I'm not seeing it (eye drops) here, I'll have to reorder it. The medication was not administered. *Sertraline 25 mg give one tablet a day. (Depression/Anxiety medication). V5, RN, stated, I don't see this (Sertraline) here either, I'll have to reorder it. The medication was not administered. At 8:39 AM, V5 prepared medication for R110, and the following medication was not administered per the physician's order due to lack of verification. *Timoptic (Timolol Maleate) drops 0.5 % give 1 drop; ophthalmic (eye) twice a day. (Antiglaucoma Agents). Review of R110's electronic medication administration record does not indicate directions for which eye the medication is to be administered into. V5 stated, (R110) is alert and oriented, he told me he was doing it at home and was putting one drop in each eye. I've been giving him 1 drop in each eye. I'll check with the doctor. V5 administered the Timoptic to R110 before receiving clarification of administration directions. On 09/21/23 at 10:03 AM, V2, ADON Assistant Director of Nursing, was asked, During medication administration, what is the expectation when the nurse prepares to administer medications regarding medication availability? V2 stated, Medication should be available for medication pass. We also have a (medication storage system) it has a list of additional medications. At 12:13 PM, V2 was asked about V5, RN, administering R110's Timoptic eye drops after review of R110's electronic medication administration record that did not indicate directions for which eye the medication is to be administered into. V2 stated, The nurse should have resolved the order with the doctor prior to administration. The Medication Administration Policy, dated March 2014, states: Policy: To authorize licensed nursing personnel (RN, LPN) and Qualified Medication Aides (QMA) to prepare and administer drugs and biologicals. 1. Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates. 19. The medication administration record (MAR) will be verified against physician's orders. 28. Clarifications and/or questions related to administering medications will be directed to the next highest authority in nursing service, and if needed the attending physician or pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was provided personal privacy during a physical assessment by a medical provider, and failed to ensure residents were provided privacy during blood glucose monitoring and insulin administration. These failures applied to six (R49, R71, R84, R94, R101, and R112) of six residents reviewed for nursing care in the sample of 33 residents. Findings include: R49 is [AGE] years of age. Current diagnoses include but are not limited to: Type 2 Diabetes Mellitus, Dementia and Chronic Kidney Disease. R71 is [AGE] years of age. Current diagnoses include but are not limited to: Parkinson's Disease, Paranoid Schizophrenia, Dementia and Cognitive Communication Deficit. R84 is [AGE] years of age. Current diagnoses include but are not limited to: Type 2 Diabetes Mellitus, Dementia and Schizophrenia. R94 is [AGE] years of age. Current diagnoses include but are not limited to: Alzheimer's Disease, Hypertension, Type 2 Diabetes Mellitus and Metabolic Encephalopathy. R112 is [AGE] years of age. Current diagnoses include but are not limited to: Type 2 Diabetes Mellitus, Pneumonia, and Neurocognitive disorder with Lewy bodies. On 09/18/23 at 12:42 PM, V10, NP/Nurse Practitioner, is in the common area across from the nurse's station performing a body assessment on R71 while he is sitting in a chair at a table. V10, NP, proceeded to lift up R71 shirt exposing his chest and back area. V10, NP, then kneeled down and lifted R71's pants legs on both legs exposing his legs from the knees to his ankles. There are residents seated at two tables in the common area and staff are walking by in full view of V10, NP, and R71. V10, NP, was asked about his assessment of R71 while in the common area. V10 NP stated, I checked his arms, back, and his legs. I don't see any concerns with (R71). On 09/19/23 at 11:23 AM, V7, RN/Registered Nurse, performed blood glucose monitoring for R94 while she was seated at a table in the common area of the unit across from the nurse's station. R94 is seated at a table with R101 and R138. R53 and R103 are seated at the table behind R94's table within view. At 11:28 AM, V7, RN, lifted R94's shirt and administered nine units of Novolog insulin to R94's exposed abdomen while she is seated at the table with R101 an R138. At 11:32 AM, V7, RN/Registered Nurse, performed blood glucose monitoring for R101 while she was seated at a table in the common area of the unit across from the nurse's station. R101 is seated at a table with R94 and R138. R53 and R103 are seated at the table behind R94's table in view. At 11:50 AM, V7 RN Registered Nurse performed blood glucose monitoring for R49 while she was seated at a table in the dining room with other residents and staff present. V7 lifted R49's shirt and administered six units of Novolog insulin to R94's exposed abdomen while she is seated at the dining room table. At 11:54 AM, V7, RN/Registered Nurse performed blood glucose monitoring for R84 while she was seated at a table in the dining room with other residents and staff present. V7 lifted R84's shirt and administered ten units of Novolog insulin to R94's exposed abdomen while she is seated at the dining room table. At 11:57 AM, V7, RN /Registered Nurse, performed blood glucose monitoring for R112 while she was seated at a table in the dining room with other residents and staff present. V7 lifted R112's shirt and administered five units of Novolog insulin to R94's exposed abdomen while she is seated at the dining room table. At 12:05 PM, V7, RN, was asked about performing blood glucose monitoring and administering insulin for residents in the common area and dining room. V7 stated, It should be in the resident's room for privacy. On 09/20/23 at 2:07 PM, V10 (Nurse Practitioner) stated he did not do a full head to toe assessment for R71 after his fall on 09/18/2023, but did check on all visible areas and whatever he could check. V10 stated he reviewed R71's skin, head, neck, back, sacral area, legs, checked his range of motion in legs and arms, and did not show any signs of injury. V10 stated he felt it was necessary to perform an assessment on R71 directly where he was. V10 stated R71 could have been walked back to his room to perform an assessment. V10 stated it was reported to him R71 was resistant to care. V10 stated according to the nurses, R71 can fight and become agitated. V10 stated he would never assess in a non-private area, other than being concern about R71's safety. V21, RN, and V20, CNA/Certified Nursing Assistant, were observed walking R71 from his room after his fall incident up to the common area across from the nurse's station and sit him in a chair at the table. V21 did not perform an assessment. V21, RN, was instructed to call V10 to evaluate R71. Nurse Practitioner Progress note, dated 09/18/2023 at 9:58 PM, documents [Recorded as Late Entry on 09/19/2023 09:58 PM] Chief Complaint: Seen post Assisted Fall; Nature of Presenting Illness: (R71) is a [AGE] year-old male who was seen on 9/18/23 post assisted fall. Resident was seen sitting at the table eating lunch with one assistant. Per the nursing staff, (R71) slid from the edge of the bed with certified nursing aide assistance to the floor. No injuries were reported. The resident has continuous nonsensical speech with intermittent yelling and vowel language. No injury, swelling, bruises, or bleeding were noted from all visible sites. The undated Resident Rights Statement states: All residents have a right to a dignified existence, self- determination, and communication with and access to persons and services inside and outside the facility. This facility will protect and promote the rights of each resident, including each of the following rights: 19. The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. The Medication Administration Policy, dated March 2014, states: Policy: To authorize licensed nursing personnel (RN, LPN) and Qualified Medication Aides (QMA) to prepare and administer drugs and biologicals. 27. Residents shall be provided privacy during the administration of medications such as injections and treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy for infection control related to glucometer cleaning after resident use; failed to ensure that reusable equipment (wrist blood pressure cuff) was cleaned between use of residents; failed to perform hand hygiene prior to putting on PPE (Personal Protective Equipment) and after performing blood glucose monitoring; and failed to ensure infection control was maintained during tracheostomy care for a resident. These failures applied to four (R38, R101, R110, and R135) of four residents reviewed for nursing care in a sample of 29 residents. Findings include: R38 is [AGE] years of age. Current diagnoses include but are not limited to: Paraplegia, Tracheostomy status. R110 is [AGE] years of age. Current diagnoses include but are not limited to: Glaucoma and Type 2 diabetes mellitus with other diabetic ophthalmic complication. R135 is [AGE] years of age. Current diagnoses include but are not limited to: Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, Essential (primary hypertension, Age related nuclear cataract, bilateral, Presbyopia, and Myopia, bilateral. R101 is [AGE] years of age. Current diagnoses include but are not limited to: Type 2 Diabetes Mellitus and Metabolic Encephalopathy. On 09/19/23 at 8:16 AM, V5, RN/Registered Nurse, performed blood glucose monitoring for R135. Upon exiting R135's room and returning to the medication cart, V5, RN, set the blood glucose monitor in the top of the cart, and did not clean or wrap the monitor with a bleach wipe. V5, RN, checked R135, R110, and R38's blood pressure with a wrist blood pressure cuff prior to administering blood pressure medications. Upon leaving each resident's room, V5, RN, set the wrist blood pressure cuff on top of the medication cart, and did not clean it with a bleach wipe after using it. V5 did not clean the wrist blood pressure cuff between use with each resident. V5, RN, prepared medication for R110, who is on contact isolation. There is a contact isolation sign posted on the front of R110's room door. There is a bin next to R110's door with PPE (Personal Protective Equipment). V5 donned an isolation gown and entered R110's room without performing hand hygiene. V5, RN, had a container of hand sanitizer on the medication cart in front of R110's room. At 8:30 AM, V6, CNA/Certified Nurse Assistant, entered R110's room without putting on a isolation gown. V6 spoke with V5, RN, and stepped out of R110's room back into the hallway. V6, CNA, took an isolation gown from the PPE (Personal Protective Equipment) bin next to R110's room, and put it on without performing hand hygiene. There are hand sanitizer dispensers on the wall in the hallway next to R110's room, and there is a container of hand sanitizer on V5, RN's, medication cart that is directly in front of R110's door. At 8:56 AM, V5, RN, put on gloves and performed suctioning for R38,, who has a tracheostomy (surgically created hole in the windpipe as an alternative for breathing). V5, RN, then cleaned a moderate amount of mucus from R38's oxygen collar with a gauze dressing. V5, RN, opened a sterile gauze dressing and placed it under R38's oxygen collar and tracheostomy while wearing the same gloves she used to suction and clean R38's tracheostomy and oxygen collar. V5, RN, did not discard the gloves she used to suction and clean R38's tracheostomy and oxygen collar. V5 did not wash or sanitize her hands and put on a clean pair of gloves prior to placing a clean gauze dressing under R38's oxygen collar and tracheostomy. At 9:10 AM, V5, RN, stated, It (glucometer) should be wiped with a bleach wipe and cover it with the wipe for a few minutes. I just forgot; I did know it needed to be done. V5, RN, was asked about what should be done when using medical equipment such as a wrist blood pressure cuff between residents. V5 RN stated, It (blood pressure cuff) should be wiped with a bleach wipe. V5, RN, was asked about steps to be performed prior to donning PPE (Personal Protective Equipment). V5, RN, stated, Wash my hands or use hand sanitizer before putting on the gown. V5, RN, was asked about using the same gloves to suction and clean R38's tracheostomy and oxygen collar then apply a clean gauze dressing. V5 stated, I should have changed my gloves and washed my hands before I put the dressing on. At 11:16 AM, V6, CNA, was asked about entering a room with a contact isolation sign and using PPE. V6, CNA, stated, The sign on the door was to make sure I gown up before going in. I should wash my hands or sanitize them before I put it (isolation gown) on. There are hand sanitizer dispensers on the walls. At 11:34 AM, V7, RN, was wearing the gloves she performed R101's blood glucose monitoring while documenting on the laptop computer on the medication cart. On 09/20/23 at 10:30 AM, V1, Administrator, provided the PPE Personal Protective Equipment Competency for V5, RN, and V6 ,CNA. V5's competency was completed on 1/29/29. V6's competency was completed on 8/10/23. On 09/21/23 at 10:03 AM, V2, ADON Assistant Director of Nursing, stated, The nurse should clean the glucometer with the appropriate bleach wipe. Wipe it down and wrap it and allow it to sit for the appropriate amount of time. Nursing staff have been trained. V2 was asked what step should be completed prior to putting on PPE (Personal Protective Equipment)? V2 stated, Wash their hands or use hand sanitizer before putting on PPE. When asked about using medical equipment such as a wrist blood pressure cuff between residents, V2 stated, The blood pressure cuff should be wiped down with the appropriate disinfectant between residents. V2, ADON, was asked about V5, RN, being observed using the same gloves to suction and clean R38's tracheostomy and oxygen collar then apply a clean gauze dressing. V2 stated, The nurse should throw away the gloves, wash her hands or use hand sanitizer then place the clean dressing on. V2, ADON, was asked about V7, RN, wearing the gloves she performed R101's blood glucose monitoring while documenting on the laptop computer on the medication cart. V2 stated, The nurse should have taken off the gloves before touching anything because she could have been in contact with blood. The 01/20/2015 Glucometer Cleaning Policy states: 1. The glucometer/ accu-check machines MUST be cleaned between every use. 2. Use Germicidal/Antimicrobial Disposable Wipe. 3. Prepare a barrier surface such as placing a paper towel on the medication cart. 4. Put on gloves. 5. Unfold the clean wipe and clean the glucometer. 6. Thoroughly wet the surface. 7. Allow the machine to remain visibly wet for a full 2 minutes (You can wrap the machine in the wipe). Set a timer. 8. If the glucometer machine does not remain visibly wet for a full 2 minutes, repeat number 3-5 of this procedure. 9. Throw wipe away. DO NOT REUSE WIPES. 10. DO NOT SUBSTITUTE THIS PROCEDURE WITH ANOTHER WIPE. All nurses are required to utilize this procedure. All nurses should be able to recite this procedure. The undated Standard Precaution Policy states: Resident Care Equipment- Infection Control b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and single use items are properly discarded. The Hand Washing/ Hand Hygiene Policy, dated March 2020, states: Policy: It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids. 1. All personnel shall be educated on recognized hand-washing/hand hygiene procedures and shall follow such procedures. 4. When hands are not visibly soiled, employees may use an alcohol based hand rub (foam, gel, liquid) containing at least 60% alcohol in all of the following situations: c. before donning gloves; f. before handling clean or soiled dressing, gauze pads, etc.; g. before moving from a contaminated body site to a clean body site during resident care; h. before and after putting on and upon removal of PPE, including gloves; j. after handling used dressings, potentially contaminated equipment, etc.; k. after contact with objects such as medical devices or equipment in the immediate vicinity of a resident that may be potentially contaminated; m. after removing gloves. 5. Dispense enough ABHR hand rub to cover all surfaces of your hands. Rub your hands together until they feel dry. This should take around 20 seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a physician about residents not receiving their ordered medications for four (R3, R4, R5, R6) of six reviewed for physician notification. Findings Include: 1. R3 is a [AGE] year old with the following diagnosis: type 2 diabetes, hypertension, and transient ischemic attacks. The Medication Administration Record, dated 08/2023, documents on 8/20/23, R3 did not receive the following ordered medications: Aspirin 81 milligrams (mg) - 1 tablet at 9AM; Insulin glargine 100 units/milliliter (mL) - 32 units at 9PM; Metformin 500 mg - 2 tablets at 9PM; Metoprolol 25 mg - 1 tablet at 9AM; Insulin NPH 100 unit/mL - 2 units at 4PM and 11PM; and Xarelto 2.5mg - 1 tablet at 9AM. Aspirin and Xarelto prevent blood clot formation, Insulin and Metformin help control blood sugar levels, and Metoprolol helps control high blood pressure. 2. R4 is a [AGE] year old with the following diagnosis: quadriplegia, adult failure to thrive, hypertension, chronic embolism/thrombosis of the veins, and idiopathic epilepsy. On 8/23/23 at 3:08PM, R4 stated during the morning one day over the past weekend, R4 did not receive any scheduled medications. R4 endorsed asking a CNA (Certified Nursing Assistant) where the nurse was, but the CNA was not able to answer. R4 stated R4 takes a medication for blood clots and anxiety every day, and those medications should not be missed. The Medication Administration Record, dated 08/2023, documents on 08/20/23 R4 did not receive the following ordered medications: Eliquis 5 mg - 1 tablet at 9AM; Metoprolol 50 mg - 1 tablet at 9AM; and Lorazepam 0.5mg - half a tablet at 9AM and 1 PM. Eliquis prevents blood clot formation, Metoprolol help control high blood pressure, and Lorazepam help control anxiety. 3. R5 is a [AGE] year old with the following diagnosis: congestive heart failure, type 2 diabetes and hypertension. On 8/23/23 at 3:47PM, R5 stated R5 did not get scheduled medication over the weekend, but was unable to say what day. When asked how often this happens, R5 endorsed about 2 or 3 times per month. R5 reported missing 1 dose of an anti-tremor medication, and a medication for mood stability. The Medication Administration Record, dated 08/2023, documents on 08/20/23 R5 did not receive the following ordered medications: Amlodipine 5 mg - 2 tablets at 9AM; Benzotropine 0.5mg - 2 tablets at 9AM; Coreg 25 mg - 1 tablet at 8AM; Depakote 250mg - 1 tablet at 9AM; Hydralazine 100mg - 1 tablet at 9AM; Januvia 100mg - 1 tablet at 9AM; Lasix 40mg - 1 tablet at 9AM; and Metformin 500mg - 1 tablet at 9AM. Amlodipine, Coreg, and Hydralazine help control high blood pressure; Januvia and Metformin help control blood sugar levels, Lasix prevents fluid overload; Depakote helps stabilize mood and a certain level of the medication needs to be in the body to be most effective; and Benzotropine is used to help prevent tremors. 4. R6 is a [AGE] year old with the following diagnosis: hemiplegia following a cerebral infarction, cognitive communication deficit, chronic kidney disease, and hypertensive heart failure. The Medication Administration Record dated 08/2023 documents on 8/20/23 R6 did not receive the following ordered medications: Eliquis 5 mg - 1 tablet at 9AM and 9PM; Keppra 100mg/mL - 7.5 mL at 9AM and 9PM; Lasix 20 mg - 1 tablet at 9AM; Lisinopril 20 mg - 1 tablet at 9AM; Metoprolol 100mg - 1 tablet at 9PM; and spironolactone 25 mg - 1 tablet at 9AM. Eliquis prevents blood clot formation, Keppra helps prevent seizures, Lasix and Spironolactone helps prevent fluid overload, and Lisinopril and Metoprolol help control high blood pressure. R3 and R6 were interviewed during this investigation, but were not able to remember if they missed any ordered medications within the last week. On 8/29/23 at 12:16PM, V8 (Nurse) stated some of the residents were not able to get their medications on the night shift of 8/20/23 due to being so short staffed. On 8/29/23 at 2:05PM, V10 (Nurse) stated, If the medication is not being given, then staff must call the physician. The physicians need to be aware that the ordered medication is not being given. On 8/29/23 at 2:40PM, V12 (Nurse) stated, If a nurse is not going to give the ordered medication, then they need to let the physician know. On 8/30/23 at 1:16PM, V2 (Assistant Director of Nursing/ADON) stated if the medications are not going to be given, then the physician needs to be notified. V2 stated, That is our protocol. V2 endorsed staff would call the physician to get extra guidance. On 8/30/23 at 2:07PM, V18 (Director of Nursing/DON) stated the physician needs to be called if medication is not going to be given that is prescribed. V18 endorsed the physician needs to be called because they were the one to prescribe the medication, so they need to know what's going on with the resident. On 8/30/23 at 5:34PM, V19 (Medical Director) stated, A physician needs to be notified about medications not being given if they are ordered. That is general policy with all buildings; to notify the physician. V19 endorsed physicians need to understand the reason why the medication is not being given, or why is being missed, to see if there is an alternative method to giving it. V19 reported when a resident misses a significant medication, the impact can vary case to case. Some residents might not be bothered what other residents have a reaction or a decline in vital signs for missing a medication. On 8/31/23 at 12:29PM, V1 (Administrator) stated if a medication is missed, then staff needs to call the physician and follow up on any further orders. There is no documentation of any physician notification for missed medication doses on 8/20/23 for R3, R4, R5, or R6. The policy titled, Medication Administration Policy,, dated 03/2014, documents, Policy Specifications: . 25. Medications not received from a pharmacy and/or not administered within 24 hours from the order time to be administered will be considered a medication incident. The attending physician shall be notified in a facility designated from initiated. The policy titled, Medication and Treatment Physician Order Policy,, dated 02/2014, documents, Policy Specifications: . 16. Interruptions in the delivery schedule will be communicated to the prescribing physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to replace two open nursing shifts on day shift (7AM - 7 PM), and three open nursing shifts on night shift (7PM - 7AM) on 8/20/23, leaving two units during the day and three units during the night without a scheduled nurse, affecting 69 residents. Findings Include: R3 is a [AGE] year old with the following diagnosis: type 2 diabetes, hypertension, and transient ischemic attacks. R4 is a [AGE] year old with the following diagnosis: quadriplegia, adult failure to thrive, hypertension, chronic embolism/thrombosis of the veins, and idiopathic epilepsy. R5 is a [AGE] year old with the following diagnosis: congestive heart failure, type 2 diabetes and hypertension. R6 is a [AGE] year old with the following diagnosis: hemiplegia following a cerebral infarction, cognitive communication deficit, chronic kidney disease, and hypertensive heart failure. R6 was interviewed during this investigation, but was not able to remember if the facility was short staffed or if R6 needed to wait longer than normal for care. On 8/23/23 at 3:08PM, R4 stated hearing the staff speak about working short shift over the past weekend (08/19 and 08/20), but R4 could not remember what day the facility was short staffed. R4 stated during the morning one day over the past weekend, R4 did not receive any scheduled medications. R4 endorsed asking a CNA (Certified Nursing Assistant) where the nurse was, but the CNA was not able to answer. R4 stated R4 takes a medication for blood clots and anxiety every day and those medications should not be missed. On 8/23/23 at 3:35PM, R3 endorsed the call light response time will reach 30 - 40 minutes about 1 -2 times a month. On 8/23/23 at 3:47PM, R5 stated R5 did not get scheduled medication over the weekend, but was unable to say what day. When asked how often this happens, R5 endorsed about 2 or 3 times per month. R5 reported missing 1 dose of an anti-tremor medication and a medication for mood stability. V5 (CNA) worked on 8/20/23 on the 11PM - 7AM shift on the 700 unit. On 8/23/23 at 11:09AM, V5 stated other nurses were talking about another nurse that was supposed to be coming in, but that nurse never showed up. V5 endorsed usually there's one nurse for each side of each unit. V5 stated, I can't remember how many there were that night, but I do know that we were short at least two nurses. V5 reported having the nurses from the different units come up and check on the residents for the units that didn't have a nurse. V8 (Nurse) worked on 8/20/23 on the 7PM - 7AM shift on the 600 unit. On 8/29/23 at 12:16PM, V8 stated that night there was multiple call offs for nurses, and the nurses at the facility had to split four units. V8 endorsed only having three nurses there that night. V8 reported, When call offs happen, staff will try to split whatever sets are left over. Normally nurses have 26 to 28 residents, but that night it was just too many residents to split. V8 endorsed just making rounds on the residents on the units that didn't have a nurse. V8 stated V18 (Director of Nursing) or the manager on duty that weekend were aware of how the facility was staffed. V18 denied agency showing up to the building that night. V8 stated, I think they had someone scheduled to come, but they didn't show up from what I remember. That night we did what we could. V8 denied any management coming in that night. V8 stated some of the residents were not able to get their medications on the night shift of 8/20/23 due to being so short staffed. V9 (CNA) worked on 8/20/23 on the 3PM - 11PM shift on the 800 unit. On 8/29/23 at 12:23PM, V9 stated the 800 unit had a nurse until 7 PM, but after that, no nurse replaced the nurse that left. V9 endorsed the nurse from the 500 unit was coming up to the 800 unit to make sure everyone was OK. V9 reported being short nurses for that shift, but was unaware how many they were short. V9 stated V9 left around 11PM, and no nurse came to the 800 unit when V9 left. On 8/30/23 at 12:06PM, V16 (Staffing Coordinator) stated V16 was not involved in the staffing issues that occurred on 8/20/23, because it was a weekend. V16 endorsed a manager on duty is responsible of the staffing concerns over the weekend. V16 reported V18 (DON) was manager on duty that weekend. V16 stated, If we're not able to get any agency or other staff to come in, then we have nurse managers that will come in and work the cart. They will fill in. We have three unit managers, a DON, an ADON (Assistant Director of Nursing), and seven or eight other managers that are nurses. On 8/30/23 at 1:16PM, V2 (ADON) stated if staffing issues arise on a weekend, then the manager on duty should try to reach out to others for support. V2 endorsed the manager on duty should call other staff to come in, and if no one comes in, then V2 or V18 should be made aware. On 8/30/23 at 2:07PM, V18 (DON) stated on 8/20/23, there were a couple call offs. V18 endorsed requesting agency to come. V18 denied being aware of agency showed up to the facility. V18 denied coming to the facility. V18 stated, I was exhausted from working all week so I wasn't able to make it in. V18 endorsed using agency for both day shift and night shift for nurses. V18 reported on day shift, the facility works with six nurses, and night shift the facility should have six nurses as well, but staff can get by with five nurses. V18 stated, If the manager on duty is not at the facility, the nurse should call me and let the manager know that they are short staffed. V18 stated whoever is on call needs to go in if the staffing is not replaced. V18 stated, Either a manager on duty, myself, or the ADON need to go in. You can take time off during the week if you have to go in on the weekend. On 8/31/23 at 12:29PM, V1 (Administrator) stated, Staff rotates every other weekend, and some weekends are just harder to make sure we have all the staff here. When no staff can pick up, the facility resorts to agency for those shifts. On the weekends, a manager on duty and nurse on duty are in the building. The nurse on duty will communicate with the manager on duty about staffing issues. If there's any call offs, the nurse manager on duty will find staff to pick up and if they can't, then they would reach out to agency. V1 stated, I know for this particular day there were a few last-minute call offs, so they were difficult to find replacements. It was discussed with the CNAs to tell the RNs (Registered Nurses) on other units if there were any issues. The other nurses that were there were supposed to pass meds on the other units to help out. Even if we are short, I still expect the medication to be passed as they are ordered. I always tell my staff to do the best that you can with what you have. V1 endorsed being notified about being short staffed due to call offs, but managers were trying to get other staff in to cover. V1 reported the census usually is around 140. V1 stated, Because the call us were so last minute we weren't able to fill their spots, and other nurses were just instructed to help out on the other units. The Medication Administration Record, dated 08/2023, documents on 8/20/23, R3 did not receive the following ordered medications: Aspirin 81 milligrams (mg) - 1 tablet at 9AM; Insulin glargine 100 units/milliliter (mL) - 32 units at 9PM; Metformin 500 mg - 2 tablets at 9PM; Metoprolol 25 mg - 1 tablet at 9AM; Insulin NPH 100 unit/mL - 2 units at 4PM and 11PM; and Xarelto 2.5mg - 1 tablet at 9AM. Aspirin and Xarelto prevent blood clot formation, Insulin and Metformin help control blood sugar levels, and Metoprolol helps control high blood pressure. The Medication Administration Record, dated 08/2023, documents on 08/20/23, R4 did not receive the following ordered medications: Eliquis 5 mg - 1 tablet at 9AM; Metoprolol 50 mg - 1 tablet at 9AM; and Lorazepam 0.5mg - half a tablet at 9AM and 1 PM. Eliquis prevents blood clot formation, Metoprolol help control high blood pressure, and Lorazepam help control anxiety. The Medication Administration Record, dated 08/2023, documents on 08/20/23, R5 did not receive the following ordered medications: Amlodipine 5 mg - 2 tablets at 9AM; Benzotropine 0.5mg - 2 tablets at 9AM; Coreg 25 mg - 1 tablet at 8AM; Depakote 250mg - 1 tablet at 9AM; Hydralazine 100mg - 1 tablet at 9AM; Januvia 100mg - 1 tablet at 9AM; Lasix 40mg - 1 tablet at 9AM; and Metformin 500mg - 1 tablet at 9AM. Amlodipine, Coreg, and Hydralazine help control high blood pressure; Januvia and Metformin help control blood sugar levels, Lasix prevents fluid overload; Depakote helps stabilize mood and a certain level of the medication needs to be in the body to be most effective; and Benzotropine is used to help prevent tremors. The Medication Administration Record, dated 08/2023, documents on 8/20/23, R6 did not receive the following ordered medications: Eliquis 5 mg - 1 tablet at 9AM and 9PM; Keppra 100mg/mL - 7.5 mL at 9AM and 9PM; Lasix 20 mg - 1 tablet at 9AM; Lisinopril 20 mg - 1 tablet at 9AM; Metoprolol 100mg - 1 tablet at 9PM; and spironolactone 25 mg - 1 tablet at 9AM. Eliquis prevents blood clot formation, Keppra helps prevent seizures, Lasix and Spironolactone helps prevent fluid overload, and Lisinopril and Metoprolol help control high blood pressure. The Census Report, dated 8/20/23, documents a total of 145 residents are in the facility. Twelve residents reside on the 300 unit, 23 residents reside on the 400 unit, nine residents reside on the 700 unit, and 25 residents reside on the 800 unit. The Nursing Staffing Assignment, dated 8/20/23, documents there were no nurses scheduled for the 600 or 700 unit for the 7 AM to 7 PM shift. There also were no nurses scheduled for the 300/400 unit, 700 unit, and 800 unit for 7PM to 7AM. The Timecard Report, dated 8/19/23 and 8/20/23, documents only three nurses were clocked in for the 7 PM to 7 AM shift on this day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the administration of medication as ordered by the physician. This affected four of four residents (R3-R6) reviewed for medication error, omission and medication administration. findings Include: 1. R3 is a [AGE] year old with the following diagnosis: type 2 diabetes, hypertension, and transient ischemic attacks. The Medication Administration Record. dated 08/2023. documents on 8/20/23. R3 did not receive the following ordered medications: Aspirin 81 milligrams (mg) - 1 tablet at 9AM; Insulin glargine 100 units/milliliter (mL) - 32 units at 9PM; Metformin 500 mg - 2 tablets at 9PM; Metoprolol 25 mg - 1 tablet at 9AM; Insulin NPH 100 unit/mL - 2 units at 4PM and 11PM; and Xarelto 2.5mg - 1 tablet at 9AM. Aspirin and Xarelto prevent blood clot formation, Insulin and Metformin help control blood sugar levels, and Metoprolol helps control high blood pressure. 2. R4 is a [AGE] year old with the following diagnosis: quadriplegia, adult failure to thrive, hypertension, chronic embolism/thrombosis of the veins, and idiopathic epilepsy. The Medication Administration Record, dated 08/2023, documents on 08/20/23, R4 did not receive the following ordered medications: Eliquis 5 mg - 1 tablet at 9AM; Metoprolol 50 mg - 1 tablet at 9AM; and Lorazepam 0.5mg - half a tablet at 9AM and 1 PM. Eliquis prevents blood clot formation, Metoprolol help control high blood pressure, and Lorazepam help control anxiety. On 8/23/23 at 3:08PM, R4 stated during the morning one day over the past weekend, R4 did not receive any scheduled medications. R4 endorsed asking a CNA (Certified Nursing Assistant) where the nurse was, but the CNA was not able to answer. R4 stated R4 takes a medication for blood clots and anxiety every day and those medications should not be missed. 3. R5 is a [AGE] year old with the following diagnosis: congestive heart failure, type 2 diabetes and hypertension. The Medication Administration Record, dated 08/2023, documents on 08/20/23, R5 did not receive the following ordered medications: Amlodipine 5 mg - 2 tablets at 9AM; Benzotropine 0.5mg - 2 tablets at 9AM; Coreg 25 mg - 1 tablet at 8AM; Depakote 250mg - 1 tablet at 9AM; Hydralazine 100mg - 1 tablet at 9AM; Januvia 100mg - 1 tablet at 9AM; Lasix 40mg - 1 tablet at 9AM; and Metformin 500mg - 1 tablet at 9AM. Amlodipine, Coreg, and Hydralazine help control high blood pressure; Januvia and Metformin help control blood sugar levels, Lasix prevents fluid overload; Depakote helps stabilize mood and a certain level of the medication needs to be in the body to be most effective; and Benzotropine is used to help prevent tremors. On 8/23/23 at 3:47PM, R5 stated R5 did not get scheduled medication over the weekend, but was unable to say what day. When asked how often this happens, R5 endorsed about 2 or 3 times per month. R5 reported missing 1 dose of an anti-tremor medication and a medication for mood stability. 4. R6 is a [AGE] year old with the following diagnosis: hemiplegia following a cerebral infarction, cognitive communication deficit, chronic kidney disease, and hypertensive heart failure. The Medication Administration Record, dated 08/2023, documents on 8/20/23, R6 did not receive the following ordered medications: Eliquis 5 mg - 1 tablet at 9AM and 9PM; Keppra 100mg/mL - 7.5 mL at 9AM and 9PM; Lasix 20 mg - 1 tablet at 9AM; Lisinopril 20 mg - 1 tablet at 9AM; Metoprolol 100mg - 1 tablet at 9PM; and spironolactone 25 mg - 1 tablet at 9AM. Eliquis prevents blood clot formation, Keppra helps prevent seizures, Lasix and Spironolactone helps prevent fluid overload, and Lisinopril and Metoprolol help control high blood pressure. R3 and R6 were interviewed during this investigation but were not able to remember if they missed any ordered medications within the last week. On 8/29/23 at 12:16PM, V8 (Nurse) stated some of the residents were not able to get their medications on the night shift of 8/20/23, due to being so short staffed. On 8/29/23 at 2:40PM, V12 (Nurse) stated V12 might not have had time to chart the medications V12 gave while V12 was in the process of giving them. V12 stated, Sometimes you just give them and move onto the next person. V12 endorsed staff should chart the medication as it is being given because that's the correct way to pass medications, but sometimes there is no time to chart. V12 stated, In nursing school, they teach you if you didn't chart it then it means you didn't do it. On 8/30/23 at 1:16PM, V2 (Assistant Director of Nusing/ADON) stated a nurse should always give scheduled medications. V2 endorsed if the medication is in the building, then it needs to be administered. V2 stated, There is no instance that I could think of where residents shouldn't get their medications if they are ordered. On 8/30/23 at 5:34PM, V19 (Medical Director) stated when a resident misses a significant medication, the impact can vary case to case. Some residents might not be bothered what other residents have a reaction or a decline in vital signs for missing a medication. On 8/31/23 at 12:29PM, V1 (Administrator) stated, Even if we are short, I still expect the medication to be passed as they are ordered. I always tell my staff to do the best that you can with what you have. The policy titled, Medication Administration Policy, dated 03/2014, documents, Policy Specifications: . 19. The medication administration record (MAR) will be verified against physicians orders. 20. Medication shall be recorded on the MAR promptly after each administration by the individual who administered the drug . 2525. Medications not received from a pharmacy and/or not administered within 24 hours from the order time to be administered will be considered a medication incident. The attending physician shall be notified in a facility designated from initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement appropriate interventions to prevent falls for one resident (R5) of 3 residents reviewed for falls in a sample of 12. The failure resulted in R5 falling inside of his room. Findings include: Review of R5's face sheet documents a [AGE] year old male admitted to the facility on [DATE], and also includes the following diagnoses: Demenita, repeated falls (Admission), Weakness and Malaise. R5's incident report, dated 12/28/2022, documents R5's BIMS (Brief Interview for Mental Status) as 8 out of 15, which denotes moderately impaired cognition. R5's MDS (Minimum Data Set) section C, dated 11/13/22, documents BIMS of 8 out of 15. R5's MDS section G, dated 11/13/22, documents R5 requires 2 person physical assist with bed mobility, walking, toileting, hygiene and transfers. Review of R5's fall risk observation report, dated 12/22/2022, documents R5 as a High Risk for falls based on a risk score of 11.0 On 1/4/2023 at 2:00 PM, V4 (Certified Nurisng Assistant/CNA) stated, (R5) is normally restless, and can't be redirected all the time. On 1/5/2023 at 12:40 PM, V6 (CNA) stated R5 is a fall risk, and up with 1 assist. V6 stated someone is always with him. V6 stated R5 isn't steady standing. On 1/5/2023 at 12:23PM, V15 (Licensed Practical Nurse/LPN) stated R5 is not easy to redirect. V15 stated, (R5) refuses care, and he needs care because he is incontinent and has unsteady gait. (R5) is a high fall risk and doesn't do what he is supposed to do. On 1/6/2023 at 2:00 PM, V15 stated they don't put R5 to bed during the day because he doesn't stay in bed. The day of his fall on 1/3/2023, V15 stated when she received R5 in the morning he was still sleeping. V15 stated she had given R5 his medication and R5 went back to sleep. V15 stated this was about 8:30 AM, and she told the agency CNA to make sure she monitors him so he will not get up and fall on the floor. V15 stated later the CNA found R5 on the floor. V15 stated she is not sure if R5 was care planned for falls out of bed. There were no floor mats on R5's floor. V15 stated R5 walks small distance with assistance only. V15 stated, The other day, (R5's) legs just gave out like noodles from walking a short distance. V15 stated they had to physically lift him and put in a chair. V15 stated R5 is transfer with 1 assist. V15 stated R5 tries to get up and walk when he shouldn't. Review of Progress notes, dated 1/3/20223, documents after the fall, R5 was complaining of hitting his head. R5 was sent to the emergency room and returned the same day. Review of the R5's progress notes and care plans, documents 4 falls: On 11/24/22 - R5 found on the floor in hallway. On 11/25/2022- R5 lost his balance while ambulating in his room. On 1/1/2023, R5 lost balance and fell. Nursing note dated 1/1/2023 at 11:00 AM states CNA told R5 to sit down before he falls and resident attempted to get up without assistance anyway. Resident fell before CNA could reach him. On 1/3/2023 -Nursing note documents. Resident found by staff in his room laying supine at the foot of the bed. Resident complained of head pain. R5's nursing progress note by V15, dated 12/8/2022, documents: R5 continues to try to stand and walk but is unsteady. Requires frequent observation due to high fall risk. Review of R5's Care plans document the following: Falls: Dated 11/24/2023, Resident was noted on the floor in the hallway. Stated he lost his balance. Approach: Resident counselled to ask for assistance when he needs assistance. Falls: Dated 11/25/2023, Resident has unsteady gait. Resident lost his balance while ambulating in his room. Approach refer to rehab. Risk for falls: Dated 12/6/2022, Resident at risk for falling related to history of frequent falls, weakness and abnormal gait. Behavioral Symptoms: Dated 12/8/2022, R5 presents with wandering behaviors, wandering with or without a purpose. Falls: Dated 1/2/2023, Resident lost balance and tipped chair over. Approach: Remind resident he needs assistance to stand up. Restorative: Dated 1/2/2023 Resident requires restorative walking program due to his limitations walking related to decreased safety awareness, balance, and comorbidities. The facility's Managing Falls and fall Risk policy, dated August 2008, documents the following; Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on interview and record review, the facility failed to ensure that 4 residents (R4, R7, R10 and R11), who are on the dementia secure unit and ambulatory, have adequate lighting to safely ambulate in their rooms. This failure effects 4 residents (R4, R7, R10 and R11) of 4 residents reviewed for lighting in a sample of 12. On 1/4/2023 between 11:40 AM and 12:30 PM, a tour of the facility was conducted and surveyor observed none of the room entry wall light switches were working in the facility. On 1/6/2023 at 2:00 PM, V15, Licensed Practical Nurse, stated, On the 300/400 unit about 7 and eight people go back and fourth from their rooms all day. On 1/5/2023 at 10:39 AM, V12 (Maintenance Director) stated none of the resident room entry lights work in the entire facility. V12 stated there is no power to the lights. While going from room to room on the secure unit, V12 stated, The rooms (that have the shades down and the above the head lights off) are dark and the shades should be open. There were 9 rooms in total that were very dark and difficult to see in the rooms. R4, R7, R10 and R11's rooms were all observed to be dark and difficult to see inside once you crossed the entrance into the room. Residents would have to walk approximately 15-21 feet into the room before they are able to turn on a light. R4, R7, R10, R11 are all on the dementia secure unit and are ambulatory.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to schedule a follow-up orthopedic appointment for a resident who suffered a leg fracture following treatment received from the emergency room, and the facility failed to communicate the change in condition related to the new fracture and cast placement to the resident's primary care physician. This failure affected one (R1) of one resident reviewed for improper nursing care. Findings include: R1 is a [AGE] year old female, who was admitted to the facility on [DATE], with diagnoses listed that include Alzheimer's, Anemia, Cognitive communication deficit, dysphagia, Dementia and Hypertension. R1 was admitted to hospice services on 9/12/22. Care plan, dated 9/13/22, indicated R1 has a cast in place with the following interventions: Assessment of fractured limb will be provided per facility policy, R1 will receive follow-up x-rays, R1 will be assessed according to the facility policy. On 11/15/22 at 12:45PM, R1 was noted in bed, alert and oriented, and yelling out. She denied any pain while at rest, but yelled at staff for touching the left leg upon assessment. The left lower leg was noted to be immobilized in a soft cast and wrapped with an elastic bandage. V24 (Licensed Practical Nurse/LPN) said, I didn't know that she had a cast on the leg. I am not familiar with any orders to the leg that have to be done by nursing. I don't know how long the cast has been on or when it is coming off. Nursing progress notes, dated 9/12/22-9/13/22, documents emergency room reports and facility investigation; R1 suffered a pathological fracture of the left tibia. R1 was sent to the emergency room and had a soft cast placed. R1 returned to the facility on 9/14/22 with orders to follow-up with an orthopedic surgeon within a week. The facility was able to schedule a follow-up appointment for 9/29/22. On 11/16/22 at 11:00AM, V1 (Administrator) said, (R1) was sent to the Orthopedist on 9/29/22, but when she got there, the provider determined that they would not take her insurance. The visit would have cost the facility over $600, which we were not authorized to pay, so she came back without being seen. As far as I can tell, (R1) has not received any follow-up care from an orthopedic provider and doesn't have any appointments scheduled. V2 (ADON) said, There are no orders in the Physician Order Sheets that indicate (R1) has a cast. On 11/16/22 at 2:15PM, V25 (Medical Doctor of R1) said, I don't recall when the last time I saw (R1) was and was unaware that she has a leg fracture with a cast since September. The nurses didn't tell me about the fracture or not being able to follow up with the orthopedic doctor. Now that I am aware, I will get an Xray now, and follow up with ortho and move forward from there to take the cast off. After assessing R1, at 4:18PM on 11/16/22, V25 (Medical Doctor) said, I see that (R1) has had the cast on for over 6-8 weeks, this is not particularly a long time to have a cast, but (R1) should have followed up with the specialist by now. The toes are warm and have good circulation, but I will send her to the ER now for evaluation since she has not been able to see the orthopedist. I don't think there is an immediate issue with the cast being in place, but I would want to send for an evaluation just in case. R1 was sent to a local hospital emergency room for evaluation of left lower leg at 3:40PM on 11/16/22. Progress note, dated 11/17/22 at 8:56AM, listed R1 in the emergency room and would be admitted with a diagnosis of closed fracture tibia fibula. At 10:00AM, V26 (emergency room Nurse) said R1 had not received any new orders while in the ER and was still waiting to be seen by an Orthopedic specialist. There was no evidence of blood clots or further deformity of the left leg as noted by X-rays and scans. No follow-up x-rays were ordered according to Physicians order Sheets viewed from 9/13/22 to current. Facility policies regarding cast care and assessments, scheduling outpatient appointments/follow-ups were requested and not received during the course of this survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their call light policy for 1 of 1 (R39) by not ensuring the call light within reach. Findings include: R39's Minimum Data Set (MDS), dated [DATE] section C (cognitive pattern), documents a score of fourteen, which indicates cognitively intact. Section G (functional status) documents limited assistance with one person physical assist for toilet use and personal hygiene. No impairment to the upper extremities. Section H (bowel continence) documents frequently incontinent. On 10/16/22 at 11:30 AM, R39 was observed in bed. R39 said, I had a bowel movement. I need assistance to be changed. I don't know where my call light is located. R39's call light was observed on the floor out of reach, near the base of R39's head board. V8 (MDS Coordinator) said, (R39's) call light should be in reach. On 10/16/22 at 4:48 PM, V3 (Assistant Director of Nursing/ADON) said, The call light should be within reach. Answering the call light, revised 2008, documents: #5 when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, the facility failed to follow their policy for Advance Directives. The facility failed to put an order for a resident with a change of Advance Directives (Code Status). This deficient practice affects one resident (R1) of three residents reviewed for Advance Directives. Findings Include: R1's initial facility admission was dated 1/4/22. R1's Face Sheet, documents : There is no Advanced Directives selected for this resident. R1's DO-NOT-RESUSCITATE (DNR) PRACTITIONER ODERS FOR LIFE-SUSTAINING TREATMENT (POLST) FORM, documents R1 would like to be DNR (Do Not Resuscitate); R1's signature, dated 9/15/22, Social Service Director (V12) signature, dated 9/15/22 and Nurse Practitioner's signature, dated 9/20/22. R1's Physician Order Report for Active Orders shows there is no order for Code status stating R1 is on DNR code status. On 10/19/22 at 10:59 AM, V12 (Social Service Director) stated, We get doctor's order to become a DNR. R1 requested to change R1's code status from full code to DNR. Form was completed by me and with Nurse practitioner. Advance Directives Policy with an effective date of November 2016, reads in part: To assure resident is provided written information on advance directives in accordance with State Laws, including facility's policies for implementing these requirements. Social Service and/or the interdisciplinary care plan team will review the resident's advance directive status as documented in the resident's record at the time of initial care plan conference and reconfirm that no changes in status are desired. The team will also conduct such reviews and reconfirmations at the time of every scheduled care plan conference. If changes or revisions are required, the care plan team will initiate the necessary processed to modify the status changes in the resident's record, including contact of the resident's attending physician so that appropriate orders to reflect these status changes are secured.

Based on observation, interview, and record review, the facility failed to follow their hot water policy and ensure the water temperatures in the resident room was between 105 and 115 Fahrenheit for 2 residents in the sample of 133 residents reviewed for water temperatures. Findings include: On 10/16/22 at 11:42 AM, R119 said the water is cold when the staff gives him a bed bath. On 10/18/22 at 2:02 PM, during tour to check water temperature, R113's room water temperature was noted to be 69.9 degrees Fahrenheit, shower room temp was noted to be 102.8; R119's room water temp was noted to be 104.5 degrees Fahrenheit. On 10/18/22 at 2:02 PM, V30 (Maintenance Supervisor) said the water temperature should be 106-107 degrees Fahrenheit. Facility policy no titled noted shows in-part to ensure patient room water temperature are between 105 and 115.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their transfer and discharge policy by not providing a safe discharge from the facility. This affected 1 of 3 residents (R132) reviewed for discharge and transfer. Findings include: R132 facility face sheet shows R132 has diagnosis of other seizures, hypothyroidism, essential hypertension, intraspinal abscess, pressure ulcer, end stage renal disease, anemia, personal history of venous thrombus, depression, history myocardial infraction, congestive heart failure, anxiety, GERD, vertigo, osteoporosis, chronic pain, and diabetes mellitus. R132's discharge MDS (Minimum Data Set), dated 9/29/22, shows discharged , return not anticipated, discharged to community. BIMS (Brief Interview for Mental Status) ( cognitive status) is blank, cognitive skills for daily decision making is 2 moderately impaired; other behavior not directed toward others, rejection of care. Section G for functional status shows R132 needs extensive assist with bed mobility, transfers, locomotion on and off unit, dressing, and toilet use and personal hygiene, walking in room and in corridor did not occur, and R132 requires supervision with eating. Section H shows R132 has indwelling catheter. Section I shows diagnosis of seizures, anemia in chronic kidney disease, depression, intraspinal abscess and granuloma, pressure ulcer, osteomyelitis of vertebra thoracic region, end stage renal disease. Section N shows medications received in last 7 days are antidepressants, anticoagulants. On 10/17/22 at 3:59 PM, R132 said the social worker at the facility asked her if they could search her belongings, and she signed consent for the search. R132 said when searching her belongings, the facility said they found drugs in her belongings. R132 said that's when she told them they could no longer search her things because she knew she did not have drugs, and she did not know what they was talking about. R132 said she did not have any drugs in her belongings. R132 said the facility found 2 or 3 prescription pills in her belongings. R132 said once she asked them to stop searching her things, the social worker then said to her, if we can't search your things, you have to leave and you already signed an AMA (Against Medical Advice). R132 said she did sign for the facility to search her things, she was not aware she was really signing AMA. R132 said that's when she called her boyfriend and told him what was going on, and asked him to come to the facility because the facility is saying she had drugs in her belongings. R132 said as she was on the phone with her boyfriend and the social worker continued to persist that she had drugs; she said fine I will leave than. R132 said she didn't have anywhere else to go. R132 said she has bedsores, she's on dialysis, she has bad back pain, and she can't walk. R132 said she can't see well out of her right eye, R132 said that's why her signature on scribbled on her documents, because her vision is not good in the right eye. R132 said when her boyfriend arrived at the facility, two CNA's put her in a wheelchair and escorted her out the facility front door. R132 said her boyfriend called his aunt to pick them up, but she could not fit in the vehicle, and that's when she called 911 and the paramedics came and took her to the hospital. R132 said the facility did not give her R132's medications. The facility did not review her medical diagnosis with her, the facility did not call the medical doctor that she is aware of, the facility did not give her any paperwork, the facility did not review with her the risk of leaving against medical advice. R132 said the facility did not give her a 30 day notice of plan to discharge. R132's AMA document requested and reviewed. V12's and V13's names are noted as a witness. R132's signature is noted to be scribbled on the document. On 10/17/22 at 12:14 AM, V13 (Social Services Assistant) said R132 was found with drugs during a search of her belongings. V13 said R132 was presenting with altered mental status, and the team discussed the matter, and thought a search of R132 belonging should be conducted. V13 said during the search, V12 (social service director) found 3 pills in R132's bag. V13 said the pills were in the foil package, it was 2 white pills and a yellow pill. V13 said the pills were given to the nurse, who informed her and V13 the medication was R132's prescription medication. V13 said she heard V12 tell R132 if the facility can not search her belongings that she would have to sign AMA (Against Medical Advice). V13 then said R132 wanted to leave. She heard R132 tell her boyfriend to come and pick her up. V13 said V12 initiated the conversation about R132 signing out AMA, first. V13 was asked why she used the word drugs if they knew the medication was prescription medication that was prescribed to R132. V13 said she was just there to witness. V13 then said R132's boyfriend had a history of bring drugs to the facility. V13 said she is not aware of any incidents or complaints of R132's boyfriend bring illicit drugs to the facility. V13 said she is not aware of R132's medical background, and she does not know if R132 is on any medical conditions that would alter R132's mental status. V13 continued to say she was there just to witness; she was not involved in the situation. On 10/17/22 at 12:41 PM, V12 (Social Service Director) said R132 was on her caseload, and on 9/29/22, she was made aware R132 was drug seeking (meaning R132 was asking for pain meds that was outside of the time frame to be given), and R132 had altered mental status. V12 said she obtained consent from R132 to search her belongings, and during the search, drugs were found. V12 said the nurse (V28) identified the drugs as medication prescribed to R132. V12 said R132 is not supposed to have any medication in her possession, and this was reviewed with R132 on admission. V12 said she did not find illicit drugs in R132's possession. V12 said she did not see R132 using illicit drugs during her stay at the facility. V12 said R132 was on the phone with her boyfriend during the search, and she heard R132 tell her boyfriend she wanted to leave the facility. V12 said that's when she gave R132 the AMA paperwork to sign, because R132 was saying she wanted to leave. V12 said she had the AMA document with her when she entered R132's room; she carries the document around with her. V12 was asked if R132 wanted to leave for a little while or for good. V12 continue to say R132 wanted to leave the facility. V12 said R132 was admitted to the facility for dialysis, and R132 was calling 911 to take her to the hospital once for pain. V12 said R132 has medical conditions, but she is not entirely familiar with all R132 conditions. V12 said V2 (Director of Nursing) informed her she talked to the Medical Director and the Medical Director told them to search R132's room. V12 said she is not aware if R132 had medical condition that would cause R132 to have altered mental status. V12 said she doesn't know if R132 could walk. V12 said R132's BIMS score was 15, and with a BIMs score of 15, the resident is allowed to sign AMA. V12 said she did not review the risk and benefits of signing AMA with R132. V12 said R132 was admitted to the facility for skilled care. V12 was asked if she was aware R132 had a central line, was receiving dialysis and had a dialysis catheter, was receiving pressure ulcer treatment, and R132 said she could not walk. V12 was asked if R132 needed any referrals upon discharging. V12 said she is not aware of all of R132's medical conditions, and R132 was able to sign AMA because her BIMS score was 15. V12 said she is unaware of R132's current location. On 10/17/22 at 2:53 PM, V28 (Nurse supervisor) said she was the supervisor on duty on 9/29/22. V28 said sometime after lunch, she was informed R132 was requesting a pain medication that was not prescribed to her. V28 said when she spoke to R132, she informed R132 the medication was not prescribed, and so that's when she got the social service department involved with counseling R132. V28 said she was not involved in the AMA/discharge process for R132. V28 said V12 made her aware they found pills in R132's possession when they searched R132's room and belongings. V28 said V12 showed her the pills, it was 3 pills, a blood thinner, a Benadryl, and a hypertension medication. V28 said the medication was in its package, and she was able to read the name of the medication. V28 said the medication was R132's prescription medication( prescribed meds not facility provided) . V28 said when V12 approached her with the pills, that's when she informed her R132 signed out AMA. V28 said she did not see the document; she did not review the document. V28 said she did not review the AMA document or policy with R132. V28 said she did not review R132's medical diagnosis with her; she did not review R132's medical conditions with her. V28 said she did not contact the physician regarding the AMA situation with R132. V28 said she did not give R132 her medications from the facility. V28 said she assumed V12 talked to R132 about the risk and benefits of signing against medical advice. V28 said the nurse assigned to R132 was from the agency, and she doesn't know if the agency nurse is familiar with the facility AMA policy and practice. V28 said she does not know if the agency nurse reviewed the AMA policy and protocol with R132. V28 said she is unaware of R132's current location. On 10/18/22 at 11:40 Am, V2 (DON- Director of Nursing) said she did not want to admit R132 to the facility and she informed the facility of this. V2 said she did not want to admit R132 because R132 was trouble, and she knew R132 from a previous facility. V2 said the Medical Director did not give her an order to search R132's room/belongings. V2 said she was in communication with the Medical Director days prior to 9/29/22, and they discussed R132's behavior. V2 said R132 was confused when communicating with the nurse, and her behavior was different after R132's boyfriend had visited, but she does not know the dates. V2 said V12 made her aware she searched R132's room and drugs were found. V2 said the drugs were a empty pill bottle, one narcotic pill. V2 said she can't remember what the other pill was. V2 said she destroyed the pill and threw the pill bottle away. V2 said she does not remember what the alleged narcotic was that she destroyed. V2 continued to say she never wanted R132 to be admitted to the facility. V2 said she did not document what drugs that she destroyed. During the interview with V13, she was certain there was only 3 pills found in R132's room during the search. During the interview with V12, V12 only mentioned finding 3 pills and stated she took those pills to the nurse. V12 never mentioned taking any pills to V2, nor did she mention finding a empty pill bottle. On 10/18/22 at 10:45 AM, V11 (Medical Doctor) said R132 was under his care at the facility, and someone did contact him and inform him R132 signed out AMA and she was leaving, and drugs were found and R132 had drugs in her possession. V11 said no one at the facility informed him R132 had a central line, or R132 was receiving wound care for pressure ulcers. He did not know R132 had vision disturbance to the right eye, and he was not aware R132 could not ambulate independently and used a wheelchair for mobility. V11 said he was aware R132 was receiving dialysis. V11 was made aware that during this survey, no staff at the facility said R132 was observed taking any drugs; no one at the facility mentioned they saw R132 attempt to take extra medication. V11 said R132 should not have medication in her possession, since R132 have a history of substance abuse. V11 said he's not familiar with the facility AMA policy/ practice and the facility has a team of people that handles the AMA process. V11 said if he would have been made aware of R132 entire clinical picture and all the circumstance surrounding the alleged AMA, he would have disagreed with the discharge and have R132 sent to the hospital for further care if she wanted to leave. On 10/19/22 at 12:33 PM, V27 (Nurse) said she was the assigned nurse for R132 on 9/29/22, and she's an agency nurse. V27 said the facility did not provide training to her for AMA or discharging residents. V27 said she was not involved in the AMA/ discharge process for R132. V27 said she did not review the AMA risk and benefits with R132, she did not review R132's medical conditions with her, she did not review R132's medications with her, and she did not give R132 her medications when she left the facility. V27 said she did call the V11 (Medical Doctor) and informed him R132 had signed out AMA, and R132 was leaving the facility. V11 said the physician did not give any orders. V27 said she did not review R132's current condition with V11, she did not review R132's medical history with V11, she did not review with the physician that R132 had a central line, a dialysis line, pressure ulcers, or R132's ambulation status. V27 said she does not know if R132 could walk. V27 said she assumed the medical doctor knew of R132's medical condition because he said, the one that's on dialysis. V27 said she does not know where R132 went, but someone at the facility told her they saw a fire truck outside the facility that evening. V27 said the hospital called the facility and she informed them R132 signed out AMA. V27 said she did not see the AMA document for R132. On 10/18/22 at 12:12 PM, V4 (CNA- Certified Nursing Assistant) said she was the aide assigned to R132 on 9/29/22, and R132 left the facility around dinner time, around 530pm-6:00pm. V4 said she remembers this because she told R132 and her boyfriend she would escort R132 after they pass out the dinner trays, but they left the facility. V4 said she was told R132 had to go. V4 said that's what the staff told her. V4 declined to give the name of the staff that said R132 had to go. V4 said R132 was crying and saying, I did not have any drugs. V4 said she gathered R132 things for her. R132 progress notes, dated 9/29/22 at 4:53 PM, completed by V28, shows in-part, resident signed out Against Medical Advice. Paperwork was signed. Resident had violated terms of stay and continues to use vulgar language. Transport to hospital offered due to complaint of severe pain and was refused. Resident states boyfriend is on his way to pick her up. Writer explained importance of going to seek medical assistance due to medical complexities, but resident continues to refuse. Resident has central venous access in place as well as dialysis port. Per resident, she does not want to go to hospital to have CVC ( central venous line) removed. Resident states I don't want to be here and nobody wants me anywhere and everyone is so unfair. Further teaching ineffective. R132 progress notes, dated 9/29/22 at 4:45 PM completed by V27, shows in part, Called and spoke with V11 (medical doctor) made him aware that R132 was leaving AMA and that she had signed the paperwork to confirm. No new orders received. R132's community access observation, dated 9/26/22 completed by V12, shows R132 is unable to participate in this community access observation attributed to her exhibited impaired mobility status and exhibited ongoing substance abusive behavioral symptoms, R132 requires proper supervision while accessing the community. Score is 2- resident may not access the community independently related to recent change in medical status. R132's psychosocial assessment, dated 9/27/22 completed by V12, shows in-part, the resident goals while admitted to this facility-R132 has goals to ensure her diagnosed chronic medical health condition are stabilized and maintained approximately by skilled staff daily. Resident project duration of stay- long term care. What is the resident attitude about discharge- does not desire to be discharged . R132's care plan with problem start date ranging from 9/20/22 to 9/26/22 shows in part, R132 is at risk for falls R/T(related to) impaired mobility, R132 is at risk for abuse due to her exhibited impaired mobility status and ongoing substance abusive behavioral symptoms, R132 may not access community independently attributed to her exhibited impaired mobility status and exhibited ongoing substance abusive behavioral symptoms, and R132 plans to stay at the facility for long term care, R132 needs will be anticipated and met daily through next review, staff will attempt to anticipate R132 care and service needs daily to ensure they are being met, staff will encourage R132 to participate in facility structured programming weekly, staff will invite R132 and her family to quarterly care conferences. R132 is at risk for pain R/T Dx (diagnosis) of multiple wounds. R132's hospital note, dated 9/30/22, shows in part, [AGE] year-old patient with past medical history of t12-L osteomyelitis on long-term antibiotics from nursing home, chronic abdominal pain, chronic opioid-induced constipation, prescription opioid dependence, chronic pain syndrome, depression, seizure disorder, hypothyroidism, GERD, dyslipidemia, diastolic heart failure, ESRD on dialysis, hypertension, sacral stage 4 wound. Patient states she was kicked out the nursing home, however, per Nursing Home patient left AMA. Patient called ambulance from the nursing home outside and presented to ED at (hospital name). Assessment and plan, osteomyelitis with concerns for abscess on IV antibiotics, sacral stage 4 wound, right hip pressure injury stage 3, ESRD on HD (hemodialysis) hypertension, chronic diastolic heart failure, diabetic retinopathy bilateral eyes, right eye vitreous, history of CVA (stroke), bilateral leg weakness, physical debility, chronic abdominal pain, mood disorder, seizure disorder. Patient Nursing home is refusing to take her back. Review of R132's progress notes shows there is no documentation noted for the date and time the discharge was made, the name and title of the individual who assisted in the discharge, all assessments data obtained during the procedures; if applicable, how the resident tolerated the procedures; if applicable, if the resident refused the discharged , the reason why and the interventions taken, the signature and title of the person recording the data. There is no documentation noted prior to R132 leaving, that the facility informed the resident and/ or the legal representative, in terms he or she can understand, of the resident current treatment regimen including, but not limited to treatment for skin conditions, assistance with ambulating, transfer, toileting, feeding and bathing. Whether outside services are provided such as dialysis, chemotherapy, radiation therapy, respiratory, physical, occupational, and speech therapy and special dietary, needs, if any. If the resident or legal representative refuses information, the facility should mail information if an address is provided. There is no documentation that the Information given regarding the facility policy was recorded in the resident's clinical record and given to the resident or their representative in writing. There is no documentation noted that a facility representative request the resident or legal representative to provide information on where the resident is going: the address and telephone number. Facility resident rights policy, dated 11/2018 show,s in part, you have a right to make your own choices, your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life, your facility must ensure that you are free from retaliation and discrimination in exercising your right, your facility must provide services to keep your physical and mental health at their highest practical levels, you have the right to request, refuse, and discontinue any treatment, if you refuse treatment, your facility must tell you what may happen because of your refusal and tell you of other possible treatments, you have the right to keep living in your facility, you must be given written notice if your facility wants you to move from the facility, the reason for asking you to leave must only be for the following reason; you are a danger to yourself or others, your needs cannot be met by the facility, your health has improved and you no longer need the services of a long term care facility, you have not paid your bill after reasonable notice, and your facility closes, the notice must tell you why your facility wants you to move, tell you how to appeal the decision to the Illinois department of public health, provide a stamped and addressed envelope for you to mail your appeal in, and be received 30 days prior to the day they want you to move from Medicare or Medicaid certified facility, be received 21 days prior to the day they want you to move from a state licensed facility. Before your facility can transfer or discharge you, it must prepare you to be sure that the discharge is safe and appropriate. Facility policy titled Transfer and discharges, effective date of 9/2016, shows in part, to assure resident transfer and discharges will be conducted in accordance with residents' rights, physician orders, and in such manner as to maintain continuity of care for the resident. The facility shall permit all residents to remain in the facility and not transfer or discharge except in those circumstances outlined in the residents rights and in according with state-outlined involuntary relocation procedures, when the facility transfer or discharge a resident under any circumstance, the resident/ authorized legal representative must be notified verbally and in writing at least 30 days prior to the intended discharge unless the resident waives the notification period or in an emergency situation( including situations where the safety of other residents may be compromised). The facility must also notify and receive an order from the resident's physician regarding transfer/ discharge. Include in the written notice to the resident/ authorized legal representative the following: reason for transfer/ discharge, effective date of transfer/ discharge, location to which the resident will be transferred/ discharged , a statement that the resident has the right to appeal the action to the state. Social service personnel will coordinate development and implementation of the resident's discharge plan within 21 days of admission. Prior to voluntary discharge A licensed nurse shall evaluate the resident functional abilities and identify strengths, weakness and post discharge resident or care takers teaching needs and social services personnel shall evaluate the resident economic, psychological and social resources needs. In the event a resident or authorized legal representative request discharge against medical advice (AMA), a licensed nurse is responsible for informing the resident of the possible consequence of not following the physician orders. The facility designee will be request of the resident or spouse to sig all discharge records including AMA form. The attending physician and authorized legal representative will be promptly notified when a resident request to leave AMA. For any resident who leaves the facility AMA, medications shall be released to the resident/ authorized legal representative when ordered by the physician. Facility policy Titled Discharge Against Medical Advice, dated 3/2019, shows in part, It is the policy of this facility that a resident has the right to sign themselves out of the facility without the consent of or an order from their attending physician. If the resident exercise this right, he or she will discharge from facility against medical advice (AMA). To define the facility responsibilities when a resident voluntary discharge himself or herself from the facility without the consent of an order from his/ her attending physician. The resident and or legal representative has the right to discharge the resident without consent of or an order from the attending physician and against the attending physician medical advice. Any resident or legal representative removing the resident from the facility without the consent of or an order from the attending physician, will be requested to sign the AMA form. Prior to leaving the facility the resident or the legal representative will be informed, in terms he or she can understand, the resident current medical condition, including diagnosis. Before leaving the facility, the resident or legal representative will be informed in terms he or she can understand, of the resident medication regimen including medication name, reason/use of medication, dosage and administration times. Medication may be given to the resident or their legal representative if the attending physician or medical director is willing to provide an order to do so. The facility should follow medication disposition procedures for any remaining medication. Prior to leaving the facility the facility should attempt to inform the resident and/ or the legal representative, in terms he or she can understand, of the resident current treatment regimen including, but not limited to treatment for skin conditions, assistance with ambulating, transfer, toileting, feeding and bathing. Whether outside services are provided such as dialysis, chemotherapy, radiation therapy, respiratory, physical, occupational, and speech therapy and special dietary, needs, if any. If the resident or legal representative refuses information, the facility should mail information if an address id provide. Information given regarding 4, 5, and 6 will be recorded in the resident's clinical record and given to the resident or their representative in writing. A facility representative will request the resident or legal representative to provide information on where the resident is going: the address and telephone number. Facility policy titled Discharging the resident, dated 8/2008, shows in part, The procedures is to provide guidelines for the discharge process, the resident should be consulted about the discharge, discharge can be frightening to the resident, approach the discharge in a positive manner, assess and document residents condition at discharge, including skin assessment, if medical condition allows. The following should be recorded in the residents medical records, the date and time the discharge was made, the name and title of the individual who assisted in the discharge, all assessments data obtained during the procedures, if applicable, how the resident tolerated the procedures, if applicable, if the resident refused the discharged , the reason why and the interventions taken, the signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their transfer and discharge policy and give a 30 day notice of plan to discharge to 1 resident (R132) reviewed for discharge notice in a sample of 133. Findings Include: R132 face sheets documents R132 has diagnosis of other seizures, hypothyroidism, essential hypertension, intraspinal abscess, pressure ulcer, end stage renal disease, anemia, personal history of venous thrombus, depression, history myocardial infraction, congestive heart failure, anxiety, GERD, vertigo, osteoporosis, chronic pain, and diabetes mellitus. On 10/17/22 at 3:59 PM, R132 said the social worker at the facility asked her if they could search her belongings, and she signed consent for the search. R132 said when searching her belongings, the facility said they found drugs in her belongings. R132 said that's when she told them they could no longer search her things, because she knew she did not have drugs, and she did not know what they was talking about, R132 said she did not have any drugs in her belongings. R132 said the facility found 2 or 3 prescription pills in her belongings. R132 said once she asked them to stop searching her things, the social worker then said to her, If we can't search your things you have to leave and you already signed an AMA (Against Medical Advice). R132 said she did sign for the facility to search her things; she was not aware she was really signing AMA. R132 said that's when she called her boyfriend, and told him what was going on, and asked him to come to the facility because the facility is saying she had drugs in her belongings. R132 said as she was on the phone with her boyfriend, the social worker continued to persist that she had drugs, she said fine I will leave then. R132 said she didn't have anywhere else to go. R132 said she has bedsores, she's on dialysis, she has bad back pain, and she can't walk. R132 said she can't see well out of her right eye. R132 said that's why her signature on scribbled on her documents, because her vision is not good in the right eye. R132 said when her boyfriend arrived at the facility, two CNA's put her in a wheelchair and escorted her out the facility front door. R132 said her boyfriend called his aunt to pick them up, but she could not fit in the vehicle, and that's when she called 911 and the paramedics came and took her to the hospital. R132 said the facility did not give her R132's medications. The facility did not review her medical diagnosis with her, the facility did not call the medical doctor that she is aware of, the facility did not give her any paperwork, and the facility did not review with her the risk of leaving against medical advice. R132 said the facility did not give her a 30 day notice of plan to discharge. Review of R132's progress notes, shows there is no documentation noted for 30 day notice of plan to discharge. R132's hospital notes, dated 9/30/22, shows in part, [AGE] year-old patient with past medical history of t12-L osteomyelitis on long-term antibiotics from nursing home, chronic abdominal pain, chronic opioid-induced constipation, prescription opioid dependence, chronic pain syndrome, depression, seizure disorder, hypothyroidism, GERD, dyslipidemia, diastolic heart failure, ESRD on dialysis, hypertension, sacral stage 4 wound. Patient states she was kicked out the nursing home, however per Nursing Home patient left AMA. Patient called ambulance from the nursing home outside and presented to ED at (hospital name). Assessment and plan, osteomyelitis with concerns for abscess on IV antibiotics, sacral stage 4 wound, right hip pressure injury stage 3, ESRD on HD (hemodialysis) hypertension, chronic diastolic heart failure, diabetic retinopathy bilateral eyes, right eye vitreous, history of CVA (stroke), bilateral leg weakness, physical debility, chronic abdominal pain, mood disorder, seizure disorder. Patient Nursing home is refusing to take her back. On 10/17/22 at 12:41 PM, V12 (Social Service Director) denied giving R132 a 30 notice of plan to discharge. Facility policy titled Transfer and discharge; regular or 30 day IDT shows in -part when the facility transfer or discharge a resident under any circumstance, the resident/ authorized legal representative must be notified verbally and in writing at least 30 days prior to the intended discharge unless the resident waives the notification period or in an emergency situation( including situations where the safety of other residents may be compromised). The facility must also notify and receive an order from the resident's physician regarding transfer/ discharge.

Based on interview and record review, the facility failed to ensure resident assessments accurately reflect the resident's current status for 1 resident (R99) out of 3 reviewed for special treatments and programs in a sample of 133. Findings include: On 10/17/22 3:05 PM, V14 (Minimum Data Set/MDS coordinator) stated resident assessments are completed upon admission, quarterly, and with any significant change. V14 stated she reviews the resident's medical record for hospice orders. V14 stated she also receives an updated list of all residents in facility receiving hospice care from social services. V14 stated she does not recall if R99 is currently on hospice care. R99's MDS (Minimum Data Set), dated 9/1/22, was reviewed with V14. V14 stated it notes R99 is receiving hospice care. R99's POS reviewed with V14. V14 stated R99's order for hospice was discontinued on 3/10/22. V14 stated she will need to complete a modification of R99's assessments to remove hospice services. On 10/17/22 3:15 PM V12 (Director of Social Services) stated she has a binder with list of all residents currently receiving hospice care. V12 stated R99 is not currently receiving hospice services. V12 stated R99 was receiving hospice services from 6/2/21 until 9/24/21. Review of R99's MDS (Minimum Data Set), dated 12/1/2021, 3/2/22, 6/2/22, and 9/1/22, notes R99 is receiving hospice services. Review of R99's discontinuation of hospice services document is dated 9/24/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan to incliude fall interventions and the use of psychopharmacologic medications. This affects 3 residents (R2, R90, and R99) out of three residents reviewed for care plans in a sample of 133. Findings include: 1. Review of R2's medical record, dated 8/18/22, notes R2 slid out of wheelchair onto floor. Review of R2's falls care plan, dated 5/6/22, notes R2 is at risk for falls related to abnormalities of gait and mobility. Intervention identified: R2 will be protected from injury/trauma. Review of R2's medical record, dated 6/7/22, notes R2 developed a wound on right distal first toe, full thickness. There is no documentation found in R2's medical record noting a care plan was developed related to R2's right toe wound or ADLs (activities of daily living). 2. Review of R99's medical record, dated 2/18/22, notes R99 was observed lying on the floor; unwitnessed fall. Review of R99's falls care plan, dated 6/9/22, notes R99 is at risk for falls related to diagnosis of abnormalities of gait and mobility. Intervention identified: R99 will be protected. On 10/17/22 3:20 PM, V2 DON (Director of Nursing) stated the nurse completes the fall assessments on residents; V14 (MDS coordinator) is responsible for falls care plans. R99's fall care plan reviewed with V2. When asked to clarify what the intervention '(R99) will be protected' means, V2 responded that she does not know what it means. V2 stated that this is not an appropriate intervention. 3. R90 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia and psychosis. R90's care plan does not document any care plan for psychopharmacologic drug use. On 10/19/22 at 2:24 PM, V3, ADON (Assistant Director of Nursing) stated residents receiving an antipsychotic medication should have a care plan specific for that medication. V3 stated this facility does not have a system in place to monitor resident's behavior to determine the effectiveness of the medication. V3 stated any problem areas, wound(s), identified should be addressed on the resident's care plan. Review of this facility's comprehensive care plan policy, updated 04/2015, notes the facility's care planning/interdisciplinary team, in coordination with the resident, his/her family or his/her representative, develops and maintains a comprehensive care plan for each resident. Each resident's comprehensive care plan has been designed to: incorporate identified problem areas, reflect treatment goals and objectives in measurable outcomes. Review of this facility's psychopharmacologic drug use procedure, undated, notes psychopharmacologic drug usage must be addressed in the care plan and reassessed at least every 90 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop, coordinate, and initiate a safe discharge for a vulnerable dependent resident. This affected 1 of 3 residents (R132) reviewed for safe discharge. Findings include: R132's facility face sheet shows R132 has diagnosis of other seizures, hypothyroidism, essential hypertension, intraspinal abscess, pressure ulcer, end stage renal disease, anemia, personal history of venous thrombus, depression, history myocardial infraction, congestive heart failure, anxiety, GERD, vertigo, osteoporosis, chronic pain, and diabetes mellitus. R132's discharge MDS (Minimum Data Set), dated 9/29/22, shows, discharged , return not anticipated, discharged to community, BIMS ( cognitive status) is blank, cognitive skills for daily decision making is 2 moderately impaired, other behavior not directed toward others, rejection of care. Section G for functional status shows R132 needs extensive assist with bed mobility, transfers, locomotion on and off unit, dressing, and toilet use and personal hygiene, walking in room and in corridor did not occur, and R132 requires supervision with eating. Section H shows R132 has indwelling catheter. Section I shows diagnosis of seizures, anemia in chronic kidney disease, depression, intraspinal abscess and granuloma, pressure ulcer, osteomyelitis of vertebra thoracic region, end stage renal disease. Section N shows medications received in last 7 days are antidepressants, anticoagulants. Review of R132's care plan shows there is no plan of care noted for discharge planning. Review of R132's assessments show there were no discharge plans noted for R132. On 10/17/22 at 3:59 PM, R132 said the social worker at the facility asked her if they could search her belongings, and she signed consent for the search. R132 said when searching her belongings, the facility said they found drugs in her belongings. R132 said that's when she told them they could no longer search her things, because she knew she did not have drugs, and she did not know what they was talking about. R132 said she did not have any drugs in her belongings. R132 said the facility found 2 or 3 prescription pills in her belongings. R132 said once she asked them to stop searching her things, the social worker then said to her, If we can't search your things you have to leave and you already signed an AMA (Against Medical Advice). R132 said she did sign for the facility to search her things; she was not aware she was really signing AMA. R132 said that's when she called her boyfriend and told him what was going on, and asked him to come to the facility, because the facility is saying she had drugs in her belongings. R132 said as she was on the phone with her boyfriend, the social worker continued to persist that she had drugs; she said fine I will leave than. R132 said she didn't have anywhere else to go. R132 said she has bedsores, she's on dialysis, she has bad back pain, and she can't walk. R132 said she can't see well out of her right eye. R132 said that's why her signature is scribbled on her documents, because her vision is not good in the right eye. R132 said when her boyfriend arrived at the facility, two CNA's put her in a wheelchair and escorted her out the facility front door. R132 said her boyfriend called his aunt to pick them up, but she could not fit in the vehicle, and that's when she called 911 and the paramedics came and took her to the hospital. R132 said the facility did not give her, her medications. The facility did not review her medical diagnosis with her, the facility did not call the medical doctor that she is aware of, the facility did not give her any paperwork, the facility did not review with her the risk of leaving against medical advice. R132 said the facility did not give her a 30 day notice of plan to discharge. On 10/17/22 at 12:41 PM, V12 (Social Service Director) said R132 she did not develop a discharge plan for R132. V12 said she does not know the where R132 is currently located. Review of R132's progress notes shows there is no documentation noted for the date and time the discharge was made, the name and title of the individual who assisted in the discharge, all assessments data obtained during the procedures, if applicable, how the resident tolerated the procedures, if applicable, if the resident refused the discharged , the reason why and the interventions taken, the signature and title of the person recording the data. There is no documentation noted prior to R132's leaving the facility that the facility informed the resident and/ or the legal representative, in terms he or she can understand, of the resident current treatment regimen including, but not limited to treatment for skin conditions, assistance with ambulating, transfer, toileting, feeding and bathing. Whether outside services are provided such as dialysis, chemotherapy, radiation therapy, respiratory, physical, occupational, and speech therapy and special dietary, needs, if any. If the resident or legal representative refuses information, the facility should mail information if an address is provide. There is no documentation that the Information given regarding the facility policy was recorded in the resident's clinical record and given to the resident or their representative in writing. There is no documentation noted that a facility representative request the resident or legal representative to provide information on where the resident is going: the address and telephone number. R132's hospital note, dated 9/30/22, shows in part, [AGE] year-old patient with past medical history of t12-L osteomyelitis on long-term antibiotics from nursing home, chronic abdominal pain, chronic opioid-induced constipation, prescription opioid dependence, chronic pain syndrome, depression, seizure disorder, hypothyroidism, GERD, dyslipidemia, diastolic heart failure, ESRD on dialysis, hypertension, sacral stage 4 wound. Patient states she was kicked out the nursing home, however per Nursing Home patient left AMA. Patient called ambulance from the nursing home outside and presented to ED at (hospital name). Assessment and plan, osteomyelitis with concerns for abscess on IV antibiotics, sacral stage 4 wound, right hip pressure injury stage 3, ESRD on HD (hemodialysis) hypertension, chronic diastolic heart failure, diabetic retinopathy bilateral eyes, right eye vitreous, history of CVA (stroke), bilateral leg weakness, physical debility, chronic abdominal pain, mood disorder, seizure disorder. Patient Nursing is refusing to take her back. Facility policy discharging the resident, dated 8/2008, shows in part, the procedures is To provide guidelines for the discharge process, the resident should be consulted about the discharge, discharge can be frightening to the resident, approach the discharge in a positive manner, assess and document residents condition at discharge, including skin assessment, if medical condition allows. The following should be recorded in the residents medical records, the date and time the discharge was made, the name and title of the individual who assisted in the discharge, all assessments data obtained during the procedures, if applicable, how the resident tolerated the procedures, if applicable, if the resident refused the discharged , the reason why and the interventions taken, the signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their discharge policy and supply the resident a discharge summary and or discharge records for continuity of care. This affects 1 resident (R132) reviewed for discharge summary. Findings nclude: Review of R132's care plan shows there is no plan of care noted for discharge planning. Review of R132's assessments shows there were no discharge plans noted for R132. R132's facility face sheet shows R132 has diagnosis of other seizures, hypothyroidism, essential hypertension, intraspinal abscess, pressure ulcer, end stage renal disease, anemia, personal history of venous thrombus, depression, history myocardial infraction, congestive heart failure, anxiety, GERD, vertigo, osteoporosis, chronic pain, and diabetes mellitus. R132's discharge MDS (Minimum Data Set), dated 9/29/22, shows discharged , return not anticipated, discharged to community, BIMS (Brief Interview for Mental Status) ( cognitive status) is blank, cognitive skills for daily decision making is 2 moderately impaired, other behavior not directed toward others, rejection of care. Section G for functional status shows R132 needs extensive assist with bed mobility, transfers, locomotion on and off unit, dressing, and toilet use and personal hygiene, walking in room and in corridor did not occur, and R132 requires supervision with eating. Section H shows R132 has indwelling catheter. Section I shows diagnosis of seizures, anemia in chronic kidney disease, depression, intraspinal abscess and granuloma, pressure ulcer, osteomyelitis of vertebra thoracic region, end stage renal disease. Section N shows medications received in last 7 days are antidepressants, anticoagulants. On 10/17/22 at 3:59 PM, R132 said the social worker at the facility asked her if they could search her belongings, and she signed consent for the search. R132 said when searching her belongings, the facility said they found drugs in her belongings. R132 said that's when she told them they could no longer search her things because she knew she did not have drugs, and she did not know what they were talking about. R132 said she did not have any drugs in her belongings. R132 said the facility found 2 or 3 prescription pills in her belongings. R132 said once she asked them to stop searching her things, the social worker then said to her, If we can't search your things you have to leave and you already signed an AMA (Against Medical Advice). R132 said she did sign for the facility to search her things; she was not aware she was really signing AMA. R132 said that's when she called her boyfriend and told him what was going on, and asked him to come to the facility because the facility is saying she had drugs in her belongings. R132 said as she was on the phone with her boyfriend, the social worker continued to persist that she had drugs, she said fine I will leave than. R132 said she didn't have anywhere else to go. R132 said she has bedsores, she's on dialysis, she has bad back pain, and she can't walk. R132 said she can't see well out of her right eye. R132 said that's why her signature is scribbled on her documents, because her vision is not good in the right eye. R132 said when her boyfriend arrived at the facility, two CNA's put her in a wheelchair and escorted her out the facility front door. R132 said her boyfriend called his aunt to pick them up, but she could not fit in the vehicle, and that's when she called 911 and the paramedics came and took her to the hospital. R132 said the facility did not give her R132's medications. The facility did not review her medical diagnosis with her, the facility did not call the medical doctor that she is aware of, the facility did not give her any paperwork, the facility did not review with her the risk of leaving against medical advice. R132 said the facility did not give her a 30 day notice of plan to discharge. On 10/17/22 at 12:41 PM, V12 (Social Service Director) said she did not develop a discharge plan for R132. V12 omitted developing, documenting, and giving R132 a discharge summary/records. V12 said she does not know the where R132 is currently located. On 10/17/22 at 2:53 PM, V28 (Nurse supervisor) said she did not complete a discharge summary for R132; she did not give R132 any discharge records. On 10/19/22 at 12:33 PM, V27 (Nurse) said she did not complete a discharge summary for R132. V27 said she did not give R132 any discharge records. V27 said she did not have any involvement with the discharge except for notifying the physician. R132's hospital notes, dated 9/30/22, shows in part, [AGE] year-old patient with past medical history of t12-L osteomyelitis on long-term antibiotics from nursing home, chronic abdominal pain, chronic opioid-induced constipation, prescription opioid dependence, chronic pain syndrome, depression, seizure disorder, hypothyroidism, GERD, dyslipidemia, diastolic heart failure, ESRD on dialysis, hypertension, sacral stage 4 wound. Patient states she was kicked out the nursing home, however per Nursing Home patient left AMA. Patient called ambulance from the nursing home outside and presented to ED at (hospital name). Assessment and plan, osteomyelitis with concerns for abscess on IV antibiotics, sacral stage 4 wound, right hip pressure injury stage 3, ESRD on HD (hemodialysis) hypertension, chronic diastolic heart failure, diabetic retinopathy bilateral eyes, right eye vitreous, history of CVA (stroke), bilateral leg weakness, physical debility, chronic abdominal pain, mood disorder, seizure disorder. Patient Nursing home is refusing to take her back. Review of R132's progress notes shows there is no documentation noted for the date and time the discharge was made, the name and title of the individual who assisted in the discharge, all assessments data obtained during the procedures; as applicable, how the resident tolerated the procedures; as applicable, if the resident refused the discharged , the reason why and the interventions taken, the signature and title of the person recording the data. There is no documentation noted prior to R132's leaving the facility that the facility informed the resident and/ or the legal representative, in terms he or she can understand, of the resident current treatment regimen including, but not limited to treatment for skin conditions, assistance with ambulating, transfer, toileting, feeding and bathing. Whether outside services are provided such as dialysis, chemotherapy, radiation therapy, respiratory, physical, occupational, and speech therapy and special dietary, needs, if any. If the resident or legal representative refuses information, the facility should mail information if an address id provide. There is no documentation that the Information given regarding the facility policy was recorded in the resident's clinical record and given to the resident or their representative in writing. There is no documentation noted that a facility representative request the resident or legal representative to provide information on where the resident is going: the address and telephone number. Facility policy titled Discharging the resident, dated 8/2008, shows in part the procedures is To provide guidelines for the discharge process, the resident should be consulted about the discharge, discharge can be frightening to the resident, approach the discharge in a positive manner, assess and document residents condition at discharge, including skin assessment, if medical condition allows. The following should be recorded in the residents medical records, the date and time the discharge was made, the name and title of the individual who assisted in the discharge, all assessments data obtained during the procedures, if applicable, how the resident tolerated the procedures, if applicable, if the resident refused the discharged , the reason why and the interventions taken, the signature and title of the person recording the data. Facility policy titled Transfer and discharges, effective date of 9/2016, shows in part To assure resident transfer and discharges will be conducted in accordance with residents' rights, physician orders, and in such manner as to maintain continuity of care for the resident. The facility shall permit all residents to remain in the facility and not transfer or discharge except in those circumstances outlined in the residents rights and in according with state-outlined involuntary relocation procedures, when the facility transfer or discharge a resident under any circumstance, the resident/ authorized legal representative must be notified verbally and in writing at least 30 days prior to the intended discharge unless the resident waives the notification period or in an emergency situation( including situations where the safety of other residents may be compromised). The facility must also notify and receive an order from the resident's physician regarding transfer/ discharge. Include in the written notice to the resident/ authorized legal representative the following: reason for transfer/ discharge, effective date of transfer/ discharge, location to which the resident will be transferred/ discharged , a statement that the resident has the right to appeal the action to the state. Social service personnel will coordinate development and implementation of the resident's discharge plan within 21 days of admission. Prior to voluntary discharge a licensed nurse shall evaluate the resident functional abilities and identify strengths, weakness and post discharge resident or care takers teaching needs and social services personnel shall evaluate the resident economic, psychological and social resources needs. social services shall evaluate the resident economic, psychological and social resource needs. At the time of discharge, the post discharge plan will be presented both orally and in writing to the resident/ authorized legal representative in terms they understand. The post discharge plan shall be maintained in the clinical records and shall include the following: previously identified resident needs after discharge and plan for providing care/ services, resident or caregivers education needs and pro visions for instruction, community services required, referrals to services as needed and current information relative to the diagnosis, prior treatment, rehabilitation potential and progress towards goals. Physician will be requested to provide prescription for residents going home with new medication orders. Medication shall be released to discharged residents only when ordered by a physician. In the event a resident or authorized legal representative request discharge against medical advice (AMA), a licensed nurse is responsible for informing the resident of the possible consequence of not following the physician orders. The facility designee will be request of the resident or spouse to sign all discharge records including AMA form. The attending physician and authorized legal representative will be promptly notified when a resident request to leave AMA. For any resident who leaves the facility AMA, medications shall be released to the resident/ authorized legal representative when ordered by the physician. Facility policy Titled Discharge Against Medical Advice, dated 3/2019, shows in part It is the policy of this facility that a resident has the right to sign themselves out of the facility without the consent of or an order from their attending physician. If the resident exercise this right, he or she will discharge from facility against medical advice (AMA). To define the facility responsibilities when a resident voluntary discharge himself or herself from the facility without the consent of an order from his/ her attending physician. The resident and or legal representative has the right to discharge the resident without consent of or an order from the attending physician and against the attending physician medical advice. Any resident or legal representative removing the resident from the facility without the consent of or an order from the attending physician, will be requested to sign the AMA form. Prior to leaving the facility the resident or the legal representative will be informed, in terms he or she can understand, the resident current medical condition, including diagnosis. Before leaving the facility, the resident or legal representative will be informed in terms he or she can understand, of the resident medication regimen including medication name, reason/use of medication, dosage and administration times. Medication may be given to the resident or their legal representative if the attending physician or medical director is willing to provide an order to do so. The facility should follow medication disposition procedures for any remaining medication. Prior to leaving the facility the facility should attempt to inform the resident and/ or the legal representative, in terms he or she can understand, of the resident current treatment regimen including, but not limited to treatment for skin conditions, assistance with ambulating, transfer, toileting, feeding and bathing. Whether outside services are provided such as dialysis, chemotherapy, radiation therapy, respiratory, physical, occupational, and speech therapy and special dietary, needs, if any. If the resident or legal representative refuses information, the facility should mail information if an address id provide. Information given regarding 4, 5, and 6 will be recorded in the resident's clinical record and given to the resident or their representative in writing. A facility representative will request the resident or legal representative to provide information on where the resident is going: the address and telephone number.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to follow physician orders for one residents (R93) wound treatment for a diabetic heel ulcer for one of three residents reviewed for wounds. Findings include: R93 was admitted to the facility on [DATE], with a diagnosis of type II diabetes, end stage renal disease and hypertension. R93 physician order, dated 10/4/22, documents: cleanse wound with normal saline. Apply calcium alginate and wrap with (gauze dressing) three times a week. R93 wound care note, dated 10/11/22, documents: diabetic wound to left heel measuring 0.5x1.2x0.1cm. Dressing treatment plan continue alginate calcium three times a week. On 10/16/22 at 11:56 AM, V10(Nurse) removed gauze dressing from R93 left heel. V10 said there was no other treatment to site. V10 said she applied gauze dressing to left heel on 10/15/22, but did not have access to any wound care supplies, and just wrapped the foot with gauze dressing.

Based on observation, interview, and record review, the facility failed to follow physician's orders for splint application and failed to develop interventions to reduce or prevent the decline in mobility. This affected 2 of residents (R81, R2) reviewed for range of motion. Findings include: 1. R81 Physician orde,r dated 12/15/202,1 documents: Apply left hand splint daily as tolerated. On in AM off in PM. On 10/16/22 at 11:35 AM, R81 was observed with a left contracted hand. R81's fingers were closed in a fist. R81, who was assessed to be alert and oriented, said, I am supposed to have a carrot in my hand. On 10/16/22 at 4:43 PM, V9 (Restorative Nurse) said, (R81) has a splint for his hand. We follow the doctors orders. (R81's) splint should have been in place. 2. On 10/18/22 12:20 PM, V15, PTA (Physical Therapy Assistant) stated R2 is not currently receiving skilled therapy. V15 stated R2 was discharged from skilled therapy because R2 had plateaued in therapy. V15 stated skilled therapy provides recommendations in writing to restorative therapy, as well as a copy is given to medical records department. V15 stated R2 was discharged from skilled therapy on 8/18/22. V15 presented this surveyor with the referrals from physical therapy and occupational therapy to restorative therapy. V15 stated occupational therapy recommended active range of motion exercises. V15 stated physical therapy recommended bed mobility and therapeutic exercises to maintain R2's current level of function. On 10/18/22 at 1:07 PM, V9 (Restorative Nurse) stated restorative therapy is responsible for assessing residents ROM (range of motion), determining which restorative programs would be best for residents, and recommendations from skilled therapy for continued therapy. V9 stated a functional analysis is completed quarterly and annually on residents. V9 stated it is important for the resident to receive restorative programs to prevent further decline in ADL functional abilities. V9 stated R2's functional assessment completed on 10/4 is an error because R2 should be receiving AROM (active range of motion) and bed mobility programs. V9 stated V9 does not have any documentation noting R2 has been receiving restorative programs since 8/18/22, when R2 was discharged from skilled therapy. Review of R2's POS (physician order sheet), dated 8/18/22, occupational therapy discharge order/discontinue skilled occupational therapy services as R2 referred to restorative program. Review of R2's ADL (activities of daily living) functional assessment, dated 10/4/22, V9 (Restorative Nurse) noted R2 requires extensive assistance of 1-2 staff members with bed mobility, transfers, dressing, toileting, and bathing. Restorative nursing program recommendations: none.

Based on observations, interviews, and record reviews, the facility failed to follow their Oxygen Administration Policy by not administering oxygen rate as ordered by the physician. This affects one resident (R95) out of three residents reviewed for Respiratory Program. Findings Include: 1. R95's physician order includes Oxygen order with a start date of 3/12/22 reads: Oxygen: Trach Rate 6 liters per minute. Humidity 35%. Continuous: and Oxygen: Change tubing and mask weekly and PRN (as needed) (Label). On 10/16/22 at 10:45 AM, R95 was in bed. There was an Oxygen concentrator in room reading 5 liters per minute. On 10/16/22 at 10:50 AM, confirmed with V26 (Nurse) Oxygen level for R95 was at 5 liters per minute. V26 stated R95 was supposed to be on 6 liters per minute, as ordered by the attending physician. V26 observed adjusting oxygen concentrator from 5 liters per minute to 6 liters per minute. 2. R29's physician orders includes Oxygen order with a start date of 1/4/22 reads: Oxygen: Nasal Cannula, Rate Oxygen 3 liters per minute; And Oxygen: change tubing and mask weekly and PRN (as needed) (Label). On 10/16/22 at 11:45 AM, R29 is on oxygen administering at 3 liter per minute. Oxygen concentration in room, water bottle (bubbler) has no date and is almost empty. Oxygen tubing dated 9/28/22. On 10/16/22 at 12:45 PM, R29 called for assistance. V26 came to R29's room and R29 asked for the bottle to be change and the oxygen tubing. Confirmed with V26 the written date on the oxygen tubing was 9/28/22. On 10/18/22 at 1:58 PM, V2 (Director of Nursing) stated, The facility does weekly oxygen tubing and nebulizer tubing change. I am not sure how often we change Humidifier bottle (bubbler). If the bubbler is not working or dirty, it needs to be changed also. We change the suction machine kit (container and tubing) when they get dirty and after each use. We don't want to leave used suction canister with something in it, because it would harbor bacteria, and for good infection control practices, we have to change it after each use. Equipment Change Schedule Policy: Nasal Cannula, on admission and weekly (Monday) and PRN. Bubblers, on admission and weekly (Monday) and PRN. Oxygen Administration Policy with a revised date of March 2004, reads in part: The purpose of this procedure is to provide guidelines for safe oxygen administration. Start the flow of oxygen as ordered. Adjust the oxygen delivery so that it is comfortable for the residents and the proper flow of oxygen is being administered. Make sure the oxygen humidifier jar is labeled properly.

Based on observation, interview, and record review, the facility failed to reconcile controlled medication for 3 of 3 (R78, R79 and R94) reviewed for labeling and storage. Findings Include: On 10/17/22 at 3:57PM, V24 (nurse), said, I gave (R79's) lorazepam 1mg tablet by mouth at 2pm. I forgot to sign the medication out of the controlled drug receipt form. Its twenty-five pills in (R79's) bingo pack. (R79's) controlled drug form documents twenty-six pills left. The amount written on the controlled drug receipt form and the actual pills in the bingo card should be the same number. On 10/17/22 at 4:03 PM, during medication cart review with V24, R78 was observed with twenty pills of clonazepam 0.5mg in the bingo card. R78's controlled drug receipt form documents nineteen pills left. R94 was observed with five pills of lorazepam 0.5mg pills in the bingo card. R94's controlled drug form document six pill left. On 10/17/22 at 4:25 PM, V3 (Assistant Director of Nursing/ADON) said, Pills should be signed out as given. The controlled drug receipt should match the same number of bills in the bingo cards. Controlled Substance Storage Policy, dated 10/25/14, documents: medication included in the drug enforcement administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations.

Based on interviews and record reviews, this facility failed to obtain informed consent noting diagnosis or reason for medication, dosage, frequency, side effects, and benefits/risks prior to initiating psychotropic medication usage and monitor the effectiveness or adverse consequences of psychotropic medications by monitoring AIMS (Abnormal Involuntary Movement Scale) every 6 months. This affected 1 of 4 residents (R94) reviewed for psychotropic medication usage in a sample 133 Findings include: Review of R94's medical record notes R94 with diagnoses including major depressive disorder, anxiety disorder, and schizophrenia. On 10/17/22 3:20 PM, V2 DON (Director of Nursing) stated psychotropic medication consents are obtained by the nurse prior to the initiation of any psychotropic medications. V2 stated the completed consents are uploaded into the resident's electronic medical record. On 10/18/22 at 2:00 PM, V19 (nurse supervisor) stated psychotropic medication consents are obtained from the family or resident, if alert enough, prior to administering psychotropic medications. V19 stated the medication, dosage, frequency, intended uses, and side effects are explained to the family/resident. V19 stated the nurse cannot administer a psychotropic medication without the consent signed. V19 stated the nurse can obtain verbal consent from family representative via the telephone, as long as two nurses witness the consent. V19 stated the signed consent is uploaded into the resident's electronic medical record. Review of R94's POS (physician order sheet), dated 11/19/2021, notes an order for bupropion 150mg (milligrams) oral daily. Review of R94's MAR (medication administration record) notes R94 has been receiving bupropion 150mg oral daily. Review of R94's medical records does not note a psychotropic consent was obtained prior to initiating bupropion on 11/19/2021. Review of R94's medical record notes R94's last AIMS (Abnormal Involuntary Movement Scale) assessment was completed on 1/7/22. R94's medical record notes this assessment is to be completed every 6 months. Review of R94's psychosocial well-being care plan, dated 12/18/2021, notes R94 has a history of depression and has reported experiencing the following depressive symptoms (little interest, feeling down, trouble sleeping, feeling tired, and trouble concentrating). Intervention identified: observe for signs and symptoms of depression. Review of R94's behaviors care plan, dated 3/25/2021, notes R94 displays verbal behavior symptoms directed towards others as evidenced by verbal aggression towards peer, yelling and screaming. Intervention identified: refer for behavior management as needed. Review of this facility's psychopharmacologic drug use procedure, undated, notes AIMS testing must be done on all residents receiving antipsychotic drugs at initiation of the therapy and at least every 6 months thereafter. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis including resident response to the medication.

Based on interview and record review, the facility failed to ensure there was a plan in place for a resident to recieve dental services. This affected 1 resident (R10) reviewed for dental services in a sample of 133. Findings include: On 10/16/22 at 11:01 AM, R49 was observed with broken lower bottom teeth, R49 said she has not seen the dentist. R49 said she would like to see the dentist. On 10/18/22 at 12:29 PM, V3 (Assistant Director of Nursing/ADON) said R49 has not seen the dentist and R49 is on the list to see the dentist. Request was made to review the facility dental list. V3 presented with a document, dated 10/18/22, showing the facility intends to see patients including R49, as monthly visits will be scheduled via our clinical scheduling department, and relayed to (facility) appointed dental contact people in social service. During this survey, the facility did not present any documentation or a schedule showing a date R59 is scheduled to see the dentist. R49 census shows R49 was admitted to facility on 1/28/2021. On 10/19/22 at 5:00 PM, V31 (Resident Liaison) said she is responsible for ensuring the residents are seen by the ancillary departments, which are the eye doctor, ear doctor, foot doctor and the dentist. V31 said the current dental company is new to the facility, and they signed a contract in August 2022. V31 said the dental company has their own list of residents they see. V31 said she is not involved in the decision on who the dentist will see when they come to the facility. V31 said the residents should been seen by the dentist annually, or as needed when there's a dental emergency. V31 was asked when was the last time R49 was seen by the dentist; V31 said she does not know. V31 was asked if surveyor could review the list of residents that will be seen by the dentist on the next visit. V31 said the last list provided was in August 2022; V31 was informed the surveyor would like to review the list. V31 then said, Oh the list is on my computer I have to find it. V31 was asked how she ensures all residents are seen by the dentist annually or as requested. V31 said the dentist generates their own list. All new admissions should to be seen, and the facility should send the dental company a list of the newly admitted residents. V31 said the facility did not have a dental company in place prior to August 2022.

Based on observation, interview, and record review, the facility failed to follow food preference of a resident. This affects one resident (R6) out of three residents reviewed for dietary services. Findings Include: On 10/16/22 at 12:30 PM, R6's lunch tray was served. R6's lunch tray had broccoli on R6's plate. R6 stated, They always give me broccoli, green beans or cauliflower with my meals, and it says on my diet card No Broccoli I swear, the staff don't read my diet card. On 10/16/22 at 12:32 PM, dietary ticket on R6's lunch tray had R6's name, room number, and diet orders written on it. Also written in the bottom portion of the dietary ticket, *No Broccoli-Cauliflower-Green Beans*. On 10/18/22 at 1:40 PM, V16 (Dietary Supervisor) stated, Dietary tickets will show resident's food preferences. Dietary ticket is placed on the meal tray of each residents for each meal. During tray line food preparation in the kitchen, dietary aide will review the dietary ticket prior to setting the meal tray. Dietary aide needs to follow what is written on the dietary ticket. A couple of dietary aides will review the ticket prior to loading the tray in the food cart. Also, the facility has several new kitchen employees and everybody is in training. We fixed the problem or concern as we see it. Staff are constantly being educated and reminded to take food tray preparation slowly and read the dietary ticket to make sure the tray is correctly prepared. Dietary Services Policy reads in part: To define the facility's responsibilities for the provision of resident meal service and adequate nutrition. Other foods, when necessary, shall be served to satisfy individual appetites, including a variety of flavorful meals, which meet caloric and nutrient needs of the residents. Attention shall be given to reasonable food preferences and respect for religious practices. The facility shall not impose any religious dietary practices or laws upon residents. Should residents refuse food served, appropriate substitute of similar nutritive value will be offered. A tray identification system is established and a cardex file maintained to ensure compliance with physician's orders.

3. R126's physical order, dated 10/14/22, documents: Isolation for Organism: ESBL (Extended spectrum beta-lactamases) of the urine. Isolation Type: Contact On 10/16/22 at 12:02 PM, R126 was observed in the bed; no isolation signage was posted on R126's door, no plastic storage bin with personal protective equipment was observed outside of R126's room, and no red trash can in was inside R126's room. On 10/16/22 at 1:02 PM, R126's room was observed with a contact isolation sign posted on his door, plastic storage bin with personal protective equipment was observed outside R126's room, and a red trash can was R126's room. V5 (nurse) said, (R126) did not have an isolation set up (bin for personal protective equipment, signage or a red trash bin) this morning. (R126) is on isolation for ESBL of the urine. On 10/16/22 at 1:07 PM, V4 (Certified Nusing Assistant/CNA) said, (R126) isolation bins were set up after I passed the lunch trays. I just found out (R126) was on isolation. (R126) is on contact isolation. On 10/16/22 at 1:30 PM, V7 (Housekeeping Director) said, I just put the isolation bins out twenty minutes ago for (R126). On 10/17/22 at 3:15 PM, V5 (nurse) said, I administered (R126's) morning medication without personal protective equipment on. There wasn't a sign on (R126's) door related to isolation precaution. Isolation -categories of transmission-based precautions, dated 3/3/20, documents: Appropriate precautions shall be used either at all time (standard precautions) or for individuals who are documented or suspected to have infections or communicable disease that can be transmitted to other (transmission-based precautions). 4. On 10/18/22 at 5:30 PM - 5:44 PM, V10 (Nurse) used the glucometer to check R93's blood glucose. V10 placed the glucose machine on top of the medication cart and then placed it inside of medication cart top drawer without cleaning it. On 10/28/22 at 5:45 PM, V10 said, I was supposed to clean the glucometer with bleach wipes but I got distracted. On 10/19/22 at 10:12 AM, V2 (Director of Nursing) said, The glucometer must be clean after each use whether or not the machine will be used for another resident. Glucometer cleaning procedure, dated 1/20/2015, documents: the glucometer/accu-check machines must be cleaned between every use. Based on observation, interview, and record review, the facility failed maintain an effective infection control practice by not following their Equipment Change Schedule Policy for Oxygen equipment, isolation policy, and glucometer cleaning policy. This affected 4 residents (R95, R29,R126, R93) reviewed for infection control in a sample of 133. Findings Include: 1. R95's physician order reports for active orders reviewed. Oxygen order, with a start date of 3/12/22 reads: Oxygen: Trach Rate 6 liters per minute. Humidity 35%. Continuous: and Oxygen: Change tubing and mask weekly and PRN (as needed) (Label). On 10/16/22 at 10:45 AM, R95 was in bed. Oxygen concentrator was in room. Oxygen water bottle (bubbler) connected to the oxygen concentrator machine does not have date written on it. Oxygen tubing connected to the bubbler to trach set up for R95 shows a written date of 9/28/22. On 10/16/22 at 10:50 AM, confirmed with V26 (Nurse) the date written on oxygen tubing was 9/28/22. 2. R29's physician order reports for active orders reviewed. Oxygen order, with a start date of 1/4/22 reads: Oxygen: Nasal Cannula, Rate Oxygen 3 liters per minute; And Oxygen: change tubing and mask weekly and PRN (as needed) (Label). On 10/16/22 at 11:45 am, R29 is on oxygen administering at 3 liter per minute. Oxygen concentration in room, Water bottle (bubbler) with no date and almost empty. Oxygen tubing dated 9/28/22. On 10/16/22 at 12:45 PM, R29 called for assistance. V26 came to R29's room and R29 asked for the bottle to be change and the oxygen tubing. Confirmed with V26 the written date on the oxygen tubing was 9/28/22. On 10/18/22 at 1:58 PM, V2 (Director of Nursing) stated, The facility does weekly oxygen tubing and nebulizer tubing change. I am not sure how often we change Humidifier bottle (bubbler). If the bubbler is not working or dirty, it needs to be change also. We change the suction machine kit (container and tubing) when they get dirty and after each use. We don't want to leave used suction canister with something in it, because it would harbor bacteria, and for good infection control practices, we have to change it after each use. Equipment Change Schedule Policy: Nasal Cannula, on admission and weekly (Monday) and PRN. Bubblers, on admission and weekly (Monday) and PRN. Oxygen Administration Policy, with a revised date of March 2004, reads in part: Make sure the oxygen humidifier jar is labeled properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their bed hold policy by not providing bed hold notice at time of transfer for 4 of 4 (R32, R281, R2, R121) residents reviewed for bed hold. Findings Include: 1. R32 progress note, dated 10/12/22, documents: Resident is desaturating due to noncompliance and states she wants to go to the hospital. Resident was 72% pulse ox without oxygen and 90% pulse ox with oxygen. Doctor made aware family made aware new order carried out to transfer resident to ER. Review of R32's medical record does not document any bed hold notice given to resident. 2. R281 progress note, dated 6/14/22, documents R281 was transferred to local hospital due to change in condition. There is no documentation of bed hold notice given to resident. Review of R281's medical record does not document any bed hold notice given to resident. 3. Review of R2's medical record, dated 9/3/22, notes R2 was transported and admitted to the local hospital. There is no documentation found in R2's medical record noting R2 received bed hold policy upon transferring to the hospital on 9/3/22. 4. Review of R121's medical record, dated 7/11/22 and 10/8/22, notes R121 was transported and admitted to the local hospital. Review of this facility's discharge nurse's note, dated 7/11/22 and 10/8/22, notes no bed hold policy given. There is no documentation found in R121's medical record noting bed hold policy given prior to R121 being transported and admitted to the hospital on [DATE] or 9/14/22. On 10/18/22 at 1:20 PM, V18(Admissions) said she is not responsible for informing residents or representatives of bed hold notice. On 10/18/22 at 1:04P M, V2(Director of Nursing/DON) said nursing is not responsible for bed hold notices. Facility bed hold policy dated 11/2016 documents: Residents or representative will be informed of this policy at time of admission and at time of transfer to the hospital. The facility provides written notification at time of transfer as included in designated state form. The notice to the resident or representative will specify the facility policy, duration of the state bed hold policy and the reserve bed payment policy. In the event of an emergency hospitalization the resident shall be notified by telephone or in person of this policy within 24 hours. The staff member making the call or explaining the policy may accept verbal determination as to whether the resident desires bed hold and shall document same in the medical record an in the progress note.

Based on observation, interview, and record review, the facility failed to follow their policy for dietary services to ensure its canned goods are dent free to prevent contamination of meals served to its residents. This failure has the potential to affect all 133 residents that consume meals prepared by this facility. Findings include: A review of the current CMS 672 shows there are 133 residents residing in the facility. On 10/17/22 at 9:30 AM, this surveyor completed an initial tour of this facility's food storage room with V16 (Dietary Manager). There were (3) 106-ounce cans of spaghetti sauce and (1) 5 pound 10 ounce can of pizza sauce observed on the storage shelf to be deeply dented. On 10/17/22 at 9:30 AM, V16 (Dietary Manager) stated dented cans should not be accepted on delivery. V16 stated the dented cans should not have been placed on shelf to be used. V16 stated these cans should be thrown out to ensure not used for resident meals. V16 removed the dented cans from shelf and placed on a table. On 10/17/22 at 12:15 PM, this surveyor observed the 4 dented cans still in the storage room on table; not disposed of to prevent being used in food preparation. Review of this facility's dietary services policy, undated, notes the supply of staple food shall be maintained to adhere to dietary standards. All food products shall comply with federal, state, and local food regulations. Per the USDA's (United States Department of Agriculture) website notes to discard deeply dented cans. A deep dent is one that you can lay your finger into. Dented cans can lead to botulism, a deadly form of food poisoning.