Based on interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for misappropriation. (Resident B)Findings include:The clinical record for Resident B was reviewed on 9/2/25 at 2:24 p.m. The resident's diagnoses included, but were not limited to, diabetes, depression and chronic pain.The physician's order, dated 6/3/25, indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) every 6 hours as needed for pain.Review of the pharmacy delivery receipt, dated 8/16/25 at 6:45 p.m., indicated the resident's 30 Hydrocodone-Apap (acetaminophen) 5-325 mg were delivered and signed for by LPN 6.The incident report, dated 8/16/25, indicated on 8/19/25 Registered Nurse (RN) 7 called the pharmacy to find out why a narcotic medication that was ordered for Resident B had not been delivered. The pharmacy reported that 30 tablets of the narcotic pain medication was delivered on 8/16/25. The pharmacy sent over the signature page which showed the narcotic pain medication was signed for by Licensed Practical Nurse (LPN) 6. The LPN (6) reported she did sign for the medication and gave it to LPN 9, who was responsible for Resident B's medication. An investigation was initiated.During an interview, on 9/3/25 at 9:52 a.m., Qualified Medication Aide (QMA) 5 indicated he had noticed the resident was getting low on her pain medication. He called the pharmacy for a refill, and the pharmacy told him they would send the medication out as the resident had a current script on file. At the change of shift on 8/16/25 at 6:30 p.m., QMA 5 informed LPN 9 he had ordered the pain medication for Resident B and she was to keep an eye out for it. On 8/17/25 at 7:15 a.m., QMA 5 was about 45 minutes late after the normal shift change and did not count the narcotics in the cart with LPN 9. LPN 8 had counted the narcotics in the cart with LPN 9. QMA 5 checked the cart to see if Resident B's pain medication had arrived and he could not locate the resident's pain medication. Since LPN 8 counted the cart with LPN 9, QMA 5 asked LPN 8 if the medication for Resident B had arrived. LPN 8 indicated to QMA 5 the medication was not there when she counted with LPN 9. QMA 5 figured it had not arrived yet. LPN 9 called the facility at 5:30 p.m. on 8/17/25 and told them she had quit. At the end of QMA 5 shift, on 8/17/25, LPN 11 and QMA 5 counted the narcotics in the cart. QMA 5 advised LPN 11 he had ordered Resident B's pain medication but it had not arrived to the facility yet. On Monday, 8/18/25, Resident B's pain medication had not arrived and it was reported it to RN 7 by QMA 5. RN 7 called the pharmacy and was advised the pain medication was sent on Saturday 8/16/25 at 6:45 p.m.During a telephone interview, on 9/3/25 at 10:53 a.m., LPN 6 indicated, on 8/16/25, she had seen the pharmacy delivery person at the nurse's station. She did not see LPN 9 on the hallway anywhere. She went to the nurse's station for the medication delivery and signed for Resident B's 30 Hydrocodone's tablets. The protocol was to sign for the medication and place a signed copy in a file, which she did. LPN 6 found LPN 9 and gave LPN 9 the medication for her to put in the residents medication cart.During a telephone interview, on 9/3/25 at 12:34 p.m., RN 7 indicated on Monday, 8/18/25, QMA 5 reported to her that he had ordered pain medication for Resident B early on 8/16/25 and as of 8/18/25 the pain medication had not arrived. RN 7 called the pharmacy and was advised the medication was sent to the facility on 8/16/25 and was signed by a facility staff member. RN 7 asked the pharmacy if they could send over a copy of the requisition on who had signed for the narcotic pain medication. The pharmacy sent over the requisition which was signed in by LPN 6. When RN 7 discovered the resident's medication was missing, she then notified the Director of Nursing that somewhere between Saturday night, 8/16/25 and Sunday morning, 8/17/25, Resident B's narcotic pain medication disappeared.During a telephone interview, on 9/4/25 at 10:00 a.m., LPN 8 indicated on the morning of Sunday, 8/17/25, when she arrived to work, LPN 9 asked her to count the narcotics with her so she could leave. LPN 8 and LPN 9 counted the narcotics in the medication cart and the residents' medication cards and sheet counts were correct.During an interview, on 9/3/25 at 12:02 p.m., the Director of Nursing (DON) indicated she was notified by RN 7 about the missing narcotic pain medication for Resident B. The DON initiated an investigation and requested a drug screen for QMA 5, LPN 6, RN 7, LPN 8, and LPN 11, which were all negative. LPN 9 had refused the drug screen via text message. On 9/2/25 at 10:22 a.m., the Director of Nursing provided a current copy of the document titled Resident Rights dated 12/2016. It included, but was not limited to, Policy Interpretation and Implementation .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to .be free from .misappropriation of property The Past noncompliance began on 8/16/25. The deficient practice was corrected by 8/20/25 after the facility implemented a systemic plan that included the following actions: A 30-day look back narcotic audit was completed on all residents (8/18/25); All nursing staff were educated on abuse and misappropriation of resident property (8/19/25); The facility Implemented a narcotic count the count sheet (8/19/25); Drug screens were completed (8/20/25).This Citation relates to Intakes 2579876 and 2597024.3.1-28(a)

Based on interview and record review, the facility failed to ensure an assessment was completed by a licensed nurse and authorization given to administer an as needed narcotic pain medication by a qualified medication aide for 1 of 3 residents reviewed for quality of care. (Resident C)Findings include:The clinical record for Resident C was reviewed on 9/3/25 at 9:55 a.m. The resident's diagnoses included, but were not limited to, fibromyalgia, depression and pain.The physician's order, dated 6/20/25, indicated the resident was to receive oxycodone with acetaminophen (narcotic pain medication) 7.5 mg (milligrams) every 4 hours as needed for pain.The August controlled drug record indicated the resident received the as needed pain medication on the following dates and times by Qualified Medication Aide (QMA) 10: 7/31/25 at 8:00 p.m., 8/01/25 at 12:00 a.m. and 4:00 a.m., 8/09/25 at 9:15 p.m., 8/10/25 at 12:30 a.m., 4:00 a.m. and 8:00 p.m., 8/11/25 at 12:00 a.m. and 4:00 a.m., 8/13/25 at 9:00 p.m., 8/14/25 at 12:00 a.m., 4:00 a.m. and 8:00 p.m., 8/15/25 at 12:00 a.m. and 4:00 a.m., 8/20/25 at 8:00 p.m., 8/21/25 at 12:00 a.m. and 4:00 a.m., 8/23/25 at 8:00 p.m., 8/24/25 at 12:00 a.m. and 4:00 a.m., 8/27/25 at 8:00 p.m., and 8/28/25 at 12:00 a.m. and 4:00 a.m.The clinical record lacked a resident assessment, by a licensed nurse, for the as needed pain medication and an authorized signature on the controlled drug record.During an interview, on 9/4/25 at 10:15 a.m., QMA 5 indicated a licensed nurse must assess the resident when the need for the as needed narcotic pain medication was requested and co-sign with the QMA on the controlled drug record.On 9/3/25 at 3:15 p.m., the Director of Nursing provided a current, undated copy of the document titled Qualified Medication Aide Scope of Practice. It included, but was not limited to, The following tasks are within the scope of practice for the QMA unless prohibited by facility policy .Administer previously ordered pro re nata (PRN) medication only if authorization is obtained from the facility's licensed nurse on duty or on call. If authorization is obtained, the QMA must do the following .Document in the resident record symptoms indicating the need for the medication and the time the symptoms occurred .Document in the resident record that the facility's licensed nurse was contacted, symptoms were described, and permission was granted to administer the medication, including the time of contact .Obtain permission to administer the medication each time the symptoms occur in the resident .Ensure that the resident's record is cosigned by the licensed nurse who gave permission by the end of the nurse's shift This Citation relates to Intake 26031163.1-37

Based on interview and record review, the facility failed to ensure a resident's (Resident C) medication administration record accurately reflected the administration of narcotic pain medication for 1 of 3 residents reviewed for documentation.Findings include: The clinical record for Resident C was reviewed on 9/3/25 at 9:55 a.m. The resident's diagnosis included, but was not limited to, fibromyalgia.The physician's order, dated 6/20/25, indicated the resident was to receive oxycodone with acetaminophen, 7.5 mg (milligrams) every 4 hours as needed for pain.The August 2025 controlled drug record indicated the resident received the medication on the following dates and times:-8/02/25 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/03/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m. and 4:00 p.m.-8/08/25 at 10:00 p.m.-8/09/25 at 2:00 a.m., 6:00 a.m., 10:15 a.m., 2:15 p.m. and 9:15 p.m.-8/10/25 at 12:30 a.m. and 12:00 p.m.-8/11/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/12/25 at 12:00 a.m., 4:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/13/25 at 12:00 a.m., 4:00 a.m., 12:00 p.m. and 9:00 p.m.-8/14/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/15/25 at 12:00 a.m., 12:00 p.m. and 8:00 p.m.-8/16/25 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/17/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/18/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 6:00 p.m. and 10:00 p.m.-8/19/25 at 12:00 a.m., 6:00 a.m. and 8:00 p.m.-8/20/25 at 12:00 a.m., 4:00 a.m. and 8:00 p.m.-8/21/25 at 12:00 a.m., 8:00 a.m. and 8:00 p.m.-8/22/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/23/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/24/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m. and 4:00 p.m.-8/25/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/26/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/27/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.08/28/25 at 12:00 a.m., 8:00 a.m., 4:00 p.m. and 8:00 p.m.The August 2025 medication administration record for Resident C lacked documentation of the administration of the narcotic medication on the above dates and times.During an interview, on 9/4/25 at 2:18 p.m., Licensed Practical Nurse (LPN) 12 indicated when a resident's as needed pain medication was administered, the medication should be signed out on the controlled drug record and the medication administration record.On 9/4/25 at 12:24 p.m., the Director of Nursing provided a current copy of the document titled Documentation of Medication Administration dated 4/2007. It included, but was not limited to, The facility shall maintain a medication administration record to document all medications administered .A Nurse or Certified Medication Aide .shall document all medications administered to each resident on the resident's medication administration record .Administration of medication must be documented immediately after (never before) it is given .Documentation must include .Signature and title of the person administering the medication This Citation relates to Intake 2603116 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure a resident's (Resident B) medications were available, in a timely manner, for 1 of 3 residents reviewed for discharges. Findings include: The clinical record for Resident B was reviewed on 1/21/25 at 10:04 a.m. The resident's diagnoses included, but were not limited to, congestive heart failure, acute respiratory failure with hypoxia, heart disease, diabetes, hypertension and atrial fibrillation. The progress note, dated 12/28/24 at 10:31 a.m., indicated the resident was discharged from the facility to her home. The resident's medication orders were faxed to the pharmacy of choice. During an interview on 1/21/25 at 10:35 a.m., the complainant indicated the resident's medication list did not get sent to the pharmacy. Prior to the resident discharge, he asked about medications to take with her but was told it was not facility policy, but that the resident's medications were faxed to the pharmacy. He called the facility the next day and was told they would fax the medications over to the pharmacy again. That next day, the pharmacy indicated they did not receive the medication list. He went to the facility on the Wednesday after discharge (1/1/25) because the pharmacy never received the medication list. The facility did provide some medications that they had on stock. During an interview on 1/22/25 at 9:59 a.m., the Director of Nursing indicated she could not locate the fax confirmation where the residents medication list was sent to the pharmacy. She indicated the progress note said they were faxed. The next day, the family member called and said the pharmacy did not have the medication list. They refaxed the list again. The family member called again on Monday (12/31/24) due to the pharmacy reported they had not received the medication list. We told him to come to the facility and he was given the medications for the resident that were still at the facility. If a resident was Medicare, the facility pays for the medications. Once discharged , the medications are returned for credit. The facility will send a 3-day supply if requested. On 1/22/25 at 10:40 a.m., a request was made for a copy of family signature for the medications that were provided. The Director of Nursing indicated they only have the family sign for narcotics, but she would look for the paperwork. On 1/22/25 at 2:05 p.m., the Director of Nursing indicated the family picked up the resident's medications except for the as needed medications which were narcotics. Medications did not have to be signed for unless they are narcotics. On 1/22/25 at 3:20 p.m., the Director of Nursing indicated the family wanted the medications sent to their pharmacy of choice. The policy stated that only with a physician's order could medications be sent home with residents that are Medicare and Resident B did not have a physician's order. On 1/22/25 at 2:36 p.m., RN 8 provided a current copy of the document titled Discharge Medications dated 12/2016. It included, but was not limited to, Policy Statement .Unless otherwise specified by facility policy, or contrary to current law or regulations, medications shall be sent with the resident upon discharge On 1/22/25 at 2:56 p.m., RN 8 provided a current copy of the document titled Discharge Medications dated 1/2023. It included, but was not limited to, Policy .Medications will be sent with a discharged or transferred resident only under conditions which protect the resident and assure compliance with the law .For medications to be sent with a resident, the physician's discharge or transfer order must state which medications may be sent .For Medicare A residents, only a 5 day supply will be sent home This Citation relates to Complaint IN00450387 3.1-12(a)(21)

Based on observation, interview and record review, the facility failed to ensure residents' drawers were free of rodent droppings for 2 of 3 residents reviewed for sanitary environment. (Resident F and Resident G) Findings include: 1. The clinical record for Resident F was reviewed on 1/21/25 at 1:35 p.m. The resident's diagnoses included, but were not limited to, diabetes, hypertension and anemia. During an interview on 1/21/25 at 11:02 a.m., the resident indicated he believed the mouse problem had been taken care of as he had not seen any lately. During an observation on 1/12/25 at 11:03 a.m., the following concerns were observed: - The top drawer of the resident's night stand had multiple storage containers with snacks and crackers. The bottom of the drawer was observed with rodent droppings. - The middle drawer of the night stand was empty with rodent droppings on the bottom. - The bottom drawer of the night stand contained personal hygiene items. Rodent droppings were observed on the bottom. - The top drawer of the chest was observed with storage containers with snacks. The drawer had rodents droppings in the bottom of it. During an interview on 1/21/25 at 11:10 a.m., Staff Member 7 indicated there had been a rodent problem for a couple of months. She had went through all the resident drawers, cleaned and placed items in totes not too long ago. 2. The clinical record for Resident G was reviewed on 1/22/25 at 9:55 a.m. The resident's diagnoses included, but were not limited to, left dominant side hemiparesis, diabetes and multiple sclerosis. During an interview on 1/21/25 at 10:53 a.m., the resident indicated the last time she had seen a mouse was in the bathroom. She could not recall exactly when that was. There was definitely an issue with mice. On 1/21/25 at 10:55 a.m., the following concerns were observed: - In the top drawer of the night stand was a storage container with a lid. Rodent droppings were observed on the lid of the container and on the bottom of the drawer. - The middle drawer of the night stand was observed with rodent droppings. Review of the facility pest control logs indicated pest services were provided to the facility on 11 different occasions between 11/1/24 and 1/16/25. This Citation relates to Complaint IN00449149 3.1-19(a)

Based on observation, interview and record review, the facility failed to provide a clean and sanitary kitchen. This had the potential to affect 59 of 59 residents that received food from the kitchen. Findings include: On 1/21/25, between 11:35 a.m. and 12:03 p.m., the following concerns were observed in the kitchen: -Upon entrance to the dry storage area and to the left, rodent droppings and jelly packets were observed behind the shelves along the wall. -Behind the shelving, on the right side of the storage area, rodent droppings and condiment packets were observed. -Under the shelf where the large canned foods were kept was, a rodent trap that contained a rodent was observed. Directly behind the trap was a potato on the floor. -In the kitchen area, to the right of the ice machine, rodent droppings were observed in the corner. During an interview on 1/21/25 at 2:05 p.m., the Dietary Manager indicated there was not a cleaning schedule for the Month of January 2025. They had switched to a new system with more detailed forms, however the new forms had not been implemented yet. She could not locate the deep cleaning schedule for the month of December 2024. On 1/22/25 at 3:15 p.m., the Executive Director provided a current copy of the document titled Sanitization dated 10/2008. It included, but was not limited to, Policy Statement .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents This Citation relates to Complaint IN00449149 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete discharge Minimum Data Set (MDS) assessments for 2 of 19 MDS's reviewed. (Residents 14 and 25) Findings include: 1. The clinical record for Resident 14 was reviewed on 12/09/24 at 10:23 A.M. The resident's census indicated they were admitted to the facility on [DATE] and discharged with no anticipated return on 07/01/24. The MDS listings lacked a completed discharge assessment. 2. The clinical record for Resident 25 was reviewed on 12/09/24 at 10:26 A.M. The resident's census indicated they were admitted to the facility on [DATE] and discharged with no anticipated return on 07/01/24. The MDS listings lacked a completed discharge assessment. During an interview on 12/09/24 at 10:52 A.M., the MDS Coordinator indicated if a resident discharged from the facility then a discharge assessment should be completed. The discharge assessments for residents 14 and 25 had been missed and should have been completed. The current facility policy titled, Resident Assessment Instrument, with a revised date of September 2021, was provided by the Director of Nursing on 12/09/24 at 2:07 P.M. The policy indicated, .The Assessment Coordinator is responsible for ensuring that the Interdisplinary Assessment Team conduct timely resident assessments . 3.1-31(d)

Based on observation, interview, and record review, the facility failed to prevent a skin impairment for 1 of 17 residents reviewed for quality of care. (Resident 3) Findings include: During and observation on 12/06/24 at 1:47 P.M., Resident 3 was assisted with peri care. The resident had a bandage to the right bottom of the buttock. The dressing was clean and dry. The bandage was dated 12/06/24. The clinical record for Resident 3 was reviewed on 12/05/24 at 11:46 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/08/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stroke, anemia, hemiplegia/hemiparesis, and depression. The resident was always incontinent of bowel and bladder. A Progress Note, dated 10/23/24 at 12:53 A.M., indicated a Certified Nurse Aide (CNA) had reported an open area to the resident's upper right posterior thigh from the brief. The area measured 2.5 centimeters (cm) X (by) 1.0 cm X 0.2 cm. The area was cleansed and covered with a foam dressing. Wound Care was notified, and they were awaiting orders. A Wound MD Note, dated 10/23/24, indicated the resident had a non-pressure wound to the right buttock from brief trauma. The wound measured 0.6 cm X 3 cm X 0.1 cm. A treatment order was initiated, daily. A Wound MD Note, dated 11/27/24, indicated the resident had a non-pressure wound to the right buttock. The wound measured 0.8 cm X 1 cm X 0.1 cm. The treatment remained the same. A Care Plan, with a start date of 10/24/24, indicated the resident had a non-pressure injury to her right buttock that included the following interventions that started on 10/24/24: - administer medications per the physician's order, - contact the physician as needed, - encourage 100% of meal and fluid consumption, - encourage and assist with turning and repositioning every two hours as needed, - observe for signs and symptoms of infection, - treatments per the physician's order, and - weekly skin assessments. During an interview on 12/09/24 at 9:32 A.M., CNA 7 indicated the resident required total staff assistance with all care. She was incontinent of bowel and bladder and had a wound on the back side of her right leg. During an interview on 12/09/24 at 9:42 A.M., the Infection Preventionist/Wound Nurse, indicated the wound MD had classified the wound to the resident as trauma from the brief. She believes it was a trauma from friction of the brief not being placed properly or the resident was wearing the wrong size brief that day. The staff were not in-serviced on any brief placement or correct brief sizing. During an interview on 12/09/24 at 9:47 A.M., CNA 8 indicated the resident required a mechanical lift for transfers, was a total assist with care, was incontinent. The resident had a wound under her right buttock. She thought the wound was from the resident's brief not being positioned right. She was unsure if there was education on correct brief placements. During an interview on 12/09/24 at 10:04 A.M., the Director of Nursing (DON) indicated she believed the residents wound was from how the staff were applying the resident's brief. The resident was followed by the Wound MD. She was unsure if any staff were in-service related to brief placement, and she would not have updated the care plan with any interventions related to the brief placement or size. During an interview on 12/09/24 at 10:09 A.M., CNA 9 indicated if she needed to get residents more briefs because they were out in their room, she would look to see what size they had on. She had never had to get a resident more briefs because the night shift always put them in the resident's closets. During an interview on 12/09/24 at 10:13 A.M., the Facility Central Supply indicated if a resident ran out of briefs in their room, then the staff would go by what size the resident had on them. There was not a list saying what size brief residents wore for the staff working the floor. When a resident came to the facility the CNAs would measure them and let her know what size brief they needed and then she would order them. If a resident changed sizes, then she would be updated by the CNAs. She was never aware that Resident 3 needed new brief sizes and had not order her a different size in the last 6 months. The current facility policy titled, Urinary Continence and Incontinence-Assessment and Management, with a revised date of September 2021, was provided by the DON on 12/10/24 at 11:10 A.M. The policy indicated, .The staff and practitioner will appropriately screen for, and manage individuals with urinary incontinence .A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin . The current facility policy titled, Perineal Care, with a revised date of February 2018, was provided by the DON on 12/10/24 at 11:10 A.M. The policy indicated, .The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure the proper dose was administered related to priming the needel for the insulin kwikpens and following the physician's order for 2 of 2 resident's observed for pharmacy services. (Residents 160 and 56) Findings include: 1. During an observation on 12/5/24 at 11:00 a.m., LPN (Licensed Practical Nurse) 10 obtained Resident 160's blood sugar by glucometer. The blood sugar reading was 263 mg/dL (milligrams per deciliter). The LPN applied the needle to the Humalog kwikpen and dialed the pen to 3 units. She did not prime (dial the kwikpen to 2 units and press to remove air) the needle prior to administering 3 units of Humalog into the resident's right upper arm. During an interview on 12/5/24 at 11:15 a.m., LPN 10 indicated she had administered 4 units, then corrected herself and confirmed she had only administered 3 units of insulin to the resident. The LPN planned to administer another unit. During an observation on 12/5/24 at 11:20 a.m., LPN 10 applied the needle to the Humalog kwikpen. The LPN administered 1 more unit into Resident 160's right upper arm. She did not prime the needle prior to administering 1 unit of Humalog. The physician's order, dated 11/20/24, indicated staff were to administer the resident's Humalog kwikpen per sliding scale: If the resident's blood sugar level was 150 to 199 mg/dL give 2 units; 200 to 249 mg/dL give 3 units; 250 to 299 mg/dL give 4 units; 300-349 mg/dL give 5 units; 350 to 400 mg/dL give 6 units; 400 mg/dL plus give 7 units, subcutaneously before meals and at bedtime related to diabetes mellitus. 2. During an observation on 12/5/24 at 11:27 a.m., LPN 10 entered Resident 56's room. The resident indicated he had self obtained a high blood sugar reading. The LPN indicated she would have to obtain the blood sugar reading herself by glucometer. The blood sugar reading was 518 mg/dL when the LPN obtained the reading. The LPN indicated she would administer a total of 12 units of insulin. The LPN obtained the resident's lispro kwikpen and attempted to dial the 12 units. There was only 5 units left. She injected the 5 units of lispro into the resident's left upper arm, without priming the kwikpen needle. During an observation on 12/5/24 at 11:45 a.m., LPN 10 obtained Resident 56's lispro kwikpen from the refrigerator. She applied the needle to the kwikpen and dialed the remaining 7 units. The LPN did not prime the needle prior to administering the lispro into the resident's left upper arm. The physician's order, dated 10/14/24, indicated staff were to administer 7 units of the resident's lispro kwikpen subcutaneously before meals related to type 1 diabetes mellitus. The physicians' order, dated 11/2/24, indicated staff were to administer the resident's lispro kwikpen per sliding scale: If the resident's blood sugar was 150 to 225 mg/dL give 1 unit; 226 to 301 mg/dL give 2 units; 302 to 377 mg/dL give 3 units; 378-453 mg/dL give 4 units; 454 to 529 mg/dL give 5 units, subcutaneously before meals and at bedtime related to type 1 diabetes mellitus. During an interview on 12/5/24 at 11:51 a.m., LPN 10 indicated she did not prime the needle prior to administration. She should prime the needle with 5 units to make sure the resident received all of their insulin, in case there was air in the needle. During an interview on 12/5/24 at 1:58 p.m., the DON (Director of Nursing) indicated the staff should follow the physician's orders when administering insulin. She felt the insulin kwikpens did not require priming, as that was already built in. The Instructions For Use Humalog Kwikpen injection, for subcutaneous use 3 mL [milliliters] single-patient-use pen (100 units per mL), last copyrighted in 2023, included, but was not limited to, . Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units . The Insulin Administration policy, revised September 2014, included, but was not limited to, . 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order . Steps in the Procedure (Insulin Injections via Syringe) . 8. Check the order for amount of insulin . 12. Double check the order for the amount of insulin . 3.1-25(b)(9)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow guidelines related to dishwasher temperatures for 2 of 2 kitchen observations, infection control during dining for 1of 3 dining observations, and to maintain a resident snack refrigerator in a sanitary manner for 1 of 2 resident snack refrigerators observed. This deficient practice had the potential to affect 55 of 55 residents who received food from the kitchen. Findings include: 1. During an observation and interview of the dishwasher on 12/03/24 at 9:30 A.M., the Dietary Manager indicated there was a wash and rinse valve to monitor for the temperatures on the dishwasher. The valve indicated the rinse temperature was at 140 degrees. The Dietary Manager indicated the dishwasher temperature for the rinse cycle should be 180 degrees. She was going to have the staff stop washing the dishes and have the Maintenance Director look at it. The Dish Machine daily Temperature Record Logs for November 2024 indicated from 11/01/24 through 11/27/24 for breakfast, lunch, and dinner the rinse temperature was less than 180 degrees. During an observation and interview on 12/04/24 at 9:25 A.M., the dishwasher had the following rinse temperatures: - 140 degrees, - 160 degrees, and - 175 degrees. The Dietary Manager indicated she had in-serviced staff on reading the final rinse gauge as it was a different one then the one she had showed the day before. She was unsure why the temperature was not reaching 180 degrees. She told the staff to stop washing dishes until the maintenance director looked at it again. Her staff would rewash the dishes once the machine reached the appropriate temperature. The current facility policy titled, Dishwashing Machine Use, with a revision date of March 2010, was provided by the Administrator on 12/04/24 at 11:06 A.M. The policy indicated, .Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation .Dishwashing machine hot water sanitation rinse temperatures may not be more than 194 degrees, or less than: 180 degrees . 2. During a continuous observation on 12/03/24 from 11:28 A.M. through 11:48 A.M., the following was observed: - At 11:28 A.M., the food cart was delivered to the 100 Hallway. At 11:29 A.M., CNA 11 pushed the cart down the hall, opened the cart and took a tray into Resident 51's room. At 11:42 A.M., CNA 11 was in the hallway at the food cart. She adjusted her pants with both hands, retrieved a milk from the tub with her right hand, replaced the milk in the tub, retrieved a coffee cup with her right hand, and put coffee creamer in the cup. She squatted down and placed her right hand on her right knee, retrieved a sugar packet with her left hand, and used both hands to put the sugar in the coffee cup. She poured coffee into the cup and served the tray to a resident. At 11:44 A.M., CNA 11 retrieved a towel and cleaned spilled coffee off the floor in the hallway with her bare hands, placed the towel in a bag, and took the bag to the soiled utility room. She fixed her glasses with her right hand, fixed her shirt with both hands, touched a couple of meal tray cards in the meal cart, removed a tray from the cart, and served it to Resident 38. At 11:48 A.M., the CNA 11 retrieved an over the bed table out of a quiet room and placed it in front of Resident 54 and served her a meal tray. The CNA never washed or sanitized her hands during the meal service. During an interview on 12/09/24 at 1:52 P.M., CNA 12 indicated when serving resident's their meal trays she would wash her hands before started. If she had touched anything on herself or cleaning up spills then she would wash or sanitize her hands. The current facility policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, with a revision date of October 2017, was provided by the Director of Nursing on 12/10/24 at 10:17 A.M. The policy indicated, .All employee who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing forborne illness .Employee must wash their hands .After personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc .After engaging in other activities that contaminate the hands . 3. During an observation on 12/09/24 at 2:01 P.M., the resident snack refrigerator on the 100 Hallway contained the following items: - a plastic container that contained food that belonged to room [ROOM NUMBER] with no date on it, - two undated, plastic food containers with food in them that belonged to room [ROOM NUMBER], - 1/2 pumpkin pie with a use by date of 12/02/24, - 1/2 pecan pie with a use by date of 12/02/24, - left over dinner plate on the bottom shelf that belonged to Resident 52, that was dated 12/05/24, - a Styrofoam container labled for Resident 53 that was dated 11/28, - a plastic circle food container that contained food for Resident 53 that was dated 11/28, and - three rectangular plastic food containers that contained food for Resident 53 that were in a plastic bag, dated 11/28. During an interview on 11/09/24 at 2:03 P.M., RN 5 indicated food should be thrown out after three days. The night shift staff were to clean the refrigerators on Mondays, Wednesdays, and Fridays. There was a sign on the refrigerator to remind them. The undated sign from the refrigerator was provided by the Director of Nursing on 12/10/24 at 9:50 A.M. The sign indicated, .All items in the refrigerator must have a name and date on them. Any item not dated, or the date exceeds 3 day[s] will be thrown away. Per state law. 3RD SHIFT CNA'S You are to clean out the refrigerators on Monday, Wednesday, and Friday . The current facility policy titled, Food Brought by Family/Visitors with a revised date of October 2017, was provided by the Director of Nursing on 12/10/24 at 9:50 A.M. The policy indicated, .The nursing staff will discard perishable foods on or before the use by date . 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the equipment in resident rooms were kept clean for 6 of 26 rooms reviewed for environment. (Rooms 105, 107, 111, 114, 115, and 120) Findings include: During a tour of the facility on 12/4/24 at 11:00 a.m., the 100 and 200 Halls had several rooms observed to have a black spotty substance covering most of the slats on the following heater vents: - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. During an interview on 12/4/24 at 9:46 a.m., Resident 47 indicated she had black mold on her heater vents. When she woke up in the mornings the first thing she did was to start sneezing. During an observation on 12/5/24 at 10:00 a.m., in room [ROOM NUMBER] with the Maintenance Supervisor, he indicated the black substance on the heater vent was not black mold and it was dirt buildup. He did not have a cleaning schedule for when the vents needed cleaned. The staff would let him know when the vents were dirty and maintenance would clean them. During an interview on 12/5/24 at 1:22 p.m., CNA (Certified Nursing Aide) 4 indicated the nursing staff did not clean the heater vents. They would inform maintenance if they needed clean. She was not aware of any vents that needed cleaned. During an interview on 12/6/24 at 11:00 a.m., RN 5 indicated staff could clean the heater vents if they observed them dirty. They would also let the maintenance department know when they needed cleaned. She was not aware the vents were dirty. The Maintenance Director Job Description, dated 2023, included, but was not limited to, .To assist to maintain the physical plant, grounds, and all equipment in good working order to ensure a safe, attractive, and enjoyable living environment for the resident of the facility and in accordance with current Federal, State, and local standards governing the facility . 3.1-11

Based on interview and record review, the facility failed to ensure residents meal consumptions were documented, per the plan of care, for 2 or 3 residents reviewed for medical records. (Resident B and Resident C) Findings include: 1. The clinical record for Resident B was reviewed on 10/11/24 at 12:27 p.m. The resident's diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease and depression. The care plan, dated 7/1/20, indicated the resident required setup assistance with meals and to monitor/document percentage eaten. Review of the August 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 8/01/24, the resident's consumption for dinner was not documented. - On 8/02/24, the resident's consumption for dinner was not documented. - On 8/05/24, the resident's consumption for dinner was not documented. - On 8/06/24, the resident's consumption for dinner was not documented. - On 8/07/24, the resident's consumption for lunch was not documented. - On 8/09/24, the resident's consumption for dinner was not documented. - On 8/14/24, the resident's consumption for breakfast and lunch were not documented. - On 8/15/24, the resident's consumption for breakfast and lunch were not documented. - On 8/18/24, the resident's consumption for lunch was not documented. - On 8/25/24, the resident's consumption for breakfast and lunch were not documented. - On 8/30/24, the resident's consumption for breakfast and lunch were not documented. Review of the September 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 9/02/24, the resident's consumption for breakfast and lunch were not documented. - On 9/03/24, the resident's consumption for breakfast and lunch were not documented. During an interview on 10/15/24 at 2:35 p.m., CNA (Certified Nursing Aide) 5 indicated all resident meals should be documented in the system. 2. The clinical record for Resident C was reviewed on 10/11/24 at 1:20 p.m. The resident's diagnoses included, but were not limited to, dementia, depression and left sided hemiplegia and hemiparesis. The care plan, dated 10/21/22, indicated the resident required set up assistance will meals and to monitor/document percentage eaten. Review of the August 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 8/01/24, the resident's consumption for dinner was not documented. - On 8/02/24, the resident's consumption for dinner was not documented. - On 8/05/24, the resident's consumption for dinner was not documented. - On 8/07/24, the resident's consumption for lunch was not documented. - On 8/09/24, the resident's consumption for dinner was not documented. - On 8/11/24, the resident's consumption for dinner was not documented. - On 8/12/24, the resident's consumption for breakfast and lunch were not documented. - On 8/14/24, the resident's consumption for lunch was not documented. - On 8/15/24, the resident's consumption for breakfast and lunch were not documented. - On 8/25/24, the resident's consumption for breakfast and lunch were not documented. - On 8/30/24, the resident's consumption for breakfast and lunch were not documented. Review of the September 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 9/02/24, the resident's consumption for breakfast and lunch were not documented. - On 9/03/24, the resident's consumption for breakfast and lunch were not documented. - On 9/06/24, the resident's consumption for breakfast and lunch were not documented. - On 9/08/24, the resident's consumption for dinner was not documented. - On 9/09/24, the resident's consumption for breakfast and lunch were not documented. - On 9/10/24, the resident's consumption for breakfast, lunch, and dinner were not documented. - On 9/13/24, the resident's consumption for dinner was not documented. - On 9/14/24, the resident's consumption for dinner was not documented. - On 9/15/24, the resident's consumption for lunch and dinner were not documented. - On 9/16/24, the resident's consumption for breakfast, lunch, and dinner were not documented. - On 9/19/24, the resident's consumption for breakfast and lunch were not documented. - On 9/22/24, the resident's consumption for breakfast and lunch were not documented. - On 9/24/24, the resident's consumption for dinner was not documented. - On 9/25/24, the resident's consumption for lunch was not documented. - On 9/28/24, the resident's consumption for dinner was not documented. Review of the October 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 10/01/24, the resident's consumption for breakfast, lunch, and dinner were not documented. - On 10/02/24, the resident's consumption for breakfast and lunch were not documented. - On 10/03/24, the resident's consumption for breakfast, lunch, and dinner were not documented. - On 10/04/24, the resident's consumption for dinner was not documented. - On 10/07/24, the resident's consumption for breakfast and lunch were not documented. - On 10/08/24, the resident's consumption for lunch was not documented. - On 10/09/24, the resident's consumption for breakfast and lunch were not documented. - On 10/10/24, the resident's consumption for breakfast and lunch were not documented. - On 10/13/24, the resident's consumption for breakfast and lunch were not documented. On 10/15/24 at 11:26 a.m., the Director of Nursing provided a current copy of the document titled Nutrition (Impaired).Unplanned Weight Loss - Clinical Protocol: dated 9/2017. It included, but was not limited to, The nursing staff will .document the .dietary intake of residents in a format which permits comparisons over time On 10/15/24 at 3:15 p.m., the Infection Preventionist provided a current copy of the document titled Preparing the Resident for a Meal dated 9/2010. It included, but was not limited to, The purpose of this procedure is to prepare the resident .in order to help make meal time pleasant for the resident .Documentation .The date and time .How the resident tolerated the procedure This Citation relates to Complaint IN00442568 3.1-50(a)(1)

Based on observation, interview and record review, the facility failed to ensure residents (Resident B and Resident C) were served meals on appropriate dinner ware for 2 of 3 residents reviewed for resident rights. Findings include: 1. The clinical record for Resident B was reviewed on 2/12/24 at 1:22 p.m. The diagnosis included, but was not limited to, left sided hemiplegia and hemiparesis. On 2/12/24 at 1:15 p.m., the resident was observed resting in bed with her eyes open, call light in reach and lunch at bedside in a styrofoam container with plastic eating utensils. Meals had been served in styrofoam for well over a year. She just thought that was how all the meals were served. She thought it would be wonderful if they would serve the meals on regular plates with good silver ware. She could not cut anything up without the plastic utensils breaking. She only had one good hand and the Styrofoam makes it harder to eat. During an interview on 2/13/24 at 10:45 a.m., the Assistant Dietary Manager indicated they were using Styrofoam because the company, whom they contracted with, left. When they left, they took all of the dish ware. They ordered dishes in October and then there was a supply issue. They do have plates but were currently waiting on the plate warmers that were ordered. If the residents ate in their rooms, they usually send all disposable utensils and styrofoam. During an interview on 2/13/24 at 11:40 a.m., the Executive Director (ED) indicated they did have plates, but were waiting on the bases (plate warmers). If the residents eat in their rooms, the meals are sent in styrofoam. They were currently waiting on tray carts. The previous contracted company they had left before the contract was up in late December of 2022 and took a lot of the supplies. On 2/14/24 at 1:45 p.m., the ED indicated they had been ordering supplies all along but just did not have enough. They thought they could get more residents to go to the dining room, but that did not happen. They had several other expenditures and the meal cart was put on the back burner. She did, however, order the cart today as well as the dish ware. 2. The clinical record for Resident C was reviewed on 2/12/24 at 1:47 p.m. The diagnosis included, but was not limited to, left sided hemiplegia and hemiparesis. During an observation on 2/12/24 at 1:05 p.m., there were styrofoam meal containers on the resident's bedside table. During an interview on 2/12/24 at 2:20 p.m., the resident indicated his meals had been served in styrofoam for quite sometime. He sometimes had problems eating due to the high edges of the container the meals are served in. Review of the meal service and supplements policy, dated October 2022, indicated disposable dining dishes and flatware would be used to serve meals as needed during emergency meal service. The emergency meal service was defined as a serious weather condition, a power outage, or a significant staff shortage, etc. On 2/14/24 at 2:55 p.m., the ED provided a current copy of the document titled Resident Rights dated December 2016. It included, but was not limited to, Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to .dignified existence .dignity This Citation relates to Complaint IN00428146 3.1-3(a)

Based on interview and record review, the facility failed to ensure quarterly smoking assessments were completed for 2 of 3 residents reviewed for quality of care. (Residents B and C) Findings include: 1. The clinical record for Resident B was reviewed on 2/12/24 at 1:22 p.m. The diagnoses included, but were not limited to, left sided hermiplegia and hemiparesis, bipolar and major depressive disorder. The care plan, dated 12/21/21, indicated the resident required supervision with smoking and to update the smoking assessment quarterly and as needed. Review of Resident B's smoking risk assessments indicated a quarterly assessment was last completed on 8/17/23. The clinical record lacked documentation of a quarterly assessment for November 2023. During an interview on 2/12/24 at 2:48 p.m., the Director of Nursing indicated when the quarterly assessments were set up in the new system, the smoking assessments were not included. RN (Registered Nurse) 3 indicated per facility policy, smoking assessments were to be completed quarterly. 2. The clinical record for Resident C was reviewed on 2/12/24 at 1:47 p.m. The diagnoses included, but were not limited to, left sided hemiplegia and hemiparesis and dementia. The care plan, dated 2/17/22, indicated the resident was at risk for injury related to smoking and to update the smoking assessment quarterly and as needed. Review of Resident C's smoking risk assessments indicated a quarterly assessment was completed on 8/17/23. The clinical record lacked documentation of a quarterly assessment for November 2023. On 2/12/24 at 2:48 p.m., the Director of Nursing provided a current, undated copy of the document titled Smoking Policy - Residents. It included, but was not limited to, Policy Statement .It is the policy of this facility to be administered, in accordance with City, County, State and Federal Regulations related to smoking .A resident's ability to smoke safely will be re-evaluated quarterly This Citation relates to Complaint IN00425548 3.1-37

Based on observation, record review, and interview, the facility failed to ensure notification to the representative of a resident's change in condition for 1 of 22 residents reviewed for notification of changes. (Resident 54) Findings include: The record for Resident 54 was reviewed on 10/30/23 at 8:39 a.m. The diagnoses included, but were not limited to, muscle weakness, hypertension, dementia, Alzheimer's with late onset, and chronic kidney disease. The activities note, dated 6/27/23 at 10:28 a.m., indicated the resident was alert and made all her needs known. She sat up in her wheelchair most days in the hallway by the nurses' station and talked to most everyone. She could wheel herself around freely. She would do arts and crafts and play bingo and listen to music. She would come into the activities office and get a snack and hang out. The activities note, dated 9/14/23 at 12:14 p.m., indicated the resident seemed confused most days, however she would sit in the hall by the nurses' station and talk to everyone. She would come into the activities office and hang out and liked snacks. She was always friendly with activities staff. The Quarterly MDS (Minimum Data Set) assessment, dated 9/29/23, indicated the resident was moderate cognitively impaired, used a wheelchair with partial to moderate assistance where the helper did less than half the work, and needed substantial to maximum assistance with transfers and mobility related activities of daily living. The nurse's note, dated 10/12/23 at 8:53 a.m., indicated nursing staff requested the resident to be seen by the nurse practitioner (NP) related to her leaning to the right while up in her wheelchair and a decline in her functional condition. New orders were received during the visit for laboratory testing and urinalysis. Staff would continue to monitor. The record lacked documentation of any notification to the resident's representative of the change in the resident's condition or new orders until the nursing note on 10/19/23. The nurse's note, dated 10/19/23 at 1:00 p.m., indicated a voice mail message was left for the resident's representative requesting a return call regarding a non-emergent matter. The record lacked documentation of any further attempts to contact the resident's representative or other emergency contacts. The nurse's note, dated 10/20/23 at 6:16 p.m., indicated the resident's family member was there to see her and had questions regarding her current condition and said she was going to have the resident's representative call the nurse. The nurse spoke with the resident's representative regarding her current condition. She informed her of the negative urinalysis results, her continued leaning to the right and loss of ability to function at times. She explained a CT (computed tomography) scan could let them know if she had a stroke or not. She also explained it could just be her dementia progressing. The representative decided to have the Nurse Practitioner see the resident again on the following Monday and see if she thought a CT scan was necessary. She wanted to be notified after she was seen to see what the NP thought before she made a decision. During an observation, on 10/24/23 at 8:35 a.m., CNA (Certified Nurse Aide) 9 was attempting to feed Resident 54 while she was in bed. The resident was observed to be leaning to the right, mumbling when spoken to, and was not participating well in eating her breakfast when cued. CNA 9 indicated the resident was not very responsive and had declined. During an interview on 10/26/23 at 10:28 a.m., the resident's representative indicated overall they were concerned for the resident having a stroke. If she had a stroke there was nothing they could do, they did not want to put her through the pressures of being sent out, but she did not feel like there was a whole lot of communication. On 10/20/23 she was at a work function and her family member called and was beside herself because the resident was leaning to the right and mumbling. The first thing she said was it sounded like she had a stroke. No one from the facility had called her. She received no messages, and they did not call any other family on the list. She could have been reached. The facility said they had called and left a message, but she did not receive any calls or messages. She spoke with LPN (Licensed Practical Nurse) 7 on 10/20/23 who told her the resident was leaning to the right on 10/12/23 and about the blood work. They did not notify her of the change or the orders on 10/12/23. During an interview on 10/26/23 at 1:59 p.m., LPN 7 indicated the resident had been her normal self before she went on vacation, however when she came back, she noticed the resident was leaning to the right and it progressively worsened. One day she'd be sitting up straight and normal, the next she'd be back to just mumbling and completely out of it. She was letting food fall out of her mouth, and they now had to use a lift for her transfers. It all came on suddenly, or it came on gradually and they didn't notice it until it was significant. The last few days she had been having to put her medications in applesauce. Her normal was being alert, feeding herself completely. She ate everything in front of her and told staff if she had to use the restroom. She was alert, coherent, able to hold a conversation, and transferred with a stand and pivot. Someone said they left messages for the resident's representative, but when she talked to them, she said they left her no messages. It was a whole run around. She would notify family of changes as soon as she noticed them. She would document the notification in a progress note. If she called and left a voicemail she would call again and continue to try and reach them to discuss it. She would contact other contacts on the emergency list. She would also document each attempt. During an interview, on 10/30/23 at 8:24 a.m., Unit Manager 8 indicated she'd asked the NP to look at the resident for her leaning to the right and being tired. The resident's representative was hard to get ahold of. She called her on 10/12/23 to notify her, and she believed she'd left two voicemails. She notified family when they got orders. She would document every time she made a phone call, that was their standard. She did not contact any of the other emergency contacts on her face sheet. It was her error that notification was not documented on the initial 10/12/23 when the physician was contacted. The most current Change in a Resident's Condition or Status policy, included, but was not limited to, . Our facility shall promptly notify . representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when . b. There is a significant change in the resident's physical, mentally, or psychosocial status . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . 3.1-5(a)(2) 3.1-5(a)(3)

Based on record review and interview the facility failed to ensure a resident's treatment was timely for 1 of 5 residents reviewed for Quality of Care. (Resident 31) The record for Resident 31 was reviewed on 10/26/23 at 9:07 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease, other skin changes, and obesity. The fax sheet cover, dated 6/17/23, indicated the facility sent a fax for Resident 31 of a urinalysis and culture results to the physician. The staff inquired if the physician wanted to continue antibiotics and informed the physician the resident was having symptoms of a yeast infection. On 6/19/23, the physician responded with a fax. The fax was dated as received on 6/19/23 at 4:51 p.m. and indicated to continue the antibiotics and to start Diflucan (antifungal) 150 mg (milligram), one time. The record lacked documentation indicating the faxed order (dated 6/17/23) was received and the resident received the treatment for a yeast infection in a timely manner. The resident was not treated for five days (dated 6/22/23). The transmission log, dated 6/20/23 at 9:53 p.m., indicated the facility sent the same fax as on 6/17/23. The physician faxed back and indicated to refer to the faxed response sent on 6/19/23. The nurse's note, dated 6/21/23 at 7:01 a.m., indicated the physician replied regarding current order for antibiotics. He wrote please refer to the response in the orders from 6/19/23. The physician ordered a one-time dose of Diflucan 150 mg, by mouth to treat for a yeast infection. The nurse's note, dated 6/22/23 at 2:22 p.m., indicated the resident was to continue the antibiotic for a urinary tract infection. A new order was received on 6/22/23 to give a one dose of Diflucan 150 mg for a yeast infection. The review of the MAR (Medication Administration Record), dated 6/22/23, indicated the Diflucan 150 mg was given at 2:22 p.m. During an interview on 10/26/23 at 11:40 a.m., the DON (Director of Nursing) indicated the pharmacy delivered medications once a day. If the order went in late the medication would be delivered the next day. If the facility needed the medication before delivery, they would get the medication from a local pharmacy. During an interview on 10/26/23 at 1:30 p.m., RN 13 indicated when a nurse sent a fax to the doctor, she would add it to the pertinent charting list. If they received an order back from the physician, she would document the order in the computer and document in the nurse's notes. She did not know why the resident's order had been missed. Someone should have seen the faxed orders. The facility had a NP (Nurse Practitioner) on call seven days a week and twenty-four hours a day available. The resident should not have had to wait 5 days for the medication. During an interview on 10/30/23 at 1:00 p.m., the DON indicated the faxed request was sent to the physician on 6/17/23. The physician sent a faxed order back on 6/19/23. The resident received the medication on 6/22/23. The resident went 3 days without the medication instead of five days. A NP was not available until July. The physician was available and could have been called for the medication. The Physician Drug Orders policy, dated 1/23, included, but was not limited to, . Prescriptions will be processed only when a clear and complete order, from a person lawfully authorized to prescribe, is received. Verbal telephone orders will be received only by licensed nurse or pharmacist and confirmed in writing by the physician on a timely basis . 3.1-37(a)

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner for 3 of 3 observations. This deficient practice had the potential to affect all 57 residents currently residing at the facility. Findings include: 1. During the initial tour of the kitchen on 10/23/23 at 9:30 a.m., the following concerns were observed: - There was a heavy buildup of white under the dishwasher and dirty dish counter. - The back splatter guard of the stove had a moderate buildup of brown and black grease to it. - There was a coating of brown substance on the top of the flat top griddle. Dietary [NAME] 4 indicated That needs to be cleaned. We don't use that that often. We set stuff on it and that makes it turn brown. We use it for grilled cheeses sometimes. It was cleaned about a week ago. - There was a heavy buildup of grease on the table under the griddle. The cook indicated she needed to clean that up. - There was a moderate buildup of grease and grime on the side of the Vulcan oven as well as the wall behind, and the floor underneath of it. - There was a heavy coating of dust observed to be swaying, hanging on the wall, fan and hose in the walk-in freezer and fridge. - In the walk-in fridge there were two molded grapes, a puddle of an unidentifiable substance which was growing white fuzzy mold approximately 1 to 2 inches tall, and a gallon of milk on the floor under the metal rack. - There were black spots, appearing to be mildew, to the vents in the ceiling outside the dry storage, in front of the reach in fridge, and above the steam table. - The steam table was coated in a layer of brown and white buildup, which was streaking down the steam table base. - There was a heavy buildup of grime along the baseboards and in the corners and along the walls throughout the kitchen. 2. During a follow-up tour of the kitchen, on 10/26/23 at 9:15 a.m., the following concerns remained: - There was a heavy buildup of white under the dishwasher and dirty dish counter. - The back splatter guard of the stove had a moderate buildup of brown and black grease to it. - There were black spots, appearing to be mildew, to the vents in the ceiling outside the dry storage, in front of the reach in fridge, and above the steam table. - There was a heavy buildup of grease on the table under the griddle. Dietary [NAME] 4 indicated I got the griddle clean right after you left, I didn't get under I need maintenance to get under there. - There was a moderate buildup of grease and grime on the side of the Vulcan oven as well as the wall behind, and the floor underneath of it. - There was a heavy coating of dust observed to be swaying, hanging on the wall, fan and hose in the walk-in freezer and fridge. - In the walk-in fridge there were two molded grapes, a puddle of an unidentifiable substance which was growing white fuzzy mold approximately 1 to 2 inches tall, and a gallon of milk on the floor under the metal rack. - The steam table was coated in a layer of brown and white buildup, which was streaking down the steam table base. - There was a heavy buildup of grime along the baseboards and in the corners and along the walls throughout the kitchen. 3. During a follow-up tour, on 10/27/23 at 9:00 a.m., all the above concerns as observed on 10/26/23 remained unchanged. During an interview on 10/27/23 at 9:05 a.m., Dietary Aide 5 indicated they tried to clean the floors at least once a week. It depended on how bad it got. Their garbage disposal backed up the other day and she cleaned the floor up as good as she could. The white buildup on the floor had been there for years. They had the people and they had the time to clean it. They used to have staffing issues and didn't have time to clean everything like they should, but they had more people now. During an interview with the Dietary Manager on 10/27/23 at 9:50 a.m., she indicated the floor looked a lot better than it used to. They said it was due to the hard water they used to have. They now had a water softener and staff were working to try and clean up the lime buildup. It was just taking time. Maintenance was supposed to come out and clean the vents every week. She didn't know why they had the mildew buildup. They were only deep cleaning the kitchen once a month when they had the staff. Staff should be sweeping and mopping under and behind equipment, but if they were not deep cleaning it might be pushing stuff up under the equipment. The person who put up stock was supposed to sweep and mop under the racks in the fridges and freezer. Her goal was to get the kitchen as clean and shiny as it used to be, but it had been a challenging year. She first had to get staff in the building. They used to work the whole kitchen with 6 people. They did not have cleaning schedules. She used to use them, but staff were basically just checking off tasks and not completing them and she had quit using them. She could not provide any current cleaning checklists for the kitchen. The most current Dietary Sanitation Practices policy, included but was not limited to, . All kitchen employees will practice standard sanitary procedures . 9. Clean equipment and work units after use . 12. Daily, weekly and monthly cleaning are performed including any additional specific assignments that are designated by the food service director . 13. The kitchen, dining area and appliances are cleaned following facility policy . 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were offered pneumococcal vaccinations as recommended by the CDC (Centers for Disease Control) for 4 of 5 residents reviewed for pneumococcal immunizations. (Residents 31, 32, 41, and 50) Findings include: 1. The record for Resident 31 was reviewed on 10/23/23 at 10:40 a.m. The record indicated Resident 31 was [AGE] years old and had received Prevnar 13 (PCV13 (pneumococcal conjugate vaccine) on 11/6/19. Upon admission on [DATE], the resident's Responsible Party signed the consent form declining the administration of the pneumococcal vaccine. No further attempts were made since 7/14/21 for the resident to receive the recommended second dose of either PCV20 or PPSV23 (pneumococcal polysaccharide vaccine) after one year as recommended by the current CDC guidance. 2. The record for Resident 32 was reviewed on 10/23/23 at 10:50 a.m. The record indicated Resident 32 was [AGE] years old and had received one dose of a pneumococcal vaccine on 6/11/19 at an outside setting. Upon admission on [DATE], the resident signed the consent form declining the administration of the pneumococcal vaccine. No further attempts were made since 6/8/21 for resident to receive the recommended second dose of either PCV20 or PPSV23 (pneumococcal polysaccharide vaccine) after one year as recommended by the current CDC guidance. An interview with the Infection Preventionist on 10/26/23 at 11:30 a.m., indicated she was unable to locate what type of pneumococcal vaccine the resident had received. 3. The record for Resident 41 was reviewed on 10/26/23 at 11:00 a.m. The record indicated the resident was [AGE] years old and had received the PPSV 23 (pneumococcal polysaccharide vaccine) on 3/30/20. The record lacked documentation of any offer for the resident to receive the recommended second dose of either PCV20 or PCV15 after one year as recommended by the current CDC guidance. 4. The record for Resident 50 was reviewed on 10/23/23 at 11:10 a.m. The record for Resident 50 indicated the resident was [AGE] years old and had received the Prevnar 13 vaccine on 11/22/20. The record lacked documentation of any offer for the resident to receive the recommended second dose of either PCV20 or PPSV23 (pneumococcal polysaccharide vaccine) after one year as recommended by the current CDC guidance. In an interview with the Infection Preventionist on 10/26/23 at 9:10 a.m., she indicated they became aware a month ago of the need to be offering additional doses of the pneumococcal vaccine. They had been so focused on getting the new COVID-19 vaccine to administer as their priority and then they would focus on giving the additional pneumococcal vaccines. In a second interview with the Infection Preventionist on 10/26/23 at 10:50 a.m., she indicated they have not updated administering Pneumococcal vaccines since March 2022. Guidance for Pneumococcal Vaccine Timing for Adults was obtained from the CDC's website on 10/26/23. The guidance included, but was not limited to, . Make sure your patients are up to date with pneumococcal vaccination . Adults greater than [AGE] years old Complete pneumococcal vaccine schedules . Prior vaccines . PPSV23 only . Option A . PCV20 . Option B . PCV15 . PCV13 Only . Option A . PCV20 . Option B . PPSV23 . 3.1-13(a)

Based on observation and interview, the facility failed to ensure adequate maintenance of essential kitchen equipment for 3 of 3 observations. This deficient practice had the potential to affect all 57 residents currently residing at the facility. Findings include: During the initial tour on 10/23/23 at 9:30 a.m., in the walk-in freezer there was a heavy accumulation of ice on the floor spanning from wall to wall. Maintenance Assistant 6 was using a long-handled dustpan to break up and scoop up the ice before depositing it into a 13-gallon trash can which was halfway full of ice. The broken ice remaining on the floor was approximately one-quarter of an inch thick and appeared to have accumulated out approximately 4 feet from the fan at the back of the fridge. There was a heavy stream of water flowing from the condenser pipe and onto the floor. Maintenance Assistant 6 indicated he wasn't sure how long the ice had been accumulating. He had been notified on the radio of the issue just a few minutes prior to the observation. During an interview on 10/23/23 at 9:45 a.m., the Dietary Manager indicated the ice had been an issue for about three weeks. They had an issue in the past and the facility had replaced the condenser. Since they had done that, it was now building up ice again. They had to chop up the ice every Monday and Thursday. The ice that was in there currently had built up since the prior Thursday. Someone over the weekend must have moved the bucket they kept there to catch the accumulating ice. That's why it was so bad. It wouldn't be a problem if someone didn't move the bucket. During an interview on 10/26/23 at 11:25 a.m., the Maintenance Director indicated back in June they had to replace the compressor because it was freezing up. They got that done and then they had been cleaning the condensate line on a regular basis. It just so happened on the first day of survey it was plugged. He had someone going in every shift to check the freezer. They kept the trash can there as a precaution in case it backed up. When they cleaned the condensate line it looked like mud. They had been cleaning it out monthly. As it got hotter it got worse. Dietary should be monitoring it as well. He should have been notified before the ice got as bad as it did. Whatever had happened over the weekend, they were not notified by dietary staff. The line would get clogged, the water would build up and freeze, and when it would defrost it had nowhere to go. He had not reached out to anyone to service the drain. He had talked to upper management, but he had to get a budget approved. They did not have any contracts for servicing. He had someone going in every Wednesday checking all the equipment and lately had to have them come in daily. During an observation on 10/26/23 at 9:15 a.m., the walk-in freezer was observed to still have a trash can under the pipe with ice accumulating in it. There were multiple, new ice formations on the condenser hose with an icicle forming which was about 4 inches long. There was frost beginning to form on the door of the freezer. During an observation on 10/27/23 at 9:00 a.m., in the walk-in freezer there was a bucket trash can however there was no ice in it this time. There were multiple, new ice formations, as well as the same ones from the day prior, on the condenser hose with multiple icicle formations. The frost on the door was heavier than the day prior. The most current Malfunctions and Repairs policy, included, but was not limited to, . All malfunctions and need for repairs are reported to the dietary manager and maintenance department. Procedure: 1. When a piece of equipment malfunctions, the dietary manager is notified. 2. The dietary manager notifies the maintenance department by phone or in writing if needed, letting them know how quickly that piece of equipment is needed. 3. If repairs require outside help or the purchase of parts, this must be communicated with the facility administrator . 3.1-19(bb)

Based on record review and interview, the facility failed to ensure appropriate social services follow-up and monitoring residents with hallucinations and suicidal ideation for 3 of 4 residents reviewed for social services. (Residents 44, 12, and 35) Findings include: 1. The clinical record for Resident 44 was reviewed on 10/24/22 at 1:21 p.m. The diagnoses included, but were not limited to, major depressive disorder, dementia, Alzheimer's disease, and cognitive communication deficit. The 5-Day MDS (Minimum Data Set) assessment, dated 8/30/22, indicated the resident was cognitively intact. The care plan, dated 8/15/22, indicated the resident was at risk for suicidal ideations related to her diagnosis of depression. Interventions included, but were not limited to, 15-minute checks as needed, inpatient hospital stay per physician orders, one on one monitoring as needed, contact MD (Medical Doctor) as needed, observe for worsening signs or symptoms of suicidal ideation each shift, and psychiatric services to evaluate and treat as needed. All of the interventions were implemented on 8/15/22. The Social Services note, dated 8/15/22 at 5:18 p.m., indicated the resident had surfical thoughts and was transferred to the behavioral hospital. The Social Services note, dated 8/15/22 at 5:37 p.m., indicated the resident stated she had thoughts of hurting herself. The clinical record lacked any further assessment by the SSD (Social Services Designee) of the resident's reports of suicidal thoughts. There was no assessment of any plan or method the resident considered for hurting herself. The hospital report, dated 8/15/22, indicated the resident had suicidal ideation with a plan over the past 72 hours. On 8/15/22 the resident verbalized suicidal ideation with a plan of taking pills that she was saving up. The resident had several medication adjustments and was released to the facility at her baseline level of functioning. The nurse's note, dated 8/16/22 at 3:44 p.m., indicated the resident returned to the facility and was happy to return. She had no distress observed. The clinical record lacked documentation of any follow-up or monitoring related to the resident's suicidal ideations until 8/31/22. The social services note, dated 8/31/22, indicated the resident denied any depression or suicidal ideations. The nurse's note, dated 9/4/22 at 2:53 p.m., indicated the resident's family member requested she have her psychiatric medications re-evaluated due to her mood. She was not talking to her family member and very little to staff. She was not talking to her other family members and her main family member was very concerned. The nurse's note, dated 9/7/2 at 3:54 p.m., indicated the resident's family member requested for psychiatric services to re-evaluate the resident's psychiatric medications that were changed while the resident was in the hospital. The psychiatric provider would see the resident on their next visit. The nurse's note, dated 9/7/22 at 5:27 p.m., indicated the resident's order for Depakote 125 mg (milligrams) twice daily was changed to Depakote 125 mg at bedtime. The nurse's note, dated 9/22/22 at 4:06 p.m., indicated the nurse was informed by another staff member the resident had pocketed her food that same day and the day prior. Speech therapy would evaluate the resident. The nurse's note, dated 9/22/22 at 5:46 p.m., indicated the nurse was notified the resident was pocketing her food. Upon asking the resident why, she initially said she did not know. A few minutes later she stated, So I can die. This writer was notified that resident was pocketing her food. She told us she didn't know why. A few minutes later the nurse asked her why she was doing that, and resident stated, so I can die. The resident stated she was pocketing her food to kill myself. The resident was sent to the hospital for evaluation. The hospital report, dated 9/22/22, indicated the resident was seen due to not eating for three days. When social services asked her why she indicated because she wanted to die. At the hospital the resident said she had been feeling more sad lately and the food didn't taste very good. The resident did not appear to be at imminent risk of serious harm to self or others and did not meet criteria for involuntary admission. The resident was discharged to the facility The nurse's note, dated 9/23/22 at 1:43 p.m., indicated the resident returned from the hospital with paperwork from the social worker stating she was not at risk for self-harm or harm to others. The clinical record lacked documentation of any psychosocial follow-up by the SSD after the resident's return to the facility, or any monitoring for further suicidal ideation or pocketing of food. During an interview on 10/21/22 at 10:11 a.m., the SSD indicated he would normally go and check on the residents when they came back and make sure they were doing alright and make sure they weren't having any ideations. During an interview on 10/21/22 at 10:40 a.m., the SSD indicated he saw the resident daily up at the nurse's station, but this was his first time dealing with a resident with suicidal ideations. He had not been in social services very long. He would usually follow up with them once or twice after the incident, but he probably should be doing more. During an interview on 10/25/22 at 2:06 p.m., the DON (Director of Nursing) indicated on the first incident, they should have checked the resident's room to see if there were pills in the room and they should be making sure no medication was left at her bedside, that no one was bringing in stuff from outside. They should also be monitoring every meal to make sure and assess the resident and ensure she had nothing left in her mouth. The Suicide Precautions Policy and Procedure, dated 5/10/10, provided on 10/21/22 at 12:31 p.m. by the SSD, included, but was not limited to, . If a resident states that he or she no longer wishes to live and intends to harm him-or-herself the facility will initiate suicide precautions . 2. Maintain a one-on-one relationship with the resident. Do not leave the resident alone when actively suicidal . 4. Search the residents room thoroughly each shift for any and all potentially dangerous objects . 6. Check on resident every 15 minutes to ensure the resident's safety. Document the checks on the daily flow sheet. Staff will report no less than hourly and report any observed behavior to the charge nurse. Increase the frequency of monitoring at the nurse's discretion. Document the results . 7. The nurse will chart behaviors in the nursing notes each shift and reassess as needed . 8. Nursing and social services will document observations, efforts, interventions, and resident response in progress notes . 2. The clinical record for Resident 12 was reviewed on 10/21/22 at 9:36 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, major depressive disorder, anxiety disorder, dementia, depression, psychotic disorder, insomnia, and violent behavior. The care plan, dated 6/25/20 and last revised on 8/10/22, indicated the resident had a diagnosis of dementia, Alzheimer's and impaired decision making, short term and long-term memory loss. The interventions indicated to administer medications per physician orders, contact the physician as needed, give support to family if condition worsens, observe for worsening condition as needed, psychiatric to evaluate and treat as needed, and routine medication review. The care plan, dated 7/8/20 and last revised on 8/10/22, indicated the resident had anxiety and potential for anxious or depressed mood at times. The interventions indicated to administer medications as ordered, assess, and record anxious or depressed mood or behavior, determine patterns (time of day, precipitating factors/situations) if possible, assess changes in mental status, encourage her to maintain contact with her family. The nurse's note, dated 1/18/22 at 12:04 p.m., indicated the resident had recently taken to picking at her face. She currently had approximately 4 places on her face that were bright red. The resident had a habit of picking off scabs on her lower legs. The nursing staff had repeatedly educated the resident not to pick at scabs, and currently not to pick at her face. This behavior had been reported to social services for possible evaluation by the psychiatric nurse. The DON's note, dated 2/10/22 at 1:01 p.m., indicated she called the physician about the resident's statements and he wrote for a new order to be one on one until the psychiatric hospital could evaluate the resident. The social service note, dated 2/10/22 at 1:10 p.m., indicated the SSD was notified that the resident had made the comment she wanted to kill herself. The SSD went to the resident's room to find the resident sitting on her bed crying. He sat down beside her, and she indicated she wanted out of the facility. She indicated she had nothing to do at the facility but sit and she had been there too long. When asked if she had thoughts of wanting to hurt herself, resident indicated, Yes, I think about it from time to time, because I know it's going to be my only way out of here. The resident was immediately put on one on one at 11:30 p.m. The psychiatric hospital was notified and information was sent to intake. The nurse's note, dated 2/11/22 at 1:06 p.m., indicated two attendants from the psychiatric hospital arrived to transport the resident to the psychiatric hospital for evaluation and treatment. No behaviors were observed before the resident left the facility. The Social Service note, dated 2/11/22 at 5:22 p.m., indicated the resident did well through the night per the nursing staff. She had no signs or symptoms of suicidal ideation. The resident was sent to a psychiatric hospital at 11:50 a.m. to be evaluated and treated. The nurse's note, dated 2/28/22 at 1:29 p.m., the resident arrived back to the facility from the psychiatric hospital. The Psychiatry Initial Consult assessment, dated 3/25/22, indicated the resident was first evaluated. She denied past suicidal attempts. The clinical record lacked documentation of a Social Service follow up after the arrival back to the facility and monitoring and follow up of suicidal ideations. During an interview on 10/21/22 at 10:42 a.m., the SSD indicated he may have checked on the resident for a follow up but was not sure. During an interview on 10/21/22 at 12:31 p.m., the SSD indicated he could only find the one follow-up note and he should have assessed the resident more often after the suicidal ideation and return from the hospital. He indicated he knew to do that now. 3. The clinical record for Resident 35 was reviewed on 10/23/22 at 1:00 p.m., Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, benign neoplasm of meninges, chronic respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, generalized anxiety disorder, attention-deficit hyperactivity disorder, major depressive disorder, recurrent, benign neoplasm of the brain and psychotic disorder with hallucinations due to known physiological condition. The Day Minimum Data Set (MDS) assessment, dated 10/12/22, and the Quarterly assessment , dated 9/8/22, indicated the resident was cognitively intact with occasional forgetfulness and had no hallucinations during the assessment periods. A Social Services note, dated 6/27/2022 at 5:35 p.m., indicated the resident was having self reported hallucinations per nursing note on 6/26/22. No further documentation by the Social Worker was made to indicate he had followed up with the resident or staff on her hallucinations. He only made a referral for the psychiatric nurse to see the resident on next visit to the facility. A nursing note, dated 7/16/22 at 12:39 a.m., indicated the resident was heard yelling down the hall and upon entrance to her room to check on the resident, the resident immediately started yelling and cussing at the nurse and speaking nonsense. When the nurse tried to get the resident to explain what was wrong, the resident yelled and cussed that it was none of her business and to get out of her room. Upon re-approach a short time later, the resident continued to yell and cuss and began swinging her arms in an attempt to hit the staff. She again told the staff to get the hell out of my room. The resident continued to yell and cuss and spoke nonsense at the nursing staff when checked again later and refused care. A nursing note, dated 7/16/2022 at 2:13 a.m., indicated the resident had called the local ambulance company to come and get her. When the company verified with the nurse if the resident was okay, the nurse explained she was being combative and refusing care. The ambulance then indicated they were en route to take the resident to the local hospital. A nursing note, dated 7/16/22 at 2:19 a.m., indicated the resident's family member was contacted to speak with the resident in an attempt to calm her down. After the resident was off the phone, the nurse went into the resident's room to offer help and the resident again yelled get the hell out. All attempts at re-approaching, changing care giver, and redirecting failed. EMS (Emergency Medical Service) then arrived to take the resident to the hospital. The resident was returned to the facility a few hours later. A nursing note, dated 7/17/22 at 3:00 p.m., indicated the resident was heard yelling and screaming from her room. When the Certified Nursing Aide (CNA) 11 went to see what the resident needed, she became very loud, agitated and aggressive toward him. Yelling, screaming and cursing at him. When the nurse entered the resident's room, she was lying in bed yelling, screaming and cursing that she had been in the same spot in the same room all day. Staff tried to tell her because she had COVID, she was unable to leave her room. Despite this explanation, the resident continued to argue with staff that she was able to leave the room because she had gone to the hospital the day before. After staff left the room, the resident started yelling, screaming and cursing again. When the nurse came back into the room with some medication, she was standing with her walker yelling, screaming and cursing making statements that made absolutely no sense and were completely untrue. Saying no one had checked on her all day; she was going to call the police because staff were holding her hostage. She asked the CNA to call her family member, but she did not like her family member's answers to her demands of wanting to go home and hung up on him. When the staff tried to get her to sit down as they were afraid she was going to fall and break a hip, the resident responded that it was good as maybe it would kill her as she was ready to go. The family member was notified again of the resident's behaviors and he indicated he would come in. It was also explained to the family member that if this behavior continued, the facility might have to send the resident to a psychiatric hospital for evaluation and treatment. The resident's clinical record lacked documentation pertaining to the SSD having spoken to or assessed the resident for causes after she was sent to and from the hospital for the behaviors on 7/16 and 7/17/22. The Social Services note, dated 7/25/22 at 4:30 p.m., only indicated the resident had behaviors of cussing at staff. No discussion was held between the Social Worker and the staff as to reasons for the behaviors. A nursing note, dated 7/30/22 at 11:00 a.m., indicated the resident had been inappropriate with staff as well as therapy staff. Resident was yelling at the Physical Therapy assistant for various issues. A nursing note, dated 8/18/22 at 5:51 a.m., indicated when the nurse came back into the resident's room to provide care, the resident was very aggressive, yelling, trying to throw out cups and clothing at staff. Documentation was lacking of the Social Worker having assessed the resident for causes of her behaviors on 8/18/22 or having had a discussion with the staff on the behaviors. A nursing note, dated 8/24/22 at 1:29 a.m., indicated the resident refused her night medications three times; was very aggressive, cursing, being rude to staff, started to throw out cups at staff. The resident also told a CNA she wished to fall down to the floor so she will die of bleeding due to being on blood thinners. New orders were received to send the resident to the hospital for evaluation. The resident returned a few hours later. The Social Worker did speak with the resident on 8/25/22 at 8:33 a.m., although she continued to have delusions and hallucinations during their conversation. A nursing note, dated 8/25/22 at 2:49 p.m., indicated the resident was currently sitting at the nurses station and stated that there are wholes [sic] in the walls of this building and the entire building is shaking. Attempts to reassure the resident were not effective as she did not believe what the nurse was telling her. Also while sitting at the nurses station, the resident kept talking to the CNA and told her there was dust hanging down and was getting all over the CNA. Attempts at redirection were again unsuccessful as the resident argued with the nurse that she knew exactly what she was seeing. The Activities staff also reported the resident didn't want to go into her room as it wasn't her room since she indicated she just had new furniture delivered. This was not a true statement. Family member and Physician notified of the current hallucinations. Documentation was lacking of the Social Worker having spoken to the resident or staff about her hallucinations on 8/25/22. A Social Services note, dated 9/8/22 at 4:12 p.m., indicated the resident showed no signs of hallucinations, delusions or behaviors during the assessment period. A nursing note, dated 10/3/22 at 3:42 p.m., indicated the resident was hallucinating this day and indicated she had a man come in and try to take her car away for $14.99. Resident was trying to get out of bed thinking she was in the wrong room. The resident also indicated she saw dogs that weren't there and saw ink on table that wasn't there. A nursing note, dated 10/4/22 at 2:48 a.m., indicated the resident was alert with increased hallucinations. A nursing note, dated 10/5/22 at 2:47 a.m., indicated the resident was alert with increased confusion and increased hallucinations. Documentation was lacking of the Social Worker having addressed the resident's hallucinations on 10/3,10/4 and 10/5/22 with the resident or staff. A Social Services note, dated 10/12/22 at 4:43 p.m., only indicated the resident has had hallucinations per nursing notes and no behaviors were noted during review period. A care plan, dated 6/21/22, indicated the resident had hallucinations. No interventions for Social Work involvement were listed except to have psych services evaluate and treat the resident. A care plan, dated 6/12/22 and revised on 9/14/22, indicated the resident made false accusations and falsely accused others of wrong doing. The SSD intervention was to have psych services evaluate and treat the resident and for all staff to encourage the resident to talk about feelings as needed. During an interview with the Social Worker on 10/24/22 at 1:30 p.m., he indicated nursing would report to him whenever behaviors, hallucinations, etc occurred with the resident, although they did not always tell him in a timely manner. He would then go and talk with the resident and assessed them and made sure psych services saw them as well. He further indicated the resident had acted out a lot since admission because she didn't want to be in the facility and she had those brain tumors. Her hallucinations were not as bad now as they were since she had been put on medication and it had eased up. Her vision was also impaired due to the tumors so she said she sees things that really were not there. If a resident was sent to the emergency room or hospital due to behaviors or hallucinations, within 24 to 48 hours he would go and see them to assess them. On 10/21/22 at 2:30 p.m., the Director of Nursing (DON) presented a signed copy of the Social Worker's Job Description dated 9/10/20. Review of this Job Description included, but was not limited to, .Duties and Responsibilities: Administrative Functions .Interview residents as necessary .Record and maintain regular Social Service progress notes indicating response to treatment plan and/or adjustment to institutional life . Maintain routine visits to residents and perform services as necessary . Work with emotional problems including assisting resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care . Assist in interpreting social, psychological, and emotional needs of the resident/family to the medical staff, attending physician, and other resident care team members . 3.1-34(a)

3. The clinical record for Resident 44 was reviewed on 10/24/22 at 1:21 p.m. The diagnoses included, but were not limited to, major depressive disorder, dementia, Alzheimer's disease, and cognitive communication deficit. The 5-Day MDS assessment, dated 8/30/22, indicated the resident was cognitively intact. The care plan, dated 8/15/22, indicated the resident was at risk for suicidal ideations related to her diagnosis of depression. Interventions included, but were not limited to, 15-minute checks as needed, inpatient hospital stay per physician orders, one on one monitoring as needed, contact MD as needed, observe for worsening signs or symptoms of suicidal ideation each shift, and psychiatric services to evaluate and treat as needed. All of the interventions were implemented on 8/15/22. The Social Services note, dated 8/15/22 at 5:18 p.m., indicated the resident had surfical thoughts and was transferred to the behavioral hospital. The Social Services note, dated 8/15/22 at 5:37 p.m., indicated the resident stated she had thoughts of hurting herself. The hospital report, dated 8/15/22, indicated the resident had suicidal ideation with a plan over the past 72 hours. On 8/15/22 the resident verbalized suicidal ideation with a plan of taking pills that she was saving up. The resident had several medication adjustments and was released to the facility at her baseline level of functioning. The care plan lacked any interventions to address the resident indicating she had been saving pills to take. The nurse's note, dated 9/22/22 at 5:46 p.m., indicated the nurse was notified the resident was pocketing her food. Upon asking the resident why, she initially said she did not know. A few minutes later she stated, So I can die. This writer was notified that resident was pocketing her food. She told us she didn't know why. A few minutes later the nurse asked her why she was doing that, and resident stated, so I can die. The resident stated she was pocketing her food to kill myself. The resident was sent to the hospital for evaluation. The hospital report, dated 9/22/22, indicated the resident was seen due to not eating for 3 days. When social services asked her why she indicated because she wanted to die. At the hospital the resident said she had been feeling more sad lately and the food didn't taste very good. The resident did not appear to be at imminent risk of serious harm to self or others and did not meet criteria for involuntary admission. The resident was discharged to the facility The nurse's note, dated 9/23/22 at 1:43 p.m., indicated the resident returned from the hospital with paperwork from the social worker stating she was not at risk for self-harm or harm to others. The care plan lacked documentation of any interventions to address the resident's behaviors of pocketing food with an intent to kill herself. During an interview, on 10/25/22 at 2:06 p.m., the DON (Director of Nursing) indicated on the first incident, they should have checked the resident's room to see if there were pills in the room and they should be making sure no medication was left at her bedside, that no one was bringing in stuff from outside. They should also be monitoring every meal to make sure and assess the resident and ensure she had nothing left in her mouth. 4. The clinical record for Resident 4 was reviewed on 10/19/22 at 1:00 p.m. The diagnoses included, but were not limited to, osteoporosis pathological fracture, Alzheimer's disease, anxiety disorder, Covid-19, dementia, psychotic disorder, difficulty walking, displaced intertrochanteric fracture of left femur, major depressive disorder, pneumonia, and urinary tract infection. The Annual MDS assessment, dated 7/9/22, indicated the resident was cognitively intact. She was frequently incontinent and required extensive assistance with toileting and personal hygiene. She was not on a bowel and bladder program. The clinical record lacked documentation indicating a care plan was initiated with appropriate intervention for the development of urinary tract infections. The nurse's note, dated 2/13/22 at 12:15 a.m., indicated the resident's UA and C&S (culture and sensitivity) result were e-coli,aerococcus urine faxed to the physician. The nurse's note dated 2/15/22, indicated the resident was continued on Macrobid for a UTI. Isolation continued for E-coli. The physician ordered Cipro 250 mg BID x 7 days for a secondary bacteria in her urine. The urinalysis, dated 2/24/22, indicated the resident had escherichia coli (E-coli) in her urine. The urinalysis, dated 3/11/22, indicated the resident had escherichia coli ESBL (Extended-spectrum beta-lactamase) positive bacteria. The nurse's note dated 3/13/22, at 4:37 p.m., indicated the UA culture was reported, received and confirmed that the resident had a UTI. The culture indicated her urine was positive for E Coli. A call was placed to the doctor and received a new order for Macrobid 100 mg (Milligram) BID (2 times a day) x 7 days. The urinalysis, dated 5/17/21, indicated the resident had escherichia coli bacteria growth. The urinalysis, dated 8/22/22, indicated the resident had escherichia coli bacteria growth. The nurse's note dated 8/28/22, indicated the resident was on continuous Macrobid related to UTI with e-coli. During an interview on 10/24/22 at 10:24 a.m., LPN (Licensed Practical Nurse) 4 indicated the care plans would be updated by the unit manager with new interventions. The care plan should be initiated or updated when a problem was identified. They need to be updated as soon as possible. The Care Plans, Comprehensive Person-Centered policy, last revised December 2016, provided on 10/24/22 at 9:35 a.m., by the Director of Nursing, included, but was not limited to, .1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers . 3.1-35(b)(1) Based on record review and interview, the facility failed to develop a care plan with resident centered interventions for urinary tract infections (UTI) and suicidal ideation for 4 of 16 residents whose care plans were reviewed. (Residents 57, 12, 44, and 4) Findings include: 1. The clinical record for Resident 57 was reviewed on 10/19/22 at 1:45 p.m. The diagnoses included, but were not limited to, urinary tract infections, hypertension, and reduced mobility. The Quarterly MDS (Minimum Data Set) assessment, dated 10/3/22, indicated the resident was cognitively intact. She required extensive assistance of two staff members for toileting and limited assistance of two staff members for bed mobility. The care plan, dated 6/27/22 and last revised on 10/12/22, indicated the resident was incontinent of bowel and bladder. The interventions, dated 6/28/22, indicated to assist the resident with toileting every 2 hours and as needed, provide peri care and apply a barrier cream after incontinent episodes, complete the bowel and bladder assessment after admission, quarterly and as needed, record bowel movements every shift daily, and record episodes of continent and incontinent voiding and bowel movements. The care plan lacked documentation for current preventative measures to prevent urinary tract infections. The nurse's note, dated 7/1/22 at 12:24 p.m., indicated the resident was continued on Cefdinir twice daily for a UTI. The nurse's note, dated 7/9/22 at 6:46 p.m., indicated the facility received signed laboratory orders from the physician to repeat the CBC (complete blood count) in one week, do a UA (urinalysis) and CXR (chest x-ray) to rule out an underlying infection. The nurse's note, dated 7/15/22 at 6:22 a.m., indicated the UA with culture and sensitivity were collected via clean catch specimen. No foul odor was noted from the urine. The urine was clear golden yellow. The resident tolerated the collection with no difficulties. Denies burning or irritation when urinating. The laboratory company was at the facility to pick up the specimen and draw a CBC with differential. The nurse's note, dated 7/20/22 at 1:25 a.m., indicated the UA with culture and sensitivity were collected via clean catch specimen. The urine was a golden yellow. No foul odor was observed. The urinalysis, completed on 7/26/22, indicated less than 100,000 GNR (gram negative rods). The urine contained one plus blood. The nurse's note, dated 7/26/22 at 3:48 p.m., indicated the UA res with culture and sensitivity results were received by fax from the laboratory and showed two organisms growing less than 10,000 CFU/mL (colony forming units per milliliter), no sensitivity would be done. The results were faxed to the physician. The nurse's note, dated 9/11/22 at 12:24 p.m., indicated the resident voiced to the nurse frequent urination and pain. She also had a burning sensation. The UA was collected and an order was entered. The nurse's note, dated 9/13/22 at 12:38 p.m., indicated the partial UA results were faxed to the MD (Medical Doctor) and he sent over an order to start the resident on Macrobid 100 mg (milligrams) po (by mouth) BID (twice daily) for 7 days pending C&S (culture and sensitivity). The nurse notified the resident as well as the POA (power of attorney). The nurse's note, dated 9/13/22 at 10:59 p.m., indicated the resident was started on Macrobid 100 mg two times daily for seven days. The nurse's note, dated 9/14/22 at 12:48 p.m., indicated the UA with culture and sensitivity results were faxed to the physician's office. The organism was sensitive to the current ordered Macrobid. Staff would wait for the physician's response to adjust the medications if indicated. The nurse's note, dated 10/18/22 at 5:43 p.m., indicated a new order from the physician for a UA with culture and sensitivity related to the resident's memory decline and to refer the resident to psychiatric services for evaluation. The urinalysis, completed on 9/4/22, indicated greater than 100,000 CFU/mL klebsiella pneumoniae and less than 10,000 CFU/mL of mixed flora. No sensitivity was completed. The urine was yellow with turbid clarity, one plus blood and two plus protein, two plus leukocytes, and many bacteria. An order for Macrobid 100 mg twice daily for 7 days was received. 2. The clinical record for Resident 12 was reviewed on 10/21/22 at 9:36 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, major depressive disorder, anxiety disorder, dementia, depression, psychotic disorder, insomnia, and violent behavior. The Quarterly MDS assessment, dated 7/21/22, indicated the resident was moderately cognitively impaired. The care plan, dated 6/25/20 and last revised on 8/10/22, indicated the resident had a diagnosis of dementia, Alzheimer's and impaired decision making, short term and long-term memory loss. The interventions indicated to administer medications per physician orders, contact the physician as needed, give support to family if condition worsened, observe for worsening condition as needed, psychiatric to evaluate and treat as needed, and routine medication review. The care plan, dated 7/8/20, revised on 2/28/22, and last revised on 8/10/22, indicated the resident had anxiety and potential for anxious or depressed mood at times. The interventions indicated to administer medications as ordered, assess and record anxious or depressed mood or behavior, determine patterns (time of day, precipitating factors/situations) if possible, assess changes in mental status, encourage her to maintain contact with her family. The care plan lacked documentation of suicidal ideation's, monitoring or interventions to prevent future occurrences. The social services note, dated 11/17/21 at 12:08 p.m., indicated the resident was standing in the door of her room when the SSD (Social Services Designee) entered the room. She stated that she had little interest in doing things, and sometimes had trouble concentrating. The resident had a diagnosis of dementia and was taking Aricept. She also had a diagnosis of mood affective disorder and was taking Quetiapine and Citalopram. She had no behaviors documented during the review period. She showed no signs or symptoms of delirium, delusions, or hallucinations. The nurse's note, dated 1/18/22 at 12:04 p.m., indicated the resident had recently taken to picking at her face. She currently had approximately 4 places on her face that were bright red. The resident had a habit of picking off scabs on her lower legs. The nursing staff had repeatedly educated the resident not to pick at scabs, and not to pick at her face. This behavior had been reported to social services for possible evaluation by the psychiatric nurse. The DON's (Director of Nursing) note, dated 2/10/22 at 1:01 p.m., indicated she called the physician about the resident's statements, and he wrote for a new order for the resident to be one on one (one staff to one resident) until the psychiatric hospital could evaluate the resident. The social service note, dated 2/10/22 at 1:10 p.m., indicated SSD was notified that the resident had made the comment she wanted to kill herself. The SSD went to the resident's room to find the resident sitting on her bed crying. He sat down beside her, and she indicated she wanted out of the facility. She indicated she had nothing to do here but sit and she had been there too long. When asked if she had thoughts of wanting to hurt herself, resident indicated, Yes, I think about it from time to time, because I know it's going to be my only way out of here. The resident was immediately put on one on one at 11:30 p.m. The psychiatric hospital was notified, and information was sent to intake. The nurse's note, dated 2/10/22 at 6:11 p.m., indicated the resident had been quietly laying in her bed without signs or symptoms of wanting to cause harm to herself or others. The CNA (Certified Nurse Aide) was at the resident's bedside for one on one. The nurse's note, dated 2/11/22 at 5:42 a.m., indicated the resident slept most of the night with no sign that she was trying to hurt herself. She was pleasant and cooperative. The resident took her nighttime medications without difficulty. The nurse's note, dated 2/11/22 at 1:06 p.m., indicated two attendants from the psychiatric hospital arrived to transport the resident to the psychiatric hospital for evaluation and treatment. No behaviors were observed before the resident left the facility. The Social Service note, dated 2/11/22 at 5:22 p.m., indicated the resident did well through the night per the nursing staff. She had no signs or symptoms of suicidal ideation. The resident was sent to a psychiatric hospital at 11:50 a.m. to be evaluated and treated. The nurse's note, dated 2/28/22 at 1:29 p.m., the resident arrived back to the facility from the psychiatric hospital. The nurse's note, dated 3/23/22 at 6:07 a.m., indicated the resident was wandering down the hall multiple times. Each time she was asked where she was going and she indicated she was not supposed to be at the facility, her family had dropped her off at the facility, and she was waiting for family to come back. The resident was redirected and assisted back to her room multiple times. She shown that all of her things were at the facility, this was her home, and she was supposed to be here. She seemed to understand and would lay down and try to sleep each time for about 20 minutes before coming into the hallway again. At approximately 5:30 a.m. the resident was observed sitting in the parlor, with a box and a bag of her things packed. When she was asked what she was doing, she indicated, I'm waiting for my . [family] to come get me if . [family] doesn't get here soon I'm going to get pneumonia, I'm freezing. She was redirected back to her room, assisted her into her bed, and explained again that she now lived at the facility. She verbalized understanding and indicated, Oh yeah that's right, I don't know why I'm so confused. The nurse's note, dated 7/29/22 at 3:43 p.m., indicated the resident had increased confusion. The resident indicated, I don't know why I am here. I feel like I have been here forever. The nurse's note, dated 10/18/22 at 6:19 a.m., the nurse was alerted to resident's room by the assigned CNA. When the nurse entered the resident's room, the resident was sitting on her bed, with a skin scratch measuring 1.5 cm (centimeters) and bruises measuring 3 cm long by 3 cm wide and 3 cm long by 2 cm wide on the left lower extremities. The resident indicated she scratched it. The physician was notified for a dressing order. During an interview on 10/24/22 at 11:08 a.m., LPN 21 indicated the resident was seen by psychiatric services, but was unsure if it was every 2 weeks when the psychiatric company came to the facility. One year ago or so, she said something about wanting to kill herself, to the therapist. There were 2 other staff who heard this in the hall. She was monitored in the E-MAR (Electronic Medication Administration Record) for behaviors, when a medication was administered. If a resident mentioned wanting to kill themselves, they would conduct a one on one with staff for the resident to prevent harm. They would also let the unit manager know. During an interview on 10/24/22 at 11:30 a.m., the DON indicated the note she wrote in February 2022 was about the resident wanting to kill herself.

2. The clinical record for Resident 53 was reviewed on 10/19/22 at 2:04 p.m. The diagnoses included, but were not limited to, history of falling, anoxic brain damage, cerebrovascular disease, Alzheimer's disease, anxiety disorder, pain in bilateral feet, dementia, need for assistance with personal care, and muscle weakness. The 5-day MDS (Minimum Data St) assessment, dated 9/25/22, indicated the resident was moderately cognitively impaired, required extensive assistance of one or more staff with bed mobility, and limited assistance of two of more staff with transfers. The care plan, last revised on 10/5/22, indicated the resident was at risk for falls related to her general weakness. Her goal was to be free of falls or any fall related injuries through the next review. Interventions included, but were not limited to; update fall assessment each quarter and as needed, gripper socks when out of bed (dated 8/30/17); keep call light in reach when she is in her room and encourage and remind her to call for assistance as needed (dated 4/4/18); night light in bathroom (dated 5/6/20); remind to ask for assistance with transfers (dated 12/22/20); place call don't fall sign in room (dated 1/21/21); therapy to screen for appropriate assistance device (dated 11/17/21); encourage to keep walker by bedside (dated 2/2/22); grab bar on outside of the bathroom door, therapy to screen, therapy to screen and evaluate walker (dated 1/26/22); on antibiotic related to a urinary tract infection(dated 8/8/22); collect urinalysis (UA), basic metabolic panel (BMP), and complete blood count (CBC) (dated 9/12/22); and hospice to evaluate and treat (dated 10/17/22). The nurse's note, dated 11/15/21 at 4:16 p.m., indicated the resident fell while putting things away in her dresser after getting dizzy. She then scooted on her bottom to her bathroom and pulled the emergency call light. She had no injuries. The IDT (Interdisciplinary Team) note, dated 11/16/21 at 2:19 p.m., indicated the resident fell while putting clothing away and getting dizzy. A new order for therapy to screen was added as an intervention. The care plan did not reflect any revision with new interventions from therapy. The nurse's note, dated 11/17/21 at 6:29 p.m., indicated the resident called out for help and was found sitting on the floor bleeding from her head. The resident was transported to the hospital. The hospital report, dated 11/17/21, indicated the resident had a scalp laceration to her head from a fall at her nursing home in which she hit her head on her dresser. The wound was closed with 5 staples. The IDT note, dated 11/18/21 at 4:26 p.m., indicated the resident fell while going to the bathroom with a cane and slipped and hit her head. She was sent to the ER and returned with 5 staples to her head. A new order was written to have therapy screen her for an appropriate assistance device. The care plan did not reflect any revision with new interventions from therapy. The nurse's note, dated 1/26/22 at 4:22 p.m., indicated the resident had a fall while she was attempting to go to the restroom and got dizzy and fell on her bottom. There were no apparent injuries. The nurse's note, dated 2/2/22 at 10:02 p.m., indicated the resident had slipped out of her bed and landed on her bottom. The nurse's note, dated 4/5/22 at 10:26 a.m., indicated the resident's emergency alarm was on. The resident was found sitting on the floor facing the bathroom door. She stated I just went down. There were no apparent injuries. The IDT note, dated 4/7/22 at 12:06 p.m., indicated prior to the fall on 4/4/22 the resident was attempting to walk to the bathroom. The emergency light was sounding and the resident stated she just went down. The new intervention was to place the resident's walker at her bedside and instruct her not to ambulate without her walker and notify staff as needed for assistance. The resident's fall care plan lacked documentation of the new intervention being added. The nurse's note, dated 4/12/22 at 4:50 p.m., indicated the resident was found sitting in the floor of her room on her bottom. The resident stated she was ambulating from the bathroom back to bed and her walker got away from her. There were no visible injuries. The IDT note, dated 4/13/22 at 10:32 a.m., indicated the resident had a fall on 4/12/22. The note lacked documentation of any new interventions. The care plan lacked documentation of any new interventions. 3. The clinical record for Resident 22 was reviewed on 10/20/22 at 8:48 a.m. The diagnoses included, but were not limited to, wedge compression fracture fourth lumbar vertebra, legal blindness, congestive heart failure, Alzheimer's disease, macular degeneration, epilepsy, and repeated falls. The Significant Change MDS assessment, dated 8/24/22, indicated the resident was cognitively intact and required extensive assistance of one staff member with bed mobility and transfers. The care plan, last revised on 10/9/22, indicated the resident was at risk for falls. Interventions included, but were not limited to; staff to assist the resident with all transfers as needed (dated 6/15/20); encourage rest periods to avoid overtiring (dated 6/5/20); refer to PT/OT (physical therapy/occupational therapy) for evaluation and treatment as indicated (dated 6/15/20); had taken constipation medication (dated 12/23/21); call light in reach (dated 6/15/21); therapy to screen (dated 5/25/22); check auto locking brakes (dated 9/8/22); and hospice to provide reclining wheelchair (dated 10/11/22). The nurse's note, dated 12/23/21 at 4:01 p.m., indicated the resident self-reported having fallen in the bathroom and hit her head on the arm rest of her wheelchair. The resident stated, I stood up and missed the side of my chair and hit my head. She then pulled bathroom call light to alert staff while she was still in the bathroom. The IDT note, dated 12/29/21 at 1:32 p.m., indicated the IDT met to review the fall that occurred 12/23/21 at 3:45 p.m. The resident self-reported a fall in her bathroom. The new intervention was specified as, . she had taken stuff for constipation and was in a hurry . The care plan lacked documentation of any further preventative interventions. The nurse's note, dated 5/25/22 at 12:00 p.m., indicated the resident had fall while in the bathroom. There were no injuries observed. She was found with her feet in front of toilet and head towards door on back. The IDT note, dated 5/26/22 at 1:53 p.m., indicated the IDT met to review fall that occurred 5/25/22 at 12:00 p.m. Prior to the fall the resident was going to the bathroom. The resident was found sitting on the floor back toward the door. The new intervention was for PT/OT to evaluate and treat. The care plan lacked documentation of any further update with preventative interventions. The nurse's note, dated 9/8/22 at 12:01 p.m., indicated the nurse was called into resident's room and witnessed resident on the floor kneeling beside bed facing the window with her wheelchair behind her. When the nurse asked what happened, the resident stated she wanted to go to bed. The IDT note, dated 9/9/22 at 12:39 p.m., indicated the IDT met to review the fall on 9/8/22 at 12:01 p.m. The new intervention was to have the resident's auto lock brakes checked to ensure working properly. Maintenance did check and the brakes were working properly. The care plan lacked documentation of any further update with preventative interventions. During an interview on 10/24/22 at 1:42 p.m., the Unit Manager indicated when a resident fell, the IDT came together and came up with new interventions for the fall. Usually, they came up with a new intervention each time, or modified an old one. Usually new interventions would be added to the care plan when they did the IDT note, the care plan would be updated at that time. During an interview on 10/25/22 at 2:06 p.m., the DON (Director of Nursing) indicated when a resident fell the nurse documented it and the next morning, she printed it off and brought it to clinical meeting. Therapy and the clinical team sat down and came up with new interventions. They did a different intervention for each fall. 4. The clinical record for Resident 8 was reviewed on 10/19/22 at 10:55 a.m. The diagnoses included, but were not limited to, chronic kidney disease, fracture of other parts, heart disease, major depressive disorder, urinary tract infections, anxiety disorder, bacterial infections, Alzheimer's, irritable bowel syndrome,repeated falls and a history of falling. The Quarterly MDS assessment, dated 7/8/22, indicated the resident was severely cognitively impaired. She required limited assistance with toileting and was occasionally incontinent of bladder. The care plan, dated 2/24/22 to 2/28/22, indicated the resident had a diagnosis of a UTI. Interventions included, but were not limited to: observe for signs and symptoms of burning or pain on urination, observe for frequency and urgency, offer and encourage fluids and record intake, contact the physician as needed, and administer medications as ordered. The care plan, dated 4/20/22 and last revised 9/6/22, indicated the resident required isolation due to E-coli (escherichia coli) pathogen in her urine. Interventions included, but were not limited to, medications per the physician orders. The clinical record lacked documentation indicating the interventions were updated and revised for the prevention of UTI's. The nurse's note, dated 3/13/22 at 11:18 a.m., indicated the resident was on antibiotic therapy related to a UTI. She was on contact isolation. The nurse's note, dated 4/18/22 at 12:01 p.m., indicated a call was received from the urology office, after reviewing the C&S (culture and sensitivity) report and new a order was received to change Amoxicillin to Augmentin 500 mg (milligrams) BID (twice daily) for 10 days per the physician. A follow-up appointment was scheduled. The nurse's note, dated 4/20/22 at 3:16 p.m., indicated due to multiple bacterial organisms observed via urine culture new orders were received by the physician to start Zosyn 4.5 grams IV (intravenous) BID for 7 days. The Augmentin was discontinued. A midline was placed in the right arm. The nurse's note, dated 5/13/22 at 10:35 a.m., indicated the resident continued on antibiotic therapy due to a UTI. No adverse effects noted to therapy. The nurse's note, dated 7/19/22 at 8:43 p.m., indicated doxycycline started for a UTI. No adverse reaction observed or reported. The nurse's note, dated 9/06/22 at 12:15 p.m., indicted the physician ordered Tetracycline 500 mg BID for 7 days due to a UTI. The nurse's note, dated 10/19/22 at 4:06 a.m., indicated the resident was alert with confusion. She had no complaints of pain or discomfort. She voided and cloudy urine was collected and ready for pick up. The nurse's note, dated 4/24/22 at 12:19 p.m., indicated the resident was on continues IV antibiotic Zosyn via midline in her right upper arm for a UTI. No signs and symptoms of infection at midline site. The Care Plans, Comprehensive Person-Centered policy, last revised December 2016, provided on 10/24/22 at 9:35 a.m., by the Director of Nursing, included, but was not limited to, .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 14. The interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment . 3.1-35 (a)(e) Based on record review and interview, the facility failed to revise and update a care plan related to urinary tract infections (UTI) for 4 of 16 residents review for care plan revision. (Residents 24, 53, 22, and 8) Findings include: 1. The clinical record for Resident 24 was reviewed on 10/20/22 at 10:18 a.m. The diagnoses included, but were not limited to urinary tract infection, chronic kidney disease, Alzheimer's disease, interstitial cystitis, anemia in chronic kidney, benign prostatic hypertension, and retention of urine. The Quarterly MDS (Minimum Data Set) assessment, dated 8/26/22, indicated the resident was cognitively intact. He required limited assistance of one staff for transfers, toileting, locomotion, bed mobility and personal hygiene. The care plan, dated 5/1/19 and last revised on 9/7/22, indicated the resident had chronic UTIs. The interventions included, but were not limited to, administer medications per physician order (dated 1/4/19), contact the physician as needed (dated 1/7/19), and observe for burning during urination (dated 1/7/19). The care plan lacked documentation of updated UTI preventative measures and interventions. The nurse's note, dated 5/9/22 at 11:47 p.m., indicated the resident had returned from the hospital with new orders to increase the Bactrim DS (double strength) to twice daily for the urinary tract infection. Oral fluids of water were encouraged and taken without difficulty. The nurse's note, dated 7/1/22 at 3:12 a.m., indicated the urinalysis was pending. The resident was encouraged to change his pull-up when soiled, to prevent UTI symptoms. The nurse's note, dated 7/5/22 at 9:22 a.m., indicated the facility received a returned fax from the physician on the urinalysis results. The resident was to start Macrobid 100 mg twice daily for 7 days and to hold the Bactrim DS until the Macrobid was completed. The urinalysis results, dated 7/21/22, indicated the urine was cloudy. There was 2 plus leukocytes, 21 to 50 HPF (high power field) white blood cells, few epithelial cells, and calcium oxalate crystals and mucous were present. An order to repeat in one week was obtained. The nurse's note, dated 7/24/22 at 1:18 p.m., indicated the resident was admitted to a local hospital with a UTI and COVID-19. The nurse's note, dated 7/28/22 at 8:54 a.m., indicated the resident returned from hospital with orders for Macrobid 100 mg twice daily for 7 days and the prophylactic Bactrim DS was discontinued. The physician was faxed, and a new order was given to continue the Macrobid 100 mg orally, daily, prophylactically for a UTI. The urinalysis results, dated 9/23/22, indicated the urine was cloudy yellow, with few epithelial cells. Calcium oxalate crystals and mucous were present. During an interview on 10/21/22 at 12:44 p.m., QMA (Qualified Medication Aide) 5 indicated the interventions for UTIs were proper pericare, cranberry capsules, and to encourage fluids. He found the interventions in the care plans. The most important intervention was to conduct good pericare. Residents needed to be checked and changed also. During an interview on 10/24/22 at 10:15 a.m., LPN (Licensed Practical Nurse) 6, indicated care plans were initiated by the unit coordinator. This was done quarterly and as needed. This was done with falls, pain, skin changes, etc. The nurse would enter the updated interventions in the care plan once a fall or other change occurred.

Based observation, record review and interview the facility failed to ensure appropriate preventive measures were in place to prevent falls and determine the root cause of resident falls for 5 out of 7 residents reviewed for accidents. (Residents 24, 22, 8, 4, and 53) Findings include: 1. The clinical record for Resident 53 was reviewed on 10/19/22 at 2:04 p.m. The diagnoses included, but were not limited to, history of falling, anoxic brain damage, cerebrovascular disease, Alzheimer's disease, anxiety disorder, pain in bilateral feet, dementia, need for assistance with personal care, and muscle weakness. The 5-day MDS (Minimum Data Set) assessment, dated 9/25/22, indicated the resident was moderately cognitively impaired, required extensive assistance of one or more staff with bed mobility, and limited assistance of two of more staff with transfers. The care plan, last revised 10/5/22, indicated the resident was at risk for falls related to her general weakness. Her goal was to be free of falls or any fall related injuries through the next review. The interventions included, but were not limited to; update fall assessment each quarter and as needed, gripper socks when out of bed (dated 8/30/17); keep call light in reach when she is in her room and encourage and remind her to call for assistance as needed (dated 4/4/18); night light in bathroom (dated 5/6/20); remind to ask for assistance with transfers (dated 12/22/20); place call don't fall sign in room (dated 1/21/21); therapy to screen for appropriate assistance device (dated 11/17/21); encourage to keep walker by bedside (dated 2/2/22); grab bar on outside of the bathroom door, therapy to screen, therapy to screen and evaluate walker (dated 1/26/22); on antibiotic related to a urinary tract infection (UTI) (dated 8/8/22); collect urinalysis (US), basic metabolic panel (BMP), and complete blood count (CBC) (dated 9/12/22); and hospice to evaluate and treat (dated 10/17/22). The nurse's note, dated 11/15/21 at 4:16 p.m., indicated the resident fell while putting things away in her dresser after getting dizzy. She then scooted on her bottom to her bathroom and pulled the emergency call light. She had no injuries. The IDT (Interdisciplinary Team) note, dated 11/16/21 at 2:19 p.m., indicated the resident fell while putting clothing away and getting dizzy. A new order for therapy to screen was added as an intervention. The clinical record lacked documentation of any further preventative interventions. The nurse's note, dated 11/17/21 at 6:29 p.m., indicated the resident called out for help and was found sitting on the floor bleeding from her head. The resident was transported to the hospital. The nurse's note, dated 11/17/21 at 11:06 p.m., indicated the resident returned with 5 staples to her head. The hospital report, dated 11/17/21, indicated the resident had a scalp laceration to her head from a fall at her nursing home in which she hit her head on her dresser. The wound was closed with 5 staples. The IDT note, dated 11/18/21 at 4:26 p.m., indicated the resident fell while going to the bathroom with a cane and slipped and hit her head. She was sent to the hospital and returned with 5 staples to her head. A new order was written to have therapy screen her for an appropriate assistance device. The clinical record lacked documentation of any further interventions. The nurse's note, dated 1/26/22 at 4:22 p.m., indicated the resident had a fall while she was attempting to go to the restroom and got dizzy and fell on her bottom. There were no apparent injuries. The nurse's note, dated 2/2/22 at 10:02 p.m., indicated the resident had slipped out of her bed and landed on her bottom. The IDT note, dated 2/3/22 at 12:00 p.m., indicated for the fall on 1/26/22 the resident stated she was attempting to go to the restroom and got lightheaded and fell on her bottom. A new order for therapy to screen was written. The clinical record lacked documentation of any further interventions. The IDT note, dated 2/3/22 at 4:45 p.m., indicated for the fall on 2/2/22, the resident stated she slipped out of the bed and lowered herself to the floor. New orders for a UA (urinalysis) and x-ray were given. The clinical record lacked documentation of any further interventions. The nurse's note, dated 4/5/22 at 10:26 a.m., indicated the resident's emergency alarm was on. The resident was found sitting on the floor facing the bathroom door. She stated, I just went down. There were no apparent injuries. The IDT note, dated 4/7/22 at 12:06 p.m., indicated prior to the fall on 4/4/22 the resident was attempting to walk to the bathroom. The emergency light was sounding, and the resident stated she just went down. The new intervention was to place the resident's walker at her bedside and instruct her not to ambulate without her walker and notify staff as needed for assistance. The nurse's note, dated 4/12/22 at 4:50 p.m., indicated the resident was found sitting in the floor of her room on her bottom. The resident stated she was ambulating from the bathroom back to bed and her walker got away from her. There were no visible injuries. The IDT note, dated 4/13/22 at 10:32 a.m., indicated the resident had a fall on 4/12/22. The note lacked documentation of any new interventions. The nurse's note, dated 8/6/22 at 3:56 p.m., indicated the resident had an assisted fall at 8:50 a.m. The aide was walking the resident to the bathroom and her knees started to give out, so the aide assisted her to the floor. There were no apparent injuries. The IDT note, dated 8/8/22 at 10:51 a.m , indicated the resident fell when her knees gave out while ambulating to the restroom. The new intervention identified was the resident being on an antibiotic for a urinary tract infection. The nurse's note, dated 9/13/22 at 3:29 a.m., indicated the resident was sitting on the floor in the bathroom. There were no apparent injuries. The IDT note, dated 9/14/22 at 9:10 a.m., indicated the new intervention for the fall on 9/13/22 was to obtain a UA, CBC, and BMP. The nurse's note, dated 10/16/22 at 10:53 a.m., indicated the resident had a fall trying to transfer from her bed to the bathroom and fell in the bathroom. There were no apparent injuries. The IDT review, dated 10/17/22 at 12:20 p.m., indicated the new intervention was for hospice to evaluate and treat the resident. The clinical record lacked documentation of any further preventative interventions. During an interview on 10/24/22 at 1:40 p.m., LPN (Licensed Practical Nurse) 7 indicated the resident had increased confusion. She had to be checked every 2 hours. The cause of her many falls was her increasing confusion. They kept her door open so they could watch her. When a resident fell, floor staff did not do the care plans, the IDT team did. 2. The clinical record for Resident 22 was reviewed on 10/20/22 at 8:48 a.m. The diagnoses included, but were not limited to, wedge compression fracture fourth lumbar vertebra, legal blindness, congestive heart failure, Alzheimer's disease, macular degeneration, epilepsy, and repeated falls. The Significant Change MDS assessment, dated 8/24/22, indicated the resident was cognitively intact and required extensive assistance of one staff member with bed mobility and transfers. The care plan, last revised on 10/9/22, indicated the resident was at risk for falls. The interventions included, but were not limited to, staff to assist the resident with all transfers as needed (dated 6/15/20), encourage rest periods to avoid overtiring (dated 6/5/20), refer to PT/OT (physical therapy/occupational therapy) for evaluation and treatment as indicated (dated 6/15/20), had taken constipation medication (dated 12/23/21), call light in reach (dated 6/15/21), therapy to screen (dated 5/25/22), check auto locking brakes (dated 9/8/22), and hospice to provide reclining wheelchair (dated 10/11/22). The nurse's note, dated 12/23/21 at 4:01 p.m., indicated the resident self-reported having fallen in the bathroom and hit her head on the arm rest of her wheelchair. The resident stated, I stood up and missed the side of my chair and hit my head. She then pulled bathroom call light to alert staff while she was still in the bathroom. The IDT note, dated 12/29/21 at 1:32 p.m., indicated the IDT met to review the fall that occurred 12/23/21 at 3:45 p.m. The resident self-reported a fall in her bathroom. The new intervention was specified as, . she had taken stuff for constipation and was in a hurry . The clinical record lacked documentation of any further preventative interventions. The nurse's note, dated 12/30/21 at 10:49 a.m., indicated the resident was sent to the hospital for an increase in back pain. The nurse's note, dated 12/30/21 at 5:58 p.m., indicated the resident returned to the facility with a compression fracture to her 4th lumbar vertebra. She was to wear a brace when out of bed and follow-up with the physician in 4 to 6 weeks. The nurse's note, dated 5/25/22 at 12:00 p.m., indicated the resident had fall while in the bathroom. There were no injuries observed. She was found with her feet in front of toilet and head towards the door on her back. The IDT note, dated 5/26/22 at 1:53 p.m., indicated the IDT met to review fall that occurred 5/25/22 at 12:00 p.m. Prior to the fall the resident was going to the bathroom. The resident was found sitting on the floor back toward the door. The new intervention was for PT/OT (physical therapy/occupational therapy) to evaluate and treat. The nurse's note, dated 7/19/22 at 5:52 p.m., indicated the resident attempted to transfer from her bed to her w/c (wheelchair) and did not lock the w/c brakes. The resident was found sitting on floor with her back up against the nightstand at 11:15 a.m. She had a reddened area on her left mid back and a bruise on her left inner wrist which was purple in color. The resident stated her left hand hurt. A left forearm and left hand x-ray was ordered. The x-ray results were negative for any acute findings. The IDT note, dated 7/20/22 at 10:45 a.m., indicated the IDT met to review the fall on 7/19/20 at 11:15 a.m. The resident attempted to transfer from her bed to her w/c and did not lock her w/c brakes. She was found sitting on the floor with her back up against the nightstand. The new intervention was for auto lock brakes to her wheelchair. The nurse's note, dated 9/8/22 at 12:01 p.m., indicated the nurse was called into resident's room and witnessed resident on the floor kneeling beside bed facing the window with her wheelchair behind her. When the nurse asked what happened, the resident stated she wanted to go to bed. The IDT note, dated 9/9/22 at 12:39 p.m., indicated the IDT met to review the fall on 9/8/22 at 12:01 p.m. The new intervention was to have the resident's auto lock brakes checked to ensure working properly. Maintenance did check and the brakes were working properly. The clinical record lacked documentation of any further root cause analysis or preventative interventions. The nurse's note, dated 10/9/22 at 1:00 p.m., indicated the resident's roommate alerted the nurse the resident had fallen out of her chair in their bedroom. The nurse observed the resident on the floor in front of her wheelchair, face down on her knees, underneath bedside table. The resident indicated she hit her head and she had a small bump with bruising that appeared to be new on her right upper forehead. The IDT note, dated 10/11/22 at 12:10 p.m., indicated the IDT team met and reviewed fall the resident's fall on 10/9/22 at 12:30 p.m. The note lacked documentation of any root cause analysis of the fall. The new intervention was for hospice to evaluate and treat. The clinical record lacked documentation of any further preventative interventions During an interview on 10/24/22 at 1:42 p.m., the Unit Manager indicated when a resident fell the IDT came together and came up with new interventions for the fall. They did not have steps they followed. It was individual to the resident's needs. They discussed what interventions would be appropriate, but there was no standard for what happened and what the next step would be. She was familiar with what a root cause analysis was, but they did not do it as part of their IDT meetings. The goal of the fall intervention would be to prevent further falls. Usually, they came up with a new intervention each time, or modified an old one. For instance, if a resident had an auto lock brake on their wheelchair, the new intervention might be to reassess those auto lock brakes. If they were functioning that probably was not the cause of the fall and they needed to reassess the intervention. The resident being on medication for constipation and being in a hurry might have been the cause of the fall, but it wasn't an appropriate intervention. Usually new interventions would be added to the care plan when they did the IDT note, the care plan would be updated at that time. During an interview on 10/25/22 at 2:06 p.m., the DON (Director of Nursing) indicated when a resident fell the nurse documented it and the next morning, she printed it off and brought it to clinical meeting. Therapy and the clinical team sat down and came up with new interventions. They talked to therapy about the cause of the fall, but they did not document any of that. They did a different intervention for each fall. On the instance where the resident had a fall and the new intervention was, she had taken medication for constipation and was in a hurry, that was the cause of the fall but was not a preventative intervention. If the brakes on a wheelchair were checked and they were fine, they needed to implement another intervention. 4. The clinical record for Resident 4 was reviewed on 10/19/22 at 1:00 p.m. The diagnoses included, but were not limited to, osteoporosis pathological fracture, Alzheimer's disease, anxiety disorder, Covid-19, dementia, psychotic disorder, difficulty walking, displaced intertrochanteric fracture of left femur, major depressive disorder, pneumonia, and urinary tract infection. The Annual MDS (Minimal Data Set) assessment, dated 7/9/22, indicated the resident was cognitively intact. The resident required extensive assistance with transfers. Her balance and walking was not steady. The physician's order, dated 3/25/22, indicated mobility by wheelchair. The care plan, dated 7/16/18 and last revised on 7/20/22, indicated the resident was at risk for falls. The interventions included, but were not limited to; assist the resident with all transfers as needed, encourage rest periods to avoid overtiring, keep the call light and her favorite things (telephone, TV remote, etc.) near at all times, make sure pathways in her room are free from clutter and ensure adequate lighting (dated 6/10/19); provide night light as necessary or requested, observe for changes in gait when walking, notify the physician as needed, update the Fall Assessment each quarter and as needed (dated 6/11/19); encourage the resident to call for assistance before getting out of bed (dated 6/25/19); occupational and physical to evaluate as needed (dated 10/9/20, 12/21/21 and 1/21/21); auto lock brakes (dated 12/5/19); remind the resident to always lock the wheelchair brakes (dated 11/30/20 and 1/13/20); continue the current interventions (dated 1/9/20); gripper socks (dated 6/9/20); no fall sign (dated 8/3/20); dycem to recliner (dated 11/20/20 and 6/1/21); educate the resident on asking for assistance with transfers (dated 6/10/19); dycem under the quilt pad in her recliner (dated 4/14/21); fix auto locking breaks (dated 4/26/21); x-rays (dated 5/15/15); urinary analysis with culture and sensitivity (dated 5/17/21); dycem to her wheelchair, and gripper tape on both sides of the bed (dated 12/24/21); maintenance to assess the wheelchair for repair to auto locking breaks (dated 12/5/10 and 8/28/22); wheelchair modification (dated 1/15/21 and 1/20/21); fix auto locking brakes (dated 4/26/21); continue with therapy (dated 1/3/20); send to the emergency room for evaluation and treatment, encourage to call for assistance before getting out of bed (dated 6/25/19); continue with current interventions (dated 6/2/22 and 10/9/20); complete Blood count (CBC), basic metabolic panel (BMP) and urinalysis (UA) with culture and sensitivity (C&S) (dated 1/17/20, 5/17/21, and 8/19/22); gripper socks (dated 6/9/20); and no call no fall sign (dated 8/3/20). The IDT note, dated 12/21/21 at 1:21 p.m., indicated the IDT met to review a fall that occurred 12/21/21 at 6:45 a.m. Prior to the fall, the resident was sitting in her wheelchair. She was found on the floor. The clinical record lacked documentation indicating the root cause of the residents fall and appropriate interventions were implemented. A nurse's note, dated 12/24/21, indicated the nurse was called to resident's room by the CNA. The CNA heard the resident calling for help and went into her room to find her lying on the floor between her bed and the window. When the nurse entered the room the resident was sitting on her bottom with her legs out in front of her. The nurse assessed the resident no injuries were observed. The resident stated that she was trying on her new socks and thought they were the kind that didn't slip but they weren't. Her feet started to slide so she slid herself off the side of the bed onto the floor on to her bottom. Her bottom was the only thing she hit and that nothing hurt. She had no complaints of pain or discomfort. She was able to move all extremities without difficulty. The resident's shoes were put on and she was assisted off the floor and sat on the side of the bed by staff. The IDT note dated 8/29/22, indicated IDT met to review a resident fall that occurred 8/28/22 at 3:45 p.m. The CNA informed the nurse that Resident 4 had an unwitnessed fall. The nurse went immediately to her room and found Resident 4 sitting on the floor with her wheel chair by her side. A neurological check was immediately given along with skin and pain assessment. An abrasion along the spine was observed measuring 1 cm (centimeters) wide and 4.5 cm long. No other signs of injury were noted and the resident did not have any complaints of pain. Staff assisted the resident into her wheel chair. When asked what happened she stated she was trying to transfer out of her chair and move to her wheel chair, the wheel chair slid away from her and she scraped her back on the way down to the floor. Resident 4 stated that she did not hit her head on the way down. The new intervention was to have maintenance assess the resident's wheelchair for proper functioning of auto locking breaks. The nurse's note, dated 9/19/22 at 1:23 p.m., indicated the Interdisciplinary Team met regarding a fall without injury on 9/17/22 at 6:50 am. The charge nurse at time of fall indicated the CNA alerted the nurse that the resident was sitting on the floor. Upon arrival the nurse observed the resident sitting on the floor, on the right side of her bed, back leaning against bedside drawer, and her bilateral lower extremities were straight forward. When she asked what happened. the resident stated I'm trying to get up . The new intervention was to obtain a CBC (Complete Blood Count), BMP (Basic Metabolic Panel); urinalysis with culture and sensitivity (if indicated). During an interview on 10/24/22 at 9:30 a.m., QMA (Qualified Medication Aide) 8 indicated fall interventions included, bright colored tape, for the residents at high risk for fall would be monitored more closely, strips on the floor, nonskid footwear, handicap bars, and fall education. During an interview on 10/24/22 at 10:24 a.m., LPN (Licensed Practical Nurse) 9 indicated the care plans would be updated by the unit manager with new interventions. The care plan should be initiated or updated when a problem was identified. They needed to be updated as soon as possible. 5. During an observation on 10/19/22 at 10:55 a.m., Resident 8 was observed coming out of the bathroom without her walker or staff assistance. She had one sock and one shoe on. Her left foot was bare. The clinical record for Resident 8 was reviewed on 10/19/22 at 10:55 a.m. The diagnoses included, but were not limited to, chronic kidney disease, fracture of other parts, heart disease, major depressive disorder, urinary tract infections, anxiety disorder, bacterial infections, Alzheimer's, irritable bowel syndrome, repeated falls and a history of falling. The Quarterly MDS (Minimal Data Set) assessment, dated 7/8/22, indicated the resident was severely cognitively impaired. She required supervision with transfers and walking. The care plan, dated 7/16/18 and last revised 10/14/22, indicated the resident was at risk for falls. The interventions included, but were not limited to; assist the resident with all transfers using her walker and a gait belt for safety, de-clutter the room and move the beds, keep the call light within reach and remind and encourage her to use it to call for assistance as needed (dated 2/24/22), physical therapy and occupational therapy to evaluate and treat as indicated (dated 2/24/22 and 8/30/22); reassess quarterly and as needed, follow-up (dated 2/24/22); urinalysis with a culture and sensitivity (C&S) if indicated 3 days post antibiotics (dated 4/18/22); schedule follow-up appointment with neurology (dated 2/28/22); emergency room visit for evaluation and treatment if indicated, antibiotic order changed per urologist based on the C&S results (dated 4/18/22); continue current interventions (dated 7/2/22); send to the emergency room for treatment and evaluation (dated 8/9/22); family to take slide on shoes home (dated 9/19/22); maintenance to replace grip strip tape in the shower room (dated 10/14/22); and send to the emergency room for evaluation and treatment as indicated (dated 3/11/22 and 10/14/22). The clinical record lacked documentation indicating appropriate interventions and the root cause of the resident's falls. The IDT met to review the fall that occurred on 2/27/22 at 6:30 p.m The resident was in the room across the hall and came out into the hallway yelling that the resident was in the floor. Upon entering the room she was found sitting on her buttocks next to her spouse's bed. He was sitting on the side of his bed holding the resident's hand. She denied pain or discomfort. She was assessed with no injuries noted. She was assisted off the floor and into the wheelchair. She moved all extremities well. She and her family member were brought out to sit by the nurses station. She was asked what she was doing and she replied just sitting on the floor. When asked if she was hurt anywhere she said no but that's going to get bigger referring to the bruising from a previous fall. The new interventions are to repeat UA with/ C&S (if indicated) 3 days post antibiotic therapy and to schedule a follow-up appointment with the neurologist. The IDT note, dated 3/15/22 at 12:00 p.m., indicated the resident had a fall that occurred on 3/11/22 at 12:45 p.m. She was in the room across the hall and staff was notified that the resident had fallen. The resident was found on the floor received an abrasion to her right forehead and complained of her right leg hurting. The new interventions was send to hospital for evaluation and treatment as indicated. The IDT note, dated 4/18/22 at 9:00 a.m., indicated the resident was very emotional that morning thinking that her father had passed away. She had gotten herself and her family member dressed. Both were walking up the hall from their room with her stating We have to go! We have to get there he has done passed. The CNA assisted the family member back to the room without issues. The nurse attempted to reassure and redirect the resident. All attempts were unsuccessful. Resident 8 was sitting in a chair, visible to the nurse from nurse's station, looking out the window stating I am waiting for them to get here. She stood up and lost her balance. She fell back onto the chair then slid down to the floor with the nurse witnessing the incident. The resident was able to move all of her extremities without increased pain or discomfort. The new intervention was antibiotics order changed per urologist based on the C&S results. Will repeat UA with/ C&S (if indicated) 3 days post antibiotics. The IDT note, dated 7/11/22 at 12:42 p.m., indicated the resident was observed laying on her right side asleep with her head on a pillow next to the toilet with her walker by her feet as if she had walked into the bathroom to lay down in the floor and go to sleep. When asked what happened the resident stated she must have rolled out of bed. Informed her that she was in the bathroom floor and she then stated that she rolled out of the bed and scooted into the bathroom. When asked how she got her walker in there with her she was unable to answer. Staff assisted the resident from laying to a sitting to a standing position with complaints of pain in both hips and her lower back. Assisted the resident into the bed and head to toe assessment revealed a reddened blanchable area on her right shoulder from pressure of the hard bathroom floor and old scattered bruises. When asked if her shoulder hurt she stated that it did hurt. Her hips appeared to be in alignment. She was able to move all of her extremities, but stated that it hurt when she goes from sitting to standing or standing to sitting. She denied hitting her head. She was confused and at baseline. Staff would continue current interventions at that time. The IDT note, dated 8/9/22 at 12:24 p.m., indicated the nurse heard some noise while passing the resident's room. When staff entered the room the resident was lying on the floor on her right side between the bed and the window the resident was asked what had happened she stated she was trying to hold her family member. An assessment was done while the resident was on the floor. The resident received a skin laceration on her left arm measuring 7.5 cm, as well as a skin tear to the right arm measuring a 6 cm. The resident complained of severe pain in her right upper leg and neck. The new intervention was to send the resident to the emergency room for evaluation. The IDT note, dated 8/30/22 at 2:21 p.m., indicated the CNA found the resident sitting on the floor. with her bilateral lower extremities straight forward and her back was leaning against the right side of the bed. When asked what happened, the resident stated that she slid down onto the floor. The new intervention was to have PT to evaluate and treat as indicated. The IDT note, dated 9/19/22 at 10:45 a.m., indicated the CNA found the resident laying on the floor, on her right side outside of the bathroom . The resident obtained 2 skin tears to her right elbow and a skin tear to her left lower leg. The new intervention was to have the family to take the resident's slide on shoes home. The IDT note, dated 10/17/22 at 9:34 a.m., indicated the CNA came out of the shower room indicating Resident 8 had fallen in the shower while preparing for her shower. While holding on to the shower chair she turned her head to check the water temperature with her other hand and felt the shower chair move. When she turned around Resident 8 had tried to stand up and slid out of the shower chair onto the floor. She hit the back of her head on the wall on the way down to the floor. Upon entering the shower room the resident was observed sitting on her buttocks with her legs out in front of her. She was holding her head saying that it hurt. Staff put a hospital gown on her and laid her flat on her back with her head on a blanket. She was assessed and complained of head pain and a finger on her left was hurting. She had a small, raised area on the back right side of her head. She started to complain of knee pain and a new bruise was observed on her left knee. The new intervention was to send the resident to the hospital for evaluation and treatment and replace grip strips in shower room. During an interview on 10/24/22 at 10:30 a.m., QMA 8 indicated fall interventions included, bright colored tape, for the residents at high risk for fall would be monitored more closely, strips on the floor, nonskid footwear, handicap bars, and fall education. During an interview on 10/24/22 at 10:24 a.m., LPN 9 indicated the care plans would be updated by the unit manager with new interventions. The care plan should be initiated or updated when a problem was identified. They need to be updated as soon as possible. The Fall Protocol policy, last revised March 2018, provided on 10//24/22 at 9:35 a.m. by the Director of Nursing, included, but was not limited to, . 2. In addition, the nurse shall assess and document/report the following . Precipitating factors, details on how fall occurred . For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall . Often, multiple factors contribute to a falling problem . If the cause of a fall is unclear, or if a fall may have significant medical causes such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help identify causes and contributing factors . After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling . The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable . The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling . If the individual continues to fall, staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions . As needed, and after an appropriately thorough review, the physician will document any uncorrectable risk factors and underlying causes . 3.1-45(a)(1) 3. The clinical record for Resident 24 was reviewed on 10/20/22 at 10:18 a.m. The diagnoses included, but were not limited to metabolic encephalopathy, urinary tract infections, Alzheimer's disease, panlobular emphysema, atherosclerosis of the aorta, abdominal aortic aneurysm, pleural effusion, chronic obstructive pulmonary disease, decreased circulation of the hands and feet, corns and callosities, shortness of breath, history of falling, muscle weakness and difficulty in walking. The Quarterly MDS assessment, dated 8/26/22, indicated the resident was cognitively intact. He required limited assistance of one staff for transfers, toileting, locomotion, bed mobility and personal hygiene. The care plan, dated 12/19/18 and last revised on 9/21/22, indicated the resident was at risk for falls with the following falls on 10/27/21, 7/18/22, 9/7/22, and 9/21/22. The interventions indicated the following: to encourage the resident to ask for assistance as needed, encourage rest periods to avoid overtiring, provide night light as necessary or requested, refer to physical therapy or occupational therapy, update fall assessment quarterly and as needed, notify the physician as needed (dated 12/7/18); to wear gripper socks at all times (dated 3/4/19); therapy to screen (dated 6/12/19); encourage the resident to lay down when tired (dated 8/8/19); new hand rails to head

Based on observation and interview, the facility failed to ensure the kitchen, dry storage room and equipment were clean and in good repair during 3 of 3 kitchen observations. Findings include: 1. During the initial kitchen tour on 10/18/22 between 9:25 a.m. and 10:00 a.m., while accompanied by the acting Dietary Manager (DM) the following observations were made: - Inside the milk/soda walk in refrigerator - the 2 condenser fans and an area of approximately 1 inch around the fans unit and the ceiling 2 feet out from the condenser fans had a black greasy dust on them. The fans were running at this time. - Inside the walk in fruit/vegetable refrigerator the floor had onion skins on it, cardboard pieces were under the shelves and in the walk way. There was a build-up of black dirt and food particles in the corners, the floor around the carts' wheels and 6 inches around the entire floor from the baseboards out. The ceiling 1 foot away from the condenser fans had black grease on it. - The walk-in freezer was observed to have a 1 foot long by 4 inch wide frost build up on both the door and the door frame. There was a frozen ice puddle on the floor which was several inches thick by 4 feet in length and 8 feet width with ice frost on the wall behind this ice puddle which measured 3 feet by 4 feet. The floor was littered with cardboard pieces and food debris. The DM indicated at this time that maintenance was getting bids on fixing the freezer as a pipe had broken, but it had been at least 2 months since he started that the ice puddle on the floor had been like that. The Salad prep aide indicated it was more like 4 to 5 months since it was last fixed. - 2 of 2 ceiling vents above the food prep area and 2 feet surrounding the vents had black grease dust on them - food was being prepped on the counter at this time. - 9 of 9 ceiling vents had black dust on vents as well as the surrounding ceiling. - 14 of 14 ceiling sprinkler heads were rusty with black dust on the sprinkler and 1 foot of the ceiling surrounding them. - the top of the knife holder had light dust and white specks on it. - dry storage room's air duct vent extending from the ceiling above the cereal rack was covered with a white mesh net. This mesh was now black and the cereal rack had gray dust on the top shelf. The DM indicated that he was told anything above 6 feet in the kitchen was maintenance's responsibility to clean. 2. During the tray line observation, on 10/18/22 between 10:48 a.m. and 11:15 a.m., the same issues remained as previously identified at 9:45 a.m. In addition there were two deep fryers which had brown food particles in the oil and on top of the frame surrounding the oil. Three sides of each fryer, the right side of the stove, the left side of the tilt skillet, and the floor in front of and underneath the fryers had a heavy build-up of brown oil. 3. During a kitchen observation, on 10/20/22 between 10:30 a.m. and 11:00 a.m., the same areas of concerns identified on 10/18/22 at 9:45 a.m. and at 10:48 a.m. remained. During an interview with the Executive Director on 10/24/22 at 8:35 a.m., she indicated the dietary department had a cleaning schedule, but they just weren't using it. All areas of the kitchen needing cleaning, including the ceiling tiles and vents, fell under the dietary's responsibility to clean, not maintenance. 3.1-21(i)(3)

4. During an observation on 10/18/22 at 11:34 a.m., the Hospice Volunteer was observed enter the building without a face mask on. Eight staff members were observed at the nurses station and in the hallways and seen the visitor without the mask and and no one approached the visitor with a mask and educating the visitor on mask usage. The visitor entered a resident's unit then turned around and went to the nurse's station and asked a staff member for the room number for a resident he was going to visit. The staff member did not make any attempt to encourage the visitor to wear a mask. 5. During an observation on 10/20/22 at 3:00 p.m., the Maintenance Man was observed walking down the hallway and into the dining room with his mask down. Four residents were observed in the dining room watching a movie on the television. The review of the Community Transmission Positive Rate Log, on 10/24/22 at 3:00 p.m., indicated the county positivity transmission rate was high. During an interview on 10/24/22 at 3:00 p.m., the Infection Preventionist indicated the staff would be monitored for compliance by observations of handwashing, proper PPE usage, and daily check offs. Visitors would be educated not to visit if they had symptoms. Education on signs and symptoms are posted on the doors and the proper PPE's to wear. All staff and visitors must wear a mask at all times while in the facility. The staff and visitors had been educated on proper use of the PPE's. The facility offer visitors and staff mask. The surgical mask are required to enter the facility. The county positivity was high at this time. 3.1-18(a) Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed related to proper use of personal protective equipment (PPE) for 6 of 9 staff observed for Infection Prevention. (Dietary Aide 14, Dietary [NAME] 15, Housekeeping Supervisor, Social Services Designee, Hospice Volunteer, and Maintenance Man) Findings include: 1. During the initial tour of the kitchen with the Acting Dietary Manager (DM), on 10/18/22 between 9:25 a.m. and 10:00 a.m., the following concerns were observed: a. The Dishwashing Aide walked through the kitchen talking to another worker without her mask on. When questioned if masks were required to be worn at all times, Dietary Aide 14 indicated that yes they were. Throughout the rest of the observation of the kitchen, Dietary Aide 14 was observed with her mask half pulled up covering her mouth only but not her nose. b. Dietary [NAME] 15 was observed with no mask covering her nose or mouth. 2. During the lunch tray line observation on 10/18/22 between 10:48 a.m. and 11:15 a.m., Dietary Aide 14 was observed with her with mask down off her face and then it was pulled up to only below her nose while she completed setting up the resident food trays. 3. During a random observation on 10/24/22 at 1:05 p.m., the Housekeeping Supervisor entered the front of the building. There was a sign on the door which indicated a mask was to be worn at all times. The Housekeeping Supervisor stopped at the snack machines next to the resident dining room, and then walked down to Assisted Living with no mask on. At 1:12 p.m., he was observed at the snack machines without a mask on and Resident 57 was observed to have been wheeled past him while he was at the snack machines. 4. During a random observation on 10/24/22 at 3:30 p.m., the Social Services Designee was observed to be sitting in his office speaking with Resident 14 who was leaning across the Social Worker's desk. The Social Services Designee had no mask on. On 10/24/22 at 3:20 p.m., the Infection Preventionist presented a memo, dated 9/30/22, which she indicated she had passed out to all staff. This memo indicated that all staff were still required to wear face masks. She also included pictures of how the mask was to be worn properly which covered their mouth and nose.