Based on observation, record review, and interview, the facility failed to ensure a physician ordered medication was administered and documented appropriately for 1 of 3 residents reviewed for quality of care. (Resident B) Findings include: During an interview on 6/9/25 at 1:35 p.m., Resident B indicated he had not received his nicotine patch 3-4 days last week and then again today. During the interview with Resident B, QMA 3 entered the room with his pain medication and indicated she had not applied his nicotine patch this morning because he had been in therapy. During a follow-up interview on 6/9/25 at 2:20 p.m., Resident B indicated QMA 3 had returned to his room, around 1:40 p.m., shortly after the initial interview and applied his nicotine patch. The clinical record for Resident B was reviewed on 6/9/25 at 12:21 p.m. Diagnoses included displaced right hip fracture with routine healing following surgical intervention, chronic obstructive pulmonary disease, and adjustment disorder with depressed mood. Current signed physician's orders for the resident included, Nicotine patch 21 mg (milligram)/24 hours, apply one patch daily between 7:00 a.m. and 11:00 a.m. Special instructions indicated to remove old patch before applying a new one and to rotate administration sites. The order was dated 5/30/25. A Proof of Delivery record, dated 4/30/25 to 6/9/25, for Resident B included Nicotine 21 mg/24 hour patch, shipped 30 patches on 5/30/25 and received 5/31/25 at 3:32 a.m. A review of the residents electronic medication administration record (eMAR) indicated the nicotine patch had been administered daily per physician's order, beginning on 5/31/25. An administration history record, provided by the DON on 6/9/25 at 3:14 p.m., indicated the nicotine patch had been administered on 6/9/25 at 10:44 a.m. by QMA 3, not the actual administration time of 1:40 p.m. A medication count for Resident B's nicotine patches was completed with QMA 6 on 6/9/25 at 2:05 p.m. QMA 6 indicated there were 23 patches remaining in the medication sleeve. The count according to the eMAR and administration history record, should have been 20 patches remaining in the medication sleeve. During a telephone interview on 6/10/25 at 4:01 p.m., QMA 3 indicated she had administered Resident B's medications at 10:44 a.m., but had forgotten to open the nicotine patch to place on the resident. When she returned to the resident's room, he had gone to therapy and she forgot about it until later in the day. It had been documented as given because she had intended to apply the patch at the time. She realized the medication should not be documented as given until it was administered. The eMAR for the administrations from the previous week was documented accurately and she had provided the patch to the resident. She had no knowledge of the patch not being administered as ordered. During an interview on 6/10/25 at 3:14 p.m., the DON indicated the patch had been pulled from the medication cart with the oral medications on 6/9/25 and had not been administered with his oral medications because he had gone to therapy. She must have forgotten and applied it after 1:00 p.m. and marked it as administered at 10:44 a.m. They prefer staff mark as administered following administration of the medications. She had interviewed the previous week's nursing staff who had documented administering the nicotine patch, and all had indicated they had administered the patch. She could not explain why there were three patches that were unaccounted as being administered remaining in the medication cart. A current facility policy, revised 6/30/23, titled, General Dose Preparation and Medication Administration, provided by the Administrator on 6/9/25 at 3:26 p.m., included the following: Procedure 7. After medication administration, the community should: 7.1 Document necessary medication administration/assistance/observation/treatment information (e.g., when medications are opened, when medications are give, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms or electronic medication records. This citation relates to Complaint IN00460788. 3.1-25(a)

Based on observation, record review, and interview, the facility failed to ensure a self-administration assessment had been completed for a resident who was observed to self-administer her medications for 1 or 1 random observation (Resident 15). Findings include: During a random observation of the breakfast meal in the main dining room, on 8/12/24 at 7:40 a.m., a medication cup containing 4 pills sat on the table in front of Resident 15. She self-administered the medications when her tray was delivered. No staff were present to observe the resident self-administer her medications. Resident 15's record was reviewed on 8/15/24 at 9:19 a.m. The profile indicated the resident's diagnoses included, but were not limited to, essential hypertension (a condition in which the blood vessels have persistently raised pressure), heart failure (a condition that occurs when the heart can't pump enough blood and oxygen to the body) and age-related macular degeneration (an eye disease that causes a breakdown of cells in the center of the retina, which is the light-sensitive tissue at the back of the eye). A quarterly Minimum Data Set (MDS) assessment, dated 7/17/24, indicated the resident had severe cognitive deficit and received medications, which included, but were not limited to, diuretic (a drug that increases the amount of urine the kidneys produce, helping the body get rid of extra fluid and salt) and antiplatelet (medications that prevent platelets from sticking together and forming blood clots). A review of the resident's record including assessments lacked documentation of an assessment to determine the resident's ability to self-administer medications. A review of the resident's record including care plans lacked documentation of her ability to self-administer her own medications. A review of the resident's record including physician's orders lacked documentation of an order for Resident 15 to self-administer her medications. A physician's order, dated 5/21/24, indicated to administer one 75 milligram (mg) tablet of clopidogrel (antiplatelet medication), one time a day. A physician's order, dated 5/21/24, indicated to administer one 20 mg tablet of furosemide (diuretic medication), one time a day. A physician's order, dated 5/21/24, indicated to administer one 50 mg tablet of metoprolol succinate (antihypertensive medication), one time a day. A physician's order, dated 6/12/24, indicated to administer one Preservision AREDS 2 tablet (medication to treat moderate to advanced macular degeneration), one time a day. During an interview, on 8/12/24 at 9:29 a.m., the Resident 15 indicated she requested the nurses to leave her pills on her table for her to take later because she took a water pill. If she took the water pill prior to coming down for her meal, she ended up having to go to the bathroom in the middle of her meals. Some of the nurses had been leaving them on her table, but the nurse on the evening shift refused to leave the pills on the table for her. During an interview, on 8/15/24 at 10:12 a.m., the Director of Nursing (DON) indicated there were not any residents in the facility that self-administered their own medications. The nurses should know better than to leave medications for any resident to take without their supervision. During an interview, on 8/16/24 at 10:39 a.m., Licensed Practical Nurse (LPN) 16 indicated the residents must always be supervised when giving medications. During an interview, on 8/16/24 at 10:45 a.m., LPN 17 indicated medications should never be left for a resident to take unsupervised. On 8/15/24 at 10:38 a.m., the DON provided a document, with a revision date of 1/2015, titled, Self Administration of Medications, and indicated it was the policy currently in use by the facility. The policy indicated, .Procedure .If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation. A physician order will be obtained specifying the resident's ability to self-administer medications .The resident will be assessed for continued self-administration of medications quarterly and with any significant change of condition. The resident's care plan will be updated to include self-administration 3.1-11(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure care plan meetings were completed timely for 2 of 24 residents reviewed for care plan meetings (Residents 12 and 24). Findings include: 1. During an interview on 8/12/24 at 11:10 a.m., Resident 12 indicated she could not remember having any care plan meeting in the last three years. On 8/13/24 at 2:24 p.m., Resident 12's record was reviewed. Care plan meeting documentation was located for 5/8/24, 2/13/24, and 9/11/23. The record lacked care plan meeting documentation from between 9/11/23 and 2/13/24. A quarterly Minimum Data Set (MDS) assessment, completed 7/29/24, indicated Resident 12 had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. During an interview on 8/14/24 at 10:39 a.m., the Social Services Director (SSD) indicated she might have done the assessment but did not complete the meeting note. During an interview on 8/14/24 at 11:17 a.m., the SSD indicated that she did not have any notes, documentation, or proof that the care plan meetings happened on paper or in the electronic medical record. During an interview on 8/14/24 at 12:01 p.m., the SSD indicated she did not do the care plan meetings at the time of the bedside assessments. She returned at another time to talk to do them. They did not use the care conference tab located in the electronic medical record. 2. During an interview, on 8/12/24 at 9:55 a.m., Resident 24 indicated he did not remember being invited to or attending a care plan meeting recently. He could not recall when the last one was. Resident 24's record was reviewed on 8/13/24 at 1:47 p.m. A significant change in status, Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment. Census information indicated the resident was admitted to the facility on [DATE]. A Care Plan Summary note, dated 4/17/24 at 4:26 p.m., indicated a care plan meeting was conducted on this day for Resident 24. A Care Plan Summary note, dated 6/19/24 at 9:44 a.m., indicated a care plan meeting was conducted on this day for Resident 24. Resident 24's record lacked documentation of a quarterly care plan meeting being conducted between the months of August 2023 and April 2024. During an interview, on 8/14/24 at 11:56 a.m., Social Service Director (SSD) indicated the care plan meetings were to be conducted annually and quarterly. The SSD was unable to provide documentation that Resident 24 care plan meetings were conducted on a quarterly basis and that she must have forgotten to document the care plan meeting in his chart. During an interview, on 8/15/24 at 10:20 a.m., the Administrator indicated they do not have documentation to show where the care plan meetings were conducted quarterly. She further indicated it was their company policy that the SSD would open an observation and complete the documentation in the computer system when the care plan meetings were conducted. On 8/14/24 at 12:13 p.m., the SSD provided a document, with a revised date of 8/23, titled, IDT Comprehensive Care Plan Policy, and indicated it was the current policy being used by the facility. The policy indicated, .Resident, resident's representative, or others as designated by resident will be invited to care plan review. The care plan review may be conducted face to face, via phone conference, video conference, or through written communication per resident and or representative preference. Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment 3.1-35(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Qualified Medication Aide (QMA) followed proper standards of practice for 1 of 1 residents reviewed for pressure ulcer care (Resident 218). Findings include: During an interview, on 8/12/24 at 9:29 a.m., Resident 218 indicated she had several open areas to her bottom, and they had been there since before her admission to the facility. She acquired the areas while living at home. During an interview, on 8/14/24 at 7:50 a.m., QMA 3 indicated Resident 218 was getting ready to take a shower and therefore she would not be doing the dressing change until after her shower. She further indicated the dressing changes would be completed by the wound Nurse Practitioner, the Assistant Director of Nursing, or other staff working the hall. During an interview, on 8/14/24 at 8:30 a.m., Resident 218 indicated QMA 3 had completed her pressure ulcer dressing changes before to her bottom. Resident 218's record was reviewed on 8/13/24 at 2:23 p.m. The profile indicated the resident diagnoses included, but were not limited to, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and wedge compression fracture of T11-T12 vertebra (a type of vertebral compression fracture that occurs when the bone in the front of the spine column collapses and loses height resulting in a wedged shape). An admission minimum data set (MDS) assessment dated [DATE], indicated the resident was cognitively intact and had one stage 3 (full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) pressure ulcer, two unstageable (when the stage is not clear due to the base of the wound being covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) pressure ulcers, and three deep tissue injuries (purple or maroon area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear). A physician order, dated 8/5/24 with no end date, indicated to cleanse wounds to gluteal cleft, left and right gluteal folds with normal saline, apply skin prep to peri wound (the area of tissue surrounding a wound), apply medical grade honey (natural, non-toxic agent that can be used to treat wounds) to wound beds, cover with bordered foam, and change daily and as needed. A care plan, dated 8/5/24, indicated the resident had impaired skin integrity: Pressure injuries to gluteal cleft (a deep groove that runs between the buttocks from the sacrum to the perineum), right gluteal fold (a horizontal crease in the skin that separates the upper thigh from the buttocks), left gluteal fold, left heel, right heel, and left 5th toe related to wedge compression fracture of the thoracic vertebra, history of falls, and generalized weakness. Interventions included but were not limited to, assess wound weekly documenting measurements and description, float heels while in bed, and treat as ordered by physician. A skin and wound note, dated 8/7/24 at 9:01 a.m., indicated the following pressure wounds: a. An unstageable pressure ulcer to left gluteal fold. The wound measures 3 by (x) 2 cm (centimeters) with a depth of 0.1 cm. b. A stage 3 pressure ulcer to right gluteal fold. The wound measures 1.5 x 0.5 cm with a depth of 0.1cm. c. An unstageable pressure ulcer to coccyx. The wound measures 2 x 1.5 cm with a depth of 0.1 cm. During an observation, on 8/14/24 at 9:48 a.m., the Assistant Director of Nursing (ADON) removed an old dressing to Resident 218's left gluteal wound. The dressing had no date or staff initials on it. During an observation, on 8/14/24 at 9:56 a.m., the ADON removed an old dressing to the resident's coccyx and the dressing only contained a date of 8/13. There were no staff initials on the old dressing. During an observation, on 8/14/24 at 10:04 a.m., the ADON removed an old dressing to the resident's right gluteal fold and the dressing only contained a date of 8/13. There were no staff initials on the old dressing. During an interview, on 8/14/24 at 10:09 a.m., the ADON indicated nursing staff should place a date and their initials on the dressing when it was completed. Review of August 2024, Treatment Administration Record (TAR) indicated QMA 3 documented as completing the dressing changes to Resident 218's pressure wounds 4 out of 9 days. During an interview, on 8/14/24 at 10:52 a.m., Director of Nursing (DON) indicated QMAs were only allowed to do stage 1 dressing changes and anything over stage 1 must be completed by licensed nursing staff. During an interview, on 8/14/24 at 11:36 a.m., QMA 7 indicated she was allowed to do dressing changes on wounds that were a stage 1 or less. They were not allowed to do dressing changes on anything over a stage 1. During an interview, on 8/14/24 at 1:58 p.m., the DON indicated QMA 3 was questioned and the QMA thought she had accidently selected the complete all button when she was administering medications to Resident 218. The QMA indicated that explained how her initials got into the box as completing the dressing changes. The DON indicated when staff placed their initials in the documentation box that would be taken as they were the person who completed the treatment. On 8/14/24 at 1:55 p.m., the Administrator provided a document with a revised date of 07/23, titled, Dressing Change Clean Technique, and indicated it was the current policy being used by the facility. The policy indicated, .date and initial new dressing On 8/14/24 at 1:55 p.m., Administrator provided a document with a revised date of 07/24, titled, QMA Parameters and Scope of Practice, and indicated it was the currently policy being used by the facility. The policy indicated, .At no time should a QMA .8. Administer a treatment that involves an advanced skin condition, including Stage II, III, and IV pressure ulcers 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure medication storage areas were free from personal drinks, and failed to ensure expired medication was disposed of (Resident 38) for 2 of 4 medication carts reviewed for medication storage. Findings include: 1. During observation of medication storage and labeling on 8/15/24 at 10:58 a.m., in the bottom drawer of the A-hall medication cart, observed a plastic restaurant cup with a label on the outside indicating it to be iced coffee from 8/15/24. The drink was stored amongst residents medications. During an interview with Licensed Practical Nurse (LPN) 16 on 8/15/24 at 10:59 a.m., she indicated the drink belonged to her, and food or drink were not to be stored inside the medication carts. During an interview with the Administrator (ADM) on 8/16/24 at 9:57 a.m., she indicated staff were not supposed to have personal drinks in patient care areas, including the medication carts, and were supposed to keep them in the break room. 2. During an observation of medication storage and labeling on 8/15/24 at 11:19 a.m., in the top right drawer of the C-hall medication cart, observed latanoprost 0.005% eyedrops for Resident 38 with an opened date of 7/2/24. During an interview on 8/15/24 at 11:20 a.m., Licensed Practical Nurse (LPN) 10 indicated that she knew the eye drops were out of date, they were only good for six weeks after opening, and she had already ordered more. During an interview on 8/15/24 at 11:38 a.m., LPN 10 indicated she confirmed with the pharmacy that the eye drops were only good for six weeks after opening. They had been ordered, but the pharmacy did not get them delivered in time, they were on their way today. On 8/16/24 at 10:15 a.m. Resident 38's record was reviewed. Her diagnoses included, but were not limited to, acquired absence of eye (surgical removal of the eye), glaucoma (occurs when fluid builds up in the front part of the eye, increasing the pressure and causing damage to the optic nerve), and history of endophthalmitis (a serious infection of the fluid within the eye), A physician's order, dated 3/7/24, indicated to administer latanoprost 0.005% (medication used to decrease pressure in the eye) ophthalmic (eye), one drop at bedtime. A medication administration record (MAR) for Resident 38 indicated that the latanoprost 0.005% ophthalmic was administered on 8/13/24, 8/14/24, and held on 8/15/24 due to the medication not being available, with a comment that indicated they were waiting on arrival from the pharmacy. During an interview with LPN 10 on 8/16/24 at 10:22 a.m., she indicated a new bottle of eyedrops was delivered, they used the new bottle last night and it was dated. The last day the eyedrops should have been used was 8/13/24. Anything documented as given after that should have been documented as giving expired medications until the new bottle arrived. On 8/15/24 at 11:55 a.m., the LPN 10 provided a document with a revision date of 6/30/23 and identified it as the current facility policy, titled, Storage and Expiration Dating of Medications, Biologicals. The policy indicated, .3.5 The community should ensure food is not stored in the refrigerator, freezer or general storage areas where medications and biologicals are stored .4. The community should ensure that medications and biologicals that .(2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier 3.1-25(o)

Based on observation, record review, and interview, the facility failed to ensure residents were addressed in a dignified manner for 3 of 3 residents reviewed for dignity (Residents 18, 30, and 10). Findings Include: 1. During the lunch meal observation, on 5/30/23 at 12:20 p.m., Resident 18 was sitting at the lunch table and was being assisted with eating by Activity Assistant 5. Activity Assistant 5 addressed Resident 18 as Mama. She asked Resident 18, Mama, would you like to take a bite? Activity Assistant 5 proceeded to assist the Resident 18 with eating and asked, Mama, would you like to take a drink? Resident 18's record was reviewed on 6/1/23 at 10:00 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood. The record lacked a care plan indicating resident preferred to be called Mama. A significant change of status Minimum Data Set (MDS) assessment, dated 3/22/23, indicated the resident had a severe cognitive deficit and required a 1 person to assist with eating. 2. During the lunch meal observation, on 5/30/23 at 12:25 p.m., Resident 30 was sitting at the lunch table and was being assisted with eating by Activity Assistant 5. Activity Assistant 5 had addressed Resident 10 as Mama. She asked Resident 10, Mama, are you hungry? Activity Assistant 5 proceeded to assist the resident with eating and indicated, Mama, I need you to open your mouth to eat the food. Resident 30's record was reviewed on 6/2/23 at 9:58 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dysphagia (difficulty in swallowing), and urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). The record lacked a care plan indicating resident preferred to be called Mama. A quarterly Minimum Data Set (MDS) assessment, dated 3/27/23, indicated the resident had a severe cognitive impairment and was unable to complete the BIMS (brief interview for mental status) test and required a 2 person assist with bed mobility, dressing, toileting, and transfers. The resident required 1 person to assist with eating. 3. During the lunch meal observation, on 5/30/23 at 12:38 p.m., Resident 10 was observed to be sitting in a chair in the dining room with a small side table in front of her for eating. Activity Assistant 5 spoke with the resident and asked, Mama are you done eating? Activity Assistant immediately laughed and indicated she meant to say her name instead of Mama. Resident 10's record was reviewed on 6/2/23 at 9:54 a.m. The profile indicated the resident's diagnoses included, but were not limited to, vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to your brain) without behavioral disturbance, hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs) and need for assistance with personal care. The record lacked a care plan indicating resident preferred to be called Mama. A quarterly Minimum Data Set (MDS) assessment, dated 4/12/23, indicated the resident had a severe cognitive deficit and required a 2 person assist with bed mobility, dressing, toileting, and transfers. The resident required 1 person to assist with eating. During an interview, on 6/2/23 at 9:35 a.m., Dementia Care Director indicated staff were to address residents by their name unless care planned otherwise. It is not the expectation of the staff to call residents by the name Mama. On 6/2/23 at 1:48 p.m., the Executive Director provided and identified a document as a currently facility policy, titled Resident Rights, revised dated 11/16. The policy indicated, .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well-being, and proper delivery of care 3.1-3(a)

2. On 5/30/23 at 12:05 p.m., Resident 15 was observed during lunch meal in the main dining room with dark debris under her fingernails while feeding herself with her bare hands. On 6/1/23 at 11:00 a.m., Resident 15 was observed in the main dining room with dark debris under her fingernails. On 6/2/23 at 9:42 a.m., Resident 15 was observed with dark debris under her fingernails. On 6/5/23 at 11:45 a.m., Resident 15 was observed in dining room with dark debris under her fingernails. On 6/6/23 at 9:00 a.m., Resident 15 was observed sitting outside the front of the building in a wheelchair with dark debris under her fingernails. On 6/1/23 at, 2:17 p.m., Certified Nursing Assistant (CNA) 15 indicated, Resident 15 required total assistance for activities of daily living (ADL) (activities related to personal care to include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) and staff were to trim and clean the residents' nails as needed. On 6/02/23 at 9:45 a.m., the Activity Director indicated the activity department staff provided nail care on Wednesdays and Sundays. If a resident's nails were soiled, staff would clean the nails and apply polish if the resident wanted it done. At times, when the residents were in bed, the activities department staff were not able to get the residents' nails done. On 6/2/23 at 9:51 a.m., CNA 7 indicated, she was supposed to clean the residents' nails during showers and when needed. On 6/2/23 at 9:56 a.m., the DON indicated the ADL care including nail care and shaving facial hair was normally done on the resident's shower days as the resident allowed it. The clinical record for Resident 15 was reviewed on 5/30/23 at 1:00 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks) and need for assistance with personal care. A quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 4/13/23, indicated the resident was an extensive assist for ADLs including bed mobility, transfers, eating, toileting, bathing, and personal hygiene assistance from the staff. A care plan, dated 3/8/22, indicated the resident required assistance with ADLs including bed mobility, transfers, eating and toileting with a goal of the resident had a desire to improve current functional status. Review of the shower sheets from 5/2/23 to 5/31/23, indicated the resident received a total of 14 showers with nail care provided 7 times. 3. On 5/30/23 at 12:00 p.m., Resident 34 was observed during the noon meal in the main dining room with dark debris under her fingernails. On 6/1/23 at 11:00 a.m., Resident 34 was observed in the main dining room her fingernails were soiled with dark debris under the fingernails. On 6/5/23 at 11:45 a.m., Resident 34 was observed in the main dining room with dark debris under her fingernails. On 6/6/23 at 9:00 a.m., Resident 34 was observed sitting outside in the front of the building in a wheelchair with her fingernails heavily soiled under the nails with dark debris. On 6/2/23 at 9:50 a.m., the Activity Director indicated the activity department staff provided nail care on Wednesdays and Sundays. If a resident's nails were soiled, the activity staff would clean the fingernails and apply polish if the resident wanted it done. At times, when the residents were in bed, the staff were not able to get the residents' fingernails done. On 5/30/23 at 1:30 p.m., the clinical record for Resident 34 was reviewed. Diagnoses included, but were not limited, hemiplegia (one-sided muscle paralysis or weakness), hemiparesis (a relatively mild loss of strength) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the left non-dominant side, contracture of muscle left forearm, contracture of muscle left hand, muscle weakness, and need for assistance with personal care. A care plan, dated, 10/19/22, indicated Resident 34 enjoyed self-care of going to the beauty shop and the ability to express her preferences with a goal of the resident strengths will be maintained and encouraged. A care plan, dated 7/24/2018, indicated Resident 34 required staff assistance with ADLs including bed mobility, transfers, eating and toileting, with a goal of the resident had a desire to improve current functional status. Review of the shower sheets, from 5/1/23 to 5/29/23, indicated the resident received a total of 4 showers, refused 5 showers, and received nail care on one day. 4. On 5/31/23 at 9:58 a.m., Resident 38 was observed with dark debris under her fingernails. On 6/2/23 at 11:39 a.m., Resident 38 was observed with dark debris under her fingernails. On 6/5/23 at 12:00 a.m., Resident 38 was observed with dark debris under her fingernails. On 6/2/23 at 11:41 a.m., Resident 38 was observed sitting in a wheelchair in the main dining room at a table waiting on the noon meal service with dark debris under the resident's fingernails. Registered Nurse (RN) 17 indicated the Resident 38's fingernails were dirty with dark debris and should be soaked and cleaned to remove the debris. On 5/30/23 at 2:00 p.m., the clinical record for Resident 38 was reviewed. Diagnoses included, but were not limited, muscle weakness (generalized), atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain or discomfort that keeps coming back) and (a condition which affects the arteries that supply the heart with blood. It is usually caused by atherosclerosis which is a buildup of plaque inside the artery walls). A quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 4/27/23, indicated, the resident required extensive assistance which included assistance with personal hygiene care, nutrition, hydration, bathing and dressing. A care plan, dated 4/20/23, indicated the Resident 38 required assistance and/or monitoring AM/PM care, nutrition, hydration, and elimination with an intervention included, but not limited to, the resident will have activities of daily living (ADL) which included assistance with personal hygiene care, nutrition, hydration, bathing, and dressing. Review of the shower sheets from 5/1/23 to 5/29/23, indicated the resident received a total of 13 showers and nail care was provided on 11 days. On 6/2/23 at 1:48 p.m., the Executive Director provided and identified a document as a currently facility policy, titled Resident Rights, revised dated 11/16. The policy indicated, .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well-being, and proper delivery of care 3.1-38(a)(3) Based on observation, record review, and interview, the facility failed to ensure Activities of Daily Living (ADL, activities related to personal care) were completed for 4 of 24 residents reviewed for ADL care (Residents 57, 15, 34, and 38). Findings include: 1. During the initial observation of Resident 57, on 5/3/23 at 12:14 p.m., the resident was sitting in the dining room for her lunch meal. The resident was observed to have long chin hairs. During a random observation, on 5/31/23 at 10:10 a.m., the resident was observed during an activity in the dining room. The resident was observed to have long chin hairs. During a random observation, on 6/2/23 at 11:42 a.m., the resident was observed in dining room for her lunch meal. The resident was observed to have long chin hairs. During a random observation, on 6/5/23 at 9:31 a.m., the resident was observed sitting in the lounge area next to the bird aviary. The resident was observed to have long chin hairs. Resident 57's record was reviewed on 6/2/23 at 11:44 a.m. The profile indicated the resident's diagnoses included, but were not limited to the need for assistance with personal care. A quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents), on 4/20/23, indicated the resident had no cognitive deficit and required extensive assist of 1 with personal hygiene and was totally dependent with bathing. A care plan, dated 1/28/23, indicated the resident required assistance with ADLs. An intervention, dated 2/1/23, indicated to provide assistance with dressing, grooming, and hygiene. Review of shower sheets, dated 3/3/25 to 5/30/23, indicated the resident had been shaved on 4/14/23. The shower sheets lacked documentation of shaving having been completed on any other dates. During an interview, on 6/5/23 at 9:36 a.m., Certified Nursing Assistant (CNA) 12 indicated the resident's chin hair should have been removed during her daily care or during her showers. She could not remember a time when the resident refused her care. She was unsure why the care had not been completed.

Based on observation, interview, and record review, the facility failed to document, report, and address a skin condition on a resident for 1 of 24 residents reviewed for skin conditions (Resident 28). Findings include: During an initial observation, on 5/30/23 at 12:11 p.m., a faded bruise-like discoloration was observed on Resident 28's left temple area. During a family telephone interview, on 5/31/23 at 9:44 a.m., the resident's family member indicated she was not aware of any incident or a discolored area on the resident's temple. She had visited the week prior and did not notice any skin issues at that time. During an interview, on 5/31/23 at 10:01 a.m., the Director of Nursing (DON) indicated she was not aware of the resident having a discolored area to the side of her head. During the initial pool record review, on 5/30/23 at 2:16 p.m., the record lacked documentation of any event where the resident had received an injury. Resident 28's record was reviewed on 6/2/23 at 10:19 a.m. The profile indicated the resident's diagnoses included, but were not limited to, encephalopathy (any disease of the brain that alters brain function or structure) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A significant change Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 4/18/23, indicated the resident was rarely/never understood, had no documented behaviors, was total dependence of 2 with transfers, had no fall history and had no documented skin issues. A care plan, dated 5/24/18, indicated the resident was at risk for skin breakdown. An intervention, dated 5/31/23, indicated when resident was agitated, staff were to support resident's head away from Hoyer bar during transfer. A weekly skin assessment, dated 5/28/23, lacked documentation of any discoloration or any abnormal markings on the resident's body/face. An event documentation, dated 5/31/23, indicated a discoloration to the resident's left temple had been discovered. The event lacked documentation of a cause. On 6/1/23 at 2:10 p.m., Licensed Practical Nurse (LPN) 9 provided a document which indicated on 5/25/23, she and a night shift Certified Nursing Assistant (CNA) had been transferring the resident via Hoyer Lift (a device which allows a person to be lifted and transferred with a minimum of physical effort). During the transfer the resident jerked forward and bumped her left temple on the side of the Hoyer lift. A small red mark appeared, but no bruising had been noted. The progress notes lacked documentation of the resident bumping her head on the side of the Hoyer lift and of any red mark as a result. A progress note, dated 6/1/23 at 2:18 a.m., indicated yellow discoloration continued to resident's left temple area. An IDT (Interdisciplinary team) Initial Wound Review progress note, dated 6/1/23 at 7:11 p.m., indicated the type of skin injury was a non-ulcer (i.e. skin tear, rash, bruise, abrasion, lesions, burns, surgical wound, other trauma) was described as yellow/green discoloration to left side of head, temple area. No pain noted. No signs or symptoms of infection. Interventions in place prior to wound / skin injury development included staff assist with ADLs (activities of daily living), transfers .Root-cause determination: hit head on bar of Hoyer lift. New interventions initiated: when resident is agitated, staff to support resident's head away from Hoyer bar during transfer. Therapy referral warranted: No. Current treatment order: observe site for complications. Family and physician had been notified. During an interview, on 6/2/23 at 11:13 a.m., the DON indicated the Executive Director (ED) had begun to look for a policy related to reporting findings when the issue had been brought to the staff's attention. Any new event involving a resident, should be reported and documented immediately. On 6/2/23 at 12:00 p.m., the DON provided a document, dated 7/2020, titled, Documentation Guidelines for Nursing, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To accurately document in an organized manner all information related to the resident in the medical record .8. New skin event: Initiate for any newly identified skin conditions 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (a semi-flexible plastic tube with one end inserted into the bladder) which is attached to a urinary drainage bag did not touch the floor and staff failed to follow the proper procedure for changing a urinary drainage leg bag (a urinary drainage device attached to the resident's leg) to a standard urinary drainage bag for 1 of 1 resident reviewed for catheter care (Resident 55). Findings include: On 5/30/23 at 3:30 p.m., Resident 55 was observed sitting in a wheelchair with a urinary catheter drainage bag within a dignity bag (a cloth bag that covered the urinary catheter drainage bag) laying on the floor under the wheelchair. On 6/1/23 at 11:16 a.m., during an observation the resident was lying in a bed and the resident's catheter drainage bag and tubing was on the floor next to the bed. On 6/2/23 at 12:00 p.m., Certified Nurse Aide (CNA) 3 was observed removing an unbagged used urinary drainage bag from a grab bar in the resident's shared bathroom. CNA 3 detached Resident 55's urinary drainage leg bag tubing from the urinary catheter tubing and placed the drainage leg bag tubing on the bed, then attached a standard urinary drainage bag without cleaning the urinary drainage bag tubing tip with alcohol prior to attaching to the catheter tubing. At the same time CNA 3 indicated, she should have washed the urinary drainage tubing tip with hot water and then should have cleaned the tubing with an alcohol wipe, prior to attaching the urinary drainage tubing to the catheter tubing. On 6/5/23 at 11:59 a.m., the Director of Nursing (DON) and Executive Director (ED) were asked if they allowed the urinary drainage bag to touch the floor. The DON indicated, she had never been asked that question before and would have to look for a policy. The clinical record for Resident 55 was reviewed on 5/30/23 at 2:00 p.m. Diagnoses included, but were not limited to, unspecified displaced fracture of fifth cervical vertebra, (a bone broken in the cervical (neck) region of the spine.), neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems), and need for assistance with personal care. The quarterly Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) assessment, dated 4/10/23, indicated the resident had an indwelling urinary catheter related to the diagnosis of neuromuscular dysfunction of bladder. A care plan, dated 11/11/2022, indicated the resident had neuromuscular dysfunction of bladder and required a urinary catheter placement. On 6/5/23 at 1:37 p.m., the Executive Director (ED) provided and identified a document as a current facility policy, Titled Nursing, with a revised date of 6/2023. The policy indicated, .Component/Guidelines: .2 Resident Care Equipment .b. Urinary catheters should have a catheter bag cover over them or a wash basin underneath them as a barrier to prevent catheter bag or tubing from touching the ground .ii. Place soiled equipment in plastic bag .v. Clean and disinfect equipment per facility guidelines .vii. Place cleaned/disinfected equipment in clean plastic bag On 6/5/23 at 1:38 p.m., the Executive Director (ED) provided and identified a document as a current facility policy, titled Converting A Urinary Drainage Bag To A Leg Bag, with a revised date of 3/2012. The policy indicated, .Procedure Steps: .7. Place paper towel or cloth towel under tubing at the point the catheter connects with the urinary drainage bag tubing .10. With the catheter tubing kinked in one hand to prevent urinary drainage during the transition, gently twist the catheter tubing and urinary drainage tubing in an effort to separate the two at the connection .12. Cap the open end of the tubing leading to the urinary drainage bad with an available cap or cover the open end of the tubing with alcohol swabs to prevent contamination .14. Remove the cape on the leg bag drainage tubing and gently insert and secure into the open end of the catheter tubing 3.1-41(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 25's record was reviewed on 6/1/23 at 9:45 a.m., The profile indicated the resident's diagnoses included, but were not limited to, Paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), Gastro-esophageal reflux disease without esophagitis (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus). An admission Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 4/20/23, indicated the resident had moderate cognitive deficit and did not receive an anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart).within the 7 day look back period. A physician's order, dated 12/1/22, indicated Clopidogrel (it prevents platelets (a type of blood cell) from sticking together and forming a dangerous blood clot) 75 mg tablet once daily. A physician's order indicated Xarelto (rivaroxaban-an anticoagulant medication which is used to prevent blood clots from forming due to a certain irregular heartbeat (atrial fibrillation) 15 mg tablet, once daily. Unnecessary medication record review indicated the resident was on Clopidogrel 75 mg daily (QD). Pharmacy recommendation, dated 3/3/23, indicated a recommendation to begin Pantoprazole 20 mg QD. Physician agreed and signed recommendation on 3/30/23. Medical record did not indicate this order was implemented. On 06/01/23 9:58 a.m., the DON reviewed the pharmacy recommendation and indicated she was unable to find supporting documentation in the medical record of the order being implemented. On 6/2/23 at 1:47 p.m., the Executive Director (ED) provided a document, with a revision dated of 3/3/20, titled, LTC (Long Term Care) Facility's Pharmacy Services and Procedure Manual: Medication Regimen Review, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .7. Facility should encourage the Prescriber/Physician .receiving the medication regimen review (MRR) and Director of Nursing (DON) to act upon the recommendations contained in the MRR .8. Facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner .11. The attending physician should address the consultant pharmacist's recommendation no later than their next visit to the facility to assess the resident, either 30 or 60 days per applicable regulation 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(a)(3) 3.1-48(a)(4) 3.1-48(a)(5) 3.1-48(a)(6) Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed and initiated for 2 of 5 residents reviewed for unnecessary medications (Residents 22 and 25). Findings include: 1. Resident 22's record was reviewed on 6/1/23 at 11:36 a.m. The profile indicated the resident's diagnoses included, but were not limited to, vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time), and atherosclerotic heart disease ( a common condition that develops when a sticky substance called plaque builds up inside your arteries). An annual Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 9/6/22, indicated the resident had moderate cognitive deficit and received an anticoagulant medication (a substance that is used to prevent and treat blood clots in blood vessels and the heart). A physician's order, dated 8/30/19, indicated Plavix (clopidogrel-an antiplatelet medicine which reduces the risk of blood clots forming) 75 milligram (mg) tablet, once daily due to atherosclerotic heart disease. A physician's order, dated 6/3/22, indicated Xarelto (rivaroxaban-an anticoagulant medication) 15 mg tablet, once daily for atrial fibrillation. A pharmacy recommendation, dated 3/3/23, indicated the resident received the antiplatelet medication and had not received gastroprotection (protection of gastric tissue against aggressive conditions). The resident had additional risk factors for gastrointestinal (GI-the organs that take in food and liquids and break them down into substances that the body can use for energy, growth, and tissue repair) ulceration (the formation of a break on the skin or on the surface of an organ) which included, but were not limited to, age [AGE] and concomitant (occurring or existing at the same time as something else) use of anticoagulant medication. The recommendation was to initiate pantoprazole (a type of medicine called a proton pump inhibitor [PPI] which inhibits acid production in the stomach). A historical review of the resident's physician's orders lacked documentation that the pantoprazole had ever been ordered or initiated. During an interview, on 6/2/23 at 10:09 a.m., the Director of Nursing (DON) indicated she was unsure why the recommendation had not been addressed. The recommendations should always be addressed when received.

Based on observation, interview, and record review, the facility failed to ensure proper food handling for 1 of 2 dining observations and failed to ensure proper handwashing for 3 of 3 dining observations. Findings include: 1. During a dining observation, on 5/30/23 at 11:32 a.m., Activity Assistant 14 was preparing drinks for the residents. She scooped ice into 2 glasses and returned the scoop into the ice bucket. The Activity Assistant served the drinks to 2 residents and returned to the cart to prepare more drinks. At 11:41 a.m., the ice scoop remained in the ice bucket. At 11:43 a.m., another staff member approached the ice bucket and placed the ice scoop into an empty pitcher next to the ice bucket. During an interview, on 6/5/23 at 11:01 a.m., the Culinary Manager indicated staff were not to leave the ice scoop in the ice bucket. They were to return it to the empty pitcher on the cart by the ice bucket. On 6/5/23 at 1:37 p.m., the Executive Director provided a document, dated 2/02 with a revised date 5/23, titled. Food Storage, and indicated it was the policy currently used by the facility. The policy indicated, .Scoops are not to be stored in the food 2. During a dining observation of the closed unit, on 5/30/23 at 12:15 p.m., Activity Assistant 5 was observed to wash her hands for less than 20 seconds and touched the faucet handles with bare hands, without paper towels, when turning off the water. Activity Assistant went to the food cart to begin serving trays to the residents. 3. During a dining observation of the closed unit, on 6/1/23 at 9:19 a.m., Certified Nursing Aid (CNA) 4 was observed to wet a washcloth at the sink. She proceeded to add soap to the washcloth and touched the faucet handles with bare hands, without paper towels, when she turned off the water. CNA 4 then went to the table and placed the washcloth down by the resident she assisted with the breakfast meal. The washcloth was later used to clean Resident 18's face and hands. During an interview, on 6/2/23 at 9:31 a.m., CNA 11 indicated staff were to wash their hands for a total of 40-60 seconds and they were to turn off the faucet handles by using a paper towel. Staff were not to touch the faucet handles with their bare hands. During an interview, on 6/2/23 at 10:47 a.m., the Culinary Manager indicated staff were not to touch the faucet handles with their bare hands and the process of handwashing should last 40-60 seconds in total. On 6/2/23 at 11:35 a.m., the Culinary Manager provided a document, dated 3/18 with a revised date 12/21, titled, Hand Hygiene Policy, and indicated it was the policy currently used by the facility. The policy indicated, .To provide a standardized approach to hand hygiene to reduce or minimize the transmission of infection from potential microorganism on the hands of all employees 3.1-21(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the grievance policy was followed for a resident with missing personal property for 1 of 1 resident reviewed for personal property (Resident 5). Findings include: During an interview on, 3/11/22 at 10:11 a.m., Resident 5 indicated she had bras and slacks missing. Her daughter had purchased some other clothing items a couple of weeks ago. The staff had taken them to the laundry to mark them with her name, and she had not seen them since. 03/15/22 11:22 AM Resident 5's record was reviewed on 3/15/22 at 11:22 a.m. The record indicated the resident had been admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to, unspecified dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of the events section of the resident's record lacked documentation of any reported missing personal items. A Concern/Grievance Form, dated 3/3/22, indicated the Memory Care Coordinator (MCC) had received a concern from the resident that she only had 6 of 8 bras that were with her at admission. The form indicated the department responsible for the concern was the laundry. The form indicated the MCC had went to the laundry to look for the items but lacked documentation of the laundry department's notification of the missing items. A Concern/Grievance Form, dated 3/16/22, indicated the MCC had received a concern from the resident's family that the resident was missing 2 tops, bras, and several pairs of socks. The form indicated the department responsible for the concern was the laundry. The form lacked documentation of the laundry department's notification of the missing items. During a telephone interview, on 3/17/22 at 9:25 a.m., the resident's family member indicated she had reported missing clothing items to the facility at least 3 weeks or so ago. She had requested to do the resident's personal laundry when she moved in but was told that the facility preferred to do the resident's laundry. The family member figured this was due to COVID-19. The missing items were again mentioned to the facility during a care plan meeting for the resident on 3/16/22. During an interview, on 3/17/22 at 9:29 a.m., the Social Services Director (SSD) indicated she was the person responsible for handling reported concerns of any resident's missing personal property. She had been notified of the resident's missing items, by the resident's family member on 3/3/22. She recommended the family member to report the missing items to the MCC. During an interview, on 3/17/22 at 11:15 a.m., the Laundry Supervisor indicated she had only been notified about the resident's missing items about 1 week prior to the date of this interview. She had been told of the missing items by the Registered Nurse (RN) on the Memory Care Unit. At that time, she went and spoke directly to the resident. When missing items are reported to the laundry, she would first look for the items and, if the items were not found, she would report the missing items so a grievance report could be established. When she was unable to located any of the missing items and had reported it to the MCC on 3/16/22. During an interview, with the Administrator (ADM) and the Director of Nursing (DON), on 3/17/22 at 10:02 a.m., both the ADM and DON indicated they were not aware of the resident's missing items. Any reported missing items should be documented as grievance on the grievance form. All reported grievances would be brought to the morning meeting of the Interdisciplinary Team (IDT) and discussed. The ADM indicated if the missing items had been reported and documented on a grievance form, they should have been brought to the morning meeting and discussed with all members of the IDT. On 3/17/22 at 11:45 a.m., the ADM provided a document, with a revision date of January 2019, titled, Resident Concerns and Grievances, and indicated it was the policy currently being used by the facility. The policy indicated, POLICY: Resident, representative or family concerns/grievances occurring during the resident's stay shall be responded to promptly .the Executive Director/Grievance Official shall review all complaints .PROCEDURE: .The Concern/Grievance Form is then referred to the Department .for review 3.1-7(a) 3.1-7(2)(b)

Based on record review and interview the facility failed to ensure treatments were completed as ordered by the physician for a resident with a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for 1 of 1 residents reviewed for pressure ulcers (Resident 53). Findings include: Resident 53's record was reviewed on 3/15/22 at 11:52 a.m. An annual Minimum Data Set (MDS) assessment, dated 6/15/21, indicated the resident had a moderate cognitive impairment and one stage four pressure ulcer (a deep wound that reaches the muscles, ligaments, or even bone), present upon admission to the facility. Diagnoses on the resident's profile included, but were not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis) following cerebral infarction (a disruption in blood supply to the brain) affecting right dominant side. An observation, dated 2/21/22, titled interdisciplinary team (IDT) wound review, indicated the resident had a stage four pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). The area worsened since the previous week, and the treatment was changed to medihoney (a gel used to treat wounds and burns) with foam dressing change daily and as needed. A physician's order, dated 2/25/22, and discontinued on 3/15/22, indicated cleanse wound to coccyx with foaming cleanser, pat dry, apply medihoney gel 80 percent, and cover with foam dressing daily to stage four pressure ulcer of sacral (tailbone) region. A Treatment Administration Record (TAR), dated February 2022, lacked documentation the medihoney treatment was offered, refused, or completed to the stage four pressure ulcer to the sacral region on 2/26/22 and 2/27/22. A TAR, dated March 2022, indicated the medihoney treatment was not applied to the stage four pressure ulcer to the sacral region related to it being unavailable on 3/2/22, 3/3/22, 3/4/22, 3/5/22, 3/6/22, 3/7/22, 3/8/22, 3/9/22, and 3/12/22, but lacked documentation the physician was notified. On 3/11/22, the medihoney was on back order, would arrive Monday, the physician was aware, but lacked documentation of a new treatment being ordered. A physician's order, dated 3/15/22, indicated cleanse wound to coccyx (tailbone) with wound spray or normal saline, pat dry, apply Therahoney gel to wound bed and cover with a foam dressing, change daily. A care plan, goal target dated 5/5/22, indicated the resident admitted to the facility with a stage four pressure ulcer that involved the sacrum, coccyx, and spine area. Interventions included but were not limited to treatments to be completed as ordered. During an interview, on 3/16/22 at 9:28 a.m., the Assistant Director of Nursing Services (ADNS) indicated there was an issue with the pharmacy getting the medihoney delivered to the facility. She was not aware it was an issue until later. The facility now has it in the house stock supply and is Therahoney. The treatment was changed to Therahoney because that is the brand, they were able to obtain. The wound deteriorated on 2/24/22, so the treatment was changed at that time. The wound has not deteriorated since. On 3/16/22 at 11:25 a.m., the Medical Records Nurse provided a document titled, SKIN MANAGEMENT PROGRAM, and indicated it was the policy currently being used by the facility. The policy indicated, .POLICY: It is the policy of .to ensure that .a resident with a pressure ulcer receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 2 of 5 residents reviewed for unnecessary medications (Residents 40 and 8). Findings include: 1. Resident 40's record was reviewed on 3/15/22 at 9:13 a.m. Diagnoses on the resident's profile included, but were not limited to, type two diabetes mellitus (impairment in the way the body regulates and uses sugar) without complications. A quarterly Minimum Data Set (MDS) assessment, dated 2/10/22, indicated the resident had a severe cognitive impairment. A physician's order, dated 1/26/22, indicated Lantus insulin pen, 100 units (u)/milliliter (ml), administer 40 u subcutaneous (SQ) (the fatty layer between the skin and muscle) daily at bedtime related to type two diabetes mellitus without complications. The order lacked parameters for when the medication should be held. A Medication Administration Record (MAR), dated February 2022, indicated the Lantus was not administered on 2/5/22 related to no intake, 2/9/22 related to poor intake, 2/18/22 related to fasting blood sugar 116, and 2/20/22 related to poor intake and fasting blood sugar 111. The MAR lacked documentation the physician was notified the insulin was not administered. A MAR, dated March 2022, indicated the Lantus was not administered on 3/6/22 related to blood sugar 139 and no intake, 3/8/22 related to the resident's condition, 3/9/22 related to resident lethargic and no intake, and 3/12/22 related to fasting blood sugar 101. The MAR lacked documentation the physician was notified the insulin was not administered. During an interview, on 3/15/22 at 1:27 p.m., the Director of Nursing (DON) indicated the insulin should have had parameters to hold the insulin if there were specific instances the physician did not want the medication administered. 2. Resident 8's record was reviewed on 3/14/22 at 1:41 p.m. Diagnoses on the resident's profile included, but were not limited to, constipation unspecified, rheumatoid arthritis (a chronic inflammatory disorder affecting many joints) unspecified. An admission Minimum Data Set (MDS) assessment, dated 3/4/22, indicated the resident was cognitively intact. A physician's order, dated 2/25/22, indicated Miralax (a laxative) 17 grams orally daily related to constipation unspecified, to be administered at 7:00 a.m. A physician's order, dated 2/25/22, indicated gabapentin (a medication for nerve pain) 300 milligrams (mg) by mouth three times a day at 7:00 a.m., 1:00 p.m., and 8:00 p.m. for rheumatoid arthritis unspecified. A physician's order, dated 2/25/22, indicated oxycodone-acetaminophen 10-325 mg every six hours as needed for moderate to severe pain. A Medication Administration Record (MAR), dated February 2022, lacked documentation the Miralax and gabapentin were administered, offered, or refused at 7:00 a.m., on 2/26/22 and 2/27/22. A MAR, dated March 2022, lacked documentation the Miralax and gabapentin were administered, offered, or refused at 7:00 a.m., on 3/2/22, 3/7/22, 3/8/22, 3/9/22, 3/12/22, and 3/13/22. During an interview, on 3/15/22 at 9:17 a.m., Licensed Practical Nurse (LPN) 20 indicated medications scheduled to be administered at 7:00 a.m., should have been administered by the day shift nurse. If the medication was not signed off, it was not documented as administered. On 3/15/22 at 1:27 p.m., the Director of Nursing (DON) provided a document titled, .General Dose Preparation and Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 6.1 Document necessary medication administration/treatment information 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure the COVID-19 Infection Control vaccination policy and procedures were followed for 7 of 7 contracted staff working in the facility near residents for 6 of 6 days working in the facility. Findings include: On 3/11/22 at 9:50 a.m., during the initial tour of the facility, contractors, wearing medical face masks, were present in the C-wing unit, observed replacing the cove base and lower wall covering in the hall. On 3/11/22 at 10:37 a.m., during the initial tour of the memory care unit, contractors were present in the unit observed replacing the cove base and the lower wall covering. The contractors were present in the dining/activity room area during an activity with five residents present and one resident wandering around the area who was re-directed each time the resident began to walk towards the area where the contractors were working. All the contractors were observed wearing medical face masks. On 3/11/22 at 11:53 a.m., during the lunch meal observation of the memory care unit, the contractors were present prior to the meal trays being passed. Seven residents were present in the dining room and one resident was observed being redirected by staff, when the resident would walk to the area where the contractors were working. The contractors completed their work, left the unit, and exited the building through the front doors of the facility for a lunch break. On 3/14/22 at 1:39 p.m., contractors, wearing medical face masks, were observed in the central hall of the facility by the nurses' station, replacing the cove base and lower wall covering. On 3/14/22 at 1:47 p.m., contractors, wearing medical face masks, were observed in the memory care unit replacing the cove base and lower wall covering. On 3/15/22 at 1:18 p.m., the Administrator (ADM) indicated the lower wall covering had to be replaced due to the covering was not fire resistant and needed to be replaced with a fire-resistant covering. On 3/15/22 at 3:06 p.m., ADM indicated the seven contractors, sent by the facility's corporation, were working in the building on March 7, 8, 9, 10, 11, and 14, 2022. The contractors were screened with the COVID-19 questionnaire prior to entering the building. The contractors were not vaccinated nor tested for COVID-19 and were not exempted by the facility corporation for the COVID-19 vaccinations. On 3/16/22 at 2:38 p.m., ADM indicated the facility staff screened everyone including the contracted staff with the COVID-19 questionnaire. If the contracted staff were not vaccinated, facility staff would ask if they had an exemption with their contracted company. The facility had asked the contracted companies, like hospice companies, to only send vaccinated staff. ADM indicated the contractors, replacing the cove base and lower walls in the facility, were not vaccinated, but did not provide direct care to any of the residents in the facility. On 3/16/22 at 2:52 p.m., the Director of Nursing (DON) indicated all staff were instructed to redirect all residents away from the contractors that were replacing the cove base and lower wall covering in the building. On 3/14/22 at 3:00 p.m., ADM provided and identified a document as a current facility policy, titled COVID-19 Employee Vaccination Requirement, with a revision date of 2/11/22, which indicated, .The Company is committed to the safety and health of our team members, the community and most importantly, the residents we serve. The Company must implement a mandatory vaccination policy requiring COVID-19 vaccination(s) for all employees in all locations for all ASC affiliated healthcare employers. This will include new employees hired as well as all contractors, vendors and students as well as volunteers and trainees who provide any care, treatment or other services for the facility and the Company. This will be in accordance with the US Government's COVID-19 Vaccination Mandate for healthcare workers and the Centers for Medicare & Medicaid Services (CMS) 3.1-18(b)