Based on record review and interview, the facility failed to ensure the responsible party was notified of a unwitnessed fall in a timely manner for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes: Resident B's record was reviewed on 3/31/25 at 10:47 a.m. Diagnoses included, but were not limited to, fracture of the left femur, hypertension (high blood pressure), depression, chronic kidney disease, history of falling and dementia. A Nurse's Note, dated 1/8/25 at 12:25 a.m., indicated Resident B was noted on the floor in her room by the CNA. The resident was assessed and was alert and oriented to situation and self. The resident was noted to have a bruise to the left frontal side of her head with a small bump. The resident had also complained of soreness to her left hip and back. The resident refused pain medication and refused to go to the hospital. A message was left to notify the Nurse Practitioner. A Nurse's Note, dated 1/8/25 at 1:04 a.m., indicated medication was given for pain in the left hip and lower back. A Nurse's Note, dated 1/8/25 at 3:12 a.m., indicated the resident's son was called and notified about the situation and indicated to send the resident to the hospital. A Quarterly Minimum Data Set (MDS) assessment, dated 1/13/25, indicated the resident was severely impaired for daily decision making. The resident had impairment on both sides of her lower extremities. Supervision and touching assistance was required for eating, oral hygiene, upper body dressing, and personal hygiene. The resident required substantial/maximum assistance with toilet hygiene, shower/bathing, putting on footwear and lower body dressing. The resident transferred from sit to stand, chair to bed, toilet transfer and roll left to right with partial/moderate assistance. During an interview on 3/31/25 at 2:15 p.m., the Executive Director (ED) indicated she understood the concern regarding delayed notification after a fall. During an interview on 3/31/25 at 2:12 p.m., the Director of Nursing (DON) indicated the nurse at the time of the resident's fall did not feel there was anything concerning regarding the resident's hip, she was more focused on the neurological assessments and that is why she had waited to call the resident's son. She understood the concern and had nothing further to add. The current 2024 Changes in Resident's Condition or Status policy, provided by the Executive Director on 3/31/25 at 10:45 a.m., indicated . A facility must immediately inform the resident, consult with resident's physician, and notify, consistent with his or her authority , the resident representative when there is (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention . This citation relates to Complaint IN00451276. 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to ensure fall interventions were updated to prevent injury for a resident with multiple falls for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: On 3/31/25 at 12:09 p.m., Resident D was not observed in his room. There was a mattress leaning on the side of the wall, there was a touch pad call light, gym shoes by the bedside, and the bed had two half side rails. Resident D's record was reviewed on 3/31/25 at 1:17 p.m. The diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), stroke, and hemiplegia (paralysis on one side of the body). The admission Minimum Data Set (MDS) assessment, dated 1/16/25, indicated the resident was severely impaired for daily decision making. The resident required substantial/maximum assistance for bed mobility, transferring and toileting. A Care Plan, last updated on 1/31/25, indicated the resident was at risk for falls related to decreased mobility, weakness, high blood pressure, depression, and hemiparesis/hemiplegia affecting right side of the body. Approaches were to assist with ADL's (activities of daily living) as needed, have a mattress on the floor at bedside, call light within reach, complete a fall risk assessment, and orient resident to room. The last two months were reviewed and the resident had four falls on the following dates: 2/3/25 3/2/25 3/13/25 3/25/25 A Health Status Note, dated 3/2/25 at 11:10 a.m., indicated the resident was seen leaning in her wheelchair and the nurse assisted the resident to sit up in the chair. When the writer walked away and came back several minutes later, the resident was lying on the floor. Assessments were completed and the resident had a small bump to the back of her head. A Health Status Note, dated 3/13/25 at 2:36 p.m., indicated the resident was seen lying on her right side on the floor in front of her wheelchair near the nurse's station. Two nurses assessed the resident and the resident bumped the side of her right head and had a small abrasion to the right outer elbow. A Health Status Note, dated 3/25/25 at 7:26 a.m., indicated the resident was sitting in her wheelchair by the nurses' station and the nurse observed the resident leaning over. Before the nurse could reach the resident, she fell onto her left side and hit her head on the floor. Swelling and bruising were noted to the left forehead. There was no documentation in the resident's record to indicate the facility added interventions to address the resident's wheelchair use or positioning after the resident's multiple falls from her wheelchair. During an interview on 3/31/25 at 2:34 p.m., the Executive Director (ED) indicated there was no updated care plan for Resident D's recurrent falls. The current 2022 Fall Management policy, provided by the Executive Director on 3/31/25 at 10:45 a.m., indicated .4. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS, upon a fall event and as needed thereafter . This citation relates to Complaint IN00451276. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a discharge summary was completed at the time of discharge for a resident going home who required home health services for 1 of 3 residents reviewed for discharge (Resident B). Finding includes: Resident B's record was reviewed on 9/11/24 at 9:43 a.m. The diagnoses included, but were not limited to, paraplegia (paralysis of lower body), chronic kidney disease stage 3, and high blood pressure. The Discharge Minimum Data Set assessment, dated 9/1/24, indicated the resident was cognitively intact for daily decision making. He was totally dependent on staff for toileting, bathing, and transfers. He had an indwelling catheter and an ostomy (an artificial opening). He was taking antipsychotic, antidepressant, and anticoagulant medications. Resident B's Care Plans upon discharge included, but were not limited to, the resident would be long term care, had an ostomy, required extensive assistance for his activities of daily living (ADL) tasks for bed mobility, transfers, and toileting, had an indwelling Foley (urinary) catheter, and had oxygen therapy. A Physician's Order, dated 7/16/24, indicated the resident was on continuous oxygen therapy at 4 liters per minute via nasal cannula. The Discharge Summary Information assessment, dated 8/28/24 at 4:23 p.m., indicated the resident was discharged to home by ambulance. The reason for discharge was left blank. The clothing and valuables were not marked as received or stored. Physical assessment on discharge and instructions were listed as follows: - Physical and Mental Functioning Status: assist with one with ADLs and bed mobility, mechanical lift for transfers - Nutritional Status: regular diet with thin liquids and feeds self with set up - Special treatments and procedures: Colostomy 2.75 or 70 millimeter size appliance and catheter 20 french with 5 milliliter bulb - Mental, Psychosocial, and Behavior Status: alert and oriented - Continence: incontinent of bladder, resident colostomy with ostomy care per staff - Skin Condition: warm and dry no open areas noted - Resident established his own in home nursing, physical and occupational therapy as well as his own ADL assistance through a home health agency - Medications: Pre-discharge and post-discharge medications that have been reconciled with attached medications to take after discharge from the facility was blank - Recapitulation of Stay: Nursing was blank - Copy of instructions given to: was blank - Name of patient/patient representative giving consent: was blank - Received by and date: was blank The Discharge Summary Information assessment did not address the resident being on oxygen therapy and was incomplete. During an interview on 9/11/24 at 1:04 p.m., the Director of Nursing indicated the Discharge Summary Information assessment should have been completed and oxygen should have been addressed on the form. The resident had set everything up for his own discharge as he decided that he was going to leave that weekend with family. Social Services had talked with the home health company and others involved with his care at home to ensure he had the equipment he needed and was set to move home, however it was not documented. A Policy titled, Area of Focus: Discharge Process and Bed Holds, noted as current, indicated, .How .In the event that the resident requires transfer or discharge the documentation in the medical record should include: .7. A discharge summary must be completed for discharges. This citation relates to Complaint IN00442864. 3.1-36(a)(1) 3.1-36(b)

Based on record review and interview, the facility failed to ensure there was an adequate indication for use of a scheduled antifungal powder for 1 of 3 residents reviewed for non-pressure skin conditions (Resident B) Finding includes: Resident B's record was reviewed on 9/11/24 at 9:43 a.m. The diagnoses included, but were not limited to, paraplegia (paralysis of lower body), chronic kidney disease stage 3, and high blood pressure. The Discharge Minimum Data Set assessment, dated 9/1/24, indicated the resident was cognitively intact for daily decision making. He was totally dependent on staff for toileting, bathing, and transfers. A Physician's Order, dated 7/16/24, indicated nystatin external powder (antifungal powder) 100,000 unit/gram, apply to right and left skin folds topically every shift for skin irritation. The July and August 2024 Medication and Treatment Administration Record indicated the nystatin powder was administered three times each day to the groin area. A Weekly Skin Assessment was completed on 7/20, 7/27, 8/3, 8/10, 8/17, 8/24, and 8/31/24. There were no skin abnormalities noted to the groin or any other areas on the assessments. During an interview on 9/11/24 at 11:22 a.m., the Assistant Director of Nursing indicated she was unable to locate documentation related to any type of skin conditions and the nystatin powder should have just been an as needed order for any new skin condition that was observed. This citation relates to Complaint IN00442864. 3.1-48(a)(4)

Based on observation, record review, and interview, the facility failed to ensure a resident received the assistive devices needed to maintain hearing related to hearing aids not administered to a resident as per the physician's order for 1 of 2 residents reviewed for vision/hearing. (Resident 4) Finding includes: On 6/11/24 at 11:48 a.m., Resident 4 was observed sitting in the dining area with other residents. The resident kept saying huh when other people were talking. The resident did not have hearing aids observed to either ear. On 6/11/24 at 3:08 p.m., Resident 4 was sitting in a wheelchair in his room. The resident indicated he could not hear the questions being asked. The resident did not have hearing aids observed to either ear and was unaware where his hearing aids were. Record review for Resident 4 was completed on 6/11/24 at 3:11 p.m. Diagnoses included, but were not limited to coronary artery disease, heart failure, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 3/26/24, indicated the resident was cognitively impaired. The resident had difficulty hearing and used a hearing aid. The resident required a partial moderate assistance for dressing the upper body. A Care Plan, dated 9/19/23, indicated the resident required extensive assistance from staff to complete his ADL (assistance of daily living) tasks of bed mobility, transfers, and limited assistance for meals. An intervention, dated 1/25/24, included for his hearing aids to be put in his ears in the morning and taken out at night time. A Care Plan, dated 4/2/24, indicated the resident had a communication problem related to hearing deficit. The resident had hearing aids which he removed at times and misplaced them under the bed, under dressers, and his covers. Interventions included to assist with hearing aids (left and right), remove hearing aids and place in container as needed, and search the resident's room if the resident, staff, or visitors report the hearing aids are missing. The June 2024 Physician's Order Summary indicated the following order: - Hearing aids in the morning and out at night time. Document when put in and removal at bedtime. The June 2024 Medication Administration Record and Treatment Administration Record did not have any documentation related to the hearing aid order. During an interview on 6/11/24 at 3:09 p.m., CNA 1 indicated she was unaware if the resident wore hearing aids. During and interview on 6/11/24 at 3:16 p.m., LPN 1 looked into her medication cart and could not find the resident's hearing aids. She indicated she believed the resident's hearing aids were lost and she would go to his room and look for them. The resident would take them out himself sometimes, set them down and lose them. The staff were supposed to put them in and take them out every day and put them in the medication cart. She was unaware if that was supposed to be documented anywhere. During an interview on 6/11/24 at 3::25 p.m., the Director of Nursing (DON) indicated she was not sure why the hearing aid order did not populate for the nursing staff to document the resident's hearing aids were put in and taken out each day. The facility had replaced the resident's hearing aids once because he had lost them. The staff were supposed to be making sure they had documented when they are put in and then taken out, and that they are placed into the medication cart after they are removed. 3.1-39(a)

3. The record for Resident 42 was reviewed on 6/10/24 at 12:19 p.m. The diagnoses included, but were not limited to, atrial fibrillation (abnormal heart rhythm), dementia, depression, muscle weakness, adult failure to thrive, anxiety, and left shoulder fracture. The Significant Change MDS assessment, dated 5/29/24, indicated the resident was severely impaired for daily decision making. The resident had no impairment of the upper and lower extremities and used a wheelchair. Eating and oral hygiene required supervision or touching assistance. Lower body dressing, toileting and bathing required dependent assistance. A Care Plan, dated 4/12/24, indicated the resident had unplanned/unexpected weight loss related to poor intake. Interventions were to record food intake for each meal, and alert the dietician when supplements were not being consumed for more than 48 hours. The resident weighed 106 pounds on 2/27/24. A weight obtained on 5/24/24 indicated the resident weighed 87 pounds, which was a 28.57% weight loss in 3 months. The meal consumption intake logs indicated the following: - The breakfast meal was not documented on 5/15, 5/21,5/22, 5/25, 5/26, 5/30, 6/1, 6/8, 6/10, 6/11, and 6/12/24. - The lunch meal not documented on 5/22, 5/25, and 6/1/24. - The dinner meal was not documented on 5/18, 5/19, 6/3,6/4, 6/5, 6/9, and 6/10/24. During an interview on 6/13/24 at 1:20 p.m., the DON indicated the CNAs were expected to document meal consumption percentage eaten in the computer under the Task section for Meal Consumption. A current facility policy titled, Nutritional Intake, provided by the Director of Nursing on 6/14/24 at 3:03 p.m., indicated the facility will document the nutritional intake on each individual resident. 3.1-46(a)(1) 2. On 6/13/24 at 12:15 p.m., Resident 14 was observed eating lunch. Resident 14 received a house shake with her lunch. Resident 14 consumed about 75% of her shake and ate about 50% of the food on her plate. The resident's record was reviewed on 6/13/24 at 11:26 a.m. Diagnoses included, but were not limited to, gastroesophageal reflux disease without esophagitis, constipation, and type 2 diabetic mellitus with diabetic neuropathy. The Quarterly MDS assessment, dated 3/12/24, indicated the resident was cognitively impaired. A Care Plan, dated 5/14/24, indicated to record Resident 14's food intake at each meal. Weight Assessments indicated the resident weighed 177 pounds on 1/12/24 and 162 pounds on 6/7/24, which was an 8.47% weight loss. The meal consumption logs indicated the following: 5/17/24 - dinner meal was not documented 5/18/24 - no meals were documented 5/19/24 - breakfast and lunch meals were not documented 5/20/24 - breakfast and dinner were not documented 5/27/24 - dinner meal were not documented 5/31/24 - breakfast and lunch meals were not documented 6/6/24 - breakfast and lunch were not documented 6/7/24 - no meals were documented 6/8/24 - breakfast and lunch were not documented 6/10/24 - no meals were documented During an interview on 6/13/24 at 2:35 p.m., the Assistant Director of Nursing (ADON) indicated the food consumption logs should have been completed for the resident. Based on record review and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 3 of 5 residents reviewed for nutrition. (Residents 59, 14, and 42) Findings include: 1. Record review for Resident 59 was completed on 6/12/24 at 3:11 p.m. Diagnoses included, but were not limited to, hypertension, dementia, and failure to thrive. The Quarterly Minimum Data Set (MDS) assessment, dated 5/13/24, indicated the resident was cognitively impaired. The resident required a substantial maximal assistance with eating. A Care Plan, dated 1/11/24, indicated the resident had unplanned/unexpected weight loss related to poor food intake. Interventions included to alert the dietician when consumption was poor for more than 48 hours and to record food intake at each meal. The resident weighed 109 pounds on 11/30/23. A weight obtained on 6/7/24 indicated the resident weighed 97 pounds, which was a 11.01 % (percent) weight loss. The Task Meal Consumption Logs were documented with percentage of meals eaten. The last 30 days lacked documentation for the following meals: - Breakfast on 5/16/24, 5/22/24, 5/25/24, 5/26/24, 5/29/24, 6/1/24, 6/3/24, 6/9/24, 6/10/24, and 6/12/24. - Lunch on 5/18/24, 5/22/24, 6/10/24, and 6/12/24. - Dinner on 5/16/24, 6/9/24, 6/10/24, and 6/11/24. During an interview on 6/13/24 at 1:20 p.m., the Director of Nursing (DON) indicated the CNAs were expected to document meal consumption percentage eaten in the computer under the Task section for Meal Consumption.

Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 2 of 3 residents reviewed for oxygen use. (Residents 42 and 48) Findings include: 1. On 6/10/24 at 11:25 a.m., Resident 42 was observed lying in bed wearing oxygen via nasal cannula. The oxygen flow rate was set under 2 liters. On 6/10/24 at 12:04 p.m., the resident's oxygen was in place and the flow rate was set under 2 liters. On 6/11/24 at 11:59 a.m., the resident was observed lying in bed and oxygen was in place via nasal cannula. The flow rate was set just under 2 liters. On 6/11/24 at 3:36 p.m., the resident was observed asleep in bed. Oxygen was in place and the flow rate was set below 2 liters. The record for Resident 42 was reviewed on 6/10/24 at 12:19 p.m. The diagnoses included, but were not limited to, atrial fibrillation (abnormal heart rhythm), dementia, depression, muscle weakness, adult failure to thrive, anxiety, and left shoulder fracture. The Significant Change Minimum Data Set (MDS) Assessment, dated 5/29/24, indicated the resident was severely impaired for daily decision making. The resident had no impairment of the upper and lower extremities and used a wheelchair. Eating and oral hygiene required supervision or touching assistance. Lower body dressing, toileting and bathing required dependent assistance. A Care Plan, dated 4/25/24, indicated the resident received oxygen therapy. Interventions were to administer oxygen settings per physician orders and administer medications as ordered. A Physician's order, dated 4/25/24, indicated to administer oxygen via nasal cannula continuously at 2 liters/minute for hypoxia. The June 2024 Medication Administration Record (MAR) indicated oxygen was signed out as being given at 2 liters every shift on the following dates: 6/10/24 and 6/11/24. During an interview on 6/12/24 at 11:34 a.m., the Director of Nursing (DON) indicated she would correct the resident's oxygen flow rate. No additional information was provided. 2. On 6/10/24 at 9:18 a.m., Resident 48 was observed sitting in her wheelchair watching her phone. The resident wore oxygen via nasal cannula and the flow rate was set at 3.5 liters. The oxygen canister had an oxygen sticker label that was marked 2 liters in red. On 6/10/24 at 11:55 a.m., the resident was observed asleep in bed, her nasal cannula was in place and the oxygen flow rate was set at 2.5 liters. On 6/11/24 at 11:58 a.m., the resident's oxygen was in place via nasal cannula and the flow rate was set at 2.5 liters. The record for Resident 48 was reviewed on 6/11/24 at 3:19 p.m. The diagnoses included, but were not limited to, hemiplegia, heart failure, stroke, diabetes, hypertension (high blood pressure), and chronic obstructive pulmonary disease. The Quarterly MDS Assessment, dated 6/6/24, indicated the resident was cognitively intact for daily decision making. The resident had an impairment on one side of her upper and lower extremity. The resident used oxygen and a wheelchair. A Care Plan, dated 6/11/24, indicated the resident received oxygen therapy. Interventions were to administer oxygen settings per physician orders and to administer medications as ordered. A Physician's order, dated 6/3/24, indicated to administer oxygen via nasal cannula continuously at 2 liters/minute for shortness of breath. The June 2024 MAR indicated oxygen was signed out as being given at 2 liters every shift on the following dates: 6/10/24 and 6/11/24. During an interview on 6/12/24 at 11:34 a.m., the DON indicated she would correct the resident's oxygen flow rate. No additional information was provided. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure the resident's Physician was notified in a timely manner of increased pain and leg swelling, for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: The closed record for Resident D was reviewed on 4/1/24 at 1:04 p.m. Diagnoses included, but were not limited to, history of falling, metabolic encephalopathy (an infection that causes brain damage), and osteomyelitis (bone infection). The Significant Change Minimum Data Set (MDS) assessment, dated 2/22/24, indicated the resident was cognitively impaired for daily decision making and dependent on staff for bed mobility and transfers. An Event Note, dated 3/14/24 at 3:00 p.m., indicated the CNA asked LPN 1 to look at the resident's right leg. The resident's leg was assessed and their left leg was observed to be pressing against the right leg. An indentation from the left leg was visible on the right leg. The right leg had bruising and a stage one area to the right leg. The Nurse Practitioner (NP), Director of Nursing (DON), and the resident's spouse were notified. The NP assessed the resident and ordered a pillow to be placed between the resident's legs at bedtime. A Nurses' Note, dated 3/14/24 at 9:04 p.m., indicated the resident had received two Tylenol 325 milligram (mg) tablets for pain. An entry at 10:14 p.m., indicated the NP was notified the resident appeared to be in pain throughout the day but would not complain. A Nurses' Note, dated 3/15/24 at 9:31 a.m., indicated the resident was receiving 650 mg Tylenol twice a day (BID) for complaints of leg pain, continued as ordered. A Skilled Note, dated 3/15/24 at 11:03 a.m., indicated routine Tylenol continued for complaints of leg pain. A Nurses' Note, dated 3/15/24 at 1:45 p.m., indicated an x-ray of the left hip and knee was ordered related to pain and deformity. At 6:20 p.m., the NP was notified of the x-ray results and orders were received to send the resident to the emergency room. The resident was diagnosed with a left femoral shaft fracture and bilateral tibia/fibula fractures with diffuse osteoporosis. A facility investigation was initiated. A statement obtained from LPN 1 on 3/15/24 indicated a CNA asked the LPN to look at the resident's right leg. The resident's leg was assessed and the left leg was observed to be pressing against the right leg. An indentation from the left leg was visible on the right leg. The right leg was bruised with a nonblanchable red spot. The NP assessed the resident and ordered a pillow to be placed between the resident's legs at bedtime. Around 9:20 p.m., she began to complete sacral wound care. As the LPN and CNA were turning the resident in bed, the resident was to be groaning more as if in pain. The resident denied pain. The LPN asked the CNA if she thought the resident appeared to be in more pain than usual, and the CNA replied she wasn't sure. The LPN noticed the left leg looked deformed but with no bruising or swelling. On 3/15/24 at about 7:00 a.m., the same CNA told LPN 1 the resident did seem to be in more pain, although the resident denied being in pain. The LPN reached to touch the resident's left leg to see if it hurt. The resident slapped the LPN's hand away and admitted that the left leg did hurt. The NP was notified. During an interview, on 4/2/24 at 11:50 a.m., LPN 1 indicated when she was completing wound care for Resident D, the resident seemed to be in more pain than usual, even though the resident denied the pain. LPN 1 indicated she couldn't call the NP because it was too late, there were signs posted at the nurses' stations that her hours were until 9:00 p.m., and even though the resident seemed to be in pain, she voiced she wasn't, that's why she didn't call. The NP had assessed the resident earlier in the day. She also indicated the resident's left leg looked different during wound care, but she wasn't sure if that was the norm or not due to having contractures. LPN 1 indicated the next morning, the resident's left leg definitely looked different and wouldn't let her touch it, the resident kept shooing her hand away. It was then that she notified the NP again, and the resident was seen and orders were received. During an interview, on 4/2/24 at 1:20 p.m., the Director of Nursing indicated the Physician should have been contacted after the resident seemed to be experiencing pain, and after the leg swelling was noted. Even if the NP did not want to be contacted after 9:00 p.m., the Physician should have been contacted. The DON indicated staff could call her any time for guidance. This citation relates to Complaint IN00431405. 3.1-5(a)(2)

Based on record review and interview, the facility failed to ensure adequate supervision was provided in the shower for a resident who was leaning in their shower chair, for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: The closed record for Resident D was reviewed on 4/1/24 at 1:04 p.m. Diagnoses included, but were not limited to, history of falling, metabolic encephalopathy (an infection that causes brain damage), and osteomyelitis (bone infection). The Significant Change Minimum Data Set (MDS) assessment, dated 2/22/24, indicated the resident was cognitively impaired for daily decision making and dependent on staff for bed mobility and transfers. A Care Plan, dated 1/23/24, indicated the resident required ADL (activities of daily living) assistance and therapy services to maintain or attain their highest level of function. Interventions included, but were not limited to, extensive assist of 2 to complete transfers. Nurses' Notes, dated 2/11/24 at 10:05 p.m., indicated the CNA notified the writer the resident was on the floor in the shower room. The resident was assessed and a bump was noted on the left side of their forehead. The resident was a three person assist back into the wheelchair. The resident was transferred back to bed with a two person assist. Neurological checks were performed and the resident was later transported to the hospital for evaluation. The facility fall investigation, dated 2/11/24, indicated the resident was being assisted in the shower room and they were leaning in the shower chair. The CNA attempted to reposition them and they fell forward hitting their face. The resident was noted to have a bump on the left side of the forehead. . A statement obtained from the CNA, on 2/11/24, indicated the incident took place on 2/11/24 at 5:00 p.m. The CNA indicated when she was in the shower room with the resident, they kept leaning over in the shower chair. The CNA tried readjusting the resident a few times, but they kept leaning, and then they leaned again and the chair tipped over, and the resident fell on their face. During an interview, on 4/2/24 at 1:20 p.m., the Director of Nursing (DON) indicated the CNA who had the resident in the shower room should have pulled the emergency call light and waited for more assistance. The DON indicated the resident did not normally lean in the shower chair when being bathed. This citation relates to Complaints IN00430978 and IN00431405. 3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents had an assessment and Physician's Orders to self-administer their own medications, for 4 of 4 residents reviewed for self-administration of medication. (Residents C, F, G and H) Findings includes 1. During a random observation on 4/1/24 at 1:37 p.m., Resident C was observed in bed and awake. The resident was confused and not oriented to time and place. At that time, there was a tube of Bacitracin ointment on the dresser and 1 over the counter bottle of Genteal tears eye solution. The bottle of eye drops was located on a high top dresser and completely out of reach for the resident. During a random observation, on 4/2/24 at 8:25 a.m., the resident was observed in bed. At that time, the bottle of eye drops was still located on the high top dresser and out of reach for the resident. The record for Resident C was reviewed on 4/1/24 at 3:20 p.m. Diagnoses included, but were not limited to, contusion right lower leg and foot, osteoarthritis, dry eye syndrome, high blood pressure, difficulty walking, and muscle weakness. Physician's Orders, dated 3/28/24, indicated Bacitracin Zinc External Ointment, apply to toes topically one time a day and leave open to air until healed. Physician's Orders, dated 8/20/23, indicated Refresh Tears 0.5%, instill 1 drop in both eyes three times a day for dry eyes. The patient may self-administer. There was no documentation of a self-administration of medication assessment or an order for the Bacitracin ointment to be left at the bedside. During an interview, on 4/2/24 at 11:30 a.m., the Director of Nursing (DON) indicated the resident's son could have brought in the bottle of eye drops and given them to her, however, the Bacitracin ointment should not have been left at the bedside. 2. During a random observation, on 4/1/24 at 1:00 p.m., Resident F was observed sitting on the side of the bed. At that time, the Physical Therapist (PT) was in the room preparing to change the bandages on the left foot. There were 2 medication cups observed on the resident's over bed table with the resident's name written on them. One of the medication cups contained 1 white unidentified pill. During an interview at that time, the resident indicated it was a Melatonin tablet that he had requested last evening, but never took it. The record for Resident F was reviewed on 4/2/24 at 9:25 a.m. The resident was admitted on [DATE] from the hospital. Diagnoses included, but were not limited to, osteomyelitis left ankle and foot, abscess to the left foot, type 2 diabetes, open wound to the left foot, high blood pressure, and peripheral vascular disease. The admission Minimum Data Set (MDS) assessment, dated 3/8/24, indicated the resident was cognitively intact for daily decision making. The resident was admitted with a diabetic foot ulcer. Physician's Orders, dated 3/12/24, indicated Melatonin 5 milligrams (mg), give 1 tablet by mouth as needed for insomnia. There was no documentation of a self-administration of medication assessment or a Physician's Order to self-administer his own medications. During an interview, on 4/2/24 at 11:30 a.m., the Director of Nursing indicated she was aware of the medication cups with the resident's name on them and the pill that was left inside of one of them. She had them on her desk in her office. The resident had no order to self-administer his own medications or an assessment to do so. 3. During a random observation, on 4/1/24 at 9:50 a.m., Resident G was observed in her bed reading a book. At that time, there was a bottle of eye drops placed inside a medication cup on the over bed table. The resident indicated she administered the eye drops to herself every evening, that way she knew she got them. The record for Resident G was reviewed on 4/2/24 at 11:14 a.m. Diagnoses included, but were not limited to, high blood pressure and type 2 diabetes. Physician's Orders, dated 1/25/23, indicated Latanoprost Ophthalmic Solution 0.005%, instill 1 drop in both eyes at bedtime for ocular hypertension. There was no Physician's Order for the resident to self-administer the eye drops. There was no self-administration of medication assessment to self-administer the eye drops. During an interview, on 4/1/24 at 1:25 p.m., the Director of Nursing indicated there was no order for the resident to administer the eye drops or a self-administration of medication assessment completed. 4. During a random observation, on 4/1/24 at 9:59 a.m., Resident H was seated in a wheelchair with an over bed table. There was a medication cup on that table with 3 white pills on a napkin. During an interview with the resident at that time, she indicated she was taking her water pills. The record for Resident H was reviewed on 4/2/24 at 10:16 a.m. Diagnoses included, but were not limited to, heart disease, high blood pressure, edema, chronic obstructive pulmonary disease. The Care Plan, dated 3/6/24, indicated, the resident had a Physician's Order for self-administration of the following medications: Vicks VapoRub, Saline Nasal Spray, Sore throat spray, [NAME] throat drops, and an inhaler. There was no Physician's Order for the resident to self-administer her daily medications. There was no self-administration of medication assessment to self-administer her daily medications. During an interview, on 4/2/24 at 1:15 p.m., the Director of Nursing indicated the resident had no Physician's Order to self-administer her daily medications and no assessment completed. The current 8/29/24 Self-Administration of Medication policy, provided by the Infection Preventionist on 4/2/24 at 12:54 p.m., indicated the team in consultation with the Physician for the resident will conduct an assessment of the resident's cognitive, physical, and visual ability to carry out this responsibility. The interdisciplinary assessment will be completed in the electronic medication record. This citation relates to Complaint IN00430795. 3.1-11(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The closed record for Resident B was reviewed on [DATE] at 11:32 a.m. The resident was admitted on [DATE] from the hospital, and expired in the facility on [DATE]. Diagnoses included, but were not limited to, stroke, sepsis, absence of the left foot, chronic kidney disease, end stage renal disease, type 2 diabetes, atrial fibrillation, adult failure thrive, dependence on renal dialysis, high blood pressure, and severe peripheral vascular disease. The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact for daily decision making and needed substantial to maximal assist with rolling to the left and right. The resident was admitted with diabetic ulcers. The Care Plan, revised on [DATE], indicated the resident had diabetic ulcers to the right inner ankle, left foot, right 4th toe, right great toe, right second toe, right lateral foot, and right heel. A Nursing admission Assessment, dated [DATE], indicated the resident was admitted with necrotic areas to both feet and right heel, an open wound with necrotic tissue to the right inside of the right foot, and an open wound to the left outer foot. The Wound Observation Tool, dated [DATE], indicated the following wounds and measurements: a. right heel: 100% black necrotic tissue with no drainage, measured 6 centimeter (cm) by 3.8 cm. b. right lateral foot: 100% black necrotic tissue with no drainage, measured 6 cm by 2.9 cm. c. right great toe: 100% black necrotic tissue with no drainage, measured 1.8 cm by 1.5 cm. d. right 4th toe: 100% black necrotic tissue with no drainage, measured 1.5 cm by 1.5 cm e. left foot (stump): granulation tissue with small amount of drainage, measured 4.8 cm by 3.4 cm by 0.3 cm (depth) f. right inner ankle: 100% black necrotic tissue with no drainage, measured 2.5 cm by 2 cm The Wound Observation Tool, dated [DATE], indicated the following wounds and measurements: a. right heel: 100% black necrotic tissue with no drainage, measured 7.5 centimeter (cm) by 6 cm. b. right lateral foot: 100% black necrotic tissue with no drainage, measured 3.2 cm by 3 cm. c. right great toe: 100% black necrotic tissue with no drainage, measured 1.5 cm by 2.5 cm. d. right 4th toe: 100% black necrotic tissue with no drainage, measured 1.5 cm by 1.5 cm Physician's Orders, dated [DATE], indicated to cleanse the left outer foot with normal saline, apply a non-adherent gauze, and wrap with kerlix, every Tuesday, Thursday and Saturday. Physician's Orders, dated [DATE], indicated to cleanse the wounds to the right heel, right lateral foot, right great toe and 4th toe with normal saline, apply Iodosorb External Gel 0.9%, and cover with a non-adherent gauze and wrap with kerlix, every Tuesday, Thursday and Saturday. The Treatment Administration Record (TAR), dated 1/2024, indicated the Iodosorb treatment to the right foot wounds was coded with a 10 (other see nurses notes) on 1/11 and a 7 (hold see progress notes) on [DATE]. The left outer foot bandage change was not signed out as being completed and was coded with a 10 on [DATE] and a 7 on [DATE]. Nurses' Notes, dated [DATE] at 2:45 p.m., indicated .Bandages not changed today per wound care nurse, [name] LPN. Bandages changed and treatment done yesterday. Bandages are clean and dry Schedule will resume on Saturday. Pt. [patient] aware. Nurses' Notes, dated [DATE] at 1:53 p.m., indicated wound treatments were not completed due to the resident being at the foot doctor. Physician's Orders, dated [DATE], indicated to cleanse the right heel, right great toe, right lateral foot and right ankle with normal saline, apply a foam dressing, and wrap with kerlix, every Monday, Wednesday, and Saturday for black areas. Cleanse the left outer foot with normal saline, apply Iodosorb to the wound, cover with a dry dressing, and wrap with kerlix, every other day. The 2/2024 TAR, indicated a 7 was documented on [DATE] and the treatments were not signed out as being completed, for both the right foot and left outer foot. Nurses' Notes, dated [DATE] at 1:55 p.m., indicated the wound treatments were not completed as ordered due to the treatments being done the previous shift. There was no documentation on the TAR or in Nurses' Notes to indicate the treatment to the resident's wounds had been completed on the previous shift. During an interview, on [DATE] at 11:30 a.m., the Wound Nurse indicated the resident's wound treatments should have been completed as ordered by the doctor. 3. During a random observation, on [DATE] at 1:37 p.m., Resident C was observed in bed and awake. The resident's feet were observed in bilateral heel boots, and the top of her toes on both feet were noted with dried blood and open areas. The record for Resident C was reviewed on [DATE] at 3:20 p.m. Diagnoses included, but were not limited to, contusion right lower leg and foot, osteoarthritis, dry eye syndrome, high blood pressure, difficulty walking, and muscle weakness. The resident was admitted to the hospital on [DATE] after a fall, and returned back to the facility on [DATE]. Physician's Orders, dated [DATE] and discontinued on [DATE], indicated Bacitracin Ointment, apply to the toes topically, one time after cleansing with normal saline, and cover with a Band-Aid. Physician's Orders, dated [DATE], indicated Bacitracin Zinc External Ointment, apply to the toes topically, one time a day, and leave open to air until healed. The Nurse admission Assessment, dated [DATE], indicated the resident was readmitted with lost toe nails on both feet and there was a treatment in place. There was no wound assessment of the resident's toes and open areas. During an interview, on [DATE] at 1:15 p.m., the Director of Nursing indicated there was no assessment of the resident's feet and her missing toe nails. 4. During a random observation, on [DATE] at 1:00 p.m., Resident F was observed sitting on the side of the bed. At that time, the Physical Therapist (PT) was in the room preparing to change the bandages on the left foot. The resident's left heel was observed with a large amount of yellow slough (dead tissue, usually cream or yellow in color) and a moderate amount of black necrotic tissue. There was also another black and hard necrotic area on the left foot between the second and third toes. After cleansing the wound, the PT squeezed a dime size amount of Santyl (debriding agent) ointment onto a dry gauze sponge. She picked up the gauze sponge and spread the Santyl ointment onto the wound, and left the sponge in place. She then put a dry foam bandage over the top of the gauze sponge and wrapped the foot with a kerlix bandage. During an interview at that time, the PT indicated they were only doing a treatment to the left heel. On [DATE] at 8:22 a.m., the resident was observed sitting up in bed with the left foot in a heel boot and a red non-skid sock over the tip of his foot. The resident was asked to remove the red sock so the bandage could be viewed. After the sock was removed, there was no bandage observed covering the black necrotic area between the second and third toe. The resident indicated no staff had completed a treatment to the toe the previous day. The record for Resident F was reviewed on [DATE] at 9:25 a.m. The resident was admitted on [DATE] from the hospital. Diagnoses included, but were not limited to, osteomyelitis left ankle and foot, abscess to the left foot, type 2 diabetes, open wound to the left foot, high blood pressure, and peripheral vascular disease. The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact for daily decision making. The resident was admitted with a diabetic foot ulcer. Physician's Orders, dated [DATE], indicated to cleanse the left second toe with wound wash, apply Santyl, cover with gauze, and wrap in kerlix, every evening shift. Physician's Orders, dated [DATE], indicated PT wound care to the left heel 5 times a week for 30 days. Cleanse the area with wound cleanser, and perform sharp, selective debridement using forceps, scissors, or scalpel. The PT may perform CPI (Close Pulse Irrigation) as needed to remove nonviable, necrotic tissue to the wound bed. Apply Santyl and cover with a foam dressing. The Wound Observation Tool, dated [DATE], indicated the following measurements: a. left toe, unchanged, 100% black necrotic and measured 1 centimeter (cm) by 0.8 cm. b. left heel, unchanged 25% black necrotic and 75% slough, measured 6 cm by 6 cm. During an interview, on [DATE] at 11:30 a.m., the Director of Nursing indicated treatments were to be done as ordered by the Physician. The current [DATE] Skin Integrity and Pressure Ulcer/Injury Prevention and Management policy, provided by the Infection Preventionist on [DATE] at 12:34 p.m., indicated a skin assessment/inspection occurred on admission/readmission. Skin observations also occurred throughout points of care provided by CNAs. Any changes or open areas were to be reported to the nurse, as well as if topical bandages were identified as soiled, saturated, or dislodged. The nurse would complete further inspection/assessment and provide treatment if needed. This citation relates to Complaints IN00430795, IN00430978, and IN00431405. 3.1-37(a) Based on observation, record review, and interview, the facility failed to ensure a resident was sent to the hospital in a timely manner, related to complaints of increased pain and leg swelling, for 1 of 3 residents reviewed for accidents. The facility also failed to ensure treatments were completed for diabetic ulcers and an assessment was completed for new non-pressure wounds to the toes, for 3 of 3 residents reviewed for skin conditions non-pressure related. (Residents D, B, C, and F) Findings include: 1. The closed record for Resident D was reviewed on [DATE] at 1:04 p.m. Diagnoses included, but were not limited to, history of falling, metabolic encephalopathy (an infection that causes brain damage), and osteomyelitis (bone infection). The Significant Change Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively impaired for daily decision making and dependent on staff for bed mobility and transfers. A Care Plan, dated [DATE], indicated the resident required ADL (activities of daily living) assistance and therapy services to maintain or attain their highest level of function. Interventions included, but were not limited to, extensive assist of 2 to complete transfers. A Physician's Order, dated [DATE], indicated the resident was to receive Acetaminophen (Tylenol) 325 milligrams (mg), 2 tablets every 4 hours as needed (PRN) for pain or fever. Nurses' Notes, dated [DATE] at 2:30 p.m., indicated the resident was medicated with two Tylenol 325 mg tablets for complaints of right leg pain. An Event Note, dated [DATE] at 3:00 p.m., indicated the CNA asked LPN 1 to look at the resident's right leg. The resident's leg was assessed and the left leg was observed to be pressing against the right leg. An indentation from the left leg was visible on the right leg. The right leg had bruising and a stage one area to the right leg. The Nurse Practitioner (NP), Director of Nursing (DON), and the resident's spouse were notified. The NP assessed the resident and ordered a pillow to be placed between the resident's legs at bedtime. The resident was helped out of bed. The resident was complaining of pain and given as needed (PRN) Tylenol. A Nurses' Note, dated [DATE] at 9:04 p.m., indicated the resident had received two Tylenol 325 mg tablets for pain. An entry at 10:14 p.m., indicated the NP was notified that the resident appeared to be in pain throughout the day, but would not complain. A Physician's Order, dated [DATE], indicated the resident was to receive Tylenol 325 mg, 2 tablets twice a day for pain starting [DATE]. A Nurses' Note, dated [DATE] at 9:31 a.m., indicated the resident was receiving 650 mg Tylenol twice a day (BID) for complaints of leg pain, continued as ordered. A Skilled Note, dated [DATE] at 11:03 a.m., indicated routine Tylenol continued for complaints of leg pain. A Nurses' Note, dated [DATE] at 1:45 p.m., indicated an x-ray of the left hip and knee was ordered, related to pain and deformity. At 6:20 p.m., the NP was notified of the x-ray results and orders were received to send the resident to the emergency room. At 6:32 p.m., transport was dispatched to the facility. The resident was admitted to the hospital with a left femoral shaft fracture and bilateral tibia/fibula fractures with diffuse osteoporosis. A facility investigation was initiated. A statement obtained from LPN 1 on [DATE] indicated a CNA asked the LPN to look at the resident's right leg. The resident's leg was assessed and the left leg was observed to be pressing against the right leg. An indentation from the left leg was visible on the right leg. The right leg was bruised with a nonblanchable red spot. The NP assessed the resident and ordered a pillow to be placed between the resident's legs at bedtime. Around 9:20 p.m., the LPN began to complete sacral wound care. As the LPN and CNA were turning the resident in bed, the resident was to be groaning more as if in pain, although the resident denied pain. The LPN asked the CNA if she thought the resident appeared to be in more pain than usual and the CNA replied she wasn't sure. The LPN noticed the left leg looked deformed, but had no bruising or swelling. On [DATE] at about 7:00 a.m., the same CNA told LPN 1 the resident did seem to be in more pain. The resident denied being in pain. The LPN reached to touch the resident's left leg to see if it hurt. The resident slapped the LPN's hand away and admitted that the left leg did hurt. The NP was notified. During an interview, on [DATE] at 11:50 a.m., LPN 1 indicated when she was completing wound care for Resident D, the resident seemed to be in more pain than usual, even though the resident denied the pain. LPN 1 indicated she couldn't call the NP because it was too late, there were signs posted at the nurses' stations that her hours were until 9:00 p.m. and even though the resident seemed to be in pain, they voiced they weren't, that's why she didn't call. The NP had assessed the resident earlier in the day. She also indicated the resident's left leg looked different during wound care, but she wasn't sure if that was the norm or not due to having contractures. LPN 1 indicated the next morning, the resident's left leg definitely looked different and the resident wouldn't let her touch it, the resident kept shooing her hand away. It was then that she notified the NP again, and the resident was seen and orders were received. During an interview, on [DATE] at 1:20 p.m., the Director of Nursing (DON) indicated x-rays should have been ordered when the bruising and pain were noted on [DATE] or the resident should have been sent out for evaluation. The DON indicated staff could call her any time for guidance.

Based on observation, record review, and interview, the facility failed to ensure residents had an assessment to self-administer their own medications for 2 random residents reviewed for self-administration of medication. (Residents 50 and 74) Findings include: 1. On 4/24/23 at 10:52 a.m., Resident 50 was observed in her room with a nasal spray and an inhaler at her bedside. The record for Resident 50 was reviewed on 4/26/23 at 10:36 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 3/30/23, indicated the resident was cognitively intact. A Care Plan, dated 5/23/22 and revised on 3/31/23, indicated the resident had a Physician's Order for self-administration of Vicks Vapo Rub, saline nasal spray, sore throat spray, Luden's throat drops, and an inhaler. Interventions included, but were not limited to, assess the resident's ability to safely self-administer medications specified on admission/readmission, quarterly, with a change in medication orders, and with significant changes in condition. A Physician's Order, dated 4/25/23, indicated the resident was to receive an Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) mcg (micrograms), 1 puff, inhale orally every 4 hours as needed for wheezing, may self-administer and keep at the bedside. Physician's Orders, dated 5/17/22 and listed as current on the April 2023 Physician's Order Summary (POS), indicated the resident was to receive Sore Throat Spray Liquid 1.4 % (Phenol). Give 1 spray by mouth as needed for sore throat, may keep at bedside and self-administer. Saline Nasal Spray Solution 1 spray alternating nostrils as needed for nasal congestion may keep at bedside and self-administer. Vicks Vapo Rub ointment 4.7-1.2-2.6%, apply to chest topically as needed for nasal congestion. May keep at bedside and self-administer. A Physician's Order, dated 3/22/22 and listed as current on the April 2023 POS, indicated the resident may keep her Albuterol MDI inhaler at the bedside and self-administer. There was no self-administration of medication assessment available for review. Interview with the Director of Nursing on 4/27/23 at 1:30 p.m., indicated she thought an assessment had been completed last fall. 2. On 4/25/23 at 9:40 a.m. and 3:15 p.m., Resident 74 was observed in his room. An Albuterol inhaler was observed on his bed. Interview with the resident at that time, indicated he was allowed to keep the inhaler in his room. On 4/26/23 at 9:29 a.m., the resident was in his room seated in his wheelchair. The resident's inhaler remained at the bedside. The record for Resident 74 was reviewed on 4/27/23 at 8:58 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, malignant neoplasm of right bronchus of lung, and emphysema. The admission Minimum Data Set (MDS) assessment, dated 3/27/23, indicated the resident was moderately impaired for daily decision making. The resident did not have a self-administration of medication assessment available for review. He also did not have a care plan related to self-administration of medications. A Care Plan, dated 3/31/23, indicated the resident had impaired cognitive ability/ impaired thought processes related to short term memory deficits. Interventions included, but were not limited to, administer medications as ordered and allow extra time for the resident to respond to questions and instructions. A Physician's Order, dated 4/7/23, indicated the resident was to receive ProAir HFA Inhalation Aerosol Solution 108 (90 Base) micrograms (mcg) Albuterol Sulfate, 2 puffs, inhale orally every 4 hours as needed for wheezing, dyspnea, or prior to physical activity. May keep at bedside. Interview with the Director of Nursing on 4/27/23 at 1:30 p.m., indicated a self-administration of medication assessment should have been completed. 3.1-11(a)

Based on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADLs) related to nail care. (Resident 69) Finding includes: Interview with Resident 69 on 4/24/23 at 10:35 a.m., indicated her toenails were very long and they needed to be cut. The resident had told staff that she needed assistance cutting them, but they had not helped her. The resident's toenails were observed during the interview and were noted to be very long. Resident 69's record was reviewed on 4/26/23 at 1:22 p.m. Diagnoses included, but were not limited to, heart disease, chronic obstructive pulmonary disease, end stage renal disease, and type 2 diabetes mellitus. A Significant Change in Status Minimum Data Set (MDS) assessment, dated 3/28/23, indicated the resident was cognitively intact for daily decision making. She required extensive assistance with one person physical assist for personal hygiene. Interview with the Assistant Director of Nursing on 4/27/23 at 2:38 p.m., indicated the resident was on the list to be seen by podiatry upon their next visit to the facility. Interview with the Director of Nursing on 4/28/23 at 9:58 a.m., indicated she assessed the resident's toenails and cut her toenails as they were very long and needed cut. They should have been addressed sooner. 3.1-38(a)(3)(E)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the resident received 1 to 1 activities at least 3 times a week for 1 of 1 residents reviewed for activities. (Resident 6) Finding includes: On 4/24/23 at 1:33 p.m. Resident 6 was observed in bed. At that time, the television was on, however, there was no sound and it was trying to connect to the internet. On 4/25/23 at 9:00 a.m., the resident was observed in bed with his eyes closed. There was no television or radio playing. The record for Resident 6 was reviewed on 4/26/23 at 1:45 p.m. Diagnoses included, but were not limited to, pericardial effusion, cerebral hemorrhage, intellectual disabilities, altered mental status, acute kidney failure, and expressive language disorder. The resident was admitted to the hospital on [DATE] and returned on 4/17/23 with hospice services. A Significant Change Minimum Data Set (MDS) Assessment, dated 4/21/23, was in progress. The Quarterly Minimum Data Set (MDS) assessment, dated 1/30/23, indicated the resident was severely impaired for decision making. The resident needed extensive assist with a 2 person physical assist for bed mobility and transfers. A Care Plan, dated 4/19/23, indicated the resident had little or no activity involvement related to his preference of being in an environment without a lot of noise. The resident would benefit from having a 1 to 1 activity three times a week. The 1 to 1 activities documented for the resident were music, watched TV, and read short stories. The resident's response was documented as well. The resident received 1 to 1 activities on the following dates: January/February 2023: 1/30, 2/2, 2/7, 2/11, 2/16, 2/20, and 2/25/23 March 2023: 3/1, 3/6, 3/10, 3/13, 3/17, 3/21, 3/25, and 3/29/23 April 2023: 4/2, 4/6, 4/10, 4/12, (hospital 4/13-4/17), 4/19, 4/22, and 4/24/23 The 1 to 1 activities were not completed at least three times a week. Interview with the Activity Director on 4/27/23 at 11:18 a.m., indicated the resident was to have 1:1 activities 3 times a week and she would be addressing the issue with her staff. 3.1-33(b)(8)

Based on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the treatment and services necessary to promote healing related to treatments not being completed as ordered and pressure reduction devices not being used for 2 of 3 residents reviewed for pressure ulcers. (Residents 1 and 50) Findings include: 1. On 4/28/23 at 10:59 a.m., Resident 1 was observed in her room in bed. Agency LPN 2 used hand sanitizer and donned gloves and proceeded to remove the resident's blanket exposing her feet. Three foam dressings, dated 4/24/23, were observed on the resident's right foot. Three foam dressings on the resident's overbed table, were dated 4/28/23. The LPN indicated she would take care of the resident's dressings and proceeded to remove each dressing one at a time and replace them with the pink foam dressings, dated 4/28. The LPN did not cleanse the wounds with normal saline and Medihoney (a debriding ointment) was not applied. The record for Resident 1 was reviewed on 4/26/23 at 1:28 p.m. Diagnoses included, but were not limited to, cerebral palsy, profound intellectual disabilities, and disorder of the nose and nasal sinuses. The 3/27/23 Significant Change Minimum Data Set (MDS) assessment indicated the resident was severely impaired for daily decision making. She was also dependent on staff for bed mobility. The resident was identified as having one Stage 1 and four Stage 2 pressure areas that were present on readmission. A Care Plan, dated 3/27/23, indicated the resident had a break in skin integrity. She had a blister to the right heel, two Stage 2 areas to the right foot, a blister to the left heel, and a Stage 1 to her left hip. Interventions included, but were not limited to, weekly skin checks and treatments as ordered. A Physician's Order, dated 3/31/23, indicated Medihoney Wound/Burn Dressing External Gel was to be applied to the top of the right foot and side of the foot topically on the evening shift every 3 days. Cleanse areas to the top of the right foot and side of the right foot with NS, apply Medihoney and cover with foam dressings. This order also applied to the right heel and left hip. The April 2023 Medication Administration Record (MAR), indicated the treatments were signed out as being completed on the evening shift on 4/27/23. Interview with the Assistant Director of Nursing on 4/28/23 at 11:10 a.m., indicated the treatment should have been completed as ordered on 4/27/23. She also indicated the wounds should have been cleansed with normal saline and Medihoney should have been applied as ordered. 2. On 4/25/23 at 2:05 p.m. and 3:10 p.m., Resident 50 was seated in her wheelchair in her room. She was wearing non-skid socks and slippers. She did not have a heel boot in use. On 4/26/23 at 9:30 a.m., the resident was again in her room watching television. She was wearing non-skid socks and slippers. She did not have a heel boot in use. At 11:30 a.m., she was seated in her wheelchair in the hall. She was propelling her wheelchair with her feet. She was wearing slippers and non-skid socks. At 1:39 p.m., the resident continued to wear her slippers and non-skid socks with no heel boot in use. On 4/27/23 at 9:10 a.m., the resident was seated in her wheelchair in her room. She was wearing her slippers and non-skid socks. Interview with the resident at that time, indicated she did not like wearing the boot and at night she elevated her foot on a pillow. The record for Resident 50 was reviewed on 4/26/23 at 10:36 a.m. Diagnoses included, but were not limited to, atherosclerotic heart disease, hypertension, and edema. The Quarterly Minimum Data Set (MDS) assessment, dated 3/30/23, indicated the resident was cognitively intact and she had a Stage 2 pressure ulcer. A Care Plan, dated 3/2/23, indicated the resident required ADL (activities of daily living) assistance and therapy services needed to maintain or attain highest level of function. The resident required limited assistance with toileting, transfers, bed mobility and set up assistance for meals. Interventions included, but were not limited to, pressure reducing boot to the right lower extremity, may remove for care. A Physician's Order, dated 3/15/23, indicated the resident was to wear a pressure reducing boot to the right lower extremity. The boot could be removed for care. A Physician's Order, dated 4/14/23, indicated the resident was to receive Santyl Ointment to her right heel daily. The area was to be cleansed with normal saline, apply Santyl, and cover with a dry dressing. The April 2023 Treatment Administration Record (TAR), indicated the pressure reducing boot had been signed out as being applied every shift for the month. Interview with the Assistant Director of Nursing on 4/27/23 at 1:30 p.m., indicated the resident preferred to wear the boot at night and her orders and care plan should have been updated. The Director of Nursing also indicated at that time, the boot shouldn't have been signed out as being applied if it wasn't worn. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident was free from accidents and received supervision with medications related to proper interventions not in place to prevent the resident from falling and not staying with the resident until all of her medications were consumed for 1 of 3 residents reviewed for accidents. (Resident 27) Finding includes: On 4/25/23 at 9:00 a.m., Resident 27 was observed lying sideways in bed. At that time, she had on a pair of fuzzy socks, there was nothing on the bottom of them to prevent the resident from falling. Her wheelchair was parked by the bed and there was no dycem on top of the cushion to prevent the resident from sliding out of the wheelchair. There was no floor mat beside her bed. On 4/25/23 at 10:00 a.m., the resident was observed sitting up in her wheelchair, wearing the same fuzzy socks and self-propelling her wheelchair On 4/25/23 at 2:00 p.m., the resident was observed lying sideways in bed, wearing the same pair of fuzzy socks. There was no floor mat on the ground beside the bed, nor was there a dycem in the wheelchair on top or under the cushion. On 4/26/23 9:20 a.m., the resident was observed lying on her side in bed with her head slightly elevated. At that time, she was holding a medication cup full of pills in her right hand. There was no nurse in the room at that time. She was wearing a pair of fuzzy socks with no skids on the bottom of them. There was no floor mat beside the bed, nor was there a dycem on top of or under the cushion in the wheelchair. Shortly, thereafter, LPN 1 entered the room and asked if the resident had taken her medications. Interview with LPN 1 at that time, indicated the resident took a long time to take her medications. She was asked if this was the facility's policy to leave the medications with the resident and not observe them being swallowed. The LPN indicated she was just outside the door in the hallway, but was not in full view of the resident. The LPN took the medication cup from the resident's hand and assisted her to a sitting position so the pills could be administered. The nurse indicated she was aware she was supposed to stay with each resident until the medications were swallowed. On 4/26/23 at 10:40 a.m., and 1:35 p.m., the resident was observed self-propelling her wheelchair, wearing the same pair of fuzzy socks with no skids on the bottom of them. The record for Resident 27 was reviewed on 4/25/23 at 2:50 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia, edema, major depressive disorder, osteoporosis, and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 3/21/23, indicated the resident was not cognitively intact. The resident needed extensive assist with a 1 person physical assist with bed mobility and transfers and has had no falls since the last assessment. A Care Plan, updated 3/14/23, indicated the resident was at risk for falls. The approaches were to provide a dycem to the wheelchair, a floor mat bedside the bed, and appropriate footwear. The Quarterly Fall Risk Evaluation, dated 3/7/23, indicated the resident has had no falls in the last 90 days. Interview with the Director of Nursing on 4/27/23 at 10:45 a.m., indicated the resident would put herself to bed and get out of bed without assistance. She was able to self-propel her wheelchair with her feet. She should have been wearing non-skid socks and the dycem should be in her wheelchair. The nurse should not have left the medications with the resident for her to take by herself. It was the facility's policy for nursing staff to stay with the resident until all of the medications were consumed. Interview with the Assistant Director of Nursing at that time, indicated she had just discontinued the floor mat yesterday. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status related to meal consumption records not completed for a resident with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 74) Finding includes: The record for Resident 74 was reviewed on 4/27/23 at 8:58 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, malignant neoplasm of right bronchus of lung, and emphysema. The admission Minimum Data Set (MDS) assessment, dated 3/27/23, indicated the resident was moderately impaired for daily decision making. He required supervision with eating and received a therapeutic diet. A Care Plan, dated 3/29/23, indicated the resident was at risk for weight fluctuations related to his current health status. He had the diagnosis of cancer and his body mass index (BMI) was 22. Interventions included, but were not limited to, assistance with meals as needed and diet per order. A Physician's Order, dated 3/23/23, indicated the resident was to receive a regular diet with diet condiments. A Physician's Order, dated 3/29/23, indicated the resident was to receive Ensure (a nutritional supplement) three times a day. The resident's admission weight on 3/23/23 was 153 pounds. On 4/13/23, the resident weighed 115 pounds. A Dietary Note, dated 4/12/23 at 3:41 p.m., indicated the resident tolerated his diet and texture well and he fed himself with some set up in his room. His food intake was 76-100% and he received Ensure three times a day for extra nutritional support. His current weight was 153 pounds. Continue to monitor weights and intakes. A Registered Dietitian (RD) Progress Note, dated 4/25/23 at 11:07 a.m., indicated the resident weighed 153 pounds on 3/23/23, 115 pounds on 4/13/23, and 117 pounds per staff verbalization. The resident had a 23.5% weight loss since admission. The Food Consumption sheets for March and April 2023 indicated the following: - No food intake was documented on 4/11, 4/16, 4/18, 4/19, 4/21, 4/23, and 4/26/23. - No breakfast or lunch intake was documented on 3/29 and 4/24/23. - No dinner intake was documented on 3/31, 4/1, 4/5, 4/6, 4/7, 4/10, 4/12, and 4/20/23. Interview with the Assistant Director of Nursing on 4/27/23 at 2:30 p.m., indicated that she questioned the accuracy of the resident's admission weight. She also indicated the food consumption logs should have been completed. 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure psychotropic medications were monitored for side effects and effectiveness as well as ensuring Abnormal Involuntary Movement Scale (AIMS) assessments were completed for 1 of 5 residents reviewed for unnecessary medications. (Resident 47) Finding includes: Resident 47's record was reviewed on 4/25/23 at 1:31 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 3/24/23, indicated the resident was cognitively intact for daily decision making. She received antidepressant, anti-anxiety, and antipsychotic medications. A Physician's Order, dated 2/17/22, indicated the resident was to receive brexpiprazole (an antipsychotic medication) 0.5 milligrams (mg) one time a day. The order was discontinued on 6/12/22. A Physician's Order, dated 6/15/22, indicated the resident was to receive brexpiprazole 0.5 mg one time a day. The order was discontinued on 8/15/22. A Physician's Order, dated 8/16/22, indicated the resident was to receive brexpiprazole 0.25 mg one time a day. The order was discontinued on 2/21/23. A Physician's Order, dated 3/19/22, indicated the resident was to receive brexpiprazole 1 mg one time a day. The order was discontinued on 4/10/23. A Physician's Order, dated 4/11/23, indicated the resident was to receive brexpiprazole 0.5 mg one time a day. The order was discontinued on 4/24/23. A Physician's Order, dated 4/25/23, indicated the resident was to receive brexpiprazole 0.25 mg one time a day. A Care Plan, dated 4/8/23, indicated the resident used a psychotropic medication related to behavior management. Interventions, included but were not limited to, observe and report any adverse reactions of psychotropic medications such as unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles, or shaking. An Abnormal Involuntary Movement Scale (AIMS) initial assessment was completed on 3/17/22. A Quarterly AIMS assessment was completed on 2/13/23. Interview with the Assistant Director of Nursing on 4/28/23 at 9:58 a.m., indicated the AIMS should have been completed quarterly. A Policy titled, Area of Focus: Psychotropic Medication Management, indicated .How .Evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms, in order to identify the underlying cause(s), including adverse consequences of medications; (Abnormal Involuntary Movement Scale, AIMS) Assessment tool should be used for all antipsychotic medications . 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from significant medication errors related to the incorrect administration of insulin for 1 of 5 residents observed during medication pass. (Resident 331) Finding includes: During a medication administration observation on 4/28/23 at 10:50 a.m., RN 1 prepared Resident 331's insulin and checked the resident's orders. She dialed the resident's Lispro insulin pen to 2 units. She washed her hands and applied her gloves. She cleaned the resident's right arm and injected the insulin pen into the resident's arm. She had not primed the insulin pen or performed an air shot prior to administering the insulin. Interview with RN 1 on 4/28/23 at 11:04 a.m., indicated she did not know she was supposed to prime the insulin pen prior to administering insulin to the resident. Interview with the DON on 4/28/23 at 11:12 a.m. indicated RN 1 should have primed the insulin pen prior to injecting the resident and she would inservice RN 1. A facility policy titled, Medication Storage and Administration Quick Reference Guide, Insulin Vials and Pens and provided by the DON as current, indicated, . Prime [Air Shot] insulin pens prior to each administration with 2 units or manufacturer's recommendations. Hold the pen with the needle up, tap to move any air bubbles to the top . 3.1-48(c)(2)

Based on observation and interview, the facility failed to ensure medications were properly stored for safety, labeled, and dated for 1 of 1 medication storage rooms observed. (West Wing Medication Storage Room). Finding includes: During a medication storage observation on 4/28/23 at 10:12 a.m., the [NAME] Wing Medication Storage Room was observed with LPN 2. Ativan (2 vials) were found in the refrigerator inside a plastic container. The plastic container did not have a lock on it. The Medication room was locked, however the refrigerator was not locked. Interview Agency LPN 2 and she indicated she thought the plastic zip tie on the container was a lock. 4/28/23 10:18 a.m., the DON indicated the Ativan should have been in a locked box, or the refrigerator should have a lock on it. The pharmacist had told her to put a lock on the refrigerator a while ago. A facility policy titled, Medication Storage and Administration Quick Reference Guide, Medication Cart Security and HIPPA, provided by the DON as current, indicated, . Med storage keys are retained by designated staff. Controlled medications must be stored separately, double locked, permanently affixed compartments . 3.1-25(j) 3.1-25(o)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 4/24/23 at 10:45 a.m., a reddish/purple discoloration was observed on Resident 384's right and left lower hands. On 4/26/23 at 10:34 a.m., the reddish/purple discoloration remained to the resident's right and left lower hands. The record for Resident 384 was reviewed on 4/26/23 at 9:30 a.m. Diagnoses included, but were not limited to, anemia, atrial fibrillation (irregular heart rhythm), heart failure, and hypertension. The admission Minimum Data Set (MDS) assessment, dated 4/18/23, indicated the resident had cognitive impairment. The resident needed limited assistance with 1-person physical assist for bed mobility and transfers. A Physician's Order, dated 4/14/23, indicated the resident received Aspirin 81 milligrams (mg) daily for heart health and clopidogrel bisulfate (Plavix, anti platelet medication) 75 mg daily for heart. A Physician's Order, dated 4/18/23, indicated to monitor for signs and symptoms (s/s) of bleeding: including black tarry stools, bleeding gums, bruising/nosebleed related to anticoagulant use; document every shift. Document a (+) if signs and symptoms were present and (-) if signs and symptoms were not present. The Weekly Skin Observation sheet, dated 4/21/23, indicated the resident's skin was intact and there was no documentation of bruising. There was no documentation on the April 2023 Treatment Administration Record (TAR) related to monitoring for medication side effects. . Interview on 4/26/23 at 10:36 a.m. with Agency LPN 1 regarding the areas on the resident's hands indicated she did not see any orders and she would assess the resident and let the Nurse Practitioner know. Interview on 4/27/23 at 2:37 p.m., with the Assistant Director of Nursing, regarding the resident's bruising indicated she was unaware and had no further information to provide. 3.1-37(a) 3. During an observation on 4/24/23 at 10:21 a.m., Resident 181 was observed sitting in a wheelchair. At that time, she had large bruises observed to the right outer and upper arm. The bruises were dark purple and blue in color. The record for Resident 181 was reviewed on 4/25/23 at 2:30 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to, cirrhosis of the liver, atrial fibrillation, high blood pressure, heart disease, heart failure, and dementia. The admission Minimum Data Set (MDS) assessment was still in progress. A Care Plan, dated 4/24/23, indicated the resident was on anticoagulant therapy. The approaches were to observe for and report adverse reactions such as blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, and bruising. A Nursing admission Assessment, dated 4/18/23, indicated the resident was admitted with right arm-multiple purple/red bruises and left arm-1.3 [cm] centimeters by 1 cm purple/red bruise. There was no other documentation of any other bruising at the time of admission or measurements taken of the other bruises on the right arm. Physician's Orders, dated 4/18/23, indicated Rivaroxaban (an anticoagulant medication) tablet 20 milligrams (mg). Give 1 tablet by mouth in the evening and monitor for signs and symptoms of bleeding, including black tarry stools, bleeding gums, bruising, and nose bleed every shift. Document a (+) if signs and symptoms were present and (-) if signs and symptoms were not present. A Weekly Skin Integrity Data Collection Assessment, dated 4/25/23, indicated the resident's skin was intact and there were no new areas. There was no documentation in Nursing Notes from 4/18/23 to 4/27/23 regarding any bruising to her left or right arms. The 4/2023 Treatment Administration Record (TAR) indicated there was a - sign documented from 4/19-4/27/23, indicating there were no adverse signs or symptoms of anticoagulant use. Interview with the Director of Nursing on 4/27/23 at 10:45 a.m., indicated she had been having trouble with the nursing staff documenting and following up on the bruises after they were identified. The facility's policy was that bruises were to be assessed, measured, and documented on a wound report and then measured and assessed weekly until healed. There were no other measurements or assessments of the bruising after the resident was admitted . 4. During an observation on 4/24/23 at 10:30 a.m., Resident 59 was observed in bed. At that time, there was a large discoloration to the right arm that was dark red in color. The record for Resident 59 was reviewed on 4/26/23 at 9:55 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, chronic kidney disease, dementia, COPD, sleep apnea, and anemia. The admission Minimum Data Set (MDS) assessment, dated 3/28/23, indicated the resident was not cognitively intact. She was an extensive assist with a 2 person physical assist for bed mobility and transfers. She used oxygen while a resident and in the last 7 days, received an anticoagulant medication 6 times. A Care Plan, dated 3/29/23, indicated the resident was on anticoagulant therapy. The approaches were to observe for and report adverse reactions such as blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, and bruising. Physician's Orders, dated 3/22/23, indicated Apixaban (an anticoagulant medication) 5 milligrams (mg). Give 1 tablet by mouth 2 times a day and monitor for signs and symptoms of bleeding, including black tarry stools, bleeding gums, bruising, and nose bleed every shift. Document a (+) if signs and symptoms were present and (-) if signs and symptoms were not present. The Nursing admission Assessment, dated 3/22/23, indicated the resident had bruises in the following areas: right antecubital that measured 2 centimeters (cm) by 2 cm, the right upper forearm that measured 1 cm by 1 cm, the right forearm that measured 2 cm by 4 cm, the left antecubital that measured 1 cm by 0.5 cm, and the back of the left wrist that measured 3 cm by 2.5 cm. The Weekly Skin Integrity Data Collection Assessment, completed on 3/29, 4/5, 4/12, 4/19, and 4/26/23 indicated the resident had no bruising on her body. A Nurses' Note, dated 4/3/23 at 2:42 p.m., indicated a lump was found on the resident's sternum that measured 3 cm by 3 cm. The Nurse Practitioner (NP) was notified and no new orders were obtained. A Nurses' Notes, on 4/4/23 at 3:11 p.m., indicated the resident had no complaints of pain to the lump on her sternum. A Nurses' Note, dated 4/6/23 at 12:30 a.m., indicated upon assessment a large hard mass was observed to the left rib cage just below the left breast that measured 6 cm by 9 cm. A message was left for the NP. The resident denied any pain or discomfort to the area. A Nurses' Note, dated 4/6/23 at 2:05 p.m., indicated masses remained to the sternum and left rib cage area. There was a hard mass to the right rib cage area that measured 5 cm by 7 cm. The NP and the resident's daughter were notified. A NP Progress Note, recorded as a late entry on 4/26/23 at 9:10 p.m., for 4/7/23 at 9:09 p.m., indicated the patient requested a NP visit for complaints of soreness along the chest. She reported the CNA told her she had a bony lump in the center of her chest. The patient reported she begun to feel tenderness at the lump and along the lower anterior rib cage with palpation. A physical exam indicated there were no abnormal bony prominences or masses palpated at the tender areas of ribs and the sternum. It could have possibly been a case of mild barrel chest deformity from COPD. Physician's Orders, dated 4/7/23 at 3:38 p.m., indicated X-ray sternum and bilateral lower anterior rib cage. The X-rays were completed on 4/10/23 and indicated there was no evidence of a fracture. Interview with the Director of Nursing on 4/27/23 at 10:45 a.m., indicated she had been having trouble with the nursing staff documenting and following up on the bruises after they were identified. Bruises were to be assessed, measured, and documented on a wound report and then measured and assessed weekly until healed. There were no other measurements or assessments of the bruising after the resident was admitted . The NP was made aware of the masses, however, she wanted to assess the areas before ordering anything, and she believed she was out of town that week. The NP made a progress note on 4/7/23 and ordered the X-rays. The Physician could have been notified on 4/3/23 instead of the NP and the X-ray could have been completed earlier and before 4/10/23. Based on observation, record review, and interview, the facility failed to ensure skin tears and areas of bruising were assessed, monitored, and treatments were completed as ordered for 4 of 5 residents reviewed for skin conditions non-pressure related and 1 of 2 residents reviewed for anticoagulant (a blood thinner) medication side effects. The facility also failed to ensure an edema glove was in use as ordered for 1 of 1 residents reviewed for edema and treatment was completed timely for 1 of 1 residents reviewed for a change in condition. (Residents 1, 74, 181, 59, and 384) Findings include: 1. On 4/24/23 at 1:46 p.m., Resident 1 was observed in her room in bed. She did not have an edema glove to her right hand. On 4/26/23 at 9:30 a.m., 11:30 a.m., and 1:40 p.m., the resident's edema glove to the right hand was not in use. On 4/27/23 at 9:10 a.m., the resident's edema glove to the right hand was not in use. The record for Resident 1 was reviewed on 4/26/23 at 1:28 p.m. Diagnoses included, but were not limited to, cerebral palsy, profound intellectual disabilities, and disorder of the nose and nasal sinuses. The 3/27/23 Significant Change Minimum Data Set (MDS) assessment indicated the resident was severely impaired for daily decision making. A Care Plan, dated 3/27/23, indicated the resident had an ADL (activities of daily living) self-care performance deficit in bed mobility, dressing/grooming, bathing, transfers, eating, locomotion, and toileting related to her disease process. She required total assist with bed mobility, eating, transfers, and toileting. She also required assist with upper body dressing. Interventions included, but were not limited to, edema glove to her right hand. A Physician's Order, dated 3/27/23, indicated the resident was to have an edema glove to the right hand. The order for the edema glove was not listed on the March and April 2023 Treatment Administration Records (TARs). Interview with the Director of Nursing on 4/27/23 at 1:30 p.m., indicated the resident's edema glove should have been in use. She also indicated the order should have been listed on the TAR. 2. On 4/24/23 at 2:10 p.m., a foam dressing was observed to Resident 74's right elbow. The dressing was dated 4/20/23 and areas of dried blood were observed on the dressing. Multiple areas of reddish/purple discoloration were observed on the resident's right arm and hand. The resident did not have a dressing to his right hand. On 4/25/23 at 9:40 a.m. and 3:15 p.m., the discoloration remained to the resident's right arm and hand. There was no dressing to the resident's right elbow or hand. On 4/26/23 at 9:29 a.m., the discoloration remained to the resident's right arm and hand. There was no dressing to the resident's right elbow or hand. The record for Resident 74 was reviewed on 4/27/23 at 8:58 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, malignant neoplasm of right bronchus of lung, emphysema, and COVID-19. The admission Minimum Data Set (MDS) assessment, dated 3/27/23, indicated the resident was moderately impaired for daily decision making and she required extensive assistance for bed mobility and transfers. The resident was also identified as having skin tears. A Care Plan, dated 3/29/23, indicated the resident was receiving anticoagulant therapy, Apixaban (a blood thinner). Interventions included, but were not limited to, observe for and report as needed (prn) adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. A Physician's Order, dated 3/23/23, indicated the resident was to receive Apixaban 5 milligrams (mg) twice a day for atrial fibrillation (an irregular heart beat). Monitor for signs and symptoms of bleeding, including black tarry stools, bleeding gums, bruising, and nose bleed related to anticoagulant use every shift. Document (+) if signs and symptoms were present and (-) if signs and symptoms were not present. The April 2023 Medication Administration Record (MAR), indicated the resident did not have any signs or symptoms of side effects each shift for the month of April. There were no Physician's Orders to monitor the bruising to the resident's right arm and hand. A Care Plan, dated 4/7/23, indicated the resident had a skin tear to the right hand. Interventions included, but were not limited to, assess location, size and treatment of the skin tear. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to the Physician. There was no Care Plan related to the area to the right elbow. A Physician's Order, dated 4/6/23, indicated to cleanse the area to the right hand with normal saline, pat dry, and cover with a foam dressing every day shift every 3 day(s) for a skin tear. Start on 4/9/23. The April 2024 Treatment Administration Record (TAR), indicated the resident's treatment was signed out as being completed on 4/24/23. A Physician's Order, dated 4/20/23, indicated Bacitracin Plus External Ointment 500 units/gram was to be applied to the right elbow topically every night shift every 3 days. Cleanse the area with normal saline, apply bacitracin, and cover with a foam dressing. The April 2023 TAR, indicated the treatment to the right elbow was signed out as being completed on 4/23 and 4/26/23. The Weekly Skin Integrity Data Collection forms, dated 4/20 and 4/27/23, identified the skin tear to the right elbow. There was no documentation related to the bruising on the right arm and hand. Interview with the Director of Nursing on 4/27/23 at 1:30 p.m., indicated the dressing to the elbow and hand should have been changed as ordered and documentation related to the bruising should have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 4/24/23 at 11:34 a.m., Resident 37 was observed sitting in his wheelchair. An oxygen concentrator was observed next to the resident's wheel chair. The resident's nasal cannula was sitting on the outside of the resident's nose. The resident indicated the cannula would often come off. The oxygen tubing was not connected to the oxygen concentrator and the oxygen concentrator was not turned on. On 4/25/23 at 09:28 a.m., Resident 37 was observed sitting in his wheel chair with the nasal cannula in his nose. The resident was receiving oxygen from his portable oxygen concentrator connected to the back of his wheel chair. The oxygen dial was observed at 1 liter. The record review for Resident 37 was completed on 4/25/23 at 1:42 p.m. Diagnoses included, but were not limited to COPD, respiratory failure, hypertension and hyperlipidemia. The admission Minimum Data Set (MDS) assessment, dated 3/5/23, indicated the resident was moderately cognitively impaired for daily decision making. A Physician's Order, dated 3/2/23, indicated supplemental oxygen via nasal cannula at 5 LPM (liters/minute) continuously per nasal cannula. A Care Plan, dated 3/28/23, indicated the resident was receiving oxygen therapy due to respiratory illness. Interventions included, but were not limited to, observe for signs and symptoms of respiratory distress and report to MD as needed. Nurses' Notes, dated 4/21, 4/22, 4/24 and 4/25/23 indicated the resident's oxygen flow rate was 2 LPM. During an interview on 4/26/23 at 9:17 a.m., Agency LPN 1 indicated she had corrected the oxygen flow rate to 5 LPM. During an interview on 4/27/23 at 2:37 p.m., the ADON indicated she was not aware of the incorrect flow rate. 3. 1-47(a)(6) 4. On 4/24/23 at 10:41 a.m., Resident 69's oxygen concentrator was set to 3 liters per minute and the tubing was dated 4/24/23. On 4/26/23 at 9:22 a.m., Resident 69's oxygen concentrator was set to 3 liters per minute and the tubing was dated 4/24/23. Resident 69's record was reviewed on 4/26/23 at 1:22 p.m. Diagnoses included, but were not limited to, heart disease, chronic obstructive pulmonary disease, end stage renal disease, and type 2 diabetes mellitus. A Significant Change in Status Minimum Data Set (MDS) assessment, dated 3/28/23, indicated the resident was cognitively intact for daily decision making. She used oxygen therapy. A Physician's Order, dated 4/11/23, indicated oxygen at 2 liters per minute continuously via nasal cannula. It could be off for up to 10 minutes for up to 6 times daily for refills. A Care Plan, dated 3/1/23, indicated the resident had oxygen therapy related to a respiratory illness. Interventions included, but were not limited to, oxygen per Physician's Orders. Interview with the Director of Nursing on 4/27/23 at 1:15 p.m., indicated the resident's oxygen concentrator should have been set to 2 liters per minute as per the Physician's Orders. 3. On 4/24/23 at 10:30 a.m., and 2:48 p.m., on 4/25/23 at 9:00 a.m., 2:00 p.m., and 3:10 p.m., and on 4/26/23 at 9:10 a.m., Resident 59 was observed in bed. At those times, she was wearing oxygen at 4 liters per minute. The record for Resident 59 was reviewed on 4/26/23 at 9:55 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, chronic kidney disease, dementia, COPD, sleep apnea, and anemia. The admission Minimum Data Set (MDS) assessment, dated 3/28/23, indicated the resident was not cognitively intact. She was an extensive assist with a 2 person physical assist for bed mobility and transfers. She used oxygen while a resident and in the last 7 days. A Care Plan, dated 3/29/23, indicated the resident had oxygen therapy related to COPD. The approaches were to administer oxygen as ordered. Physician's Orders, dated 3/27/23, indicated oxygen at 3 liters per minute continuously per nasal cannula. Interview with the Assistant Director of Nursing on 4/27/23 at 10:30 a.m., indicated the resident's oxygen should be set at 3 liters per minute. Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and positioned correctly for 5 of 5 residents reviewed for oxygen. (Residents 1, 132, 59, 69, and 37) Findings include: 1. On 4/24/23 at 11:36 a.m. and 1:46 p.m., Resident 1 was observed in her room in bed. Her nasal cannula was not in her nares and her oxygen concentrator was set at 2 liters. On 4/25/23 at 2:09 p.m., the resident's oxygen concentrator was set at below 2 liters. At 3:13 p.m., the resident's oxygen prongs were not in both nares. The oxygen concentrator remained below 2 liters. The record for Resident 1 was reviewed on 4/26/23 at 1:28 p.m. Diagnoses included, but were not limited to, cerebral palsy, profound intellectual disabilities, and disorder of the nose and nasal sinuses. The 3/27/23 Significant Change Minimum Data Set (MDS) assessment indicated the resident was severely impaired for daily decision making and she was receiving oxygen while a resident of the facility. A Care Plan, dated 3/28/23, indicated the resident had oxygen therapy related to respiratory illness. Interventions included, but were not limited to, oxygen per Physician's Order. A Physician's Order, dated 3/27/23, indicated the resident was to receive oxygen at 2 liters per minute continuously per nasal cannula. Interview with the Director of Nursing on 4/27/23 at 1:30 p.m., indicated the resident's oxygen should have been in both nares and the concentrator should have been set at 2 liters. 2. On 4/25/23 at 9:08 a.m., Resident 132 was observed in his room in bed. He was wearing oxygen via nasal cannula and his oxygen concentrator was set at 3 liters. At 1:59 p.m., the resident was seated in his wheelchair and oxygen per nasal cannula was in use. His portable oxygen tank was set at 3 liters. At 3:10 p.m., the resident was in his room sleeping. Oxygen per nasal cannula was in use and his oxygen concentrator was set at 3 liters. The record for Resident 132 was reviewed on 4/25/23 at 2:11 p.m. Diagnoses included, but were not limited to, congestive heart failure, atrial fibrillation (an irregular heart beat), pulmonary edema, and dyspnea (difficulty breathing). The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 4/21/23, was in progress. A Physician's Order, dated 4/17/23, indicated the resident was to receive oxygen at 2 liters continuously per nasal cannula. Interview with the Director of Nursing on 4/27/23 at 1:30 p.m., indicated the oxygen flow rate should have been set at 2 liters.

Based on observation and interview, the facility failed to ensure a sanitary kitchen related to two dishes of food sitting open and not covered on the top of the stove and an accumulation of grease and dried food spillage in and around the stove in 1 of 1 kitchen observed. (Main Kitchen). This had the potential to affect 87 residents who received food from the kitchen. Findings include: During the initial kitchen tour on 4/24/23 at 8:58 a.m. with the Food Service Manager the following was observed: a. Two dishes filled with green beans, carrots and corn were opened and not covered on top of the stove. b. There was accumulation of grease on the stove and on the back splash. c. Inside the oven was a large amount of burnt substances with aluminum foil scattered on the bottom of the oven. d. There was a large accumulation of grease and dry food spillage inside the convection oven. e. There was an accumulation of grease and dust in the slats of the oven hood. f. The pipes in the kitchen had a buildup of grease and dust next to the stove right by the stove top. Interview with the Food Service Manager at that time, indicated all the above areas needed to be cleaned. 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure the kitchen area was clean and in good repair related to dirty floors, cabinets, pipes and walls in 1 of 1 kitchens observed. (Main Kitchen) Findings include: During the initial kitchen tour on 4/24/23 at 8:58 a.m. with the Food Service Manager, the following was observed: a. The floor had a buildup of dirt and debris. b. Dirt was observed on the pipes in kitchen and underneath the dishwasher. c. Dirt was observed underneath the cabinets in the dish room. d. There was an accumulation of dirt and dust on the wall behind the stove. Interview with the Food Service Manager at that time, indicated all the above areas needed to be cleaned. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders and an assessment to self-administer their own medications for 1 of 1 residents reviewed for self-administration of medication. (Resident 8) Finding Includes: On 5/16/22 at 11:44 a.m., a bottle of saline nasal spray solution, a bottle of sore throat spray, and an albuterol inhaler was observed on the bedside stand in Resident 8's room. On 5/17/22 at 3:10 p.m., the bottle of saline nasal spray, a bottle of sore throat spray, and an albuterol inhaler remained on the bedside stand. The record for Resident 8 was reviewed on 5/16/22 at 2:00 p.m. Diagnoses included, but were not limited to, high blood pressure, chronic obstructive pulmonary disease (COPD), and respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 3/1/22, indicated the resident was cognitively intact. A Physician's Order, dated 8/31/21 at 3:30 p.m., indicated albuterol sulfate aerosol solution 1 puff inhale orally every four hours as needed. The resident did not have a Care Plan for self-administering medications, nor did she have a self-administration of medication assessment completed. The May 2022 Physician's Order Summary (POS) indicated the resident did not have an order for the saline nasal spray and sore throat spray. Interview with LPN 1 on 5/17/22 at 3:20 p.m., indicated he was not aware of the resident keeping saline nasal spray or sore throat spray at her bedside stand. Interview with the Director of Nursing on 5/17/22 at 3:23 p.m., indicated the resident should have orders and a self-administration assessment completed for the saline nasal spray solution and sore throat spray. 3.1-11(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The record for Resident E was reviewed on 5/17/22 at 11:48 a.m. Diagnoses included, but were not limited to, non-Alzheimer's dementia, high blood pressure, depression, and chronic lung disease. A Quarterly Minimum Data Set (MDS) assessment, dated 3/22/22, indicated the resident was severely cognitively impaired. Resident E required extensive assistance with one person physical assist for bed mobility, transfers, and toilet use and required a one person physical assist with physical help in part of the bathing activities. A Care Plan, initiated on 3/8/21, indicated the resident had a self-care performance deficit with interventions including, but not limited to, the resident preferred to have showers on Wednesday and Saturday during the day. Shower logs for the months of April and May 2022 indicated the resident did not receive a shower on 4/9/22, 4/13/22, 4/16/22, 4/20/22, 4/23/22, 4/30/22, 5/4/22, 5/11/22, and 5/14/22. Interview with the Director of Nursing (DON) on 5/19/22 at 11:16 a.m., indicated the resident was sent to the hospital on 4/10/22 and since then, he had been feeling down and would often refuse showers. The DON indicated the record lacked any documentation of refusals. This Federal tag relates to Complaint IN00376209. 3.1-38(a)(3)(E) 3.1-38(a)(2)(A) Based on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with ADL's (activities of daily living) related to nail care and bathing for 3 of 3 residents reviewed for ADL's. (Residents D, B and E) Findings include: 1. On 5/17/22 at 3:00 p.m., CNA 3 was asked to remove the bed linens from Resident B so his right arm could be observed. At that time, the residents's right hand was in the shape of a fist and his fingernails were long. The resident's left hand was observed with long and dirty nails. On 5/18/22 10:35 a.m., CNA 1 was observed performing nail care for the resident. The resident's right and left hand nails were long. The left hand nails were dirty as well. She used a wet wash cloth to clean under his left hand nails, in which dark colored debris was removed. She used another wash cloth to clean his right hand. The wash cloth was brown discolored after cleaning the inside of his hand. Interview with CNA 1 at that time, indicated the resident's fingernails were long and in need of trimming. Nail care was to be done as needed. The record for Resident B was reviewed on 05/17/22 at 1:46 p.m. Diagnoses included but were not limited to, stroke, right side hemiplegia, major depressive disorder, paranoid schizophrenia, dysphagia following a stroke, dementia without behaviors, high blood pressure, psychosis, and mental disorders. The Significant Change Minimum Data Set (MDS) assessment, dated 3/3/22, indicated the resident was moderately cognitively impaired, and had no impairment to the upper or lower extremities. The Care Plan, updated on 5/17/22, indicated the resident needed ADL assistance. Interview with the Director of Nursing on 5/18/22 at 11:30 a.m., indicated the resident's fingernails were to be cleaned and trimmed as needed. 2. The closed record for Resident B was reviewed on 5/18/22 at 9:18 a.m. The resident was admitted on [DATE], discharged to the hospital on 2/24/22, readmitted on [DATE], and then discharged again to the hospital on 3/17/22, after which he did not return. Diagnoses included but were not limited to, kidney disease, open wounds to the right and left hands, end stage renal disease, high blood pressure, type 2 diabetes, congestive heart failure, depression, anemia, and atrial fibrillation. A Significant Change Minimum Data Set (MDS) assessment, dated 3/8/22, indicated the resident was cognitively intact and was totally dependent on staff for bathing. A Care Plan, revised on 3/4/22, indicated the resident needed ADL assistance. The approaches were to provide showers on Sunday evenings. Shower sheets indicated the resident was bathed on 1/29, 2/9, and 3/4/22. Computer documentation for ADL's indicated the resident was bathed on 1/26, 2/9, and 3/4/22. There was no Care Plan indicating the resident refused showers or documentation in Nursing Notes the resident refused showers. Interview with the Director of Nursing on 5/19/22 at 11:30 a.m., indicated the resident would not always let staff give him a shower, however, there was no Care Plan or documentation in progress notes of any refusals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an interview with Resident 18 on 5/16/22 at 2:31 p.m., he indicated his right hand had been swollen for a long time. His right hand and fingers were swollen compared to the left hand. The resident also had a atrial/venous fistula (used for dialysis) in his upper right arm. The record for Resident 18 was reviewed on 5/17/22 at 3:15 p.m. Diagnoses included, but were not limited to, heart disease, end stage renal disease, atrial fibrillation, high blood pressure, heart failure, anemia, right and left leg below the knee amputation, type 1 diabetes, and osteoarthritis. The Significant Change Minimum Data Set (MDS) assessment, dated 3/12/22, indicated the resident was cognitively intact and received Insulin for the last 6 days. There was no Care Plan for edema. There was no documentation in Nursing Notes from 5/1-5/17/22 regarding any swelling of the right hand or fingers. Interview with the Director of Nursing (DON) on 5/19/22 at 1:15 p.m., indicated she was unaware of any swelling to the right hand. Interview with the Assistant Director of Nursing (ADON) on 5/19/22 at 1:25 p.m., indicated she just had the NP (Nurse Practitioner) assess his hand and fingers and the resident indicated it was nothing new and it has always been swollen. The NP asked the resident if he had any pain to the hand and the resident stated he did not. The ADON indicated there was no documentation in the clinical record regarding the swelling to the right hand. Interview with the DON at 1:30 p.m., indicated there should have been some type of assessment or documentation regarding the swelling of the right hand. 3.1-37(a) Based on observation, record review, and interview, the facility failed to assess and monitor residents after a change in condition for 1 of 1 residents reviewed for death and 1 of 1 residents reviewed for edema. The facility also failed to ensure preventive measures were in place to prevent skin tears for 1 of 1 residents reviewed for skin conditions (non-pressure related). (Residents 74, 277, and 18) Findings include: 1. The closed record for Resident 74 was reviewed on 5/19/22 at 9:57 a.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, hypertensive heart disease, cardiomegaly, and history of COVID-19. The admission Minimum Data Set (MDS) assessment, dated 1/26/22, indicated the resident was cognitively intact and needed extensive assistance with bed mobility and transfers. On 2/21/22, the resident was sent to the emergency room for chest pain and difficulty breathing. She returned to the facility on 2/25/22. Nurses' Notes, dated 2/26/22 at 3:45 p.m., indicated the resident had oxygen in use at 5 liters and no acute distress was noted. Nurses' Notes, dated 2/26/22 at 6:00 p.m., indicated the resident's respirations were rapid and even, oxygen was in use and her oxygen saturation level was 78%. Her pulse was 110 and she had no complaints regarding any respiratory distress. She responded to questions appropriately and when asked if she wanted to go to the hospital she said she was okay. The next entry at 10:28 p.m., indicated no rise and fall of the chest was noted and vital signs were absent. The resident's Physician and family were notified. Interview with the Director of Nursing on 5/19/22 at 2:20 p.m., indicated a follow up assessment should have been completed prior to 4 1/2 hours after the documented change in condition. 2. On 5/16/22 at 2:45 p.m., Resident 277 was observed in her wheelchair in her room. She had a gauze dressing to her left lower leg and no padding was noted on her wheelchair leg. On 5/17/22 at 1:52 p.m. and 3:04 p.m., no padding was observed to the resident's wheelchair leg. On 5/18/22 at 11:34 a.m., the resident was observed in her room in her wheelchair. There was no padding to the resident's wheelchair leg. The record for Resident 277 was reviewed on 5/17/22 at 2:25 p.m. Diagnoses included, but were not limited to, surgical aftercare following surgery of the digestive system, chronic obstructive pulmonary disease, and emphysema. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 5/16/22 was in progress. The resident required extensive assistance with bed mobility and transfers. An Event Note, dated 5/11/22 at 11:41 a.m., indicated the resident was being transferred from the bed to her wheelchair. An open area to the left lateral leg was noted, 5 centimeters (cm) x 2 cm triangle shape. The area was cleansed and a dry dressing was applied. A Physician's Order, dated 5/12/22, indicated the resident's left lateral leg was to be cleansed daily with wound wash, a mediplex dressing was to be applied, the area was to be covered with an abd pad and wrapped with kerlix daily. Special instructions on the May 2022 Physician's Order Summary (POS), indicated the left lower post of the resident's wheelchair was to be padded. The Care Plan, dated 5/12/22, indicated the resident had a break in skin integrity related to a wound to the left lateral leg. Interventions included, but were not limited to, treatment as ordered and weekly skin checks. Interview with the Assistant Director of Nursing on 5/19/22 at 12:15 p.m., indicated she had padded the wheelchair leg herself at the time of the occurrence. She also indicated the padding must have been removed when the wheelchair was cleaned and not reapplied.

Based on observation, record review, and interview, the facility failed to provide treatment for limited range of motion related to a hand splint not in place for 1 of 2 residents reviewed for range of motion. (Resident D) Finding includes: On 5/17/22 at 10:45 a.m. and 3:00 p.m., Resident D was observed in bed. At those times, his right hand was in the shape of a fist and there was no hand splint noted. On 5/18/22 at 10:03 a.m., the resident was receiving a.m. care by staff. His right hand was in the shape of a fist and there was no hand splint noted. On 5/18/22 at 1:30 p.m., the resident was observed in bed. At that time, his right hand was in the shape of a fist and there was no hand splint noted. On 5/19/22 at 8:40 a.m., and 10:38 a.m., the resident was observed in bed. At those times, his right hand was in the shape of a fist and there was no hand splint noted. The record for Resident D was reviewed on 5/17/22 at 1:46 p.m. Diagnoses included but were not limited to, stroke, right side hemiplegia, major depressive disorder, paranoid schizophrenia, dysphagia following a stroke, dementia without behaviors, high blood pressure, psychosis, and mental disorders. The Significant Change Minimum Data Set (MDS) assessment, dated 3/3/22, indicated the resident was moderately cognitively impaired, and had no impairment to the upper or lower extremities. The Care Plan, updated on 5/17/22, indicated the resident needed ADL assistance and therapy services. The Nursing approaches were to provide adaptive/safety equipment and educate on use. Resting hand splint when out of bed. Physician's Orders, dated 9/18/20 and on the current 5/2022 Order Summary, indicated resting hand splint to right hand/wrist when out of bed. May remove for care. Interview with the Director of Nursing on 5/19/22 at 11:30 a.m., indicated the resident may get out of bed once or twice a week, but had not been up lately. The hand splint was to be applied when out of bed, however, the order needed to be changed if the resident was no longer getting up every day. 3.1-42(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure oxygen was being administered as ordered for 1 of 1 residents reviewed for oxygen. (Resident 277) Finding includes: On 5/16/22 at 2:45 p.m., Resident 277 was in her room seated in her wheelchair. The resident had oxygen by the way of a nasal cannula in use. The oxygen concentrator was set at 2 liters. On 5/17/22 at 9:30 a.m., the resident's oxygen was in use. At 10:30 a.m., the resident's oxygen was switched to a portable tank for therapy. At 1:52 p.m. and 3:04 p.m., the resident was in bed sleeping with the oxygen in use. On 5/18/22 at 11:34 a.m. and 1:45 p.m., the resident's oxygen was in use and the oxygen concentrator was set at 2 liters. The record for Resident 277 was reviewed on 5/17/22 at 2:25 p.m. Diagnoses included, but were not limited to, surgical aftercare following surgery of the digestive system, chronic obstructive pulmonary disease, and emphysema. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 5/16/22, was in progress. A Physician's Order, dated 5/13/22, indicated the resident was to have oxygen at 2 liters per minute per nasal cannula as needed (prn). The resident's oxygen saturation level was to be checked every shift and staff could titrate to keep above 90% The May 2022 Medication Administration Record (MAR), indicated the prn oxygen had not been signed out as being used 5/13 thru 5/19/22. Interview with the Director of Nursing on 5/19/22 at 2:20 p.m., indicated a clarification order would be obtained. An updated Physician's Order, dated 5/19/22, indicated the resident was to receive oxygen 2 liters per nasal cannula each shift. 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure a CNA did not provide care outside of the scope of practice related to placing tube feedings on hold and turning on tube feeding pumps for 1 of 1 residents reviewed for tube feeding. (Resident B) Finding includes: On 5/18/22 at 10:03 a.m., CNA 1 and CNA 2 were observed providing a.m. care for Resident B. The resident was connected to a tube feeding pump, however, the pump indicated the enteral feeding was on hold. At 10:15 a.m., the tube feeding pump started to beep. CNA 2 pushed the hold button and the machine stopped beeping. At 10:25 a.m., the pump started to beep again, CNA 1 placed the tube feeding on hold by pushing the button. The CNA had finished most of the care and rolled the resident's head of the bed up and repositioned him. She then started to clean and cut his fingernails. The pump begun beeping again at 10:35 a.m., the CNA was in the middle of care and let the pump beep. At 10:39 a.m., CNA 1 indicated since his head was up, she was going to turn the enteral feeding back on. The pump indicated the enteral feeding was now infusing. Interview with CNA 1 at 10:45 a.m., indicated she normally put the tube feeding on hold for care. When she finished with care, she pressed the start button and feeding was resumed. She was unaware she was not supposed to manage feeding pumps and it was out of her scope of practice. The record for Resident B was reviewed on 05/17/22 at 1:46 p.m. Diagnoses included but were not limited to, stroke, right side hemiplegia, major depressive disorder, paranoid schizophrenia, dysphagia following a stroke, dementia without behaviors, high blood pressure, psychosis, and mental disorders. The Significant Change Minimum Data Set (MDS) assessment, dated 3/3/22, indicated the resident was moderately cognitively impaired, and had no impairment to the upper or lower extremities. Physician's Orders, dated 1/27/22, indicated Enteral Feed Jevity 1.5 at 75 milliliters per hour times 20 hours. Interview with the Director of Nursing on 5/18/22 at 11:30 a.m., indicated CNAs were not to turn enteral feedings on, off or place enteral feedings on hold. 3.1-35(g)(2)

Based on record review and interview, the facility failed to ensure insulin was administered as ordered by the Physician for 2 of 2 residents reviewed for insulin dependent diabetes mellitus. (Residents 9 and 18) Findings include: 1. The record for Resident 9 was reviewed on 5/18/22 at 3:00 p.m. Diagnoses included, but were not limited to, type 2 diabetes, acute kidney failure, and chronic kidney disease. The Quarterly Minimum Data Set (MDS) assessment, dated 3/2/22, indicated the resident was cognitively intact and received insulin in the last 7 days. Physician's Orders, dated 7/7/21, indicated Novolog insulin flex pen. Inject 15 units subcutaneously before meals. Physician's Orders, dated 7/19/21, indicated the resident received dialysis every Monday, Wednesday and Fridays with a 10:30 a.m. chair time. Physician's Orders, dated 3/10/22, indicated Basaglar KwikPen Solution Pen-injector (Glargine) 100 units per milliliter. Inject 36 unit subcutaneously one time a day. The Medication Administration Record (MAR) for 4/2022 indicated the insulin scheduled for 11 a.m. was not signed out on dialysis days of 4/1, 4/4, 4/5 4/6, 4/8. 4/11, 4/13, 4/16, 4/18, 4/20, 4/22, 4/25, 4/27 and 4/29/22. All of the above days were coded with a 5 meaning the resident was absent from the facility. The MAR for 5/2022 indicated the insulin scheduled for 11 a.m. was not signed out on dialysis days of 5/2, 5/4, 5/6, 5/9, 5/11, 5/13, 5/16 and 5/18/22. All of the above days were coded with a 5 meaning the resident was absent from the facility. Interview with the Director of Nursing on 5/19/22 at 1:30 p.m., indicated the resident was out of the building at dialysis on Mondays, Wednesdays, and Fridays during the time when the 11:00 a.m. insulin was scheduled. 2. The record for Resident 18 was reviewed on 5/17/22 at 3:15 p.m. Diagnoses included, but were not limited to, heart disease, end stage renal disease, atrial fibrillation, high blood pressure, heart failure, anemia, right and left leg below the knee amputation, type 1 diabetes, and osteoarthritis. The Significant Change Minimum Data Set (MDS) assessment, dated 3/12/22, indicated the resident was cognitively intact and received Insulin in the last 6 days. Physician's Orders on the current 5/2022 order statement indicated the resident received dialysis on Mondays, Wednesdays and Fridays. Physician's Orders, dated 3/5/22, indicated Insulin Lispro Solution: Inject as per sliding scale: if 150 - 179 = 1U (unit); 180 - 209 = 2U; 210 - 239 = 3U; 240 - 269 = 4U; 270 - 299 = 5U; 300 - 329 = 6U; 330 - 359 = 7U; 360 - 400 = 8U, subcutaneously before meals for diabetes. If blood sugar over 400 give 9U and notify doctor. The Medication Administration Record (MAR) for 4/2022, indicated a 5 was coded in the box for 4/16 and 4/23/22 at 11:00 a.m. The number 5 indicated the resident was absent from the building. The MAR for 5/2022, indicated a 5 was coded for the 11:00 a.m. insulin on 5/4, 5/16 and 5/18/22 Interview with the Director of Nursing on 5/19/22 at 1:15 p.m., indicated the resident went to dialysis on Mondays, Wednesdays, and Fridays and he did have an insulin order for sliding scale insulin before meals. 3.1-48(a)(6)

Based on observation, record review, and interview, the facility failed to ensure a resident was free from significant medication errors related to the incorrect administration of insulin for 1 of 6 residents observed during medication pass. (Resident 18) Finding includes: On 5/18/22 at 4:00 p.m., LPN 2 was observed preparing Insulin for Resident 18. She removed an insulin pen from the medication cart. She placed a disposable needle on the pen and dialed it to 1 unit. She entered the resident's room and he indicated he would like it in his arm. She wiped his arm with an alcohol wipe and administered the insulin. The LPN did not prime the needle prior to administration. Interview with LPN 2 on 05/18/22 at 4:19 p.m. indicated she was aware the insulin pen should have been primed prior to use with either 1.5 or 2 units of insulin. Interview with the Director of Nursing (DON) on 5/19/22 at 1:20 p.m., indicated most of the floor nurses were unaware the insulin pen needed to be primed prior to use. The current 2021 Guidance for Using Insulin Products policy, provided by the DON, indicated To minimize air bubbles in pen-like devices prime the pen prior to use each and every injection by pushing 2 units into the air until a drop of insulin is seen at the top of the needle. 3.1-48(c)(2)