**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure room temperatures were at the appropriate temperatures on the Behavior Unit (BHU). This deficient practice had the potential to affect 27 of 27 residents residing on the BHU. Finding includes: During an observation on the Behavior Unit on 12/20/2024 at 9:40 A.M., with the Maintenance Director the following ambient air temperature readings were obtained utilizing the facility's laser thermometer inside resident room, pointed at the following walls: Rm. 400--the inside wall temperature was 63 degrees Fahrenheit, and the outside wall temperature was 64 degrees Fahrenheit. Rm. 401--the inside wall temperature was 66 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 402--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 403--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 404--the inside wall temperature was 69 degrees Fahrenheit, and the out side wall temperature was 64 degrees Fahrenheit. Rm. 405--the inside wall temperature was 71 degrees Fahrenheit, and the out side wall temperature was 67 degrees Fahrenheit. Rm. 406--the inside wall temperature was 69 degrees Fahrenheit, and the out side wall temperature was 64 degrees Fahrenheit. Rm. 407--the inside wall temperature was 71 degrees Fahrenheit, and the out side wall temperature was 67 degrees Fahrenheit. Rm. 408--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 409--the inside wall temperature was 69 degrees Fahrenheit and the out side wall temperature was 64 degrees Fahrenheit. Rm. 410--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 411--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. There were 2 blankets rolled up along and placed on the window ledge. The resident was observed to have blankets on his lap. Rm. 412--the inside wall temperature was 68 degrees Fahrenheit, and the out side wall temperature was 64 degrees Fahrenheit. Rm. 413--the inside wall temperature was 63 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 414--the inside wall temperature was 63 degrees Fahrenheit, and the out side wall temperature was 58 degrees Fahrenheit. The resident was observed wrapped in a blanket sleeping. In the common area behind the nursing station and outside of resident rooms 405, 406 and 407, the ambient air temperatures registered 70 and 71 degrees Fahrenheit. During an observation of the [NAME] unit, on 12/202024 at 10:57 A.M with the Maintenance Director., the following ambient air temperature readings were obtained utilizing the facility's laser thermometer inside resident rooms, pointed at the following walls Rm. 400--the inside wall temperature was 64 degrees Fahrenheit, and the outside wall temperature was 64 degrees Fahrenheit. Rm. 401--the inside wall temperature was 65 degrees Fahrenheit, and the out side wall temperature was 61 degrees Fahrenheit. Rm. 402--the inside wall temperature was 66 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 403--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 68 degrees Fahrenheit. Rm. 404--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 405--the inside wall temperature was 70 degrees Fahrenheit, and the out side wall temperature was 66 degrees Fahrenheit. Rm. 406--the inside wall temperature was 68 degrees Fahrenheit, and the out side wall temperature was 66 degrees Fahrenheit. Rm. 407--the inside wall temperature was 69 degrees Fahrenheit, and the out side wall temperature was 67 degrees Fahrenheit. Rm. 408--the inside wall temperature was 69 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 409--the inside wall temperature was 67degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 410--the inside wall temperature was 66 degrees Fahrenheit, and the out side wall temperature was 64 degrees Fahrenheit. Rm. 411--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 412--the inside wall temperature was 65 degrees Fahrenheit, and the out side wall temperature was 61 degrees Fahrenheit. Rm. 413--the inside wall temperature was 66 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 414--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 68 degrees Fahrenheit. During an interview, on 12/20/2024 at 10:00 A.M., the Maintenance Director indicated that someone must had shut off one of the facility's boilers and that was the reason why the temperatures were too cool. He indicated the previous maintenance director had shown some of the nurses how to turn off the boiler He indicated the nurses would go outside the facility to the garage door, put in the code to open the garage door, go in and turn off the boiler using the toggle switch. No reason was given as to why the nursing staff would have turned off one of the boilers. During an interview, on 12/20/2024 at 10:04 A.M., QMA 2 indicated she could not control the temperature in the building as there was no thermostat. She indicated no residents had complained to her of being too cold on the unit. She indicated the residents usually wore sweaters to stay warm. During an interview, on 12/20/2024 at 10:10 A.M., the Maintenance Director indicated there were no thermostats in the facility. He indicated someone had shut the boiler off and he had turned it back on earlier in the morning. He indicated once the boiler was activated, the temperatures in the resident rooms would rise. During an interview, on 12/20/2024 at 10:18 A.M., Resident B, a resident on the BHU, indicated it was colder at night time and she used two blankets. She indicated her room was cold at times. During an interview, on 12/20/2024 at 10:37 A.M., Resident C was observed wearing the following clothing:: a t-shirt, a long sleeve flannel shirt and 2 fleece blankets folded over on his lap and extending down to his legs. Resident C indicated it got too cold in his room. He indicated he had a thermometer in his room and stated it was current reading 70 degrees. Resident C indicated the staff had placed towels on the window ledge because there was cold air coming in around the window blowing on him when he was in bed. He indicated the cold was like a fan going- it was cold. Resident C indicated he used to have a room on the other side of the unit and that room was too cold too When asked if he had informed any of the staff about the cold air temperature, Resident C indicated yes, the nurse especially. He indicated staff would come in his room and state boy it's cold in here. During an interview, on 12/20/2024 at 10:45 A.M., Resident E indicated he liked it cool and would put on extra clothes when it got too cold in his room. During an interview, on 12/20/2024 at 10:28 A.M., CNA 3 indicated since the facility had gotten the boiler fixed, it did not get very cold on the unit. During an interview, on 12/20/2024 at 10:20 A.M., the Maintenance Director indicated he completed temperature checks throughout the facility weekly, but had not completed the checks every week. The Maintenance Director provided a binder of papers titled, Building Temperatures that indicated the following: A building temperature log sheet, dated 10/17/2025, indicated: no temperatures were documented for rooms 400, 406, 408, 410. The air vent temperature by room [ROOM NUMBER] was documented at 68.4 degrees Fahrenheit and the air vent temperature by room [ROOM NUMBER] was documented 68.1 degrees Fahrenheit. A building temperature log sheet, dated 10/25/2024, indicated: there were no temperatures documented for rooms: 406, 408 and 414. The air vent temperature by room [ROOM NUMBER] was 68.6 degrees Fahrenheit and the air vent temperature by room [ROOM NUMBER] was 68.4 degrees degrees Fahrenheit. A building temperature log sheet, dated 11/1/2024, indicated: there were no temperatures documented for rooms: 400, 410, and 414. The air vent temperature by room [ROOM NUMBER] was blank and the air vent temperature by room [ROOM NUMBER] was 74.6 degrees Fahrenheit A building temperature log sheet, dated 11/8/2024, indicated: there were no temperatures documented for rooms: 400, 406, 408, and 410. The air vent temperatures by rooms [ROOM NUMBERS] were blank. A building temperature log sheet, dated 11/15/2024, indicated: there were no temperatures documented for rooms: 406, 408, 410, and 414. The air vent temperatures by rooms [ROOM NUMBERS] were blank. A building temperature log sheet, dated 11/20/2024, indicated: there were no temperatures documented for rooms: 400, 406, 408 and 410. The air vent temperatures by rooms [ROOM NUMBERS] were blank. A building temperature log sheet, dated 12/10/2024, indicated: there were no temperatures documented for rooms: 406, 408, 410 and 414. The air vent temperatures by rooms [ROOM NUMBERS] were blank. During an interview, on 12/20/2024 at 11:55 A.M., the Administrator indicated the facility had not been without heat and the boiler was never broken. She indicated there were some gauges that needed to be be replaced on the boiler, but it was still functional. A policy was requested, on 12/20/2024 at 11:58 A.M., related to monitoring of resident room temperatures. On 12/20/2024 at 12:00 P.M., the Administrator indicated the facility had no policy regarding the monitoring of resident room temperatures. This citation relates to Complaints IN00448692 and IN00448302. 3.1-19(h)

Based on observation, record review and interview, the facility failed to ensure care plans related to respiratory status were revised for 1 of 25 residents reviewed. (Resident 7) Finding includes: During an observation, on 10/21/2024 at 10:54 A.M., Resident 7 was receiving 2 liters (L) of oxygen via a nasal cannula (NC). During an observation, on 10/22/24 at 9:54 A.M., Resident 7 was receiving 2L of oxygen via a NC. During an observation, on 10/23/2024 at 1:57 P.M., Resident 7 was receiving 2L of oxygen via a NC. The medical record for Resident 7 was reviewed on 10/23/2024 at 11:55 A.M. Diagnoses included, but were not limited to: delusional disorder, diabetes mellitus, peripheral vascular disease, obstructive sleep apnea, heart failure, acquired absence of left leg below knee, hypertension, depression, anxiety, chronic obstructive pulmonary disease and history of transient ischemic accident and cerebrovascular accident. There was no physician's order for the use of oxygen for Resident 7. During an interview, on 10/24/2024 at 9:51 A.M. with the Director of Nursing, she indicated a physician's order was not required because the oxygen use was a nursing measure. She indicated she was unaware of Resident 7's oxygen use and did not know how long the resident had been receiving oxygen. A Quarterly Minimum Data Set (MDS) assessment, dated 8/5/2024, indicated Resident 7 had a diagnosis of chronic obstructive pulmonary disease and had not received oxygen therapy. Resident 7's current Care Plan, dated 8/5/2024, lacked documentation including oxygen therapy as a current intervention for the resident. During an interview, on 10/25/2024 at 9:44 A.M., LPN 4 indicated Resident 7's care plan should have been updated to include oxygen therapy. On 10/25/2024 at 2:55 P.M., the Director of Nursing provided a policy titled, Comprehensive Care Plan, dated 11/17/2017 and indicated the policy was the one currently used by the facility. The policy indicated, .the care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving . 3.1-35(d)(2)(B)

Deficiency Text Not Available

Based on observation, record review and interview, the facility failed to provide splinting to prevent further contractures of a resident's upper extremity for 1 of 3 residents reviewed for mobility. (Resident 18) Finding includes: During an observation, on 10/21/2024 at 11:06 A.M., Resident 18 was unable to move her right hand, which was partially closed with contractures (shortening of muscles, tendons, skin and nearby soft tissues that causes the joints to shorten and become very stiff preventing normal movement). During an interview, on 10/21/2024 at 11:07 A.M., Resident 18 indicated the staff were supposed to stretch her hand, but they did not do it. A record review for Resident 18 was completed on 10/23/2024 at 10:23 A.M. Diagnoses include but were not limited to: Hemiplegia and hemiparesis, Lung and Brain Cancer, depression and anxiety. An admission Restorative Observation Form, dated 7/30/2023, indicated Resident 18 had no existing contractures or limited Range of Motion (ROM). A Care Plan, initiated 7/31/2023 and revised on 6/28/2024, indicated Resident 18 had an ADL (activity of daily living) self-care performance and functional mobility deficit related to flaccid (limp) right side due to an old stroke. Interventions initiated on 7/31/24 included: The resident has a contracture of the right hand and wrist: Provide skin care daily as ordered to keep clean and prevent skin breakdown; keep hand roll in palm of hand. A Restorative Observation Form, dated 10/31/2023, indicated Resident 18 had an existing contracture or limited ROM of the right wrist at 75 percent of normal mobility and the right hand/fingers at 75 percent of normal mobility. A Restorative Observation Form, dated 2/2/2024, indicated Resident 18 had no existing contractures or limited ROM. A Restorative Observation Form, dated 5/2/2024, indicated Resident 18 had an existing contracture or limited ROM. The right wrist, hand and fingers were now fixed with no mobility. The form indicated Resident 18 was not receiving any restorative programs. During an interview, on 10/23/2024 at 11:07 A.M., Resident 18 was asked if staff had been stretching or putting anything in her hand. She indicated they had not stretched her hand nor placed anything in her hands. Resident 18 was observed with nothing in her right hand nor was she wearing a splint to her right hand. A Hospice Nurse's Visit Note, dated 11/14/2023, indicated the following: .nurse delivered to patient. The writer placed brace on patient's right hand/wrist. Patient noted brace felt good. Updated facility SN of brace. A Hospice Nurse Visit Note, dated 2/19/2024, indicated the following: Patient has her sling on her right shoulder and brace on her right wrist. Patient reports these two items are helping her shoulder and wrist to not hurt so much . The Hospice Social Worker note, dated 12/6/2023, indicated the following: Patient voicing desire to have a brace that keeps her hand straight with goal of retaining use of right arm. Patient currently has hand piece to prevent further contraction of right hand.'' A Hospice Care Plan, dated 10/24/24 at 1:56 P.M., indicated: DME/assistive device needs. Interventions included, but were not limited to: 5 hand/wrist brace start 11/14/2023. During an interview, on 10/24/2024 at 2:04 P.M., CNA 14 indicated Resident 18 had a contracture to her right hand and there should have been a hand pillow (small pillow with a strap that goes over the back of her hand) in her right hand. CNA 14 indicated staff completed basic ROM (Range of Motion) while providing routine care. During an observation, on 10/24/2024 at 2:10 P.M., Resident 18 was in bed with no device in her right hand. During an interview, on 10/24/2024 at 2:11 P.M., Resident 18 indicated she did not have a pillow in her hand and she did not know where it was but she knew she was supposed to be wearing something in her hand. During an interview, on 10/24/2024 at 2:10 P.M., the Director of Rehabilitation indicated Resident 18 had transitioned into hospice care once she was admitted and therapy had not worked with her. During an interview, on 10/25/2024 at 12:05 P.M., LPN 13 indicated Resident 18 had contractures identified on the Restorative Assessment of minimal impairment completed on 10/31/2023. In addition, the May 2024 assessment had identified the resident's right hand contratures as fixed/no mobility. LPN 13 indicated Resident 13 was on no formal ROM or restorative program and staff completed basic ROM with routine care. During an interview, on 10/25/2024 at 2:10 P.M., the Corporate Nurse indicated the facility did not have a formal restorative program and they did not have a policy speciic to contracure prevention. 3.1-42(a)(2)

Based on interview and record review, the facility failed to check gastric residual volumes (GRV) and contact the resident's physician as ordered for 1 of 1 resident reviewed for tube feedings. (Resident 3) Finding includes: A record review for Resident 3 was completed on 10/22/2024 at 1:30 P.M. Diagnoses included, but were not limited to: Schizoaffective disorder, non-Alzheimer dementia, malnutrition, Bi-polar, autism, and dysphagia. A Quarterly Minimum Data Set (MDS) assessment, dated 9/19/2024, indicated Resident 3 received a mechanically altered diet and had a feeding tube. Resident 3's Physician Order's regarding the feeding tube included: Jevity1.5 of 300 ml (milliliter) bolus (single large dose given at once) four times a day, and a 240 ml bolus at bedtime with 175 mls of water before and after each bolus. Check residuals before beginning the feedings and before medication administration. If the residuals amounts are greater than 100 ml, hold the feedings and recheck in 1 hour. If not resolved, call the physician. A Care Plan, initiated on 8/22/2024, indicated Resident 3 received enteral feeding related to dysphagia, poor oral intake: combine feedings and oral intake for pleasure foods. Interventions included but were not limited to: the resident is dependent with tube feeding and water flushes; check for tube placement and gastric contents/residual volume per facility protocol and record; and hold feedings as ordered. The Medication Administration Record (MAR), dated October 2024, indicated Resident 3's residual checks were only documented twice daily. In addition, there were documented residuals over 100 mls with no documentation to support the feedings had been held and/or the physician had been notified. During an interview, on 10/23/2024 at 2:50 P.M., LPN 5 indicated nursing staff should be checking residuals 5 times a day and if the residual was over 100 mls, they should be holding the feeding, based on the physician orders. The current facility policy, titled Transcription of Physician Orders-Procedure, dated 11/3/2022, was provided by the Director of Nursing on 10/23/2024 at 3:33 P.M., and indicated the policy was the one currently used by the facility. The policy indicated . 2. To document and give clear indication that physician orders have been processed and action taken 3.1-44(a)(2)

Based on observation, interview and record review, the facility failed to ensure proper labeling and storage of respiratory equipment and provide necessary respiratory services according to physician orders for 2 of 2 residents reviewed for respiratory care. (Residents 7 and 238) Findings included: 1. During an observation, on 10/21/2024 at 10:54 A.M., Resident 7 was receiving 2 liters (L) of oxygen via nasal cannula (NC) and the resident's oxygen tubing was undated and without a bag. During an observation, on 10/22/24 at 9:54 A.M., Resident 7 was receiving 2L oxygen via NC and oxygen tubing was undated and without a bag. During an observation, on 10/23/2024 at 1:57 P.M., Resident 7 was receiving 2L oxygen via NC and oxygen tubing was undated and without a bag. The medical record for Resident 7 was reviewed on 10/23/2024 at 11:55 A.M. Diagnoses included but were not limited to: delusional disorder, diabetes mellitus, peripheral vascular disease, obstructive sleep apnea, heart failure, acquired absence of left leg below knee, hypertension, depression, anxiety, chronic obstructive pulmonary disease and history of transient ischemic accident and cerebrovascular accident. A Quarterly Minimum Data Set (MDS) assessment, dated 8/5/2024, indicated Resident 7 had a diagnosis of chronic obstructive pulmonary disease and did not receive oxygen therapy. 2. During an observation, on 10/22/2024 at 9:30 A.M., Resident 238's oxygen tubing was without date or bag and the humidification bottle was undated. During an observation, on 10/23/2024 at 9:37 A.M., Resident 238's oxygen tubing was without a bag and the tubing and the humidification bottle were undated. During an observation, on 10/24/2024 at 11:21 A.M., Resident 238's oxygen tubing was without a bag and was undated and there was no date on the humidification bottle. The medical record for Resident 238 was reviewed on 10/22/2024 at 2:12 P.M. Diagnoses included but were not limited to: fracture of the left fibula, acute and chronic respiratory failure, hemiparesis and hemiplegia following cerebrovascular accident, chronic obstructive pulmonary disease, nontraumatic subdural hemorrhage, morbid obesity, chronic kidney disease, atrioventricular block, bipolar disease, dependence on wheelchair, pacemaker and celiac disease. An admission MDS assessment, dated 10/10/2024, indicated the resident was receiving oxygen therapy. Resident 238's current Physician Orders included, but were not limited to: change out, date, and label oxygen humidifier 500cc and oxygen tubing every Sunday - every night shift every Sunday when in use. During an interview, on 10/23/2024 at 2:50 P.M., LPN 2 indicated both the oxygen tubing and the humidification bottle should be changed and dated every Sunday night. During an interview, on 10/24/2024 at 9:51 A.M., the Director of Nursing (DON) indicated all oxygen tubing should be stored in a bag that was dated but the humidification bottles did not need to be dated. On 10/24/2024 at 10:25 A.M., the Director of Nursing provided a policy titled, Oxygen and Respiratory Equipment: Changing/Cleaning, dated 1/17/2019 and indicated the policy was the one currently used by the facility. The policy indicated, .nasal cannulas are to be changed once a week and as needed .a clean plastic bag .will be provided to store the cannula when it is not in use. It will be dated with the date the tubing is changed . 3.1-47(a)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to transcribe and administer ordered comfort medications for 1 of 1 resident reviewed for hospice services. (Resident B) and failed to ensure controlled narcotics were reconciled, counted and documented every shift for 2 of 3 narcotic count log books reviewed. ([NAME] Terrace & Behavioral Unit) Findings include: 1. A record review for Resident B was completed, on 10/22/2024 at 1:44 P.M. Diagnoses included, but were not limited to: pneumonia, chronic obstructive pulmonary disease (COPD), acute respiratory failure and generalized anxiety. A Nursing Progress Note, dated 10/10/2024 at 3:50 P.M., indicated Resident B was admitted to Hospice services with a diagnosis of senile degeneration of the brain. He was prescribed hydrocodone (pain medication) 5-325 milligrams every six hours as needed and lorazepam (antianxiety medication) 0.5 milligrams every six hours as needed for anxiety/agitation. A Nursing Progress Note, dated 10/12/2024 at 4:11 P.M., indicated Resident B had audible gurgling with secretions/mucus. The nurse had attempted multiple attempts to suction Resident B to ensure a clear airway, but Resident B started screaming, No and placed his hands over his mouth, not allowing the nurse to perform suctioning. A Nursing Progress Note, dated 10/12/2024 at 2:13 P.M., indicated the nurse called the Hospice company to determine if a Hospice nurse would come to the facility due to Resident B refusing to be suctioned. The Hospice company indicated a nurse would come to the facility later in the day to assess and provide care for Resident B. A Nursing Progress Note, dated 10/12/2024 at 4:05 P.M., indicated the Hospice nurse had arrived at the facility and assessed Resident B. The Hospice nurse ordered hyoscyamine tablets to help with Resident B's secretions. The hospice nurse evaluated Resident B, noting his respirations were increased, labored and had periods of apnea (temporary cessation of breathing). A Hospice Nursing Note, dated 10/12/2024 at 5:46 P.M., indicated LPN 6 was instructed to administer Tylenol and to administer hyoscyamine for excess secretions once the medication was delivered. LPN 6 had voiced understanding. A Nursing Progress Note, dated 10/16/2024 at 12:48 A.M., indicated Resident B required suctioning to remove excess secretions. His respirations were even, but elevated to 28 breaths per minute. A Nursing Progress Note, dated 10/16/2024 at 2:20 A.M., indicated Resident B required suctioning to remove excess secretions. A Nursing Progress Note, dated 10/18/2024 at 12:31 P.M., indicated the Hospice nurse came to the facility and assessed Resident B. The Hospice nurse indicated Resident B's respirations were 32 breaths per minute, his oxygen saturation was 56 percent on room air and Resident B appeared uncomfortable. The Hospice nurse indicated Resident B needed Morphine (a narcotic pain medication). The Hospice nurse left an order for the Morphine and indicated a prescription would be sent to the pharmacy for the Morphine medication, 0.25 milliliters every three hours as needed for dyspnea and pain. A Hospice Nursing Note, dated 10/18/2024 at 4:59 P.M., indicated an order was provided to LPN 6 for Morphine as needed for Resident B and LPN 6 was encouraged to administer the Morphine as soon as possible. LPN 6 had verbalized understanding. A Care Plan, dated 10/10/2024 and revised on 10/22/2024, indicated Resident B has a terminal condition and was under hospice care. The Care Plan goal was to be free from unrelenting pain and discomfort. Interventions included, but were not limited to: -Maintain good communication with hospice. -Notify the physician and hospice if pain or discomfort was not alleviated by current medication or treatment regimen. -Notify the physician and then hospice for a change in condition. -Observe for signs and symptoms of pain or discomfort, such as facial grimacing, complaints of pain, moaning or restless movements and promptly treat per order. A Care Plan, dated 8/9/2024 and revised on 10/24/2024, indicated Resident B was on pain medication therapy related to impaired mobility, frail condition, shortness of breath and pain. The goal was for Resident B to be free of any discomfort or adverse side effects from the pain medication. Interventions included, but were not limited to: -Administer analgesic medications as ordered by the physician. Monitor/document side effects and effectiveness every shift. -Review for pain medication efficacy. Assess whether pain intensity is acceptable to resident. Review of the October MAR (Medication Administration Record) for October 2024 for Resident B indicated neither the hyoscyamine nor the Morphine had been administered. During an interview, on 10/23/2024 at 2:52 P.M., LPN 6 indicated she did not note the order or administer the recommended hyoscyamine because she needed to confirm the order with the facility's house doctor. She indicated she did not note the order or administer the Morphine pain medication either. LPN 6 indicated she could not give the Morphine until an actual prescription was sent to the pharmacy and she was unsure if or when it had been sent by the Hospice doctor. She indicated she could have called a nurse practitioner to get the script fo the medications sent to the pharmacy so the morphine could be administered, but she had not called. LPN 6 did not indicate a reason why she had not taken the time to confirm the Hospice order for hyoscyamine with the facility's house physician when the order from Hospice had been received on 10/12/2024. In addition, although the 10/18/2024 Nursing Progress Note and the Hospice Progress note both indicated LPN 6 had received an order from Hospice for Morphine for Resident B and LPN 6 had voiced understanding that Hospice has sent the order for the Morphine to the pharmacy, she still indicated she was unsure if the prescription for the Morphine had been sent to the pharmacy. The Regional Director of Nursing Services indicated on 10/25/2024 at 10:54 A.M., the facility does not have a policy for following physician order, but the facility followed the standard of practice. 2. A Medication Storage observation for the Garden Medication Cart was completed on 10/25/2024 at 10:20 A.M., with RN 18. The narcotic log book lacked signatures for the following dates and times: 9/4 for the night shift signing on. 9/4 for the night shift signing off. 9/5 for the day shift signing on. 9/5 for the day shift shift signing off. 9/5 for the night shift signing on. 9/6 for the night shift signing off. 9/9 for the day shift signing off. 9/16 for the day shift signing on. 9/16 for the night shift signing on. 9/17 for the night shift signing off. 9/18 for the night shift signing off. 9/23 for the night shift signing off. 10/4 for the day shift signing off. 10/5 for the day shift signing off. 10/5 for the night shift signing on. 10/5 for the night shift signing off. 10/6 for the day shift signing on. 10/7 for the night shift signing on. 10/8 for the night shift signing off. 10/13 for the night shift signing on. 10/13 for the night shift signing off. 10/14 for the night shift signing off. 10/18 for the night shift signing off. 10/20 for the day shift signing off. 10/20 for the night shift signing on. 10/21 for the night shift signing off. 10/21 for the day shift signing off. 3. A Medication Storage observation of the Behavior unit medication cart was completed on 10/25/2024 at 10:30 A.M., with Qualified Medication Aide (QMA) 16. The narcotic log book lacked signatures for the following dates and times: 10/3 for the day/evening shift signing off. 10/4 for the day/evening shift signing off. 10/7 for the day/evening shift signing off. 10/8 for the day/evening shift signing off. 10/11 for the day/evening shift signing off. 10/14 for the day/evening shift signing off 10/15 for the day/evening shift signing off. During an interview, on 10/25/2024 at 10:37 A.M., QMA 16 indicated two licensed nursing staff should have signed the narcotic book between shifts. On 10/25/2024 at 10:54 A.M., the Regional Director of Nursing Services (RDNS) provided the policy titled, Narcotic/Controlled Substance-Counting, with a revised date of 11/26/2017, and indicated the policy was the one currently used by the facility. The policy indicated . Purpose: 1. To count controlled substances with a partner and to verify the accuracy of the log sheets. 2. Knowledge of correct response should an error be discovered in the control substance count. General Guidelines: 1. Always participate in the counting of the controlled substances at the beginning and ending of your shift. General Procedure for Counting Controlled Substances: 1. Follow your facilities specific guidelines and use their specific log sheet .16. Sign name, time and date of completed count This citation relates to complaint IN00442512. 3.1-37(a) 3.1-25(e)(2) 3.1-25(e)(3)

Deficiency Text Not Available

Deficiency Text Not Available

Based on observation and interview, the facility failed to provide sanitary serving of food plates for 1 of 3 dining rooms observed during the lunch meal service. This had the potential to affect 14 residents on the dementia unit. Finding includes: During a continuous observation, on 10/21/2024 from 11:52 A.M. through 12:17 P.M., the activities assistant was observed to serve plates with her thumb over the rim of the plate to 5 of 12 residents in the dining room. During an interview, on 10/21/2024 at 12:02 P.M., the activity assistant indicated she had not been educated on how to properly serve dinnerware. She indicated her thumb should not have been on the top of the plate. A current policy titled, Resident Tray Delivery, was provided by the Regional Director of Nursing Services, on 10/25/2024 at 10:54 A.M. The policy did not address proper handling of dinnerware when serving the residents. 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure safe infection control practices were followed regarding obtaining a blood sugar sample and administering insulin for 1 of 2 residents observed administering insulin. (Residents 43) Finding includes: During a medication administration observation, on 10/25/2024 at 8:35 A.M., LPN 17 was observed to donn (apply) gloves and walk to the main dining area. He then placed the glucometer (device to monitor blood glucose levels) on a dirty dining room table. Next, LPN 17 wiped the finger of Resident 43 with an alcohol pad. and then obtained the blood sample from Resident 43's finger. Afterwards, he removed the test strip, placed it in his gloves and removed his gloves. During an interview, on 10/25/2024 at 8:37 A.M., LPN 17 indicated he should not have obtained the blood sugar sample in the dining room and should have used a barrier between the dining room table and the glucometer. On 10/25/2024 at 12:25 P.M., the Corporate Nurse provided the policy titled, Insulin Pen Procedure, dated 8/4/2020, and indicated the policy was the one currently used by the facility. The policy indicated . Select a clean , dry work area 3.1-18(a)

2. A record review of Resident 35 was completed on 9/27/2023 at 10:22 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, history of cardiac arrest, and hepatitis C. An Annual Minimum Data Set (MDS) assessment, dated 8/8/2023, indicated Resident 35 had severe cognitive impairment and received insulin injections for seven days of the seven day look back period. A Physician's Order, dated 8/16/2023, indicated to monitor blood glucose fingerstick monitoring twice daily, and to call the physician if Resident 35's blood glucose was under 60 or above 400. A review of Resident 35's blood glucose results indicated a blood glucose of 425 on 9/14/2023, and 424 on 9/24/2023. During an interview on 9/28/2023 at 1:24 P.M., LPN 10 indicated if a blood glucose level was out of range from the provided scale the physician provided, then the physician should be called immediately. On 9/29/2023 at 9:43 A.M., the Director of Nursing indicated the doctor would be contacted when the blood glucose reaches 401 for Resident 35. She reviewed the Medication Administration Record, and indicated a checkmark was present indicating the blood glucose level was obtained, but she could not find a Physician Progress Note where the physician had been notified of the out-of-range blood glucose levels. 3. During an interview on 9/26/2023 at 9:43 A.M., the guardian for Resident D indicated she did not get notified of changes in treatments, or a recent hospitalization. A record review was completed on 9/27/2023 at 8:40 A.M. Diagnoses included, but were not limited to: psychosis, history of traumatic brain injury, vascular dementia, anxiety disorder, and affective disorder. An Annual Minimum Data Set (MDS) assessment, dated 9/18/2023, indicated Resident D had severe cognitive impairment. A Nurse's Note, dated 6/16/2023 at 9:33 A.M., indicated Resident D came to the staff with a complaint of a headache, requesting treatment for the headache. This was very unusual for this resident. Tylenol was administered, and complaints of the headache continued. The physician was notified of the unusualness of Resident D to come to staff with complaints of a headache, and requesting treatment. Resident D's current Tylenol order was updated to every six hours. On 6/16/2023 at 12:03 P.M., Resident D was observed by staff in his room with tremors to bilateral hands, and continued to complain of a headache. The physician was updated again on Resident D's condition. On 6/16/2023 at 12:10 P.M., new orders were received for stat labs, and the POA was called, and a message left to return call to facility. On 6/17/2023 at 12:09 P.M., Resident D had a temperature of 101.3 Fahrenheit after he received Tylenol. He had diminished lung sounds and wheezing noted. A new order was received from the physician for Invanz (an antibiotic) one gram intramuscularly daily for five days. On 6/18/2023 at 10:45 P.M., Resident D had an unwitnessed fall in his room. He was bedside, wrapped in a blanket, confused, sweaty, and breathing hard. The physician was notified, and an order was obtained to send to the emergency room. The note indicated staff attempted to call the guardian, but whomever answered indicated it was a wrong number. No further attempts were made to call the guardian or the secondary contact in the medical record. Resident D was discharged to the hospital on 6/18/2023, and returned on 6/22/2023. During an interview on 9/28/2023 1:21 P.M., LPN 10 indicated all new physician orders should be communicated with the Power of Attorney/Guardian of the resident. She indicated if the first contact listed cannot be reached, she would call the next contact. On 9/29/2023 at 9:53 A.M., the Director of Nursing (DON), indicated the Power of Attorney/Guardian should be notified of all new orders and changes of condition, the nursing staff should have tried to contact the guardian again. On 9/28/2023 at 1:20 P.M., the Director of Nursing provided the policy titled, Weights, dated 10/17/2019, and indicated the policy was the one currently used by the facility. The policy indicated .3. Re-weight should be obtained if there is a difference of 5# or greater (loss or gain) since previous recorded weight. 6. Undesired or anticipated weight gains/loss of 5% in 30 days, 7.5 % in three months, or 10% in six months shall be reported to the physician, Dietician and/or Dietary Manager as appropriate On 9/29/2023 at 9:55 A.M., a policy titled, Physician-Family Notification-Change in Condition, was provided by the Regional Nurse Consultant. The policy indicated, .To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner .The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner, and if known, notify the resident's legal representative or an interested family member when there is: (B) A significant change in the resident's physical, mental, or psychosocial status .(C) A need to alter treatment significantly .A Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences, or commence a new form of treatment to deal with a problem .(D) A decision to transfer or discharge the resident from the facility This Federal tag relates to complaint IN00412410. 3.1-5(a)(3) 3.1-5(a)(4) Based on record review and interview, the facility failed to notify the physician of significant weight losses, abnormal blood glucose levels and failed to notify the family of a hospitalization and change of condition in 3 of 3 residents reviewed for physician notification. (Resident 21, C & D) Findings include: 1. A record review was completed on, 9/28/2023 at 2:19 P.M. Resident 21's diagnoses included, but were not limited to obstructive uropathy, diabetes, dementia, arthritis, Parkinson's disease and malnutrition. An admission MDS (Minimum Data Set) assessment, dated 6/9/2023, indicated Resident 21 required total assistance of 2 staff for bed mobility, transfers, bathing, and personal hygiene. Resident 21's weight history indicated on 6/23/2023 the weight was documented as 150.0. On 8/14/2023 Resident 21 was admitted to the hospital to have a leg amputation and returned on 8/25/2023. Resident 21's weights are as follows: A readmission weight was not obtained. On 8/28/23 the resident's weight was documented as 128.5. On 9/1/23 the resident's weight was documented as 136.5 showing a gain of 8 lbs. in 4 days. On 9/15/23 the resident's weight was documented as 129.5 showing a loss of 7 lbs. indicating a 5.13% loss in 15 days. On 9/28/23 the resident's weight was documented as 129.0. A current care plan, dated 8/30/2023, indicated the resident had an unplanned/unexpected weight loss related to poor food intake and a right leg below the knee amputation. Interventions included: Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. Monitor and record food intake at each meal A current care plan, dated 9/28/2023, indicated the resident had a nutritional problem or potential nutritional problem related to protein malnutrition, diabetes, dysphagia, poor oral intake at times. She was on a general puree diet with double portions with pudding thick liquids. Interventions included, but were not limited to, monitor/record/report to MD PRN (as needed) signs and symptoms of malnutrition/ significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5 % in 3 months, and >10% in 6 months. The clinical record lacked the documentation to show the physician had been notified of the residents significant weight changes from 8/28/2023 to 9/15/2023. During an interview, on 9/28/33023 at 10:53 A.M., the Assistant Director of Nursing indicated there was no documentation of the physician being notified of the weight loss and should have been.

Based on record review and interview, the facility failed to ensure accurate clinical information was provided to the hospital for a hospital transfer, failed to obtain an order to transfer a resident to the hospital causing an unnecessary emergency room visit, and failed to obtain a physicians order to discharge to the hospital for 3 of 3 residents reviewed for hospitalization. (Residents 21) Finding includes: 1. A record review was completed on 9/28/2023 at 2:19 P.M. Resident 21's diagnoses included, but were not limited to anemia, dysphagia (difficulty in swallowing), diabetes, dementia, arthritis, and Parkinson's disease. An admission MDS (Minimum Data Set) Assessment, dated 6/29/2023, indicated the resident required extensive assist of 2 staff for bed mobility, transfers, dressing, eating and toilet use, and did not ambulate. Had a surgical wound, and 1 stage 2, and 1 stage 3 pressure ulcers. Treatment orders included: clease the area to the right hip with wound wash. Pat dry, and pack wound with 1/2 strength Dakin's soaked gauze and cover with dry border dressing once daily and PRN (as needed) for soilage and dislodgment. Current Physician orders, included pureed texture, pudding consistency diet. Allergies included: Cefepime, Morphine and ACE inhibitors. A Skin Condition Report sheet, dated 8/2/2023 indicated Resident 21 had a surgical wound to the right foot related to amputation of the right toes. Sutures remain. Moderate drainage noted. Resident currently started on antibiotic therapy. Resident has a history of chronic osteomyelitis (bone infection). A Progress Note, dated 8/14/2023, indicated the Physician had seen the resident and indicated the resident would be sent to the hospital on 8/15/2023 for direct admit. A Nursing Home to Hospital Transfer Form, dated 8/15/2023, indicated under the Diet section the question of trouble swallowing was checked No. Special consistency (thickened liquids, crushed med's etc. was check No. The section for Skin/Wound Care concerning pressure ulcers the documenting was checked n/a. The Usual Functional Status: the documentation was for Ambulated only with human assistance. Allergies indicated Cefepime only. For the Risk Alerts the was no documentation for pressure ulcers. The form completed by was signed by the Social Service staff. During an interview, on 9/28/2023 at 3:39 P.M., the Director of Nursing indicted the form was not accurate. During an interview, on 9/28/2023 at 4:18 P.M., the Social Service staff indicated she either help a nurse because she was new, and indicated obviously I did it cause it has my name on it. The Social Service staff indicated that some of the information she did not know, and the information was inaccurate. On 9/29/2023 at 9:24 A.M., the Director of Nursing provided the policy titled, Discharge/Transfer of Resident, undated and indicated the policy was the one currently used by the facility. The policy indicated .7. Complete Transfer Form Accurately and completely including vital signs. Rationale/Amplification: Ensure that resident's current physical and psycho/social assessment, medications and current treatment is completely described and available to the receiving facility upon transfer This Federal tag relates to complaint IN00412410. 3.1-12(a)(3)

Based on observation, record review, and interview the facility failed to provide personal hygiene to a resident unable to complete per self for 1 of 5 residents reviewed for activities of daily living. (Resident 21). Finding includes: During an observation, on 9/25/2023 at 1:55 P.M., Resident 21 was observed in his bed with contracted hands, dirty nails to both hands and unshaved with a large growth of whiskers. During an observation, on 9/26/2023 at 9:28 A.M., Resident 21 was observed unshaven with a large growth of whiskers. During an observation, on 9/27/2023 at 2:23 P.M., Resident 21 was observed unshaven with a large growth of whiskers. During an observation, on 9/28/2023 at 1:45 P.M., Resident 21 was observed unshaven with a large growth of whiskers. During an observation ,on 9/29/2023 at 9:30 A.M., Resident 21 was observed unshaven with a large growth of whiskers. A record review was completed on, 9/28/2023 at 2:19 P.M. Resident 21's diagnoses included, but were not limited to obstructive uropathy, diabetes, dementia, arthritis, Parkinson's disease and malnutrition. Required total assist of 2 staff for bed mobility, transfers, bathing, and personal hygiene. A current care plan, dated 9/26/2023, indicated the resident had an ADL (activities of daily living) self-care performance deficit. Required assist with mobility and ADLs including bed mobility, toileting, eating, and transferring related to Parkinson's disease, arthritis and dementia. Total care for all ADLs. Interventions included, but were not limited to: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Provide sponge bath when a full bath or shower cannot be tolerated. The resident requires total assist. Personal Hygiene/Oral Care: The resident requires total assist. Resident 21's shower documentation indicated the resident had received showers on the following dates: 9/4, 9/7. 9/14, 9/18, and 9/22. Bed baths were received on 8/31, 9/5, 9/11, 9/26 and 9/29. During an interview, on 9/29/2923 at 9:39 A.M., CNA 7 indicated the resident had not been shaved and should have been. On 9/29/2023 at 11:09 A.M., the Assistant Director of Nursing provided the policy titled, Bathing-Shower and Tub Bath, dated 1/31/2018, and indicated the policy was the one currently being used. The policy indicated .To ensure resident's cleanliness to maintain proper hygiene and dignity. A shower, tub bath or bed/sponge bath will be offered according to resident's preference two times per week or according to the resident's preferred frequency and as needed or requested A policy was requested for providing personal hygiene, on 9/29/2023 at 1:49 P.M., the Director of Nursing indicated they did not have a policy on personal hygiene. 3.1-38(a)(3)

Based on record review and interview, the facility failed to provide education to the nursing staff on care of nephrostomy tubes for 1 of 26 residents reviewed. (Resident C) Finding includes: A record Review of Resident C was completed on 9/25/2023 at 11:28 P.M. Diagnoses included, but were not limited to: traumatic brain injury, tracheostomy, PEG tube, aphasia, a stage 3 and 4 decubitus ulcer, and quadriplegia. A Nurse's Note, dated 7/22/2023 at 12:06 P.M., indicated Resident C had recently readmitted to the facility with bilateral nephrostomy tubes. The nephrostomy tubes were leaking approximately ninety percent of the urine excreted onto the bed and Resident C. On 7/22/2023 at 12:10 P.M. at 12:10 P.M., a Nurse's Note indicated a decision was made to send Resident C to the hospital based on barely any urine drained properly through the nephrostomy tubes. A Physician's Order could not be located in the medical record, nor documentation of the physician being updated on the resident's condition. An Emergency Documentation, dated 7/22/2023 at 6:55 P.M., indicated, .Bilat [Bilateral] nephrostomy tubes aspirated sediment but did not flush. Noted stopcock in place on 'lock' to bilat nephrostomy tubes. Stopcock was rotated open to both nephrostomy tubes. There was immediate return of yellow urine. Leg bags were changed bilaterally. Urine continued to flow freely from bilat tubes .Urine output was approx [approximately] 550 mL [milliliters] from R [right] nephrostomy tube. Urine output was 250 mL from L [left] nephrostomy tube During an interview on 9/29/2023 at 10:49 A.M. LPN 9 indicated when caring for nephrostomy tubes the main task was to keep the tubes flushed. He indicated the procedure required the nurse to turn the stopcock to the off position, flush the tubes, and open the stopcock. He indicated he had not received any training on nephrostomy tubes at the facility, but the discharging hospital provided instruction for care. On 9/29/2023 at 1:33 P.M., the Director of Nursing (DON) indicated staff training was not performed on nephrostomy tubes, and the resident came from the hospital with instructions. She indicated the nurse should have tried to look at the valves (stopcock) or call someone if she didn't understand how to provide care for the nephrostomy tubes. The DON indicated the nurse was a newer nurse, and may not have known how the nephrostomy tubes work. On 9/29/2023 at 3:10 P.M., the DON indicated LPN 8's job specific orientation could not be found in the employee's file. LPN 8 was hired at the facility on 4/2/2023. A policy titled, Employee Education, was provided by the Unit Manager on 9/29/2023 at 2:53 P.M. The policy indicated, .The facility shall provide a Staff Education Plan in accordance with State and Federal regulations .7. The facility will ensure that nursing staff are able to demonstrate competency in skills and techniques necessary to care residents'' needs, as identified through resident assessments, and described in the plan of care This Federal tag relates to complaint IN00412410.

Based on observation, record review and interview, the facility failed to provide water at the bed side for 1 of 2 residents reviewed for hydration. (Resident 20) Findings include: During an observation, on 9/25/2023 at 2:03 P.M., no water container was noted on the bedside table. A record review was completed on, 9/27/2023 at 9:01 A.M. Resident 20's diagnoses included, but were not limited to: Cerebral palsy, dementia and osteoarthritis. A Quarterly MDS (Minimum Data Set) Assessment, dated 8/25/2023, indicated the resident had severe cognitive function. Required total assistance of 2 staff for bed mobility, transfers, and toilet use, and extensive assistance for dressing and 1 staff for eating. Resident 20's diet order was a regular texture and thin liquids and assist with all meals. A current care plan, dated 9/25/2023, indicated the resident was on a regular diet with thin liquids, ice cream at lunch and dinner, snacks four times a day. Interventions: encourage resident to be up for all meals. Monitor for signs/ symptoms of aspiration. Position for eating and drinking safely. Provide diet as ordered. Uses cup with straw. A current care plan, dated 7/28/2023, indicated the resident had an ADL self-care performance and functional mobility deficit with a risk of decline and require assist with ADLs and mobility including bed mobility, toileting, transfer and eating related to diagnoses's of Cerebral palsy, dementia, chronic pain, osteoarthritis, dysphagia, general weakness, blindness. Interventions included: EATING: The resident requires Physical Assist; resident is able to feed self some items such as a cookie or sandwich once she is assisted with holding the item in her hand, however resident requires total assist with all fluid intake and all food items requiring utensils. A current care plan, dated 4/17/2023, indicated Resident 20 was at risk for dehydration related to: Cognitive loss/may not recognize thirst, impaired mobility, impaired cognitive status, dysphagia, history of IV fluids for hydration, poor nutritional intake at times. Interventions included: Check skin turgor as indicated. Evaluate diet, refer to Dietician as needed. Observe for and report to nurse/physician: Dry mucus membranes, Confusion, Muscle weakness, Constipation, Sunken eyes, Dizziness, Irritability, Fever, Pneumonia, disorientation, Urinary tract infection, Tachycardia, Weight loss, Dry and poor skin elasticity, Less urine output, Increased heart rate, Low blood pressure (hypotension) or Increased infection occurrence. Obtain vital signs as ordered and report any irregularities. Offer extra fluids at med pass as ordered; see MAR (Medication Administration Record)/TAR (Treatment Administration Record). During an observation on 9/27/2023 at 9:22 A.M., Resident 20 had no water available at the bed side. During an interview, on 9/27/2023 at 9:43 A.M., the Director of Nursing indicted there should be water at the bedside and there was not. On 9/28/2023 the Corporate Nurse provided the policy titled, Water Pass-Hydration, dated 11/28/2012, and indicated the policy was the one currently used by the facility. The policy indicated .'' Fresh cold ice waster will be provided to each resident a minimum of three times each day, unless contraindicated 3.1-46

Based on observation, interview and record review, the facility failed to ensure an insulin cart and a treatment cart were kept locked when unattended during 2 of 2 random observations. (100 and 200 Halls) Findings include: 1. During a random observation, on 9/27/2023 at 10:59 A.M., the insulin cart on the long hall was unlocked. During an interview, on 9/27/2023 at 11:00 A.M., LPN 8 indicated the cart should not be unlocked. 2. During a random observation, on 9/28/2023 at 11:25 A.M., the treatment cart on 100 hall was unlocked. QMA 5 walked by the cart and locked it. During an interview, on 9/28/2023 at 11:26 A.M. QMA 5 indicated the cart should not be unlocked. On 9/28/2023 at 5:20 P.M., the Corporate Nurse provided the policy titled,Medication Storage, dated 7/2/2019 and indicated the policy was the one currently used by the facility. The policy indicated . 3. Facility should ensured that all medications and biological's, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors 3.1-25(m)

Based on observation, interview and record review, the facility failed to ensure expired liquids and spices were not in use, failed to ensure the pantry and activity refrigerators were clean and without undated, unnamed foods, in 1 of 1 kitchens and 2 of 2 pantries observed. (Main kitchen, nourishment and activity cafe' pantry) Findings include: 1. During the initial tour of the main kitchen on 9/25/2023 at 9:45 A.M., with the Dietary Manager, the following items were observed: - In the walk in cooler there was 2 containers with small cartons of milk that were expired. There were 8 cartons with the expiration date of 9/18/23, 10 cartons with the expiration date of 9/19/23 and 50 cartons with the expiration date of 9/23/2023. - In the walk in freezer, a large build of ice was observed hanging down on the right side of the condenser. During an interview, on 9/25/2023 at 9:50 A.M., the Dietary Manager indicated the milk should have been pulled and the ice build up should not be there. 2. During a followup observation of the kitchen, on 9/28/2023 at 1:06 P.M., the following was observed: - An opened (6/14/2021) container of the Ginger spice with a used by date of 12/24/2022. A container of ground nutmeg with an opened date of 11/2/2022 and a used by date of 5/2/2023. During an interview, on 9/28/2023 at 1:08 P.M., the Dietary Manager indicted the spices should have been thrown away. 3. During an observation of the nourishment pantry, on 9/28/2023 at 2:14 P.M.,with the Dietary Manager, the following were observed: - In a refrigerator freezer section there was a bag of pizza pieces with no resident identifiers. An opened bottle of water with no name, and 2 broken crisper drawers with visible dirt underneath them. During an interview, on 9/28/2023 at 2:16 P.M., the Dietary Manager indicated the food items should have had a name on it, the water bottle should have a name on it, and the refrigerator should have been cleaned. 4. During an observation of the cafe' pantry, on 9/28/2023 at 2:20 P.M., with Activity staff 12 the following was observed: -In the freezer there were long frozen pop cycles singles and 2 bags with chunks of ice on them, 2 opened containers of whipped topping with no date opened and ice crystals in the middle of the topping. A microwave cheese pizza with no name. During an interview, on 9/28/2023 at 2:23 P.M., Activity Staff 12 indicated the food items should have had a date opened on them and the ice was due to the fridge not working properly. She indicated the facility was looking to get a new one. On 9/26/2023 at 1:30 P.M., the Director of Nursing provided the policy titled,Labeling and Dating Foods (Date Marking), dated 2020, and indicated the policy was the one currently used by the facility. The policy indicated . 2. Date marking for refrigerated storage food items. Once a case is opened, the individual, refrigerated food items are dated with the dated the item was received into the facility and placed in/on the proper storage location utilizing thefirst in- first out method of rotation. Once opened, all ready to eat, potential hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufactures expiration date. 3. Date marking for freezer storage food items . Frozen food packages removed from the case will be dated with the date the item was received into the facility will be stored using the first in- first out method of rotation 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure the dignity of 1 of 3 residents with indwelling urinary catheters was maintained. (Resident 59) Finding includes: During the initial tour of the facility, conducted on 7/5/2022 between 10:00 A.M. - 11:00 A.M., a urinary catheter bag for Resident 59 was uncovered and secured on the right side of the resident's bed frame. Yellow urine was visible to the hallway when the resident's door was open. On 7/5/2022 at 3:30 P.M., Resident 59's urinary catheter bag was noted to be uncovered and visible from the hallway. On 7/6/2022 at 8:47 A.M., Resident 59 was observed in his bed, eating breakfast. Resident 59's urinary catheter bag was noted to be uncovered with urine visible from the hallway, when the resident's door was open. On 7/6/2022 at 11:39 A.M., Resident 59 was observed in the hallway ambulating with a therapy staff member. The resident was utilizing a walker to assist him with walking and his uncovered urinary catheter bag was noted to be attached to the side of the walker. During an interview with Resident 59, conducted on 7/6/2022 at 2:10 P.M., he disclosed the urinary catheter was new to him since his recent hospital stay and he was unclear if the need for the catheter was going to be permanent. Resident 59 indicated he preferred to have his room door wide open so he could see what was going on. On 7/8/2022 in the afternoon, Resident 59 was observed returning from an outside medical appointment. His indwelling catheter bag was noted to be covered with a pillowcase that was knotted at the top. Review of the facility's policy and procedure, titled Catheter Care, provided by the Assistant Director of Nursing, on 7/11/2022 at 3:00 P.M. included the following guideline: .7. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly. May place drainage bag and excess tubing in a secondary vinyl bag or other similar device to prevent primary contact with floor or other surfaces. This was the only portion of the policy that mentioned covering the urinary catheter bag. 3.1-3(a)

Based on record review, observation and interview, the facility failed to notify the physician of significant weight loss for 2 of 5 residents reviewed for Nutrition. (Residents 4 and 61) Findings include: 1. A clinical record review was completed on 7/8/2022 at 8:28 A.M. Resident 4's diagnoses included, but were not limited to: seizures, diabetes, dementia, anxiety, bipolar, and Schizophrenia. A Quarterly MDS (Minimum Data Set) assessment, dated 6/6/2022, indicated Resident 4 was severely cognitively impaired, required limited assist of 1 staff for bed mobility, dressing, eating, and had weight loss. Resident 4's physician orders included: a regular no concentrated sweets diet, Med Pass (fortified nutritional shake) 90 ml ( milliliters) four times a day ordered on 1/20/2022, offer snack at hs (hour of sleep) ordered on 6/16/2022, and weekly weights. Resident 4's weights for 6 months: 12/28/2021--127.5 1/18/2022--112.0 1/25/2022--116.0 2/22/2022--115.5 3/29/2022--120.0 4/26/2022--118.0 5/24/2022--119.5 6/23/2022--114.0 Resident 4 had a significant weight loss of 15.5 lbs. a 9% (per cent) loss from December 2021 to January 2022. Resident 4 had a 13.5 lbs. a 10.59% loss from December 2021 to June 2022. A current care plan, dated 6/24/2021 and revised on 3/10/2022, indicated Resident 4 had unplanned/unexpected weight loss related to poor intake. Interventions included: if weight declines persists, contact physician and dietician immediately. Monitor and record food intake at each meal. Offer snacks four times a day and weigh weekly. A Nutritional Assessment, dated 1/20/2022, indicated Resident 4's most current weight was 112 on 1/18/2022. Usual body weight range was documented as 125-130. Her eating patterns were supervision. Weight status: BMI<19 or >27, 5% weight change in 30 days, >7.5% weight change in 90 days, and >10% weight change in 6 months. Comments: RD (Registered Dietician) consult for -10.0% change (Comparison Weight) 7/27/21, 131.0 lbs. -14.5%, -19.0 lbs. For -7.5% change (Comparison Weight) 10/26/2021 129.5 lbs.-13.5%, -17.5 lbs. For -5% change (Comparison weight) 12/21/2021 123.5 lbs -9.3%, -11.5 lbs. Current January weight 112 lbs. She is on weekly weights and this current weight of 112 seems off compared to the other weights. Due to weight loss would suggest four times a day 90 ml sugar free med pass and monitor next available weight to verify accuracy of weight change. The dietary recommendation was to discontinue the Med Pass twice a day, and now give it four times a day. A Nutrition Progress Note, dated 6/9/2022, indicated: weight on 6/7/2022 at 115 lbs. down 10.2% x 180 days. Consumes 75-100% at most meals. Supplement with sugar free med pass 2.0 at 90 ml 4 x day that helps stabilize weight. Estimated nutritional needs should be met with diet, supplements and intakes. No new recommendations. Continue with plan of care. The clinical record lacked documentation to show the family or the physician had been notified of the significant weight losses from December 2021 to January 2022 and from December 2021 to June 2022. During an interview, on 7/1120/22 at 4:45 P.M., the ADON indicated the physician and family should have been notified of the weight losses. 2. A clinical record review was completed on 7/07/2022 at 2:11 P.M. Resident 61's diagnoses included, but were not limited to: Parkinson's disease, vascular dementia with behavioral disturbance, gastroesophageal reflux disease, hemiplegia, schizophrenia and pseudobulbar affect. A Quarterly MDS (Minimum Data Set) assessment, dated 5/27/2022. Resident 61 was severely cognitively impaired, required extensive assist of 1 staff for bed mobility, transfers, walking, dressing and eating. Weight documented as 175 lbs. A current care plan, dated 12/7/2021, indicated Resident 61 had an unplanned/unexpected weight loss related to recent hospitalization. Interventions included: monitor and evaluate any weight loss. Determine percentage loss and follow facility protocol for weight loss, and monitor and record food intake at each meal. A current care plan, dated 12/13/2021 and revised on 7/12/2022, indicated Resident 61 was unable to consume regular consistency foods and required no added salt fortified foods, pureed, double portions, and thin consistency liquids. Interventions included: 1/2/2020 food placed in bowls for meals as tolerated, monitor weight monthly, obtain weekly weight as ordered and provide diet as ordered. Resident 61's monthly weights: 1/2/2022---190.0 2/3/2022---192.0 3/16/2022--187.5 4/12/2022--182.5 5/10/2022--177.0 6/13/2022--175.0 7/5/2022----159.5 Resident 61 had a weight loss of 8.86 % in 1 month from June 2022 to July 2022, and a weight loss of 16.05 % in 6 months from January 2022 to July 2022. A Physician's Progress Note, dated 5/2/2022, indicated mild weight loss due to poor appetite but not enough to need intervention. Weight loss will be monitored. A Nutrition Progress Note, dated 5/4/2022, indicated: weight on 5/3/2022 178 Lbs. down 5.3% in 30 days, triggers a significant weight loss x 30 days. On mechanical soft/NAS diet and consumes 75-100% at most meals. BMI at 25.5 within normal limits. May suggest fortified foods as resident is eating well. Continue with the plan of care. A Nutrition Progress Note, dated 6/10/2022, indicated: weight on 5/31/22 at 175 lbs; down 13.4% x 180 days. BMI at 27.4- overweight. On a mechanical soft/NAS/fortified foods diet and consumes 75-100% at most meals. Fortified foods added in May. No new recommendations as interventions are in place and eating well. Continue with plan of care. A Physician's Progress Note, dated 7/4/2022, indicated weight loss noted but patient is eating well and weight loss is now stabilizing. A Nutrition Progress Note, dated 7/6/2022, indicated: weight on 7/5/2022 at 159.5 lbs; down 8.9% x 30 days. BMI at 22.9- wnl (within normal limits). On a puree/NAS diet and consumes 75-100% at most meals. Diet downgraded on 6/28/2022. Food in bowls. On Risperdal for behaviors- may see weight changes with drug. Will suggest double portions of pureed foods to help increase calories. Continue with plan of care. The clinical record lacked the documentation to show the physician had been notified of the most recent significant weight loss of 8.98 % in 1 month from June to July 2022. During an interview, on 7/11/2022 at 4:45 P.M., the ADON indicated the physician and family should have been notified of the weight losses. On 7/8/2022 at 10:36 A.M. the Administrator provided the policy titled, Weight Assessment and Intervention, dated 2020, and indicated the policy is the one currently used by the facility. The policy indicated .4. Any weight change of 5% or more since the previous weight assessment shall be re-taken the next day to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, Registered Dietitian, Dining Services Manager, or other members of the interdisciplinary team within 24 hours. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss shall be based on the following criteria. 1 month -Significant loss- 5%. Severe Loss is Greater than 5%. 3 months-Significant Loss- 7.5%. Severe Loss is Greater than 7.5% 6 months -Significant Loss. Severe Loss is Greater the 10% 3.1-5(a)(1) 3.1-5(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an initial interview on 7/5/2022 at 2:38 P.M., Resident 1 indicated that care plan meetings were not completed. A record review was completed on 7/8/2022 at 11:01 A.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease (COPD), congestive heart failure, peripheral vascular disease, and generalized anxiety. A Significant Change MDS on 6/16/22, indicated Resident 1 is cognitively intact. A Care Conference Assessment was completed on 12/8/2021 at 12:04 P.M., and 3/3/2022 at 2:55 P.M. The assessment indicated, Resident 1 was in attendance via bedside. A Significant Change MDS was completed on 6/16/2022 and a Quarterly MDS on 2/22/2022. During an interview on 7/12/2022 at 10:39 A.M., the Social Service Director (SSD) indicated care plan meetings are completed every three months on Wednesdays. The care plan conferences do not follow the MDS schedule. She indicated Resident 1 was hospitalized from [DATE]-[DATE], and a meeting was not completed. The care plan meeting was scheduled for 6/1/2022 and should have had a care conference meeting on 6/15/2022. On 7/8/2022 at 10:36 A.M. the Administrator provided the policy titled, Comprehensive Care Plan, dated 11/28/2012, and indicated the policy was the one currently used by the facility. The policy indicated . The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. The resident and/or representative shall be invited to review the plan of care with the interdisciplinary team either in person, via telephone or video conference(if available) at least quarterly 3.1-35(a)(1) 3.1-35(D0(2)(B) Based on record review, observation and interview, the facility failed to update resident care plans for weight loss, falls and failed to ensure care plan meetings were held timely for 3 of 24 residents whose care plans were reviewed. (Residents 4, 16, & 1) Findings include: 1. A clinical record review was completed on 7/8/2022 at 8:28 A.M. Resident 4's diagnoses included, but were not limited to: seizures, diabetes, dementia, anxiety, bipolar and Schizophrenia. A Quarterly MDS (Minimum Data Set) assessment, dated 6/6/2022 indicated Resident 4 was severely cognitively impaired, required limited assist of 1 staff for bed mobility, transfers, dressing, eating and had weight loss of over 5% in a month or 10% in the past 6 months. Resident 4 had a weight loss of 11.5 lbs.(9% ) from December 2021 to January 2022, and 13.5 Lbs. (10.59%) from December 2021 to June 2022. Resident 4's current physician orders indicated the resident was to receive Med Pass (fortified nutritional shake) of 90 ml (milliliters) four times a day ordered on 1/20/2022, weekly weights, offer bed time snacks. A current care plan, dated 3/10/2022, indicated Resident 4 had an unplanned/unexpected weight loss related to poor food intake. Interventions included: If weight decline persists, contact physician and dietician immediately. Monitor and record food intake at each meal. Offer snacks QID (four times a day). Weigh weekly. The care plan lacked the fortified nutritional shake that was ordered 1/20/2022. During an interview, on 7/11/2022 at 4:45 P.M., the ADON indicated they do a risk meeting with weights and go through them and sometimes one will slip through the cracks. 2. A clinical record review was completed on 7/11/2022 at 10:37 A.M. Resident 16's diagnoses included, but were not limited to: dementia, hemiplegia, malnutrition, anxiety, depression, bipolar, and Schizophrenia. A Quarterly MDS (Minimum Data Set) assessment, dated 4/11/2022 indicated Resident 16 had 1 fall with no injury and another fall with injury not major, and required extensive assist for bed mobility, transfers, dressing, and toilet use. A Nurses Progress Note, dated 6/30/2022, indicated Resident 16 had an un-witnessed fall on 6/30/2022 at 5:15 P.M. Location of Fall: resident room was attempting to walk and fell a few feet from the bed. Assessment: Un-witnessed fall, neurological checks initiated. Alert and disoriented per usual baseline. No changes in range of motion from normal baseline. New injury observed. Laceration to nose and hematoma to forehead MD and family notified . A Nursing IDT Note, dated 7/1/2022 at 9:25 A.M., indicated: . Summary of the fall: Resident found on floor a few feet from his bed. Large amount of bleeding from nose. Pressure applied to laceration using clean gauze. Root cause of fall: Transferring independently. Intervention and care plan updated: lap tray to be placed to wheel chair A current care plan, dated 12/30/2020 and revised on 3/11/2022, indicated Resident 16 was at risk for falls related to: hemiplegia, impaired mobility, able to bear minimal weight for transfers, dementia, impaired safety awareness and impaired cognitive function. Interventions included, but were not limited to: anti-roll backs on wheel chair, anti tippers on wheel chair, anticipate needs and meet needs, call light in reach and encourage to use it. Dycem (non skid pad) to wheelchair. Mat on floor be bedside while resident is in bed and removed when not in bed. OT (Occupational Therapy) to screen for safety and transfers. Room move to be closer to nursing station and increased visual observation. On 7/11/2022 at 10:30 A.M., resident 16 was observed sitting in his wheelchair at a table in the lounge area, with no anti tippers, no anti roll backs, and no lap tray on the wheelchair. During an interview, on 7/11/2022 at 11:39 A.M., CNA 6 showed the Visual/Bedside [NAME] Report sheet of what Resident 16 should have on the wheelchair. The [NAME] sheet indicated the anti-rollbacks, anti tippers and the dycem were to be on the wheelchair, and a lap tray to the right side of the wheelchair for positioning, comfort, safety related to hemi (paralysis) status. During an interview, on 7/12/2022 at 11:02 A.M., the ADON indicated therapy staff do not do any therapy in the red zone (positive Covid rooms). She indicated they were going to have them assess Resident 16 for the lap tray, but he had Covid and they do not go in to the red rooms. She indicated the care plan was not updated.

Based on record review, observation and interview, the facility failed to ensure showers were provided timely for 2 of 5 residents reviewed for Adl care (Activities of Daily Living). (Residents 33 & 187) Findings include: 1. During an observation on 7/5/2022 at 2:50 P.M., Resident 33 was lying in bed with no socks on, with the soles of both feet blackened. A clinical record review was completed on 7/7/2022 at 1:25 P.M. Resident 33's diagnoses included, but were not limited to: anxiety, schizophrenia, dysphagia, chronic pancolitis and colostomy status. A 5 day MDS (Minimum Data Set) assessment, dated 5/9/2022, indicated Resident 33 was severely cognitively impaired, required limited assist of 1 staff for bed mobility, extensive assist of 2 staff for personal hygiene and total assist of 2 staff for bathing. A current care plan, dated 2/11/2021 and revised on 5/11/2022, indicated Resident 33 had an ADL (activities of daily living) self care performance deficit and required assist with ADL's related to diagnoses of schizophrenia,anxiety,impaired cognitive status, impaired thought process and impaired safety awareness. Interventions included, but were not limited to: Bathing/Showering: the resident requires physical assist from staff. Resident 33's shower documentation,dated 6/13/2022 to 7/12/2022, indicated the resident had 1 shower documented on 7/7/2022, refused 5 times and had no documentation for the 2 other scheduled shower days. Review of Resident 33's behavior documentation from 6/13/2022 to 7/12/2022 indicated the resident had no documented behaviors of refusing showers during this time period. During an interview, on 7/11/2022 at 11:36 A.M., CNA 6 indicated they will put the socks on, then he takes them off. She indicated the resident is to get a shower twice a week, and if he refused they would keep going in, and if he still refused, then a bed bath would be given and it should be charted. During an interview, on 7/12/2022 at 10:55 A.M., the ADON indicated he should have gotten more than 2 showers in 30 days. 2. A clinical record review was completed on 7/6/2022 at 2:26 P.M. Resident 187's diagnoses included, but were not limited to: anxiety, depression, psychotic disorder, dementia, and traumatic brain injury. A Quarterly MDS (Minimum Data Set) assessment, dated 6/3/2022, indicated Resident 187 was severely cognitively impaired, required extensive assist of 2 staff for bed mobility, transfers, dressing and toilet use, and was totally dependant on 2 staff for bathing. A current care plan, dated 5/11/2022, indicated Resident 187 had an ADL self-care performance deficit and required assist with ADLs including bed mobility, toileting, transfer, dressing and bathing. Interventions included, but were not limited to: Staff to assist as needed with all ADL care including, but not limited to: toileting, bed mobility, eating, transfers, oral/dental care, showers/bath, dressing. Bathing/Showering: Resident requires physical assist with bathing/showering and personal hygiene. The shower documentation for Resident 187 dated 6/15/2022 to 7/9/2022, indicated the resident had 2 showers documented, 5 times documented as not applicable and no documentation for one other scheduled shower day. A Nurse's Note, dated 7/2/2022 at 3:53 P.M., indicated shower schedule Wednesday and Saturday evenings. Resident in isolation. A Nurse's Note, dated 7/6/2022 at 2:22 P.M., indicated shower schedule Wednesday and Saturday evenings. Resident in isolation. During an interview, on 7/11/2022 at 11:46 A.M., CNA 6 indicated the resident does take his showers and should have had more than 2 in 30 days. On 7/11/2022 at 2:48 P.M., the Assistant Director of Nursing provided the policy titled,Bathing- Shower and Tub Bath, dated 11/28/2012, and indicated the policy was the one currently used by the facility. The policy indicated . A shower, tub bath or bed/sponge bath will be offered to resident's preference two times per week or according to the resident's preferred frequency and as needed or requested.If resident resists or refuses care, stop the care and report to nurse.Document bathing task and assistance provided in the electronic record, including pertinent observations 3.1-38(a)(3)

Based on observation, record review and interview, the facility failed to ensure preventative measure ordered for pressure ulcers were in place for 2 of 2 residents (Residents 14 & 12), and did not develop pressure ulcers after admission for 1 of 2 residents (Resident 12) reviewed for pressure ulcer care and pressure ulcer prevention. Findings include: 1. During an observation on 7/5/2022 at 10:20 A.M., Resident 14 was observed lying on his back on a low air loss mattress, Prevalon boots (a boot that floats the heels and relieves pressure) on both feet with a pillow between his legs. On 7/11/2022 at 9:35 A.M., Resident 14 was observed lying on his back sleeping with a pillow under head and a pillow to the left of his head. He did not have the Prevalon boots on his feet. At 11:38 A.M., he is lying on his back sleeping. He did not have the Prevalon boots on his feet and his feet are not floated off the mattress. At 12:04 P.M., Resident 14 continued to lay on his back and his heels are not floated from the mattress. At 1:42 P.M., Resident 14 was observed lying on his back sleeping with a pillow under head and a pillow to the left of his head. He did not have the Prevalon boots on his feet. His feet are not floated. On 7/12/2022 at 8:47 A.M., Resident 14 was lying on his back. He does not have Prevalon boots in place. His feet are not floating off the mattress. At 11:14 A.M., he was lying with a pillow under the right side of his buttock sleeping. He does not have Prevalon boots in place. His feet are not floating off the mattress. At 1:52 P.M., Resident 14 was lying reclined in a Broda chair (a tilt-in-space reclining wheelchair). He did not have the Prevalon boots in place. His right foot was resting on his left leg. A record review of Resident 14 was completed on 7/11/2022 at 9:52 P.M. Diagnoses included, but were not limited to: Parkinson's disease, vascular dementia, and heart failure. A Quarterly Minimum Data Set (MDS) on 4/8/2022 indicated Resident 14 had severe cognitive impairment. He was dependent on bed mobility and toileting with two or more staff members., He has an indwelling catheter, and a Stage 4 pressure ulcer without a turning/repositioning program. A Skin and Wound Evaluation on 7/6/2022 at 1:35 P.M., indicated a pressure ulcer, stage 4, on the coccyx that was present on admission. The pressure ulcer currently measures 0.9cm x 1.6cm x 0.6 cm (centimeters). An Other Skin Condition Report on 7/6/2022 at 3:15 P.M., indicated abrasions/scratches to the left great and second toe. The second left toes skin condition developed on 3/22/2022. The great toes skin condition developed on 5/18/2022. A Physician's Order on 6/19/2020, indicated, Prevalon boots to bilateral feet on at all times as tolerated for protection/prevention; may remove for care. A Care Plan on 8/19/2020, and revised on 6/2/2022, indicated, resident 14 had the potential for impaired skin integrity, had a stage four pressure ulcer, and abrasions to the left great and second toe. The goals of treatment indicated to have no further skin breakdown and to remain free from complications of the stage four pressure ulcer. The interventions in place included avoid skin to skin contact, Prevalon boots to bilateral feet as tolerated, to stay off of his back and do side to side turning for wound healing. During an interview on 7/12/2022 at 8:49 A.M., CNA 4 indicated Resident 14 should be turned every two hours with a pillow to assist in positioning and to wear his boots for pressure ulcer interventions. 2. Resident 12 was observed on 7/5/2022 at 11:45 A.M., lying in his bed awake. There were gauze dressing noted to both feet. The resident was lying on a concave regular mattress. There were quilted boots noted on the floor, near the wall at the end of the resident's bed. The clinical record for Resident 12 was reviewed on 7/6/2022 at 2:00 P.M. Resident 12 was admitted to the facility after recovering from aspiration pneumonia. The resident also had diagnoses including but not limited to: abnormalities of gait and mobility, unsteadiness on feet, chronic gout, excoriation of the skin (skin picking disorder) and peripheral vascular disease. During an interview with Resident 12's health care representative, conducted on 7/5/22 at 3;21 P.M , he indicated the facility was having trouble with the resident's heels. Review of an admission assessment, completed on 3/29/2022, indicated the resident was admitted to the facility with scabs on several of his toes and a reddened groin and buttocks area. Review of a Braden Assessment (assessment to determine the resident's risk for developing pressure areas), completed on 3/29/2022, indicated the resident scored 15, which indicted he was at risk of pressure ulcer development. The initial care plan related to skin/pressure ulcer prevention indicated the following: I have a potential for impairment to skin integrity r/t [related to]: COPD [chronic obstructive pulmonary disease], DM [Diabetes Mellitus] with neuropathy, dementia; impaired cognitive status, impaired safety awareness, morbid obesity, PVD [Peripheral vascular disease], anemia, depression, anxiety, incontinence of b/b [bowel and bladder] at times and Resident has excoriated areas from picking on axilla and groin with tx. [treatments] The plan had a goal for the resident not to develop any further alteration in skin integrity. The interventions included: Administer/monitor effectiveness of medications as ordered, Assess/record changes in skin status, Ensure linens are wrinkle free, Keep skin clean and dry. Use lotion on dry skin, Minimize pressure over bony prominences Protective skin barrier cream as ordered., Provide diet as ordered and monitor nutritional status and dietary needs, Report pertinent changes in skin status to physician and Treatment as ordered. The plan was updated with interventions added on 6/16/2022 to encourage the resident to wear booties/heel protectors while in bed and encourage resident to wear shoes when up in wheelchair. The plan was again updated on 6/30/2022 to apply an air mattress to his bed. Review of skin assessments indicated an initial pressure ulcer assessment, completed on 5/19/2022 which indicated the resident had developed a Stage 2 pressure ulcer to his left heel. The wound was documented as having 100 % on the wound bed with granulated tissue and a treatment for a gentimican and Dakin's mixture was ordered. Treatment orders were updated and changed on 5/20/2022, 6/23/2022, 6/29/2022 and 7/7/2022. The current wound treatment was to cleanse the wound, pat dry, apply santyl ointment to the wound bed and paint the edges of the wound with betadine solution, and cover with a dry dressing. The resident also received an oral antibiotic to treat a wound infection from 6/29/2022 for 14 days. A subsequent assessment of the left heel, dated 6/8/2022 indicated the left heel had healed, however, there was an initial assessment of the resident's right heel, which indicated the resident had a 9 cm by 7 cm wound with scant drainage and 100 percent granulated tissue in the wound bed. An assessment, dated 6/15/2022 indicated the right heel wound was improving, had a moderate amount of drainage and still had 100 percent of the wound bed display granulation tissue. However, the 6/29/2022 assessment indicated the right heel was unchanged, but 30 % eschar in the wound bed was documented. In addition, the resident's left heel reopened and a 13 by 2.5 cm (centimeter) wound with a heavy serous exudate and signs of infection was noted. The assessment indicated an antibiotic was ordered and the treatment was changed. An assessment, completed on 7/6/2022, indicated the right heel was improving and now only exhibited eschar in 20 percent of the wound bed. The left heel was also documented as improving with 20 percent eschar in the wound bed. Observation of Resident 12's wounds, completed on 7/12/22 at 2:18 P.M., indicated the resident's right heel had a tennis ball sized wound with approximately 45 percent covered with eschar. In addition, the skin around the wound bed was dry and had a rolled edge. The left heel was observed to have a tennis ball sized wound with approximately 80% of the wound bed covered with eschar. The skin around the wound bed was dry, scaly and had rolled edges. A small amount of dark thick yellow and bright red blood drainage were noted on the old dressings from the left heel. During an interview with RN 11, who was completing the dressing change, she indicated the wounds were not stageable due to the eschar tissue. RN 11 indicted she had never noted Resident 12 to be on an air mattress. RN 11 indicated she did work for the agency but usually, routinely worked at the facility a few days per week. She indicated the resident was care planned to wear the Prevalon boots or floated heels while in bed and shoes while up out of bed. RN 11 indicated she had not seen Resident 12 wear shoes recently and she felt the shoes would be inappropriate due to the location of the resident's pressure ulcers. In addition, a Venous and Atrial Doppler test was ordered on 7/6/2022. The results of the Doppler test indicated the resident had normal arterial and venous blood flow to both feet. Observation of Resident 12 on 7/5/2022 - 7/8/2022 and 07/11/2022 - 7/12/2022 indicated there was no air mattress for his bed. In addition, on 7/6/2022 at 8:47 A.M., Resident 12 was observed seated in his wheelchair. His feet were noted to have gauze dressings on both heels and the resident was noted to rub the bottoms of his feet on the frame of the overbed table while he ate his breakfast. On 7/11/2022 at 9:18 AM., Resident 12 was observed lying in his bed with a partially consumed breakfast tray on the overbed table in front of him. He was noted to be wearing non skid socks on both feet and the padded boots were noted to be stacked along the wall in the corner of the resident's room. The resident's feet were not floated on any pillows. On 7/11/2022 at 11:31 A.M., Resident 12 was assisted from his bed into his wheelchair. The resident was noted to be wearing non skid socks on both feet. During an interview with QMA 13, she indicated the resident used to wear shoes but had not been wearing the shoes due to sores on the resident's feet. On 7/12/2022 at 1:39 P.M., the Regional Corporate Nurse provided a current policy titled, .Purpose: to prevent and treat pressure ulcer/pressure injury .5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated .9. Pressure reducing mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air air loss, alternating pressure, etc. maybe used as determined clinically appropriate. Speciality mattresses are typically used for residents who have Stage 2 wounds or one or more Stage 3 or Stage 4 wounds .11. Use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels, toes, and malleoli as indicated 3.1-40(a)(1) 3.1-40(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure interventions to prevent falls were implemented and failed to follow through with a therapy referral for evaluation related to a fall timely for 1 of 5 residents reviewed for accidents. (Resident 16) Finding includes: During an observation, on 7/6/2022 at 2:18 P.M., Resident 16 was observed in a wheelchair in his room with facial bruising. A clinical record review was completed on 7/11/2022 at 10:37 A.M. Resident 16's diagnoses included, but were not limited to: hypertension, dementia, hemiplegia, malnutrition, anxiety, depression, bipolar, and schizophrenia. A Quarterly MDS (Minimum Data Set) assessment, dated 4/11/2022, indicated Resident 16 was severely cognitively impaired, had 1 fall with no injury and 1 with injury not major. Has impaired range of motion to upper and lower extremities on 1 side. Required extensive assist of 1 staff for bed mobility, dressing eating and toilet use and extensive assist of 2 staff for transfers. An MDS Progress Note, dated 6/30/2022 at 8:37 A.M., indicated the resident remained in strict single room isolation with no roommate due to highly transmissible significant virus. All services including but not limited to meals and nursing services are provided in the resident's room. Activity services were also provided to the resident in the resident's room. A Fall- Initial Occurrence Note, dated 6/30/2022 at 5:15 P.M., indicated Resident 16 had an un-witnessed fall at 5:15 P.M. in his room where he had attempted to walk and fell a few feet from the bed. Assessment: Un-witnessed fall, neurological checks initiated. Alert and disoriented per usual baseline. No changes in range of motion from normal baseline. New injury observed. Laceration to nose and hematoma to forehead MD and family notified. A Nurse's Note, dated 6/30/2022 at 9:15 P.M., indicated the resident returned from the emergency room with a Nasal Bone fracture. No staples/sutures. Skin glue applied to laceration in ER. Upon arrival, the resident continuously picked at laceration. A Fall IDT (interdisciplinary team) Note, dated 7/1/2022 at 9:25 A.M., indicated Summary of the fall: Resident found on floor a few feet from his bed. Large amount of bleeding from nose. Additional staff called for assistance. 2 CNAs entered the room. Obtained vital signs while resident remained on floor. Pillow placed under his head for comfort, and pressure applied to laceration using clean gauze. Root cause of fall: Transferring independently. Intervention and care plan updated: lap tray to be placed to wheel chair. A Fall Risk Assessment, dated 7/1/2022, indicated the resident had a score of 15 indicating at risk for falls. A current care plan, dated 3/11/2022, indicated Resident 16 was at risk for falls related to: hemiplegia, impaired mobility, able to bear minimal weight for transfers, dementia, impaired safety awareness and impaired cognitive function. Interventions included, but were not limited to: anti-roll backs on wheel chair, anti tippers on wheel chair, anticipate needs and meet needs, call light in reach and encourage to use it. Dycem (non skid pad) to wheelchair. Mat on floor be bedside while resident is in bed and removed when not in bed. OT (Occupational Therapy) to screen for safety and transfers. Room move to be closer to nursing station and increased visual observation. The care plan lacked the intervention for the lap tray. During an observation, on 7/11/2022 at 10:30 A.M., Resident 16 was observed sitting in a wheelchair at a table in the lounge area. No anti tippers, no anti roll backs, dycem, or a lap tray were observed on the wheelchair. During an interview, on 7/11/2022 at 11:14 A.M., CNA 8 indicated she did not know if there was to be Dycem on the wheel chair and knew nothing about a lap tray. During an interview, on 7/11/2022 at 11:39 A.M., CNA 6 showed the Visual/Bedside [NAME] Report sheet of what Resident 16 should have on the wheelchair. The [NAME] sheet indicated the anti-rollbacks, anti tippers and the Dycem were to be on the wheelchair, and a lap tray to the right side of the wheelchair for positioning, comfort, safety related to hemi status. During an interview, on 7/12/2022 at 11:02 A.M., the ADON indicated therapy staff do not do any therapy in the red zone (positive Covid rooms). She indicated they were going to have them assess Resident 16 for the lap tray, but he had Covid and they do not go in to the red rooms. The ADON indicated Resident 16 should have been assessed by therapy and maintenance should have installed the anti-tippers and anti-roll backs to the wheelchair. During interview, on 7/12/2022 at 2:59 P.M., PTA (physical therapy aide) 9 indicated the team had suggested a belt or lap tray. He indicated the OT (occupational therapist) only comes twice a week and the resident got Covid and they do not do therapy in the positive Covid rooms. PTA 9 indicated it was not a documented policy not to treat in the positive rooms, but was adopted amongst themselves in the therapy department. A Physician's Order, dated 7/11/2022, 11 days after the fall, indicated: Therapy OT to evaluate and treat 3-5 times week for 4 weeks for therapeutic exercises and activity wheelchair management and self care training one time only for 4 weeks. On 7/12/2022 at 5:00P.M., the Administrator provided the policy titled, Fall Prevention Program, dated 11/28/2012, and indicated the policy was the one currently used by the facility. The policy indicated .Safety interventions will be implemented for each resident identified at risk. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. Residents will be observed approximately every 2 hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care. Each resident will be screened by a specialist therapist at the time of admission, quarterly, after each fall, as appropriate, and with significant change in the resident's mental and functional abilities 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to provide toileting needs for 2 of 5 residents reviewed for bladder continence (Resident 53 & 12) and prevent urinary tract infection for 1 of 4 residents reviewed for urinary tract infections. (Residents 60, 53, & 12) Findings include: 1. During an observation on 7/6/2022 at 11:49 A.M., Resident 60 was observed yelling out constantly Mommy from her room with the door shut. When she was approached, Resident 60 stated, I don't feel good. On 7/6/2022 at 12:01 P.M., Resident 60 was observed stating, Honey my back is hurting. On 7/7/2022 at 9:58 A.M., she was observed yelling out in her darkened room, I've got to go pee. On 7/8/2022 at 2:11 P.M., Resident 60 was observed yelling, My back is hurting. On 7/11/2022 at 10:51 A.M., Resident 60 is observed screaming in the common area of the dementia unit, I want out of here, I want to go home, My back hurts. A record review was completed on 7/8/2022 at 11:26 A.M. Diagnoses included, but were not limited to: dementia with behavioral disturbance, diabetes mellitus type 2, major depressive disorder with severe psychotic symptoms, and convulsions. An admission Minimum Data Set (MDS) on 5/26/22 indicated Resident (60) had severe cognitive impairment. She needed limited assistance with the assistance of one staff member for toileting. A Nurse's Note on 6/28/2022 at 10:02 P.M., indicated, Staff reported to writer that resident was urinating more frequently. Urine dark yellow, cloudy, with a foul odor noted. New order for a UA C&S [urinalysis with culture and sensitivity] noted. Urine obtained via clean catch. Specimen placed in refrigerator and lab notified. Will request am [morning] staff to notify family. Will continue to monitor. On 7/4/2022 a Physician Progress Note on 7/4/2022 at 11:23 P.M., indicated, .Significant agitation and we did im [intramuscularly] Ativan given and patient is sleeping and calm .agitation and we will get ua [urinalysis] too A urinalysis with culture and sensitivity was collected on 6/29/2022 and the laboratory received the specimen on 6/29/2022. The urinalysis result was printed by the facility on 7/2/2022. The culture and sensitivity indicated, a bacterium of Klebsiella pneumoniae greater than 100,000 CFU/ml (colony forming units per milliliter). A Physician's Order, on 7/7/2022, indicated, ceftriaxone one gram intramuscularly one time a day for UTI (urinary tract infection) times 5 days. The Medication Administration Record (MAR) for July 2022, indicated ceftriaxone one gram was administered on 7/8/2022 at 6:00 A.M. A Care Plan on 7/7/2022, indicated, Resident 60 had signs and symptoms of a urinary tract infection. An intervention included to give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. On 7/7/2022 a Care Plan indicated, Resident 60 was on antibiotic therapy related to signs and symptoms of a urinary tract infection. Am intervention included to give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. During an interview on 7/12/2022 at 8:34 A.M., the Assistant Director of Nursing (ADON) indicated antibiotic therapy should begin as soon as possible. She indicated the facility physician visits the facility on Monday and Thursday, and the nurse practitioner visits the facility on Wednesday. She indicated she did not know the policy, but felt the antibiotic should have been started sooner than 7/8/2022. She indicated the result may have come into the facility on the weekend or agency staff could have caused the delay. 2. During an interview with Resident 12's representative, conducted on 7/5/2022 at 3:25 P.M., he indicated Resident 12's wheelchair would not fit into the bathroom attached to his room, so staff had to toilet him in the shower room across the hall. Resident 12's representative indicated he thought Resident 12 was frequently incontinent of urine and needed staff to assist him to get to the bathroom. Resident 12 was observed 7/5/2022 at 10:01 A.M., lying in his bed asleep. An empty urinal was noted hanging on the side of the assist bars to his bed. The resident remained in his bed asleep and/or awake at times, until 12:10 P.M. when a nursing staff member assisted him to sit on the edge of his bed so he could feed himself the meal tray she had delivered. The resident was not observed to be toileted or offered assistance to utilize the urinal. Resident 12 was observed on 7/6/2022 at 8:47 A.M., seated in a wheelchair in his room, feeding himself breakfast. At 9:30 A.M., the resident was assisted back into his bed and his brief was changed. He was not offered an opportunity to use the urinal and/or go to the toilet. The resident remained in his bed from 9:30 A.M. to 12:42 P.M. The resident's lunch tray was delivered to his room but was left covered on his overbed table. Resident 12 was observed on 7/7/2022 at 10:23 A.M., lying in his bed awake. Resident 12 was observed to remain in his bed and was observed feeding himself lunch at 12:57 P.M. At 2:52 P.M., Resident 12 was heard yelling Help. Agency nurse, LPN 3, responded to Resident 12's room and he was observed to have removed the covers, was attempting to swing his legs over the side of the bed and was heard telling Agency nurse 3 that he needed to Pee. Agency nurse 3 asked several staff members if Resident 12 was on a toileting program and then asked if he could use a urinal. Staff members told her Resident 12 could probably use a urinal. She obtained a urinal and assist Resident 12 to utilize the urinal. On 7/8/2022 at 9:33 A.M., Resident 12 was observed undressed, in bed with a nebulizer mask and oxygen tubing on his face. The resident remained in bed until 11:35 A.M., when he was heard yelling Help. QMA 1 and CNAs 7 and 10 eventually all entered the room. The resident was assisted to stand at the side of the bed and CNA 7 and 10 removed his wet brief, wiped his buttocks area applied a new pull up style incontinence brief and assisted the resident to dress. The resident was having difficulty standing, could not complete a transfer and complained of not feeling well. The resident was then assisted back into bed. The resident was not offered an opportunity to utilize the urinal and/or the toilet. Resident 12 was heard again yelling Help and indicated he wanted to get up out of bed. Agency RN 11 was notified but she did not assist the resident to transfer out of bed. At 12:15 P.M., QMA 1 administered crushed oral medications and obtained Resident 12's blood sugar level but he was not assisted to utilize the toilet or offered a urinal. On 7/8/2022 at 1:51 P.M., Resident 12 was heard yelling Help. RN 11 and CNA 10 assisted Resident 12 into his wheelchair. He was dressed but was not offered any toileting opportunity. At 2:11 P.M., Resident 12 was observed to propel his wheelchair into the hallway and then back into his room was observed attempting to propel his wheelchair into the attached bathroom. Resident 12 indicated he needed to go to the bathroom. The resident's wheelchair would not fit into the doorway of the bathroom door in his room. CNA 12 was alerted and she indicated she was going to attempt to convince the resident to use a urinal instead of the bathroom. At 2:15 P.M., CNA 12 was observed pushing Resident 12 into the shower room, located across the hall from Resident 12's room. CNA 12 then assisted Resident 12 to transfer onto the toilet. Interview with CNA 12, on 7/8/2022 at 2:23 P.M. indicated Resident 12 was able to be continent of his bowels on the toilet. She indicated his continence varied at times. On 7/11/2022 at 9:10 A.M. Resident 12 was observed lying in his bed, awake. The resident remained in his bed until 11:28 A.M., when QMAs 1 and 13 entered his room and transferred the resident into the wheelchair. He brief was changed and he was assisted to dress but he was not offered an opportunity to use the toilet. Interview with QMA 13, on 7/11/2022 at 1:56 P.M. indicated Resident 12 did not have a toileting plan and is mostly incontinent. She indicated he is checked about every 2 hours for incontinence. The clinical record for Resident 12 was reviewed on 7/6/2022 at 2:00 P.M. Resident 12 was admitted to the facility after recovering from aspiration pneumonia. The resident also had diagnoses including but not limited to: abnormalities of gait and mobility, unsteadiness on feet, constipation, benign prostatic hyperplasia with lower urinary tract symptoms, very low levels of personal hygiene and dementia with Lewy bodies unspecified, The admission Minimum Data Set (MDS) assessment, completed on 4/4/2022 indicated the resident was frequently incontinent of his bowels and bladder and required extensive staff assistance of two for toileting and transfer needs. The admission Bowel and Bladder Assessment, completed on 6/22/2022 indicated the resident went to the restroom, required staff assistance and utilized bot incontinence products and a bedpan/urinal. The current care plan regarding incontinence for Resident 12, current through 9/28/2022, indicated the resident was to be toileted before and after meals, upon rising in the AM and before bed at night. 3. During the initial tour of the facility, conducted on 7/5/2022 between 10:05 A.M. - 11:30 A.M., Resident 53's room was noted to have a very strong urine odor. Resident 53 was observed to spend his time up in his wheelchair, either in his room watching television and/or propelling himself around the facility. On 7/6/2022 from 8:47 A.M. - 11:39 A.M., Resident 53 was observed propelling himself in the hallway and/or was in his room watching television. No staff were noted to offer any toileting opportunities. On 7/7/2022 at 2:52 PM., Resident 53 was observed to propel himself into a public bathroom. QMA 13 was alerted, knocked on the door and indicated the resident had transferred himself onto the toilet. She indicated usually he requested staff assistance to use the toilet and utilized the urinal independently in his room. On 7/8/2022 at 9:33 A.M., Resident 53 was observed to propel himself into his room and remained in his room from 9;33 A.M. - 11:34 A.M. without any toileting assistance. On 7/11/2022 from 9:10 A.M. - 12:09 P.M., Resident 53 was observed propelling himself in the hallway towards his room and/or in his room. No staff were observed entering his room to offer any toileting assistance. A Dietary Manager did greet the resident at 10:23 A.M. but no nursing staff were noted in the room until 12:09 P.M., when Resident 53's lunch tray was delivered. The most recent quarterly MDS assessment for Resident 53, completed on 5/22/22, indicated the resident required the extensive assistance of two staff for transferring and toileting needs and was occasionally incontinent of his bladder and frequently incontinent of his bowels. The bowel and bladder assessment, completed on 5/22/2022 indicated the resident used a bed pan and urinal, was occasionally incontinent of his bowels and had multiple times of bladder incontinence per day. The current care plan related to toileting needs for Resident 53, current through 8/18/2022, indicated the resident was to be toileted before and after meals, upon rising in the AM and before bed at night. A policy was provided on 4/12/2022 at 1:39 P.M. by the Regional Nurse Consultant. The policy titled, Urinary Tract Infections [UTI]. The policy did not indicate when a urinary tract infection should be treated. 4.1-41(a)(2)

Based on observation, interview and record review, the facility failed to ensure a significant change in a resident's nutritional status was assessed timely and interventions implemented timely to address the weight loss for 1 of 4 residents reviewed for nutritional needs. (Resident 25) Finding includes: During the initial tour of the facility, conducted on 7/5/2022 between 10:00 A.M. - 11:05 A.M., Resident 25 was observed lying flat in her bed. The resident's meal tray was delivered to her room at 12:10 P.M. The resident's tray was not set up, there was plastic covering her bowl of dessert and the tray was not really in the resident's reach. The resident was not cued to sit up to eat her food. At 2:40 PM., Resident 25 was observed lying in her bed awake. Her meal tray was on the overbed table, just out of her reach and was untouched. On 7/6/22 at 8:47 A.M., Resident 25 was observed lying flat in her bed, her breakfast tray was observed untouched on her overbed table. The resident was awake and said she was going to eat but made no attempt to sit up to eat her breakfast tray. At 9:30 A.M., Resident 25 was noted in the same position, her plastic coffee mug had been moved and was 1/2 empty with some coffee spilt onto her tray and overbed table. At 12:23 P.M., Resident 25 was observed lying in her bed, facing the wall. The breakfast tray was still noted on her overbed table and 1/2 of a piece of toast had been eaten. Not set up for meals,, not eating food left on overbed table On 7/7/2022 at 1:20 P.M., Resident 25 was observed lying in her bed, awake. Her untouched lunch tray was noted on her overbed table. On 7/8/2022 at 1:51 P.M., Resident 25 was observed lying in her bed, on her back, asleep. Her lunch tray was noted on her overbed table with only a bite taken of the dessert. There was also an unopened, wrapped Danish pastry on her overbed table. On 7/11/2022 at 8:18 A.M., Resident 25 was observed lying in her bed, awake with one leg bent and hanging off the side of her bed. Her breakfast tray was noted on the overbed table. A few bites of biscuits and gravy had been consumed but there was still plastic wrap on the plastic bowl of cereal. The clinical record for Resident 25 was reviewed on 7/6/2022 at 2:40 P.M. Resident 25 had diagnoses, including but not limited to: cognitive communication deficit and chronic obstruction pulmonary disease. The most recent Minimum Data Set (MDS) assessment, completed on 5/5/2022 indicated the resident was moderately cognitively impaired, required limited assistance of one staff for eating needs and had experienced a weight change of either 5 % loss/gain in the past 30 days or 10 % loss/gain in the past 180 days Review of the resident's weights indicated her weight on 5/5/2022 was 159 pounds and her weight on 6/22/22 was 145 pounds, an 11.01% weight loss in 30 days. The most recent Physician's Progress Note for Resident 25, completed on 7/7/2022 at 5:06 P.M., indicated the resident did not have any swelling and there was no mention of any recent weight loss. The most recent nutritional note, completed by the Registered Dietician, dated 3/4/2022 indicated at the time, the resident's weight was 157 pounds and her weight was stable at the time. On 7/11/2022 a request for any nutritional assessments regarding Resident 25's significant weight loss was requested. A nutritional assessment, completed on 7/11/2022 by the registered dietician was provided by the Corporate nurse consultant on 7/12/2022 at 3:00 P.M. The note acknowledged the 6/22/2022 weight and indicated there had been an 11% weight loss in 5 weeks. The note continued and indicated the resident consumed 50 - 100 % of her meals. The note recommended a reweigh be obtained and a nutritional supplement of med pass be initiated three times a day to increase calories and protein. A physician's order for the supplement was obtained on 7/11/2022. 3.1-46

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5 percent (%) for 2 of 7 residents observed during medication pass. Seven (7) medication errors were observed during 33 opportunities for error in medication administration. This resulted in a medication error rate of 24.24%. The errors involved 2 residents (Resident 19 and 31) in a sample of 2. Findings include: 1. On 7/8/2022 at 8:15 A.M., Resident 19 was observed being administered furosemide 20 mg (milligrams), vitamin D3 400 IU (International Unit), Eliquis 5 mg, amiodarone 200 mg 2 tabs, esomeprazole 20 mg, hydrochlorothiazide 12.5 mg, oxybutynin 15 mg, potassium chloride 10 meq (milliequilivant), pravastatin 10 mg, vitamin B-12 500 mcg (micrograms), budesonide 3 mg 3 capsules, ProAir HAS 90 mcg 2 inhalations, Advair Diskus 100-50 mg inhalation, and fluticasone 50 mcg 1 spray to each nostril. A review of Resident 19's Physician Orders indicated Advair Diskus 100-50 mg to rinse and spit the mouth after use. Resident 19 did not rinse her mouth after use of the inhalant. The packaging directions for esomeprazole 20 mg indicated, to administer the medication one hour prior to eating. Resident 19 had finished her breakfast prior to the administration of this medication. The packaging directions for ProAir HAS 90 mcg indicated, to what 5 minutes between inhalations. Resident 19 took two inhalations immediately together. During an interview on 7/8/2022 at 8:28 A.M., QMA 2 indicated, Resident 19 should have rinsed her mouth after the administration of the Advair Diskus. She indicated Resident 19 should have waited five minutes between inhalations of the ProAir. QMA 19 was not aware of any indications related to the administration of the esomeprazole. 2. On 7/8/2022 at 8:39 A.M., Resident 31 was observed being administered carvedilol 25 mg, acetaminophen 325 mg 2 tablets, loratadine 10 mg, duloxetine 20 mg, lisinopril 5 mg, risperidone 0.25 mg, senna 8.6 mg, fluticasone 50 mcg 2 sprays each nostril, and Refresh 0.5-1-0.5% eye drops 1 drop in both eyes. A review of Resident 31's Physician Orders indicated Resident 31 was also to receive aspirin 325 mg, Norvasc 5 mg, and vitamin D3 100 IU. These were not administered. During the administration of the medications, Resident 31 did not use the Refresh single use container provided by QMA 1. Resident 31 picked up a used single use container from her bedside table and self-administered from the container. QMA 1 did not stop Resident 31 from using the opened, previously used container. During an interview on 7/8/2022 at 8:45 A.M., QMA 1 indicated, Resident 31 should not have administered a previously used container of the eye drops. The previously used container should have been discarded at the time of use. On 7/8/2022 at 10:36 A.M., the Administrator provided a current policy titled, Medication Pass: Process and Procedure. The policy indicated, .9. Administration of medication a. Administer medication in accordance with frequency prescribed by physician On 7/12/2022 at 1:39 P.M., the Regional Corporate Nurse provided a current policy titled, Eye Drop Administration. The policy indicated, Medications will be administered in a safe and effective manner. The policy does not address administration of a single-dose eye drop container and the disposal of the container. On 7/12/2022 at 1:39 P.M., the Regional Corporate Nurse provided a current policy titled, Oral Inhalation Administration. The policy indicated, .Metered Dose and Dry-Powder Inhalers . 14. If another puff of the same or different medication is required, wait at least 1-2 minutes between .15. For steroid inhalers, provide the resident with a cup pf water and instruct them to rinse their mouth and spit the water back into the cup 3.1-48(c)(1)

Based on observation, interview and record review, the facility failed to ensure food items in the freezer were dated/labeled and sealed securely after opening, failed to ensure used by dates were on foods, failed to dispose of expired foods, failed to ensure cooking utensils/oven/ice machine/refrigerators were clean and in good condition in the main kitchen for in 1 of 1 pantries observed- behavior unit pantry. This deficient practice had the potential to affect 80 of 81 residents who received meals out of the kitchen. Findings include: 1. During an observation of the main kitchen on 7/5/2022 at 9:54 A.M., with dietary staff 5, the following was observed: the freezer had a zip lock bag of pre-made pancakes, dated 5/31/2022, and an opened box of chocolate chip cookies (frozen dough) not sealed securely. During an interview, on 7/5/2022 at 10:00 A.M., dietary staff indicated the pancakes should have been thrown out and the cookie dough should have been sealed. 2. On 7/6/2022 at 11:09 A.M. during a follow up observation in the main kitchen with dietary staff 5, the following were observed: The oven had dried food substances and grease along the edges. Two (2) opened blocks of white cheese slices were undated. Three skillets with the Teflon coating were pealed off. Three stainless steel containers with dried food substances along the edges. Four small desert bowls with dried specs of food. The refrigerator had a torn rubber seal along thee bottom of the right side door and an area of food along the edge of the seal. The ice machine had a ripped seal along the bottom edge of the opening and inside above where the ice was held, was a white piece of hard plastic with a brown substance along the edge of the piece. During an interview, on 7/6/2022 at 11:24 A.M., dietary staff 5 indicated the cheese should have had dates on them, the skillets should have been thrown away, the dishes were not cleaned, the fridge should not have a torn seal and the ice machine was not clean. 3. On 7/8/2022 at 11:01 A.M., during an observation of the behavior unit kitchen with CNA 6, the following was observed: The refrigerator had a large build up of ice in the freezer and the bottom crisper drawers had water and food debris. Two opened containers of Med Pass and thickened liquid with no opened dates. During an interview, on 7/8/2022 at 11:04 A.M., CNA 6 indicated the freezer should not be like that, the refrigerator should have been clean and the opened containers should have had dates on them. On 7/11/2022 at 2:48 P.M., the ADON ( Assistant Director of Nursing) provided the policy titled, Labeling and Dating Foods (Date Marking), dated 2020, and indicated the policy was the one currently used by the facility. The policy indicated .2. Date marking for refrigerated storage food items.Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufactures expiration date. 3. Date marking for freezer food items.Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. 4. Prepared food or opened food items should be discarded when: The food item does not have a specific manufactures expiration date and had been refrigerated for 7 days On 7/11/2022 at 2:48 P.M., the ADON provided the policy titled, Cleaning Instructions: Kettles and Utensils, dated 2020, and indicated the policy was the one currently used by the facility. The policy indicated .Kettles and utensils will be cleaned and sanitized regularly. 1. Clean interior and exterior with hot water and detergent. 2. Scour when necessary. 3. Rinse with clean water. 4. Sanitize with the appropriate sanitizing solution and allow to air dry On 7/11/2022 at 2:48 P.M., the ADON provided the policy titled, Ice Handling and Cleaning, dated 2020. The policy indicated .7. Ice machine will be emptied at least quarterly and thoroughly cleaned with an approved sanitizer to remove any settlement or mineral build-up in the ice discharge area and floor off the machine On 7/11/2022 at 2:48 P.M., the ADON provided the policy titled,Food- Resident Pantry-Safe Storage, dated 11/28/2012, and indicated the policy was the one currently used by the facility. The policy indicated .The dietary staff is responsible for daily nutrition pantry refrigerator cleaning and defrosting, if required and documentation of temperatures. Nursing staff should clean any spills as they occur between daily cleaning.If food or beverages are used for multiple residents, the date open shall be written on the container 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure infection control policies and procedures were in place and implemented regarding COVID -19 isolation, oxygen storage and glove use during dressing changes. Findings include: 1. On 7/8/22 at 9:53 A.M., Maintenance Employee 14, entered room [ROOM NUMBER] wearing only a surgical mask. The room was marked with two Yellow zone isolation signs which indicated the resident was in droplet precautions. At 10:22 A.M., Employee 14 exited the room and was queried as to why he did not wear the appropriate personal protective equipment. Employee 14 indicated he was not aware room [ROOM NUMBER] was in isolation and he Didn't pay no attention. to the signage outside the room door. On 7/8/2022 at 2:28 P.M., RN 11 entered room [ROOM NUMBER] after donning a disposable gown, an N95 mask and gloves. RN 11 was wearing prescription glasses. room [ROOM NUMBER] was marked with Red signs which indicated the resident was in Droplet precautions. During an interview with the Administrator, on 7/7/2022 at 12:57 P.M., she confirmed the resident in room [ROOM NUMBER] had tested positive for COVID 19 infection. During an interview with RN 11, when she exited room [ROOM NUMBER], she indicated she figured her prescription glasses were good enough eyewear. On 7/8/2022 at 11:35 A.M., QMA 1 was observed exiting room [ROOM NUMBER], a Red Zone room. The QMA removed her eyewear and N95 mask, but had a surgical mask underneath the N95. She did not remove and replace the surgical mask before she continued to care for other residents. Review of the facility policy and procedure, titled Infection Control - Interim COVID 19 policy, provided by the Administrator on 7/5/2022, included the following guidelines: .PPE (Personal Protective Equipment) in Yellow Zone. All recommended COVID-19 PPE should be worn during direct care of residents under yellow zone quarantine which includes use of eye protection (i.e. goggles or a disposable face shied that covers the front and sides of the face, N95 respirator, gloves and gown and PPE in Red Zone: All recommended COVID-19 PPE should be worn during direct care of resident under red zone isolation, which includes use of eye protections (i.e. goggles or a disposable face shied that covers the front an sides of the face), N95 respirator, gloves and gown .N95 should be discarded upon exiting the Red Zone 2. On 7/5/2022 at 10:05 A.M., respiratory tubing connected to a nebulizer mask was noted draped over the dresser in Resident 12's room. The tubing was dated 6/26/2022. The tubing and mask was observed on 7/6/2022 - 7/8/2022 and on 7/11/2022 - 07/12/2022 , draped over the dresser when not in use. The tubing continued to be dated for 6/26/2022 Review of the facility policy and procedure, titled, Oxygen and Respiratory Equipment- Changing/Cleaning, provided by the Corporate Nurse consultant on 7/12/2022 at 3:00 P.M., included the following procedure: .a. The hand held nebulizer should be changed weekly and PRN. b. A clean plastic bag, with a ziploc or draw string, etc will be provided with each new set up, and will be marked with the date the set up was changed .to store the cannula when it is not in use 3. During the observation of a dressing change, conducted on 7/12/22 at 2:18 PM, RN 11 had donned disposable gloves and removed the dressing from Resident 12's right foot. There was a moderate amount of serous drainage on the old dressing. The nurse then cleaned the resident's wound with spray on wound cleanser, dabbing the cleaner around the wound with a gauze dressing she was holding in her gloved hand. Next, she dried the wound. RN 11 then proceeded to apply ointment to the wound bed with a wooden applicator, then dabbed Betadine liquid around the wound edges with her contaminated gloved hand and a piece of gauze. She then applied a thick absorbent dressing and wrapped gauze about the resident's foot to hold the dressing in place. She then removed her gloves and washed her hands. During an interview with RN 11, just after the dressing change she confirmed she probably should have changed her gloves inbetween the soiled and clean portions of the dressing change. 3.1-21(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure resident rooms and equipment were maintained in a clean manner and/or were not in disrepair on 2 of 3 nursing units. Finding includes: 1. During the initial tour of the facility, conducted on 7/5/2022 between 10:00 A.M. - 11:30 A.M., the following environmental issues were noted. These issues remained throughout the survey process and were noted again on the environmental tour of the facility, conducted with the Maintenance Director and the Administrator, on 7/12/22 from 10:12 A.M. - 11:10 A.M.: Unit 1: room [ROOM NUMBER]- The overbed table frame was dirty with dried creamy yellow substance and the room had a persistent, pervasive urine odor. During an interview with the Administrator, during the Environmental tour, she indicated the resident urinated all over the room. Unit 1: room [ROOM NUMBER]- The over bed tabletop was missing laminate around the edges. Unit 1: room [ROOM NUMBER]- A dried pink puddle was noted on the floor under the bed near the right wheels and towards the head of the bed. The bedside table frame was heavily soiled with dried liquid spots and the mat of the floor next to the resident's bed was soiled with black marks and dried spilled liquids. Unit 1: room [ROOM NUMBER]- The wall next to the bed had several large gouges of missing drywall and paint along the length of the bed and the overbed table frame was dirty with dried food debris and dried liquid spots. Unit 2: room [ROOM NUMBER] - The light socket by the end of Bed 1 did not have a cover and had electrical equipment plugged into the exposed outlet. Unit 2: room [ROOM NUMBER] - The wall by the bathroom and closet was noted to have scrape [NAME] with missing drywall and paint. Unit 2: room [ROOM NUMBER] - The privacy curtain by Bed 1 was visibly soiled with spots of brown colored and red/pink colored substances. During an interview with the Administrator, during the environmental tour, she indicated the facility had some new overbid tables in the building. The Administrator indicated the facility was in the process of ordering new nightstands and dressers. A cleaning and preventative maintenance policy was requested but not received on 04/12/2022 at 2:30 P.M. 3.1-19(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 7/12/2022 at 1:39 P.M., the Regional Corporate Nurse provided a current policy titled, Comprehensive Care Plans. The policy indicted, .To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The resident and/or resident's representative shall be invited to review the plan of care with the interdisciplinary team either in person, via telephone, or video conference at least quarterly 3,1-35(a) 3.1-35(d)(2)(B) Based on observation, record review and interview, the facility failed to ensure care plans were developed regarding behavior needs for 4 of 22 residents reviewed for care planning. Findings include: 1. During an observation, on 7/5/2022 at 12:03 P.M., Resident 60 was observed yelling out from her room with the door closed. On 7/6/2022 at 11:49 A.M., Resident 60 was observed constantly yelling out, Mommy. When the staff approached Resident 60 in her room, she indicated, I don't feel good. The staff left her room and shut the door. At 12:12 P.M., she was observed yelling from her room, Come get me up. On 7/7/2022 at 9:58 A.M., Resident 60 was observed yelling from her room, I've got to go pee. At 1:15 P.M., she was observed sitting on the edge of her bed, Come and get me. I'm cold. She was attended to by staff, put back into bed in her dark room. On 7/11/2022 at 10:51 A.M., Resident 60 was screaming in the common area, I want out of here. I want to go home. My back hurts. A record review of Resident 60 was completed on 7/8/2022 at 11:26 A.M. Diagnoses included, but were not limited to: dementia with behavioral disturbance, Major depressive disorder with severe psychotic symptoms, and convulsions. An admission Minimum Data Set (MDS) Assessment, on 5/26/2022, indicated Resident 60 had severe cognitive impairment. During the assessment period, the MDS indicated she had one to three days of verbal behavioral symptoms directed towards others and one to three days of behavioral symptoms not directed towards others. She received an antipsychotic and antidepressant medication six out of the seven assessment days and an antianxiety medication one day out the seven assessment days. A Nurse's Note, on 6/2/2022 at 7:56 A.M., indicated, Resident began screaming at 7:00 this morning asking for her sister and demanding for food. Resident has been disruptive to other patients. Redirection was attempted, however not effective. Resident seems very anxious and is walking with an unsteady gait. Will notify the Dr. [Doctor] On 6/4/2022 at 5:10 A.M., a Nurse's Note indicated, Resident frequently yelling out for husband, demanding staff call husband to come and get her. Resident mostly stayed in room, or right outside of entrance to room. Yelling continued throughout the night. Attempts to redirect and reorient unsuccessful. On 6/7/2022 at 11:57 A.M., a Nurse's Note indicated, Resident has been yelling out all morning ¨where is my husband¨ being very disruptive to other residents and causing them to become agitated and have behavioral expressions as well. All attempts to redirect or distract has been ineffective. Resident is also being combative with staff and very uncooperative, also interfering with other residents care and disruptive at meals. On 6/10/2022 at 12:32 P.M., a Nurse's Note indicated, Resident has been having extreme repetitive behaviors since she has awakened this AM. Resident has been yelling non-stop about her husband; having her hair done; where she is; and any other thought that is getting stuck in her thought process. Resident has started and exacerbated the behaviors in every other resident on this unit since she join the common area. Resident is impossible to redirect and seems to have zero short term memory retention at this time. At 1:05 P.M., a Nurse's Note indicated, This nurse obtained a new order for Haldol 5mg x [times] 1 dose to be given now r/t [related to] increased anxiety and agitation. Resident has been asking everyone about her husband, wanting to know where he is and when he is going to come in. When staff answers resident, it goes completely unnoticed. Resident has been telling other resident's to shut up, and bossing them around while telling them that they are bothering her. In actuality it has been this resident's constant yelling out that has escalated the behaviors on the unit this shift. At 6:25 P.M., a Nurse's Note indicated, Haldol has been ineffective on resident at this time. Resident's behaviors have continued without pause during this shift. Resident is yelling at staff, and other resident's still. On 6/13/2022 at 11:28 A.M., a Nurse's Note indicated, New order for Ativan 0.5 mg po q 6 hours d/t increase agitation/anxiety. Residents spouse aware of the new order and was ok with it. On 6/17/2022 at 2:12 P.M., a Nurse's Note indicated, Resident was noted in her room upset that her husband had left for the day. Resident's roommate was brought to the room for a check and change and to be laid down. [Resident 60] then got out of bed and came over to her roommate's wheelchair and attempted to remove her from the room. When nurse aide attempted to stop resident and separate them, [NAME] took her fist and swung full force at her roommate making contact and hitting her in the right side of her forehead. Residents have been separated and neuros were started on the roommate. On 6/17/2022 at 5:24 P.M., a Nurse's Note for Behavior/Mood Charting indicated, Description of the behavior: Resident has been noted with what appears to be elevated anxiety, agitation, aggression, and tearfulness. Intervention: Resident has been given quite time, she has taken a nap, she was visited by her husband, and she was offered snacks and fluids. Outcome and Prevention: Behaviors have continued to escalate as the day progressed. So much so that resident has been aggressive and physical with other resident's and staff. On 6/21/2022 at 12:29 P.M., a Nurse's Note indicated, Resident has been yelling and screaming out all morning for her husband and yelling and screaming impatiently for staff for any need that she has. Writer gave prn Ativan 0.5mg at 10am which was in effective resident was content for about 1 hour then began yelling and screaming out for husband again during lunch disrupting other residents. resident then went to her room and began yelling out extremely loud for husband and has continued to yell and scream unable to be redirected or distracted. On 6/28/2022 at 3:36 P.M., a nurse's entry in the Behavior/Mood Assessment indicated, Behavior noted this shift: Wandered, verbally aggressive and resistive to cares, Mood: was questions/seems lost or bored, repeated verbalizations, and displayed anger with self and others, Location: in activities and in common area with television, Interventions: assessed for pain, conversation, given food, left alone and reapproached, prn medication given, massage/touch, reassured, television/radio, toileted, Resident response: uncooperative and behavior continues Duration: greater than 1 hour, Outcome: unchanged MD notified and new order for U/A C&S [urinalysis with culture a nd sensitivity]. On 6/28/22 at 4:00 P.M., a nurse's entry in the Behavior/Mood Assessment indicated, Behavior physically aggressive, 05:55 Resident was screaming when I entered unit. Repeatedly asking to be driven to her home. Prior nurse administered PRN Ativan. Continuously asking residents can you take me home Can you drive me home open the door for me, I need to get out of here. Refused breakfast. Accepted morning medications. Asked resident multiple times to lower her voice. Aggressor pulled on another resident's hands leading him to door, he became very upset and screamed don't touch me and raised his hand in a striking motion, staff intervened and separated residents. Resident specific behavior triggers: Approximately 0900 resident went to room and fell asleep in bed, awoke before lunch was served. Sat herself at table and ate less than 25%. Got up and started to yell. Repeatedly asking the same questions. Exit seeking and asking staff and residents to let her out. Became angry when we asked her to lower her voice. Resident pacing unit pushing on every door to find a way out. Yelling let me out, someone let me out help, help me. A PRN 0.5 Ativan was administered accepted. Behaviors continued with more aggression. Other residents becoming agitated with constant yelling and repeated question of whether or not someone could take her home. 13:55 Call placed to doctor about behavior. One time additional dose of prn Ativan received. Order put in and medication pulled. When attempting to administer medication, resident smacked writers hand and knocked med cup out of my hand and onto floor. medication wasted and charted. DON notified. 14:32 resident swinging at others unsuccessfully. Resident made a one on one for monitoring. Pacing and yelling continued. Snacks and drink offered and refused. Offered a warm shower and a nap. Resident refused suggestions. Music videos played without calming effects. Activities aid attempted sensory exercises. 15:24 resident slapped CNA across face. DON notified. 15:36 resident pushed another resident while both sitting on couch. Aggressor wanted the couch to herself. 5:40 call placed to doctor about continued and worsening behavior. Order given for a one time dose of Haldol 7.5 IM. DON notified, order placed and medication pulled. 15:43 resident pushed CNA. Resident seated in front of television with movie playing. 15:48 resident hit and scratched CNA's right arm. 16:15 administration of medication with the assistance of three CNA's for safe and sterile administration. Ventrogluteal site cleansed with alcohol pad before administration. One on one assigned to monitor. Mood repeated verbalizations, display anger with self/others, unpleasant morning mood, agitated/easily upset Interventions: 1:1 with staff, activity, assessed for pain, conversation, given food, prn medication given, music, offered snack, redirected, television/radio. On 7/4/2022 at 11:22 A.M. indicated, Resident given 1 mg [milligram] Ativan injection in left Deltoid for agitation Resident tolerated well. On 7/4/2022 at 5:49 P.M., a Nurse's Note indicated, Called to Garden unit, Resident in dining room screaming for mommy., Resident threw glass of juice across dining room. Attempted to turn over dining room table and became physically aggressive with staff. Resident very upset and confused because mommy was not present. Resident also having delusions/hallucinations of mommy under the table. Resident taken back to her room. Resident yelling and screaming about many random things. Resident continues to be physically abusive to staff. After about 20 minutes resident has started to wear herself out with screaming and yelling. Resident eating when I exited the room. Resident is a one to one at this point in time. On 7/6/22 6:18 P.M., a Nurse's Note indicated, At times verbally and physically aggressive Behavior Triggers:: Not getting a response or the response they wanted from staff or another resident to a question they asked. Resident had family visit. When family left resident began screaming constantly, was physically and verbally aggressive. Resident placed self on floor. Attempted to console resident failed. Resident continued to be physically and verbally aggressive. Mood: Displayed anger with self/other, agitated/easily upset; location: resident's room; Interventions: 1:1 with staff, assessed for pain, conversation, offered snack, reassured, toileted, offered resident dinner and conversation; Resident Response: Accepted; Resident needed 5mg Haldol IM On 7/6/22 7:36 P.M., a Nurse's Note indicated, Behaviors in the PM, was verbally aggressive, resistive to care, Behavior triggers: Not getting a response or the response they wanted from staff or another resident to a question they asked. Mood: Crying/tearfulness noted, Made negative statements, Unrealistic fears about environment, Agitated/easily upset, Exaggerates; Location: Hallway Interventions: 1:1 with staff, PRN medication given; Resident was given Haldol injection see progress not. Response: Uncooperative A Physician Progress Note, on 6/2/2022 at 5:55 P.M., indicated, .increase anxiety as per nurse as she continues to wait for the husband to pick her up. we will increase Buspar to 10 mg tid [three times a day] On 6/6/2022 at 6:24 P.M., a Physician Progress Note indicated, .anxiety is better but still there .anxiety. we will increase Buspar to 15 mg tid. it has been helping the patient On 6/8/2022 at 9:07 A.M., a Physician Progress Note (entry from Nurse Practitioner) indicated, .Visit today for nursing concerns of resident having increasing behaviors. On Monday her Lexapro was increased. Reports from nursing resident was seen by [attending physician] and increased Buspar. Medications and dosages reviewed during visit .spoke with Psych NP [nurse practitioner] and [facility physician] during my visit. [facility physician] advised to increase Buspar to 15mg TID and follow On 6/30/2022 at 4:27 P.M., a Physician Progress Note indicated, .Patient has had agitations needing Haldol and Ativan with Buspar. no significant agitations today On 7/4/2022 at 11:23 P.M., a Physician Progress Note, indicated, .Significant agitation and we did im [intramuscularly] Ativan given and patient is sleeping and calm On 7/7/2022 at 4:53 P.M., a Physician Progress Note, indicated, .still having some agitations but not too far from her usual. hallucination is still noted . anxiety with agitation noted . Resident 60's Care Plans were requested on 7/11/2022 at 12:05 P.M. A Care Plan on 5/23/2022, indicated Resident 60 uses psychotropic medications related to aggression, agitation, and psychosis. The Care Plan did not include Resident 60's behavioral triggers or interventions to prevent behaviors. On 7/12/2022 at 2:32 P.M., a requested Care Plan for behaviors was received. The Care Plan indicated, Resident 60 uses psychotropic medications related to aggression, agitation, and psychosis. The Care Plan now include Resident 60's behavioral triggers or interventions to prevent behaviors. Behavioral triggers and interventions of reassure/redirect resident, offer snack and drinks, try to engage activities, like doing puzzles, likes to clean, remind resident husband is working. An interview on 7/12/2022 at 9:57 A.M., with the Assistant Director of Nursing (ADON), indicated that family visits triggers behaviors upon them exiting the building. During an interview on 7/12/2022 at 2:38 P.M., the MDS Coordinator indicated she did not update the care plan received on 7/12/2022. On 7/12/22 at2:45 P.M., the Social Service Director (SSD) indicated she went to check on the care plan and noted that at that time there was not a trigger or interventions in the care plan. The SSD checked her personal computer files and indicated she had developed a plan in her personal behavioral management plan on 6/24/2022, and then copied and pasted it to the care plan today During an interview on 7/12/2022 2:54 P.M., LPN 3 indicated that behavioral triggers and interventions would be found in the care plan and listed on the [NAME] (the resident's plan of care for CNA's from the care plan. 2. During the initial tour of the facility, conducted on 7/5/2022 between 10:05 A.M. - 11:30 A.M., Resident 53's room was noted to have a very strong urine odor. Resident 53 was observed to spend his time up in his wheelchair, either in his room watching television and/or propelling himself around the facility. On 7/6/2022 from 8:47 A.M. - 11:39 A.M., Resident 53 was observed propelling himself in the hallway and/or was in his room watching television. No staff were noted to offer any toileting opportunities. On 7/7/2022 at 2:52 PM., Resident 53 was observed to propel himself into a public bathroom. QMA 13 was alerted, knocked on the door and indicated the resident had transferred himself onto the toilet. She indicated usually he requested staff assistance to use the toilet and utilized the urinal independently in his room. On 7/8/2022 at 9:33 A.M., Resident 53 was observed to propel himself into his room and remained in his room from 9;33 A.M. - 11:34 A.M. without any toileting assistance. On 7/11/2022 from 9:10 A.M. - 12:09 P.M., Resident 53 was observed propelling himself in the hallway towards his room and/or in his room. No staff were observed entering his room to offer any toileting assistance. A Dietary Manager did greet the resident at 10:23 A.M. but no nursing staff were noted in the room until 12:09 P.M., when Resident 53's lunch tray was delivered. The most recent quarterly MDS assessment for Resident 53, completed on 5/22/22, indicated the resident required the extensive assistance of two staff for transferring and toileting needs and was occasionally incontinent of his bladder and frequently incontinent of his bowels. The bowel and bladder assessment, completed on 5/22/2022 indicated the resident used a bed pan and urinal, was occasionally incontinent of his bowels and had multiple times of bladder incontinence per day. The current care plan related to toileting needs for Resident 53, current through 8/18/2022, indicated the resident was to be toileted before and after meals, upon rising in the AM and before bed at night 3. Resident 12 was observed on 7/6/2022 at 8:47 A.M., seated in a wheelchair in his room, feeding himself breakfast. At 9:30 A.M., the resident was assisted back into his bed and his brief was changed. He was not offered an opportunity to use the urinal and/or go to the toilet. The resident remained in his bed from 9:30 A.M. to 12:42 P.M. The resident's lunch tray was delivered to his room but was left covered on his overbed table. Resident 12 was observed on 7/7/2022 at 10:23 A.M., lying in his bed awake. Resident 12 was observed to remain in his bed and was observed feeding himself lunch at 12:57 P.M. At 2:52 P.M., Resident 12 was heard yelling Help. Agency nurse, LPN 3, responded to Resident 12's room and he was observed to have removed the covers, was attempting to swing his legs over the side of the bed and was heard telling Agency nurse 3 that he needed to Pee. Agency nurse 3 asked several staff members if Resident 12 was on a toileting program and then asked if he could use a urinal. Staff members told her Resident 12 could probably use a urinal. She obtained a urinal and assist Resident 12 to utilize the urinal. On 7/8/2022 at 9:33 A.M., Resident 12 was observed undressed, in bed with a nebulizer mask and oxygen tubing on his face. The resident remained in bed until 11:35 A.M., when he was heard yelling Help. QMA 1 and CNAs 7 and 10 eventually all entered the room. The resident was assisted to stand at the side of the bed and CNA 7 and 10 removed his wet brief, wiped his buttocks area applied a new pull up style incontinence brief and assisted the resident to dress. The resident was having difficulty standing, could not complete a transfer and complained of not feeling well. The resident was then assisted back into bed. The resident was not offered an opportunity to utilize the urinal and/or the toilet. Resident 12 was heard again yelling Help and indicated he wanted to get up out of bed. Agency RN 11 was notified but she did not assist the resident to transfer out of bed. At 12:15 P.M., QMA 1 administered crushed oral medications and obtained Resident 12's blood sugar level but he was not assisted to utilize the toilet or offered a urinal. On 7/8/2022 at 1:51 P.M., Resident 12 was heard yelling Help. RN 11 and CNA 10 assisted Resident 12 into his wheelchair. He was dressed but was not offered any toileting opportunity. At 2:11 P.M., Resident 12 was observed to propel his wheelchair into the hallway and then back into his room was observed attempting to propel his wheelchair into the attached bathroom. Resident 12 indicated he needed to go to the bathroom. The resident's wheelchair would not fit into the doorway of the bathroom door in his room. CNA 12 was alerted and she indicated she was going to attempt to convince the resident to use a urinal instead of the bathroom. At 2:15 P.M., CNA 12 was observed pushing Resident 12 into the shower room, located across the hall from Resident 12's room. CNA 12 then assisted Resident 12 to transfer onto the toilet. Interview with CNA 12, on 7/8/2022 at 2:23 P.M. indicated Resident 12 was able to be continent of his bowels on the toilet. She indicated his continence varied at times. On 7/11/2022 at 9:10 A.M. Resident 12 was observed lying in his bed, awake. The resident remained in his bed until 11:28 A.M., when QMAs 1 and 13 entered his room and transferred the resident into the wheelchair. He brief was changed and he was assisted to dress but he was not offered an opportunity to use the toilet. Interview with QMA 13, on 7/11/2022 at 1:56 P.M. indicated Resident 12 did not have a toileting plan and is mostly incontinent. She indicated he is checked about every 2 hours for incontinence. The clinical record for Resident 12 was reviewed on 7/6/2022 at 2:00 P.M. Resident 12 was admitted to the facility after recovering from aspiration pneumonia. The resident also had diagnoses including but not limited to: abnormalities of gait and mobility, unsteadiness on feet, constipation, [NAME] prostatic hyperplasia with lower urinary tract symptoms, very low levels of personal hygiene and dementia with lewy bodies unspecified, The admission Minimum Data Set (MDS) assessment, completed on 4/4/2022 indicated the resident was frequently incontinent of his bowels and bladder and required extensive staff assistance of two for toileting and transfer needs. The admission Bowel and Bladder Assessment, completed on 6/22/2022 indicated the resident went to the restroom, required staff assistance and utilized bot incontinence products and a bedpan/urinal. The current care plan regarding incontinence for Resident 12, current through 9/28/2022, indicated the resident was to be toileted before and after meals, upon rising in the AM and before bed at night. 4. During an interview with Resident 12's representative, conducted on 7/5/2022 at 3:15 P.M., it was disclosed Resident 12's dentures had been recently refitted and fit perfectly but the resident was not wearing his dentures and his family member felt he needed to be wearing them at meal times to properly chew his food. He indicated he was unsure why the resident was not wearing his dentures and knew he sometimes refused to do things due to his dementia. While discussing the dentures, Resident 12 interrupted the interview and indicated he desired to wear his dentures. Resident 12 was observed on 7/6/2022 at 8:47 A.M., seated in his wheelchair feeding himself breakfast. He was not wearing his dentures On 7/7/2022 at 12:48 P.M. Resident 12 was observed in his bed, feeding himself lunch and he was not wearing dentures. On 7/8/2022 at 11:35 A.M., Resident 12 was assisted with care, his brief was changed and he was dressed in shorts and a T-shirt. He was not offered oral care, nor was he offered assistance with his dentures. On 7/11/2022 at 9:18 A.M., Resident 12 was observed in his bed, a partially consumed breakfast tray was on the overbed table. He was not observed to be wearing his dentures. On 7/11/2022 at 11:31 A.M., he was assisted to dress and transfer to his wheelchair. He was not wearing his dentures. He was served his lunch tray at 12:22 P.M. and was not offered assistance with his dentures. During an interview with QMA 13, conducted on 7/12/22 at 3:11 P.M., she indicated she thought Resident 12 wore dentures. CNA 12, overheard the question and indicated Resident 12 definitely was supposed to wear his dentures. QMA 13 then proceeded to go to Resident 12's room and located his dentures in a yellow denture cup on the shelf above the handwashing sink in his room. She was unaware why the resident had not been wearing his dentures recently. Review of the current care plan regarding Assistance for Daily Living for Resident 12, current through 08/19/2022, indicated the resident had upper and lower dentures and required staff assistance daily for denture cleansing/care and oral care. Review of the routine charting of Activities of Daily Living indicated there was no specific documentation regarding the use of dentures. The resident was documented as requiring extensive staff assistance for personal hygiene, which did include brushing of teeth. 5. During an interview with the representative for Resident 12, conducted on 7/5/2022 at 3:17 P.M., Resident 12 was observed drinking unthickened soda with a straw from a large disposable cup. The resident's representative indicated Resident 12 had been admitted to the long term care facility from the hospital due to pneumonia caused from a swallowing issue. Resident 12 was noted to have a slightly wet sounding cough after drinking the soda from the straw The current diet order for Resident 12 was for a mechanically soft/ground meats with nectar thickened liquid. The current care plan for Resident 12, current through 09/28/2022 indicated the resident was to receive a NCS (No concentrated sweets) diet, Mechanically soft foods with Nectar thickened liquids. On 7/7/2022 at 2:05 P.M., a pitcher of water and small, 1/2 full glass of water, utilized when administering medications, was noted on the dresser beside Resident 12's bed. On 7/8/2022 at 9:33 A.M., a pitcher of unthickened water with a straw, was noted on the dresser beside the resident's bed. On 7/11/2022 at 9:18 A.M., Resident 12 was observed sitting up in bed with a partially consumed breakfast tray in front of him on an overbed table. A 1/2 full glass of unthickened orange juice was noted on the tray. 6. Resident 12 was observed on 7/5/2022 at 11:45 A.M., lying in his bed awake. There were gauze dressing noted to both feet. The resident was lying on a concave regular mattress. There were quilted boots noted on the floor, near the wall at the end of the resident's bed. The clinical record for Resident 12 was reviewed on 7/6/2022 at 2:00 P.M. Resident 12 was admitted to the facility after recovering from aspiration pneumonia. The resident also had diagnoses including but not limited to: abnormalities of gait and mobility, unsteadiness on feet, chronic gout, excoriation of the skin (skin picking disorder) and peripheral vascular disease. During an interview with Resident 12's health care representative, conducted on 7/5/22 at 3;21 PM., he indicated the facility was having trouble with the resident's heels. Review of an admission assessment, completed on 3/29/2022 indicated the resident was admitted to the facility with scabs on several of his toes and a reddened groin and buttocks area. The initial care plan related to skin/pressure ulcer prevention indicated the following: I have a potential for impairment to skin integrity r/t: COPD (chronic obstructive pulmonary disease, DM (Diabetes Mellitus) with neuropathy, dementia; impaired cognitive status, impaired safety awareness, morbid obesity, PVD (Peripheral vascular disease), anemia, depression, anxiety, incontinence of b/b (bowel and bladder) at times and Resident has excoriated areas from picking on axilla and groin with tx The plan had a goal for the resident not to develop any further alteration in skin integrity. The interventions included: Administer/monitor effectiveness of medications as ordered, Assess/record changes in skin status, Ensure linens are wrinkle free, Keep skin clean and dry. Use lotion on dry skin, Minimize pressure over boney prominences Protective skin barrier cream as ordered., Provide diet as ordered and monitor nutritional status and dietary needs, Report pertinent changes in skin status to physician and Treatment as ordered. The plan was updated with interventions added on 6/16/2022 to encourage the resident to wear booties/heel protectors while in bed and encourage resident to wear shoes when up in wheelchair. The plan was again updated on 6/30/2022 to apply an air mattress to his bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A record review of Resident 60 was completed on 7/8/2022 at 11:26 A.M. Diagnoses included, but were not limited to: dementia with behavioral disturbance, Major depressive disorder with severe psychotic symptoms, and convulsions. An admission Minimum Data Set (MDS) Assessment, on 5/26/2022, indicated Resident 60 had severe cognitive impairment. During the assessment period, the MDS indicated she had one to three days of verbal behavioral symptoms directed towards others and one to three days of behavioral symptoms not directed towards others. She received an antipsychotic and antidepressant medication six out of the seven assessment days and an antianxiety medication one day out the seven assessment days. A Physician Order Summary, dated 7/11/2022, indicated Resident 60 was prescribed Ativan 0.5 mg (milligrams) one tablet every six hours as needed for agitation/anxiety starting 6/13/2022. The Ativan order did not indicate a stop date for treatment. A review of the Medication Administration record for June 2022 and July 2002 indicated, Resident 60 received the as needed Ativan after 6/26/2022, on 6/27/2022, 6/28/2022, 6/30/2022, 7/1/2022, 7/2/2022 (2 doses), 7/4/2022, 7/5/2022, 7/6/2022, 7/9/2022 (3 doses), 7/10/2022, and 7/11/2022. A Physician Progress Note on 7/11/2022 at 7:30 P.M., indicated, Resident 60 was being seen for a follow-up visit for history of delusions, paranoia, psychotropic medication use, insomnia, cognitive impairment, depression, and anxiety. The facility physician indicated, .Since last visit provider contacted last week by staff d/t [due to} needing PRN [as needed} Ativan d/t agitation, anxiety. Has had Resident to Resident altercation apparently on unit d/t distress. She was restarted on PRN lorazepam, using with some regularity. Orders per below. Will allow PRN to D/C and schedule dosing for comfort and anxiety control .Initiate Lorazepam 0.5 mg PO TID- Rx sent. We will D/C PRN dose as routine becomes available During an interview on 7/12/2022 at 2:34 P.M., the Assistant Director of Nursing (ADON) indicated, as needed psychotropic medications should only be prescribed for two weeks, but if the resident has a review with the psych nurse practitioner, the order will be extended due to having the documentation. On 7/8/2022 at 10:36 A.M., the Administrator provided the policy titled,Psychotropic Medication- Gradual Dose Reduction, dated 11/28/2012, and indicated the policy was the one currently used by the facility. The policy indicated .To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per standards of practice, and are at the lowest therapeutic dose to treat such conditions. Residents on anti-psychotic drug therapy will be monitored for tardive dyskinesia side effects every 6 months through the use of the AIMS scale. PRN Psychotropic's: . PRN antipsychotic medications shall be limited to 14 days. If deemed appropriate to continue for greater than 14 days, the attending physician or prescribing practitioner will evaluate the resident and enter a new order for PRN administration as indicated, not to exceed 14 days. Gradual Dose Reductions (GDR). Residents who use psychotropic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue or reduce the medication. A gradual dose reduction shall be encouraged at least twice yearly unless previous attempts at reduction have been unsuccessful or reduction is clinically contraindicated. The drug reduction will continue until eliminated or the clinical condition of resident worsens 3.1-48(b)(1) Based on record review, interview and observation, the facility failed to complete a GDR (gradual dose reduction) on a antipsychotic medication, failed to complete AIMS assessment timely, failed to have documented nonpharmalogical interventions prior to administering an as needed antipsychotic medication and failed to not administer an as needed antipsychotic medication after the medication was to be discontinued for 3 of 7 residents reviewed for unnecessary medications. (Residents 61, 12 and 60) Findings include: 1. During an observation, on 7/5/2022 at 12:28 P.M., Resident 61 was observed to have lounge thrusts and a resting tremor to the left hand. During an observation, on 7/11/2022 at 10:25 A.M., Resident 61 was observed having resting tremors to the left thumb while sitting in a chair in the lounge area, and having tongue thrusts. A clinical record review was completed on 7/7/2022 at 2:11 P.M. Resident 61's current diagnoses included, but were not limited to: Parkinson's disease, anxiety, depression, other psychotic disorder, vascular dementia with behavioral disturbance, hemiplegia, seizures, Schizophrenia and pseudobulbar affect. A Quarterly MDS (Minimum Data Set) assessment, dated 5/27/2022,indicated Resident 61 was severely cognitively impaired, received antipsychotic and antidepressant medications routinely. Current Physician Orders, dated July 2022, indicated the resident had received: Paxil (anti depressant) 40 mg (milligrams) daily for anxiety. Risperdal (antipsychotic) 2 mg twice a day for Schizophrenia. Medroxy Progesterone Acetate Suspension Prefilled syringe 150 MG/ML--Inject 150 mg intramuscularly one time a day every Wednesday for sexual suppression. Melatonin Tablet 3 mg at bedtime for insomnia. A current care plan, dated 11/8/2021, indicated the resident had the potential for adverse side effects related to medication use related to: anti-psychotic use for psychotic disorder, PBA, schizophrenia, and behaviors. Interventions included: Administer medications per MD orders. Observe for adverse side effects. Observe for:Uncommon Side Effects: Tardive Dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, jaundice. An AIMS (Abnormal Involuntary Movement Scale) assessment, dated 11/5/2021,indicated the residents score was a 7. During an interview, on 7/12/2022 at 9:51 A.M., CNA 7 indicated the resident sticks his tongue out all the time, even when we try to feed him. During an interview, on 7/12/2022 at 10:17 A.M., the ADON indicated that the NP (Nurse Practitioner) should be notified of the tremors and the side effects of the medications and indicated Resident 61 should have had an AIMS assessment completed every 6 months. 2. The clinical record for Resident 12 was reviewed on 7/6/2022 at 2:30 PM. Resident 12 was admitted to the facility with diagnoses, including but not limited to: status post pneumonia due to inhalation of food and vomit, delusional disorder, schizoaffective disorder, dementia with Lewy bodies, anxiety disorder and major depressive disorder recurrent. The admission Minimum Data Set (MDS) assessment for Resident 12, completed on 4/22/2022, indicated the resident had severe cognitive impairment and displayed delusional behaviors and verbally abusive behavior that did not pose a threat to the resident or others, but did impair the resident's ability to participate in activities and socialize with others. The current care plan related to behaviors and psychotropic medication use for Resident 12, current through 9/29/2022, indicated the following interventions were to be utilized if the resident displayed behavioral issues: Reassure and redirect, meet needs promptly, offer snacks and food, talk about golfing and joke around with him (Resident 12). The current Physician's Orders included orders for the antipsychotic medication, Risperdal 1 mg three times a day for delusional disorder, Memantine HCL 10 mg one time a day for the Dementia with Lewy Bodies Depakote ER 24 hour release 250 mg one tablet two times day related to major depressive disorder and Sertraline (an antidepressant) 50 mg , three tablets once a day related to major depressive disorder. In addition, the resident received a one time dose of Haldol (an antipsychotic medication) 2 mg orally on 6/12/2022. to treat an anxiety disorder. Review of a nurse's note dated 6/12/2022 at 4:39 A.M., indicated the following: Resident yelling and cursing during the noc (night) for at least 2 hrs. Several attempts made to calm resident with no success. Roommate and other residents on the hall threatening to 'kick his ass'. Resident given 1 x (time) order Haloperidol 2 mg. Resident also moved to room [ROOM NUMBER]. Review of the behavior tracking form, completed by the certified nursing assistants each shift for June 2022 indicated of the 30 days in June, the resident was only documented as having behavioral issues on 10 of 90 shifts. On June 12, 2022 on the evening shift the resident was documented as having displayed yelling/screaming and biting behaviors and the intervention attempted but unsuccessful was 1:1 supervision. On the night shift of June 12, 2022 the resident was documented as having displayed yelling/screaming and abusive language behaviors. The intervention documented as attempted was a quiet environment and it was not successful. During an interview with the Corporate Nurse on 07/12/2022 at 11:22 AM., she indicated the nurse had documented several attempts in regards to interventions attempted prior to the administration of the PRN Haldol dose for Resident 12. She indicated the nursing staff would not document every type of intervention attempted. There was no documentation in the nursing notes, nor on the behavior tracking form completed by the Certified Nursing Assistants to indicated the resident centered interventions, such as snack/food, talking about golf and joking around with the resident were attempted as designated in his behavior plan of care.