**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 45 residents. Based on record review and interview, the facility failed to ensure nursing staff possessed current licensure as required. This deficient practice placed all the residents residing in the facility at risk for not attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. Findings included: - The Kansas State Board of Nursing License Verification, printed on [DATE], documented Licensed Nurse (LN) G's Licensed Practical Nursing (LPN) license expired on [DATE]. The Facility's Working Schedule for the month of [DATE], documented LN G worked eight days out of twenty-three days as an LPN after LN G's license had expired. LN G was the only Licensed Nurse on the evening shift, 06:00 PM to 06:00 AM, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], LN G was suspended and taken off the schedule until her license was reinstated. On [DATE] at 10:30 AM, Administrative Nurse D stated LN G had come to her on [DATE] to tell her that she had forgotten to renew her nursing license by [DATE] when the nursing license expired. Administrative Nurse D stated LN G was immediately taken off the schedule and she notified Administrative Staff A On [DATE] at 11:00 AM, Administrative Staff A stated she expected licensed nursing staff to be aware of when their nursing license expired and take care of renewing their license. Administrative Staff A stated the facility did not have any system ensuring licensed nursing staff employed by the facility maintained their licensure at the time of the incident. Administrative Staff A stated the facility's business office manager will run a monthly report to ensure staff renew their licenses on a timely basis. No employee would be allowed to work in a registered, licensed, or certified position without proof of active license status. The facility's Staffing, Sufficient and Competent Nursing, revised [DATE], documented the facility provided sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements by state law. The facility identified and implemented immediate corrective actions, which were completed on [DATE] and included: the facility's business office manager will run a monthly report to ensure staff renew their licenses on a timely basis. No employee will be allowed to work in a registered, licensed, or certified position without proof of active license status. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at an F scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 45 residents. Based on record review and interview, the facility failed to ensure adequate administrative oversight when the facility failed to monitor and ensure all nurses practicing in the facility maintained active license as required to provide the residents residing in the facility with the care they needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This deficient practice placed the residents residing in the facility at risk for lack of quality nursing care. Findings included: - The Kansas State Board of Nursing License Verification, printed on [DATE], documented Licensed Nurse (LN) G's Licensed Practical Nursing (LPN) license expired on [DATE]. The Facility's Working Schedule for the month of [DATE], documented LN G worked eight days out of twenty-three days as an LPN after LN G's license had expired. LN G was the only Licensed Nurse on the evening shift, 06:00 PM to 06:00 AM, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], LN G was suspended and taken off the schedule until her license was reinstated. On [DATE] at 10:30 AM, Administrative Nurse D stated LN G had come to her on [DATE] to tell her that she had forgotten to renew her nursing license by [DATE] when the nursing license expired. Administrative Nurse D stated LN G was immediately taken off the schedule and she notified Administrative Staff A. On [DATE] at 11:00 AM, Administrative Staff A stated she expected licensed nursing staff to be aware of when their nursing license expired and take care of renewing their license. Administrative Staff A stated the facility did not have any system ensuring licensed nursing staff employed by the facility maintained their licensure at the time of the incident. Administrative Staff A stated the facility's business office manager will run a monthly report to ensure staff renew their licenses on a timely basis. No employee would be allowed to work in a registered, licensed, or certified position without proof of active license status. The facility's Staffing, Sufficient and Competent Nursing, revised [DATE], documented the facility provided sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements by state law. The facility identified and implemented immediate corrective actions, which were completed on [DATE] and included: the facility's business office manager will run a monthly report to ensure staff renew their licenses on a timely basis. No employee will be allowed to work in a registered, licensed, or certified position without proof of active license status. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at an F scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 44 residents. The sample included 12 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote dignity for Resident (R) 22, when staff called R22 Honey multiple times instead of addressing her by her proper name. This placed the resident at risk for undignified care and services. Findings included: - The Electronic Medical Record (EMR) documented R22 had diagnoses of moderate dementia with psychotic disturbance, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), agitation (feelings of aggravation or restlessness brought on by a provocation or a medical condition), anxiety ( mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear, restlessness (the inability to relax as a result of anxiety), and chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for all activities of daily living (ADLs) and had inattention and disorganized thinking. The assessment further documented that R22 had physical and verbal behaviors, and rejected care for 4 to 6 days. R22 received antipsychotic (a class of medication used to treat psychosis and other mental-emotional conditions), and antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) medication. The Quarterly MDS, dated 07/25/24, documented R22 had severely impaired cognition. R22 was dependent upon staff for all ADLs, had disorganized thinking, and altered level of consciousness. The assessment further documented R22 had physical and verbal behaviors for 4 to 6 days and rejection of care for 1 to 3 days. R22 received antipsychotic and antidepressant medication. R22's Care Plan, dated 08/12/24, initiated on 03/14/22 directed staff to reminisce with the resident using photos of family and friends. The update, dated 04/19/22, directed staff to offer her a sucker or chocolate when she was anxious or agitated, encourage her to participate in activities, and if she did not want to attend, sit and talk with her for a bit. The update, dated 04/23/22, documented R22 was physically aggressive, would hit, kick, and attempt to bite during bedtime care and directed staff to give her as many choices as possible about care and activities, engage calmly in conversations, consult a psychiatrist as indicated, administer medications as ordered, answer her questions, and do not touch her until she was ready. The update, dated 06/17/22, documented R22 only tolerated one person at a time, needed personal space, and directed staff to sit her alone at a table during mealtime when she was agitated. The care plan directed staff to modify her environment, adjust the room temperature to a comfortable level, and reduce noise. The update, dated 02/24/23, directed staff to anticipate and meet her needs, provide a program of activities that were of interest, and accommodate her status. The update dated 08/06/23, directed staff to offer her the fidget board. R22's Care Plan lacked evidence the resident preferred to be called Honey. On 08/26/24 at 11:18 AM, observation revealed R22 sat at the dining table and yelled Help! Help! over and over. Certified Nurse Aid (CNA) M went to the table and asked R22 if she needed something, called her Honey multiple times, and offered to take her into the living room area to watch television. CNA M asked R22 if she wanted to watch Little House on the Prairie, and R22 stated Yes. CNA M did not change the channel to the television show R22 wanted to watch, but stated, Oh here's a farm show you would like, can I transfer you into the recliner Honey? R22 continued to yell Help and CNA made a shushing noise towards R22. CNA M stated, Let me know if you want the channel changed and she walked away. Continued observation revealed R22 started to yell, Help! Help! CNA M went to her and stated Did you not like this show Honey R22 stated, NO! CNA M asked R22 if she wanted the channel changed to Little House on the Prairie and R22 stated Yes. On 08/28/24 at 03:45 PM, Licensed Nurse (LN) G stated staff should call the resident by her name unless they have been given permission to call them by something else. On 08/29/24 at 11:30 AM Administrative Nurse D stated staff should not call R22 Honey as that is not very dignified and is unsure if R22 would like to be called Honey. The facility's Dignity policy, dated 02/2021. documented residents were treated with dignity and respect at all times and staff should promptly respond to a resident's request for toileting assistance. Staff are expected to treat cognitively impaired residents with dignity and sensitivity. The facility failed to promote dignity for R22 when staff called R22 Honey multiple times instead of addressing her by her proper name. This placed the resident at risk for undignified care and services.

The facility had a census of 44 residents. The sample included 12 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the correct CMS Form 10055, Skilled Nursing Facility [SNF] Advanced Beneficiary Notice [ABN] which included the estimated cost to continue services for skilled services to the resident or their representative for three residents: Resident (R) 1, R16, and R145. This placed all three residents at risk for uninformed decisions regarding skilled services. Findings included: - The Medicare SNF ABN form 10055 informs the beneficiaries Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included options for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for payment of services. (3) I do not want the listed services. The facility's Medicare ABN form staff provided to R1 (or their representative) was CMS-R-131. The facility's Medicare ABN form staff provided to R16 (or their representative) was from CMS-R-131. The facility's Medicare ABN form staff provided to R145 (or their representative) was from CMS-R-131. On 08/28/24 at 08:00 AM, Social Services X stated he did not realize he had been providing the families with the correct CMS form. The facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices policy, dated 09/23, documented that residents were informed in advance when changes would occur to their bills, The facility would provide a Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) to residents for initiation, reduction, or termination of Medicare benefits. The facility failed to provide R1, R16, and R145 the correct SNF ABN from CMS 10055 as required. This placed all three residents at risk for uninformed decisions regarding skilled services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Electronic Medical Record (EMR) for R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough glucose is made or the body cannot respond to the insulin), edema (excess watery fluid in the tissues of the body), vaginitis (inflammation of the vagina that can result in discharge, itching, and pain), urinary tract infection (UTI-an infection in any part of the urinary system), kidney disease (damage to or disease of a kidney), and a femur fracture (broken thigh bone). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had severely impaired cognition and was dependent on all activities of daily living (ADLs). R1 was always incontinent of bowel and frequently incontinent of bladder. R1 received an antidepressant (medication used to treat mood disorders and relieve symptoms of depression), a diuretic (medication to promote the formation and excretion of urine), and an anticoagulant (medication that prevents blood clots from forming in the bloodstream) medication. R1's Quarterly MDS, dated 06/19/24, documented R1 had moderately impaired cognition and was dependent upon staff for toileting and transfers. R1 required substantial assistance with dressing and personal hygiene. R1 was always incontinent of bladder and bowel and received anticoagulant, diuretic, and opioid (narcotic pain medication) medication. R1's Care Plan, dated 06/27/24 and initiated on 03/22/22, documented R1 was dependent upon two staff for toileting and one for personal hygiene. The update, dated 04/01/22 directed staff to administer medications as ordered and monitor for edema. The update dated 04/10/24 documented R1 was a full sling lift. The Progress Note, dated 01/16/24 at 09:52 AM, documented R1 was admitted to the hospital due to increased weight and edema. The Progress Note, dated 03/25/34 at 11:23 AM, documented R1 was admitted to the hospital due to a fall with a fracture. The Progress Note, dated 06/10/24 at 02:23 AM, documented R1 was admitted to the hospital due to abnormal vaginal bleeding. R1's clinical record lacked evidence the resident or her representative was provided a written notice when she was transferred to the hospital on the above dates. On 08/26/24 at 11:56 AM, observation revealed R1 was at the dining table visiting with her family. On 08/28/24 at 07:53 AM, Social Service X stated he was unaware he was required to notify the LTCO when a resident went to the hospital. Social Service X stated he was also unaware of any written notification required to the resident or representative. Social Services X stated he provided the resident's representative with a bed hold notice. On 08/29/24 at 11:30 AM, Administrative Nurse D stated she was not aware the appropriate documentation was not provided to the resident or her representative. The facility's Transfer or Discharge Notice Policy, revised March 2024, documented a copy of the notice would be sent to the office of the state Long-Term Care Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. The facility failed to provide R11 or her representative written notice regarding R11's facility-initiated transfer. This placed the resident at risk of uninformed care choices. The facility had a census of 44 residents. The sample included 12 residents with three reviewed for hospitalization. Based on record review and interview the facility failed to provide a written notice for a facility-initiated transfer for Resident (R) 5, R11, and R1 or their representatives when they were transferred to the hospital. The facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) of the discharges. This placed the residents at risk for uninformed care choices. Findings included: - R5's Electronic Medical Record (EMR) documented the resident had diagnoses of pain in the knee and hyponatremia (concentration of sodium in your blood is abnormally low). R5's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented that R5 required partial, moderate staff assistance with oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene, and transfers. R5 required supervision with ambulation. R5's Care Plan, revised 07/21/24, documented R5 received pain medication and was at high risk for falls pertaining to lack of vision. The care plan instructed staff to be sure R5's call light was within reach and encourage him to use it for assistance as needed, provide prompt response to all requests for assistance, and make sure R5 used his assistive device when walking. R5's Progress Notes, dated 02/26/24 at 11:00 AM and 03/18/24 at 07:00 PM documented the resident was transferred to the hospital. R5's clinical record lacked evidence the resident or representative was provided written notice. On 08/27/24 at 08:00 AM, observation revealed R5 sat in a chair at the kitchenette counter On 08/29/24 at 11:30 AM, Administrative Staff D stated she was not aware the appropriate documentation was not provided to the resident or his representative. On 08/28/24 at 07:53 AM, Social Service X stated he was unaware he was required to notify the LTCO when a resident went to the hospital. Social Service X stated he was also unaware of any written notification required to the resident or representative. Social Services X stated he provided the resident's representative with a bed hold notice. On 08/29/24 at 11:30 AM, Administrative Staff D stated she was not aware the appropriate documentation was not provided to the resident or his representative. The facility's Transfer or Discharge Notice Policy, revised March 2024, documented a copy of the notice would be sent to the office of the state Long-Term Care Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. The facility failed to provide R5 or his representative written notice regarding R5's transfer to the hospital and failed to notify the office of the LTCO. This placed the resident and/or her representative at risk of uninformed care choices. - R11's Electronic Medical Record (EMR) documented R11 had a diagnosis of heart failure. R11's Quarterly Minimum Data Set (MDS), 07/12/24, documented R11 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R11 had heart failure. R11's Care Plan, revised 07/19/24-, documented R11 had coronary artery disease (a condition that occurs when the heart's blood supply is reduced due to plaque (sticky substance) buildup in the arteries). The care plan instructed staff to administer medications to R11 as the physician ordered, encourage compliance with the treatment regimen, monitor blood pressure and notify the physician of any abnormal readings, monitor R11's cholesterol (a fat-like substance in the body) levels, and report findings to the physician. The Progress Note, dated 01/31/2024 at 12:30 PM, documented R11 was admitted to the hospital. R11's clinical record lacked evidence the resident or representative was provided a written notice when she was transferred to the hospital. On 08/27/24 at 01:00 PM, observation revealed R11 ambulated down the hall with a walker. On 08/28/24 at 07:53 AM, Social Service X stated he was unaware he was required to notify the LTCO when a resident went to the hospital. Social Service X stated he was also unaware of any written notification required to the resident or representative. Social Services X stated he provided the resident's representative with a bed hold notice. On 08/29/24 at 11:30 AM, Administrative Nurse D stated she was not aware the appropriate documentation was not provided to the resident or her representative. The facility's Transfer or Discharge Notice Policy, revised March 2024, documented a copy of the notice would be sent to the office of the state Long-Term Care Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. The facility failed to provide R11 or her representative written notice regarding R11's facility-initiated transfer. This placed the resident at risk of uninformed care choices.

The facility had a census of 44 residents. The sample included 12 residents, with four reviewed for accidents. Based on observation, record review, and interview the facility failed to ensure staff followed the care plan to prevent accidents when staff failed to place Resident (R) 9's alarm (a device designed to monitor a patient's movements) underneath her when she was in bed per her plan of care resulting in a fall. This also placed R9 at risk for injuries from falls. Findings included: - R9's Electronic Medical Record (EMR) documented R9 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), muscle weakness, unsteadiness on her feet, and a history of falling. R9's Quarterly Minimum Data Assessment, (MDS) revised 07/12/24, documented R9 had a Brief Interview of Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The MDS documented R9 used a walker and had a fall with injury during the observation period. R9's Care Plan revised 04/22/24, documented R9 was a high risk for falls, and used a bed and chair alarm. The plan instructed staff to ensure the alarm was on at all times when R9 was in bed or a wheelchair. The Progress Note, dated 08/24/24 at 01:18 AM, documented that Certified Nurse Aide (CNA) N notified the nurse that R9 was on the floor. When the nurse entered the room R9 was against the bathroom door. The nurse noticed R9's bed alarm was in place but the box to the bed alarm was missing. The note documented CNA N stated he left the box in the living room and he was not aware that the box needed to be transferred to her bed alarm. On 08/27/24 at 09:44 AM, observation revealed R9 sat quietly in a wheelchair in the activity room at an exercise activity. On 08/28/24 at 02:05 PM, Licensed Nurse (LN) G stated to prevent R9 from falling staff placed a pressure alarm underneath R9 when she was in bed or a wheelchair to notify staff when R9 tried to get up. On 08/29/24 at 09:23 AM, Administrative Nurse D verified R9 had a fall on 08/24/24 at 01:18 AM from her bed because the staff had not placed the alarm box on the bed alarm as the care plan instructed. Administrative Nurse D stated staff should ensure R9's alarm device was in place at all times when R9 was in her wheelchair or bed. Administrative Nurse D stated R9 now had two separate alarms one for the bed and one for her wheelchair. The facility's Falls-Clinical Protocol Policy, revised in March 2018, documented that if interventions have been successful in fall prevention, the staff would continue with current approaches. If the individual continues to fall, the staff and physician would re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and reconsider the current interventions. The facility staff failed to place an alarm underneath R9 when she was in bed per her plan of care and R9 had a fall. This also placed R9 at risk for injuries from a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 44 residents. The sample included 12 residents, with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide adequate respiratory care and services for Resident (R) 22 when staff did not provide her oxygen during the breakfast meal and failed to store the oxygen tubing and cannula (a medical device that delivers supplemental oxygen to patients through their nose) in a sanitary manner when not in use. This placed R22 at risk for respiratory complications. Findings included: - The Electronic Medical Record (EMR) documented R22 had diagnoses of moderate dementia (a progressive mental disorder characterized by failing memory and confusion) with psychotic disturbance, depression (an abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for all activities of daily living (ADLs). R22 did not have shortness of breath and received oxygen daily. R22 did not receive a diuretic (treats fluid retention) medication. R22's Care Plan, dated 08/12/24, initiated on 02/28/22, directed staff to monitor her for signs and symptoms of respiratory distress and report to the physician as needed, have continuous oxygen at 2 liters (L) per minute via nasal cannula and titrate (adjust the flow) to keep the oxygen saturation above 90%. The Physician's Order, dated 08/12/24, directed staff to administer continuous oxygen via nasal cannula at 2L to keep saturation above 90%, notify the physician of all changes, and monitor R22's oxygen saturation every shift for COPD. On 08/26/24 at 11:18 AM, observation revealed R22 sat at the dining table and did not have her oxygen concentrator with her at the dining room table. Further observation revealed staff took R22 to the living room area and did not bring her oxygen to her. CNA M stated R22 refused her oxygen earlier, and staff could not force her to wear it, so she did not bring it to the table. Continued observation revealed after being questioned, CNA M brought out R22's oxygen concentrator and stated, You forgot your oxygen Honey, can I put it on? R22 responded Yes. On 08/27/24 at 09:05 AM, observation revealed R22 at the dining table. Staff attempted to fix her oxygen cannula as it was partially out of her nose but R22 did not allow it. Further observation revealed the CNA took the oxygen tubing and laid it over the handles of the wheelchair and the cannula was resting against R22's back. On 08/28/24 at 09:31 AM, CNA Q removed R22's oxygen and placed the tubing in the bag on the concentrator. CNA Q took R22 to her room for care, then brought her back and tried to put R22's oxygen on and R22 would not let her so CNA Q laid the oxygen tubing in R22's lap. On 08/28/24 at 09:30 AM, CNA Q stated she did not know why she did not place the oxygen tubing in the bag as she had previously. On 8/28/24 at 03:45 PM, Licensed Nurse (LN) G stated staff should put the oxygen tubing in the bag that was provided on the concentrator. LN G said staff should have checked R22's oxygen saturation after R22 went without oxygen for that period. On 8/29/24 at 11:30 AM Administrative Nurse D stated there were bags provided to the residents with oxygen for the staff to put the oxygen tubing in if the resident was not wearing it. The facility's Oxygen Administration policy, dated 10/2010, documented the procedure was to provide guidelines for safe oxygen administration, and if a resident refused the oxygen, document the reason why and what interventions were taken. The facility failed to provide adequate respiratory care and services for R22 when staff did not provide her oxygen during the breakfast meal and failed to store the oxygen tubing and cannula in a sanitary manner when not in use. This placed R22 at risk for respiratory complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 44 residents. The sample included 12 residents with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on observation, record review, and interview, the facility failed to provide dementia care and services for Resident (R) 22, who had dementia and behaviors. This placed R22 at risk for abuse and decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R22 had diagnoses of moderate dementia with psychotic disturbance, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), agitation (feelings of aggravation or restlessness brought on by a provocation or a medical condition), anxiety ( mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, restlessness (the inability to relax as a result of anxiety), and Chronic Obstructive Pulmonary Disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for all activities of daily living (ADLs) and had inattention and disorganized thinking. The assessment further documented R22 had physical and verbal behaviors, and rejected care for 4 to 6 days. R22 received antipsychotic (a class of medication used to treat psychosis and other mental-emotional conditions), and antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) medication. The Quarterly MDS, dated 07/25/24, documented R22 had severely impaired cognition. R22 was dependent upon staff for all ADLs, had disorganized thinking, and altered level of consciousness. The assessment further documented R22 had physical and verbal behaviors for 4 to 6 days and rejection of care for 1 to 3 days. R22 received antipsychotic and antidepressant medication. R22's Care Plan, dated 08/12/24, initiated on 03/14/22 directed staff to reminisce with the resident using photos of family and friends. The update, dated 04/19/22, directed staff to offer her a sucker or chocolate when she was anxious or agitated, encourage her to participate in activities, and if she did not want to attend, sit and talk with her for a bit. The update, dated 04/23/22, documented R22 was physically aggressive, would hit, kick, and attempt to bite during bedtime care and directed staff to give her as many choices as possible about care and activities, engage calmly in conversations, consult a psychiatrist as indicated, administer medications as ordered, answer her questions, and do not touch her until she was ready. The update, dated 06/17/22, documented R22 only tolerated one person at a time, needed personal space, and directed staff to sit her alone at a table during mealtime when she was agitated. The care plan directed staff to modify her environment, adjust the room temperature to a comfortable level, and reduce noise. The update, dated 02/24/23, directed staff to anticipate and meet her needs, provide a program of activities that were of interest, and accommodate her status. The update dated 08/06/23, directed staff to offer her the fidget board. The Physician's Order, dated 07/19/22, directed staff to administer quetiapine (an antipsychotic medication), 50 milligrams (mg), by mouth, twice per day, for dementia with psychotic disturbance. The Physician's Order, dated 10/21/22, directed staff to administer divalproex sodium (a medication used to prevent seizures and also used for mood and behaviors), 125 mg, by mouth, twice per day, for agitation. The Physician's Order, dated 12/13/23, directed staff to administer vilazodone (an antidepressant medication), 40 mg, by mouth, daily for depression. The Physician's Order, dated 02/06/24, directed staff to administer Remeron (an antidepressant medication), 7.5 mg, by mouth, at bedtime for appetite stimulant. The Physician's Order, dated 08/12/24, directed staff to administer continuous oxygen via nasal cannula at 2 Liters to keep saturation above 90%, notify the physician of all changes, and monitor her saturation every shift for COPD. The Nurse's Note, dated 02/14/24 at 01:46 AM, documented R22 was combative with staff at dinner. She yelled, Help! Help!, spit her food at the Certified Nurse Aide (CNA), and attempted to hit the CNA. R22 was put to bed early but continued to hit both CNAs. The Nurse's Note, dated 07/28/24 at 10:50 PM, documented that R22 was combative when assisted to bed. She bit and pinched the CNA. The Nurse's Note, dated 08/01/24 at 02:12 AM, documented R22 bit, kicked, and pinched staff during care, and received an abrasion (scrape) to her right foot. R22 was placed into bed and offered water; staff put her bed in a low position with a blue mat. The Nurse's Note, dated 08/12/24 at 10:39 PM, documented R22 yelled Help! for hours and started to lose her voice. Staff checked on R22 every 30 minutes as she tried to self-transfer out of bed. The note documented that R22 tried to bite, punch, and dig her nails into staff when she was toileted. The Nurse's Note, dated 08/25/24 at 02:34 AM, documented that R22 yelled most of the day and hit and bit staff members during care. On 08/26/24 at 11:18 AM, observation revealed R22 sat at the dining table and yelled Help! Help! over and over. Certified Nurse Aid (CNA) M went to the table and asked R22 if she needed something, called her Honey multiple times, and offered to take her into the living room area to watch television. CNA M asked R22 if she wanted to watch Little House on the Prairie, and R22 stated Yes. CNA M did not change the channel to the television show R22 wanted to watch, but stated, Oh here's a farm show you would like, can I transfer you into the recliner Honey? R22 continued to yell Help and CNA made a shushing noise towards R22. CNA M stated, Let me know if you want the channel changed and she walked away. Continued observation revealed R22 started to yell, Help! Help! CNA M went to her and stated Did you not like this show Honey R22 stated, NO! CNA M asked R22 if she wanted the channel changed to Little House on the Prairie and R22 stated Yes. CNA M changed the channel to a movie and did not change it to the program R22 wanted to watch. CNA M stated she did not know why she did not change the channel to the program R22 wanted to watch and stated that R22 had refused her oxygen earlier, so she did not bring it to the table. On 08/27/24 at 12:23 PM, the Meadowlark House dining room had residents waiting for the noon meal, and two CNAs present. One CNA cooked the meal, and one assisted the residents. R22 sat at the dining table and yelled Help! I need to go to the bathroom! loudly and as staff did not respond, the level of need in her voice raised as she continued to say she needed to go to the bathroom. Continued observation revealed CNA O looked over at the resident but did not respond to her, went into the kitchen area, and told the second CNA that R22 needed to go to the bathroom but neither CNA responded to R22. Observation revealed at 12:39 PM, R22 continued to request toileting and would often yell Help! Help!. CNA O went over to the resident and placed a blanket around her shoulders but did not offer toileting. Continued observation revealed CNA O fixed herself a plate of food took it into the nurse's room and shut the door. At 01:00 PM, CNA O came out of the room and when questioned stated R22 would be toileted when the residents were done with the meal. CNA O further stated that there were only two CNAs working in the house that day, and R22 required the assistance of two staff. CNA O said that R22 was a check and change and did not sit on the toilet. On 08/27/24 at 09:05 AM, observation revealed R22 at the dining table, yelling Help! Help! over and over. R22 looked over at another table with residents talking, and started to yell, Shut up! shut up! R22 continued to yell Help! and then yelled Shut up if anyone responded to her. The staff did not offer any other alternatives except food and fluids. R22 continued to yell throughout meal service until Consultant GG entered the household and offered to take R22 outside. On 08/28/24 at 09:31 AM, observation revealed R22 at the dining table continuously yelling Help! or Shut up! Staff offered her food but she did not want anything. R22 started to spell out her name, and then say her name out loud and another resident tried to talk to her but R22 told her to Shut up! Observation revealed at 09:30 AM, CNA Q removed R22's oxygen and placed the tubing in the bag on the concentrator. CNA Q took R22 to her room for care, then brought her back and tried to put R22's oxygen on and R22 would not let her so CNA Q laid the oxygen tubing in R22's lap. On 08/28/24 at 09:23 AM, CNA P stated she did not know what interventions to offer R22 when she had behaviors but said she would offer her food and fluids. On 08/28/24 at 09:30 AM, CNA Q stated this was her first day in the house and that she was unsure what interventions to offer R22 when she had behaviors. CNA Q further stated they receive dementia training prior to working and they are given a list of residents and how to care for them when they come on shift. On 8/28/24 at 03:45 PM, Licensed Nurse (LN) G stated staff should have called her to assist R22 with toileting. LN G stated the staff should engage with R22 and talk with her when she gets upset, especially about her farm and cat. On 08/28/24 at 04:00 PM, Certified Medication Aide (CMA) R stated the medication aides help the CNAs if they need anything and said she would assist with R22 if needed. On 8/29/24 at 11:30 AM Administrative Nurse D stated staff should have tried to get the show she wanted on TV and should offer her the activity box they have for her. Administrative Nurse D further stated staff should try to sit down and talk to her. Administrative Nurse D stated all staff gets dementia with behavior training. The facility's Dementia- Clinical Protocol, dated 11/2018, documented individuals with confirmed dementia the staff would identify a resident-centered care plan to maximize remaining function and quality of life. The nursing assistants would receive initial training in the care of residents with dementia and related behaviors and services would be conducted annually thereafter. Interventions and the overall plan would be adjusted depending on the resident's progression of dementia. The facility failed to provide dementia care and services for R22 in order to promote and maintain R22's highest practicable well-being. This placed R22 at risk for abuse and decreased quality of life.

The facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to prepare all the food items on the noon menu while preparing Resident (R) 20 and R22's pureed diet. This placed the residents at risk for impaired nutrition. Findings included: - On 08/27/24 at 11:22 AM, a review of the noon meal consisted of chicken parmesan, buttered penne pasta, asparagus tips, fruit crisp, and garlic toast. On 08/27/24 at 11:22 AM, Dietary Staff (DS) CC reported the Meadowlark Kitchenette had two residents who received a pureed diet. DS CC stated staff only prepared mashed potatoes and gravy for R22 at the noon meal and R20 would receive the full pureed diet. DS CC placed a 4-ounce (oz) piece of chicken parmesan into the blender container, added two (8 oz) ladles of red marinate sauce into the container, and blended it. DS CC reported it was still too thick and added another 8-oz ladle of marinate sauce, then blended to the consistency of mashed potatoes. Further observation revealed DS CC placed an unmeasured amount of hot water into a bowl added an unmeasured amount of boxed potato flakes and stirred with a fork. Continued observation revealed at 12:13 PM, DS CC retrieved two bowls, placed them on the counter, and then placed two (4oz) scoops of cooked noodles into the blender. DS CC blended, then added one (4oz) scoop of hot water from the noodle pan and blended to the consistency of mashed potatoes. When asked about the other food items on the menu, DS CC stated she would not prepare the bread, asparagus, or the fruit crisp for the residents who were on a pureed diet; they would receive protein ice cream as their dessert and a can of V8 juice (a juice made mainly from water and tomato concentrate, and concentrate of eight vegetables, specifically: beets, celery, carrots, lettuce, parsley, watercress, spinach, and tomato). Further observation revealed DS CC retrieved a 5.5 milliliter (ml) can of V8 juice, poured it into a glass, and served it to R20. On 08/27/24 at 12:45 PM, Dietary Manager BB verified DS CC had not prepared all the food items for R20 and R22's pureed diet. On 08/28/24 at 01:15 PM, Registered Dietitian CC stated he expected staff to prepare the same food items on the menu for the residents who received a pureed diet as the other residents, but V8 juice was a good vegetable replacement. Upon request, the facility did not provide a pureed diet recipe. The facility kitchen staff failed to puree all the food items on the noon menu in one of three kitchenettes. This placed R20 and R22 at risk for impaired nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 44 residents. The sample included 12 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination to Resident (R) 9 per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the resident at risk for pneumococcal infection and related complications. Findings included: - R9's admission Minimum Data Set dated 12/02/23 documented R9 admitted to the facility on [DATE]. The MDS documented R9 received the influenza (flu) vaccine before admitting to the facility. The MDs documented R9's pneumococcal vaccination was not up to date, and was not offered. A review of R9's clinical medical records lacked evidence the facility offered and received the vaccination or of a signed declination for the PCV20 vaccine. On 08/28/24 at 11:48 AM, Administrative Nurse D stated she could not find any documentation that R9 was offered the PCV20 on admission but stated the resident had an influenza vaccine prior to admission. Administrative Nurse D stated the pharmacy keeps track of which immunizations residents are eligible for. The facility's Pneumococcal Vaccine Policy, revised in October 2023, documented all residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated are offered the vaccine series within thirty day (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. The facility failed to offer R9 the PCV20 pneumococcal vaccination. This deficient practice placed the resident at risk of acquiring, spreading, and experiencing complications from pneumonia.

The facility had a census of 44 residents. Based on observation, interview, and record review the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week, placing all residents who reside at the facility at risk of decreased quality of care. Findings included: - The Payroll Based Journal (PBJ-a required detail of staffing information submitted by nursing homes to the Centers for Medicare and Medicaid Services) documented the facility lacked eight consecutive hours of RN coverage for the following months: April 2023- seven days May 2023- seven days June 2023- six days July 2023- eight days August 2023- six days September 2023- six days October 2023- eight days November 2023- four days December 2023- four days March 2024- four days April 2024- four days May 2024- four days June 2024- eight days July 2024- eight days August 2024- six days On 08/29/24 at 08:27 AM, Administrative Nurse D verified the facility did not have an RN on duty for eight consecutive hours on the dates listed on the PBJ. The facility's Staffing, Sufficient and Competent Nursing policy, dated 09/22, documented the facility provided enough nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled for more than eight (8) hours depending on the acuity needs of the resident. The facility failed to provide RN coverage eight consecutive hours a day, seven days a week, placing all residents who reside at the facility at risk of lack of assessments and inappropriate care.

The facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 44 residents who resided in the facility and received meals from the facility's kitchens. This placed the residents at risk for inadequate nutrition. Findings included: - On 08/27/24 at 11:22 AM, a review of the noon meal consisted of chicken parmesan, buttered penne pasta, asparagus tips, fruit crisp, and garlic toast. On 08/27/24 at 11:30 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 08/26/24 at 08:00 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had enrolled in the classes. On 08/29/24 at 07:15 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. The facility's Dietitian Policy, revised in November 2022, documented that if a dietitian is not employed full-time (35 or more hours per week) a director of food and nutrition services would be designated. This individual would: Be a certified dietary manager or be a certified food service manager or be nationally certified in food service management and safety; or Had an associate's (or higher) degree in food service management or hospitality, if the course includes food service or restaurant management from an accredited institution; or Had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety and management, by no later than October 1, 2023, that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing, receiving; and met any state requirement for food service or dietary managers; and received frequently scheduled consultations from a qualified dietitian or qualified nutrition professional. The facility failed to employ a full-time certified dietary manager for 44 residents who resided in the facility and received meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

The facility had a census of 44 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This placed the residents who received their meals from the facility's kitchens at risk for foodborne illness. Findings included: - On 08/26/24 at 11:48 PM observation of the noon meal, in the Sunflower House, revealed the following: Dietary Staff (DS) DD applied gloves and touched the refrigerator, counter, and pans. Then, wearing the same soiled gloves, DS DD touched a resident's roast beef while cutting it up, and then continued to serve residents their plates. Further observation revealed DS DD, with the same soiled gloves, took a baked potato out of the oven, placed it on a resident's plate, and held onto it while cutting it. Further observation revealed DS DD continued the same process, with the same soiled gloves, when plating the other residents' roast beef and baked potatoes. Continued observation revealed DS DD, wearing the same soiled gloves, wiped her right gloved hand across her nose and then served strawberry shortcakes to each resident at the dining room table. After serving the cake, DS DD removed and discarded the gloves. DS DD applied new gloves and touched the cabinets, touched the refrigerator handle, then with the same soiled gloves, used her hands to take two slices of bread out of the toaster and place them on a plate. DS DD touched the refrigerator handle, took mayonnaise out of the refrigerator, touched the jar, and then held one slice of toast at a time in her left hand while she spread mayonnaise on the two slices of toast with her right hand. Continued observation revealed DS DD, with the same soiled gloves, took the roast beef, placed it on one slice of toast, and then placed the other slice of toast on top of the roast beef, placed mayonnaise on the bread, and then placed on a plate and served to a resident. A review of the Cottonwood House kitchenette logs revealed missing documentation on the following dates in August 2024 for the kitchen refrigerator, kitchen freezer, pantry refrigerator, pantry freezer, small juice refrigerator, food, and dishwasher temperatures, and the sanitizer parts per million (PPM) tests for the dishwasher: 08/01/24-pureed diet temp, ground, casserole temp, meat temp, vegetable temp, starch temp dessert temp, dishwasher, and PPM for breakfast and lunch 08/02/24-breakfast, lunch, dinner-all temperatures and PPM tests 08/03/24- breakfast, lunch, -all temperatures and PPM tests 08/04/24-breakfast, dinner-all temperatures and PPM tests 08/05/24-breakfast, lunch, dinner all temperatures, and PPM tests 08/06/24-breakfast, lunch and dinner-all temperatures and PPM tests 08/07/24-breakfast, all lunch food temps missing 08/08/24-breakfast, lunch purred and ground, dinner all temperatures and PPM tests 08/09/24-breakfast, lunch, dinner all temperatures, and PPM tests 08/10/24-breakfast meat, vegetable, starch dessert, dinner all temperatures and PPM tests 08/11/24-breakfast, lunch, dinner -all meals temperatures and PPM tests 08/12/24-breakfast and lunch all temperatures and PPM test, dinner pureed and ground dishwasher temp 08/13/24-breakfast, lunch, and dinner all meals temperatures and PPM test 08/14/24-breakfast and lunch all temperatures and PPM tests 08/15/24-breakfast food items, dishwasher temperatures PPM 08/16/24-breakfast, lunch, and dinner all temperatures and PPM tests 08/17/24-breakfast and lunch, all temperatures and PPM tests 08/18/24-breakfast, lunch, dinner all temperatures, and PPM tests 08/19/24- lunch and dinner all temperatures and PPM tests. 08/20/24-breakfast -pantry refrigerator, pantry freezer, small juice refrigerator, food items temperature, and PPM test, lunch- pantry refrigerator, pantry freeze, small juice refrigerator temperatures and PPM tests and dinner all temperatures and PPM tests 08/21/24-breakfast and lunch, all temperatures and PPM tests 08/22/24- breakfast and lunch, all temperatures and PPM tests On 08/27/24 at 0154 PM, DM BB verified the lack of documentation in the above findings and stated administrative staff had identified the lack of documentation and were working on a new form for staff to document on. On 08/27/24 at 12:13 PM, observation in the Cottonwood House during the preparation of the pureed diets, DS CC retrieved two bowls, placed them on the counter, placed 2(4oz) scoops of noodles into a blender, blended, added 1 (4oz) scoop hot water from the pan the noodles were cooked in, blended to the consistency of mashed potatoes. DS CC left the blender container used to puree the noodles on the blender and the lid upside down on the counter. Further observation revealed at 12:35 PM, DS CC reported the facility had one ground meat diet, placed a chicken breast into the same soiled blender used to puree the noodles, blended to ground consistency, placed the ground chicken on a plate, and served it to a resident. Continued observation revealed at 12:45 PM, DS BB pushed an uncovered food tray cart down the hall to two residents' rooms. At 12:50 PM, DS BB verified she had delivered the uncovered room trays to the residents and stated she was told that staff did not have to cover the trays when delivering them down the hall due to the house being a homelike setting. On 08/28/24 at 10:23 AM, observation in the Meadowlark House dry storage room refrigerator revealed a turkey breast and a package of pork chops thawing in the same pan. The refrigerator lacked thermometers in the refrigerator and freezer. DS EE verified the finding and stated the turkey breast and pork chops should be in separate pans and the refrigerator and freezer should have backup thermometers. Observation revealed DS EE retrieved a new pan and placed the turkey breast in the pan. On 08/28/24 at 01:15 PM, Registered Dietician (RD) HH stated he expected staff to put different food items in a different pan when storing them in the refrigerator. RD HH stated staff, when plating and serving a resident's food items, should have all the items needed for the meal out of the refrigerator and should change gloves and wash hands, then deglove between tasks. RD HH stated staff should cover food items when delivering them down the hall. RD HH stated staff should record the temperatures of all refrigerators and freezers, and check PPM tests daily. The facility's Food Preparation and Service Policy, revised in November 2022, documented Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Food preparation staff should adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. The policy documented that when serving residents in a dining room or outside a resident's room where trained staff are serving food/beverage choices directly from a mobile food cart or steam table, there is no need for food to be covered. However, food should be covered when traveling a distance (down a hallway, to a different unit or floor). The policy documented that when verifying food temperatures, staff use a thermometer that is clean, sanitized, and calibrated to ensure accuracy. The policy documented that raw meat should be stored separately and in drip-proof containers, and in a manner that prevents cross-contamination from other foods in the refrigerator. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. The facility's Refrigerators and Freezers Policy, revised in November 2022, documented the facility would ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and would observe food expiration guidelines. Monthly tracking sheets for all refrigerators and freezers would be posted to record temperatures. The sheets include time, refrigerator temperature, temperature of potential hazardous food (PHF), and Time/temperature control for safety (TCS) food with initials. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This placed the residents at risk for foodborne illness.

The facility had a census of 44 residents. Based on interviews and record review the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter (Q) 3 indicated no licensed nurse coverage on seven dates. The PBJ report for FY 2023 Q4 recorded no licensed nurse coverage on nine dates. The PBJ report for FY 2024 Q2 recorded no licensed nurse on four dates. A review of the facility licensed nurse payroll data for the dates listed above revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 08/28/24 at 07:58 AM, Administrative Staff A stated the information for the PBJ was submitted from someone off campus and she did not realize there were submission problems. Administrative Staff A further stated there was always a licensed nurse in the building and they have more registered nurses than they used to, so she was unsure why the PBJ showed they did not have licensed nurses in the building each day. The facility's Reporting Direct Care Staffing information was reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. Staffing information was collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility identified a census of 43 residents with three residents reviewed for medication errors. Based on record review and interview, the facility failed to ensure an antibiotic for a urinary tract infection (UTI-an infection in any part of the urinary system) for Resident (R) 2 was available for administration. This deficient practice placed R2 at risk for a worsening UTI and health complications. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and UTI. The Quarterly Minimum Data Set (MDS), dated 03/14/24, documented R2 had a Brief Interview for Mental Status score of three which indicated severely impaired cognition. The MDS documented R2 was dependent on staff assistance for toileting and bathing. The MDS documented R2 did not have a UTI in the last thirty days of the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/13/23, documented R2 had severe cognitive impairment and was at risk for communication deficit and activity of daily living (ADL's) decline. R2's Care Plan revised 06/05/23, directed staff R2 had bladder incontinence and used disposable briefs. Staff were directed to change R2 with each incontinent episode and as needed and clean R2's peri area with each incontinent episode. The care plan directed staff to administer R2's medications as ordered. The Other Progress Note, dated 02/06/24, documented that R2's primary care physician sent orders to obtain a urine sample for R2 due to her increased confusion and agitation. A urine collection hat was placed on R2's toilet but R2 was removing it and refusing to void in the hat. The Urinalysis Microscopic Report, dated 02/07/24, documented R2's urine had white blood cells and bacteria in her urine. The Urine Culture Report, dated 02/08/24, documented R2's urine grew out Gram-positive Enterococcus (lactic acid bacteria). On 02/08/24 the facility received a new order to administer Macrobid (antibiotic) 100 milligrams (mg) twice a day for five days for R2's UTI. The Antibiotic Monitoring Note, dated 02/10/24, documented the Macrobid had not been started yet as it had not been received from the pharmacy. The Antibiotic Monitoring Note, dated 02/11/24, documented the Macrobid had not arrived from the pharmacy. R2's February 2024 Medication Administration Record (MAR), documented 100 mg of Macrobid was to be given to R2 twice a day for five days. R2's first dose of Macrobid was scheduled to be administered on 02/08/24 on the evening medication pass. The dose was documented as unavailable. The subsequent doses for 02/09/24, 02/10/24, 02/11/24, 02/12/24, and 02/13/24 were all documented as unavailable. R2 was not administered her antibiotic for five days. A new order for Macrobid 100 mg by mouth twice a day for five days was placed in the EMR to start on the evening medication pass on 02/13/24. The Antibiotic Monitoring Note, dated 02/13/24, documented that night was R2's first dose of antibiotic and staff will continue to monitor. R2 was unavailable for observation or interview. On 04/01/24 at 02:00 PM, Administrative Nurse D stated that she directed her staff to use the Macrobid from the emergency kit until the antibiotic was delivered from R2's pharmacy and she had not followed up to ensure R2 was receiving her antibiotic for the UTI. The Administering Medications Policy, revised in April 2019, documented that medications are to be administered in a safe and timely manner and as prescribed. The Director of Nursing supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by the resident's need and benefit, not staff convenience. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. The facility failed to ensure R2's antibiotic for a UTI was available for administration. This deficient practice placed R2 at risk for a worsening urinary tract infection and health complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 43 residents with three residents reviewed for medications. Based on record review and interview, the facility failed to monitor Resident (R) 2's psychotropic (alters mood or thought) medication used off-label use for insomnia (inability to sleep) after a trial increase. This deficient practice placed R2 at risk for inadequate oversight, lack of physician involvement, and ineffective dosing for Trazodone. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and urinary tract infection (UTI). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status score of three which indicated severely impaired cognition. The MDS documented R2 was totally dependent on staff assistance for toileting and bathing. The MDS documented R2 did not have a UTI in the last thirty days of the assessment period. The MDS documented R2 received an anti-depressant (medication used to treat mood disorders). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated [DATE], documented R2 had severe cognitive impairment and was at risk for communication deficit and activity of daily living (ADL's) decline. R2's Care Plan revised [DATE], directed staff R2 was at risk for adverse reactions to Trazodone (antidepressant) and directed staff to monitor R2 for possible signs and symptoms: falls, weight loss, fatigue, agitation, depression, lethargy, unsteadiness, confusion poor appetite, constipation, diarrhea, bruising, and red eyes. The Order Fax, dated [DATE], documented R2's primary care provider ordered Trazodone 50 milligrams (mg) at nighttime for insomnia. The Order Note, dated [DATE], documented to increase R2's Trazodone to 75 mg at nighttime and monitor R2 for over-sedation or morning drowsiness. The Order Note, dated [DATE], documented R2 continued to have insomnia and Trazodone was not helping. R2's provider ordered to increase R2's Trazodone to 100 mg for a trial for one week. The Medication Administration Record (MAR), dated [DATE] documented R2 received 75 mg of Trazodone on [DATE]. The MAR documented R2 received 100 mg of Trazodone from [DATE] through [DATE]. R2's MAR, after [DATE] documented all dosages were discontinued and the Trazodone was not administered. R2's clinical record lacked evidence staff monitored the effectiveness of the trail dose of Trazadone and lacked evidence staff notified the physician regarding the outcomes of the trial or to inform the order was expired and request further orders. The Order Note, dated [DATE] documented to restart Trazodone 50 mg, one and a half tabs, by mouth at nighttime for insomnia. R2 was unavailable for observation or interview. On [DATE] at 02:00 PM, Administrative Nurse D stated she normally put in the new orders, but she must not have been at the facility the day the trial order for Trazodone 100 mg was ordered by R2's primary care provider. Administrative Nurse D stated staff should have placed R2's Trazodone 75 mg on hold during the trial dosage increase of Trazodone 100 mg and then the Trazodone 75 mg dose should have been scheduled to restart the day after the trial week. Administrative Nurse D stated an order for monitoring the effectiveness of Trazodone 100 mg related to R2's insomnia should have been placed in the Treatment Administration Record (TAR) and another order to contact R2's primary care provider regarding the effectiveness of the dosage increase. The Administering Medications Policy, revised [DATE], documented medications are to be administered in a safe and timely manner and as prescribed. The Director of Nursing supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by the resident need and benefit, not staff convenience. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. The facility failed to monitor R2's psychotropic medication used off-label use for insomnia after a trial increase. This deficient practice placed R2 at risk for inadequate oversight, lack of physician involvement, and ineffective dosing for Trazodone.

The facility identified a census of 44 residents with three residents reviewed for pain. Based on record review, observation, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for Resident (R) 1 respiratory needs and equipment. This deficient practice placed R1 at risk for respiratory well-being due to uncommunicated care needs. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polyneuropathy (the simultaneous malfunction of peripheral nerves throughout the body), chronic pain, hypokalemia (low level of potassium in the blood), and edema (swelling). The Quarterly Minimum Data Set (MDS), dated 12/07/23, documented R1 had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS documented R1 required oxygen and a non-invasive ventilator (a machine that provides ventilatory support without using an artificial airway). The MDS documented R1 had received diuretics (medication to promote the formation and excretion of urine), opioids (a class of medications derived from the poppy plant to relieve pain), and anti-depressants (a class of medications used to treat mood disorders) medications. The Activities of Daily Living/Rehabilitation Potential Care Area Assessment (CAA), dated 06/27/23, documented R1 reported having frequent pain in her bilateral hips. R1 was generally independent with bed mobility, but required limited assistance for transfer, supervision for ambulation and locomotion, and required assistance with dressing and toileting. The Pain CAA, dated 06/27/23, documented R1 had diagnoses of COPD, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and myalgia (muscle pain). R1 reported she had an increase in pain when sitting too long in one position and had improvement in pain with pain medication and repositioning. R1's Care Plan, dated 02/27/24, documented R1 received Lasix (diuretic), duloxetine (anti-depressant, used for pain control), and Norco (an opioid pain medication) and staff were directed to administer the medications as ordered. The care plan directed staff R1 required limited staff assistance for her activities of daily living. The care plan lacked any documentation or direction regarding R1's Trilogy non-invasive ventilator. On 03/04/24 at 10:30 AM, observation revealed R1 sat in her wheelchair and visited with her daughter in her room. R1 had on oxygen via nasal cannula. R1 had two-to-three-word dyspnea (shortness of air). A Trilogy non-invasive ventilator sat on a table behind R1's recliner to the right of her bed. On 03/04/24 at 10:30 AM, R1 stated she had missed medication multiple times in February. R1 stated that her pain had been uncontrollable in the middle of February, she could hardly move or sleep. R1 stated she felt it was the facility's responsibility to make sure that she had all her medications available for her to take and she felt it showed irresponsibility on the facility's part in not making sure she had those medications. R1 stated she had difficulty at night getting staff to hook up the Trilogy and make sure the oxygen settings were moved up to seven liters because the nurse was not always on the unit. R1 stated she often fell asleep sitting in her chair waiting for someone to come and assist her with the Trilogy. R1 stated she felt like staff would then yell at her about why she did not call somebody to put it on or have the Certified Nurse's Aides (CNA) put it on. R1 stated she was told the CNAs could not touch her Trilogy or titrate oxygen and she just could not understand why the nurses were not taking responsibility for it. On 03/04/24 at 10:15 AM, Licensed Nurse (LN) G verified there were no orders for R1's Trilogy non-invasive ventilator and nothing in R1's care plan regarding R1's Trilogy non-invasive ventilator. On 03/04/24 at 01:00 PM, Administrative Staff A was unaware there were no orders for R1's Trilogy non-invasive ventilator or that R1's care plan did not reflect R1's usage of the Trilogy. The Care Plans, Comprehensive Person-Centered, policy revised March 2022, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; any specialized services to be provided as a result of recommendations; and which professional services are responsible for each element of care. The facility failed to develop and implement a comprehensive person-centered care plan for R1's respiratory needs and equipment. This deficient practice placed R1 at risk for respiratory well-being due to uncommunicated care needs.

The facility identified a census of 44 residents with three residents reviewed for pain. Based on record review, observation, and interview, the facility failed to provide appropriate care and services to provide respiratory care with the Trilogy non-invasive ventilator (an all-in-one ventilation device capable of delivering both invasive and non-invasive ventilation that can be more finely calibrated and adjusted to meet individual needs) to Resident (R) 1. The facility did not have orders from the primary care physician regarding how to run the Trilogy non-invasive ventilator, what settings the non-invasive ventilator needed to be set at, or how and when to clean the Trilogy non-invasive ventilator. This deficient practice placed R1 at risk for respiratory failure. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polyneuropathy (the simultaneous malfunction of peripheral nerves throughout the body), chronic pain, hypokalemia (low level of potassium in the blood), and edema (swelling). The Quarterly Minimum Data Set (MDS), dated 12/07/23, documented R1 had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS documented R1 required oxygen and a non-invasive ventilator (a machine that provides ventilatory support without using an artificial airway). The MDS documented R1 had received diuretics (medication to promote the formation and excretion of urine), opioids (a class of medications derived from the poppy plant to relieve pain), and anti-depressants (a class of medications used to treat mood disorders) medications. The Activities of Daily Living/Rehabilitation Potential Care Area Assessment (CAA), dated 06/27/23, documented R1 reported having frequent pain in her bilateral hips. R1 was generally independent with bed mobility, but required limited assistance for transfer, supervision for ambulation and locomotion, and required assistance with dressing and toileting. The Pain CAA, dated 06/27/23, documented R1 had diagnoses of COPD, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and myalgia (muscle pain). R1 reported she had an increase in pain when sitting too long in one position and had improvement in pain with pain medication and repositioning. R1's Care Plan, dated 02/27/24, documented R1 received Lasix (diuretic), duloxetine (anti-depressant, used for pain control), and Norco (an opioid pain medication) and staff were directed to administer the medications as ordered. The care plan directed staff R1 required limited staff assistance for her activities of daily living. The care plan lacked any documentation or direction regarding R1's Trilogy non-invasive ventilator. The January Order Summary Report, signed by R1's primary care physician on 01/24/24, documented R1 was receiving hydrocodone/acetaminophen 10/325 mg four times a day and duloxetine 60 mg twice a day. The order report lacked any orders regarding R1's Trilogy non-invasive ventilator. On 03/04/24 at 10:30 AM, observation revealed R1 sat in her wheelchair and visited with her daughter in her room. R1 had on oxygen via nasal cannula. R1 had two-to-three-word dyspnea (shortness of air). A Trilogy non-invasive ventilator sat on a table behind R1's recliner to the right of her bed. On 03/04/24 at 10:30 AM, R1 stated she had missed medication multiple times in February. R1 stated that her pain had been uncontrollable in the middle of February, she could hardly move or sleep. R1 stated she felt it was the facility's responsibility to make sure that she had all her medications available for her to take and she felt it showed irresponsibility on the facility's part in not making sure she had those medications. R1 stated she had difficulty at night getting staff to hook up the Trilogy and make sure the oxygen settings were moved up to seven liters because the nurse was not always on the unit. R1 stated she often fell asleep sitting in her chair waiting for someone to come and assist her with the Trilogy. R1 stated she felt like staff would then yell at her about why she did not call somebody to put it on or have the Certified Nurse's Aides (CNA) put it on. R1 stated she was told the CNAs could not touch her Trilogy or titrate oxygen and she just could not understand why the nurses were not taking responsibility for it. On 03/04/24 at 10:15 AM, Licensed Nurse (LN) G verified there were no orders for R1's Trilogy non-invasive ventilator and nothing in R1's care plan regarding R1's Trilogy non-invasive ventilator. On 03/04/24 at 01:00 PM, Administrative Staff A was unaware there were no orders for R1's Trilogy non-invasive ventilator or that R1's care plan did not reflect R1's usage of the Trilogy. The CPAP (Continuous Positive Airway Pressure - a machine that uses mild air pressure to keep breathing airways open while sleeping)/BIPAP (a Bilevel Positive Airway Pressure - is a form of a non-invasive ventilator used if a person can breathe on their own but cannot get enough oxygen or get rid of carbon dioxide), policy revised March 2015, documented the purpose of the policy was to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen, to improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease, and to promote resident comfort and safety. Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. Review the resident's medical record to determine his or her baseline oxygen saturation or arterial blood gases (ABGs), respiratory, circulatory, and gastrointestinal status. Review the physician's order to determine the oxygen concentration and flow and the PEEP pressure. Review and follow the manufacturer's instructions for machine setup and oxygen delivery. The facility failed to provide appropriate care and services to provide respiratory care with the Trilogy non-invasive ventilator for R1. This deficient practice placed R1 at risk for respiratory failure.

The facility identified a census of 44 residents with three residents reviewed for pain. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 received her pain medication as ordered to help alleviate her pain. This deficient practice placed R1 at risk of pain and emotional distress from being in pain. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polyneuropathy (the simultaneous malfunction of peripheral nerves throughout the body), chronic pain, hypokalemia (low level of potassium in the blood), and edema (swelling). The Quarterly Minimum Data Set (MDS), dated 12/07/23, documented R1 had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS documented R1 required oxygen and a non-invasive ventilator (a machine that provides ventilatory support without using an artificial airway). The MDS documented R1 had received diuretics (medication to promote the formation and excretion of urine), opioids (a class of medications derived from the poppy plant to relieve pain), and anti-depressants (a class of medications used to treat mood disorders) medications. The Activities of Daily Living/Rehabilitation Potential Care Area Assessment (CAA), dated 06/27/23, documented R1 reported having frequent pain in her bilateral hips. R1 was generally independent with bed mobility, but required limited assistance for transfer, supervision for ambulation and locomotion, and required assistance with dressing and toileting. The Pain CAA, dated 06/27/23, documented R1 had diagnoses of COPD, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and myalgia (muscle pain). R1 reported she had an increase in pain when sitting too long in one position and had improvement in pain with pain medication and repositioning. R1's Care Plan, dated 02/27/24, documented R1 received Lasix (diuretic), duloxetine (anti-depressant, used for pain control), and Norco (an opioid pain medication) and staff were directed to administer the medications as ordered. The care plan directed staff R1 required limited staff assistance for her activities of daily living. The care plan lacked any documentation or direction regarding R1's Trilogy non-invasive ventilator. R1's EMR documented an order from her primary care physician on 08/16/23 to give hydrocodone/acetaminophen (Norco-pain medication) 10/325 milligrams (mg) by mouth four times a day for pain. R1's EMR documented an order received from her primary care physician on 11/25/23 to give duloxetine 30 mg two capsules by mouth (total of 60 mg) twice a day for fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance). The Pharmacy Gradual Dose Reduction Request, dated 12/05/23, documented the pharmacist requested R1's primary care physician to do a dose reduction on R1's duloxetine. R1's primary care physician responded, Duloxetine is for fibromyalgia. Continue the same dose. The January Order Summary Report, signed by R1's primary care physician on 01/24/24, documented R1 was receiving hydrocodone/acetaminophen 10/325 mg four times a day and duloxetine 60 mg twice a day. The February MAR, documented R1 had not received her hydrocodone/acetaminophen 10/325 mg at all on 02/12/24 due to the medication being unavailable. The February MAR, documented R1 had not received her duloxetine 60 mg for a total of three days February 14th, 15th, and 16th due to the medication being unavailable. R1's clinical record lacked evidence staff notified R1's physician that the pain medications were not given to R1. On 03/04/24 at 10:30 AM, observation revealed R1 sat in her wheelchair and visited with her daughter in her room. R1 had on oxygen via nasal cannula. R1 had two-to-three-word dyspnea (shortness of air). A Trilogy non-invasive ventilator sat on a table behind R1's recliner to the right of her bed. On 03/04/24 at 10:30 AM, R1 stated she had missed medication multiple times in February. R1 stated that her pain had been uncontrollable in the middle of February, she could hardly move or sleep. R1 stated she felt it was the facility's responsibility to make sure that she had all her medications available for her to take and she felt it showed irresponsibility on the facility's part in not making sure she had those medications. On 03/04/24 at 10:15 AM, Licensed Nurse (LN) G stated one of the Certified Medication Aides (CMA) M got all the medications that needed to be re-ordered and wrote them down from the tabs the other CMAs pulled off the medication cards. After CMA G wrote all the medications down, she would give the re-order sheet to either the charge nurse on duty that day, the Assistant Director of Nursing (ADON), or the Director of Nursing (DON), and then they would ensure the medications were ordered from whatever pharmacy the residents used. LN G was uncertain regarding the dates R1 missed her medications and stated she would have to check on it. LN G stated she was not sure about why R1 had not received her duloxetine for fibromyalgia for three days. LN G stated the facility had to buy R1's hydrocodone/acetaminophen because when R1 changed pharmacy, the prescription could not be refilled. On 03/04/24 at 11:00 AM, CMA M stated she wrote down all the medications that needed to be re-ordered on all three units of medication carts. CMA M stated the CMAs pulled the tabs off the medication cards and placed them in a plastic basket to be re-ordered, and then she would write all the medications down and give them to the administrative nurses for them to order. CMA M stated the nurses used to run a report on what medications needed to be ordered but she did not know how to do that. On 03/04/24 at 11:15 AM, CMA N stated she did not know why R1 had not received her pain medication in mid-February. On 03/04/24 at 01:00 PM, Administrative Staff A acknowledged that R1 not receiving her medications as ordered was a problem. Administrative Staff A stated the processes for re-ordering medication needed to be reviewed. The Pain Clinical Protocol Policy, revised October 2022, documented the physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing diagnoses and conditions that commonly cause pain. It also includes a review of any treatments the resident currently is receiving for pain, including complimentary and non-pharmacologic treatments. The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. Staff will provide the elements of a comforting and appropriate physical and complementary intervention. The facility failed to ensure R1 had her pain medication administered as ordered to help alleviate her pain. This deficient practice placed R1 at risk of pain and emotional distress from being in pain.

The facility identified a census of 44 residents with three residents reviewed for medication errors. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 was free from medication errors. This deficient practice placed R1 at risk of medical complications from not receiving her medications as they were ordered by her physician. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polyneuropathy (the simultaneous malfunction of peripheral nerves throughout the body), chronic pain, hypokalemia (low level of potassium in the blood), and edema (swelling). The Quarterly Minimum Data Set (MDS), dated 12/07/23, documented R1 had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS documented R1 required oxygen and a non-invasive ventilator (a machine that provides ventilatory support without using an artificial airway). The MDS documented R1 had received diuretics (medication to promote the formation and excretion of urine), opioids (a class of medications derived from the poppy plant to relieve pain), and anti-depressants (a class of medications used to treat mood disorders) medications. The Activities of Daily Living/Rehabilitation Potential Care Area Assessment (CAA), dated 06/27/23, documented R1 reported having frequent pain in her bilateral hips. R1 was generally independent with bed mobility, but required limited assistance for transfer, supervision for ambulation and locomotion, and required assistance with dressing and toileting. The Pain CAA, dated 06/27/23, documented R1 had diagnoses of COPD, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and myalgia (muscle pain). R1 reported she had an increase in pain when sitting too long in one position and had improvement in pain with pain medication and repositioning. R1's Care Plan, dated 02/27/24, documented R1 received Lasix (diuretic), duloxetine (anti-depressant, used for pain control), and Norco (an opioid pain medication) and staff were directed to administer the medications as ordered. The care plan directed staff R1 required limited staff assistance for her activities of daily living. The care plan lacked any documentation or direction regarding R1's Trilogy non-invasive ventilator. R1's EMR documented an order from her primary care physician on 08/16/23 to give hydrocodone/acetaminophen (Norco-pain medication) 10/325 milligrams (mg) by mouth four times a day for pain. R1's EMR documented an order received from her primary care physician on 11/02/23 to give potassium chloride (electrolyte supplement) 10 milliequivalents (meq) by mouth daily for hypokalemia. R1's EMR documented an order received from her primary care physician on 11/25/23 to give duloxetine 30 mg two capsules by mouth (total of 60 mg) twice a day for fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance). The Pharmacy Gradual Dose Reduction Request, dated 12/05/23, documented the pharmacist requested R1's primary care physician to do a dose reduction on R1's duloxetine. R1's primary care physician responded, Duloxetine is for fibromyalgia. Continue the same dose. The January Order Summary Report, signed by R1's primary care physician on 01/24/24, documented R1 was receiving hydrocodone/acetaminophen 10/325 mg four times a day, potassium chloride 10 meq daily, and duloxetine 60 mg twice a day. The January Medication Administration Record (MAR), documented R1 had not received her potassium chloride 10 meq for twenty-four days in January due to the medication being unavailable. The February MAR, documented R1 had not received her hydrocodone/acetaminophen 10/325 mg at all on 02/12/24 due to the medication being unavailable. The February MAR, documented R1 had not received her duloxetine 60 mg for a total of three days February 14th, 15th, and 16th due to the medication being unavailable. The February MAR, documented R1 had not received her potassium chloride 10 meq for twenty-five days in February due to the medication being unavailable. The facility failed to notify R1's physician that the medications were not given to R1. On 03/04/24 at 10:30 AM, observation revealed R1 sat in her wheelchair and visited with her daughter in her room. R1 had on oxygen via nasal cannula. R1 had two-to-three-word dyspnea (shortness of air). A Trilogy non-invasive ventilator sat on a table behind R1's recliner to the right of her bed. On 03/04/24 at 10:30 AM, R1 stated she had missed medication multiple times in February. R1 stated that her pain had been uncontrollable in the middle of February, she could hardly move or sleep. R1 stated she felt it was the facility's responsibility to make sure that she had all her medications available for her to take and she felt it showed irresponsibility on the facility's part in not making sure she had those medications. On 03/04/24 at 10:15 AM, Licensed Nurse (LN) G stated one of the Certified Medication Aides (CMA) M got all the medications that needed to be re-ordered and wrote them down from the tabs the other CMAs pulled off the medication cards. After CMA G wrote all the medications down, she would give the re-order sheet to either the charge nurse on duty that day, the Assistant Director of Nursing (ADON), or the Director of Nursing (DON), and then they would ensure the medications were ordered from whatever pharmacy the residents used. LN G was uncertain regarding the dates R1 missed her medications and stated she would have to check on it. On 03/04/24 at 11:00 AM, CMA M stated she wrote down all the medications that needed to be re-ordered on all three units medication carts. CMA M stated the CMAs pulled the tabs off the medication cards and placed them in a plastic basket to be re-ordered, and then she would write all the medications down and give them to the administrative nurses for them to order. CMA M stated the nurses used to run a report on what medications needed to be ordered but she did not know how to do that. CMA M stated she had no idea R1 was out of her potassium chloride because if she did not get a tag in the basket, she did not know something needed re-ordered. CMA M stated she searched the medication cart for R1's hall and there was no potassium chloride for R1 in the cart. On 03/04/24 at 11:15 AM, CMA N stated that she had documented R1's potassium that morning before she realized the medication was not available and she went back and struck out the administration. CMA N stated she had not let anyone know the potassium was unavailable. On 03/04/24 at 01:00 PM, Administrative Staff A acknowledged that R1 not receiving her medications as ordered was a problem. Administrative Staff A stated the processes for re-ordering medication needed to be reviewed. The Administering Medications Policy, dated April 2019, documented that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with the prescriber's orders. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff. The facility failed to ensure R1 was free from medication errors. This deficient practice placed R1 at risk of medical complications from not receiving her medications as they were ordered by her physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to notify the physician of Resident (R) 2's suicidal ideations, R7's elopement ( when a resident exits the facility without the knowledge or supervision of staff) in winter weather, R13's lack of bowel movements and R23's verbalizations of wanting to die. This placed the residents at risk for delayed treatment due to lack of physician involvement. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), chronic pain, chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity, difficulty or discomfort in breathing), altered mental status, chronic atrial fibrillation (rapid, irregular heart beat), need of assistance with personal care, and urinary tract infection (UTI). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had severe cognitive impairment, rejection of care behavior which occurred one to three days of the look back period. She required extensive assistance of one to two persons for activities of daily living (ADL)w, was not steady with transitions or balance, and was only able to [NAME] with staff assistance. The MDS further documented R2 was frequently incontinent of urine, received scheduled pain medication, insulin (medication to regulate blood sugar levels), anticoagulant (medication to decrease blood's ability to clot), and antibiotic (medication used to treat infections). R2 used oxygen and had occupational and physical therapy services. The Behavioral Symptoms Care Area Assessment (CAA), dated 03/29/23, documented R2 had frequent crying for two days and no other behaviors. R2's Care Plan lacked direction for depression and suicidal ideations. The Progress Note dated 08/09/23 at 11:30 AM, documented R2 had suicidal ideation over the weekend and staff initiated hourly rounding and observation when she was wishing to hurt herself. The note recorded the care plan was updated 08/09/23. The EMR lacked further documentation of R2's suicidal ideation, nursing and social service assessment and follow up, and lacked physician and family notification. On 08/28/23 at 04:34 PM observation revealed R2 sat in her room, in a wheelchair, with her head tilted toward her chest and her eyes closed. R2 wore oxygen tubing to her nose, and her call light was attached to the wheelchair. On 08/30/23 at 02:30 PM observation revealed R2 rested in bed which was positioned close to the floor. There was a mat on the floor next to the bed. On 08/31/23 at 09:38 AM, Licensed Nurse (LN) H reported she was working when R2 told her that R2 wanted to die and verbalized a plan of wrapping a cord around her neck. LN H was not working in the capacity of nurse and reported it to the charge nurse. LN H reported she stayed near R2 following the threat. LN reported the provider, family, administrator, director of nursing, and social services should have been notified by the nurse on duty. On 08/31/23 at 12:47 PM, Administrative Nurse D verified she was aware of R2's suicidal statement and plan of using the call light cord to end her life. Administrative Nurse D reported she checked on R2 and R2 seemed to be fine. Administrative Nurse D did not know if the physician or family was notified of R2's suicidal statement or plan. On 08/31/23 at 02:00 PM, Social Service X stated he was informed of R2's suicidal statement the following day. Social Service X reported he talked to R2 and staff and the resident seemed fine. Social Service X expected nursing staff to have notified the physician and family. Social Service X reported R2's family may have been offered mental health services but was not clear if she had been on mental health services in the past. Social Service X reported he had not documented his visit and staff reports in the EMR. The facility's Depression Clinical Protocol policy, dated 11/2018, documented the physician and staff will review available information and inquire further to identify and document individuals who have a history of depression or another mood disorder, other psychiatric disorder(s), psychiatric treatment or hospitalizations, or suicide attempts. In addition, the nurse shall assess and document/report whether mood decline is associated with anorexia, crying, sleeplessness, suicidal ideation, onset, duration, frequency, severity of signs and symptoms. The facility failed to notify R2's physician of suicidal ideations with a plan of wrapping a cord around her neck which placed R2 for unmet care needs. -The Electronic Medical Record (EMR) documented R27 had diagnoses of restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (progressive mental disorder characterized by failing memory and confusion), need for assistance with personal cares, adjustment disorder with depressed mood, generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), abnormalities of gait and mobility, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R27 had severe cognitive impairment, had inattention and disorganized thinking behavior which fluctuated, was independent with no set up or physical help from staff with activities of daily living, and no alarms or restraint use. The MDS further documented R27 had received an antianxiety medication four days out of seven days of the look back period and an antibiotic (medication used to treat infection) seven days of seven day look back period. The Elopement Risk/Wanderer Care Plan, dated 04/29/22, with goal of R27 would not leave facility unattended and safety maintained through the next review date. The care plan lacked ongoing intervention for elopement/wandering. The Progress Note, dated 11/15/22 at 02:14 AM, documented R27 was found outside in the fenced patio area at 01:00 AM with another resident. Both residents did not have coats on and the temperature outside at the time was aground 20 degrees Fahrenheit (F.), however, both residents had blankets with them. R27 was supposed to be in quarantine for Covid-19 (highly contagious respiratory virus). After the certified nurse aide found her outside, R27 was taken to her room and was angry and began to slam her doors and hitting the wall with her feet and dresser. R27's clinical record lacked evidence of notification to facility administration, family, or physician. On 08/30/23 at 08:42 AM, observation revealed R27 left her room with her husband, and walked independently with a walker. On 08/30/23 at 12:38 PM, Administrative Nurse D stated staff should have notified the physician when R27 was found outside on 11/15/22. The facility's Wandering and Elopements policy, dated 03/2019, documented the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall contact the Attending Physician and report findings and condition of the resident. The facility failed to notify the physician when R27 left the building unattended. This placed R27 at risk of delayed treatment due to lack of physician involvement. - The Electronic Medical Record (EMR) for R13 documented diagnoses of constipation (difficulty passing stool), chronic pain (pain that carries on for longer than 12 weeks despite medication or treatment), major depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), hypertension (high blood pressure), and iron deficiency (too little iron in the body). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of one staff for dressing and personal hygiene. The assessment further documented R13 had occasional bowel incontinence. The Medication Care Plan, dated 06/01/23, initiated on 04/27/22, directed staff to administer medication as ordered and to monitor for side effects, signs and symptoms of constipation, and received extensive assist of one staff for toileting. The Physician's Order, dated 04/27/22, directed staff to administer MiraLAX (a laxative to help with constipation), 17 gram (gm), by mouth, daily for constipation. The Physician's Order, dated 04/27/22, directed staff to administer Milk of Magnesia (MOM) laxative to help with constipation), 1200 milligrams (mg)/15 milliliters (ml), administer 30 ml as needed for constipation, contact the provider if there are three days without a significant bowel movement. The Bowel Monitoring Record, dated May 2023, revealed R13 did not have a bowel movement for the following days: 05/11/23-5/14/23 (four consecutive days) The Bowel Monitoring Record, dated August 2023, revealed R13 did not have a bowel movement for the following days: 08/18/23-08/22/23 (five consecutive days) R13's clinical record lacked evidence the physician was notified as ordered for the two separate incidents, On 08/29/23 at 09:28 AM, observation revealed R13 seated at the dining room table eating breakfast. On 08/30/23 at 10:00 AM, Certified Nurse Aide (CNA) M stated if a resident did not have a bowel movement, she documented it in the kiosk (a small, stand-alone device providing information for staff on a computer screen and was often used for services provided). On 08/30/23 at 11:45 AM, Licensed Nurse (LN) G verified there were no bowel movements charted on the days in question, and R13's record lacked evidence the medications were given as ordered. LN G verified the physician was not notified of the lack of bowel movements for R13. On 08/31/23 at 12:48 PM, Administrative Nurse D stated there had been trouble with the documentation of bowel movements and the facility were getting ready to start a new way to monitor resident bowel movements. Upon request, a policy for notification to the physician, was not provided by the facility. The facility failed to notify the physician as ordered for an interval with no bowel movements for R13. This placed the resident at risk for delayed treatment due to lack of physician involvement. - The Electronic Medical Recorded (EMR) for R23 documented diagnoses of multiple sclerosis (a potentially disabling disease of the pain and spinal cord), pressure ulcers, vitamin deficiency, protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), osteomyelitis (inflammation of one or bone marrow usually due to infection), hypertension (high blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Annual Minimum Data Set (MDS), dated [DATE], documented R23 had moderately impaired cognition, and was dependent upon one staff member for transfers, and toileting. R23 required extensive assistance of two staff for bed mobility, extensive assistance of one staff for dressing and personal hygiene. The assessment further documented R23 had thoughts she would be better off dead or hurting himself never or only one day and received antidepressant (medication used to treat mood disorders and relieve symptoms of depression) medication. R23's Quarterly MDS, dated 08/16/23, documented R23 had intact cognition and was dependent upon two staff for bed mobility, transfers, toileting. R23 required extensive assistance of two staff for dressing, and dependent upon one staff for personal hygiene. The assessment further documented R23 had thoughts she would be better off dead or hurting himself never or only one day and received antidepressant (medication used to treat mood disorders and relieve symptoms of depression) medication. The Care Plan, dated 07/06/23, initiated on 06/08/22 documented R23 received antidepressant medication and directed staff to monitor and documented side effects and effectiveness of medication. The care plan further directed staff to monitor adverse reactions of the medication related to change in behaviors, withdrawal, suicidal thoughts, hallucinations, delusions and social isolation. The care plan lacked documentation of R23's vocalization of wanting to die and direction to staff how to process her feelings. The Physician's Order, dated 01/18/22, directed staff to administer citalopram hydrobromide (an antidepressant medication), 10 milligrams (mg), 1 tablet, by mouth, in the morning, for depression. The Physician's Order, dated 04/11/22, directed staff to administer mirtazapine (an antidepressant medication), 7.5 mg , 1 tablet, by mouth, at bedtime, for depression. The Nurse's Note, dated 08/12/23 at 05:36 PM, documented R23 voiced to staff two times that she wanted to die and did not want the nurse to do anything with her and to leave her alone. The EMR lacked documentation the physician was notified. On 08/29/23 at 01:30 PM, observation revealed Administrative Nurse D washed her hands, gloved, and removed R23's sock and 4 x 4 gauze dressing. Administrative Nurse D measured the wound, provided wound care, put R23's sock back on, and applied a green left heel protector. On 08/29/23 at 01:30 PM, Licensed Nurse (LN) H stated R23 says things like she wants to die all the time but has never had a plan. LN H said when R23 said this to her, she told the Director of Nursing about it. LN H verified she did not document her conversation with the Director of Nursing and said that R23 was a very complicated resident. On 08/31/23 at 12:48 PM, Administrative Nurse D stated R23 had periods of negative moments and would say things that she would forget she said. Administrative Nurse D said within the week the facility would be talking with R23 about hospice or palliative care and staff should have notified the physician. On 08/31/23 01:37 PM, Social Service X stated he was unaware of the statements R23 made about wanting to die and stated he should have been made aware so he could talk with her. Social Service X further stated R23's family have discussed talking to her about hospice services within the next week and the facility would have staff that would be able to visit with her about those feelings. Social Service X stated when he had talked with R23 about depression, R23 always told him that she was not depressed and did not want to give up. The facility's Depression-Clinical Protocol policy, dated 11/18, documented the nurse shall assess, document, and report suicidal ideation to the physician so the physician can evaluate the underlying causes of the mood disorder and contributing factors. The facility failed to notify the physician of verbalizations of desire to die from R23. This placed the resident at risk for delayed treatment due to lack of physician involvement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to identify Resident (R)27's leaving the facility without the knowledge of staff in the middle of the night as an allegation of neglect and report to the state agency as required. This placed R27 at risk for unidentified and/or ongoing neglect. Findings included: -The Electronic Medical Record (EMR) documented R27 had diagnoses of restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (progressive mental disorder characterized by failing memory and confusion), need for assistance with personal cares, adjustment disorder with depressed mood, generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), abnormalities of gait and mobility, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R27 had severe cognitive impairment, had inattention and disorganized thinking behavior which fluctuated, was independent with no set up or physical help from staff with activities of daily living, and no alarms or restraint use. The MDS further documented R27 had received an antianxiety (medication used to treat anxiety) medication four days out of seven days of the look back period and an antibiotic (medication used to treat infection) seven days of seven day look back period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/22/22, documented R27 took an antidepressant (medication used to treat depression- abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) for anorexia (lack or loss of appetite) and antianxiety. The Elopement Risk/Wanderer Care Plan, dated 04/29/22, documented a goal of R27 would not leave the facility unattended and safety would be maintained through the next review date. The care plan directed staff to provide structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory loss. The Progress Note, dated 11/07/22 at 03:22 PM, documented R27 tested positive for Covid-19 (a highly contagious respiratory disease), and the family and physician were notified. The note further documented R27 would eat in her room and remain on isolation until cleared to participate in social settings. The Progress Note, dated 11/07/22 at 08:33 PM, recorded the physician ordered buspirone (medication used to treat anxiety disorder) twice a day. The Progress Note, dated 11/15/22 at 02:14 AM, documented R27 was found outside in the fenced patio area at 01:00 AM with another resident. Both residents did not have coats on and the temperature outside at the time was aground 20 degrees Fahrenheit (F.), however, both residents had blankets with them. R27 was supposed to be in quarantine for Covid-19. After the certified nurse aide found her outside, R27 was taken to her room and was angry and began to slam her doors and hitting the wall with her feet and dresser. R27's clinical record lacked evidence of immediate physical assessment due to inclement weather and attempts at self-harm and lacked notification to facility administration, family, or physician. On 08/30/23 at 08:42 AM, observation revealed R27 left her room with her husband, and walked independently with a walker. On 08/30/23 at 12:38 PM, Administrative Nurse D reported she heard about the tweezer incident but had not been in the facility at that time due to Covid 19. She said she was unsure if the resident's room was searched for other hazardous items and said she expected nursing staff to notify both family and physician of incident. Administrative Nurse D stated upon investigation of R27 being found outside on 11/15/22 had been that staff had heard the door to the patio and went to check finding R27 inside the facility standing with a resident whose room was next to the patio door and who also had been wandering the halls. Administrative Nurse D stated the egressed door alarm had not been engaged, therefore no alarm sounded when R27 had left the building. Administrative Nurse D reported the incident had not been reported to the state agency. The facility's Abuse and Neglect Clinical Protocol, dated 03/2018, documented the nurse will assess the individual and document related findings. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. The physician will provide adequate documentation regarding significant negative outcomes that have resulted from a resident's underlying medical illnesses or conditions, despite appropriate care. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistence with applicable laws and regulations. The facility failed to identify R27's leaving the facility without the knowledge of staff in the middle of the night as an allegation of neglect and report to the state agency as required. This placed R27 at risk for unidentified and/or ongoing neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to investigate Resident (R)27's incident of tweezers in her throat as well as R27 exiting the facility without staff awareness during winter weather. This failure placed R27 at risk for ongoing neglect and unidentified care needs. Findings included: -The Electronic Medical Record (EMR) documented R27 had diagnoses of restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (progressive mental disorder characterized by failing memory and confusion), need for assistance with personal cares, adjustment disorder with depressed mood, generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), abnormalities of gait and mobility, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R27 had severe cognitive impairment, had inattention and disorganized thinking behavior which fluctuated, was independent with no set up or physical help from staff with activities of daily living, and no alarms or restraint use. The MDS further documented R27 had received an antianxiety (medication used to treat anxiety) medication four days out of seven days of the look back period and an antibiotic (medication used to treat infection) seven days of seven day look back period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/22/22, documented R27 took an antidepressant (medication used to treat depression- abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) for anorexia (lack or loss of appetite) and an antianxiety . The Elopement Risk/Wanderer Care Plan, dated 04/29/22, documented a goal of R27 would not leave the facility unattended and safety would be maintained through the next review date. The care plan directed staff to provide structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory loss. The Progress Note, dated 11/07/22 at 03:22 PM, documented R27 tested positive for Covid-19 (a highly contagious respiratory disease), and the family and physician were notified. The note further documented R27 would eat in her room and remain on isolation until cleared to participate in social settings. The Progress Note, dated 11/07/22 at 08:33 PM, recorded the physician ordered buspirone (medication used to treat anxiety disorder) twice a day. The Progress Note, dated 11/12/22 at 08:50 AM, recorded R27 was found by a certified nurse aid with tweezers down her throat at 07:50 AM, R27 was alert and oriented after the tweezers were removed and her oxygen saturation was 98 percent. R27 did not answer questions as to why she did that. The tweezers were taken, and the resident was left in the room eating breakfast as if nothing happened. R27's representatives and the assistant director of nursing were notified. R27's clinical record lacked evidence of further investigation or assessment of R27's condition related to tweezers or other items of safety found or removed. The Progress Note, dated 11/15/22 at 02:14 AM, documented R27 was found outside in the fenced patio area at 01:00 AM with another resident. Both residents did not have coats on and the temperature outside at the time was aground 20 degrees Fahrenheit (F.), however both residents had blankets with them. R27 was supposed to be in quarantine for Covid-19. After the certified nurse aide found her outside, R27 was taken to her room and was angry and began to slam her doors and hitting the wall with her feet and dresser. R27's clinical record lacked evidence of immediate physical assessment due to inclement weather and attempts at self-harm and lacked evidence of invvestigation. On 08/30/23 at 08:42 AM, observation revealed R27 left her room with her husband, and walked independently with a walker. On 08/30/23 at 12:38 PM, Administrative Nurse D reported she heard about the tweezer incident but had not been in the facility at that time due to Covid 19. She said she was unsure if the resident's room was searched for other hazardous items and said she expected nursing staff to notify both family and physician of incident. Administrative Nurse D stated R27 was found outside on 11/15/22. Administrative Nurse D said no alarm sounded when R27 left the building. Administrative Nurse D reported the incident had not been reported to the state agency. Administrative Nurse D was unable to provide an investigation related to the event. The facility's Accident and Incident-Investigating and Reporting policy, dated 07/2017, documented all accidents or incidents involving residents, employers, visitors, vendor, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form for each occurrence. Incident/Accident report will be reviewed by the Safety Committee for trends related to accidents or safety hazards in the facility and to analyze any individual resident vulnerabilities. The facility failed to investigate R27's incident of tweezers in her throat as well as R27 exiting the facility without staff awareness during winter weather. This failure placed R27 at risk for ongoing neglect and unidentified care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide care and treatment in accordance with professional standards of practice when a Certified Nurse Aide (CNA) used tweezers to remove a blackhead on Resident (R)19's back without instruction or supervision from a licensed nurse, and the facility further failed to provide a dressing change to R31's wrist when sanguineous drainage (leakage of fresh blood) seeped through the dressing. This placed the residents at risk for inappropriate skin care and related complications. Findings included: - The Electronic Medical Record (EMR) for R19 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), sebaceous cyst (a small, slow-growing, noncancerous bump beneath the skin), anxiety (mental or emotional reaction charactered by apprehension, uncertainty and irrational fear, and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had intact cognition and was independent with all activities of daily living (ADLs) except for eating which required supervision and set up assistance. The MDS further documented R19 had no skin issues. The Care Plan, dated 07/20/23, initiated on 12/13/22, directed staff to follow the facility's policies and protocols for prevention and treatment of skin breakdown, monitor, document, and report as needed any changes in skin status weekly by the licensed nurse. The care plan further documented R19 required assistance of one staff for bathing and personal hygiene. The care plan lacked direction to staff related to the infected area on R19's back and how to care for it. The EMR lacked evidence a skin assessment was completed for R19's infected sore on his back. The Nurse's Note, dated 08/23/23 at 07:30 AM, documented the nurse was called by a CNA to R19's room to look at his back. The note further documented R19 reported to the CNA that during his last bath, a CNA dug a blackhead out of his back and now the area was sore. The area was draining whitish fluid and had redness around it. The resident complained of pain with palpation. The note documented R19 would be sent to the clinic for further evaluation. The Physician's Report, dated 08/23/23 documented an infected Winer's pore (enlarged blackhead pimple) versus sebaceous cyst (small, slow-growing, noncancerous bump beneath the skin) was removed from R19's midline back. The area had mild purulent (thick, containing pus) drainage and directed staff to observe the dressing daily, wash R19's back with soapy water, pat dry, use triple antibiotic ointment, and put a bandage on it. The Physician's Order, dated 08/23/23, directed staff to administer doxycycline (an antibiotic), 100 milligrams (mg), by mouth, twice a day for a week for an infected sebaceous cyst. On 08/30/23 at 04:45 PM, observation revealed Licensed Nurse (LN) G washed her hands, donned clean gloves, and removed the soiled dressing from R19's back. Further observation revealed a small purple area in the middle of his back, with no drainage noted. LN G donned clean gloves, washed the area with soap and water, donned clean gloves, applied triple antibiotic ointment on the area, and placed an Opsite dressing (a transparent, adhesive film) over it. On 08/30/23 at 04:45 PM, R19 stated his back no longer hurt . R19 stated he had not asked the CNA to doing anything to the area on his back but she used a pair of tweezers to dig out the blackhead. On 08/30/23 at 05:00 PM, LN G verified that a CNA used tweezers to remove the blackhead out of R19's back and the area became infected. On 08/31/23 at 08:00 AM, CNA O stated CNAs were not supposed to perform skin procedures on the residents and reported and that the area on R19's back got worse after a couple days. On 08/31/23 at 12:48 PM, Administrative Nurse D stated the CNA should have asked the nurse to look at the area on R19's back as it was not in a CNA's scope of practice to dig out blackheads on the residents. Administrative Nurse D further stated a skin assessment should have been completed. The facility's Infections-Clinical Protocol policy, dated 03/18, documented the nursing staff would monitor the progress of a resident with an infection until it was resolved and would report to the physician at least weekly until the resident was stable or improving and would evaluate the duration of any antibiotics and whether the antibiotics could be stopped. The facility failed to provide care and treatment in accordance with professional standards of practice when when a CNA used tweezers to dig out a blackhead on R19's back and it became infected. This placed R19 at risk for further infection and skin complications. - The Electronic Medical Record (EMR) for R31 documented diagnoses of history of falls, lack of coordination, diastolic hear failure (a condition in which the hearts main pumping chamber becomes still and unable to fill properly), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion) and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS further documented R31 had no skin issues. The Care Plan, dated 06/01/23, initiated on 10/20/22 documented R31 had potential for skin breakdown due to refusals to change positions. The update, dated 02/11/23, directed staff to keep skin clean and dry, and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surfaces. The care plan lacked direction to staff how to provide treatment to the skin tear on his left wrist. The EMR lacked documentation how R31 received the skin tear to his inner left wrist or treatment of the skin tear. On 08/29/23 at 08:39 AM, observation revealed R31 had a bandage to his inner left wrist with brown drainage that seeped through the bandage. On 08/30/23 at 11:49 AM, observation revealed R31 had the same bandage to his inner left wrist with brown drainage which seeped through the bandage. On 08/31/23 at 11:00 AM, observation revealed R31 had the same bandage to his inner left wrist with brown drainage soaked through the bandage. On 08/30/23 at 11:49 AM, Administrative Nurse D stated the dressing to his wrist was supposed to be changed every two days and she would look into why it had not been changed. Administrative Nurse D verified the EMR lacked direction to staff for treatment of the skin tear. Upon request a policy for skin tears and treatment was not provided by the facility. The facility failed to provide skin care, including assessment, treatment orders and dressing changes for R31's skin tear on his wrist. This placed the resident at risk for delayed healing and infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide care and treatment in accordance with professional standards of practice when staff failed to monitor and provide pain medication to Resident (R)16, who had severe pain in her shoulder after an incident with the sit to stand lift. This placed the resident at risk for prolonged pain. Findings included: - The Electronic Medical Record (EMR) for R16 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), muscle weakness, and pain. The Annual Minimum Data Set (MDS), dated [DATE], documented R16 had severely impaired cognition and required extensive assistance of three staff for bed mobility, transfers, toileting; R16 did not ambulate. The MDS further documented R16 rarely had pain and received non medication interventions for pain. The Pain Interview Assessment, dated 05/23/23, documented R16 had pain and staff used repositioning to help alleviate her pain. The Pain Care Plan, dated 06/09/23, initiated on 08/02/21, documented R16 had chronic pain and directed staff to administer pain medication, reposition R16, and monitor for response to the pain medication. The care plan further directed staff to monitor, record, and report any complaints by the resident of pain or requests for pain treatment, observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motions, withdrawal or resistance to care, or any change in usual activity attendance relate to pain or discomfort. The Physician's Order, dated 08/02/21, directed staff to administer acetaminophen (used to treat minor aches and pains), 500 milligrams (mg), by mouth, every four fours, as needed for pain. The Physician's Order, dated 09/26/22, directed staff to administer Aleve (an anti-inflammatory medication), 220 mg, by mouth, every 12 hours, as needed for pain and administer with a meal, snack, or milk. The Nurse's Note, dated 08/01/23 at 07:46 PM, documented R16 stated that her right shoulder was in so much pain after getting in her bed. The note further documented staff used the sit to stand lift to transfer her and it quit working and the emergency button did not work either and the two staff had to help her out of the lift and transfer her to safety. The note documented R16's family was notified to see if they wanted R16 taken to the hospital for x-rays (a photographic or digital image of the internal composition of something), or an appointment to see the physician in the morning, and her family declined both. Review of the EMR lacked documentation R16 was provided with pain medication for the right shuolder pain after the incident. On 08/29/23 at 12:47 PM, observation revealed Certified Nurse AIde (CNA) M placed the sit to stand lift sling around R16's waist, asked R16 to place her feet on the foot pad of the lift, attached the sling to the lift, and had R16 hold onto the handled of the lift. CNA P used the remote to lift R16 up to a standing position and transferred her to her bed without concern. On 08/29/23 at 12:47 PM, CNA M stated that the lift was kept in the bathroom and should be plugged in when not in use. CNA M further stated she was not aware of any problems with the lift but would inform maintenance if she had problems with it working correctly. On 08/30/23 at 11:45 AM, Licensed Nurse (LN) G stated she was unaware of any incidents with the lift but said if R16 had pain, she would administer as needed pain medication. On 08/31/23 at 12:48 PM, Administrative Nurse D stated R16 should have been given pain medication and follow-up documentation should have been completed. The facility's Assessment and Follow-UP: Role of the Nurse policy, dated September 2012, directed staff to conduct supplemental assessments including pain, functional, activity level assessments, and make the resident as comfortable as possible. The facility failed to provide care and treatment in accordance with professional standards of practice when staff failed to assess and provide pain medication to R16, who reported severe pain in her shoulder after the sit to stand lift quit working and staff had to help her out of the lift and transfer her to safety. This placed the resident at risk for further pain .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide the appropriate treatment and services to attain the highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being when staff failed to provide Resident (R)2 with mental health services when reporting suicidal ideations. This placed R2 residents at risk for unmet mental health care needs. Findings included: -The Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), chronic pain, chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity, difficulty or discomfort in breathing), altered mental status, chronic atrial fibrillation (rapid, irregular heart beat), need of assistance with personal care, and urinary tract infection (UTI). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had severe cognitive impairment, rejection of care behavior which occurred one to three days of the look back period. She required extensive assistance of one to two persons for activities of daily living (ADL)w, was not steady with transitions or balance, and was only able to [NAME] with staff assistance. The MDS further documented R2 was frequently incontinent of urine, received scheduled pain medication, insulin (medication to regulate blood sugar levels), anticoagulant (medication to decrease blood's ability to clot), and antibiotic (medication used to treat infections). R2 used oxygen and had occupational and physical therapy services. The Behavioral Symptoms Care Area Assessment (CAA), dated 03/29/23, documented R2 had frequent crying for two days and no other behaviors. R2's Care Plan lacked direction for depression and suicidal ideations. The Progress Note dated 08/09/23 at 11:30 AM, documented R2 had suicidal ideation over the weekend and staff initiated hourly rounding and observation when she was wishing to hurt herself. The note recorded the care plan was updated 08/09/23. The EMR lacked further documentation of R2's suicidal ideation, nursing and social service assessment and follow up. R2's record lacked physician and family notification and lacked evidence mental health services were offered or provided. On 08/28/23 at 04:34 PM observation revealed R2 sat in her room, in a wheelchair, with her head tilted toward her chest and her eyes closed. R2 wore oxygen tubing to her nose, and her call light was attached to the wheelchair. On 08/31/23 at 09:38 AM, Licensed Nurse (LN) H reported she was working when R2 told her that R2 wanted to die and verbalized a plan of wrapping a cord around her neck. LN H was not working in the capacity of nurse and reported it to the charge nurse. LN H reported she stayed near R2 following the threat. LN reported the provider, family, administrator, director of nursing, and social services should have been notified by the nurse on duty. On 08/31/23 at 12:47 PM, Administrative Nurse D verified she was aware of R2's suicidal statement and plan of using the call light cord to end her life. Administrative Nurse D reported she checked on R2 and R2 seemed to be fine. Administrative Nurse D did not know if the physician or family was notified of R2's suicidal statement or plan. Administrative Nurse D reported she was not aware if the staff checked the room for cords or other items R2 may have used to harm herself and said the staff should have implemented 15- minute checks. Administrative Nurse D was unsure in R2 had current psychological consult or treatment. On 08/31/23 at 02:00 PM, Social Service X, stated he was informed of R2's suicidal statement the following day. Social Service X reported he talked to R2 and staff and the resident seemed fine. Social Service X expected nursing staff to have notified the physician and family. Social Service X reported R2's family may have been offered mental health services but was not clear if she had been on mental health services in the past. Social Service X reported he had not documented his visit and staff reports in the EMR. The facility's Behavioral Health Service policy, dated 07/05/20, documented an Interdisciplinary team (IDT) approach will be taken to include the resident, their family, or resident representative, to ensure that resident's individualized behavioral health care needs are met. Identify, address, and/or obtain necessary services for the behavioral health care needs of the residents. Review and revise behavioral health care plans that have not been effective and/or when the resident has had a change in condition. The facility failed to provide R2 the appropriate treatment and services after voicing suicidal ideations with appropriate treatment and services to attain highest practicable mental and psychosocial well-being, which placed the resident at risk for unmet mental health care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to identify and provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of two sampled residents, Resident (R) 2 who had reported suicidal ideations and lacked social service involvement, and R23 who reported wanting to die and social services was not aware of reported concern. This placed the residents at risk for further decline of their emotional and mental well-being. Findings included: - The Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), chronic pain, chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity, difficulty or discomfort in breathing), altered mental status, chronic atrial fibrillation (rapid, irregular heart beat), need of assistance with personal care, and urinary tract infection (UTI). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had severe cognitive impairment, rejection of care behavior which occurred one to three days of the look back period. She required extensive assistance of one to two persons for activities of daily living (ADL)w, was not steady with transitions or balance, and was only able to [NAME] with staff assistance. The MDS further documented R2 was frequently incontinent of urine, received scheduled pain medication, insulin (medication to regulate blood sugar levels), anticoagulant (medication to decrease blood's ability to clot), and antibiotic (medication used to treat infections). R2 used oxygen and had occupational and physical therapy services. The Behavioral Symptoms Care Area Assessment (CAA), dated 03/29/23, documented R2 had frequent crying for two days and no other behaviors. R2's Care Plan lacked direction for depression and suicidal ideations. The Progress Note dated 08/09/23 at 11:30 AM, documented R2 had suicidal ideation over the weekend and staff initiated hourly rounding and observation when she was wishing to hurt herself. The note recorded the care plan was updated 08/09/23. The EMR lacked further documentation of R2's suicidal ideation including social service assessment and follow up. R2's record lacked evidence mental health services were offered or provided. On 08/28/23 at 04:34 PM observation revealed R2 sat in her room, in a wheelchair, with her head tilted toward her chest and her eyes closed. R2 wore oxygen tubing to her nose, and her call light was attached to the wheelchair. On 08/31/23 at 09:38 AM, Licensed Nurse (LN) H reported she was working when R2 told her that R2 wanted to die and verbalized a plan of wrapping a cord around her neck. LN H was not working in the capacity of nurse and reported it to the charge nurse. LN H reported she stayed near R2 following the threat. LN reported the provider, family, administrator, director of nursing, and social services should have been notified by the nurse on duty. On 08/31/23 at 12:47 PM, Administrative Nurse D verified she was aware of R2's suicidal statement and plan of using the call light cord to end her life. Administrative Nurse D reported she checked on R2 and R2 seemed to be fine. Administrative Nurse D did not know if the physician or family was notified of R2's suicidal statement or plan. Administrative Nurse D reported she was not aware if the staff checked the room for cords or other items R2 may have used to harm herself and said the staff should have implemented 15- minute checks. Administrative Nurse D was unsure in R2 had current psychological consult or treatment. On 08/31/23 at 02:00 PM, Social Service X stated he was informed of R2's suicidal statement the following day. Social Service X reported he talked to R2 and staff and the resident seemed fine. Social Service X expected nursing staff to have notified the physician and family. Social Service X reported R2's family may have been offered mental health services but was not clear if she had been on mental health services in the past. Social Service X reported he had not documented his visit and staff reports in the EMR. The facility's Social Services policy, dated 09/2021, documented the facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. Medically related social services are provided to maintain or improve each resident's ability to control everyday physical needs, and mental and psychosocial needs. The facility staff is able to identify and address factors that have a potential negative effect on psychosocial functioning. Not all medically related social services are provided by a qualified social worker. However, the facility is responsible for ensuring tat all residents are provided these services whether by a staff member r through referrals to an outside agency. The facility failed to identify and provide medically related social service to R2 who reported suicidal ideations which placed the resident at risk of unmet psychosocial needs. - The Electronic Medical Recorded (EMR) for R23 documented diagnoses of multiple sclerosis (a potentially disabling disease of the pain and spinal cord), pressure ulcers, vitamin deficiency, protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), osteomyelitis (inflammation of one or bone marrow usually due to infection), hypertension (high blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Annual Minimum Data Set (MDS), dated [DATE], documented R23 had moderately impaired cognition, and was dependent upon one staff member for transfers, and toileting. R23 required extensive assistance of two staff for bed mobility, extensive assistance of one staff for dressing and personal hygiene. The assessment further documented R23 had thoughts she would be better off dead or hurting himself never or only one day and received antidepressant (medication used to treat mood disorders and relieve symptoms of depression) medication. R23's Quarterly MDS, dated 08/16/23, documented R23 had intact cognition and was dependent upon two staff for bed mobility, transfers, toileting. R23 required extensive assistance of two staff for dressing, and dependent upon one staff for personal hygiene. The assessment further documented R23 had thoughts she would be better off dead or hurting himself never or only one day and received antidepressant (medication used to treat mood disorders and relieve symptoms of depression) medication. The Care Plan, dated 07/06/23,initiated on 06/08/22 documented R23 received antidepressant medication and directed staff to monitor and documentd side effects and effectiveness of medication. The care plan further directed staff to monitor adverse reactions of the medication related to change in behaviors, withdrawal, suicidal thoughts, hallucinations, delusions and social isolation. The care plan lacked documentation of R23's vocalization of wanting to die and direction to staff how to process her feelings. The Physician's Order, dated 01/18/22, directed staff to administer citalopram hydrobromide (an antidepressant medication), 10 milligrams (mg), 1 tablet, by mouth, in the morning, for depression. The Physician's Order, dated 04/11/22, directed staff to administer mirtazapine (an antidepressant medication), 7.5 mg , 1 tablet, by mouth, at bedtime, for depression. The Nurse's Note, dated 08/12/23 at 05:36 PM, documented R23 voiced to staff two timesthat she wanted to die and did not want the nurse to do anything with her and to leave her alone. The EMR lacked documentation the physician was notified and lacked follow-up from the facility. On 08/29/23 at 01:30 PM, observation revealed Administrative Nurse D washed her hands, gloved, and removed R23's sock and 4 x 4 gauze dressing. Administrative Nurse D measured the wound, provided wound care, put R23's sock back on, and applied a green left heel protector. On 08/29/23 at 01:30 PM, Licensed Nurse (LN) H stated R23 says things like she wants to die all the time but has never had a plan. LN H said when R23 said this to her, she told the Director of Nursing about it. LN H verified she did not document her conversation with the Director of Nursing and said that R23 was a very complicated resident. On 08/31/23 at 12:48 PM, Administrative Nurse D stated R23 had periods of negative moments and would say things that she would forget she said. Administrative Nurse D said within the week the facility would be talking with hR23 about hospice or palliative care. On 08/31/23 01:37 PM, Social Service X stated he was unaware of the statements R23 made about wanting to die and stated he should have been made aware so he could talk with her. Social Service X further stated R23's family have discussed talking to her about hospice services within the next week and the facility would have staff that would be able to visit with her about those feelings. Social Service X stated when he had talked with R23 about depression, R23 always told him that she was not depressed and did not want to give up. The facility's Social Service policy, dated 09/21, documented the facility provided medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The policy further documented the social worker/social services staff were responsible for meeting the needs of residents who are grieving from losses's and coping with stressful events. The facility failed to identify and provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for R23, who stated she wanted to die twice. This placed the resident at risk for further decline of her emotional and mental well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to provide physician ordered medications for lack of bowel movements, and failed to contact the physician for one resident, Resident (R) 13, who had a history of constipation. This placed the resident at risk for impaction. Findings inlcuded: - The Electronic Medical Record (EMR) for R13 documented diagnoses of constipation (difficulty passing stool), chronic pain (pain that carries on for longer than 12 weeks despite medication or treatment), major depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), hypertension (high blood pressure), and iron deficiency (too little iron in the body). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of one staff for dressing and personal hygiene. The assessment further documented R13 had occasional bowel incontinence. The Medication Care Plan, dated 06/01/23, initiated on 04/27/22, directed staff to administer medication as ordered and to monitor for side effects, signs and symptoms of constipation, and received extensive assist of one staff for toileting. The Physician's Order, dated 04/27/22, directed staff to administer Miralax (a laxative to help with constipation), 17 gram (gm), by mouth, daily for constipation. The Physician's Order, dated 04/27/22, directed staff to administer Milk of Magnesia (MOM-a laxative to help with constipation), 1200 milligrams (mg)/15 milliliters (ml), administer 30 ml as needed for constipation, contact the provider if there are three days without a significant bowel movement. The Bowel Monitoring Record, dated May 2023, revealed R13 did not have a bowel movement for the following days: 05/11/23-5/14/23 (4 consecutive days) The Medication Administration Record (MAR), dated May 2023 lacked documentation the staff provided the MOM during the lack of bowel elimination on the above dates and lacked documentation the physician was notified as ordered. The Bowel Monitoring Record, dated August 2023, revealed R13 did not have a bowel movement for the following days: 08/18/23-08/22/23 (5 consecutive days) The MAR, dated August 2023 lacked documentation the staff provided the MOM during the lack of bowel elimination on the above dates and lacked documentation the physician was notified as ordered. On 08/29/23 at 09:28 AM, observation revealed R13 sat at the dining room table eating breakfast. On 08/30/23 at 10:00 AM, Certified Nurse Aide M stated, if a resident did not have a bowel movement, she documented it in the kiosk (a small, stand-alone device providing information for staff on a computer screen and was often used for services provided). On 08/30/23 at 11:45 AM, Licensed Nurse (LN) G verified there were no bowel movements charted on the days in question, and R13's record lacked evidence the medications were given as ordered. LN G verified the physician was not notified of the lack of bowel movements for R13. On 08/31/23 at 12:48 PM, Administrative Nurse D stated there had been trouble with the documentation of bowel movements and the facility were getting ready to start a new way to monitor resident bowel movements. Upon request, a policy for bowel movement protocol, was not provided by the facility. The facility failed to monitor bowel movements, provide physician ordered medications, and contact the physician for R13, who had a history of constipation. This placed the resident at risk for impaction and health decline.

- On 08/29/23 at 12:28 PM, observation revealed Dietary Staff (DS) DD prepare the pureed (a texture-modified diet in which all food to have a soft, pudding like consistency) meals for two residents. DS DD blended in an industrial blender, a beef cube steak and placed it on a plate. DS DD then provided one of the two plates with mashed potatoes. DS DD then took the temperature of the blended/pureed beef cube steak which was 109 degrees Fahrenheit (F). and placed it in the microwave oven until the resident returned to the dining room. Once the resident returned the plate was heated and the temperature was not retaken nor did the plate contain a vegetable. Meanwhile the other plate with the pureed/blended cubed beef steak sat on the counter. DS DD placed mashed potatoes and pureed mixed vegetables on the plate, and this was served to a resident without taking the meat temperature. On 08/30/23 at 02:39 PM, DS DD verified the pureed beef cubed steak temperature of 109 F, and said he was not certain of the holding temperature for that food item. DS DD also verified mashed potatoes were served but not the mixed vegetable due to food allergy of the resident. DS DD confirmed he had not substituted a vegetable for the resident. On 08/30/23 at 3:30 PM DS BB verified the pureed beef cube steak was not held at the proper temperature and a vegetable should have been provided to the resident who could not eat the mixed vegetables due to food allergies. The facility failed to prepare foods by methods that conserve palatable and nutritive value by serving beef steak at incorrect temperature and the nutrient value by omitting a vegetable serving to two residents who received pureed diets in the household. This placed the resident at risk of foodborne illness and unmet dietary needs. The facility had a census of 41 residents. Based on observation, record review, and interview, the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance, when dietary staff failed to follow a recipe while preparing a pureed (texture-modified diet in which all food to have a soft, pudding like consistency) diet for one resident in the Cottonwood Household and failed to prepare foods by methods that conserve palatable and nutritive value by serving beef steak at incorrect temperature and the nutritive value by omitting a vegetable serving to two residents who received pureed diets in the Sunflower Household. This placed the resident's at risk for unmet dietary needs and at risk of foodborne illness. Findings included: - On 08/29/23 at 12:31 PM, observation revealed Dietary Staff CC prepare the pureed meal for one resident. DS CC blended in an industrial blender, a beef cube steak, two unmeasured scoops of brown gravy and unmeasured amount of milk. Continued observation revealed DS CC did not obtain a temperature of the pureed food before she served it to the resident. Observation revealed DS CC had not followed a recipe for the pureed food items. On 08/30/23 at 12:15 PM, DS CC stated she does not use recipes when she prepared the pureed diet and did not realize she needed to retake the temperature of the pureed food before serving it. On 08/31/23 at 02:28 PM, Dietary Staff BB stated staff had been educated to make sure they used recipes for the pureed diet and will provide further education to her staff. The facility's Food Preparation and Service policy, revised 11/22, documented food and nutrition services employees prepare, distribute and serve food in a manner that complied with safe food handling practices. The facility kitchen staff failed to follow a recipe when preparing one resident's pureed diet, this placed the resident at risk for impaired nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure essential equipment was maintained in safe operating condition. This placed the residents who used the lift at risk for preventable accidents. Findings included: - The Electronic Medical Record (EMR) for R16 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), muscle weakness, and pain. The Annual Minimum Data Set (MDS), dated [DATE], documented R16 had severely impaired cognition and required extensive assistance of three staff for bed mobility, transfers, toileting; R16 did not ambulate. The MDS further documented R16 rarely had pain and received non medication interventions for pain. The Pain Care Plan, dated 06/09/23, initiated on 08/02/21, documented R16 had chronic pain and directed staff to administer pain medication, reposition R16, and monitor for response to the pain medication. The care plan further directed staff to monitor, record, and report any complaints by the resident of pain or requests for pain treatment, observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motions, withdrawal or resistance to care, or any change in usual activity attendance relate to pain or discomfort. The Nurse's Note, dated 08/01/23 at 07:46 PM, documented R16 stated that her right shoulder was in so much pain after getting in her bed. The note further documented staff used the sit to stand lift to transfer her and it quit working and the emergency button did not work either and the two staff had to help her out of the lift and transfer her to safety. On 08/29/23 at 12:47 PM, observation revealed CNA M placed the sit to stand lift sling around R16's waist, asked R16 to place her feet on the foot pad of the lift, attached the sling to the lift, and had R16 hold onto the handled of the lift. CNA P used the remote to lift R16 up to a standing position and transferred her to her bed without concern. On 08/29/23 at 12:47 PM, CNA M stated that the lift was kept in the bathroom and should be plugged in when not in use. CNA M further stated she was not aware of any problems with the lift but would inform maintenance if she had problems with it working correctly. On 08/30/23 at 08:35 AM, Maintenance U stated he checked the sit to stand lifts every two to three months but could not provide documentation when that lift had been lastked. Maintenance U stated he thought it was the lift that staff took to the landfill and just replaced it with a spare they had. On 08/31/23 at 12:48 PM, Administrative Nurse D stated the lifts wee plugged in the resident bathrooms and we checked by maintenance. Upon request, a policy for maintaining essential equipment was not provided by the facility. The facility failed to ensure essential equipment was maintained in safe operating condition. This placed the residents who used the lift at risk for preventable accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), chronic pain, chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity, difficulty or discomfort in breathing), altered mental status, chronic atrial fibrillation (rapid, irregular heart beat), need of assistance with personal care, and urinary tract infection (UTI). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had severe cognitive impairment, rejection of care behavior which occurred one to three days of the look back period. She required extensive assistance of one to two persons for activities of daily living (ADL)w, was not steady with transitions or balance, and was only able to [NAME] with staff assistance. The MDS further documented R2 was frequently incontinent of urine, received scheduled pain medication, insulin (medication to regulate blood sugar levels), anticoagulant (medication to decrease blood's ability to clot), and antibiotic (medication used to treat infections). R2 used oxygen and had occupational and physical therapy services. The Behavioral Symptoms Care Area Assessment (CAA), dated 03/29/23, documented R2 had frequent crying for two days and no other behaviors. R2's Care Plan lacked direction for depression and suicidal ideations. The Progress Note dated 08/09/23 at 11:30 AM, documented R2 had suicidal ideation over the weekend and staff initiated hourly rounding and observation when she was wishing to hurt herself. The note recorded the care plan was updated 08/09/23. The EMR lacked further documentation of R2's suicidal ideation including social service assessment and follow up. R2's record lacked evidence mental health services were offered or provided. On 08/28/23 at 04:34 PM observation revealed R2 sat in her room, in a wheelchair, with her head tilted toward her chest and her eyes closed. R2 wore oxygen tubing to her nose, and her call light was attached to the wheelchair. On 08/31/23 at 09:38 AM, Licensed Nurse (LN) H reported she was working when R2 told her that R2 wanted to die and verbalized a plan of wrapping a cord around her neck. LN H was not working in the capacity of nurse and reported it to the charge nurse. LN H reported she stayed near R2 following the threat. LN reported the provider, family, administrator, director of nursing, and social services should have been notified by the nurse on duty. On 08/31/23 at 12:47 PM, Administrative Nurse D verified she was aware of R2's suicidal statement and plan of using the call light cord to end her life. Administrative Nurse D reported she checked on R2 and R2 seemed to be fine. Administrative Nurse D did not know if the physician or family was notified of R2's suicidal statement or plan. Administrative Nurse D reported she was not aware if the staff checked the room for cords or other items R2 may have used to harm herself and said the staff should have implemented 15- minute checks. Administrative Nurse D was unsure in R2 had current psychological consult or treatment and was uncertain if any interventions added to the care plan to address R2's mood. The facility's Care Plan, Comprehensive Person-Centered policy, dated 03/22, documented the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when the desired outcome was not met, when the resident had been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required quarterly assessment. The facility failed to revise the care plan with interventions addressing mood after R2 stated she wanted to die. This placed the resident a risk for further decline of her emotional and mental well-being due to uncommunicated care needs. The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with meaningful resident centered interventions for falls for Resident (R) 31, and R34. The failed to revise the care plan related to mood for R23 and R2. This placed the resident's at risk for inappropriate care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R31 documented diagnoses of history of falls, lack of coordination, diastolic heart failure (a condition in which the hearts main pumping chamber becomes still and unable to fill properly), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion) and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], documented R31 had severely impaired cognition and required supervision and one staff for bed mobility, ambulation, dressing, toileting, and personal hygiene. The assessment further documented R31 had unsteady balance, had no functional impairment, and had no falls. The Fall Care Area Assessment [CAA]. dated 09/06/22, documented R31 had severe cognitive impairment, had unsteady balance but able to stabilize without staff assistance and without any assistive device, and had no functional limited range of motion. The Quarterly MDS, dated 06/05/23, documented R31 had severely impaired cognition and required extensive assistance of three staff for bed mobility, transfers, dressing, toileting, and ambulation occurred once or twice. The MDS further documented R31 had unsteady balance, upper functional assessment on both sides, and lower functional impairment on one side. The Fall Risk Assessment, dated 08/31/22, 09/14/22, 09/17/22, 11/17/22, 02/13/23, 05/13/23, 05/26/23, 06/23/23, 07/20/23, 07/30/23, 08/22/23, and 08/30/23 documented a high risk for falls. The Care Plan, dated 06/01/23, initiated on 09/01/22, directed staff to make sure R31's call light was within reach and encourage R31 to use it for assistance as needed. R31 would be supervised while ambulating outside of his room and had a restorative ambulation program to assist with strengthening. The update, dated 11/17/22, directed staff to toilet R31 after meals. The update, dated 05/25/23, directed staff to make sure his walker was by his bedside, place a pressure alarm on his bed, remove the air mattress from his bed and replace it with a regular mattress. The update, dated 06/05/23, directed staff to keep R31's bed in the low position at night. The update, dated 06/22/23, directed staff to have R31 wear non-slid socks when in bed. The update, dated 07/19/23, directed staff to place a body pillow beside him when he was lying in bed. The update, dated 07/30/23, directed staff to not leave R31 unsupervised when seated in his wheelchair. The update, dated 08/21/23, directs staff to start a 3-day toileting diary to establish a toileting schedule. The update, dated 08/31/23, directed staff to put gripper socks on over his regular socks. The Fall Investigation, dated 09/14/22 at 02:33 AM, documented R31 had an unwitnessed fall in his shower. The investigation documented R31 was found in the bathroom shower, the floor was wet, and R 31 sustained a skin tear to his right elbow. The investigation documented R31 was educated to ask for assistance when he wanted to take a shower. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall in order to implement interventions to prevent further falls. The Fall Investigation, dated 09/17/22, untimed, documented R31 went to the nurses station to talk to staff. When he turned around to go back to his room, R31's walker got caught in the door frame, and he fell. The investigation further documented R31 sustained skin tears to his knuckles on the left hand which measured 0.5 centimeters (cm) x 2.5 cm, the edges were approximated and steri-strips (adhesive wound closures) were applied and covered with a band aide. The left had also had two skin tears which the first measured 0.5 cm x 1.5 cm and the second measured 0.5 cm x 1.8 cm, the edges were unable to be approximated. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall in order to implement interventions to prevent further falls. The Fall Investigation, dated 09/18/23 at 12:37 AM, documented R31 had an unwitnessed fall in his room next to his nightstand. The investigation further documented R31 sustained a skin tear to the back of his head and R31 was educated to use his call light for assistance. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall in order to implement interventions to prevent further falls. The Fall Investigation, dated 11/17/22 at 06:04 PM, documented R31 was found by staff on the floor in his bathroom as he ambulated without assistance and sustained a skin tear on his right palm. The investigation further documented staff were educated to provide activities that promote exercise and strength building when possible. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. The Nurse's Note, dated 03/15/23 at 03:30 AM, documented staff found R31 squatting at his bedside, walker within reach of his left hand. The note further documented staff assisted R31 to [NAME] down and his call light was within reach. The Nurse's Note, dated 03/16/23 at 06:20 AM, documented R31 had an unwitnessed fall on 03/15/23 and had no complaint of injury. The EMR lacked documentation an investigation was completed for the 03/15/23 fall. The Nurse's Note, dated 05/08/23 at 05:30 PM, documented R31 got tangled up in his walker and fell to his knees and sustained a bruise to his right knee. The EMR lacked documentation an investigation was completed for the fall. The Nurse's Note, dated 05/25/23 at 11:15 PM, documented R31 was found on the floor in his room with his feet facing the top of the bed and his head facing the foot of the bed lying on his right side. R31 was unable to tell staff what he had been trying to do. R31 had two new skin tears to his right arm, one on the elbow that measured 4.5 cm x 1 cm, and the other was on his wrist and measured 1 cm x 1 cm. The investigation documented no external or internal rotation was noted and R31 denied pain. The nurse and the nurse aide stood R31 up and he complained of pain in one of his legs. The nurse performed range of motion on his lower extremities and R31 complained of severe pain in his right leg. The nurse called emergency medical services to transport R31 to the hospital for observation. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. The Nurse's Note, date 05/30/23 at 05:32 PM documented R31 readmitted to the facility after surgery for a nondisplaced intertrochanteric fracture of the right femur. A bed alarm was placed on his bed per family request, and R31 was weight bearing as tolerated. R31 self-transferred to his bed without staff present and he was educated on the need to use his call light. The Physician's Order, dated 05/31/23 at 01:47 PM, directed staff to monitor the dressing for drainage and do not remove the dressing until 06/09/23. The Nurse's Note, dated 06/09/23 at 01:10 PM, documented the 10 staples were removed from R31's lower right hip and 9 staples were removed from R31's upper right hip and steri stips were put into place. The Fall Investigation, dated 06/22/23 at 09:15 PM, documented R31 fell out of bed onto his back. The investigation further documented R31 was soiled at time of discovery, was assessed for injury, complained of bilateral hip pain, did hit the back of his head but did not want to be transported to the emergency room to be evaluated. The investigation documented staff had not followed R31's care plan and staff were educated to keep bed in the lowest position and he was wearing white socks with no grip. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. The Fall Investigation, dated 07/30/23, documented R31 tried to stand up alone in the dining room and walk back to his room while staff answered call lights, lost his balance and fell. Staff were directed to no longer let R31 be left unsupervised in his wheelchair. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. The Fall Investigation, dated 08/21/23, untimed, documented staff heard his bed alarm sounding, went to his room and he was attempting to self-transfer and fell. The investigation further documented R31 sustained a skin tear to his right inner arm and left palm. The investigation further documented R31's incontinence brief was soiled with bowel movement and staff thought he was attempting to get to the bathroom. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. The Fall Investigation, dated 08/30/23 at 06:55 PM, documented R31 fell in his room when he tried to get out of his bed. The investigation documented staff found R31 on the floor with his feet toward the head of the bed and his feet toward the head of his bed, was not wearing gripper socks due to refusal to wear them after his shower. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. On 08/29/23 at 01:07 PM, observation revealed R31 lying in bed. R31 did not have a body pillow and he wore regular white socks on his feet. Further observation revealed Certified Nurse Aide (CNA) M placed a gait belt around R31's waist and R31 stood up, pivoted, and sat him down in his wheelchair. On 08/29/23 at 01:10 PM, CNA M stated R31 was impulsive, would try to transfer himself so staff were directed to make sure his bed was always in low position. On 08/30/23 at 11:45 AM, Licensed Nurse (LN) G stated R31 often tried to get up on his own and would fall. LN G further stated, R31 had a bed alarm and a fall matt, and if he fell on his fall matt, if was not considered a fall. This Surveyor never observed a fall matt in R31's room. On 08/31/23 at 12:48 PM, Administrative Nurse D stated staff did not follow the care plan for one of R31's falls and verified there were two falls that were not investigated at all. She stated she had not completed root cause analysis for the falls but was in process of starting to do those. LN G stated interventions were put into place for R31's falls after he had an injury with a fall. The facility's Care Plan, Comprehensive Person-Centered policy, dated 03/22, documented the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when the desired outcome was not met, when the resident had been readmitted to the facility fro a hospital stay and at least quarterly, in conjunction with the required quarterly assessment. The facility failed to revise the care plan with meaningful person centered careplans after R31 had falls. This placed the resident a risk for further falls and injury. - The Electronic Medical Record (EMR) for R34 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), unsteadiness on feet, history of falling, lack of coordination, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), need for continuous supervision, and hypertension (high blood pressure). The admission Minimum Data Set (MDS), dated [DATE], documented R34 had intact cognition and required limited assistance of one staff for bed mobility, transfers, ambulation, toileting and personal hygiene. The MDS further documented R34 had unsteady balance, upper functional impairment on one side, had no alarms, and no falls since admission. R34's Quarterly MDS, dated 06/08/23, documented R34 had moderately impaired cognition and was independent with bed mobility, transfers, ambulation, dressing, and toileting. The MDS further documented R34 had steady balance, no functional impairment, and no falls during the lookback period. The Fall Risk Assessment, dated 10/20/22, 11/11/22, 11/16/22,12/29/22, 01/10/23, 02/27/23, 03/08/23, 06/05/23, 07/11/23, documented R34 was a high risk for falls. The Fall Care Plan, dated 06/22/23, initiated on 11/11/22, directed staff to make sure R34's call light was within reach when sitting in the recliner. The update, dated 11/26/22, directed staff to provide activities that promoted exercise and strength building where possible. The update, dated 12/29/22, directed staff to make sure any assistive devices were within reach when sitting in the recliner. The update, dated 01/09/23, directed staff to ensure her shoes were the proper fit if her shoe caught the carpet or flooring. The update, dated 07/11/23, directed staff to evaluate the stability of her recliner and reinforce to ensure no sliding when attempting to get out of the recliner. R34's EMR documented falls on these dates: 11/11/22, 11/25/22, 12/29/22, 07/11/23. R34's clinical record lacked evidence of a root cause analysis to identify causative factors for her falls. On 08/29/23 at 12:56 PM, observation revealed R34 independently ambulated with her walker to the dining room. Further observation revealed her shoes squeaked as she walked due to her not picking her feet up when she walked. On 08/31/23 at 09:50 AM, observation revealed R34 had two recliners in her room. There was no carpet. R34 stated she liked to sit in the recliner closest to the window but she had to pull it away from the wall so that it did not scratch the wall. R34 further stated she never had any falls in the facility and that no one fixed her recliner so that it did not slide across the floor. On 08/30/23 at 03:00 PM, Licensed Nurse (LN) G stated R34 was independent with ambulation, and had a manual recliner. LN G did not know about 34's falls. On 08/31/23 at 09:32 AM, Certified Nurse Aide (CNA) O stated R34 had a few falls out of her recliner and required stand by assistance when she ambulated. On 08/31/23 at 12:48 PM, Administrative Nurse D stated the interventions for R34 did not really address the safety factors related to her falls and verified she had not completed any root cause analysis for R34's falls. The facility's Care Plan, Comprehensive Person-Centered policy, dated 03/22, documented the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when the desired outcome was not met, when the resident had been readmitted to the facility fro a hospital stay and at least quarterly, in conjunction with the required quarterly assessment. The facility failed to revise the care plan after R34 had falls. This placed the resident a risk for further falls and injury due to uncommunicated care needs. - The Electronic Medical Recorded (EMR) for R23 documented diagnoses of multiple sclerosis (a potentially disabling disease of the pain and spinal cord), pressure ulcers, vitamin deficiency, protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), osteomyelitis (inflammation of one or bone marrow usually due to infection), hypertension (high blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Annual Minimum Data Set (MDS), dated [DATE], documented R23 had moderately impaired cognition, and was dependent upon one staff member for transfers, and toileting. R23 required extensive assistance of two staff for bed mobility, extensive assistance of one staff for dressing and personal hygiene. The assessment further documented R23 had thoughts she would be better off dead or hurting himself never or only one day and received antidepressant (medication used to treat mood disorders and relieve symptoms of depression) medication. R23's Quarterly MDS, dated 08/16/23, documented R23 had intact cognition and was dependent upon two staff for bed mobility, transfers, toileting. R23 required extensive assistance of two staff for dressing, and dependent upon one staff for personal hygiene. The assessment further documented R23 had thoughts she would be better off dead or hurting himself never or only one day and received antidepressant (medication used to treat mood disorders and relieve symptoms of depression) medication. The Care Plan, dated 07/06/23, initiated on 06/08/22 documented R23 received antidepressant medication and directed staff to monitor and documented side effects and effectiveness of medication. The care plan further directed staff to monitor adverse reactions of the medication related to change in behaviors, withdrawal, suicidal thoughts, hallucinations, delusions and social isolation. The care plan lacked documentation of R23's vocalization of wanting to die and direction to staff how to process her feelings. The Physician's Order, dated 01/18/22, directed staff to administer citalopram hydrobromide (an antidepressant medication), 10 milligrams (mg), 1 tablet, by mouth, in the morning, for depression. The Physician's Order, dated 04/11/22, directed staff to administer mirtazapine (an antidepressant medication), 7.5 mg , 1 tablet, by mouth, at bedtime, for depression. The Nurse's Note, dated 08/12/23 at 05:36 PM, documented R23 voiced to staff two times that she wanted to die and did not want the nurse to do anything with her and to leave her alone. The EMR lacked documentation the physician was notified and lacked follow-up from the facility. On 08/29/23 at 01:30 PM, observation revealed Administrative Nurse D washed her hands, gloved, and removed R23's sock and 4 x 4 gauze dressing. Administrative Nurse D measured the wound, provided wound care, put R23's sock back on, and applied a green left heel protector. On 08/29/23 at 01:30 PM, Licensed Nurse (LN) H stated R23 says things like she wants to die all the time but has never had a plan. LN H said when R23 said this to her, she told the Director of Nursing about it. LN H verified she did not document her conversation with the Director of Nursing and said that R23 was a very complicated resident and the care plan should be updated. On 08/31/23 at 12:48 PM, Administrative Nurse D stated R23 had periods of negative moments and would say things that she would forget she said. Administrative Nurse D said within the week the facility would be talking with R23 about hospice or palliative care. On 08/31/23 01:37 PM, Social Service X stated he was unaware of the statements R23 made about wanting to die and stated he should have been made aware so he could talk with her. Social Service X further stated R23's family have discussed talking to her about hospice services within the next week and the facility would have staff that would be able to visit with her about those feelings. Social Service X stated when he had talked with R23 about depression, R23 always told him that she was not depressed and did not want to give up. The facility's Care Plan, Comprehensive Person-Centered policy, dated 03/22, documented the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when the desired outcome was not met, when the resident had been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required quarterly assessment. The facility failed to revise the care plan after R23 stated she wanted to die. This placed the resident a risk for further decline of her emotional and mental well-being due to uncommunicated care needs.

The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to prepare, store, and serve food in accordance with professional standards for food service safety for one of three households. The facility staff failed to change gloves after touching their clothing, doors, papers, and other objects, and touched pancakes with the same contaminated gloves. This placed the residents at risk for food borne illness in two of three households. Findings included: On 08/29/23 at 08:30 AM, observation in the Cottonwood Household revealed Dietary Staff CC wore gloves as she prepared breakfast. Further observation revealed DS CC picked up a pancake and moved it to the side of the plate with her gloved hands so that she could pour syrup on the bottom pancake. She went to a drawer with clothing protectors, opened it and put the protector on a resident. DS CC went to a resident room with the same soiled gloves and returned with a dirty cup that she put on the kitchen cabinet. DS CC touched paper in a notebook, and began to make oatmeal with the same soiled gloves. Observation revealed DS CC continued to make oatmeal, retrieved a bowl and tray out of a cabinet and her gloved thumb touched the inside of the bowl. DS CC served the oatmeal to a resident and removed her gloves. DS CC put on another set of gloves, opened the freezer drawer with her gloved hands, took out a bag of french toast sticks. DS CC removed a few french toast sticks out of the bag with her soiled gloved hands, and placed them on a plate. DS CC removed the soiled gloves. On 08/30/23 at 12:15 PM, DS CC stated she was not aware when she should change her gloves. On 08/30/23 at 02:28 PM, DS BB stated she was aware that some of her staff were unsure when to change gloves and stated she would reeducate them on the usage of gloves. The facility Food Preparation and Service policy, revised ll/22, documented cross contamination can occur when harmful substances, i.e, chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils are not adequately cleaned. The facility failed to prepare and serve in accordance with professional standards for food service safety. This placed the resident's in the Cottonwood Household at risk for food borne illnesses.

The facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week, placing all the residents who resided at the facility at risk of lack of assessments and inappropriate care. Finding included: - Review of Payroll Based Journal (PBJ- a required detail information submitted by nursing homes of staffing required from the Centers of Medicare and Medicaid Services[CMS]) revealed the facility lacked RN eight-hour coverage for the months of August 2022, September 2022, October 2022, November 2022, December 2022, January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, and August 2023. On 08/30/23 12:38 PM, Administrative Nurse D verified the days without eight consecutive RN coverage a day in the months listed above. Upon request, the facility did not provide a policy for eight consecutive RN daily coverage. On 08/30/23 Administrative Staff A stated the CMS requirements would be considered the policy. The facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week placing the residents who resided in the facility at risk of lack of assessment and inappropriate care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Electronic Medical Record (EMR) documented R1 had diagnoses of hypertension (high blood pressure), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), chronic pain (persistent pain that lasts weeks to years and may be caused by inflammation or dysfunctional nerves), vitamin deficiency (a condition of a long-term lack of a vitamin), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and fracture of the right humerus (upper arm bone is broken). The Significant Change Minimum Data Set (MDS), dated 12/22/21, documented the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The MDS documented R1 had functional lower impairment on both sides, was at risk for pressure ulcers, had no skin issues, no turning or repositioning program, and no pressure relieving device for her bed or chair. The Pressure Ulcer Care Area Assessment (CAA), dated 12/22/21, documented the resident required extensive assistance for bed mobility, transfers, dressing and toileting with frequent bowel and bladder incontinence. The CAA further documented R1 did not have skin impairment but remained at risk for the development of pressure ulcers. The Pressure Ulcer Care Plan, revised 01/06/22, originally dated 10/22/20, directed staff to educate the resident, family, and caregivers to the causes of skin breakdown including transfers, good nutrition, and frequent positioning. An intervention, dated 02/27/22 directed staff to document weekly the treatment of each skin breakdown, width, length, type of tissue and exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ especially in inflammation), and apply dressing changes per order until the appointment with the specialist and wound vac (a treatment that is vacuum-assisted by applying gentle suction to a wound to help it heal) application. On 03/15/22 at 08:30 AM, observation revealed R1 sat on a shower chair, in a sling, attached to the full body lift, naked from the waist down. As R1 was raised, blood dripped from her buttocks. On the shower chair, a thin gel cushion had slipped off to the front of the shower chair and there was smeared blood all over the seat of the shower chair. As staff placed R1 in bed using the sling and lift, R1 began to have a bowel movement. Certified Nurse Aide (CNA) O rolled R1 to her right side, so CNA MM could provide personal care. During this roll, R1 moaned. CNA MM finished care and as both CNAs rolled the resident onto her back, R1 moaned again. R1 was left lying on the bed without an incontinence brief, uncovered, as the CNAs waited for the nurse to come to the room to do R1's daily wound care. At 08:40 AM, Administrative Nurse D washed her hands, donned clean gloves, and both CNA's went to the right side of the bed to roll R1 onto her right side while Administrative Nurse D performed wound care. As R1 was rolled, her body tensed, and her face and right shoulder were pressed against the bed rail. As Administrative Nurse D removed the calcium alginate packing from R1's wound, R1 stated, ouch. Upon inquiry, Administrative Nurse D stated R1 had scheduled pain medication. Continued observation revealed Administrative Nurse D changed her gloves, flushed the wound with normal saline, repacked the wound with calcium alginate, and placed a foam dressing over the wound. On 03/15/22 at 08:48 AM, CNA MM stated they should cover the resident after cares and should not have let the resident lay uncovered. On 03/16/22 at 11:20 AM, Administrative Nurse D stated staff should cover the resident when not providing cares. The facility's Dignity policy, dated February 2021, documented each resident shall be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The residents are treated with respect and dignity at all times. Staff promote, maintain, and protect resident privacy including bodily privacy during assistance with personal care and during treatment process. The facility failed to promote care in a manner to maintain and enhance dignity and respect for R1 when they failed to cover her during cares, placing the resident at risk for undignified care and services. The facility had a census of 34 residents. The sample included 12 residents of which two were reviewed for dignity. Based on observation, record review and interview the facility failed to treat Resident (R) 3 and R1 with respect and dignity during care, placing the residents at risk for embarrassment and an undignified environment. Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus ( a chronic condition that affects the way the body processes blood sugar). R3's Significant Change Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition, required extensive staff assistance with bed mobility, and transfers. R3 had functional impairment in the left lower extremity, and was incontinent of bowel and bladder. The Incontinence Care Plan, dated 02/17/22, directed the staff to provide incontinent care for R3 as needed and to use good hand hygiene when providing care. On 03/15/22 at 11:45 AM, observation revealed R3 laid in his bed on his right side. Certified Nurse Aide (CNA) N stood on the left side of the resident's bed and CNA O on the right. CNA N and CNA O applied clean gloves. CNA N unhooked R3's incontinence brief which revealed R3 incontinent of stool. CNA N used cleansing wipes to clean the resident's buttocks. CNA N then removed her gloves and tossed the soiled gloves along with the soiled wipes across the resident and into a trash can on the other side of the bed. CNA O rolled the resident over and CNA O chuckled and stated, Oh [R3] you peed the bed. CNA O applied a clean brief using her same soiled gloves. CNA N washed her hands in the sink but did not dry her hands as no paper towels were available. CNA N proceeded to shake her hands in the air to attempt to dry them. After R3 was transferred to his wheelchair, he requested a piece of candy from the jar at his bedside. CNA N opened the jar with her wet hands and obtained a piece of candy from the jar with her same wet hands. CNA N then provided the resident with the piece of candy. CNA O was not observed washing her hands. On 03/16/22 at 01:30 PM, Administrative Nurse D verified she expected the staff to provide dignity for R3 when caring for him, and the statement CNA O made when the resident was incontinent was unacceptable. The facility's Dignity policy, dated February 2021, stated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. The facility failed to provide dignity for R3 during incontinent care, placing the resident at risk for embarrassment and an undignified environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to develop a comprehensive care plan for diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) for Resident (R) 3. This placed the resident at risk for elevated blood sugars and adverse side effects. Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus. The Significant Change Minimum Data Set (MDS), dated [DATE], recorded R3 had severely impaired cognition, required extensive staff assistance with bed mobility, transfers, and had functional impairment in the left lower extremity. The Cognitive Loss Care Area Assessment (CAA), dated 02/17/22, recorded R3's cognition fluctuated and R3 had poor decision making skills. Review of the medical record lacked a care plan for diabetes mellitus. The Physician's Order, dated 08/25/21, directed the staff to administer Glipizide (an oral diabetes medicine that helps control blood sugar levels) 10 milligrams (mg) PO (by mouth) daily in the morning, and Januvia (an oral diabetes medication which helps to control blood glucose levels) 50 mg PO daily in the morning. The Physician's Order, dated 10/13/21, directed the staff to administer Farxiga (an oral diabetes medicine that helps control blood sugar levels) 10 mg PO daily in the morning. Review of the medical record revealed no documentation of blood glucose testing (checking levels of sugar in the blood). The United States Food and Drug Administration (FDA) stated when receiving oral antidiabetic medications the blood glucose was to be tested on a routine basis. Side effects from the use of these medications can cause hypoglycemia (low blood sugar). On 03/15/22 at 11:45 AM, observation revealed R3 laid in his bed. On 03/16/22 at 11:40 AM, Licensed Nurse (LN) G verified R3 received three different oral antidiabetic medications every morning. LN G verified no blood glucose monitoring was completed. On 03/16/22 at 01:30 PM, Administrative Nurse D verified R3 received three oral antidiabetic medications on a routine basis every morning. Administrative Nurse D also verified no blood glucose monitoring was completed since the medications were ordered in August 2021 and October 2021. Administrative Nurse D verified the facility lacked a comprehensive care plan for diabetes mellitus for R3. The facility's Obtaining a Finger Stick Blood Glucose Level, policy dated October 2011, states when a resident receives a diabetic medication the blood glucose is to be monitored. The facility's Comprehensive Care Plan, policy dated December 2016, stated a comprehensive person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan will include comprehensive objectives and time frames, reflect treatment goals, timetables and objectives in measurable outcomes. Areas of concerns that are identified during the resident assessment will be evaluated and interventions will be added to the care plan. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes. The facility failed to develop a comprehensive care plan to assess blood sugars to ensure appropriate care and treatment for R3, placing the resident at risk for elevated blood sugars and adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents, with two reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent skin breakdown for one sampled resident, Resident (R) 20, who had a Stage 2 (partial thickness loss) pressure ulcer. This placed R20 at risk for further skin breakdown. Findings included: - The Electronic Medical Record (EMR) for R20 documented diagnoses of dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). R20's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The MDS further documented the resident had lower functional impairment on both sides, risk for skin break down, no skin issues, no turning and repositioning program, and no pressure relieving device for his bed and chair. The Pressure Ulcer Care Area Assessment (CAA), dated 04/10/21, documented R20 required staff assistance with bed mobility and transfers and was incontinent of bowel. The CAA further documented the resident was at risk for skin breakdown. The Pressure Ulcer Care Plan, revised 01/13/22, originally dated 05/29/21, documented the resident was at risk for pressure injury due to limited mobility and incontinence. An intervention, dated 06/15/21, directed staff to teach the resident the importance of changing positions, the causes of skin breakdown, required a pressure relieving device, and to document weekly treatments. The Care Plan lacked documentation the resident had a facility acquired pressure ulcer and further interventions to prevent skin breakdown. The Physician's Order, dated 05/06/21, directed staff to administer a multivitamin tablet daily and provide a house supplement four times a day for skin problems. The Physician's Order, dated 05/06/21, directed staff to administer Vitamin C, 500 milligrams (mg), twice a day, for skin. The Skin Observation Tool, dated 02/25/22, documented the resident had a wound on his right gluteal fold (a prominent fold on the back of the upper thigh that marks the upper limit of the thigh from the lower limit of the buttock) and staff would continue to monitor. The Skin Observation Tool, dated 02/27/22, documented the resident had a wound on his right gluteal fold from friction, documented the physician was aware, and to continue to monitor. The Fax Communication to the physician, dated 03/08/22, documented R20 had an open sore on his right-side buttocks which measured 4 centimeters (cm) x 3.5 cm, with eschar (dry, dark scab or falling away of dead skin) and purulent (containing pus) drainage. The Physician's Order, dated 03/10/22, directed staff to apply heel protectors while R20 was in bed, place an air mattress on the bed, and lay the resident down in bed every two hours to off load pressure. A Wound Data Collection Tool, dated 03/14/22, documented a Stage 2 pressure ulcer on the right gluteal fold which measured 5 cm x 4.2 cm x 0.1 cm, with 60 percent (%) granulation (the part of the healing process in which lumpy, pink tissue containing new connective tissue that formed around the edge of the wound), moderate serosanguineous (discharge that contains both blood and clear yellow liquid known as blood serum) discharge, the wound margins were macerated (skin that had been exposed to moisture for too long), with wet, white, waterlogged tissue, and had no odor or suspected infection. The tool further documented staff were educated to offload and keep R20 out of the wheelchair. The Physician's Order, dated 03/14/22, directed staff to cleanse the wound with wound cleanser, apply medihoney (decreases bacterial growth within a wound), and cover with a padded dressing, daily and as needed (PRN). On 03/16/22 at 10:00 AM, observation revealed R20 laid on his left side, Licensed Nurse (LN) G donned clean gloves, and cleansed the wound with wound cleanser. LN G donned clean gloves, took a clear plastic grid to measure the wound, and found the wound measured 4.5 cm x 4 cm. LN G used skin prep (forms a protective film or barrier) around the outside of the wound, placed the medihoney dressing on the wound, and covered it with a padded foam dressing. On 03/15/22 at 09:20 AM, Certified Nurse Aide N stated the resident liked to be in his recliner and now staff repositioned the resident every two hours. On 03/15/22 at 09:30 AM, Administrative Nurse D stated R20 obtained the wound as a shearing wound from the sling when staff used the sling lift. On 03/16/22 at 10:00 AM, LN G stated R20 received the wound from shearing when being offloaded and wound care was provided daily. LN G stated nurses can update the care plan when there are new interventions. On 03/16/22 at 11:20 AM, Administrative Nurse D stated the care plan should be updated when there are changes with the resident. The facility's Care Plan, Comprehensive Person Centered policy, dated December 2016, documented the team must review and update the care plan when there has been significant change in the resident's condition, when the outcome is not met and at least quarterly in conjunction with the required quarterly MDS assessment. The facility failed to revise R20's care plan with interventions to prevent skin breakdown for R20, who had a history of skin breakdown, and a facility acquired pressure ulcer, placing the resident at risk for further breakdown.

The facility had a census of 34 residents. The sample included 12 residents, with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide appropriate cares to prevent shearing when repositioning for one sampled resident, Resident R (1), placing the resident at risk for skin injury. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of hypertension (high blood pressure), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), chronic pain (persistent pain that lasts weeks to years and may be caused by inflammation or dysfunctional nerves), vitamin deficiency (a condition of a long-term lack of a vitamin), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and fracture of the right humerus (upper arm bone is broken). The Significant Change Minimum Data Set (MDS), dated 12/22/21, documented the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The MDS documented R1 had functional lower impairment on both sides, was at risk for pressure ulcers, had no skin issues, no turning or repositioning program, and no pressure relieving device for her bed or chair. The ADL Care Plan, dated 01/06/22, documented the resident required assistance with ADLs due to weakness and pain, required one to two staff assist while in bed, a full lift with two staff for transfers, and directed staff to provide gentle range of motion as tolerated with daily care. The Skin Observation Tool, dated 02/08/22, documented R1's left buttock had a shearing (the separation of skin layers caused by friction or trauma) wound which measured 2 centimeters (cm) x 1.1 cm. The Fax Communication to the physician, dated 02/08/22, documented R1 had several areas of bruising and potential skin shearing thought to be caused by improper removal of the lift sling. On 03/15/22 at 08:30 AM, observation revealed R1 sat on a shower chair, in a sling, attached to the full body lift, naked from the waist down. As R1 was raised, blood dripped from her buttocks. On the shower chair, a thin gel cushion had slipped off to the front of the shower chair and there was smeared blood all over the seat of the shower chair. As staff placed R1 in the bed using the sling and lift, R1 began to have a bowel movement. Certified Nurse Aide (CNA) O rolled R1 to her right side, so CNA MM could provide personal care. During this roll, R1 moaned. CNA MM finished care and as both CNAs rolled the resident onto her back, R1 moaned again. R1 was left lying on the bed without an incontinence brief, uncovered, as the CNAs waited for the nurse to come to the room to do R1's daily wound care. At 08:40 AM, Administrative Nurse D washed her hands, donned clean gloves, and both CNAs went to the right side of the bed to roll R1 onto her right side while Administrative Nurse D performed wound care. As R1 was rolled, her body tensed, and her face and right shoulder were pressed against the bed rail. As Administrative Nurse D removed the calcium alginate packing from R1's wound, R1 stated, ouch. Upon inquiry, Administrative Nurse D stated R1 had scheduled pain medication. Continued observation revealed Administrative Nurse D changed her gloves, flushed the wound with normal saline, repacked the wound with calcium alginate, and placed a foam dressing over the wound. On 03/15/22 at 03:05 PM, observation revealed the CNA P and CNA Q attempted to place the full body sling underneath R1. The sling was bunched up underneath the resident and the CNAs were having difficulty getting the sling in the right position to attach it to the lift. CNA Q took the leg straps and criss crossed them to attach to the sling as CNA P attached the top straps to the lift. CNA Q started to lift R1 up with the lift and quickly lowered the resident as the sling was not fully underneath her. CNA P and CNA Q, again attempted to reposition the sling under R1 but had continued difficulty and stated they would call Administrative Nurse D to assist with the sling placement. At 03:35 PM, Administrative Nurse D came to R1's room and went behind the resident's wheelchair and had R1 lean forward to allow Administrative Nurse D to adjust the sling underneath her. Administrative Nurse D was able to get the sling placed underneath R1 but needed to readjust the leg straps of the sling. Administrative Nurse D stood in front of the resident, and stated This is gonna hurt and proceeded to pull on the left lift sling leg strap. Observation revealed R1 grimaced (to distort one's face in an expression usually of pain) and replied Ow! as Administrative Nurse D pulled on the strap and the staff were able to attach the straps to the lift. R1 was transferred to the bed onto her back and had three pillows behind her which caused her neck to bend down so her chin touched her chest. CNA Q started to pull down R1's pants to check if the incontinence brief required changing. CNA Q rolled R1 onto her right side which caused her shoulder to smash against the bed rail so they could pull down her pants and remove the soiled incontinence brief. CNA P rolled R1 onto her left to perform pericare. CNA Q placed a clean incontinence brief on R1 and took a pillow and placed it under R1's left side to off load the pressure. R1's neck continued to be bent in an awkward position with her chin to her chest, her body crooked and her right elbow smashed against the side rail. CNA P asked R1 if she was comfortable and R1 stated NO!. CNA P and CNA Q attempted to reposition R1 by raising the head of the bed, but that caused pain to R1 and they quickly lowered it. R1 stated It will be alright and CNA Q placed a folded up blanket under R1's right arm. R1's head and neck were still angled down. On 03/15/22 at 03:45 PM, CNA P stated they had training on the full lift using the sling but had difficulty with sling placement because they cannot leave the sling under R1 anymore due to skin breakdown from the sling. CNA P stated R1 always had three pillows behind her neck and a pillow under her left side because of back pain and stated they always repositioned her that way. On 03/16/22 at 11:21 AM, Administrative Nurse D stated staff should be more careful putting on the sling and repositioning R1. The facility's Activities of Daily Living policy, dated March 2018, documented a resident would be provided with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living. The appropriate care and services would be provided for residents who are unable to carry out adl's independently, with consent of the resident and in accordance with the plan of care including appropriate support and assist with mobility, hygiene, elimination, dining and communication. The facility failed to provide appropriate transfers to prevent shearing when repositioning R1, placing the resident at risk for skin injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents with five reviewed for accidents. Based on observation, record review and interview, the facility failed to provide a safe environment for one of the five sampled residents, Resident (R) 3 who recently had a hip fracture (broken bone). This placed the resident at risk for further accidents. Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning),and type 2 diabetes mellitus ( a chronic condition that affects the way the body processes blood sugar). The Significant Change Minimum Data Set (MDS), dated [DATE], recorded R3 had severely impaired cognition, required extensive staff assistance with bed mobility, transfers, and had functional impairment in the left lower extremity. The Cognitive Loss Care Area Assessment (CAA), dated 02/17/22, recorded R3's cognition fluctuated and had R3 poor decision making skills. The Fall CAA, dated 02/17/22, recorded the resident was at high risk for falls and had a recent left hip fracture, which occurred at the facility. The Activities of Daily Living (ADL) Care Plan, dated 02/17/22, directed the staff to use two staff to transfer the resident with the full mechanical lift in and out of bed. The Fall Care Plan, dated 02/17/22, directed the staff to use a chair alarm to be placed on the wheelchair when R3 was out of bed due to the resident's poor cognition and forgetfulness to ask for help with transfers. The Fall Risk Assessment, dated 02/17/22, documented a score of 18 (high risk for falls). The Nurse Note, dated 02/11/22, recorded R3 returned from the hospital after receiving a left hip fracture repair. R3's clinical record lacked evidence nursing staff assessed R3 after the fall occured. On 03/15/22 at 11:45 AM, observation revealed R3 laid on a low bed in his room. Certified Nurse Aide (CNA) N and CNA O entered the resident's room. CNA N raised the bed up, while CNA O placed a lift sling under R3. CNA N attached the lift sling to the mechanical lift and raised the resident from the bed while CNA O held onto the back of R3 while the mechanical lift lowered him to his wheelchair. CNA N then unhooked the mechanical lift and removed the lift sling from R3. CNA O then pushed the resident in his wheelchair to the dining room. No body alarm was attached to the wheelchair. On 03/16/22 at 09:10 AM, observation revealed CNA NN pushed R3 in his wheelchair from the dining room to his room. No alarm was attached to the wheelchair. CNA OO entered the resident's room and placed a gait belt around R3's waist, while CNA NN stood on the opposite side of the resident. CNA NN asked R3 to stand up from the wheelchair while CNA NN and CNA OO held onto the gait belt. The resident was unable to stand and CNA NN and CNA OO lifted R3 with the gait belt and placed him in his bed. On 03/16/22 at 10:30 AM, CNA NN used the kiosk (hand held computer program) and verified R3's care plan directed the CNAs to use a mechanical lift for all transfers and to use an alarm on the wheelchair. CNA NN stated she was unaware they were to use a mechanical lift for transfers and an alarm was to be on the resident's wheelchair. On 03/16/22 at 11:40 AM, Licensed Nurse (LN) G verified the direct care staff are to use a mechanical lift when transferring the resident and an alarm was to be on the wheelchair for safety. On 03/16/22 at 01:30 PM, Administrative Nurse D verified R3 was to be transferred with a full mechanical lift and an alarm was to be placed on the resident's wheelchair when he was in the wheelchair. Administrative Nurse D also verified R3's fall that occurred on 02/07/22 at 06:10 PM in the dining room which resulted in the resident receiving a left hip fracture. Administrative Nurse D stated it was change of shift for the nurses and a licensed nurse did not complete an assessment of the resident after the fall. Emergency Management Services (EMS) were notified by a licensed nurse and R3 was transported to the hospital. The facility's Falls policy, dated March 2018, stated the nurse shall assess and document the fall. The facility is to identify risk factors and prevent falls and injuries from occurring. The facility failed to provide a safe environment for R3 by not using a mechanical lift for transfers, and an alarm on his wheelchair, placing the resident at risk for further injury while recovering from a hip fracture.

The facility had a census of 34 residents. The sample included 12 residents, with four reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide necessary nutritional assessments and treatment for weight loss for one of four residents, Resident (R) 31. This placed the resident at risk for further weight loss and decline. Findings included: - The Electronic Medical Record (EMR) for R31 documented diagnoses of dementia without behavioral disturbance (progressive disorder characterized by failing memory and confusion), small cell carcinoma of the lung (an aggressive fast growing cancer that forms in tissues of the lung and can spread to other parts of the body), hypothyroidism (condition characterized by hyperactivity of the thyroid gland), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness). R31's Quarterly Minimum Data Set, dated 02/03/22, documented the resident had severely impaired cognition and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The assessment further documented the resident required supervision and set up assistance for eating, was 68 inches tall, weighed 133 pounds (lbs), and had no weight loss or gain. The revised Nutritional Care Plan, dated 02/10/22, originally dated 08/17/21, directed staff to have the Registered Dietician (RD) to evaluate and make diet change recommendations as needed, provide and serve diet as ordered, and monitor intake and record every meal. Monitor, record, and report to the physician as needed for signs of malnutrition, significant weight loss of three lbs in one month, more than five percent in one month, more than seven and a half percent in three months, and more than 10 percent in six months. The update, dated 02/08/22, documented the resident loved salads, fresh vegetables, pancakes and waffles with fruit and whipped cream on top. The update directed staff to monitor the resident during meals and if R31 was not eating, offer her another choice of foods she preferred. The Physicians Order, dated 07/30/21, directed staff to provide a regular diet with regular texture and consistency. R31's Vital Sign Log-Weights recorded the following: 09/14/21 146.4 09/20/21 146.0 09/27/21 147.8 10/05/21 146.0 10/13/21 146.8 10/19/21 146.0 10/25/21 146.0 10/29/21 146.8 11/19/21 142.2 11/22/21 142.0 01/13/22 135.2 01/18/22 135.2 01/24/22 136.2 01/31/22 132.8 02/11/22 129.4 02/21/22 128.8 03/07/22 128.8 03/14/22 127.8 03/16/22 129.2 (11.5% in 180 days) The Mini Nutritional Assessment, dated 01/31/21, documented the resident had no decrease in food intake, no weight loss, and had mild dementia. The Nurse's Note, dated 03/10/11 at 02:04 PM, documented the resident had weight loss, staff were discussing milkshakes and were educated to offer snacks. R31's Nutrition/Dietary Assessment, dated 08/04/21, documented the resident weight at 142.6 lbs, Body Mass Index (BMI) 21.7, was new to long term care, food intake was fair, and recommended to encourage the resident with verbal cues to eat and drink. The Mini Nutritional Assessment, dated 01/31/22, documented the resident was at risk for malnutrition, had a moderate decrease in food intake and had weight loss of between 2.2 lbs and 6.6 lbs. The Fax Communication to the Physician, dated 02/25/22, documented the resident continued to have weight loss, had not seen the dietician since 08/04/21, and he would be contacted to ask for another consultation. Review of the medical record revealed the dietician had not been contacted by the facility regarding the resident's weight loss as of 03/16/22. On 03/16/22 at 08:15 AM, observation revealed R31 ate her bowl of cereal but pushed away her plate of scrambled eggs and toast, and was not offered assistance by staff. On 03/16/22 at 01:00 PM, observation revealed the resident ate all of her roast beef with gravy, a brownie, and most of her potatoes. On 03/16/22 at 11:30 AM, Licensed Nurse (LN) G stated the resident had not received any supplements for her weight loss and how much she ate of her food depended upon which residents sat with her as she would give away her food in the past. On 03/16/22 at 11:50 AM, Administrative Staff D stated staff had discussed the resident's weight loss and had involved the family to determine what interventions would be most beneficial for the resident but had not documented any of the discussion. Administrative Staff D verified she had not contacted Dietary Consultant GG about R31's weight loss. On 03/16/22 at 01:05 PM, Dietary Consultant GG stated he was unaware the resident had a weight loss as no one at the facility had contacted him regarding the resident's weight loss and would make recommendations to the facility for the weight loss. On 03/17/22 at 09:41 AM, R31's representative stated she was aware of the resident's weight loss and did not feel the resident would drink any supplements but R31 liked milkshakes with ice cream and would ask the facility to make R31 milkshakes every day. The facility's Weight Assessment and Intervention policy, dated September 2008, documented the multidisciplinary staff would strive to prevent, monitor, and intervene for undesirable weight loss for the residents. The nursing staff would measure residents weights on admission, the next day, and weekly for two weeks thereafter. The policy further documented that if no weight concerns were noted at that point, weights would be measured monthly. The policy documented any weight change of 5% or more since the last weight, an assessment would be retaken the next day for confirmation. If the weight was verified, nursing staff would immediately notify the dietician in writing, and verbal notification must be confirmed in writing and the dietician would respond within 24 hours of receipt of written confirmation. The policy documented interventions for undesirable weight loss should be based on careful consideration, resident choice, preferences, nutrition and hydration needs, the use of supplementation and/or feeding tubes, end of life decisions and advanced directives. The facility failed to contact the Registered Dietician for recommendations for R31's 11.5% weight loss in six months, placing the resident at risk for further weight loss and decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding Resident (R) 3's antidiabetic medications (medication to stabilize blood sugar) and the lack of associated blood sugar monitoring. This placed R3 at risk for adverse outcomes including hypoglycemia (low blood sugar). Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus ( a chronic condition that affects the way the body processes blood sugar). The Significant Change Minimum Data Set (MDS), dated [DATE], recorded R3 had severely impaired cognition, required extensive staff assistance with bed mobility, transfers, and had functional impairment in the left lower extremity. The Cognitive Loss Care Area Assessment (CAA), dated 02/17/22, recorded R3's cognition fluctuated and had poor decision making skills. The Physician's Order, dated 08/25/21, directed the staff to administer Glipizide (an oral diabetes medicine that helped control blood sugar levels) 10 milligrams (mg) PO (by mouth) daily in morning, and Januvia (an oral diabetes medication which helps to control blood sugar levels) 50 mg PO daily in morning. The Physician's Order, dated 10/13/21, directed the staff to administer Farxiga (an oral diabetes medicine that helps control blood sugar levels) 10 mg PO daily in morning. Review of the medical record revealed no documentation of blood sugar testing (checking levels of sugar in the blood). The monthly pharmacy reviews for August, September, October, November, December 2021, January, February 2022, lacked recommendations by the pharmacist for blood sugar monitoring. The United States Food and Drug Administration (FDA) stated when receiving oral antidiabetic medications the blood sugar was to be tested on a routine basis. Side effects from the use of these medication can cause hypoglycemia (low blood sugar). On 03/15/22 at 11:45 AM, observation revealed R3 laid in his bed. On 03/16/22 at 11:40 AM, Licensed Nurse (LN) G verified R3 received three different oral antidiabetic medications every morning. LN G verified no blood sugar monitoring was completed. On 03/16/22 at 12:10 PM, Consultant Pharmacist HH verified no recommendations were made to the facility regarding R3's use of oral antidiabetic medication. Consultant Pharmacist HH stated the facility should be checking R3's blood sugar two to three times a week while he received these medications. On 03/16/22 at 01:30 PM, Administrative Nurse D verified R3 received three oral antidiabetic medications on a routine basis every morning. Administrative Nurse D also verified no blood sugar monitoring was completed since the medications were ordered in August 2021 and October 2021. The facility's Medication Regimen Review policy, dated May 2019, states a medication regimen of each resident will be done monthly by a Licensed Pharmacist. Recommendations in writing will be provided to the Director of Nursing and the resident's physician. The facility's Obtaining a Finger Stick Blood Glucose Level policy, dated October 2011, states when a resident receives a diabetic medication the blood sugar is to be monitored. The facility failed to ensure the Consultant Pharmacist HH identified and reported irregularities regarding R3's antidiabetic medications and the lack of associated blood sugar monitoring. This placed R3 at risk for adverse outcomes including hypoglycemia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to monitor blood sugar for one of five sampled residents, Resident (R) 3 who received routine antidiabetic medications (medication to stabilize blood sugar). This placed R3 at risk for adverse medication side effects. Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). The Significant Change Minimum Data Set (MDS), dated [DATE], recorded R3 had severely impaired cognition, required extensive staff assistance with bed mobility, transfers, and had functional impairment in the left lower extremity. The Cognitive Loss Care Area Assessment (CAA), dated 02/17/22, recorded R3's cognition fluctuated and had poor decision making skills. The Physician's Order, dated 08/25/21, directed the staff to administer Glipizide (an oral diabetes medicine that helped control blood sugar levels) 10 milligrams (mg) PO (by mouth) daily in morning, and Januvia (an oral diabetes medication which helped to control blood sugar levels) 50 mg PO daily in morning. The Physician's Order, dated 10/13/21, directed the staff to administer Farxiga (an oral diabetes medicine that helped control blood sugar levels) 10 mg PO daily in morning. Review of the medical record revealed no documentation of blood sugar testing (checking levels of sugar in the blood). The United States Food and Drug Administration (FDA) stated when receiving oral antidiabetic medications the blood sugar was to be tested on a routine basis. Side effects from the use of these medication could cause hypoglycemia (low blood sugar). On 03/15/22 at 11:45 AM, observation revealed R3 laid in his bed. On 03/16/22 at 11:40 AM, Licensed Nurse (LN) G verified R3 received three different oral antidiabetic medications every morning. LN G verified no blood sugar monitoring was completed. On 3/16/22 at 01:30 PM, Administrative Nurse D verified R3 received three oral antidiabetic medications on a routine basis every morning. Administrative Nurse D also verified no blood sugar monitoring was completed since the medications were ordered in August 2021 and October 2021. The facility's Obtaining a Finger Stick Blood Glucose Level, dated October 2011, states when a resident receives a diabetic medication the blood glucose is to be monitored. The facility failed to adequately assess blood sugars to ensure appropriate care and treatment for R3, placing the resident at risk for elevated blood sugars and adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - On 03/15/22 at 09:55 AM, observation revealed Administrative Nurse D gathered supplies, entered Resident (R) 2's room and told R2 she was going to administer his insulin to him. Administrative Nurse D dialed up the correct amount of insulin on a basaglar (long-acting insulin kwikpen [a disposable single-patient-use prefilled pen containing insulin]), used hand sanitizer on her hands, then without applying gloves, administered R2's insulin in his abdomen. On 03/15/22 at 09:55 AM, Administrative Nurse D verified she had not applied gloves when administering R2's insulin and stated she normally does not wear gloves because she is not in contact with body fluids or blood, but if there was bleeding from the insulin injection site she probably would be in contact with blood. Upon request the facility failed to provide a policy regarding administration of a basaglar kwikpen insulin pen. The facility staff failed to apply gloves when administering basaglar kwikpen insulin to R2. This placed the resident at risk for transmission of communicable diseases and infections. The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to exercise adequate infection control measures when they failed to utilize proper hand hygiene and failed to handle soiled trash appropriately during direct care for Resident (R) 3. The facility further failed to ensure staff used adequate personal protective equipment while administering an insulin (a medication to stabilize blood glucose) injection. This placed the affected residents at increased risk for infectious disease and illness. Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus ( a chronic condition that affects the way the body processes blood sugar). R3's Significant Change Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition, required extensive staff assistance with bed mobility, transfers, had functional impairment in the left lower extremity and incontinent of bowel and bladder. The Incontinence Care Plan, dated 02/17/22, directed the staff to provide incontinent care for R3 as needed and to use good hand hygiene when providing care. On 03/15/22 at 11:45 AM, observation revealed R3 laid in his bed on his right side. Certified Nurse Aide (CNA) N stood on the left side of the resident's bed and CNA O on the right. CNA N and CNA O applied clean gloves. CNA N unhooked R3's incontinence brief which revealed R3 was incontinent of stool. CNA N used cleansing wipes to clean the resident's buttocks. CNA N then removed her gloves and tossed the soiled gloves along with the soiled wipes across the resident and into a trash can on the other side of the bed. CNA O rolled the resident over and applied a clean brief using her same soiled gloves. CNA N washed her hands in the sink but did not dry her hands as no paper towels were available. CNA N proceeded to shake her hands in the air to attempt to dry them. After R3 was transferred to his wheelchair, he requested a piece of candy from the jar at his bedside. CNA N opened the jar with her wet hands and obtained a piece of candy from the jar with her same wet hands. CNA N then provided the resident with the piece of candy. CNA O was not observed washing her hands. On 03/16/22 at 01:30 PM, Administrative Nurse D verified the staff are to change gloves and wash hands during care. Administrative Nurse D verified it is not acceptable to not dry hands after washing hands and to not toss soiled gloves across the resident into a trash can. The facility's Hand Hygiene policy, dated August 2019, stated the facility considers hand hygiene the primary means to prevent the spread of infection. Hand hygiene supplies will be readily accessible and convenient for staff to use. When removing gloves pinch the glove at the wrist and peel away from the hand, turning the glove inside out. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. Perform hand hygiene, dispose of gloves properly in trash. The facility failed to provide adequate hand hygiene during incontinent care for R3, placing him at risk for infection and poor hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents of which four were reviewed for respiratory care. Based on observation, record review, and interview, the facility staff failed to provide necessary respiratory care and services for Resident (R) 1, R5, R19, and R27, when staff stored their uncovered nebulizer masks on top of their nebulizer machines. This placed R1, R5, R19, and R27 at increased risk for complications and respiratory infection. Findings included: - R1's Electronic Medical Record (EMR) documented she had diagnoses of shortness of breath, chronic atrial fibrillation (rapid, irregular heart beat ), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R1's Significant Change Minimal Data Set (MDS), dated [DATE] documented the resident had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required total staff assistance with locomotion off the unit, extensive staff assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene, and supervision with eating. The MDS documented the resident received oxygen and no respiratory therapy. R1's Respiratory Status/Difficulty Breathing Care Plan, revised on 01/04/22, instructed staff to maintain a clear airway by encouraging resident to clear her own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. The Care Plan instructed staff to properly align R1's body for optimal breathing pattern, administer medications as ordered by the physician, monitor for signs or symptoms of respiratory distress, and report to the physician as needed. R1's Physician Order, dated 02/27/22, instructed staff to administer one ipratropium-albuterol solution (a sterile inhalation solution), 0.5-2.5 (3) milligram (mg)/3 milliliter (ml), by nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) treatment every six hours, as needed for congestion. On 03/14/22 at 09:00 AM, observation revealed R1's uncovered nebulizer mask stored on top of the nebulizer machine. On 03/14/22 at 02:30 PM, observation revealed R1's uncovered nebulizer mask stored on top of the nebulizer machine. On 03/15/22 at 03:47 PM, observation revealed R1's uncovered nebulizer mask stored on top of the nebulizer machine. On 03/15/22 at 03:50 PM, Administrative Nurse D verified R1's uncovered nebulizer mask stored on top of the nebulizer machine and stated it should be stored inside a plastic bag. The facility's Administering Medication Through a Small Volume (handheld) Nebulizer policy, revised on October 2010, instructed staff to store resident's nebulizer equipment in a plastic bag with the resident's name and the date on it. The facility failed to properly store R1's nebulizer mask, when staff stored it uncovered on top of the nebulizer machine. This placed the resident at risk for an infection. - R5's EMR documented she had diagnoses of chronic obstructive pulmonary disease ( progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypoxemia (abnormal deficiency in the concentration of oxygen in blood), shortness of breath, and acute (disease characterized by a relatively sudden onset of symptoms that are usually severe) upper respiratory (network of organs and tissues that help you breathe) infection. R5's Annual MDS, dated 02/23/22, documented R5 had a BIMS score of 12, which indicated moderate cognitive impairment. The MDS documented R5 required total staff assistance with transfers and toilet use, extensive staff assistance with the rest of activities of daily living (ADLs) except independent with eating. The MDS documented R5 received respiratory therapy for total of 56 minutes for two days during the lookback period. R5's Oxygen Therapy Care Plan, revised on 02/28/22, documented the resident received oxygen therapy, instructed staff to monitor for signs or symptoms of respiratory distress, and report to the physician as needed if any signs. The Care Plan instructed staff to administer oxygen therapy, two liters (L) per nasal cannula or mask as to keep R5's oxygen saturation >90% at night. R5's Physician Order, dated 02/18/22, instructed staff to administer to R5 ipratropium-albuterol solution, 0.5-2.5 (3) mg/3 ml inhalation orally by nebulizer three times a day for cough/wheezing. R5's Physician Order, dated 02/22/22, instructed staff to administer ipratropium-albuterol solution, 0.5-2.5 (3) mg/3 ml -1 inhalation inhale orally by nebulizer every four hours as needed for cough related to chronic obstructive pulmonary disease. On 03/14/22 at 04:00 PM, observation revealed R5's uncovered nebulizer mask stored on top of the nebulizer machine. On 03/15/22 at 08:58 AM, observation revealed R5's uncovered nebulizer mask stored on top of the nebulizer machine. On 03/15/22 at 12:52 PM, Administrative Nurse D verified R5's uncovered nebulizer mask stored on top of her nebulizer machine and stated staff should store resident nebulizer masks and tubing in a plastic bag and label and date them. The facility's Administering Medication Through a Small Volume (handheld) Nebulizer policy, revised on October 2010, instructed staff to store resident's nebulizer equipment in a plastic bag with the resident's name and the date on it. The facility failed to properly store R5's nebulizer mask, when staff stored it uncovered on top of the nebulizer machine. This placed the resident at risk for an infection. - R19's EMR documented the resident had diagnoses of chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing ) and hypoxemia (abnormal deficiency in the concentration of oxygen in blood). R19's Quarterly MDS, dated 01/05/22, documented R19 had a BIMS of 15, which indicated intact cognition. The MDS documented R19 required extensive staff assistance with bed mobility, transfers, dressing, toilet use, limited staff assistance with locomotion on and off the unit and personal hygiene, and supervision with eating. The MDS documented the resident had not received respiratory therapy. R19's Oxygen Therapy Care Plan, dated 01/11/22, instructed staff to administer oxygen to R19 to maintain oxygen saturation >92% at night. The Physician Order, dated 2/26/22, instructed staff to administer DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol) one inhalation orally by nebulizer every day shift related to COPD and administer to R19 one inhalation orally via nebulizer every four hours as needed. On 03/14/22 at 09:00 AM, observation revealed R19's uncovered nebulizer mask stored on top of her nebulizer machine. On 03/14/22 at 02:45 PM, observation revealed R19's uncovered nebulizer mask stored on top of her nebulizer machine. On 03/15/22 at 12:52 PM, Administrative Nurse D verified R19's uncovered mask was stored on top of her nebulizer machine, stated staff should store resident nebulizer masks and tubing in a plastic bag, and label and date them. The facility's Administering Medication Through a Small Volume (handheld) Nebulizer policy, revised on October 2010, instructed staff to store resident's nebulizer equipment in a plastic bag with the resident's name and the date on it. The facility failed to properly store R19's nebulizer mask, when staff stored it uncovered on top of the nebulizer machine. This placed the resident at risk for an infection. - R27's EMR documented the resident had a diagnoses of chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing ) and dyspnea (difficulty breathing). R27's Quarterly MDS dated 01/27/22 documented R27 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS documented R27 required extensive staff assistance with bed mobility, transfers, toilet use, walking in the room, locomotion on and off the unit, dressing, and personal hygiene, limited staff assistance with walking in the corridor, and supervision with eating. The MDS documented R27 received respiratory therapy for at least 15 minutes every day during the five day look back period. R27's Physician Order dated 01/08/22 instructed staff to administer DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol) one inhalation orally by nebulizer two times a day and one inhalation orally by nebulizer every four hours as needed for shortness of air and cough. On 03/14/22 at 03:44 PM, observation revealed R27's uncovered nebulizer mask stored on top of the nebulizer machine in her room. On 03/15/22 at 08:53 AM, observation revealed R27's uncovered nebulizer mask stored on top of the nebulizer machine in her room. On 03/15/22 at 03:50 PM, Administrative Nurse D verified the resident's uncovered nebulizer mask stored on top of the nebulizer machine in R27's room and stated staff should store it in a plastic bag. The facility's Administering Medication Through a Small Volume (handheld) Nebulizer policy, revised on October 2010, instructed staff to store resident's nebulizer equipment in a plastic bag with the resident's name and the date on it. The facility failed to properly store R27's nebulizer mask, when staff stored it uncovered on top of the nebulizer machine. This placed the resident at risk for an infection.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare and serve food in accordance with professional standards for the 34 residents who received their meals from the facility kitchen. This placed the 34 residents at risk for foodborne illness. Findings included: - On 03/14/22 at 10:22 AM, observation revealed in the two door refrigerator labeled (kitchen) a metal pan with bagged scrambled and boiled eggs, with packages of sliced ham, and sausage on top of the eggs on the top shelf. On 03/14/22 at 11:31 AM, observation revealed in the walk in refrigerator in the kitchen three five pound (lb) low fat cottage cheese containers with an expiration date of 03/12/22. On 03/14/22 at 11:56 AM, observation revealed the following: A kitchen ceiling vent by the storage room had blackish lint. The kitchen cabinets had numerous areas with dried food drippings. All around the kitchen the mopboard had brownish gray grime approximately 2 inches x 2 inches. The inside kitchen door had brown grime approximately 18 inches high x 5-6 inches wide from the bottom of the door and below the door handle. The facility's Morning [NAME] Daily Cleaning List dated 02/27/22-03/05/22 and 03/06/22-03/12/22 documented staff provided the following cleaning: sanitizing work area, wipe down top of oven, wipe down front of double oven, wipe down backsplash of stove, wipe down stove top, wash burners if heavily soiled, wipe down shelf above stove, sanitize toaster, grill, microwave inside and out, robo coupe, blender, can opener, mixers, wipe down kitchen fridge doors, sanitize cooks cart, sanitize hot plate cart, sanitize steam table, wash/sanitize to bar cutting board, sanitize three compartment sink/faucets and two compartment, take out trash, take any dirty linens to the bin, sweep the kitchen (under stoves, etc). The list lacked instructions to staff regarding cleaning the outside of the cabinets and mopboard. On 03/14/22 at 11:31 AM, Dietary Staff (DS) BB verified the three five lb cottage cheese were expired and removed and discarded them into the trash. On 03/14/22 at 11:56 AM, DS BB verified the metal pan had scrambled and boiled eggs with sliced ham and sausage patties on top of them, stated they should be stored separately, and meat should be on the bottom shelf. On 03/14/22 at 11:56 AM, DS BB verified the findings regarding cabinets, mopboard, inside entrance door, stated staff had a daily cleaning schedule to follow, and should clean them daily. The facility's Sanitization policy, revised October 2008, documented all kitchens, kitchen areas, and dining rooms should be kept clean. The facility's Food Receiving and Storage policy, revised October 2007, documented all foods stored in refrigerator and freezer, would be covered, labeled and dated (use by date). The facility failed to store, prepare and serve food in accordance with professional standards for food service safety. This placed the 34 resident who resided at the facility and received food from the facility kitchen at risk for receiving a foodborne illness.