**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 57 residents; the sample included three residents. Based on observation, interviews, and record review, the facility failed to ensure an environment free from accidents when staff failed to assess Resident (R) 1's ability to safely manage hot liquids resulting in a hot liquid spill. This deficient practice placed R1 at risk for burns and pain.Findings included:- R1's Electronic Health Record (EHR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), and Parkinsonism (a clinical syndrome characterized by a group of symptoms including resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).R1's 01/06/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R1 required set-up assistance for eating and oral care. The MDS documented R1 was dependent for toileting, bathing, dressing, and transfers. The MDS documented R1 had no skin conditions present.R1's 01/21/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R1required assistance with activities of daily living (ADL) and mobility. The CAA noted the care plan would address her need for assistance with personal care and mobility.R1's 06/24/25 Quarterly MDS documented R1 had disorganized thinking and an altered level of consciousness. The MDS documented R1 required moderate assistance for eating, oral care, and personal hygiene. The MDS documented R1 was dependent for toileting, bathing, dressing, wheelchair mobility, and transfers. The MDS documented R1 had no skin conditions present.R1's Care Plan dated 04/19/23 instructed staff to provide assistance with meals as needed. The plan directed staff to set up R1's tray and assist her with bites and sips as she was not consistently feeding herself. R1's Care Plan did not address the handling or management of hot liquids.R1's EHR lacked evidence the facility assessed R1's ability to safely manage hot liquids.The 06/08/25 Villa [NAME] Physician Communication documented R1 had declined and was unable to eat on her own again. On 06/11/25, the physician responded, Labs pending.R1's Progress Note dated 06/15/25 at 04:37 PM documented at approximately 10:25 AM, R1 lay in bed while staff cleaned her neck; there was a family member in the room. The note documented Licensed Nurse (LN) G assessed R1 and noted a large burn to her neck, shoulder, and ear on her right side. LN G noted a sticky substance on R1's neck, ear, and in her hair, along with a brown wet spot on the pillowcase that looked like coffee. At 10:50 AM, R1 requested a pain pill. The note documented staff were educated about not leaving hot drinks in reach of residents who were not able to safely handle them or who needed assistance with them.R1's Physician Orders dated 06/15/25 ordered Silvadene external cream (topical antibiotic medication primarily used to prevent and treat wound infections in patients with burns), apply topically two times a day to burns on the neck, shoulder, and ear. The Silvadene was discontinued on 06/18/25.R1's Physician Orders dated 06/18/25, ordered A&D ointment (a topical skin protectant ointment containing vitamins A and D, typically used to help heal and protect minor cuts, and burns) to the area of dryness on the right shoulder/neck and up into the hairline two times a day for exacerbation of skin condition.The 06/18/25 Physician Progress Note documented R1 sustained a burn to her right neck while trying to drink coffee in bed. The note documented orders were received for Silvadene topically, and the burn appeared to be improving at that time. The note documented that Administrative Nurse D had a discussion with the nursing staff regarding hot beverages and R1. The note documented that the burn appeared to be a first-degree burn (a burn that affects the first layer of the skin).R1's Skin/Wound Evaluation dated 06/18/25 at 04:28 PM documented a red scaly pink area measuring 13.61 centimeters (cm) by 5.85 cm and an area dimension of 59.59 cm.R1's Progress Note dated 6/18/25 at 05:16 PM documented after a review of updated pictures of the burn area with the physician and finding the area to be dry and scaly with no appearance of a burn, it was believed that the area might be more of an underlying skin condition that the resident had and not a burn. R1 will no longer get Silvadene cream on the area and will now get A&D ointment on the area per the physician, who agreed the area was not a burn at all.During an observation on 07/30/25 at 12:30 PM, CNA N picked up a cup of coffee that sat on the counter next to the coffee carafe, put a lid on the cup, and placed it on a resident's room tray. CNA N then started to walk out of the dining area. CNA N hesitated and then stated that she obtained a temperature reading of 120 degrees Fahrenheit (F.) prior to the service. Upon request, CNA N obtained a thermometer from a small cup on the counter and placed the thermometer in the coffee without sanitizing the thermometer. The coffee was 100 degrees F. Further observation of the dining area revealed a large sign with instructions for staff to obtain temperature readings of all hot liquids prior to service, and that the hot liquid temperature could not exceed 120 degrees F.On 07/30/25 at 10:10 AM, Certified Nurse Aide (CNA) M reported that she gave R1 her breakfast tray while R1 was in bed the morning of 06/15/25. CNA M reported the coffee mug had a lid on it. CNA M said she was not aware that R1 required assistance with meals. CNA M reported that she noted R1's sheets had a brown stain on them near the resident's head when she assisted R1 with care. CNA M reported that she then observed the coffee mug had no lid on it; there was coffee in the cup, and the lid was on the table. CNA M said she noted reddened skin on the right side of R1's neck and her right ear, so she got the nurse. CNA M stated that all confused residents required lids on their hot beverages, and should be in the dining room to eat, but if a resident refused, the staff would assist the residents. CNA M reported that R1 had become more confused in the past month.On 07/30/25 at 10:19 AM, CNA N reported that if a resident was not fully aware of their surroundings, shaky, and/or confused, the resident would have a lid on their hot beverage. CNA N reported some residents were care planned for covered hot beverages.On 07/30/25 at 10:25 AM, LN H stated she was unsure what the policy was regarding hot liquids before R1 spilled the hot coffee, but stated now every resident would have a lid placed on all hot beverages. LN H said if a resident was alert and oriented, they could take the lid off themselves.On 07/30/25 at 12:40 PM, Administrative Staff A and Administrative Nurse D acknowledged that none of the staff signed that they received education regarding hot liquids, except for the immediate education provided on 06/15/25, signed by the four staff members on duty at the time. Administrative Staff A reported they sent out an alert on 06/15/25 via text and email to all staff, which directed that, effective immediately, all hot liquids must have a temperature taken prior to serving and the liquid must be 120 degrees F. or lower before placing the lid on the cup and serving. Administrative Staff reported that the facility did not have a policy implemented for hot beverages yet, as she had to finish it after she completed her research. Administrative Staff A reported that there was a posting of the education for all the staff about temperatures and lids in the facility in several locations.On 07/30/25 at 01:00 PM, Administrative Nurse D reported she expected the staff to apply a lid on all hot beverages. Administrative Nurse D reported she expected staff to not serve R1 in her room as R1 had good days and bad days when she fed herself.On 07/30/25 at 01:15 PM, Administrative Staff A reported that no residents had been assessed for safety with hot liquids and reported every resident was required to have a lid placed on their hot beverages.The facility did not provide a policy for safety related to hot beverages.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 57 residents. The sample included 15 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to provide dignity and quality of life for Resident (R)5, placing the resident at risk for embarrassment and an undignified living environment. Findings included: - R5's Electronic Medical Record (EMR) recorded diagnoses of post-polio syndrome (polio, or poliomyelitis, is an infectious viral disease that can harm the nervous system. post-polio syndrome (PPS-usually occurs 15-40 years after the infection and recovery. PPS is believed to be the result of a deterioration of nerve cells called motor neurons over many years that leads to loss of muscle strength and dysfunction), and paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk). R5's Significant Change Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact), and an indwelling urinary catheter (a tube in the bladder to drain urine). R5's Care Plan dated 12/16/22, recorded a private duty nurse would change the catheter monthly and the resident would not allow any facility staff to change her catheter. The care plan recorded staff were to provide catheter care every shift, and monitor and document output. The care plan lacked any guidance for staff to cover the urinary catheter bag. On 02/03/23 at 02:30 PM, observation revealed R5 rested in bed, with the uncovered urinary catheter bag hanging on the left side of the bed frame, visible from the hall. On 02/06/23 at 08:15 AM, observation revealed R5 rested in bed, with the uncovered urinary catheter bag hanging on the left side of the bed frame, visible from the hall. On 02/08/23 at 09:45 AM, Administrative Nurse E stated the resident's urinary catheter bag should be covered at all times. The facility's Respect and Dignity policy, undated, stated the residents have the right to be treated with respect and dignity which includes personal privacy including accommodations, medical treatment and personal cares. The facility failed to cover R5's urinary catheter bag, placing the resident at risk for embarrassment and an undignified living environment

The facility had a census of 57 residents. The sample included 15 residents. Based on record review and interview, the facility failed to provide three sampled residents, Resident (R)13, R16 and R146 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, (CMS) Centers for Medicare and Medicare Services which placed them at risk to make uninformed decisions about their skilled care. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The facility failed to provide R29 the completed form 10055, which estimated the cost for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled services ended on 10/09/22. The facility failed to provide R48 the completed form 10055, which estimated cost for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled nursing services ended on 11/04/22. The facility failed to provide R157 the completed form 10055, which the estimated cost for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled nursing services ended on 08/17/22. On 02/04/23 at 11:25 AM, Social Services X verified the facility staff had not provided the resident and/or their representative the CMS form 10055. On 02/08/23 at 1:30 PM, Administrative Staff A verified the facility had lacked providing the resident and/or their representative the CMS 10055 form. The facility's Advance Beneficiary Notice of Non-Coverage policy, undated, documented ABN is a notice to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. Notifiers including physicians, providers, practitioners and suppliers' pain under Part B, as well as hospice providers and religious non-medical health care institutions pain under Part A. They must complete the ABN and deliver notice to affected beneficiaries or their representatives before providing the item or services that are the subject of the notice. The ABN will be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. A copy is given to the beneficiary or representative, and the facility retains the original copy. The facility failed to provide R29, R48, and R157, or their representatives, the completed ABN 10055 form when discharged from skilled care, which placed them at risk to make uninformed decisions about their skilled care.

The facility had a census of 57 residents. The sample included 16 residents with one resident reviewed for side rails. Based on observation, interview, and record review the facility failed to care plan the use of beds rails for Resident (R) 30. This deficient practice placed R30 at risk for impaired safety due to lack of staff direction for the use of the bed rails. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), and obesity (abnormal or excessive fat accumulation that presents a risk to health). The Significant Change Minimum Data Set (MDS), dated 12/12/22, documented R30 was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of zero. The MDS documented R30 required extensive assistance of one staff for eating, hygiene, two staff for bed mobility, and total assistance for transfers, dressing, toileting. The MDS documented R30 had no range of motion (ROM) impairment, used a wheelchair for mobility, and had no falls. The Fall Care Area Assessment (CAA), dated 12/12/22, documented R30 had been readmitted from the hospital and at times she became resistant to cares by pushing back when staff are trying to provide cares or repositioning. Staff transferred her with a full body lift, and she was dependent on staff for transfers, dressing, incontinent cares, mobility, and had no falls in the past quarter. The Fall Care Plan, dated 12/24/22, directed staff to ensure her call light was placed within reach at all times, use a full body lift for all transfers, and a wheelchair for all mobility. The care plan directed staff to use two-person assistance with bed mobility, repositioning and dressing. The care plan lacked direction for the use of side rails. The facility lacked a side rail assessment for R30. The Fall Risk Assessment, dated 12/07/22, documented R30 was a high risk for falls. On 02/06/23 at 08:46 AM, observation revealed R30's bed side rails had long gaps approximately 4.5 inches by 26 inches between the bars. On 02/06/23 at 09:30 AM, observation revealed R30 sat in her wheelchair in her room watching television. On 02/06/23 at 10:40 AM, Administrative Nurse D checked the side rails on the R30's bed. She stated hospice brought the bed to the facility. The rail gaps measured 4.5 inches tall by 26 inches wide. Administrative Nurse D verified the gap was more than 4.75 inches wide. She stated the resident used the side rails to hold herself on her side during care. The DON moved the right-side rail back and forth approximately 3 inches and then attempted to tighten the pin holding the rails. Administrative Nurse D stated staff normally do a side rail assessment and verified the facility had not assessed R30 for the use of side rails or the hospice-provided bed rails. The facility's Comprehensive Care Plan policy, dated 03/18/2018, stated the facility would develop and implement a person-centered care plan for each resident to meet a resident's medical, nursing, and psychosocial needs and would include resident specific interventions. The facility failed to care plan the use of beds rails for R30, placing R30 at risk for impaired safety due to lack of staff direction for the use of the bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 57 residents. The sample included 16 residents of which four residents were reviewed for pressure ulcers (PU-injury to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, record review, and interview, the facility failed to implement interventions to prevent Resident (R) 33's left buttock pressure ulcer from worsening and failed to implement treatment for R34's facility acquired pressure ulcer when identified. These deficient practices placed R33 and R34 at risk for delayed healing or worsening pressure ulcers. Findings included: - The Medical Diagnosis section within R33's Electronic Medical Record (EMR) included diagnoses metabolic encephalopathy (inflammatory condition of the brain ), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), overactive bladder, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain )with agitation, intertrochanteric (hip area of large thigh bone) fracture of left femur , muscle weakness, other abnormalities of gait and mobility, and need for assistance with personal care. R33's admission Minimum Data Set (MDS), dated [DATE], lacked a cognition assessment, but documented R33 had inattention, disorganized thinking, other behavioral symptoms not directed toward others, and rejected evaluation or care behaviors which occurred one to three days during look back period. The MDS further documented R33 required extensive assistance of two staff for bed mobility and transfers and required extensive assistance of one staff for eating. R33 had incontinence of urine and bowel, weighed 121 pounds (lbs.), received as needed pain medication for daily indicators of pain with vocal and facial expressions. The MDS further documented an unhealed stage two pressure ulcer (break in the top two layers of skin) a deep tissue injury (DTI-a pressure related injury to tissue under intact skin) were present on admission. R33 had pressure reducing devices for the bed and chair, turning/repositioning program, pressure ulcer/injury care, and application of ointment/medication other than to feet. The Pressure Ulcer Care Area Assessment (CAA), dated 01/25/23, documented R33 had surgical repair of a left hip fracture, required extensive assistance of two staff for bed mobility and transfers, used wheelchair for mobility, had three areas of skin impairment: a surgical wound, stage two pressure ulcer, and a suspected DTI. R33 had a low air loss mattress and a cushion in the wheelchair. The CAA further documented worsening of the PU related to the need for repositioning assistance. The Baseline Care Plan, dated 01/12/23, documented R33 had a moderate risk of developing pressure ulcers, and had heel protectors to elevate heels. It directed staff to provide barrier cream, reposition every two hours and documented R33's wounds were located on the left buttock and the left heel. The facility Skin/Wound Documentation form, dated 01/12/23, documented a buttock stage two pressure ulcer which measured 1.0-centimeter (cm) in length by 0.5 cm in width, Chamosym (moisture barrier) cream twice a day (BID) and as needed. R33's left heel DTI measured 3 cm in length by 0.6 cm in width; staff were to cover with bordered foam dressing and change daily. The Weekly Wound Assessment, dated 01/23/23, documented the physician was notified on admission of R33's left pressure area and DTI and R33 had padded boots. The left heel overall impression was unchanged, dry, dark purple in color, not open, hard to touch, and did not blanch. The left heel measured 4.1 cm in length by 2.1 cm in width, the periwound (tissue surrounding a wound) was dry and irregular shaped. The assessment directed to apply skin prep (liquid skin barrier) to the wound, cover with bordered foam, and change daily. The left buttock stage two pressure ulcer was noted as worsening. The assessment noted epithelial (new skin growing in a superficial wound) tissue was present, measured 4 cm in length x 2 cm in width. The w periwound was dry, flaky, and slow to blanch. The left buttock wound was to be cleansed every three days and as needed, with normal saline and covered with a foam dressing. The Physician Progress Note, dated 01/25/23, documented nursing noted a left buttock pressure area, about half-dollar size open area with some erythema (redness or inflammation of the skin) and shallow. The physician plan was to use foam dressing and off-loading pressure and consider a low air loss mattress if worsening. The admission Nutrition Assessment date 01/31/23, documented R33 had a mechanical soft diet, no supplements, and poor intake. R33 weighed 113 lbs. which was a loss of seven percent (%) since 01/14/23 (two weeks post admission). The assessment further documented wound issues to left buttock and heel. The assessment noted that due to weight loss, decreased intake, and wound healing, the registered dietician (RD) recommended nutritional interventions for Prostat (supplement to treat pressure ulcers) 30 milliliters (ml) twice a day, Gelatin (protein derived from collagen) twice a day or other supplement if not available. The recommendation also included super cereal (calorie and nutrient dense meal) at breakfast and encouraged R33 to come to dining room and offer encouragement at meals. The Weekly Wound Assessment, dated 02/01/23, documented R33's left heel DTI was worsening, and had opened. There was granulation tissue present, scant bloody drainage, and measured 0.8 cm in length by 2.4 cm in width. The assessment directed to apply skin prep to wound, cover with bordered foam, and change daily. The left buttock stage two pressure ulcer was worsening and had 95 percent (%) slough (dead tissue, usually cream or yellow in color), and the periwound did not blanch. Treatment was noted to cleanse with normal saline, cover with bordered foam dressing, and change every three days and as needed. The assessment included a new observation of a suspected DTI to the left lateral (outside edge) foot, which was dark purple, hard, did not blanch, measured 1.2 cm in length by 1.4 cm in width, and directed to apply skin prep twice a day. The Physician Progress Note, dated 02/01/23, documented R33 was seen, and nursing reported episode of dark emesis. Left buttock wound discussed with nursing; wound had foam dressing. Orders noted to off load pressure and administered normal saline intravenously, again. On 02/06/23 at 07:48 AM, observation revealed R33 sat in her wheelchair, the wheelchair had pressure reducing cushion. She wore padded boots to both feet and was dressed and groomed for the day. Speech therapy was in the room assisting R33 to eat. The breakfast meal consisted of scrambled eggs, French toast with syrup, and two containers of orange juice. No super cereal was present. On 02/06/23 at 08:15 AM observation revealed speech therapy was no longer in room. R33 ate a few bites of scrambled eggs and a few bites of French toast, drank one of the orange juices. R33 remained up in the wheelchair. On 02/06/23 at 10:25 AM observation revealed nursing staff in room, R33 sat on the footrests of her wheelchair. Resident had remained in her wheelchair up to this time, over two hours. Licensed Nurse (LN) G and Certified Medication Aide (CMA) S assessed the resident and placed R33 back in the wheelchair. On 02/06/23 at 10:48 AM observation revealed staff brought R33 to the nurse's station area. Administrative Nurse D inquired how R33 was doing and R33 reported she was not good. On 02/06/23 at 11:23 AM observation revealed Certified Nurse Aide (CNA) O and LN G placed R33 in her bed and used a full body mechanical lift. Staff explained they were going to provide incontinent check and laid R33 in bed. R33 had not voided in brief, R33 rolled to her right side with pillow against R33's back (off-loading buttocks) and continued padded boots to feet. On 02/07/23 at 07:58 AM observation revealed R33 in the dining room, in her wheelchair being fed by staff. R33 had scrambled eggs, pancake with syrup, and large glass of orange juice. Staff inquired about added salt to eggs and R33 said that tasted good. No super cereal was provided to R33. On 02/07/23 at 08:45 AM observation revealed staff had brought R33 to her room where she remained in her wheelchair covered with blankets and her TV on. On 02/07/23 at 12:00 PM observations revealed CNA N and O transferring R33 from wheelchair to bed using a full body lift. CNA N and O stated the resident required extensive assistance with all activities of daily living, was to be repositioned every two hours, was incontinent of urine and bowel. Staff provided cleansing of peri rectal area, the dressing to left buttocks was removed, and a clean brief provided. Staff reported the nurse would place a new dressing to R33 after the shower. Further observation revealed left buttock wound with slough covering majority of the open wound and a dark black area at the top of the wound. Staff finished care and left R33 laying on her back. On 02/07/23 at 04:13 PM observation revealed LN I and Administrative Nurse E measured the wound. The wound measured 5.4 cm in length by 3.5 cm in width, slough covering most of the wound and eschar at 10 o'clock to 12 o'clock wound top. The periwound was red and irritated. R33 reacted with pain complaint while staff measured wound. LN I and Administrative Nurse E verified resident left buttock wound continued to worsen, and that R33 remained in her wheelchair over two hours with position changes but lacked off-loading interventions. The staff reported they were not aware of the dietician's recommendations of supplements or super cereal recommendations. Administrative Nurse E reported discussion with R33's family to involve wound care consultation and care, and review dietician's recommendations. On 02/08/23 at 07:41 AM observation revealed R33 being pushed by staff from the dining room to halfway point of Harmony Lane with padded boots. R33's left foot was dragging the floor behind the foot pedal on the floor until staff stopped and placed left foot on foot pedal. The facility's Pressure Injury Prevention and Management policy, dated 03/28/18, documented the facility is committed to prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to underlying tissue(s). The facility established and utilized a system for pressure injury prevention and management , starting with prompt assessment and treatment, including efforts to identify at risk , stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. Licensed nurses would conduct a pressure injury risk assessment on all residents upon admission /re-admission, after a change of condition, after any newly identified pressure injury, and quarterly. Assessments of pressure injuries be performed by a licensed nurse and documented in the resident's medical record. The staging of pressure injuries would be clearly identified to ensure correct coding on the Minimum Data Set (MDS). Nursing assistants would observe skin during bathing/personal cares and would report any concerns to the charge nurse immediately after the task. Interventions would be for prevention would be implemented for all residents who are assessed at risk or who have a pressure injury present. Interventions would be documented in the care plan and communicated to all relevant staff. Interventions on the resident's care plan would be modified as needed. The facility failed to provide off-loading and repositioning or follow dietician recommendations for R33's wound care and treatment. This placed R33 at risk for worsening of the wound and/or delayed healing. - R34's Electronic Medical Record (EMR), recorded a diagnosis of morbid obesity (a person is at least 100 pounds overweight), venous insufficiency peripheral (failure of the veins to adequately circulate blood, especially in the lower extremities), and diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R34's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R34 had a Brief Interview for Metal Status (BIMS) score of 15, indicating intact cognition. The assessment revealed R34 required extensive staff assistance of two for bed mobility, personal hygiene, dressing, repositioning and transfers. The resident was at risk for pressure ulcer development with moisture associated skin damage (MASD). The Activities of Daily Living (ADL) Care Plan, dated 11/02/22, recorded R34 required a full body lift for transfers, used a wheelchair for all mobility and the resident was dependent on staff for propelling. The Skin Integrity Care Plan, dated 11/02/22, documented R34 was at risk for skin breakdown and had MASD related to morbid obesity with excess skin folds, incontinence, and prolonged sitting. The Braden Scale for Predicting Pressure Ulcer Risk admission Assessment, dated 12/12/22 documented a score of 12.0, which indicated the resident was at high risk for pressure ulcer development. The Braden Scale dated 02/01/23 documented a score of 13 which indicated the resident at moderate risk for pressure ulcer development. The Nurse Progress Note, dated 01/25/23 at 05:06 PM, documented R34 had a bath and the nurse aide identified an open area on R34's coccyx (skin over the tailbone) but the note failed to document if a treatment was implemented or if the physician was notified. A 02/02/22 Physician Order documented wound treatments for the left and right buttocks. The Weekly Wound Assessment, dated 02/03/23 (added during the survey after surveyor requested assessment) documented R34 had a stage two facility acquired pressure ulcer (pressure injury which extends deeper into the skin, may appear like a scape, blister or shallow crater in the skin) on her left buttocks 5.5 centimeters (cm)length, by 2.0 cm width, no tunneling or undermining. The current treatment plan directed staff to cleanse the wound with normal saline or wound cleanser, pat dry with gauze, apply skin prep (skin barrier)to the peri wound (skin around the wound) and cover with a foam border dressing; change the dressing three times a week and as needed for soiling or dislodgement. The wound assessment documented the resident had a stage two facility acquired pressure ulcer on her right buttocks 4.0 cm by 1.3 cm, no tunneling or undermining. The treatment plan included to cleanse with normal saline or wound cleanser, pat dry with gauze, apply skin prep to the wound and cover with foam border dressing, change the dressing three times a week and as needed for soiling or dislodgement. On 02/02/23 at 03:10 PM, observation revealed R34 laid in bed on her back. Administrative Nurse D and Administrative Nurse E assisted the resident to position on her right side and removed the resident's brief. Administrative Nurse E verified an open area on the residents left and right buttocks that was facility acquired. On 02/02/23 at 01:30 PM, Administrative Nurse D stated she was not aware of the resident having a pressure ulcer. Administrative Nurse D said she would observe the resident skin and get back with the surveyors. On 02/02/23 at 3:00 PM, Administrative Nurse D verified the nurse had documented in the progress notes on 01/25/23 the resident had open areas on her coccyx but failed to inform administrative staff of the skin concerns. Administrative Nurse D verified the resident did not have any treatment until staff were questioned during the facility health resurvey on 02/02/23. The facility's Pressure Injury Prevention and Management policy, dated 03/28/18, documented the facility is committed to prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to underlying tissue(s). The facility established and utilized a system for pressure injury prevention and management , starting with prompt assessment and treatment, including efforts to identify at risk , stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. Licensed nurses would conduct a pressure injury risk assessment on all residents upon admission /re-admission, after a change of condition, after any newly identified pressure injury, and quarterly. Assessments of pressure injuries be performed by a licensed nurse and documented in the resident's medical record. The staging of pressure injuries would be clearly identified to ensure correct coding on the Minimum Data Set (MDS). Nursing assistants would observe skin during bathing/personal cares and would report any concerns to the charge nurse immediately after the task. Interventions would be for prevention would be implemented for all residents who are assessed at risk or who have a pressure injury present. Interventions would be documented in the care plan and communicated to all relevant staff. Interventions on the resident's care plan would be modified as needed. The facility failed to prevent the development of facility acquired pressure ulcers for R34 and failed to implement treatment and interventions upon identification of the skin injury placing the resident at risk for further skin breakdown, pain, and infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 57 residents and the sample included 16 residents, in which one resident was reviewed for weight loss, Resident (R) 33. Based on observation, record review, and interview, the facility failed to implement dietician's recommendations which placed the resident at risk for further weight loss, malnutrition, and delayed in wound healing. Findings included: -The Medical Diagnosis section within R33's Electronic Medical Record (EMR) included diagnoses metabolic encephalopathy (inflammatory condition of the brain ), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), overactive bladder, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain )with agitation, intertrochanteric(hip area of large thigh bone) fracture of left femur , muscle weakness, other abnormalities of gait and mobility, and need for assistance with personal care. R33's admission Minimum Data Set (MDS), dated [DATE], lacked a cognition assessment, but documented R33 had inattention, disorganized thinking, other behavioral symptoms not directed toward others, and rejected evaluation or care behaviors which occurred one to three days during look back period. The MDS further documented R33 required extensive assistance of two staff for bed mobility and transfers and required extensive assistance of one staff for eating. R33 had incontinence of urine and bowel, weighed 121 pounds (lbs.), received as need pain medication for daily indicators of pain with vocal and facial expressions. The MDS further documented an unhealed stage two pressure ulcer (break in the top two layers of skin) a deep tissue injury (DTI- a pressure related injury to tissue under intact skin) were present on admission. R33 had pressure reducing devices for the bed and chair, turning/repositioning program, pressure ulcer/injury care, and application of ointment/medication other than to feet. The Nutritional Status Care Area Assessment (CAA), dated 01/25/23, documented R33 was a few weeks post operation to repair a left hip fracture, required extensive assistance of one staff with eating and drinking. The CAA noted constipation was present and risk factors of falls, dehydration related to use of daily diuretic and the need for intake assistance, worsening of pressure ulcer status. The Baseline Care Plan dated 01/12/23 documented R33 was at risk for dehydration, on a regular diet, and required total feeding assistance. The Comprehensive Nutrition Care Plan dated 02/01/23 directed staff to obtain weight monthly, the Dietician to assess annually and as needed, help with intake of meals and fluids, to provide a mechanical soft diet with thin liquids. The Progress Notedated 01/26/23 documented R33 lacked intake the last few days; the physician approved a mechanical soft diet. R33 had been lethargic, not very responsive. The facility drew lab and administered a bag of normal saline intravenously (into vein). On 01/30/23 the EMR documented R33 weighed 113 lbs. The admission Nutrition Assessment date 01/31/23, documented R33 had a mechanical soft diet, no supplements, poor intake. R33 weighed 113 lbs. which was a loss of seven percent (%) since 01/14/23 (two weeks post admission). The document further documented wound issues to left buttock and heel. Due to weight loss, decreased intake, and wound healing recommended nutritional interventions for Prostat (supplement to treat pressure ulcers) 30 milliliters (ml) twice a day, Gelatin (protein derived from collagen) twice a day or other supplement if not available. The recommendation also included super cereal (calorie and nutrient dense meal) at breakfast and encouraged R33 to come to dining room and directed staff to offer encouragement at meals. The Progress Note, dated 02/01/23, documented R33 had dark brown emesis and the physician order administration of normal saline intravenously. On 02/06/23 the EMR documented R33 weighed 111 lbs. On 02/06/23 at 07:48 AM, observation revealed R33 sat in her wheelchair, the wheelchair had a pressure reducing cushion. R33 wore padded boots to both feet, and was dressed and groomed for the day. Speech therapy was om the room assisting R33 to eat. The breakfast meal consisted of scrambled eggs, French toast with syrup, and two containers of orange juice. R33 did not receive super cereal. On 02/06/23 at 08:15 AM observation revealed speech therapy was no longer in the room. R33 ate a few bites of scrambled eggs and a few bites of French toast, drank one of the orange juices. R33 remained in the wheelchair. On 02/06/23 01:12 PM observation revealed R33 sat in her wheelchair, in her room. Staff were present in the room for dining. The meal consisted of a noodle entree, peas, and a peach cobbler desert. R33 was fed by staff. On 02/06/23 01:31 PM observation revealed staff removed R33's lunch tray from her room. R33 only ate 25% of the meal. R33 remained in her wheelchair and staff brought her out to the nurse's station area. On 02/06/23 the EMR documented R33 weight 111 lbs. On 02/07/23 at 07:58 AM observation revealed R33 in the dining room, in her wheelchair being fed by staff. R33 had scrambled eggs, a pancake with syrup, and a large glass of orange juice. Staff inquired about added salt to eggs and R33 said that tasted good. No super cereal was provided to R33. On 02/07/23 at 04:13 PM observation revealed Licensed Nurse (LN) I and Administrative Nurse E measured R33's wound. Wound measured 5.4centimeters (cm) in length by 3.5 cm in width, R33 reacted with a pain complaint while staff measured wound. LN I and Administrative Nurse E verified resident left buttock wound continued to worsen. They verified R33 remained in her wheelchair over two hours with occassional position changes and verified R33 lacked off-loading interventions and had continued weight decline. Staff reported they were not aware of the dietician's recommendations of supplements or super cereal recommendations. Administrative Nurse E reported discussion with R33's family to involve wound care consultation and care, and review dietician's recommendations. The facility's Nutritional Management policy, dated 06/2021, documented the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status and risk factors. Evaluating/analyzing the assessment information, developing consistently implementing pertinent approaches. The facility failed to implement dietician's recommendations which placed the R33 at risk for further weight loss and delayed in wound healing.

The facility had a census of 57 residents. The sample included 16 residents with one resident reviewed for side rails. Based on observation, interview, and record review the facility failed to assess Resident (R) 30 for risk of entrapment from bed rails, obtain informed consent, and ensure the bed rail dimensions were within recommended safe dimensions. This deficient practice placed R30 at risk for entrapment in the bed rail and potentially serious injury. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), and obesity (abnormal or excessive fat accumulation that presents a risk to health). The Significant Change Minimum Data Set (MDS), dated 12/12/22, documented R30 was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of zero. The MDS documented R30 required extensive assistance of one staff for eating, hygiene, two staff for bed mobility, and total assistance for transfers, dressing, toileting. The MDS documented R30 had no range of motion (ROM) impairment, used a wheelchair for mobility, and had no falls. The Fall Care Area Assessment (CAA), dated 12/12/22, documented R30 had been readmitted from the hospital and at times she became resistant to cares by pushing back when staff are trying to provide cares or repositioning. Staff transferred her with a full body lift, and she was dependent on staff for transfers, dressing, incontinent cares, mobility, and had no falls in the past quarter. The Fall Care Plan, dated 12/24/22, directed staff to ensure her call light was placed within reach at all times, use a full body lift for all transfers, and a wheelchair for all mobility. The care plan directed staff to use two-person assistance with bed mobility, repositioning and dressing. The care plan lacked direction for the use of side rails. The facility lacked a side rail assessment for R30. The Fall Risk Assessment, dated 12/07/22, documented R30 was a high risk for falls. On 02/06/23 at 08:46 AM, observation revealed R30's bed side rails had long gaps approximately 4.5 inches by 26 inches between the bars. On 02/06/23 at 09:30 AM, observation revealed R30 sat in her wheelchair in her room watching television. On 02/06/23 at 10:40 AM, Administrative Nurse D checked the side rails on the R30's bed. She stated hospice brought the bed to the facility. The rail gaps measured 4.5 inches tall by 26 inches wide. Administrative Nurse D verified the gap was more than 4.75 inches wide. She stated the resident used the side rails to hold herself on her side during care. The DON moved the right-side rail back and forth approximately 3 inches and then attempted to tighten the pin holding the rails. Administrative Nurse D stated staff normally do a side rail assessment and verified the facility had not assessed R30 for the use of side rails or the hospice-provided bed rails. The facility's Bed and Bed Rail Use policy, dated 03/01/2018, stated the facility would conduct regular inspections of all bed rails as part of a regular preventative maintenance program to identify and avoid areas of possible entrapment. The policy stated bed frame, mattress, and bed rail inspections would be conducted upon each item entering the facility. Bed rail gap measurements would be performed to ensure safety following Food and Drug Administration (FDA) guidelines. The policy included the FDA guideline for gaps within the rails and recommended a space of less than 4.75 inches. The policy stated a restraint assessment including a bed rail assessment and bed rail gap measurements would be completed initially and at least quarterly. The facility failed to assess R30 for risk of entrapment from bed rails, obtain informed consent, and ensure the bed rail dimensions were within recommended safe dimensions, placing R30 at risk for entrapment in the bed rail and potentially serious injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 57 residents. The sample included 16 residents. Based on observation, interview and record review the facility's staff failed to safely discard a fentanyl (controlled, narcotic pain medication at high risk for abuse, addiction, or overdose) patch properly for Resident (R)10, per facility policy. This deficient practice created a risk for diversion, illicit use and accidental overdose. Findings included: - R10's Electronic Medical Records (EMR) documented diagnoses of chronic pain, Parkinson's (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R10 required extensive assistance with bed mobility, toilet use, and personal hygiene. The MDS documented R10 had frequent pain, received scheduled and as needed pain medication; her pain limited day to day activities. She received opioid medication three days of the lookback period. The Pain Assessment dated 05/22/22 with a score of 8 (a score of 8 -10 indicated severe pain). The Pain Care Plan, dated 11/14/22, directed staff to administer as needed pain medication for pain management and review the Medication Administration Record (MAR) for current medications. A Physician Order, dated 04/21/22, directed Fentanyl transdermal patch, 25 micrograms(mcg), apply topically and change patch every 72 hours. On 02/06/23 at 12:20 PM, observation revealed Certified Medication Aide (CMA) R removed a Fentanyl patch from R10's right upper scapula (back shoulder), then discarded the patch in the resident's trash can. CMA R applied a new Fentanyl patch 25 mcg to R10's left upper scapula. Continued observation revealed CMA R took the plastic bag from the trash can, with the Fentanyl patch in the plastic bag from the trash can, tied the plastic bag in a knot and placed the bag at the bottom of the trash can, CMA R then placed a new plastic bag over the old trash bag. On 02/06/23 at 12:25 PM, CMA R verified R10's Fentanyl patch was the first patch she had removed and/or applied, and she had to get verification from the Administrative Nurses as to what rotate the patch site meant. CMA R verified she was not aware of proper disposal protocol of the Fentanyl patch or the facility policy for Fentanyl patch removal. On 02/06/23 at 12:35 PM, Administrative Staff D stated CMA R should fold the old patch in half and discard the patch in a sharps container and have a nurse witness the disposal. Administrative Nurse D verified she would have an in-service with the staff for proper disposal of the patches. The Disposal of Medications and Medication Related-Supplies policy, dated June 2022, documented Fentanyl patch medication remained in the patch after removal, created a potential for abuse, misuse, diversion, or accidental exposure. Due to life threatening risk associated with exposure to or ingestion of the patch, the Food and Drug Administration (FDA) and manufacture instructions recommend consumers dispose of used Fentanyl patches by folding in half with the sticky sides together and flushing the patch down the sink or toilet. This method may not be appropriate for nursing homes, particularly in areas that state or federal laws restrict flushing of pharmaceuticals, Nursing homes may use drug disposal products or systems for Fentanyl patches and other controlled medications as long as the facility can show the product or system minimizes accidental exposure or diversion. The facility failed to ensure staff disposed of R10's Fentanyl patch per standrards and facility protocol, creating the risk for diversion, illicit use and accidental overdose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported census of 44 residents, with 12 residents selected for review, which included one reviewed for discharge summary. Based on record review and interview the facility failed to complete a discharge summary which included a recapitulation of stay, reconciliation, and disposition of medications for the one sampled resident (R)44, as required. Findings included: - Review of Resident's (R)44's undated Physician Orders, documentation revealed diagnoses which included discitis (infection of the discs between the vertebra of the spine), poliomyelitis of the vertebra (inflammation of bone or bone marrow usually due to infection, spinal (back) cord compression, and intervertebral (inside vertebra disc) displacement (misaligned) at the thoracic (mid-back) region. The Admission, Minimum Data Set (MDS) dated [DATE], documented the resident entered the facility on 12/22/2020. The documentation included the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. The resident participated in the assessment and expected to be discharged to the community. He had an active discharge plan in place and a referral was not needed. The Discharge Return Not Anticipated MDS, dated [DATE], documentation included the resident with an unplanned discharge to the community on 02/01/2021. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/04/2021, documentation included the resident would discharge home after completion of short-term rehabilitation (therapy) and completion of intravenous (IV-in the vein), antibiotics. The care plan (CP), dated, 01/22/2021, documentation included the resident to discharge to home with his wife. He would receive additional services, as needed, upon completion of his rehabilitation therapies. The Nurse's Note, dated 02/01/2021 at 03:45 PM, documented the resident discharged home at 02:40 PM. The medical record lacked a discharge summary to include medication reconciliation, disposition, and/or a discharge summary which documented recapitulation of the residents stay at the facility. On 04/15/2021 at 02:45 PM, Certified Nursing Assistant (CNA) P, stated the discharging nurse should provide the resident and /or their representative with discharge instructions and complete all documentation at the time of discharge. On 04/19/2021 at 01:16 PM, CNA O, stated the nurse completed the paperwork associated with a resident's discharge. On 04/19/2021 at 04:04 PM, Licensed Nurse (LN) H, reported when she discharged a resident she would count the medications document the disposition of the medications, which included the medication count and whether the medications were sent to the pharmacy , destroyed, and/or sent with the resident. The discharging nurse should complete a discharge summary which includes a recap of the resident's stay and the course of treatment while here. On 04/20/2021 at 12:28 PM, Administrative Nurse D, confirmed the medical record lacked documentation of a discharge summary to include a recapitulation of stay, reconciliation, and disposition of medications for the resident. The facility failed to provide a policy for completion of a discharge summary, to include the recapitulation of the resident's stay and/or reconciliation/disposition of medications at the time of discharge from the facility. The facility failed to complete a discharge summary which included a recapitulation of the resident's stay, and reconciliation/disposition of medications for resident (R)44, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 44 residents with 12 selected for review including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure equipment was in proper working condition, failed to implement a new intervention following falls, failed to implement appropriate interventions following two falls for one of the three residents, Resident (R)16. Findings included: - The Order Summary Report, dated 04/06/21, for R16, included diagnoses of osteoarthritis to her right knee, pain in her right hip, cognitive communication deficit, need for assistance with personal care, other abnormalities of gait and mobility, unsteadiness on feet, difficulty in walking, muscle weakness, low back pain, dementia (progressive mental disorder characterized by failing memory, confusion), history of falling, and repeated falls. The Significant Change in Status Minimum Data Set (MDS), dated [DATE], assessed R16 with a Brief Interview of Mental Status Score (BIMS) of 11, indicating moderate cognitive impairment and she had no falls since the prior assessment. She required limited assistance of one staff for bed mobility, transfers, walking, toilet use, and personal hygiene. She required extensive assistance of one staff for dressing and her balance was unsteady requiring staff assistance to stabilize. She used a wheelchair and a walker for locomotion and was occasionally incontinent of urine. The Falls Care Area Assessment (CAA), dated 08/26/20, revealed that R16 had severely impaired cognition and regularly not able to tell you where she was or what the current situation in her life was. She has had a significant decline in function related to a past fall with a fracture but was a very determined person and progressed back to an improved level of functioning. The CAA indicated she required limited assistance of one staff for bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene, and was working with therapy. The Quarterly MDS, dated 12/01/20, assessed R16 with a BIMS score of 4, indicating severe cognitive impairment and had two or more noninjury falls since the last assessment. She required limited assistance of one staff for bed mobility, transfers, dressing and personal hygiene. She required extensive assistance of one staff for toilet use, and walking occurred one or two times. There were no changes in her balance or bladder continence from the prior significant change MDS. The Quarterly MDS, dated 02/25/21, assessed R16 with a BIMS score of 11, indicating moderate cognitive impairment and she had two or more non injury falls and one injury fall that was not major since the last assessment. She required extensive assistance of one staff for bed mobility, transfers, and dressing, and limited assistance of one staff for walking, toilet use, and hygiene. R16 was frequently incontinent of urine, and there were no changes in her balance or bladder incontinence from the prior MDS. The Care Plan, dated 03/04/21, initiated on 07/08/20, included R16 had a history of frequent falls due to her impaired cognition, unsteady gait and medications. The staff were to arrange her overbed table to keep frequently used items in reach, keep her call light in easy reach, and give her household tasks such as folding laundry to do as a keep busy task. She was to have shoes on with increased traction, one person to assist her with transfers, and non-skid socks on at all times. Her bed was to be up against the wall to give fewer objects to maneuver around and the staff were to make her bed upon awakening. The Morse Fall Scale, dated 12/01/20, indicated that R16 had a high risk for falling. The electronic medical record revealed R16 had 10 various falls from 10/29/20 to 04/09/21. There were concerns with her fall on 12/02/20, and both falls that occurred on 01/19/21 as follows. The progress notes, dated 12/02/20 at 08:30 PM, revealed R16 had a witnessed fall from the low bed to the floor and that she continued to be impulsive and would get in and out of her bed and into her wheelchair and recliner or go to the restroom on her own. The facility fall investigation, for R16's fall on 12/02/21, indicated that she complained of feeling dizzy and was trying to get up to use the restroom. The intervention for the fall was for Physical Therapy and Occupational therapy to evaluate and treat the resident. However, the facility failed to put an immediate intervention in place prior to the therapy evaluation to prevent further falls. The progress notes, dated 01/19/21 at 04:04 PM, revealed that R16 reported she had fell trying to get out of bed. The facility fall investigation, for R16's fall on 01/19/21 at 11:25 AM, revealed the intervention for the fall was to put in place a three-day incontinence analysis to evaluate the need for individualized toileting times to aide in fall prevention. This was also not an immediate intervention to prevent further falls. The progress notes, dated 01/20/21 at 03:28 AM, revealed that R16 fell in front of her bathroom at 09:45 PM. The facility fall investigation, for the fall on 01/20/21 at 09:45 PM, indicated the intervention from the earlier fall was still in progress and instructed the staff to continue the plan of care. The facility failed to implement a new intervention to prevent further falls. The progress notes, dated 02/03/2021 at 02:28 AM, indicated that at 08:15 PM R16 had an unwitnessed fall. The progress note, dated 2/11/2021 at 04:05 PM, revealed the interdisciplinary team reviewed the fall, from 02/03/21, and the intervention was the addition of anti-roll back brakes to her wheelchair. The Care Plan, dated 03/04/21, included an intervention dated 02/02/21 for anti-roll back brakes to be placed on R16's wheelchair. On 04/15/21 at 11:14 AM, Certified Nurse Aide (CNA) N revealed that the anti-roll back brakes were to prevent the wheelchair from rolling backwards when she was not sitting in it. CNA N attempted to move the wheelchair while R16 was not sitting in it and the chair rolled backwards. CNA M stated it should not do that. She then attempted to move a lever on the brakes and tried moving the chair back again and stated there it works now except it was not catching on one side like it should. CNA N confirmed that the brakes needed to be looked at with this malfunction. On 04/15/21 at 11:28 AM, Licensed Nurse (LN) I stated the anti-roll back brakes should prevent the wheelchair from rolling backwards when she was not sitting in it. After knowledge that the brakes were not functioning properly, LN I stated she would enter a maintenance request for them to be repaired. On 04/19/21 at 11:58 AM, Certified Medication Aide (CMA) S attempted to roll R16's wheelchair backwards while the resident was not sitting in it and the wheelchair rolled backwards easily. CMA S stated that the anti-roll back brakes were not functioning, that the purpose was to keep the chair from rolling backwards when she was not sitting in it. CMA S was not aware of who monitored the functioning of the brakes, and then tried to adjust the lever on the back of the brakes without success. CMA S reported she would let someone know that the anti-roll back brakes were not working. On 04/20/21 at 03:09 PM, R16's wheelchair moved backwards without her in it, to check if the anti-roll back brakes were functioning and the wheelchair rolled easily backwards. On 04/20/21 at 03:10 PM, CMA R revealed that R16 was not good about locking her wheelchair brakes and the staff had to keep a good eye out on her. On 04/20/21 at 03:13 PM, Administrative Nurse D stated that a work order was not placed for maintenance to look at her anti-roll back brakes and did not have an answer on who monitored them for functioning. Administrative Nurse D confirmed that each fall needed a new intervention to prevent further falls and that Physical and Occupational Therapy and bowel and bladder analysis were more long-term interventions and not immediate interventions to prevent falls. The facility policy Accidents and Supervision, dated 03/01/18, indicated it was the facility policy that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. This includes implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The facility failed to monitor the functioning of R16's anti-roll back brakes and failed to act timely (five days), when they had knowledge of them malfunctioning, and failed to implement a new immediate intervention for three of her falls, to prevent further falls for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 44 residents with 12 residents selected for review including two residents reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to keep the catheter tubing from touching directly on the floor for one of the two residents reviewed, Resident (R)38, creating a risk for developing urinary tract infections. Findings included: - The Order Summary Report, dated 04/02/21, for Resident (R)38, included diagnoses of retention of urine, obstructive and reflux uropathy (urine flows backwards into the kidneys due to an obstruction), other specified disorders of bladder, and neuromuscular dysfunction of the bladder. The Annual Minimum Data Set (MDS), dated [DATE], assessed R38 with a Brief Interview of Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. R38 required extensive assist of one staff for toilet use and had an indwelling urinary catheter in place. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 10/15/20, revealed R38 had a long term indwelling catheter that was managed by the staff and he was at risk for a urinary tract infections related to the long term indwelling catheter use. The Quarterly MDS, dated 03/30/20, assessed R38 with a BIMS score of five, indicating severe cognitive impairment. He continued to require extensive assist of one staff for toileting and continued to have an indwelling catheter in place. The Care Plan, dated 01/21/21, revealed that R38 had a long-term indwelling catheter, the staff were to monitor the tubing to ensure there were no kinks present, and measure the output from the catheter every shift. The Order Summary Report, dated 04/02/21, included an order dated 11/12/20, to check R38's tubing to ensure no kinks for accurate and safe flow of urine four times daily. On 04/14/21 at 10:28 AM, R38 was sitting up in his wheelchair in his room and his urinary catheter tubing was touching directly on the floor. On 04/15/21 at 11:36 AM, R38 was sitting up in his wheelchair in the dining room and his urinary catheter tubing was touching directly on the floor. On 04/19/21 at 12:59 PM, Certified Mediation Aide (CMA) S was preparing to drain the resident's catheter urine collection bag, when she repositioned R38's feet off of the footrests of the wheelchair and onto the floor, the urinary catheter tubing again touched directly on the floor. The tubing remained on the floor during the drainage process until she placed his feet back on the footrests of the wheelchair. CMA S failed to clean the tubing after it had contact with the floor. On 04/20/21 at 09:39 AM, Consultant Nurse GG, stated the resident's urinary catheter tubing should not touch on the floor. On 04/20/21 at 09:50 AM, Licensed Nurse (LN) I stated the urinary catheter tubing should not be on the floor, and it if was it should be cleaned by the staff. On 04/20/21 at 11:03 AM, Administrative Nurse D stated the urinary catheter tubing should not be on the floor and if it was the staff should adjust the bag's positioning to keep it off of the floor. The facility policy Catheter Care Policy, dated 03/01/18, indicated the center will provide catheter care to all residents with an indwelling catheter in an effort to reduce bladder and kidney infections. The policy lacked instruction on keeping the tubing from having contact with the floor. The facility failed to keep R38's urinary catheter tubing from touching directly on the floor increasing his risk for developing a urinary tract infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 44 residents with 12 selected for review including three residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to provide appropriate cleaning and storage of two of the three sampled residents respiratory equipment including, Resident (R)34's nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) administration kit. R13 with the facility failure to clean the oxygen concentrator filter, failed to label the oxygen tubing when changed, and failed to label the distilled water container when opened and store appropriately. These practices increased the risk for R34 and R13 of developing a respiratory infection. Findings included: - The Order Summary Report, dated 03/03/21, for Resident (R)34, included diagnoses of cough and other specified symptoms and signs involving the circulatory and respiratory systems. The Annual Minimum Data Set (MDS), dated [DATE], assessed R34 with a Brief Interview of Mental Status (BIMS) score of zero, indicating severe cognitive impairment and that she did not receive any respiratory services. The Quarterly MDS, dated 03/19/21, revealed no changes in assessment from the prior MDS, dated [DATE]. The Care Plan, dated 03/31/21, lacked any instructions for respiratory interventions or treatments. The Order Summary Report, dated 03/03/21, included an order dated 09/03/20, for Ipratropium-Albuterol (a bronchodilator medication-used to relax and open the air passages to the lungs to make breathing easier) solution, 0.5-2.5 milligrams (mg)/three milliliters (mL), inhale one vial, via nebulizer, three times a day, related to other specified symptoms and signs involving the circulatory and respiratory symptoms. The electronic medical record (EMR), in the order section, lacked any instructions on cleansing or storage of the resident's nebulizer administration kit. On 04/14/21 at 01:51 PM, R34's nebulizer machine was directly sitting on the floor by her recliner, the nebulizer administration kit was on the floor with condensation noted in the medicine cup of the kit. The Treatment Administration Record, (TAR), dated 04/14/21, revealed that R34 received her second treatment of the day, scheduled at the same time as the resident's lunch. On 04/15/21 at 11:40 AM, R34's nebulizer machine and her administration kit were on the floor by her recliner, connected, with the administration kit mask in direct contact with the floor. On 04/15/21 at 02:47 PM, R34's nebulizer machine and administration kit continued to be stored directly on the floor. On 04/19/21 at 12:29 PM, Licensed Nurse (LN) H disconnected the nebulizer administration kit once the treatment was done, placed the mask on the table next to the nebulizer machine, rinsed out the medicine cup with water, then placed it on a paper towel to air dry. LN H failed to clean the nebulizer administration mask. On 04/19/21 at 12:49 PM, LN H, revealed that sometimes she would rinse the mask too with water and let it air dry on a paper towel if it looked like it needed it. When the administration kit was dry staff would put it back together and hook it onto the machine. On 04/19/21 at 01:39 PM, Administrative Nurse D, confirmed when the nebulizer treatment was done. She explained that the mouthpiece or mask and medicine cup of the administration kit should be rinsed immediately after the treatment was done and placed on a paper towel to air dry next to the machine. The machine or administration kit should not be stored on the floor. The facility policy, Nebulizer Therapy Policy, dated 03/01/18, indicated after the nebulizer treatment, staff are to disassemble and rinse the nebulizer cup and mouthpiece with water and allow to air dry on an absorbent towel. The facility failed to provide appropriate cleaning and storage of Resident (R)34's nebulizer administration kit, increasing the risk of R34 developing a respiratory infection. - Review of Resident (R)13's physician orders, dated 04/01/202, documentation diagnoses which included congestive heart failure (fluid collected around the heart). The Admission, Minimum Data Set (MDS) dated [DATE], documented she admitted on [DATE], with the Brief Interview for Mental Status (BIMS) score of six, which indicated severe cognitively impairment. The resident received oxygen after admission to the facility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/22/2021, documentation the resident had a stroke and was not able to return home to live with her spouse due to concerns which included the use of oxygen. The care plan (CP), dated 02/22/2021, directed staff the resident required oxygen at two liters a minute by way of nasal cannula, as needed, for shortness of air/breath or oxygen saturation (oxygen concentration in the blood) less than 90 percent. Change oxygen tubing, mask, and humidifier bottle and clean filter every Sunday night shift. On 04/14/2021 at 10:20 AM, the resident's oxygen tubing and nasal cannula was laying directly on the floor. There was not a container present for sanitary storage of the cannula or tubing to prevent cross contamination. The concentrator humidifier bottle lacked a date when when last changed by staff and the air filter screen was covered with a thick layer of dust. Additionally, there was a third full gallon jug of distilled water that sat directly on the floor in the resident's room. On 04/14/21 10:22 AM, Licensed Nurse (LN) G verified the findings above. He stated the staff should check the residents with oxygen for storage of tubing at each shift and throughout the day. They should use zip lock bags to store the tubing when not in use to prevent cross contamination. He stated the third shift nurse should change the tubing and humidifier bottles out every week and date the bottle and tubing when they changed them. He reported the nurses used the distilled water to fill the humidifier bottle on the oxygen concentrator. LN G reported the distilled water bottle should be dated when opened and staff should not leave the container on the floor. He verified the collection of dust on the concentrator filter and stated the filter needed cleaning. On 04/15/2021 at 1:34 PM, the concentrator humidifier bottle lacked a date when changed and the air filter was not in place on the concentrator. The concentrator air filter was laying on a paper towel on the resident's dresser. A one third full open container of distilled water, which lacked a date when opened, sat directly on the floor. On 04/15/2021 at 1:41 PM, CNA Q, stated the nurse was responsible for maintaining the oxygen and respiratory equipment in a safe and sanitary condition. She stated if she saw the resident's oxygen tubing on the floor, she would report it to the nurse. CNA Q stated the distilled water should be marked with the date when opened and should be kept in the supply closet and not in the resident's room. She stated she did not think the distilled water should be left setting on the floor. On 04/19/2021 at 10:22 AM, a gallon bottle of distilled water, was one third full, sat directly on the resident's room floor. On 04/19/2021 at 01:16 PM, CNA O, stated third shift changed out the oxygen nasal cannulas weekly. Charge nurses should check for proper storage and change the tubing if needed. Staff should label the cannulas and humidifier bottles when changed and the cannulas and tubing should be stored in bags when not in use. The distilled water should be labeled the day staff opened it and staff should not place the container on the floor. On 04/19/2021 at 4:04 PM, LN H reported the facility oxygen room had oxygen equipment supplies which included tubing and humidifier bottles. She stated tubing and humidifier bottles should be changed out weekly by the night shift nurse. The equipment should be labeled with the dates when changed. The distilled water should be stored in the clean utility room underneath the sink and not left in the resident's room. The staff should date the gallon containers of distilled water when they are opened and when they change the tubing and humidifier bottles. Oxygen tubing should be stored in a bag when not in use to prevent cross contamination. On 04/20/2021 at 9:38 AM, Administrative Nurse D stated she expected the nursing staff to monitor for proper storage of oxygen tubing in a bag when not in use. She stated the oxygen tubing and humidifier bottles should be changed and the concentrator filters should be cleaned weekly by the third shift staff. The staff should date the oxygen tubing and humidifier bottles with the date when staff changed them. The staff should keep the distilled water stored in the clean utility room and they should date the gallon jugs when they open them. They should keep the open jugs at the nurse's station and not in the resident's rooms. The distilled water containers should never be stored on the floor. The facility policy for Oxygen Concentrator, dated 03/01/2018, documentation included: .1. Wash filters weekly and as needed. 2. Change tubing weekly. 3. Change humidifier bottle weekly or as recommended by the maker. 4. The main body cabinet should be dusted when needed and can be wiped clean with a damp cloth and mild household cleaner if necessary. 5. Fill the humidifier container to the correct level with distilled water and attach to the concentrator; or use disposable humidifier. 6. Attach oxygen delivery device ordered by the physician to the concentrator . The policy did not address storage of tubing when not in use, labeling equipment with the date when put in place and/or the appropriate storage of distilled water used to fill the humidifier bottle. The facility failed to provide appropriate sanitary respiratory care in maintaining respiratory equipment to prevent the spread of infection for this resident that required oxygen, related to storage and labeling of oxygen concentrator tubing, cannula, humidifier bottle, and distilled water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 44 residents with 12 selected for review including five reviewed for unnecessary medications. Based on record review and interview, the facility failed to act upon recommendations timely from the consultant pharmacist for three of the five sampled residents, Resident (R)11, R16, and R27. Findings included: - The Order Summary Report, dated 04/10/21, for Resident (R)11 included the diagnoses of chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic atrial fibrillation (rapid, irregular heart beat), and congestive heart failure (a condition with low heart output and the becomes congested with fluid). The medication Order Summary Report, dated 04/10/21, also revealed R11 had a physician order dated 11/08/20, for diltiazem (a medication that lowers the heart rate) 90 milligrams (mg), give two tablets by mouth at bedtime for atrial fibrillation. Review of the electronic medical record (EMR), under the progress note tab, revealed on 11/10/20 the consultant pharmacist completed a medication regimen review (MRR), and recommended to the physician to change the medication to a CD (controlled delivery) formulation, like Cardizem (a heart rate lower medication) CD, to provide 24 hour effectiveness. The Consultant Pharmacist's Medication Regimen Review dated 12/14/20, revealed the consultant pharmacist completed the MRR, and requested a follow up on the previous recommendation to the prescriber regarding the use of the regular release Diltiazem. On 04/20/21 at 02:28 PM, Administrative Nurse D confirmed the facility did not act upon or complete the pharmacy recommendation timely. The facility policy, Drug Regimen Review, dated 03/01/18, instructed that the MRR will perform a drug regimen review on each resident living in this facility at the time of the resident's admission to the facility, at least monthly, and when requested by team members of the facility .The Director of Nursing will track the physician response reports and if no response is received within seven (7) working days, the DON or designee with place a phone call to the physician for a phone order response. If no response is received from the physician within 14 working days, the facility's medical director will be contacted for requested response/recommendations. The facility failed to timely act upon the consultant pharmacist recommendation to change the delivery form of the resident's heart regulating medication. - The Order Summary Report dated 04/06/21, for Resident (R)27, including diagnoses of, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), vitamin deficiency, psychotic disorder (any major mental disorder characterized by a gross impairment in reality testing ) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), dementia (progressive mental disorder characterized by failing memory, confusion), hypo-osmolality (disorder of fluid and electrolyte balance) and hyponatremia (low level of sodium in the blood), and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], assessed R27 as being rarely/never understood, could sometimes understand others, impaired short and long term memory, no memory recall, severely impaired decision making, and continuous inattention. His PHQ-9 (Patient Health Questionnaire-used to diagnosis depression and grade severity of symptoms) score answered by the staff, was 3, indicating minimal or no depression. R27 rejected care and had other behavior symptoms on one to three days. He received an antipsychotic, antidepressant, and a diuretic medication for seven days. R27 received the antipsychotic medication on a routine basis and had not had a gradual dose reduction (GDR) as the physician signed it was clinically contraindicated on 01/20/20. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/29/20, revealed R27 has slowly progressed to responding less to verbalizations to the point he will not often give an answer. He was oriented to person only and has mild depression according to his score of three on the staff interview for mood assessment. He takes quetiapine (antipsychotic medication) for his psychotic behaviors and also takes Prozac (antidepressant medication) and has had medication changes over the past year. The Behavior CAA, and the Psychotropic Drug Use CAA, dated 10/29/20, contained the same information as the Cognitive Loss/Dementia CAA. The Quarterly MDS, dated 03/08/21, revealed these changes from the Annual MDS: decision making was moderately impaired, he did not display continuous inattention, he had no rejection of care or other behavior symptoms, he did not receive a diuretic for seven days. The assessment question was answered that he did not receive an antipsychotic, so the GDR information did not trigger to be answered. The Care Plan, dated 03/30/21, indicated R27 received medications with black box warnings, has signs and symptoms of depression, displays inappropriate sexual behaviors, and has cognitive deficits. He takes medication for his dementia, psychotic disorder, depression, and DM. The Order Summary Report dated 04/06/21, included orders for the following medications: 1. On 12/09/20, alogliptin benzoate tablet, 25 milligrams (mg), in the morning, for DM. 2. On 06/06/20, Vitamin D, give 2,000 international units (IU), in the morning, for vitamin deficiency. 3. On 12/08/20, carbidopa-levidopa tab 10-100 mg, give two tabs, three times a day, for Parkinson's disease. 4. On 06/08/20, donepezil hydrogen chloride (HCl), 10 mg, at bedtime, for dementia. 5. On 02/02/21, fluoxetine HCl, 20 mg, in the morning, for depression. 6. On 03/01/21, Metformin, 500 mg, twice daily, for DM. 7. On 03/12/21, Seroquel (quetiapine) 25 mg, give 12.5 mg, every day, for psychotic disorder with delusions. The pharmacist Recommendation to Prescriber, dated 06/15/20, included a recommendation to discontinue the multivitamin received daily for supplement due to its risk of reported problems of choking/swallowing and drug interaction risk with higher number or meds. The facility failed to address the recommendation until 04/15/20, 10 months later, and then the physician agreed to discontinue the medication. The Progress Notes, located in the EMR, revealed R27 was transferred to the hospital on [DATE] and returned on 03/01/21. The Medication Administration Record, dated 03/2021, lacked an order for the multivitamin when R27 returned to the facility. The Consultant Pharmacist's Medication Review, for recommendations created between 10/18/20 and 10/26/20, included that there was no response noted in the chart to pharmacist-to-prescriber from the June 2020 GDR request on his fluoxetine/quetiapine. The facility failed to act upon the pharmacy recommendation made in June and October of 2020. The Note to attending Physician/Prescriber, date printed 10/26/20, included that R27's hemoglobin A1c (HgbA1c-lab test used to evaluate the average amount of blood glucose in the blood over the last two to three months) of 9.9 is unlikely to benefit significantly from the slight bump in Metformin (medication used to lower blood sugar levels) late September 2020. See separate recommendation regarding HCTZ. Could we consider maximizing Metformin to 1,000 mg to twice daily. Patient's use of low dose antipsychotic is unlikely to produce true antipsychotic effect, however, it can exacerbate existing issues with diabetes, and potentially increase risk of dyslipidemia, also. Can we consider a gradual dose reduction of quetiapine and utilize other psychotropic agents, if needed, as well as nonpharmacologic interventions. Buspirone may be worth consideration, particularly if anxiety is an issue. We may want to review pain also and ensure this is adequately managed, particularly if he has behaviors associated with provision of care. The facility failed to act upon the Pharmacist's recommendations. The Note to attending Physician/Prescriber, date printed 10/26/20, included that HCTZ may exacerbate (sudden increase of symptoms/disease) issues with blood sugar control. Is it worthwhile to consider an alternative diuretic, furosemide. The facility failed to act upon the Pharmacist's recommendations. The Note to Attending Physician/Prescriber, printed on 11/11/20, included that the September lipid profile was irregular. Total 212, LDL 139, Trig 143, and HDL 44. Patient is diabetic and taking an antibiotic, both risk factors for dyslipidemia. Given diabetes diagnosis, consider if statin therapy would be beneficial. The letter lacked a physician response. The facility failed to act upon the Pharmacist's recommendations. The Consultant Pharmacist's Medication Regimen Review, dated 12/14/20, included the chart was lacking responses to several pharmacist-to-prescriber recommendations of recent months: 1. One inquiry was regarding addition of other DM medications and/or maximization of Metformin, and it does appear Januvia was started, so that point is [NAME]. 2. One inquiry was regarding the potential need of a statin given irregular lipid profile, diabetes diagnosis, age <85 years, and use of an antipsychotic. 3. One inquiry was about BP's being occasionally outside of target, but that appears largely improved at this point. 4. Another letter was just a reminder that the diuretic in use, HCTZ, may exacerbate hyperglycemia and to consider if use of a different diuretic, e.g. loop diuretic like furosemide, was feasible. 5.Previous consultant pharmacist asked for Vitamin D assessment, but I would argue that truly is not needed given present low dose and perceived benefit in immune system function. The physician responded on 01/19/21, greater than 30 days after the recommendation, and ordered to discontinue the statin, discontinue the HCTZ, and discontinue the Vitamin D level. The Vitamin D lab was drawn on 08/24/20, the fax date on the lab result provided by the facility had a dated of 04/20/21 at 07:05 AM. The lab results were not available in the chart for review. The facility discontinued the HCTZ on 01/19/21. The resident was not on a statin and the pharmacist was recommended the potential need of one. The physician addressed the recommendations more than 30 days past the recommendations that was follow up recommendations from recent months. On 04/20/21 at 07:58 AM, Administrative Nurse D, stated the letters for October and November 2020 were not signed by the physician as they were not addressed until a combined letter was done in December 2020. The pharmacy recommendations should be handled within 14 days. Nurse D received the recommendations and then divided and send them out, so the nurses were aware of what was going on, then Nurse D followed up and collected them. On 04/20/21 at 09:54 AM, Licensed Nurse (LN) I stated she does not have a role with the pharmacy recommendations, that Administrative Nurse D sends the pharmacy recommendations to the doctor and receives the signed ones back by fax, then she prints them out and sends them to the nurses by email, then the nurses put the orders in, if there were changes. The facility policy Drug Regimen Review, dated 03/01/18, indicated the pharmacist's report will be provided to the attending physician's office and the Medical Director's office with a written request for a response documented on the medication review report form. A copy of the review report form will be placed in the resident's clinical record after it is sent to the residents attending physician. When the signed copy is received it will be placed in the resident's clinical record and the unsigned copy of the report will be removed and shredded. If/when an attending physician fails to respond to a Pharmacy Drug Regimen Review within seven working days, the physician will be contacted by the licensed nurse and/or the medical director. The DON will track physician response reports and if no response is received within seven working days, the DON or designee will place a phone call to the physician for a phone order response. If no response is received from the physician within fourteen working days, the facility's Medical Director will be contacted for requested response/recommendations. The facility failed to act upon the Pharmacist's recommendations in a timely manner for R27. - The Order Summary Report, dated 04/06/21, for Resident (R)16, including diagnoses of major depressive disorder, (major mood disorder), pain in her right hip, anxiety (feelings of worry or fear that are strong enough to interfere with one's daily activities) disorder, low back pain, dementia (progressive mental disorder characterized by failing memory, confusion), history of falling, and repeated falls. The Significant Change in Status Minimum Data Set (MDS), dated [DATE], assessed R16 with a Brief Interview of Mental Status Score (BIMS) of 11, indicating moderate cognitive impairment. Her PHQ-9 (Patient Health Questionnaire-used to diagnosis depression and grade severity of symptoms) score was seven, indicating mild depression. She had no behaviors other than wandering one to three days and received and antidepressant and an opioid medications seven days. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/26/20, included that R16 had moderate to severe cognitive impairment. She could be easily redirected most times and was often confused and looking for family members. She became anxious at times, has wandered, and sometimes asked staff for rides to see her folks. The Psychotropic Drug Use CAA, dated 08/26/20, included that R16 had risk factors of falls, continued weight loss due to poor appetite, pain related to osteoarthritis, depression and anxiety related to declining health and functional ability, and increasing cognitive losses related to dementia. The Quarterly MDS, dated 02/25/21, assessed R16 with a BIMS score of 11, indicating moderate cognitive impairment and a PHQ-9 score of four indicating minimal to no depression. She had rejected care one to three days, wandered four to six days, and had other behaviors not directed towards others one to three days. She received and antianxiety, antidepressant, and an opioid seven days. The Care Plan, dated 03/04/21 included that R16 had severely impaired cognition related to her dementia, that she currently takes mirtazapine (an antidepressant medication) for appetite stimulation, has a diagnosis of anxiety and receives Buspar (an antianxiety medication) routinely. R16 receives medications with black box warnings including Depakote (an anticonvulsant medication that is also used as a mood stabilizer), mirtazapine, and tramadol (medication used to treat pain). The Order Summary Report, dated 04/06/21, included orders for the following medications: 1. On 08/04/20, buspirone, 5 milligrams (mg), twice daily for anxiety. 2. On 08/09/20, Tylenol, 325 mg, give two tablets three times a day and every six hours as needed for pain. 3. On 08/14/20, mirtazapine, 30 mg, at bedtime for appetite stimulant. 4. On 09/14/20, tramadol, 50 mg, three times a day for pain. 5. On 01/27/21, Depakote, 125 mg, twice daily for dementia. The pharmacist Recommendation to Prescriber, with a print date of 06/15/20, included R16 started mirtazapine 7.5 mg at bedtime for appetite stimulation in 04/2020. Noted she had several falls recently per her electronic medical record (EMR). Her weight currently is 100 pounds per EMR, up from the lowest weight of 97.5 pounds on 05/11/20, but still lower than highest weight of 104 pounds on 04/06/20. Mirtazapine may increase her risk of falls. The physician signed on 04 and day ineligible (2020 or 2021) and marked to discontinue the mirtazapine. There was a fax date at the top of the recommendation letter of 04/16/21 at 07:06 AM. The Medication Administration Record (MAR), dated 06/2020, revealed the mirtazapine was increased to 15mg on 06/24/20. The dose was increased to 30mg on 08/14/20 and she continued, per the April 2021 MAR on the 30mg dose. The resident's weight, located in the EMR under the Weights/Vitals tab, dated 04/07/21, was 91.6 pounds, and on 06/01/21 weight was 100 pounds, indicating this medication was not effective in appetite stimulation. The facility failed to address the pharmacy recommendation for 06/15/20 until April of 2021, 10 months later, and at that time the information on the recommendation later was no longer correct. The Consultant Pharmacist's Medication Regimen Review, for recommendations created 09/15/20 and 09/21/20, included a physician signature and no date, had a fax date at the top dated 04/16/21, and lacked a response to the review. The review indicated that the order for Depakote had dementia for its use, but it was not a dementia medication. It was likely being used for mood stabilization or to assist with behaviors secondary to dementia and may need to re-evaluate the diagnosis with the physician and ensure documentation can justify its use. The diagnosis for the medication continued to be dementia, per the Order Summary Report, dated 04/06/21, as well as in the EMR under the orders tab as of 04/20/21. The facility failed to address the review note on 09/15/21 until seven months later. The Consultant Pharmacist's Medication Regimen Review, dated 10/26/20, indicated the use of divalproex increases her risk of thyroid test abnormalities. If you do not see this assessment within the last year, please ask the physician for authorization to assess this lab on the next lab day. The top of the letter included a fax date of 04/16/21. The physician signed, did not date, and did not provide instruction. The facility failed to address the review until over six months later. The pharmacist Note to Attending Physician/Prescriber, dated 11/11/20, included that the resident was taking a low dose divalproex (Depakote) for dementia and routine tramadol for pain and she had a recent fall. Divalproex can cause gait abnormalities that may increase her fall risk. Tramadol could increase her fall risk by central nervous system (CNS) side effects like dizziness and drowsiness. It seems her principle behavior is wandering around the facility. The nursing notes in the evenings imply either she has very realistic dreams or has hallucinations regarding kids making noises, such that she wanted to call the cops and report them. Some considerations: 1. Her BIMS score was an 11. If dementia is the issue, could we consider use of memantine, in the hopes that it may assist with dementia-related anxiety? Perhaps withdrawing the Divalproex down the road? 2. Could we attempt use of routine Tylenol, in the hopes that we could possibly reduce Tramadol dose in the future, in case it is contributing to hallucinations? The physician signed the note, date of month of April, day ineligible, with response to discontinue the tramadol, start Tylenol, 500 mg, three times a day for pain, and start memantine 5 mg daily for seven days, then twice daily for seven days, then 10 mg twice daily for dementia. The facility made the order changes in the EMR on 04/17/21 for the memantine. R16 had an order in place already for the Tylenol three times a day. The facility failed to address the pharmacist's recommendations until more than five months later. The Consultant Pharmacist's Medication Regimen Review, dated 12/14/20, indicated this was a second notice, and that the use of divalproex increases her risk for thyroid test abnormalities. If you do not see this assessment within the last year, please ask MD for authorization to assess this lab the next lab day. Review of the EMR, revealed the facility drew a TSH, T4, Free T4, and T3 uptake, on 01/18/21, three months following the first notice regarding the lab. The Consultant Pharmacist's Medication Regimen Review, dated 01/25/21, included to please be sure a response exists to November's pharmacist-to-prescriber inquiry about a potential dose reduction of divalproex. Note that this drug can cause gait abnormalities that may increase her fall risk. Handwritten on the form was that R16 received a new Depakote order written today 01/27/21, not decreasing the dose. On 04/20/21 at 07:58 AM, Administrative Nurse D, stated the letters for October and November 2020 were not signed by the physician as they were not addressed until a combined letter was done in December 2020. The pharmacy recommendations should be handled within 14 days. Nurse D received the recommendations and then divided and sent them out, so the nurses were aware of what was going on, then Nurse D followed up and collected them. On 04/20/21 at 09:54 AM, Licensed Nurse (LN) I stated she does not have a role with the pharmacy recommendations, that Administrative Nurse D sends the pharmacy recommendations to the doctor and received the signed ones back by fax, then Nurse D printed them out and sent them to the nurses by email, then the nurses put the orders in if there are changes. On 04/20/21 at 12:39 PM, Administrative Nurse D confirmed that the letters with fax dates for 04/16/21 were sent to the physician this month and were not addressed at the time of the recommendations. The facility policy Drug Regimen Review, dated 03/01/18, indicated the pharmacist's report will be provided to the attending physician's office and the Medical Director's office with a written request for a response documented on the medication review report form. A copy of the review report form will be placed in the resident's clinical record after it is sent to the residents attending physician. When the signed copy is received it will be placed in the resident's clinical record and the unsigned copy of the report will be removed and shredded. If/when an attending physician fails to respond to a Pharmacy Drug Regimen Review within seven working days, the physician will be contacted by the licensed nurse and/or the medical director. The DON will track physician response reports and if no response is received within seven working days, the DON or designee will place a phone call to the physician for a phone order response. If no response is received from the physician within fourteen working days, the facility's Medical Director will be contacted for requested response/recommendations. The facility failed to act upon the Pharmacist's recommendations in a timely manner for R16.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R) 11's Medication Review Report, dated 04/10/21, included a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R11 with a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. He received insulin injections six of the seven days of the assessment period. A standing physician order, dated 05/17/19, instructed the facility staff to contact the physician if the blood sugar was greater than 300. The Medication Review Report, dated 04/10/21, included an order with a start date of 03/23/21 for Novolog (insulin) flexpen solution, 100 unit/milliliter (ml) per sliding scale, inject 30 units subcutaneous with meals for diabetes mellitus. A physician order, dated 09/03/20, instructed staff of a standing order to obtain the resident's blood glucose levels fasting and two hours postprandial (after a meal). Review of the Treatment Administration Record, (TAR), dated 02/01/21 through 02/28/21, revealed R11 had blood sugar levels greater than and out of the physician ordered parameters on 35 different occasions. The elevated blood sugars ranged from 301-423. Review of the Treatment Administration Record, dated 03/01/21 through 03/31/21, revealed 34 occasions the resident's blood glucose was greater than 300 the physician's ordered parameters. The elevated blood sugars ranged from 302-422. Review of the Treatment Administration Record, dated 04/01/21 through 04/18/21, revealed eight occasions of blood sugar level greater than 300 and out of the physician ordered parameters. The elevated blood sugars ranged from 302-364. Review of the progress notes, for the dated identified above, revealed the lack of notification to the physician of the blood sugar levels greater than 300 and out of the physician ordered parameters. On 04/20/21 at 02:28 PM, Administrative Staff D confirmed the medical record lacked documentation of the nurses notification to the physician of the resident's numerous blood sugar elevations. The physician should be notified if blood sugars that were greater 300. The facility's policy, Blood Glucose Monitoring, dated 03/01/18, instructed if blood glucose results outside of prescribed parameters, staff were to immediately initiate physician prescribed interventions for hypoglycemia or hyperglycemia and report to the physician timely. The facility failed to adequately monitor R11 elevated blood glucose levels and notify the physician for further instructions, and to ensure no unnecessary medication usage. The facility reported a census of 44 residents with 12 residents selected for review including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to accurately monitor blood sugar levels out of the physician ordered parameters for two of the five reviewed residents, including Resident (R)11 and R27. Findings included: - Resident (R) 27's Order Summary Report dated 04/06/21, included a diagnosis of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], assessed R27 as being rarely/never understood, he could sometimes understand others, had impaired short and long term memory, had no memory recall, had severely impaired decision making, and had continuous inattention. He did not require insulin injections. The Quarterly MDS, dated 03/08/21, assessed R27 being rarely/never understood, could sometimes understand others, impaired short/long term memory, and decision making was moderately impaired. He did not require insulin injections. The Order Summary Report dated 04/06/21, also included a physician order, dated 10/17/20, for the staff to check R27's blood glucose level every morning and at bedtime daily. The order lacked parameters on when to notify the physician. The orders included the medication Metformin and alogliptin benzoate (medications both used to lower blood glucose levels). Review of the Treatment Administration Record, dated 02/2021, revealed that R27 had a blood glucose level at 08:00 PM of 303 on 02/16/21, 322 on 02/19/21, and 426 on 02/20/21. The progress notes, located in the electronic medical record (EMR) lacked notification to the physician for blood glucose levels on 02/16/21, 02/19/21, and 02/20/21, for further instructions. On 04/20/21 at 09:54 AM, Licensed Nurse (LN) I stated that R27 had standing orders to call the physician if the blood glucose levels were over 300 and that the parameters were not in the orders in the EMR. The standing orders from R27's physician, dated 05/17/19, included for hyperglycemia, instructed the staff to contact the doctor if greater than 300. For any episode of hypoglycemia/hyperglycemia, check blood sugar per glucometer at that time, then every two hours as needed. Check every 1 hour until blood sugar is >80. Call doctor if blood sugar remains <60 or >300. On 04/20/21 at 11:01 AM, Administrative Nurse D stated the staff were to notify the physician if the blood glucose levels were over 300. The facility policy Blood Glucose Monitoring, dated 03/01/18, revealed that if blood glucose levels were out of parameters, staff should immediately initiate physician prescribed interventions for hypoglycemia or hyperglycemia and report to the physician timely. The facility failed to notify the physician when R27's blood glucose levels were elevated out of parameters on three occasions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 44 residents with 12 selected for review including five reviewed for unnecessary medications. Based on record review and interview, the facility failed to ensure two of the residents, Resident (R)27 and R16 were free of unnecessary psychotropic medications when the facility failed to address their orders for psychotropic (class of medications capable of affecting the mind, emotions, and behavior) medications. Findings included: - The Order Summary Report dated 04/06/21, for Resident (R)27, included diagnoses of psychotic disorder (any major mental disorder characterized by a gross impairment in reality testing ) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), metabolic encephalopathy (a chemical imbalance in the blood that affects the brain that can lead to personality changes), and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], assessed R27 as being rarely/never understood, could sometimes understand others, impaired short and long term memory, no memory recall, severely impaired decision making, and continuous inattention. His PHQ-9 (Patient Health Questionnaire-used to diagnosis depression and grade severity of symptoms) score answered by the staff, was three, indicating minimal or no depression. R27 rejected care and had other behavior symptoms one to three days. He received an antipsychotic, antidepressant, and a diuretic for seven days. R27 received the antipsychotic medication on a routine basis and had not had a gradual dose reduction (GDR) as the physician signed it was clinically contraindicated on 01/20/20. The Cognitive Loss/Dementia Care Area Assessment (CAA), the Behavior CAA, and the Psychotropic Drug Use CAA, all dated 10/29/20, contained the same information, revealed R27 has slowly progressed to responding less to verbalizations to the point he will not often give an answer. He was oriented to person only and has mild depression according to his score of three on the staff interview for mood assessment. He takes quetiapine (antipsychotic medication) for his psychotic behaviors and also takes Prozac (antidepressant medication) and has had medication changes over the past year. The Quarterly MDS, dated 03/08/21, revealed these changes from the Annual MDS: decision making was moderately impaired, he did not display continuous inattention, and he had no rejection of care or other behavior symptoms. His PHQ-9 score continued at three. The assessment question was answered that he did not receive an antipsychotic, so the GDR information did not trigger to be answered. The Order Summary Report dated 04/06/21, included physician orders for these medications: 1. On 02/02/21, fluoxetine HCl, 20 milligrams (mg), in the morning, for depression. 2. On 03/12/21, Seroquel (quetiapine) 25 mg, give 12.5 mg, every day, for psychotic disorder with delusions. The Consultant Pharmacist's Medication Review, for recommendations created between 10/18/20 and 10/26/20, included that there was no response noted in the chart to pharmacist-to-prescriber June 2020 GDR request on his fluoxetine/quetiapine. The facility failed to act upon the pharmacy recommendation made in June 2020 and October 2020. The Note to attending Physician/Prescriber, date printed 10/26/20, included the patient's use of low dose antipsychotic was unlikely to produce true antipsychotic effect, however, it can exacerbate existing issues with diabetes, and potentially increase risk of dyslipidemia, also. Can we consider a gradual dose reduction of quetiapine and utilize other psychotropic agents, if needed, as well as nonpharmacologic interventions? Buspirone may be worth consideration, particularly if anxiety is an issue. We may want to review pain also and ensure this is adequately managed, particularly if he has behaviors associated with provision of care. The facility failed to act upon the Pharmacist's recommendations. The Note to Attending Physician/Prescriber, dated 01/25/21, included that R27 currently received fluoxetine 40 mg daily and quetiapine 12.5 mg twice daily. R27 was unable to participate fully in the most recent PHQ-9 assessment, staff assessment scored at a 0 (indicating minimal or no depression). It should be noted, however, that the environment changes resultant from the coronavirus policies my exacerbate anxiety/depression presently, and in the near future. The physician responded on 02/02/21 to reduce the fluoxetine to 20 mg daily. On 04/20/21 at 07:58 AM, Administrative Nurse D, stated the letters for October and November 2020 were not signed by the physician as they were not addressed. The pharmacy recommendations should be handled within 14 days. Nurse D received the recommendations and then divided and sent them out, so the nurses were aware of what was going on, then Nurse D followed up and collected them. The facility policy Drug Regimen Review, dated 03/01/18, indicated the pharmacist's report will be provided to the attending physician's office and the Medical Director's office with a written request for a response documented on the medication review report form. A copy of the review report form will be placed in the resident's clinical record after it is sent to the residents attending physician. When the signed copy is received it will be placed in the resident's clinical record and the unsigned copy of the report will be removed and shredded. If/when an attending physician fails to respond to a Pharmacy Drug Regimen Review within seven working days, the physician will be contacted by the licensed nurse and/or the medical director. The DON will track physician response reports and if no response is received within seven working days, the DON or designee will place a phone call to the physician for a phone order response. If no response is received from the physician within fourteen working days, the facility's Medical Director will be contacted for requested response/recommendations. The facility failed to address the use of psychotropic medications for this resident to ensure no unnecessary medication usage. - The Order Summary Report, dated 04/06/21, for Resident (R)16, included diagnoses of major depressive disorder, (major mood disorder), cognitive communication deficit, other abnormalities of gait and mobility, unsteadiness on feet, difficulty in walking, muscle weakness, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), anxiety (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder, dementia (progressive mental disorder characterized by failing memory, confusion), cognitive decline, history of falling, and repeated falls. The Significant Change in Status Minimum Data Set (MDS), dated [DATE], assessed R16 with a Brief Interview of Mental Status Score (BIMS) of 11, indicating moderate cognitive impairment. Her PHQ-9 (Patient Health Questionnaire-used to diagnosis depression and grade severity of symptoms) score was seven, indicating mild depression. She had no behaviors other than wandering one to three days and received and antidepressant and an opioid seven days. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/26/20, included that R16 had a diagnosis of dementia and her BIMS score varies from moderate to severe cognitive impairment. She could be easily redirected most times and is often confused and looking for family members. She becomes anxious at times, has wandered, and sometimes asks staff for rides to see her folks. The Psychotropic Drug Use CAA, dated 08/26/20, included that R16 had risk factors of falls, continued weight loss due to poor appetite, pain related to osteoarthritis, depression and anxiety related to declining health and functional ability, and increasing cognitive losses related to dementia. The Quarterly MDS, dated 02/25/21, assessed R16 with a BIMS score of 11, indicating moderate cognitive impairment and a PHQ-9 score of four indicating minimal to no depression. She had rejected care one to three days, wandered four to six days, and had other behaviors not directed towards others one to three days. She received and antianxiety, antidepressant, and an opioid seven days. The Care Plan, dated 03/04/21 included that R16 had severely impaired cognition related to her dementia, that she currently takes mirtazapine (an antidepressant medication) for appetite stimulation, has a diagnosis of anxiety and receives Buspar (an antianxiety medication) routinely. R16 receives medications with black box warnings including Depakote (an anticonvulsant medication that is also used as a mood stabilizer), mirtazapine, and tramadol (medication used to treat pain). The Order Summary Report, dated 04/06/21, included physician orders for the following psychotropic medications: 1. On 08/04/20, buspirone, 5 milligrams (mg), twice daily for anxiety. 3. On 08/14/20, mirtazapine, 30 mg, at bedtime for appetite stimulant. 3. On 01/27/21, Depakote, 125 mg, twice daily for dementia. The Recommendation to Prescriber, with a print date of 06/15/20, included R16 started mirtazapine 7.5 mg at bedtime for appetite stimulation in 04/2020. Noted she had several falls recently per her electronic medical record (EMR). Her weight currently is 100 pounds per EMR, up from the lowest weight of 97.5 pounds on 05/11/20, but still lower than highest weight of 104 pounds on 04/06/20. Mirtazapine may increase her risk of falls. The physician signed on 04 and day ineligible and marked to discontinue the mirtazapine. There is a fax date at the top of the recommendation letter of 04/16/21 at 07:06 AM. The MAR, dated 06/2020, revealed the mirtazapine was increased to 15mg on 06/24/20. The dose was increased to 30mg on 08/14/20 and she continues, per the April 2021 MAR on the 30mg dose. The resident's weight, located in the EMR under the Weights/Vitals tab, dated 04/07/21, was 91.6 pounds, and on 06/01/21 weight was 100 pounds, indicating this medication is not effective in appetite stimulation. The facility failed to address the pharmacy recommendation for 06/15/21 until April of 2021, 10 months later, and at that time the information on the recommendation letter was no longer correct. On 04/20/21 at 07:58 AM, Administrative Nurse D, stated the pharmacy recommendations should be handled within 14 days. Nurse D received the recommendations and then divided and sent them out, so the nurses were aware of what was going on, then Nurse D followed up and collected them. On 04/20/21 at 09:54 AM, Licensed Nurse (LN) I stated she does not have a role with the pharmacy recommendations, that Administrative Nurse D sends the pharmacy recommendations to the doctor and receives the signed ones back by fax, then she prints them out and sends to us by email, then we put the orders in if there are changes. On 04/20/21 at 12:39 PM, Administrative Nurse D confirmed that the letters with fax dates for 04/16/21 were sent to the physician this month and not addressed at the time of the recommendation. The facility failed to address this resident's medications to ensure no unnecessary psychotropic medication usage.

The facility reported a census of 44 residents. Based on observation and interview, the facility failed to prepare and serve food under sanitary conditions, for the residents of the facility. Findings included: - On 04/13/2021 at 11:07 AM, an initial tour of the kitchen with Dietary Staff (DS) BB, revealed seven frying pans with a brown substance and irregular cooking surfaces, which made them unsanitizable. On 04/13/2021 at 11:07 AM, DS BB verified the above and stated the seven frying pans were not the ones provided by the facility. He explained that the facility cooks brought in these seven personal frying pans from home to cook for the residents. He agreed the pans all had irregular cooking surfaces, and brown debris inside which came into direct contact with the food cooked in them. These seven pans were unsanitizable and should not be used. The facility failed to provide a policy to address the procurement and use of appropriate cookware to ensure sanitation and safe cooking practices. The facility failed to prepare and serve food under sanitary conditions for the residents of the facility.

The facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included: - On 04/19/21 at 11:40 AM, during a Kitchen tour with Dietary Staff (DS) BB, revealed the lack of a trash can adjacent to the hand washing sink in the food preparation area. An open barrel located approximately 10 feet away from the handwashing sink sat next to the bread rack. The open barrel had paper towels overflowing from the top of the barrel. On 04/19/21 at 11:40 AM, DS BB verified the above findings. He reported the kitchen staff used the barrel to dispose of the paper towels used to dry their hands after washing them. He stated they previously had a foot operated trash can adjacent to the handwashing sink, in the food preparation area, but the staff used the barrel instead. DS BB agreed the trash receptacle did not adequately contain the trash and that it should not be located next to the bread rack. Additionally, he stated the handwashing sink should have a foot operated trash receptacle at the handwashing sink for staff to dispose of paper towels and to prevent any cross contamination. The facility policy for Garbage and Refuse, dated 03/18/2021 documentation included the center shall properly dispose of garbage and refuse. Garbage and refuse containers should not be overfilled, have lids, and be covered when not in use. The facility policy for Handwashing Guidelines-Dietary Employees, dated 03/01/2018, documentation included handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink when preparing food, especially when changing preparation procedures, and when working with different raw foods during preparation. After engaging in any activities that may contaminate the hands. Staff should dispose of paper towels in a pedal opening trash can (do not touch the trash can lid with clean hands). The facility failed to maintain and/or dispose of kitchen garbage and refuse properly for the residents of the facility.

The facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to follow the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prevent transmission of the pandemic COVID-19 virus. The facility failed to ensure staff were answering screening questions appropriately at the beginning of the shift, failed to quarantine residents when a staff member tested positive for COVID-19 that previously worked two shifts with respiratory symptoms, allowed the facility staff to continue to wear cloth or surgical masks while the facility was in outbreak status (the occurrence of one or more resident and/or staff that test positive for COVID-19), and failed to have a policy in place to provide instruction on the steps the facility should take when an outbreak occurred. The above practices increased the risk of transmission of COVID-19 to the residents of the facility. Findings included: - On 04/13/21 at 09:30 AM, the Administrative Staff B reported they were in outbreak testing due to one employee that was positive for COVID-19. On 04/13/21 at 04:42 PM, Administrative Staff A confirmed the facility was currently in outbreak testing due to one positive employee. Currently no residents tested positive and no other staff tested positive. On 04/14/21 at 09:58 AM, Licensed Nurse (LN) J stated a staff member previously tested positive, staff were being tested twice a week, and staff were wearing surgical style masks right now. On 04/14/21 at 10:02 AM, residents were in the sitting area between the hallways for exercise activity had a cloth or surgical mask in place and the staff wore surgical masks. On 04/14/21 at 03:30 PM, Administrative Nurse D stated that Certified Nurse Aide (CNA) M complained of cough and runny nose on 04/08/21 for her 2:00 PM to 10:00 PM shift screenings. A rapid COVID-19 test done at that time was negative, and staff collected a PCR (polymerase chain reaction) at that time too. The PCR test returned with a positive result for COVID-19 on 04/09/21 at 06:50 AM. CNA M worked her scheduled shift on 04/08/21 since the rapid test was negative. On 04/14/21 at 03:35 PM, Administrative Staff B stated staff are allowed to perform their own screening and Administrative Staff A monitored the screening forms for completion. If someone had symptoms or an increased temperature, they would not be allowed to enter, the director of nursing (DON) or charge nurse would be contacted to recheck their temperature, and they would probably do a COVID-19 test at that time. On 04/14/21 at 03:44 PM, Certified Medication Aide (CMA) R stated the residents were not quarantined to their room right now, and a couple of weeks ago the facility updated the guidelines that there can be two residents to a table in the dining room. On 04/14/21 at 05:47 PM, residents sat in the dining room, two tables had two residents sitting there less than six feet apart and the other tables had one resident to a table. Review of the schedule for CNA M revealed on 04/06/21 and 04/08/21 the facility assigned her to work on the 2:00 PM to 10:00 PM shifts. Review of the staff screening logs, dated 04/06/21 and 04/08/21, revealed that CNA M answered No in response to the symptom questions on the screening form. Her temperature was 98.2 degrees Fahrenheit on 04/06/21 and 98.6 degrees Fahrenheit on 04/08/21. The SARS-CoV-2 (COVID-19) result summary, dated 04/09/21 at 06:49 AM, revealed that CNA M had a positive result for date of specimen collection on 04/08/21 at 02:03 PM and received in the laboratory on 04/08/21 at 05:32 PM. An electronic communication dated 04/09/21 at 09:11 AM, from Administrative Staff D to the local county health department, revealed that during routine testing on 04/08/21 that CNA M tested positive on a PCR test. CNA M reported to work with complaints of a sore throat and a mild cough and did not have a fever. A rapid test completed on 04/08/21 was negative and she worked her scheduled shift on 04/08/21 from 02:00 PM to 10:00 PM. The SARS-CoV-2 (COVID-19) result summary, dated 04/09/21 at 06:03 PM, revealed that CNA M had a positive result for date of specimen collection on 04/09/21 at 02:51 PM. On 04/15/21 at 12:00 PM, CNA M stated that she was in quarantine/isolation until she could return to work. On 04/06/21 when at home she started having symptoms of a stuffy nose, cough, and scratchy throat. She thought it was just allergies and did not report those symptoms on the screening form and worked her assigned shift from 02:00 PM to 10:00 PM that day. She reported that she walked around everywhere in the building except the dining room and provided cares to residents of one hallway of the facility. CNA M stated on 04/08/21 the facility was doing routine testing and she felt her symptoms were a lot worse than on 04/06/21. She felt like she had a fever, her throat was sore, and she had a cough. CNA M reported she requested a rapid test be done because she did not feel well and wanted to make sure it was not COVID-19, even though she thought it was just allergies. The symptoms on the screening form were answered no as she was used to circling no to the questions on the form. She was then tested and waited for results before going to her assigned area of the facility. CNA M stated she worked one hall until 06:30 PM then was moved to another hall to provide cares until 10:30 PM on 04/08/21. She wore a surgical mask during her shift. On 04/15/21 at 12:27 PM, Administrative Nurse D stated on 04/08/21, CNA M was sniffling, so we tested her to make sure she was not positive, she was in the screening area at that time. LN G assessed her. Administrative Nurse D stated if a staff feels like they have a fever and a cough or sore throat they should not report to work. A policy regarding facility response to when a staff tests positive was not available at this time, the management company was assisting to obtain one. On 04/15/21 at 12:35 PM, LN G stated he assessed CNA M on 04/08/21, conducted the rapid testing, he assessed her lung sounds and there were no issues and she had allergy-like symptoms of runny nose and sore throat. She was given the option if she wanted to work her shift or not and she did not want to go home that he recalled. An electronic communication dated 04/15/21 at 12:41 PM, from Administrative Nurse D to the local county health department, revealed that when CNA M tested positive, the facility instructed her to self-quarantine and all residents testing conducted on 04/09/21 was negative results. The facility restricted movement within the facility, suspended in room visitations, and suspended group activities. Staff repeated testing on 04/12/21 which was negative. Since that time, the facility lifted the restriction for residents to remain in their room, group activities, and allowing staff to wear surgical/cloth masks at all times, based on criteria for positivity rates in the two counties below five percent, greater than 70 percent of all residents vaccinated, first-round testing of both residents and staff resulted negative, and twice a day resident screenings revealed no indication of abnormal signs and symptoms. The local county health department returned an electronic communication back to Administrative Nurse D indicating they had no further suggestions, to keep the routines and monitoring going, and hope that this would be just an isolated case. On 04/19/21 at 09:29 AM, Administrative Nurse D stated that testing for all staff and residents completed on 04/15/21 had negative results. On 04/20/21 at 10:38 AM, Administrative Nurse E, responsible for the infection control program, stated that on 04/09/21 when the facility received the positive result for CNA M, the facility stopped visitation in the facility, stopped some of the larger group activities, continued to use the dining room, and the residents were not quarantined to their room. Administrative Nurse E stated that the facility was still in outbreak mode, and the staff continued to wear a cloth or surgical mask. On 04/20/21 at 02:46 PM, Administrative Nurse D revealed the facility lacked a policy on the steps the facility needed to take when there was an outbreak, and they follow multiple guidelines from the CDC. The health department did not respond to her electronic communication sent on 04/09/21. The facility policy Group Activities During COVID-19 Policy, dated 03/29/21, indicated it was the policy that alterations are made in programming within the Center during COVID-19 outbreaks and to meet the Center's COVID-19 prevention protocols and local, state, and federal guidelines. The facility policy, Coronavirus Surveillance Policy, dated 03/23/20, included that screening for visitors and staff included signs and symptoms of a respiratory infection, such as fever, cough, shortness of breath, or other symptoms of coronavirus (i.e. chills, muscle pain, headache, new loss of taste or smell, fatigue, congestion or runny nose, nausea or vomiting, diarrhea). Staff who have signs and symptoms of respiratory infection should not report to work. The facility policy Coronavirus Testing, revised 09/08/20, indicated an outbreak was a new COVID-19 infection in any healthcare personnel or any nursing-home onset COVID-19 infection in a resident. Staff who do not test positive for COVID-19 but have symptoms will follow the facility policy to determine when they can return to work. The facility policy Novel Coronavirus Prevention and Response, revised 07/30/2020, included the Infection Preventionist (IP) or Director of Nursing (DON) will assess facility risk associated with COVID-19 through surveillance activities of emerging diseases in the community and illnesses present in the facility. When a threat is detected, the facility will respond promptly and implement emergency and/or outbreak procedures. The policy lacked a procedure on response of a positive employee but addressed response of a positive resident or if COVID-19 is suspected in a resident. The CDC recommendations, titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 03/29/21, included residents that have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine for 14 days after their exposure. Healthcare personnel should wear an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Any new identified SARS-CoV-2 infected healthcare personnel or resident should be evaluated as a potential outbreak. Residents should generally be restricted to their rooms. Consideration should be given to halting social activities and communal dining. Recommended precautions should be continued for residents until no new cases of SARS-CoV-2 infection have been identified for at least 14 days. The facility failed to ensure staff answered screening questions appropriately at the beginning of their shifts, failed to quarantine the residents to their room when they received a positive test result for COVID-19 for a staff member who worked two previous shifts with respiratory symptoms, allowed the facility staff to continue to wear cloth or surgical masks while the facility was in outbreak status (the occurrence of one or more resident and/or staff that test positive for COVID-19), and failed to have a policy in place to provide instruction on the steps the facility staff were to take when an outbreak occurred. The above practices increased the risk of transmission of COVID-19 to the residents of the facility.