**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 47 residents, which included 16 residents sampled and reviewed for care plan development. Based on interview, observations, and record review, the facility failed to develop a comprehensive person-centered care plan for one resident. Resident (R) 35 comprehensive person-centered care plan was not completed in a timely manner of 21 days from admission. This deficient practice had the potential to lead to uncommunicated needs, which could lead to negative impacts on the resident's physical, mental and psychosocial well-being. Findings included: - R35's Electronic Health Record (EHR) revealed diagnoses that included nontraumatic chronic subdural hemorrhage (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain), muscle weakness, and repeated falls. The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident had a total mood severity score of 01, indicating minimal depression and no behaviors noted. R35 required limited assistance with activities of daily living (ADLs), with bed mobility, bathing, toileting hygiene, and dressing, supervision with ambulation, and eating. R35 was occasionally incontinent of bladder. The Quarterly MDS dated 05/26/24, documented a BIMS of 11, indicating moderately impaired cognition. R35 required limited assistance of staff with ADLs. R35 was non-ambulatory, independent with transfers and dependent for staff for wheelchair mobility. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 09/21/23, documented R35 had minimal visual impairment and she used a magnifying glass instead of glasses. The Urinary Incontinence CAA dated 09/21/23, documented R35 as occasionally incontinent of bowel and bladder and required more assistance in the evening. The Care Plan dated 07/02/24, revealed R35 required staff to provide assistance with ambulation with one staff assistance and a walker, as she requested. Staff were to provide assistance with toileting if the resident requested. R35 required staff to set up personal items and clothing daily. Review of the Progress Notes from 08/10/23 to 07/03/24 lacked any documentation in regard to completion of a care plan. On 07/01/24 at 10:19 AM, R35 sat in her recliner in her room, with her feet propped up on her wheelchair in front of recliner. R35 was watching television she was fully dressed, no socks on feet, slippers on floor in front of recliner. On 07/02/24 at 08:12 AM, R35 stated that she did not remember stating what she said yesterday, states that the staff are very nice here and states that the staff help her when she needs it. On 07/02/24 at 08:30 AM, Certified Medication Aide (CMA) Staff S stated R35 would call staff for assistance when needed. CMA S stated that the care plan on the EHR is where the staff need to read what care any resident is required to have. On 07/03/24 at 12:46 PM, Administrative Nurse E stated R35 admitted to facility on 08/10/23 and agreed that R35's person-centered care plan was not developed within seven days of required MDS. Administrative Nurse E revealed that she could not find the baseline care plan in the EHR, stated it was deleted after the comprehensive care plan was completed. On 07/03/24 at 01:00 PM Administrative Staff Nurse E stated she completed the person-centered care plan for R35 in November of 2023 when she realized the care plan had not been written by previous MDS nurse who is no longer employed at facility. The facility's policy for Care Plan, Comprehensive Person Centered, dated 03/02/23 documented: A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person centered care plan is developed within seven days of completion of the required comprehensive assessment. The facility failed to develop a comprehensive person-centered care plan for one resident. R 35 comprehensive person-centered care plan was not completed in a timely manner of 21 days from admission. This deficient practice had the potential to lead to uncommunicated needs which could lead to negative impacts on the resident's physical, mental and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 47 residents with 16 residents included in the sample. Based on observation, record review, and interview, the facility failed to review and revise the care plan for one Resident (R)1 regarding weekly weights and interventions to prevent further weight loss. Findings included: - Review of R1's diagnoses from the Electronic Health Record (EHR) documented, cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diverticulitis (inflammation of the diverticulum, in the colon, which caused pain and disturbance in bowel function), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R1 required limited assistance with activities of daily living (ADLs), with bed mobility, toileting hygiene, and dressing, set-up for eating. R1 was occasionally incontinent of bladder. The resident required a regular diet consistency and no added salt. The Quarterly MDS dated 05/17/24, documented a BIMS of 12, indicating moderately impaired cognition. The resident had a total mood severity score of 01, indicating minimal depression and no behaviors noted. R1 required limited assistance of staff with ADLs, set-up for eating. The resident required a regular diet regular consistency and no added salt. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 12/14/23, documented R1 required assistance with her ADLs. The Nutritional CAA dated 12/14/23, documented R1's weight was stable. The facility encouraged balance meals. The Care Plan dated 07/02/24, revealed R1 required staff to provide assistance to take R1 to and from meals as requested and provided supervision and set up assistance. Staff were to assist the resident as needed. Staff were instructed to see the EHR for current physician orders and treatments. Staff were instructed to monitor weights weekly and as needed. The Physician's Order dated 07/02/24, documented house supplement twice a day and a snack of choice daily for weight loss ordered 06/10/24. Lacked documentation for how much was consumed. On 07/02/24 at 02:43 PM, Administrative Nurse E revealed the weight loss and interventions should be on the care plan, that it is an Interdisciplinary Team effort, that Dietary staff BB generally adds the nutritional concerns to the care plan on the EHR. Administrative Nurse E stated that it was noted in the middle of June 2024 that R1's weight loss was not due to the fluid shifts in her body, but a true weight loss. On 07/02/24 at 03:15 PM, Dietary Staff BB revealed R1 had a true weight loss and agreed that the weight loss and interventions were not on R1's care plan. Dietary Staff BB stated that she was generally the staff member that care plans for the nutritional section of residents' care plans. On 07/03/24 at 10:30 AM, Administrative Nurse D agreed weight loss, weekly weights, and supplements should have been on R1's care plan. The facility's policy for Care Plan, Comprehensive Person Centered, dated 03/02/23 documented: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven days of completion of the required comprehensive assessment. Assessments are on going and care plans are revised as information about the residents and the residents' condition change. The facility failed to review and revise the care plan for one Resident R1 regarding weekly weights and interventions to prevent further weight loss. This deficient practice had the potential to lead to uncommunicated needs which could lead to negative impacts on the resident's physical, mental and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 47 residents with 16 sampled. Based on observation, interview, and record review, the facility failed obtain daily weights as ordered on 03/28/24 for cognitively impaired Resident (R) 1, who had an identified weight loss. This deficient practice had the potential to negatively affect the resident's physical well-being. Findings include: - Review of R1's diagnoses from the Electronic Health Record (EHR) documented, cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diverticulitis (inflammation of the diverticulum, in the colon, which caused pain and disturbance in bowel function), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R1 required limited assistance with activities of daily living (ADLs), with bed mobility, toileting hygiene, and dressing, set-up for eating. R1 was occasionally incontinent of bladder. The resident required a regular diet consistency and no added salt. The Quarterly MDS dated 05/17/24, documented a BIMS of 12, indicating moderately impaired cognition. The resident had a total mood severity score of 01, indicating minimal depression and no behaviors noted. R1 required limited assistance of staff with ADLs, set-up for eating. The resident required a regular diet regular consistency and no added salt. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 12/14/23, documented R1 required assistance with her ADLs. The Nutritional CAA dated 12/14/23, documented R1's weight was stable. The facility encouraged balance meals. The Care Plan dated 07/02/24, revealed R1 required staff to provide assistance to take R1 to and from meals as requested and provided supervision and set up assistance. Staff were to assist the resident as needed. Staff were instructed to see the EHR for current physician orders and treatments. Staff were instructed to monitor weights weekly and as needed. Review of the Progress Notes from 08/10/23 to 07/03/24 documented the following: On 02/29/24 at 09:09 AM, Consultant GG documented, R1's weight review, noting the resident's weight was up 7.5% in six months and up 3.1 percent (%) in one month. The resident had weight gain noted. On 03/16/24 at 01:18 PM, R1 was sent to hospital for possible stroke. On 04/11/24 at 09:13 AM, Consultant GG documented, R1's weight was down 9% in one month but was impacted by fluid shifts and a hospital stay. On 04/25/24 at 10:28 AM, Consultant GG documented, R1's weight was down 16 pounds since 03/13/24. R1 went to the hospital and returned with a weight loss. R1's usual weight was between 160 and 170 pounds (lbs.). On 05/09/24 at 09:31 AM, Consultant GG documented R1's weight was down 6.4% in one month and R1 stated she was not trying to lose weight. On 05/16/24 at 04:32 PM, Dietary Staff BB documented R1's weight was 150.8 (lbs.) with meal intakes at 50% and questioned a dietician referral. On 05/29/24 at 10:29 AM, the resident's physician was updated on weight loss. On 06/10/24 at 12:39 PM, Consultant GG documented R1's weight was 141 lbs. and recommended adding a house supplement twice a day and snack of choice daily for decreased appetite and weight loss. On 06/12/24 at 08:06 AM the facility notified the physician extender of the resident's weight loss and loss of appetite. Review of R1's Physician's Order in the EHR revealed a 03/28/24 order for daily weights. Review of weights in the EHR from 03/28/24 until 07/01/24 documented the following weights for R1: 04/07/24 at 06:47 AM, 161.2 lbs. 04/14/24 at 07:24 AM, 162.2 lbs. 04/21/24 at 06:56 AM, 163 lbs. 04/28/24 at 08:34 AM, 153.2 lbs. 05/05/24 at 08:06 AM, 150.6 lbs. 05/12/24 at 07:01 AM, 150.8 lbs. 05/19/24 at 07:05 AM, 150.2 lbs. 05/26/24 at 09:23 AM, 150.9 lbs. 06/02/24 at 07:04 AM, 145.6 lbs. 06/07/24 at 07:55 PM, 139.6 lbs. 06/08/24 at 07:59 AM, 141.2 lbs. 06/09/24 at 07:01 AM, 141.6 lbs. 06/10/24 at 06:49 AM, 141 lbs. 06/11/24 at 07:22 AM, 142.6 lbs. 06/12/24 at 09:31 AM, 142 lbs. 06/13/24 at 09:52 AM, 142.2 lbs. 06/15/24 at 08:15 AM, 143 lbs. 06/17/24 at 01:42 PM, 141.1 lbs. 06/18/24 at 09:56 AM, 142.6 lbs. 06/19/24 at 07:10 AM, 139.8 lbs. 06/20/24 at 08:10 AM, 140 lbs. 06/21/24 at 09:39 AM, 137.8 lbs. 06/22/24 at 06:44 AM, 142.1 lbs. 06/23/24 at 06:18 AM, 142.4 lbs. 06/24/24 07:49 AM, 141.8 lbs. 06/25/24 at 11:25 AM, 142.6 lbs. 06/26/24 at 11:47 AM, 143 lbs. 06/27/24 at 01:20 PM, 141.6 lbs. 06/28/24 at 01:42 PM, 139.8 lbs. 06/29/24 at 07:46 AM, 138.8 lbs. 06/30/24 at 09:02 AM, 140 lbs. 07/01/24 at 12:35 PM, 138.0 lbs. Observation on 07/01/24 at 12:36 PM, revealed R1 sat on the side of bed and watched television. R1 stated she was waiting for her lunch to be delivered. On 07/02/24 at 01:24 PM, Licensed Nurse (LN) H stated R1 lost weight after the resident was ill in late March 2024 and the resident had just not been herself since then. LN H stated the resident also had a lot of edema (swelling resulting from an excessive acumulation of fluid in the body tissues) that she needed to be treated for. On 07/02/24 at 02:08 PM, LN H stated the amount of house shake a resident consumed should be on the medication administration record and agreed that it was not on R1's medication administration record. LN H verified with CMA T that R1 consumed 50% of her 120 milliliter house shake and added that to the EHR order for further documentation. LN H stated that R1 became a daily weight in June of 2024. On 07/02/24 at 02:43 PM, Administrative Nurse E agreed that the current orders on the EHR stated the resident required a daily weight since 03/28/24 but could not find any daily weights documented in EHR until 06/07/24. Administrative Nurse E stated the order must have changed to weekly, but they could not locate a physician order. Administrative Nurse E stated that the house shake amount consumed should be documented in the EHR by staff. On 07/03/24 at 10:30 AM, Administrative Nurse D stated the daily weight order was correct from 03/28/24 and noted she placed the order in the EHR when R1 re-admitted to the facility and could not explain why a daily weight was not completed until 06/07/24. Administrative Nurse D stated there could be an issue with the EHR system being used and would need to reach out to the company. The facility did not provide a policy regarding weight loss and following a physician order. The facility failed to obtain daily weights as ordered for R1 on 03/28/24. This deficient practice had the potential to negatively affect the resident's physical well-being.

The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to conduct annual performance reviews for two of five Certified Nurse Aide/Medication Aides reviewed, to ensure the residents received adequate cares. Findings included: - Review of five Certified Nurse/Medication Aide's (CNA/CMA) employment records revealed the facility did not complete two of the five CMA/CNA's annual performance reviews, as follows: 1. CMA/CNA R, hired on 09/15/1995, with the most recent Annual Performance Evaluation, dated 08/20/22 (22 months past due). 2. CMA/CNA S, hired on 08/21/18, with the most recent Annual Performance Evaluation, dated 11/14/22 (19 months past due). On 07/03/24 at 12:44 PM, Administrative Staff D stated CMA/CNAs employed more than one year should have an annual performance evaluation. She verified the above findings and reported that all nursing staff were available to assist all residents of the facility. The facility lacked a policy to address the completion of an annual performance evaluation/review for CMA/CNA staff employed for a year or more. The facility failed to conduct an annual performance review for CMA/CNA staff that provided care throughout the facility to all the residents of the facility to ensure the residents received adequate cares.

The facility reported a census of 47 residents. Based on observation, interview and record review, the facility failed to monitor and serve food at safe palatable (pleasant to taste) temperatures as required. Findings included: - During an interview on 07/01/24 at 09:19 AM, Resident (R)31 revealed the food served to him was not hot. During an interview on 07/01/24 at 10:08 AM, R10 revealed he ate his meals in his room, per his choice, and the food was usually served cold. During an interview on 07/01/24 at 10:15 AM, R43 revealed the food was cold when he received it. Observation, on 07/02/24 at 11:07 AM, revealed dietary staff as they prepared food carts for lunch service to the 300 hall. A tray containing 11 slices of cheesecake sat on top of the food cart. Observation, on 07/02/24 at 11:35 AM, revealed Dietary Staff CC took the broccoli out of the steam oven and did not take the temperature, until requested. The temperature was 132 degrees Fahrenheit (F). Dietary Staff CC stated she did not know broccoli required a temperature before serving and returned it to the steamer. Dietary Staff DD obtained the temperature of the cheesecake on top of the food cart and noted it was above 50 degrees F and stated the cheesecake should not be above 42 degrees and did not know why staff removed it from the refrigerator 30 minutes before the cart was ready for distribution to the 300 hall. Observation on 07/02/24 at 11:53 AM, revealed Dietary Staff CC obtained temperatures of the food items on the steam table and revealed the cut carrots at 100 degrees F and the ground chicken at 100 degrees F. Dietary Staff CC stated when she removed the items from the oven/steamer, the temperatures were 165-190 degrees F. Dietary Staff CC stated she did not know the temperatures should be obtained prior to serving. Interview on 07/02/24 at 12:00 PM with Dietary Staff BB, revealed the facility utilized an electronic temperature monitoring/recording system, and the system did not work satisfactory, with lack of recording of the food temperatures so staff used a paper recording system. Dietary Staff BB confirmed lack of temperatures to ensure the steam table maintained food at 135 degrees F throughout the meal service. Observation on 07/03/24 at 09:16 AM revealed Dietary Staff BB provided a test tray and obtained the temperature of the scrambled eggs at 100 degrees F and hash browns at 100 degrees F. Dietary Staff BB and surveyors tasted the food, and all confirmed the food was not hot and minimally warm. The facility policy Food Preparation and Service revised 01/26/23, instructed staff to cook fresh frozen of canned fruits and vegetables to a temperature of 135 degrees F. Potentially hazardous foods (meats, poultry, seafood cut melon eggs milk, yogurt, and cottage cheese) must be maintained below 41 degrees or above 135 degrees F per type of food. The facility failed to ensure foods were maintained at 135 degrees F on the steam table and foods served to residents were maintained at palatable temperatures as required.

The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible foodborne illness for the residents in the facility. Findings included: - Observation, on 07/01/24 at 08:45 AM, revealed the following areas of concern in the dry goods pantry: One unsealed 25 pound (lbs.) bag of rice and one unsealed open 50 lbs. bag of flour in the dry goods pantry. One opened five lbs. container of teriyaki sauce with an expiration date of 04/21/24. One gallon of Worcestershire sauce, with no opened date and no expiration date, with approximately one-fourth of the gallon remaining. Observation, on 07/01/24 at 08:50 AM, revealed 12 boxes of frozen food stored directly on the floor of the walk-in freezer. Interview, on 07/01/24 at 11:30 AM, with Dietary Staff BB revealed the delivery of frozen foods came on Friday, and confirmed staff should place the items on shelves in the freezer. Observation, on 07/02/24 at 02:48 PM, during the environmental tour with Dietary Staff BB, revealed the following areas of concern: The side-by-side refrigerator contained a piece of unidentified meat wrapped in plastic, dated 06/10/24. One partially used gallon container of thousand island dressing dated 03/15/24 and a five lbs. container of salsa dated 03/15/24. Plastic wrapped sliced ham, with an open date of 06/23/24. One large, opened bag of mixed lettuce for salad, undated with noted wilting and brown discolorations on multiple pieces of lettuce. During an interview on 07/02/24 at 02:48 PM, Dietary Staff BB confirmed these items were out of date. The double-doored oven contained several areas of bubbled burned food debris on the bottom of the inside. The sides and door contained splatters and grime on the surfaces. The can opener contained grime on the surface. One large fry pan contained multiple scratches in the cooking surface. The floor cleaning machine was stored between two metal shelves holding clean serving pans and storage containers. During an interview on 07/02/24 at 03:00 PM, Dietary Staff BB confirmed the areas of concern. The facility policy Food Receiving and Storage revised 07/15/21, instructed staff to store food in a manner that complies with safe food handling practices. Pesticides and other toxic substances will not be stored in the kitchen area. The facility failed to store, prepare, and serve food in a sanitary manner to prevent potential foodborne illness for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents with 16 selected for review. Based on observation, interview and record review, the facility failed to develop a baseline care plan for one newly admitted sampled resident (R)151, to include the resident's physical disability of right below knee amputation status. Findings included: - Review of Resident (R)151's undated Physician Orders, revealed diagnoses included right below knee amputation, traumatic subdural hematoma (bleeding in the brain), and dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) was in process. The Matrix (a form that the facility documents resident status) dated 09/22/22, indicated the resident had two unstageable pressure ulcers. The Baseline Care Plan, dated 09/09/22, (resident admitted to the facility 09/16/2), instructed staff the resident required extensive assistance for toileting. Staff instructed to assist as needed as the resident had impaired gait and was a fall risk. Staff instructed to keep his bed in a low position so the resident can place feet firmly on the floor when sitting on the side of the bed and assist as needed. The resident had a history of falls. The resident had a history of pain related to chronic foot issues/sores and staff were to monitor for pain daily. Staff instructed to observe for proper use of assistive devices and to assist as needed. The care plan lacked the use of the protective boot to the resident's left foot. The resident had mental cognitive changes with hospitalization. The Transfer Form, dated 09/16/22, instructed staff to follow the wound/skin/notes/orders. The Wound Skin Progress Note dated 09/02/22, instructed staff to apply betadine topically to the eschar (dead tissue)/peri wound (skin around the wound) margins of the left foot, second through fourth toes daily. Staff instructed to not remove the eschar (dead black tissue) prematurely and to apply a [NAME] (a device with padding which enclosed the foot/leg) boot to the left foot to protect the foot/toes. Observation, on 09/22/22 at 01:51 PM, revealed the resident seated in a wheelchair in his room without a protective boot, and propelling himself with his left leg (the resident had a right below knee amputation). Observation, on 09/26/22 at 07:15 AM, revealed the resident positioned in bed, without the protective boot on the left foot. Observation, on 09/26/22 at 08:06 AM, revealed the resident seated in his wheelchair without a protective boot on. Interview, with Licensed Nurse (LN) H, at that time, revealed the resident's necrotic (dead tissue) toe wounds on his left foot were due to peripheral vascular disease. LN H stated he thought the resident wore the protective boot on his foot when in bed but could not find the boot at that time. Interview, on 09/28/22 at 10:30 AM, with Administrative Nurse D, revealed the baseline care plan did indicate the resident needed extensive assistance for transfers, but lacked the resident assessment to include the right below knee amputation, and the needed use of a protective devise to his left lower extremity to protect his toes. The facility policy Care Plans-Baseline effective 06/24/2018, instructed staff to develop the baseline plan of care to meet the resident's immediate care needs. The facility failed to include the resident's right below knee amputation and the needed use of protective device to his left lower extremities in the baseline care plan to meet the resident's needs as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents with 16 selected for review. Based on observation, interview and record review, the facility failed to review and revise one sampled dependent resident (R) 27's care plan to include interventions and treatment for her left heel blister. Findings included: - Review of Resident (R)27's Physician Order Sheet, dated 09/20/22, revealed diagnoses included protein calorie malnutrition, schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), major mood disorder, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), kyphosis ( curvature of the spine), and dementia(progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with modified independent ability in cognition for decision making. The resident required extensive assistance of two staff for bed mobility, toileting and was dependent on two staff for transfers. The resident had impairment on one side of her upper extremity and no impairment of her lower extremities. The resident had moisture associated skin damage (MASD) and no pressure ulcers. The resident was at risk for pressure ulcers and had a pressure reducing device for her chair and bed. The resident received hospice services and had a less than six-month life expectancy. The Pressure Ulcer Care Area Assessment (CAA), dated 08/04/22, assessed the resident at risk for pressure ulcers and had MASD to her buttocks and was being followed by hospice. Staff assessed her skin weekly. The Care Plan, reviewed 08/19/22, instructed staff the resident required extensive assistance of two staff for bed mobility and had very limited ability to control her body position. Staff to offer to reposition the resident frequently and ensure the resident had a pressure relieving seat cushion and mattress in place. and was incontinent of bowel and bladder. The resident was on hospice services. An addition dated 07/25/22, instructed staff to cleanse the buttocks, pat dry and apply Poly-ox powder to the excoriation (moisture damaged skin) on her buttocks/sacrum twice a day and as needed for wound healing. An addition to the care plan dated 09/07/22, instructed staff to cleanse the wound to her coccyx/gluteal are with wound cleanser, pat dry and apply med honey (a type of medicated gel, to treat wounds) cover with a dressing and change every three days and as needed. The care plan lacked identification or interventions for the resident's left heel blister. A Hospice Note, dated 09/15 /22, documented the presence of a closed blister to the resident's left heel, skin prep (a medicated solution that protects skin) applied and hospice nurse ordered a low air loss mattress. No measurements obtained until 09/22/22 at which time hospice documented the blister as 3 by 3 centimeters. The Hospice Wound Record Report, dated 09/26/22, documented hospice nurse provided skin prep to the resident's heel blister on 09/20/22 and instructed staff to apply skin prep daily and monitor for changes. Observation, on 09/26/22 at 09:02 AM, revealed a pressure reducing mattress on the bed set at firm. The resident's feet were elevated with a pillow with noticeable clear fluid accumulation on one side of the left heel blister. Observation, on 09/26/22 at 09:20 AM, with Licensed Nurse (LN) H, revealed the resident had chronic MASD. LN H measured an area with yellow slough on the resident's coccyx (bone in the lower spine) as 3 by 1 cm. LN H cleansed the area, applied medihoney and a dressing. LNH stated the resident sits in her chair for long periods of time. LN H measured the left fluid filled heel blister as 4 by 4.5 cm and applied skin prep to the blister. LN H checked the resident's right heel and found it boggy (soft) but blanchable and applied skin prep. LN H and Certified Nurse Aide (CNA) M, transferred the resident with a mechanical lift into her Broda (a type of chair with webbed slats) chair with a gel cushion on the seat. Observation, on 09/27/22 at 10:30 AM, revealed the resident positioned in bed and Administrative Nurse F stated hospice services provided wound care, as does nursing staff when needed. Administrative Nurse F stated hospice services changed the. Administrative Nurse F confirmed hospice did not provide the wound logs until requested on 09/26/22. The Hospice Notes, contained one measurement of the left heel blister on 09/22/22 of 3 by 3 cm. Administrative Nurse F confirmed the treatment for skin prep to the resident's left heel did not appear on the Medication/Treatment Administration Record for staff to apply daily but thought staff did provide the treatment. Administrative Nurse F stated the Risk Committee discussed resident status with pressure ulcers and confirmed lack of an update to the care plan to include the heel blister with interventions for care. Interview, on 09/28/22 at 10:00 AM, with Administrative Nurse D, revealed she would expect staff to update the care plan to include the heel blister. The facility policy Care Plans, Comprehensive Person-Centered revised 06/14/2018, instructed staff assessments of residents were ongoing and staff to revise care plans as information about the residents and the resident's condition changes. The facility failed to review and revise this resident's care plan to include identification, interventions and treatment for her left heel blister.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents with sixteen selected for review which included one resident reviewed for hospice services and one resident reviewed for skin issues. Based on observation, interview and record review, the facility failed to coordinate wound care with the hospice provider for the one resident (R)151 and failed to provide a protective foot device for the one resident (R)27. Findings included: - Review of Resident (R)27's undated Physician Orders, revealed diagnoses included right below knee amputation, traumatic subdural hematoma (bleeding in the brain), and dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) was in process. The Matrix (a form that the facility documents resident status) dated 09/22/22, indicated the resident had two unstageable pressure ulcers. The Baseline Care Plan, dated 09/09/22, (resident admitted to the facility 09/16/2) instructed staff the resident required extensive assistance for toileting. Staff instructed to assist as needed as the resident had impaired gait and was a fall risk. Staff instructed to keep his bed in a low position so the resident can place feet firmly on the floor when sitting on the side of the bed and assist as needed. The resident had a history of falls. The resident had a history of pain related to chronic foot issues/sores and staff to monitor for pain daily. Staff instructed to observe for proper use of assistive devices and to assist as needed. The care plan lacked the use of the protective boot to the left foot. The resident had mental cognitive changes with hospitalization. The Transfer Form, dated 09/16/22, instructed staff to follow the wound/skin/notes/orders. The Wound Skin Progress Note dated 09/02/22, instructed staff to apply betadine topically to the eschar (dead tissue)/peri wound (skin around the wound) margins of the left foot, second through fourth toes daily. Staff instructed to not remove eschar (dead black tissue) prematurely and to apply a [NAME] (a device with padding which enclosed the foot/leg) boot to the left foot to protect the foot/toes. Observation, on 09/22/22 at 1:51 PM, revealed the resident seated in a wheelchair in his room without a protective boot, and propelling himself with his left leg (the resident had a right below knee amputation.) Observation, on 09/26/22 at 07:15 AM, revealed the resident positioned in bed, without protective boot on left foot. Observation, on 09/26/22 at 08:06 AM, revealed the resident seated in his wheelchair without a protective boot on. Interview, with Licensed Nurse (LN) H, revealed the resident's necrotic (dead tissue) toe wounds on his left foot were due to peripheral vascular disease. LN H stated he thought the resident wore the protective boot on his foot when in bed but could not find the boot at that time. Interview, on 09/26/22 at 11:27 AM, with Certified Nurse Aide (CNA) M, revealed she thought the resident had a boot to wear when in bed, but could not locate it. Observation, on 09/27/22 at 07:30 AM, revealed the resident in bed without a protective boot on his left leg. Observation, on 09/27/22 at 10:30 AM, revealed the resident seated in his wheelchair, without a protective boot on his left foot, but did have a nonskin sock on. Administrative Nurse F stated the resident wore the boot when he was in bed as he allows but could not locate the boot and said it may be in laundry. Administrative Nurse F stated the resident had PVD (peripheral vascular disease of the arteries and veins causing poor circulation of blood flow) which caused the toe ulcers. Observation, on 09/28/22 at 07:30 AM, revealed the resident sleeping in bed, with the protective boot on the windowsill. The facility policy for Pressure Ulcer Risk Assessment, effective 09/20/16, instructed staff to review the resident's care plan to assess for any special needs of the resident. The facility failed to ensure staff provided the resident with a protective device for the toes of his left foot. - Review of Resident (R)151's Physician Order Sheet, dated 09/20/22, revealed diagnoses included protein calorie malnutrition, schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), major mood disorder, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), kyphosis ( curvature of the spine), and dementia(progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with modified independent ability in cognition for decision making. The resident required extensive assistance of two staff for bed mobility, toileting and was dependent on two staff for transfers. The resident had impairment on one side of her upper extremity and no impairment of her lower extremities. The resident had moisture associated skin damage (MASD) and no pressure ulcers. The resident was at risk for pressure ulcers and had a pressure reducing device for her chair and bed. The resident received hospice services and had a less than six-month life expectancy. The Pressure Ulcer Care Area Assessment (CAA), dated 08/04/22, assessed the resident at risk for pressure ulcers and had MASD to her buttocks and was being followed by hospice. Staff assessed her skin weekly. The Care Plan, dated 08/19/22, instructed staff the resident required extensive assistance of two staff for bed mobility and had very limited ability to control her body position. Staff to offer to reposition the resident frequently and ensure the resident had a pressure relieving seat cushion and mattress in place. and was incontinent of bowel and bladder. The resident was on hospice services. An entry to the care plan dated 09/07/22, instructed staff to cleanse the wound to her coccyx/gluteal are with wound cleanser, pat dry and apply med honey (a type of medicated gel, to treat wounds) cover with a dressing and change every three days and as needed. An entry dated 07/25/22, instructed staff to cleanse the buttocks, pat dry and apply Poly-ox powder to the excoriation (moisture damaged skin) on her buttocks/sacrum twice a day and as needed for wound healing. An entry dated 07/24/22, instructed staff to apply barrier cream after being changed four times a day. Review of the Matrix (a form that the facility documents resident status) dated 09/22/22, indicated the resident had a stage two facility acquired pressure ulcer. A Physician Order, dated 07/25/22, instructed staff to cleanse the buttocks, pat dry and apply Poly-ox powder to the excoriation (moisture damaged skin) on her buttocks/sacrum twice a day and as needed for wound healing. A Physician Order, dated 09/07/22, instructed staff to cleanse the coccyx/gluteal wound with wound cleanser, pat dry, apply medihoney to the wound bed and apply dressing. Staff instructed to change the dressing every three days. A Hospice Nurse Visit Log dated 09/13/22, documented hospice applied Poly-ox to the coccyx wound and covered with a foam dressing and documented the wound as a stage 2-3. The Hospice Wound Record Report dated 09/13/22 indicated that both the Poly-ox dressing applied (by the facility nurse) and medihoney by hospice. A Hospice Note, dated 09/15 /22, documented the presence of a closed blister to the resident's left heel, skin prep (a medicated solution that protects skin) applied and hospice nurse ordered a low air loss mattress. No measurements obtained until 09/22/22 at which time hospice documented the blister as 3 by 3 centimeters. Review of the Wound Record Report (for the coccyx/gluteal wound) by the hospice provider dated 09/26/22, indicated the resident had stage two pressure ulcer on each visit day starting 07/25/22 through 09/26/22 for a total of 20 visits. Hospice provided wound care of cleansing the wound with wound cleanser, patting dry, applying medihoney to the wound bed and covering with a dressing and instructed staff to change it every three days and as needed and to monitor for changes on 08/02/22, 08/09/22, 09/09/22, 09/13/22,09/20/22 and 09/21/22. The Hospice Wound Record Report, dated 09/26/22, documented hospice nurse provided skin prep to the resident's heel blister on 09/20/22 and instructed staff to apply skin prep daily and monitor for changes. Observation, on 09/26/22 at 09:02 AM, revealed a pressure reducing mattress on the bed set at firm. The resident's feet were elevated with a pillow with noticeable clear fluid accumulation on one side of the left heel blister. Observation, on 09/26/22 at 09:20 AM, with Licensed Nurse (LN) H, revealed the resident had chronic MASD. LN H measured an area with yellow slough on the resident's coccyx (bone in the lower spine) as 3 by 1 cm. LN H cleansed the area, applied medihoney and a dressing. LNH stated the resident sits in her chair for long periods of time. LN H measured the left fluid filled heel blister as 4 by 4.5 cm and applied skin prep to the blister. LN H checked the resident's right heel and found it boggy (soft) but blanchable and applied skin prep. LN H and Certified Nurse Aide (CNA) M, transferred the resident with a mechanical lift into her Broda (a type of chair with webbed slats) chair with a gel cushion on the seat. Observation, on 09/26/22 at 11:11 AM, revealed the resident stated her bottom hurt and CNA M and Certified Medication Aide (CMA) T transferred the resident back into her bed. Observation, on 09/27/22 at 10:30 AM, revealed the resident positioned in bed and Administrative Nurse F stated hospice services provided wound care, as does nursing staff when needed. Administrative Nurse F stated hospice services changed the wound care order to medihoney on 09/07/22 and did not know why hospice changed the dressing and applied medihoney on their visits from 08/02/22 through 09/21/22. Administrative Nurse F confirmed hospice did not provide the wound logs until requested on 09/26/22. The wound logs from 07/25/22 through 09/26/22 contained one measurement on 09/26/22 of the coccyx wound which was obtained by the facility nurse. (4 by 2 cm). The Hospice Notes, contained one measurement of the left heel blister on 09/22/22 of 3 by 3 cm. Administrative Nurse F confirmed the treatment for skin prep to the resident's left heel did not appear on the Medication/Treatment Administration Record for staff to apply daily but thought staff did provide the treatment. Interview, on 09/28/22 at 10:00 AM, with Administrative Nurse D, revealed the resident did not have a pressure ulcer on her coccyx/gluteal area, but had MASD and did not know why hospice documented the resident had a stage two pressure ulcer. The facility policy Pressure Ulcer Risk Assessment, effective 09/2016, instructed staff to document the condition of the resident's skin and report other information in accordance with facility policy and professional standards of practice. The facility failed to coordinate wound care with hospice for this resident with coccyx /gluteal wounds and heel blister to ensure staff provided monitoring assessments with measurements, treatments and interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents with 16 selected for review which included two residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to provide recommended additional nutritional services for one of the two residents (R)12 reviewed for nutrition. Findings included: - Review of Resident (R)12's Physician Order Sheet, undated, revealed diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), anxiety mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder and gastroesophageal reflux disease (GERD backflow of stomach contents to the esophagus). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a BIMS (brief interview for mental status score) of 13 (normal 13-15). The resident required supervision for eating and had impairment in functional range of motion in one side of her upper extremity. The Nutrition Care Area Assessment (CAA) assessed the resident was able to feed herself with set up help and no chewing or swallowing issues. The Care Plan, dated 08/03/22, instructed staff the resident could communicate her needs and wants to staff. A Physician Order, dated 07/07/22, instructed staff to administer a regular diet with regular texture and thin liquids. A Physician Order, dated 09/01/22, instructed staff to administer Boost (a nutritional supplement drink) twice a day. A Physician's Order, dated 09/01/22, instructed staff to obtain weekly weights. Review of the resident's weights as follows: admission weight on 07/07/22 was 157 pounds (lbs.) On 07/14/22, the resident weighed 154.8 lbs. On 07/20/22, the resident weighed 157 lbs. On 08/30/22, the resident weighed 148.2 lbs. (5.6% weight loss in 41 days). No further weights documented until this surveyor requested a weight on 09/27/22 at 11:06 AM. Licensed Nurse (LN) H, obtained a weight of 151.4. Interview, on 09/27/22 at 11:15 AM, with LN H, revealed staff to obtain weekly weights. Interview, on 09/27/22 at 11:27 AM, with dietary staff BB, revealed the resident did have weight loss and the Registered Dietician addressed this with recommendations sent to the physician and he/she ordered Boost twice a day and weekly weights. Dietary staff BB stated nursing staff administered the Boost. Interview, on 09/27/22 at 3:48 PM, with Certified Medication Aide (CMA) RR, revealed the Medication /Treatment Administration Record, (MAR/TAR) lacked the order for administration of the Boost. Interview, 09/27/22 at 03:51 PM, with Administrative Nurse F, revealed the order for Boost was incorrectly entered and this did not transfer over to MAR/TAR. Administrative Nurse F stated the documentation area for the weekly weights did not allow staff to record the weight but thought staff did obtain them as ordered. Interview, on 09/28/22 at 11:57 AM, with Administrative Nurse D, confirmed lack of administration of Boost, but thought staff did obtain weekly weights and had one weight (149.6) obtained on 09/25/22. The facility policy Nutritional Intervention Program, revised 02/04/2021, instructed staff to provide appropriate nutritional interventions to residents who have been identified as nutritionally At risk as indicated by weight loss, significant lab or as determined by the attending physician. The facility failed to ensure nutritional interventions as recommended by the registered dietician and ordered by the physician were in place for this resident with a 5.6% weight loss in 41 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents with 16 selected for review including five reviewed for unnecessary medications. Based on record review and interview, the facility failed to accurately monitor abd hold an antihypertensive medication (for high blood pressure) when the blood pressure was out of the physician ordered parameters for Resident (R)26 and failed to accurately monitor and notify the physician for R47 when the pulse was out of physician ordered parameters with an anti-hypertensive medication. Findings included: - The Face Sheet for Resident (R)26 included a diagnosis of hypotension (low blood pressure). The Care Plan dated 08/17/22 for R26 included he was at risk for medication side effects and included the medication midodrine (used to treat low blood pressure), which has a Black Box Warning (the strongest form of warning required by the Food and Drug Administration that indicates an increased risk of serious adverse reactions associated with the use of a medication). The Care Plan included a goal for R26 to receive his medications as ordered. The Medication Administration Record (MAR) for July 2022 for R26, included an order for midodrine, 10 milligrams (mg), three times a day, and to hold if the systolic (top number of the blood pressure, measures the force the heart exerts on the walls of the arteries each time it beats) was greater than 120 millimeters of mercury (mmHg), for hypotension, and started on 05/19/22. The Consultant Pharmacist's Medication Regimen Review for recommendations created between 06/01/22 and 06/30/22 for R26, revealed there was a hold parameter on the midodrine based on blood pressure. The parameter required the medication to be held if the systolic blood pressure was greater than 120, which was not reflected in all instances on the MAR. The report included to please review the existence of this hold parameter with staff and ensure they are acting and documenting appropriately. Next to the recommendation a handwritten note included Staff education 06/30/22. The education form dated 06/30/22, revealed the staff were to be sure to read all the special instructions on medication orders and if there were hold parameters on cardiac medications, they were to be sure and hold the medication per order, if the pulse or blood pressure was too low or high. The staff were to fill out a Stop and Watch form any time that happened to make the charge nurse aware and could notify the cardiologist or physician per order. The education included Pay close attention to Midodrine, it is to RAISE blood pressure! The education form lacked staff signatures that they had read and understood and would read and follow all special instructions on medication orders until 07/25/22. The MAR dated 07/01-07/31/22 revealed R26 systolic blood pressure was greater than 120 mmHg and the staff failed to hold the midodrine as ordered by the physician on these dates: 1. On 07/09/22 at 08:00 AM, the blood pressure was 165/80. 2. On 07/13/22 at 12:00 PM, the blood pressure was 168/86. 3. On 07/22/22 at 08:00 AM, the blood pressure was 179/89. 4. On 07/23/22 at 05:00 PM, the blood pressure was 145/58. 5. On 07/26/22 at 12:00 PM, the blood pressure was 126/73. 6. On 07/27/22 at 08:00 AM, the blood pressure was 172/87. The MAR dated 08/01-08/30/22, revealed R26 systolic blood pressure was greater than 120 mmHg and the staff failed to hold midodrine as ordered by the physician on these dates: 1. On 08/04/22 at 12:00 PM, the blood pressure was 133/74. 2. On 08/09/22 at 08:00 AM, the blood pressure was 168/60. 3. On 08/09/22 at 12:00 PM, the blood pressure was 159/81. 4. On 08/11/22 at 08:00 AM, the blood pressure was 128/68. 5. On 08/14/22 at 12:00 PM, the blood pressure was 153/72. 6. On 08/15/22 at 08:00 AM, the blood pressure was 177/73. 7. On 08/16/22 at 05:00 PM, the blood pressure was 150/78. 8. On 08/29/22 at 05:00 PM, the blood pressure was 156/74. The Consultant Pharmacist's Medication Regimen Review dated 08/30/22, revealed there was a systolic blood pressure hold parameter on midodrine and to ensure the staff were aware of the existence of the parameter, abided by it, and documented their actions accurately. The MAR dated 09/01-09/27/22 revealed R26 systolic blood pressure was greater than 120 mmHg and the staff failed to hold midodrine as ordered by the physician on these dates: 1. On 09/01/22 at 08:00 AM, the blood pressure was 172/81. 2. On 09/02/22 at 08:00 AM, the blood pressure was 176/89. 3. On 09/03/22 at 08:00 AM, the blood pressure was 139/64. 4. On 09/03/22 at 12:00 PM, the blood pressure was 178/82. 5. On 09/24/22 at 05:00 PM, the blood pressure was 126/64. 6. On 09/26/22 at 05:00 PM, the blood pressure was 143/75. On 09/27/22 at 11:57 AM, Certified Medication Aide (CMA) R stated when a medication has been held due to parameters, there was a place in the record to document the medication was not given and a place to document why the medication was held. The nurse would then be notified when the medication was held. The facility provided education about holding medications when out of physician ordered parameters and added a guide sheet to the top of the medication cart. R26 has special instructions with his medication ordered not included in the guide sheet. On 09/27/22 at 12:13 PM, Licensed Nurse (LN) G stated the CMA's let her know if a blood pressure was out of parameters most of the time when we would recheck the blood pressure. If the medication had to be held, it would be designated on the MAR. LN G stated more recently since back from the hospital his midodrine has had to be held for his systolic blood pressure greater than 120 mmHg. LN G stated would report to the physician when there were trends of holding. On 09/27/22 at 12:18 PM, Administrative Nurse D stated the staff were expected to hold a medication when out of physician ordered parameters. Administrative Staff D stated, Concerns: administrative Staff E did one on one education with the team about parameters with the medications. On 09/27/22 at 12:28 PM, Administrative Nurse E stated she provided education to the staff one on one and during their huddles. and stated after the education she did not follow up to see if the staff were holding the medication per the physician ordered parameters. Administrative Nurse E stated late spring or early summer she had the staff sign the education sheet but did not think she had them sign anything when re-educated. Administrative Nurse E stated Administrative Nurse D had just called her and had found the education sheet. On 09/27/22 at 12:38 PM, Administrative Nurse D stated the education regarding the medication and parameters began on 06/3022 and signatures were not obtained at that time, so when the education given during huddles was done, she began having Administrative Nurse E get staff signatures and dates. On 09/27/22 at 02:01 PM, Consultant HH stated on her visit on 09/16/22 she did not write any recommendations regarding the midodrine as R26 had been in the hospital during part of that month and she did see instances where the staff had been holding the medication. Consultant HH stated she did write a note to nursing on 08/30/22, reminding them of the physician ordered parameters for the midodrine. On 09/27/22 at 02:31 PM CMA S stated medication should not be given when out of physician ordered parameters and charted by mistake on 09/26/22 at 05:00 PM that she gave the medication, she must of hit the wrong button when documenting, the staff document when the medication was held, and that was a good catch. CMA S stated R26's systolic blood pressure was frequently above 120 and believed the nurse was aware of that. CMA S stated she corrected yesterday's documentation. The facility policy Administering Medications dated 11/11/19 revealed medications must be administered in accordance with the orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document information. The facility failed to accurately monitor the resident's blood pressure medication and hold it as ordered on 20 occurrences when his systolic blood pressure was out of the physician ordered parameters (greater than 120 mmHg) increasing his risk of having an elevated blood pressure. - The Face Sheet for Resident (R)47 included diagnoses of heart failure, hypertension (elevated blood pressure) and atrial fibrillation (rapid, irregular heartbeat). The Care Plan dated 07/12/22, for R47 included a goal of no exacerbations of his diagnoses over the next 90 days. His diagnoses included heart failure, atrial fibrillation, and hypertension. Staff were to monitor for exacerbations and report them to the charge nurse and/or the primary care primary care physician. The Orders tab for R47 included: On 07/07/22, metoprolol tartrate (medication used to treat hypertension and heart failure), 50 milligrams (mg), three times a day, and to call the physician if the pulse was greater than 100 or less than 50, or his systolic blood pressure (top number of the blood pressure, measures the force the heart exerts on the walls of the arteries each time it beats) was greater than 200 or less than 80. On 07/08/22, the physician order diltiazem (medication which can be used to treat hypertension), 180 mg, every day and to call the primary care physician for a pulse greater than 100 or less than 50 or systolic blood pressure greater than 200 or less than 80. The Consultant Pharmacist's Medication Regimen Review dated 06/30/22 for R47 revealed there were pulses over 100 documented on the Medication Administration Record (MAR) and to please ensure there was documentation reflecting prescriber contact, per the order on the diltiazem. Handwritten note dated 06/30/22 on the report stated, Fax sent to doctor. The Fax Form for Non-immediate Communication dated 06/30/22 for R47 revealed the diltiazem dose decreased to 180 mg, every day, on 05/25/22 and his pulses continue to run high. The form included that the facility attached his pulse and blood pressure report from 05/01/22 to current date and his medication list and asking if any the physician would like to make any changes to his medications. The physician responded on 07/15/22 Last halter monitor (portable device used to monitor heart activity) showed bradycardia so do not want to change any medication at this time. The education form dated 06/30/22, revealed the staff were to call the primary care physician if vital signs were above or below parameters and to be sure and read all the special instructions on medication orders. The Medication Administration Summary dated 08/01-08/31/22, for R47 revealed on 08/06/22, R47's pulse was 111 and on 08/06/22, his pulse was 113 for the morning dose of the diltiazem and metoprolol. The Medication Administration Summary dated 09/01-09/27/22, for R47revealed on 09/21/22 his pulse was 105 and on 09/23/22 his pulse was 101 for the morning dose of the diltiazem and metoprolol. Review of the Progress Notes dated 08/06-09/24/22, lacked physician notification of R47's pulse greater than the ordered parameters of 100. On 09/28/22 at 11:20 AM, Certified Medication Aide (CMA) R stated when a pulse was out of the physician ordered parameters for a medication, she would let the nurse know by calling them, sending them an electronic mail notification, or by filling out a Stop and Watch form. CMA R stated she notified the nurse on 09/21/22 and 09/23/22 of R47's pulse being greater than 100. On 09/28/22 at 11:23 AM, Licensed Nurse (LN) G stated when the pulse was out of the physician ordered parameters, the CMA was to contact the nurse so they could contact the physician and recheck the vital signs. LN G stated the physician notification would be documented in the progress notes and R47's notes lacked documentation for the elevated pulse on 09/21/22 and 09/23/22. LN G stated she worked both days and was 100 percent on Wednesday (09/21/22) she told the physician when she was here but did not recall if the physician had been notified on 09/23/22. On 09/28/22 at 11:36 AM, Administrative Nurse D stated she would expect the staff to notify the physician when the vitals were out of parameters for a medication order within 24 hours and the notification should be documented in the progress notes. Administrative Nurse D stated the physicians were in the building a lot and the staff notify them when things were out of parameters but did not always chart that. On 09/28/22 at 11:51 AM, LN G stated she was going to call the doctor to see if the order for notification of pulse greater than 100 continued to need to be in place, as resident's cardiologist was aware (date unknown) of the pulse out of parameters and no changes to his medication were done after the [NAME] monitor test. On 09/28/22 at 12:29 PM, LN G revealed the doctor was made aware of the pulses and provided a Physician Progress Note dated 09/28/22. The Physician Progress Note dated 09/28/22, revealed the chief complaint for R47 was occasional pulse greater than 100 first thing in the morning before medications. R47 had atrial fibrillation and his cardiologist was aware of the pulse and did a [NAME] monitor test last month. The note included a new order to change the metoprolol from 50 mg three times a day to Toprol XL (metoprolol), 200 mg, every day. The facility policy Change in a Resident's Condition or Status dated 06/20/22, revealed the nurse would notify the resident's attending physician or physician on call when there has been specific instruction to notify the physician of changes in the resident's condition. Except in medical emergencies, notifications would be made within 24 hours of a change occurring in the resident's medical condition or status. The nurse would record in the resident's medical record information relative to changes in the resident's medical condition or status. The facility failed to accurately monitor and to notify the physician when R47's pulse was out of the physician ordered parameters on four occasions and when staff notified the physician, more than 24 hours after an elevated pulse, the physician changed the resident's medication order.

The facility reported a census of 52 residents which included five residents reviewed for vaccine administration. Based on record review and interview, the facility failed to ensure residents who declined the influenza, pneumococcal and covid-19 vaccinations were provided with the benefits verses risk for these vaccines and had a system in place for acknowledgement of the benefit verses risk for declination of these vaccines. Findings included: - Review of Resident (R)22's electronic medical record Preventive Health Care, and Vaccine Spread Sheet as of 09/22/22 revealed the resident declined the Influenza vaccine, and fourth Covid-19 booster. Review of R 15's electronic medical record Preventive Health Care, and Vaccine Spread Sheet as of 09/22/22 revealed the resident refused the fourth Covid-19 booster. Review of R 18's electronic medical record Preventive Health Care, and Vaccine Spread Sheet as of 09/22/22 revealed the resident refused the Covid-19 vaccine. Review of R 36's electronic medical record Preventive Health Care, and Vaccine Spread Sheet as of 09/22/22 revealed the resident refused the Covid-19 vaccine. Review of R 31's electronic medical record Preventive Health Care, and Vaccine Spread Sheet as of 09/22/22 revealed the resident refused the Covid-19 vaccine and influenza Review of R 18's electronic medical record Preventive Health Care, and Vaccine Spread Sheet as of 09/22/22 revealed the resident refused the Covid-19 vaccine. The electronic medical record failed to evidence acknowledgement of receipt the vaccine's benefit verses risk statements to make an informed decision regarding the declination of the vaccine as required. Interview, on 09/27/22 at 4:00 PM, with Administrative Nurse E, revealed the facility did not have a system in place to document the receipt of the vaccine's benefit verses risk statements for informed declination. The facility policy for Pneumococcal Vaccine effective 03/19/18, instructed staff residents/representatives have the right to refuse vaccinations. If refused appropriate entries will be documented in each resident's medical record indicating the date of refusal of the vaccine. The facility policy Influenza Vaccine effective 06/30/17, instructed staff the resident's refusal of the vaccine on the Informed Consent for Influenza Vaccine, and placed in the resident's medical record. The facility did not provide a policy for declination of the Covid-19 vaccine. The facility failed to establish a system to bear evidence of acknowledgement of receipt of the vaccine's benefit verses risk statements to make an informed declination of the vaccine as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents. Based on observation and interview, the facility failed to store prepare and serve foods under sanitary conditions to the residents of the facility. Findings included: - On 09/21/22 at 03:11PM, the initial tour of the main kitchen, revealed the following areas/items of concerns: The following items were found to be expired: An open bag of powder sugar, undated. Two opened bags with pasta, undated. One opened large bag of bacon bits, undated, with use by date printed as 09/01/22. One opened large container of sour cream, with a use by date of 09/08/22. One, five-pound bag of grated Parmesan and [NAME] cheese, with use by date of 08/31/22. One five-pound bag of grated Swiss cheese with a use by date of 08/31/22. A small, wrapped package of Oreo cookies with a use by date of 08/27/22. One 24-ounce container with cheese pimento spread with a use by date of 08/11/22. Three 32-ounce containers of ketchup with a use by date of 09/14/22. Inside of a freezer, inside of an open plastic bag in an open box, were 16 hamburger patties resealed and without an open or expiration date. During an interview on 09/21/22 at 03:35 PM, with Dietary Staff BB stated she would expect the cook to monitor the use by dates on food items. On 09/26/22 at 10:57 AM, Dietary Staff CC was moving frozen raw chicken from a bag onto a cooking sheet and did not perform hand hygiene before or after handling the raw chicken. The staff then continued without hand hygiene touching items and began to gather equipment while touching the side of the measuring cup, multiple utensils in the drawer, dumped ground chicken into the blender and added broth following a menu. The staff blended this to the appropriate texture and used a spatula that, in between uses, was laid directly across the bowl that held the chicken. Staff then covered the food and placed it in warmer. The staff continued on without hand hygiene and gathered cooked broccoli touching potholders and foil that covered the broccoli. She measured out amounts for one puree and blended these in a clean blender. The staff then placed the used spatula directly on the table, touches the inside of the serving dish and portioned out the food then covered the food and placed it in warmer. The staff then went to the walk- in refrigerator and obtained a lemon cake single serving, opened and placed it in blender, added milk with a scoop and placed the scoop/spatula directly on table. Staff then covered the food and placed it in the refrigerator. During this entire observation the staff failed to perform any hand hygiene, contaminating all food items touched. During an interview, on 09/27/22 at 07:36 AM, Dietary Staff BB stated the expectation was for staff to complete hand hygiene between each task. Dietary Staff BB stated the expectation was for hand hygiene following touching chicken and before beginning the pureed process. Dietary Staff BB stated staff were expected to not lay utensils directly on the counter, as sheets/ barriers were available for that purpose. Dietary Staff BB confirmed staff should complete hand hygiene multiple times during the food pureeing process. Review of the Infection Control Policy dated 08/31/22, stated Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: [§] c. Before and during food preparation. The facility failed to store, prepare and serve food in a sanitary manner for the residents of the facility.