**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 92 residents. Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for two residents, that included Resident (R)31, regarding the failure to complete the Care Area Assessments (CAA) for nutrition and pressure ulcers (PU) and R 33, regarding the failure to complete CAAs for psychotropic drugs, pain and mood state. Findings included: - Review of Resident (R)31's electronic medical record (EMR) included the following diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated 02/06/24, lacked documentation for cognition. The resident had a significant weight loss, without a prescribed weight loss regimen and was at risk for the development of pressure ulcers (PU) with one unhealed stage III (full thickness pressure injury extending through the skin into the tissue below) PU at the time of the assessment, present on admission. The Nutritional Status and Pressure Ulcer/Injury Care Area Assessments (CAA), dated 02/06/24, triggered but lacked an analysis of findings. The care plan for PUs, revised 02/07/24, instructed staff to turn and reposition the resident off his back and from side to side as often as possible. Weight loss was to be expected for the resident due to his terminal diagnosis. On 03/27/24 at 04:30 PM, Administrative Staff A stated the facility was aware of the MDSs were not being completed properly. The facility had a new MDS coordinator who was currently learning the process to complete the MDSs and CAAs appropriately. The facility policy for Expanded Assessment Areas, revised 05/20/17, included: The facility utilized the Resident Assessment Instrument (RAI) for accurate completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA). The facility failed to complete an accurate MDS for this dependent resident regarding the failure to complete the Nutrition and PU CAAs. - Review of Resident (R)33's medical record revealed diagnoses that included heart failure, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The resident received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), antidepressant, (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant (medications used to treat the blood from forming clots), diuretic (medications to promote the formation and excretion of urine), opioid (narcotic pain medications) medications, and antibiotic (medication used to treat infections). The Psychotropic (medications that affect mood) Drug Use Care Area Assessment (CAA), dated 05/06/23 was undeveloped. The Pain CAA dated 05/06/23, was not developed. The Mood State CAA dated 05/06/23, was not developed. Interview, on 03/27/24 at 02:20 PM, with Administrative Nurse F confirmed the CAAs were not developed for some residents. Interview, on 03/27/24 at 04:30 PM, with Administrative Staff A, confirmed the MDS and CAAs were lacking in completeness for some residents. The facility followed the Resident Assessment Instrument (RAI) manual when completing the CAAs. The facility failed to ensure staff completed the CAAs for this resident to develop a comprehensive care plan as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 92 residents with 22 residents included in the sample. Based on observation, interview, and record review, the facility failed to revise care plans for two residents. Resident (R)9, related to the failure to care plan a fall with a fractured foot that required a special walking boot, and R9, related to skin care for a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Findings included: - R9's physician orders revealed the following diagnoses: diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and right great toe fracture (broken toe). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was dependent on a walker or wheelchair for mobility. The resident had no recent falls. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15. The resident used a walker and wheelchair for mobility. The resident had a fall with major injury since last MDS. The resident received Physical Therapy and Occupational Therapy (PT, OT) for rehabilitation. The Activities of daily living (ADL) Functional/ Rehabilitation Care Area Assessment (CAA) dated 01/04/24 revealed the resident had impaired balance and transition during transfers, and functional impairment in activity. The care plan failed to resvise the care plan to include the fall on 01/28/24 which resulted in a fractured right great toe and use of a walking boot. The physician orders dated 01/29/24 revealed the resident was to wear a surgical boot on the right foot when getting out of bed and off at bedtime, for a fracture of the right great toe. Review of the Reported Incident revealed on 01/28/24 at 03:15 AM, R9 fell from her bed. The fall resulted in a skin tear to her right elbow and a fractured right great toe. R9 was to wear a walking shoe until the fracture healed. Observation on 03/25/24 at 11:45 AM, revealed Certified Nurse Aide (CNA) UU assisted R9 to the dining room. R9 wore the walking boot. On 03/25/24 at 11:50 AM, the resident reported she fell out of bed about 5 weeks ago and had to wear the fracture boot until her fractured toe healed. On 03/27/24 at 10:30 AM Administrative Nurse F reported the care plan should have been revised to include her fall with a fracture and interventions. On 03/25/24, a policy for Care Plans was requested and was referred to the MDS manual for instructions. The facility failed to revise R9's care plan regarding this resident's fall/interventions to guide staff with cares. - Review of Resident (R)20's medical record revealed diagnoses that included deep vein thrombosis (DVT blood clots) in the right and left leg, heart disease, diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), and unstageable pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction and the wound is covered by a layer of dead tissue). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The resident had an unstageable pressure ulcer present upon admission/reentry. The resident had no impairment in function range of motion in her upper or lower extremities and was dependent on staff for Activities of Daily Living (ADL). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a BIMS score of nine, which indicated moderate cognitive impairment. The resident had no impairment in her upper or lower extremities, was dependent on staff for ADL, and at risk for pressure ulcers with no current pressure ulcer injury. The Pressure Ulcer Care Area Assessment (CAA), dated 02/05/24, assessed the resident due to impairment with functional mobility, recent acute illness, and incontinence. Licensed staff were to assess R20's skin each week and initiate proper interventions to prevent skin breakdown, and caregivers assist with repositioning as needed. The Care Plan reviewed 02/21/23, instructed staff the resident admitted to hospice. The resident had a potential for impairment of skin integrity related to fragile skin. An intervention added 11/21/23, instructed staff to avoid positioning the resident on her heals and use foam always off-loading boots when in bed due to a deep tissue injury (DTI) to the left heel following hospitalization (11/13-11/20/23). Staff instructed to apply skin prep (a solution when applied that forms a protective waterproof barrier on the skin) to bilateral (both) heels daily. The care plan failed to include the right heel pressure ulcer which developed on 02/09/24 and failed to include updated interventions for off loading devices. On 02/29/24, the physician instructed staff to apply skin prep to bilateral heels daily. A Skin/Wound New Observation note dated 02/09/24, indicated the resident developed a 1.5 by 1 centimeter (cm) deep tissue injury to her right heel. This note indicated staff to continue to utilize the off-loading boots. A Skin/Wound Weekly Observation note, dated 02/13/24, indicated the DTI measured 3.3 cm by 4.5 cm and staff instructed to continue the use of off-loading boots. A Skin/Wound Weekly Observation note, dated 02/20/24, indicated the DTI measured 4 cm by 6 cm, with a mushy feeling. A Skin/Wound Weekly Observation note, dated 03/07/24, indicated the DTI measured 6 cm by 3.5 cm with a depth of 1 cm, with wound edges intact. The note indicated a treatment of skin prep to both heels and float the heel off the bed with pillows. A Skin/Wound Weekly Observation note, dated 03/12/24, indicated the DTI measured 7 cm by 4 cm with no depth. This note indicated the area improved with softness decreased. A Skin/Wound Weekly Observation note, dated 03/19/24, indicated the DTI measured 5.2 cm by 7.4 cm with a dark colored eschar (dead tissue) and no changes in treatment. A Skin/Wound Weekly Observation note, dated 03/26/23, indicated the DTI measured 4.5 cm by 6.3 with 100% eschar with no changes in treatment. An Interdepartmental Team (IDT) Comprehensive Care Review dated 02/15/24, indicated the resident had a new DTI to her right heel with a wound treatment of offloading the heels by floating the heels. An Interdepartmental Team (IDT) note, dated 02/22/24, indicated the right heel decreased in size. An Interdepartmental Team (IDT) note, dated 03/01/24, indicated the right heel as mushy with the appearance of a blood blister. An Interdepartmental Team (IDT) note, dated 03/14/24, indicated the resident had a DTI to the right heel with stable wound margins. The resident had DVT's to both lower legs and was on hospice for end-of-life cares. The resident had a pressure redistributing mattress on her bed and used a pillow to float her heels off the surface. Observation, on 03/26/24 at 09:45 AM, revealed the resident seated in her wheelchair in her room. Certified Medication Aide (CMA) XXX and CMA Y assisted R20 to pivot transfer into her bed. CMA Y placed a pillow under the resident's calves to elevate her heels off the bed. Observation, on 03/26/24 at 10:30 AM, revealed the pillow remained under the resident's calves, but her heels laid directly on the bed. Licensed Nurse (LN) G removed the resident's socks and revealed her right heal with blue black eschar. The left heel skin was pink and intact. Interview, at that time with LN G, revealed staff applied specialized foam boots to R20's bilateral heels and the left pressure ulcer heeled, but she developed a pressure ulcer on her right heel despite the boots. LN G stated the resident could move her foot in the boot causing a shift in the off-loading ability of the boots, so staff used pillows to off load her heels. LN G confirmed the pillow ineffective in keeping the resident's heels offloaded and obtained a blanket for additional off-loading. LN G stated R20 received hospice services, and she would inform hospice of the need for more effective off-loading device. Observation, on 03/26/24 at 02:05 PM, with Administrative Nurse E, revealed the readmitted to the facility with a deep tissue injury to her left heel. The resident had bilateral DVT in her lower extremities. The resident wore specialized pressure relieving boots and with treatments, the left heel injury resolved, however, the right heel injury developed inspire of the pressure relieving boots, so staff used pillows to elevate her heels off the bed. Administrative Nurse E confirmed the pillows may not maintain their buoyancy over time to keep the heels off the bed. Administrative Nurse E measured the right heel blue/black eschar as 4.5 cm by 6.3 centimeters and then applied skin prep to both heels. Administrative Nurse E confirmed the care plan lacked updated interventions for the right heel pressure ulcer and need for alternative means to float the resident's heels. Observation, on 03/27/24 at 09:20 AM, revealed the resident sitting up in her bed, eating breakfast. A pillow and blanket positioned under the resident's calves, but her right and left heel lay directly on the surface of the mattress. Interview, at that time with CMA P, revealed the resident did move her feet when in bed. Observation on 03/27/24 at 09:59 AM, revealed Consulting Therapy Staff GG, applied a foam shelf-like positioning device with elevated lateral (outer edges) sides. Consulting Therapy Staff GG stated she was consulted for R20's heel positioning needs due to the development of the DTI to her right heel. Consulting Therapy Staff GG stated she felt this device was a more appropriate device for floating R20's heels. Interview, on 03/28/24 at 10:00 AM, with Administrative Nurse D, stated she would expect licensed nursing staff to revise the care plan to include the development of the right heel pressure ulcer and assess effectiveness of heel floating interventions and initiate alternatives. The facility policy Standards of Care and Care Planning Practice dated 04/01/23, instructed staff instructed staff to ensure that all services are provided to the resident to ensure the care plan is resident centered and specific to the unique needs of each resident. The facility failed to review and revise R20's care plan to include the development of the right heel deep tissue injury and assess the effectiveness of off-loading interventions for the prevention/healing of her deep tissue injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 92 residents with 22 residents sampled, including five residents reviewed for Activity of Daily Living (ADL). Based on observation, interview and record review, the facility failed to provide appropriate care to one dependent Resident (R)241, regarding facial shaving. Findings included: - The Physician's Order Sheet (POS), dated 03/21/24, documented Resident (R)242 had a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident was dependent on staff for all activities of daily living (ADL). The Functional Abilities Care Area Assessment (CAA), dated 01/15/24, did not trigger. The Medicare 5-day MDS, dated 03/16/24, documented the staff assessment for cognition revealed severe impairment. He was dependent on staff for all ADLs. The care plan for ADLs, revised 01/30/24, instructed staff the resident was dependent on staff for all ADLs. Review of the resident's electronic medical record (EMR), from 02/27/24 through 03/26/24, revealed the resident was dependent on staff for personal hygiene, including shaving. On 03/25/24 at 01:50 PM, the resident sat in his room in his wheelchair. He was unshaven with scraggly overgrowth of facial hair. On 03/26/24 at 09:55 AM, the resident sat in his wheelchair in the dining room. He remained unshaven with scraggly overgrowth of facial hair. On 03/27/24 at 08:29 AM, the resident sat in his wheelchair in the commons area. He remained unshaven with scraggly overgrowth of facial hair. On 03/26/24 at 01:15 PM, Certified Medication Aide (CMA) NN stated residents were to be shaved on their shower days. On 03/27/24 at 11:13 AM, Certified Nurse Aide (CNA) RR stated residents were to be shaved on their shower days. On 03/26/24 at 12:26 PM, Licensed Nurse (LN) H stated the staff were to shave the residents on their shower days and whenever they wanted to be shaven. On 03/27/24 at 01:38 PM, Administrative Nurse D stated staff were expected to shave residents on their shower days and as needed. The facility policy for Activities of Daily Living (ADL), revised 01/2024, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition. The facility failed to provide appropriate care to this dependent resident regarding facial shaving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 92 residents with 22 residents selected for review and included three residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure alternative methods of pressure relief provided for one Resident (R)20, of the three residents reviewed for pressure ulcers. Findings included: - Review of Resident (R)20's medical record revealed diagnoses that included deep vein thrombosis (DVT blood clots) in the right and left leg, heart disease, diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), and unstageable pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction and the wound is covered by a layer of dead tissue). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The resident had an unstageable pressure ulcer present upon admission/reentry. The resident had no impairment in function range of motion in her upper or lower extremities and was dependent on staff for Activities of Daily Living (ADL). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a BIMS score of nine, which indicated moderate cognitive impairment. The resident had no impairment in her upper or lower extremities, was dependent on staff for ADL, and at risk for pressure ulcers with no current pressure ulcer injury. The Pressure Ulcer Care Area Assessment (CAA), dated 02/05/24, assessed the resident due to impairment with functional mobility, recent acute illness, and incontinence. Licensed staff were to assess R20's skin each week and initiate proper interventions to prevent skin breakdown, and caregivers assist with repositioning as needed. The Care Plan reviewed 02/21/23, instructed staff the resident admitted to hospice. The resident had a potential for impairment of skin integrity related to fragile skin. An intervention added 11/21/23, instructed staff to avoid positioning the resident on her heals and use foam off-loading boots when in bed at all times due to a deep tissue injury (DTI) to the left heel following hospitalization (11/13-11/20/23). Staff instructed to apply skin prep (a solution when applied that forms a protective waterproof barrier on the skin) to bilateral (both) heels daily. On 02/29/24, the physician instructed staff to apply skin prep to bilateral heels daily. A Skin/Wound New Observation note dated 02/09/24, indicated the resident developed a 1.5 by 1 centimeter (cm) deep tissue injury to her right heel. This note indicated staff to continue to utilize the off-loading boots. A Skin/Wound Weekly Observation note, dated 02/13/24, indicated the DTI measured 3.3 cm by 4.5 cm and staff instructed to continue the use of off-loading boots. A Skin/Wound Weekly Observation note, dated 02/20/24, indicated the DTI measured 4 cm by 6 cm, with a mushy feeling. A Skin/Wound Weekly Observation note, dated 03/07/24, indicated the DTI measured 6 cm by 3.5 cm with a depth of 1 cm, with wound edges intact. The note indicated a treatment of skin prep to both heels and float the heel off the bed with pillows. A Skin/Wound Weekly Observation note, dated 03/12/24, indicated the DTI measured 7 cm by 4 cm with no depth. This note indicated the area improved with softness decreased. A Skin/Wound Weekly Observation note, dated 03/19/24, indicated the DTI measured 5.2 cm by 7.4 cm with a dark colored eschar (dead tissue) and no changes in treatment. A Skin/Wound Weekly Observation note, dated 03/26/23, indicated the DTI measured 4.5 cm by 6.3 with 100% eschar with no changes in treatment. An Interdepartmental Team (IDT) Comprehensive Care Review dated 02/15/24, indicated the resident had a new DTI to her right heel with a wound treatment of offloading the heels by floating the heels. An Interdepartmental Team (IDT) note, dated 02/22/24, indicated the right heel decreased in size. An Interdepartmental Team (IDT) note, dated 03/01/24, indicated the right heel as mushy with the appearance of a blood blister. An Interdepartmental Team (IDT) note, dated 03/14/24, indicated the resident had a DTI to the right heel with stable wound margins. The resident had DVT's to both lower legs and was on hospice for end-of-life cares. The resident had a pressure redistributing mattress on her bed and used a pillow to float her heels off the surface. Observation, on 03/26/24 at 09:45 AM, revealed the resident seated in her wheelchair in her room. Certified Medication Aide (CMA) XXX and CMA Y assisted R20 to pivot transfer into her bed. CMA Y placed a pillow under the resident's calves to elevate her heels off the bed. Observation, on 03/26/24 at 10:30 AM, revealed the pillow remained under the resident's calves, but her heels laid directly on the bed. Licensed Nurse (LN) G removed the resident's socks and revealed her right heal with blue black eschar. The left heel skin was pink and intact. Interview, at that time with LN G, revealed staff applied specialized foam boots to R20's bilateral heels and the left pressure ulcer heeled, but she developed a pressure ulcer on her right heel despite the boots. LN G stated the resident could move her foot in the boot causing a shift in the off-loading ability of the boots, so staff used pillows to off load her heels. LN G confirmed the pillow ineffective in keeping the resident's heels offloaded and obtained a blanket for additional off-loading. LN G stated R20 received hospice services, and she would inform hospice of the need for more effective off-loading device. Observation, on 03/26/24 at 02:05 PM, with Administrative Nurse E, revealed the readmitted to the facility with a deep tissue injury to her left heel. The resident had bilateral DVT in her lower extremities. The resident wore specialized pressure relieving boots and with treatments, the left heel injury resolved, however, the right heel injury developed inspire of the pressure relieving boots, so staff used pillows to elevate her heels off the bed. Administrative Nurse E confirmed the pillows may not maintain their buoyancy over time to keep the heels off the bed. Administrative Nurse E measured the right heel blue/black eschar as 4.5 cm by 6.3 centimeters and then applied skin prep to both heels. Administrative Nurse E confirmed the care plan lacked updated interventions for the right heel pressure ulcer and need for alternative means to float the resident's heels. Observation, on 03/27/24 at 09:20 AM, revealed the resident sitting up in her bed, eating breakfast. A pillow and blanket positioned under the resident's calves, but her right and left heel lay directly on the surface of the mattress. Interview, at that time with CMA P, revealed the resident did move her feet when in bed. Observation on 03/27/24 at 09:59 AM, revealed Consulting Therapy Staff GG, applied a foam shelf-like positioning device with elevated lateral (outer edges) sides. Consulting Therapy Staff GG stated she was consulted for R20's heel positioning needs due to the development of the DTI to her right heel. Consulting Therapy Staff GG stated she felt this device was a more appropriate device for floating R20's heels. Interview, on 03/28/24 at 10:00 AM, with Administrative Nurse D, stated she would expect staff to assess effectiveness of heel floating interventions and initiate alternatives. The facility lacked a policy specific for pressure ulcers. The facility policy Standards of Care and Care Planning Practice dated 04/01/23, instructed staff instructed staff to ensure that all services are provided to the resident to ensure the care plan is resident centered and specific to the unique needs of each resident. The facility failed to provide effective heel off-loading interventions in a timely manner for the prevention/healing of R20's deep tissue injury.

The facility reported a census of 92 residents with 22 selected for review, which included three residents reviewed for restorative services. Based on observation, interview and record review, the facility failed to ensure staff provided range of motion (ROM) services for one Resident (R)78, of the three residents reviewed for restorative. Findings included: - Review of Resident (R)78's electronic medical record (EMR) revealed diagnoses which included multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord) and quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord). The Modification of admission Minimum Data Set (MDS), dated 08/06/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required extensive assistance of staff with all activities of daily living (ADL) and had impairment on both sides of her upper and lower extremities. She received restorative cares for two days of the assessment period. The Activities of Daily Living Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/06/23, did not trigger. The Quarterly MDS, dated 01/23/24, documented the staff assessment for cognition revealed the resident was independent with daily decision making. She was dependent on staff for all ADLs and had impairment on both sides of her upper and lower extremities. She received active range of motion (AROM) four days of the assessment period. The care plan for restorative cares, revised 11/13/23, instructed staff the resident was to receive passive range of motion (PROM) to the upper and lower extremities and neck. Review of the Nursing Restorative Program instructions, provided by the facility, documented staff were to provide PROM and AROM with prolonged stretch at the end range or within pain tolerance for shoulder flexion (bending of a limb or joint), abduction (moving away from the body). Staff were to provide elbow flexion, extension (moving towards the body), pronation (turn so that the palm was facing downward or inward) and supination (turn so the palm is facing outward). Staff were also to perform wrist and finger flexion and extension. Perform gentle neck stretches turning the resident's head side to side, up and down and ear to shoulder. PROM and AROM of the bilateral (both) lower extremities in supine (lying on the back) hip flexion, extension, abduction and adduction (movement of a limb toward the middle of the body). Restorative programs are to be completed for 15 minutes three to six times per week. Review of the resident's EMR from 02/28/24 through 03/27/24, revealed the staff failed to complete restorative cares for eight of the day's restorative was to be performed. On 03/25/24 at 10:35 AM, Consultant staff HH stated the resident's fingernails were beginning to dig into her other fingers due to her hands being clenched so tightly. He was unsure if the resident received the ROM services she was supposed to be receiving. On 03/26/24 at 08:14 AM, Certified Nurse Aide (CNA) T stated the staff do not do ROM exercises with the resident. They had a restorative aide who would do ROM, but she quit a few weeks ago. On 03/26/24 at 08:19 AM, Certified Medication Aide (CMA) MM stated the staff will put on the resident's braces and splints but do not do ROM exercises with the resident. On 03/26/24 at 12:57 PM, CNA ZZZ stated there had not been a restorative aide for the green houses for about six weeks. The CNAs in the green houses do not do the ROM because they do not know how. On 03/27/24 at 10:37 AM, CNA QQ stated they do not do ROM exercises with the resident. On 03/26/24 at 10:37 AM, Licensed Nurse (LN) G stated the CNAs and CMAs on the green houses do not do ROM with the residents. They have not had a restorative aide in the green houses for a little over a month. On 03/28/24 at 09:51 AM, Administrative Nurse D stated the restorative aide for the green houses left about a month or two ago and were aware the restorative program was an issue at this time. The facility policy for Restorative Nursing Care, undated, included: Restorative nursing care shall be performed daily for residents who require such services. These programs include maintaining good body alignment and proper positioning and assisting residents with their routine ROM exercises. The facility failed to provide appropriate treatment and services to prevent further decrease in ROM for this dependent resident with hand contractures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 92 residents with 22 residents included in the sample, including four residents reviewed for indwelling urinary catheters (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 utilize an anchoring device for one Resident (R)78 and failed to ensure catheter tubing was kept up off the floor for R 242. Findings included: - Review of Resident (R)78's electronic medical record (EMR) revealed a diagnosis of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). The Modification of admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/06/23, documented the resident had an indwelling urinary catheter. The Quarterly MDS, dated 01/23/24, documented the staff assessment for cognition revealed the resident was independent with daily decision making. She was dependent on staff for all activities of daily living (ADLs) and had a urinary catheter. The care plan for the urinary catheter, dated 08/01/23, instructed staff to keep the catheter bag and tubing below the level of the bladder. On 03/26/24 at 08:14 AM, Certified Nurse Aide (CNA) T and Certified Medication Aide (CMA) MM were performing catheter care on the resident as she rested in her bed. When staff removed the resident's pants, the catheter tubing was not anchored to the resident's thigh. The anchoring device was folded onto itself, causing it to be ineffective in preventing tugging of the catheter tubing. On 03/26/24 at 08:14 AM, CNA T stated the catheter tubing should be anchored to the resident's leg to prevent the tubing from tugging and possibly causing pain or injury to the resident. On 03/26/24 at 08:19 AM, CMA MM stated the resident's catheter tubing anchor kept coming off, so the staff do not always put the anchor back on her. On 03/26/24 at 09:01 AM, Licensed Nurse (LN) G stated residents with a urinary catheter should have an anchor for the tubing to prevent injury to the resident. She was unaware the anchor kept coming off the resident. On 03/27/24 at 01:38 PM, Administrative Nurse D stated it was the expectation for all residents with an indwelling urinary catheter to have an anchoring device to prevent the tubing from being pulled. The facility policy for Urinary Catheter Care, dated 02/2017, included: Staff shall ensure the catheter tubing remains secure by using a catheter securing device to reduce friction and movement at the insertion site. The facility failed to utilize an anchoring device for this dependent resident with a urinary catheter in order to prevent injury to the resident. - Review of Resident (R)242's electronic medical record (EMR) revealed a diagnosis of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident was dependent on staff for all activities of daily living (ADL's) and was always incontinent of bowel and bladder. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 01/15/24, documented the resident was dependent on staff for toileting hygiene. The Medicare 5-Day MDS, dated 03/16/24, documented the staff assessment for cognition revealed severe impairment. The resident was dependent on staff for all ADLs and was always incontinent of bowel and bladder. The indwelling catheter care plan, revised 03/25/24, instructed staff to position the catheter bag and tubing below the level of the bladder. Review of the resident's EMR revealed the following physician's order: Indwelling urinary catheter for acute urinary retention (inability to urinate), ordered 03/20/24. On 03/26/24 at 09:55 AM, the resident sat in his wheelchair in the dining room. The catheter bag hung underneath the resident's wheelchair seat with the catheter tubing resting directly on the floor. On 03/26/24 at 12:26 PM, the resident sat in his wheelchair in his room. The catheter bag hung underneath the resident's wheelchair seat with the catheter tubing resting directly on the floor. On 03/27/24 at 01:15 PM, the resident sat in his wheelchair in the commons area. The catheter bag hung underneath the resident's wheelchair seat with the catheter tubing resting directly on the floor. On 03/26/24 at 01:15 PM, Certified Medication Aide (CMA) NN stated the catheter tubing should be kept off the floor. On 03/27/24 at 11:13 AM, Certified Nurse Aide (CNA) RR stated the catheter tubing should be kept in the dignity bag and not come into contact with the floor. On 03/27/24 at 01:38 PM, Administrative Nurse D stated the catheter tubing should never be on the floor. It was the expectation for staff to coil the tubing and place it in the dignity bag with the catheter bag. The facility policy for Urinary Catheter Care, dated 02/2017, included: Staff shall ensure catheter tubing and drainage bag are kept off the floor. The facility failed to prevent this dependent resident's catheter tubing from coming into contact with the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 92 residents with 22 residents included in the sample. Based on observation, interview, and record review, the facility failed to monitor one Resident (R)35, for a physician ordered fluid restriction. Findings included: - R35's physician orders revealed the following diagnoses included orthostatic hypotension (blood pressure dropping with change of position), essential (primary) hypertension (elevated blood pressure), viral hepatitis C (inflammatory condition of the liver), chronic obstructive pulmonary disease (COPD, a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic kidney disease, and fluid overload (increase in the volume of extracellular and/or intravascular fluids). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating moderate cognitive impairment. The resident used a wheelchair or walker for mobility. The quarterly MDS dated [DATE], revealed no significant changes in status. The Dehydration/ Fluid Maintenance Care Area Assessment (CAA), dated 10/12/23, revealed R35 was on a fluid restriction, and nursing staff were to monitor the resident's fluid intake. Review of the care plan dated 01/23/24, lacked guidance related to the resident's fluid restriction. The physician's order dated 04/23/23 revealed the following: The resident has a daily 2000 milliliter (ml) fluid restriction. Fluids include anything that is liquid at room temperature. During the day shift, the resident may have 480 ml at breakfast and 360 ml at lunch from dietary. The resident may have 360 ml during the shift from Nursing. A total for dayshift would be 1200 ml. During the evening shift, the resident may have 360 ml at supper from dietary. The resident may have 240 ml during the shift from nursing. A total for evening shift would be 600 ml. During the night shift, the resident may have 180 ml from nursing. A total for night shift would be 180 ml. Observation on 03/25/24 at 01:40 PM revealed the resident sat in his chair in his room with feet elevated. On 03/25/24 at 01:40 PM, the resident reported he was on an 1800 ml fluid restriction, but the staff did not bother him a whole lot because he has been on it a long time and just knows what he can drink and if he wants extra, he will just get it. On 03/26/24 at 11:55 AM, Certified Nursing Assistant (CNA) SS reported she did not know how staff monitored the resident's fluid restriction. She thought it was probably up to dietary to restrict his fluids and thought he usually had a coffee cup and a glass of fluid at each meal. She was unable to determine the amount of fluid would total for a cup of coffee and a glass of fluid. She reported there was no intake sheet to chart his fluids, but as long as he had no fluid in his room, nursing did not need to monitor his fluid intake. On 03/26/24 at 12:10 PM, Licensed nurse (LN) I reported she was not sure what the fluid restriction was. She knew they have a chart in the kitchen to tell how much each size glass held. There was no intake sheet that she was aware of and thought dietary measured the fluids. She reported staff did not monitor the resident's fluid intake. On 03/27/24 at 10:30 AM, Administrative Nurse F reported she would expect the resident's fluid restriction to be included on the care plan. All staff caring for the resident should be aware of his fluid restriction and how to monitor it. The facility lacked a policy related to fluid restrictions. The facility failed to monitor the physician prescribed fluid intake for this resident that required a fluid restriction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R)41's electronic medical record (EMR), dated 03/21/24, included a diagnosis of hypertension (HTN-elevated blood pressure). The Annual Minimum Data Set (MDS), dated 11/16/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition and had a diagnosis of HTN. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 11/16/23, documented the resident had impaired cognition. The Quarterly MDS, dated 02/09/24, documented the resident had a BIMS score of 10, indicating moderately impaired cognition and had a diagnosis of HTN. The care plan for cardiovascular, revised 02/18/24, instructed staff the resident had a diagnosis of HTN and to encourage low salt intake. Review of the resident's EMR revealed the following physician's order: Norvasc (a hypertensive medication used to lower blood pressure-BP), five milligrams (mg), by mouth (po), every day (QD) for HTN. Hold if the systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 120, ordered 12/22/23. Review of the resident's Medication Administration Record (MAR) for February 2024, revealed the following dates the SBP was outside of the ordered parameters and staff administered the medication: On 02/29/24, the resident's BP was 104/58. On 02/22/24, the resident's BP was 113/67. On 02/20/24, the resident's BP was 112/66. On 02/19/24, the resident's BP was 102/56. On 02/15/24, the resident's BP was 112/64. On 02/12/24, the resident's BP was 114/67. On 02/04/24, the resident's BP was 112/59. On 02/01/24, the resident's BP was 105/64. Review of the resident's MAR for March 2024, revealed the following dates the SBP was outside of the ordered parameters and staff administered the medication: On 03/16/24, the resident's BP was 117/60. On 03/21/24, the resident's BP was 113/80. On 03/26/24, the resident's BP was 114/74. On 03/27/24 at 08:22 AM, Certified Medication Aide (CMA) S stated the resident did have a BP parameter for her HTN medication. CMA confirmed she administered the medication to the resident with the BPs outside of parameters. On 03/27/24 at 08:25 AM, Licensed Nurse (LN) H stated the staff were to notify her if a resident's BPs were outside of the parameters ordered by the physician. She would expect the staff to follow physician's ordered parameters when administering medications. On 03/27/24 at 01:38 PM, Administrative Nurse D stated it was the expectation for staff to follow the physician's orders while administering medications, including holding a medication if the resident's BP was outside of the ordered parameters. The facility policy for Administering Medications, revised 02/2022, included: Medications must be administered in accordance with the physician's orders. Vital signs must be verified for the resident prior to administering medications. The facility failed to hold this dependent residents HTN medications when her BPs were outside of the physician's ordered parameters on multiple days. The facility reported a census of 92 residents with 22 residents selected for review, which included five residents reviewed for unnecessary medication use. Based on observation, interview, and record review, the facility failed to monitor one of the five Residents (R)7 for hypotension and bowel movements and one resident, R 41, regarding a failure to follow physician ordered blood pressure parameters. (instructions to hold medication for blood pressures below a threshold). Findings included: - Review of Resident (R) 7's medical record, revealed diagnoses that included 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), major depressive disorder (major mood disorder), and hypertension (elevated blood pressure). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The resident received antianxiety (medication to decrease anxiety), antidepressant (medications used to treat feelings of sadness), anticoagulant (medications used to prevent blood clots), and opioid (narcotic pain-relieving medications). The Psychoactive Drug Use Care Area Assessment (CAA) dated 10/23/23, was not developed. The Care Plan reviewed 01/26/24, instructed staff to consult with the provider regarding ongoing need for use of medications, which included antianxiety, antidepressant, antihypertensives, and pain medications. The physician instructed staff to administer the following medications: On 10/18/23, Levothyroxine, 75 micrograms (mcg) daily (QD), for hypothyroidism (low thyroid hormone). On 10/18/23, Lexapro, 20 milligrams (mg), QD, for major depressive disorder (MDD). On 03/18/20, Miralax, 17 grams (gm), at hour of sleep (HS), for constipation. On 03/02/24, Movantik, 12.5 mg, QD, for constipation. On 01/19/24, Naldemedine Tosylate, 0.2 mg, QD on Monday, Wednesday, and Friday, for opioid constipation, and discontinued on 03/02/24. On 01/17/23, Remeron, 15 mg, at HS for MDD. On 10/17/23, Baclofen, 5 mg, twice a day (BID), for muscle spasm. On 10/17/23, Buspirone HCL (hydrochloride), 10 mg, BID, for anxiety. On 10/17/23, MS Contin (morphine sulfate continuous release) ER (extended release), 30 mg, every12 hours, for pain. On 12/19/23, Senna, 8.6 mg, BID, for constipation. On 03/20/24, Topiramate, 50 mg, BID, for mood stabilization. On 10/17/23, Gabapentin, 300 mg, three times a day (TID), for pain. On 10/17/23, Sinemet, 25-100 mg, every six hours, for Parkinson. On 03/18/24, Milk of Magnesia, 30 milliliters, TID, for constipation as needed (prn). On 02/29/24, Norco 10-325 mg, every four hours, as needed for pain. On 10/17/23, Tylenol, 650 mg, every six hours, as needed for pain, not to exceed 3000 mg in 24 hours. On 01/28/24, the physician instructed staff to monitor vital signs weekly. Staff recorded vital signs in the electronic medical record on the treatment administration record, with the last recorded blood pressure on 03/03/24, with a blood pressure reading of 90/48. Review of the resident's blood pressures from 11/01/23 through 03/03/24 revealed a range of 80/49- 132/64 with most current blood pressure on 03/03/24 of 90/48. Interview, with Administrative Nurse E, confirmed the lack of vital signs/blood pressure monitoring since 03/03/24 due to computer issues. Administrative Nurse E stated it is the facility standard of care to monitor vital signs weekly. The facility policy Standards of Care and Care Planning Practice, dated 04/01/23 instructed staff that routine practices are services that are expected to be provided to all residents based on accepted clinical guidelines and resident status. The facility failed to monitor R7's vital signs which included blood pressure, at least weekly to determine presence of and adverse effects of hypotension. Furthermore, review of the Task B&B Bowel Elimination tab, for March 2024, revealed the resident lacked a bowel movement from 03/09/24 through 03/19/24 for a total of 10 days at which time the resident had two medium bowel movements. A Nurses' Note dated 03/14/24, indicated lack of bowel movement documented for six days, and interview with the resident confirmed the lack of bowel movement. This note indicated staff administered Miralax and lacked further documentation of bowel status. Interview, on 03/27/24 at 03:10 PM, with Certified Medication Staff (CMA) N, revealed the charge nurse notified her of the need for as needed laxative measure when a resident has not had a bowel movement in three days. Interview, on 03/28/24 at 10:14 AM, with Administrative Nurse E, revealed the electronic record had built in alerts for the charge nurse to access the bowel movement reports for residents who have not had a bowel movement in three days, however the alerts do not always show up on the dashboard. Administrative Nurse E stated she would expect Licensed staff to follow up the resident's bowel status. The facility policy Standard of Care and Care Planning Practice dated 04/01/23, instructed staff to implement bowel protocol on day three if not bowel movement. The facility policy Standing Orders dated 11/28/23 instructed staff to administer the following for constipation: Milk of Magnesia, 30 ml, every 12 hours, as needed for two doses in 24 hours. Senna, 1 tablet, twice a day, as needed. Bisacodyl suppository, one suppository per rectum, if no stools in three days. Fleets enema, rectally, as needed if Milk of Magnesia or suppository was not effective. The facility failed to monitor R7's bowel status as at risk for constipation due to opioid use, which resulted in lack of bowel movement for 10 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 92 residents with 22 residents sampled, including five residents reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to four Residents (R)31, regarding standing over the resident while feeding him and R 78, regarding the failure to use a dignity bag on the catheter collection bag, R 60, regarding not knocking on door before entering resident's room while cares were being given and R 37, regarding the facility not allowing the resident to wear compression stockings (specially made, snug-fitting, stretchy socks that gently squeeze the leg to promote circulation). Findings included: - Review of Resident (R)31's Physician Order Sheet, dated 03/21/24, documented the resident had a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS), dated [DATE], lacked documentation of the resident's cognition. He was dependent on staff for all activities of daily living (ADL). The Nutritional Status Care Area Assessment (CAA), dated 02/06/24, triggered but was not completed. The Modification of Admission/Medicare 5-Day MDS, dated 01/15/24, documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. He was dependent on staff for all ADLs. The care plan for ADLs, revised 01/02/24, instructed staff the resident required substantial assistance of one for eating. On 03/26/24 at 11:49 AM, the staff served lunch to the resident in the dining room. Certified Nurse Aide (CNA) OO began to feed the resident his meal while standing over the resident, leaning in slightly toward and over the resident, as the resident was fed. On 03/26/24 at 01:10 PM, CNA OO stated he did not sit down next to the resident while he fed him his lunch because he did not want to. He liked to stand while feeding the residents. On 03/28/24 at 09:51 AM, Administrative Nurse D stated it was the expectation for staff to sit down next to a resident while assisting them with their meals and not to stand up over the residents. The facility policy for Resident Rights, undated, included: The facility places a strong emphasis on individual dignity and self-determination for all residents. The facility failed to show respect and dignity to this dependent resident while feeding him his meal. - Review of Resident (R)78's electronic medical record (EMR) revealed a diagnosis of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). The Modification of admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/06/23, documented the resident had an indwelling urinary catheter. The Quarterly MDS, dated 01/23/24, documented the staff assessment for cognition revealed the resident was independent with daily decision making. She was dependent on staff for all activities of daily living (ADLs) and had a urinary catheter. The care plan for the urinary catheter, dated 08/01/23, instructed staff to keep the catheter bag and tubing below the level of the bladder. On 03/25/24 at 10:35 AM, the resident sat in her wheelchair in her room. The catheter bag hung below the seat of her wheelchair and lacked a dignity bag. On 03/26/24 at 08:14 AM, the resident rested in bed in her room with the door open. The resident's catheter bag hung from the bed frame and lacked a dignity bag. On 03/26/24 at 08:14 AM, Certified Nurse Aide (CNA) T stated the resident did not have a dignity bag for her catheter bag because they (CNA T) could not find one. CNA T stated catheter bags typically would be in a dignity bag. On 03/26/24 at 08:19 AM, Certified Medication Aide (CMA) MM stated the resident did not have a dignity bag for her catheter bag. CMA MM stated she was unsure as to why the resident did not have a dignity bag. On 03/27/24 at 01:38 PM, Administrative Nurse D stated it was the expectation for staff to always use a dignity bag for all residents who have a catheter bag. The facility policy for Urinary Catheter Care, dated 02/2017, included: To protect the dignity of residents who need an indwelling catheter, drainage bags will be placed in a dignity bag. The facility failed to utilize a dignity bag to hold the catheter bag of this dependent resident with an indwelling urinary catheter. - R60's physician orders revealed the following diagnoses that included diabetes mellitus type two (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and history of urinary tract infection (infection of any part of the urinary system). The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. The resident was dependent on staff for all activities of daily living (ADLs) and used a wheelchair for mobility. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) and was incontinent of bowel. The resident had a diagnosis of neurogenic bladder and chronic urinary tract infection and received an antibiotic. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 11/03/23, R60 required assistance for ADLs to keep clean and dry with bowel needs. R60 had a urinary catheter due to urinary retention. R60's Care Plan dated 10/31/23 revealed the resident had an 18 French, five cubic centimeter (cc) balloon indwelling catheter for neurogenic bladder. Staff were to position the catheter bag and tubing below the level of the bladder and attach the leg bag when out of bed. The resident has bowel incontinence related to immobility and required routine check and change incontinent care, dated 12/04/23. Observation, on 03/25/24 at 12:10 PM, revealed Certified Nursing Aides (CNA) V and CNA UU transferred R60 to the bed with the use of a total body lift. The resident had a bowel movement, and staff removed the brief. At 12:24 PM, CNA VV walked into R60's room without knocking on the door when the resident was fully exposed during incontinent care and did not excuse herself. She stayed to collect pizza orders from staff in the room. The resident remained exposed during the conversation. On 03/25/24 at 12:30 PM, CMA VV reported she reported she knew better and was not thinking and knew she should have knocked before entering as well as she should have left the room as soon as she entered and saw the resident's genitals exposed. On 03/28/24 at 08:00 AM, Administrative Nurse D reported all staff whether nursing or not, should knock on the resident's door and wait for permission to enter. At no time would it be appropriate to enter a resident's room unannounced during resident care, much less to take a staff member's pizza order. The facility's policy for Resident Rights, undated, included the facility places a strong emphasis on individual dignity and self-determination for all residents. The facility failed to maintain R60s dignity by staff entering the room unannounced during personal care, and remained in the room when the resident was exposed. - Review of Resident (R) 37's medical record revealed diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear, chronic kidney disease, congestive heart failure (a condition with low heart output and the body becomes congested with fluid), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The resident required extensive assistance of staff for dressing and personal hygiene. The Cognitive Loss Care Area Assessment (CAA), dated 07/25/23, assessed the resident's risk factors of skin breakdown, weight loss and fluid imbalance. The ADL (Activity of Daily Living) Functional/Rehabilitation CAA dated 07/25/23 did not trigger. The Care Plan reviewed 03/20/24, instructed staff the resident had a functional deficit with ADLs due to dementia(progressive mental deterioration characterized by confusion and memory failure), The resident required moderate assistance with dressing. The care plan instructed staff to ensure the resident wore appropriate footwear, as she preferred tennis shoes. Interview, on 03/25/24 at 02:10 PM, with a family member revealed R37 preferred to wear support hose and had multiple pairs of them in her drawers. The family member stated the resident often does not have them on and she assists R37 in putting them on when visiting the resident. Observation, on 03/26/24 at 11:38 AM, revealed Certified Medication Aide (CMA) M ambulated with the resident to the bathroom. The resident lacked support hose. Interview with CMA M at that time revealed the night shift washed the support hose and dried them on the towel rack in the bathroom, and they were wet this morning, but dry at this time. CMA M did not know the resident had several pairs of the compression hose in her drawers. Observation revealed several pairs of support hose in her drawer beneath the closet. Interview, on 03/28/24 at 10:00 AM, with Administrative Nurse D, revealed the resident did not have a physician order for the support hose, but could wear them as her preference and this should be indicated on the care plan. The facility policy for Resident Rights, undated, included: The facility places a strong emphasis on individual dignity and self-determination for all residents. The policy instructed staff to encourage residents to dress per their individual preferences. The facility failed to ensure staff dressed R37 in support hose as her preference to promote her sense of well-being.

The facility reported a census of 92 residents, which included 10 residents residing in one of the six Green Houses. Based on observation, record review, and interview, the facility failed to provide unstained towels and washcloths to the residents in one [NAME] House. Findings included: - Interview, on 03/27/24 at 02:45 PM, with Resident (R)43 revealed certified staff does the laundry, and supplies towels and washcloths to the resident, however the towels are often stained, rough and/or worn. Observation at that time revealed a hand towel with a large gray stain over 3 percent of the towel. Observation, on 03/28/24 at 09:06 AM, revealed eight hand towels and two washcloths with stains of varying sizes with rough coarse texture and several with areas of worn texture. Interview, on 03/28/24 at 09:06 AM, with Certified Medication Aide/Certified Nurse Aide (CMA/CNA) AA, revealed all staff on all shift's complete laundry tasks and stained linen should be thrown away, and when the supply is low, more can be ordered. Interview, on 03/28/24 at 10:45 AM, with Administrative Staff A, revealed she expected staff to throw out stained linen and order more linen when needed. The facility policy Resident Rights revised 10/22, instructed staff to provide a safe, clean, comfortable, and homelike environment. The facility failed to ensure staff provided unstained, normal textured towels and washcloths to the residents in this [NAME] House to promote a sense of well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R)78's electronic medical record (EMR) included a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Modification of the admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. It was very important for her to listen to music she liked, participate in religious services and do her favorite activities. She required total staff assistance with transfers, locomotion on and off the unit, and she had impaired range of motion (ROM) on bilateral (both) upper and lower extremities. The Activities Care Area Assessment (CAA), dated 08/06/23, documented the resident was at risk for decreased socialization and worsening depression. The facility would encourage active participation in facility functions to engage in sensory stimulation. The Quarterly MDS, dated 01/23/24, documented the staff assessment for cognition revealed the resident was independent with daily decision making. She was dependent on staff for all activities of daily living (ADL). The care plan for activities, revised 08/01/23, instructed staff the resident was dependent on staff for participation in activities. Her favorite activities included visiting, watching group activities, watching TV and listening to music. The care plan lacked the genre of music the resident enjoyed, TV shows she like to watch and lacked the resident's religion. Review of the resident's Activities admission Data Collection, dated 08/01/23, documented it was very important for her to listen to the music she liked, participate in religious services and to do her favorite activities. The primary respondent for the assessment was the resident. Review of the resident's Activities readmission Data Collection, 02/21/24, lacked activity preferences. Review of the facility's activity calendar revealed an activity of morning music would occur every morning at 09:30 AM and religious services would occur each Sunday morning at 09:30 AM and 11:00 AM. Review of the resident's EMR, from 03/01/24 through 03/27/24, revealed she participated in a social on three occasions and had visitors on two occasions. No other activities documented. On 03/26/24 at 08:14 AM, Certified Nurse Aide (CNA) T and Certified Medication Aide (CMA) MM entered the resident's room to prepare the resident for the day. The resident's room lacked a device to listen to music and her TV was not turned to a music station. On 03/27/24 at 09:48 AM, the resident sat in her wheelchair in the commons area facing the TV. The TV, which was tuned to a soap opera, had no volume. On 03/28/24 at 09:01 AM, the resident sat in her wheelchair in her room with CNA X. The TV was turned off and no music played in the resident's room. On 03/28/24 at 09:01 AM, the resident stated she prefers to listen to rap music. She stated she was a Baptist but had not been able to participate in a Baptist service for a long time. On 03/26/24 at 03:09 AM, CNA PP stated she was unsure of what the resident liked to watch on TV but staff would put her in the commons area in front of the TV so she was able to watch whatever was on at that time. On 03/27/24 at 08:14 AM, CNA T stated the resident's family would turn the TV on to a music station when they visited, but CNA T was unsure of what music the resident preferred. On 03/28/24 at 07:38 AM, Activity Staff Z stated the staff were responsible for activities in the green houses. On 03/28/24 at 09:01 AM, CNA X stated she was unsure of what music the resident preferred. On 03/28/24 at 09:51 AM, Administrative Nurse D stated it was important for the care plan to include the types of music and TV shows the resident enjoyed and should also include her religion. The facility policy for Standards of Care and Care Planning Practice, dated 04/01/23, included: Care plans should reflect resident-centered items that are unique to that resident's care. The facility failed to complete a person-centered comprehensive care plan to meet this dependent resident's activity preferences. - The Physician's Order Sheet (POS), dated 03/21/24, documented Resident (R)242 had a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident was dependent on staff for all activities of daily living (ADL). The Functional Abilities Care Area Assessment (CAA), dated 01/15/24, did not trigger. The Medicare 5-day MDS, dated 03/16/24, documented the staff assessment for cognition revealed severe impairment. He was dependent on staff for all ADLs. The care plan for ADLs, revised 01/30/24, instructed staff the resident was dependent on staff for all ADLs. The care plan lacked staff instruction on facial shaving. Review of the resident's electronic medical record (EMR), from 02/27/24 through 03/26/24, revealed the resident was dependent on staff for personal hygiene, including shaving. On 03/25/24 at 01:50 PM, the resident sat in his room in his wheelchair. He was unshaven with scraggly overgrowth of facial hair. On 03/26/24 at 09:55 AM, the resident sat in his wheelchair in the dining room. He remained unshaven with scraggly overgrowth of facial hair. On 03/27/24 at 08:29 AM, the resident sat in his wheelchair in the commons area. He remained unshaven with scraggly overgrowth of facial hair. On 03/26/24 at 01:15 PM, Certified Medication Aide (CMA) NN stated residents were to be shaved on their shower days. On 03/27/24 at 11:13 AM, Certified Nurse Aide (CNA) RR stated residents were to be shaved on their shower days. On 03/26/24 at 12:26 PM, Licensed Nurse (LN) H stated the staff were to shave the residents on their shower days and whenever they wanted to be shaven. On 03/27/24 at 01:38 PM, Administrative Nurse D stated staff instruction for the resident's facial shaving should be included on the care plan. The facility policy for Standards of Care and Care Planning Practice, dated 04/01/23, included: Care plans should reflect resident-centered items that are unique to that resident's care. The facility failed to complete a person-centered comprehensive care plan to meet this dependent resident's preferences for facial shaving. - R35's physician orders revealed the following diagnoses included orthostatic hypotension (blood pressure dropping with change of position), essential (primary) hypertension (elevated blood pressure), viral hepatitis C (inflammatory condition of the liver), chronic obstructive pulmonary disease (COPD, a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic kidney disease, and fluid overload (increase in the volume of extracellular and/or intravascular fluids). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating moderate cognitive impairment. The resident used a wheelchair or walker for mobility. The quarterly MDS dated [DATE], revealed no significant changes in status. The Dehydration/ Fluid Maintenance Care Area Assessment (CAA), dated 10/12/23, revealed R35 was on a fluid restriction, and nursing staff were to monitor the resident was drinking fluids. Review of the care plan dated 01/23/24, lacked guidance related to the resident's fluid restriction. The physician's order dated 04/23/23 revealed the following: The resident has a daily 2000 milliliter (ml) fluid restriction. Fluids include anything that is liquid at room temperature. During the day shift, the resident may have 480 ml at breakfast and 360 ml at lunch from dietary. The resident may have 360 ml during the shift from Nursing. A total for dayshift would be 1200 ml. During the evening shift, the resident may have 360 ml at supper from dietary. The resident may have 240 ml during the shift from nursing. A total for evening shift would be 600 ml. During the night shift, the resident may have 180 ml from nursing. A total for night shift would be 180 ml. Observation on 03/25/24 at 01:40 PM revealed the resident sat in his chair in his room with feet elevated. On 03/25/24 at 01:40 PM, the resident reported he was on an 1800 ml fluid restriction, but the staff did not bother him a whole lot because he has been on it a long time and just knows what he can drink and if he wants extra, he will just get it. On 03/26/24 at 11:55 AM, Certified Nursing Assistant (CNA) SS reported she did not know how staff monitored the resident's fluid restriction. She thought it was probably up to dietary to restrict his fluids and thought he usually had a coffee cup and a glass of fluid at each meal. She was unable to determine the amount of fluid would total for a cup of coffee and a glass of fluid. She reported there was no intake sheet to chart his fluids, but as long as he had no fluid in his room, nursing did not need to monitor his fluid intake. On 03/26/24 at 12:10 PM, Licensed nurse (LN) I reported she was not sure what the fluid restriction was. She knew they have a chart in the kitchen to tell how much each size glass held. There was no intake sheet that she was aware of and thought dietary measured the fluids. She reported staff did not monitor the resident's fluid intake. On 03/27/24 at 10:30 AM, Administrative Nurse F reported she would expect the resident's fluid restriction to be included on the care plan. On 03/27/24 at 04:30 PM, Administrative Staff A reported the facility had a new MDS staff but had to learn the process to get the assessments to reflect the resident's status. they know the MDS, care plan piece is not where it needs to be. On 03/25/24 a policy for Care Plans was requested and was referred to the MDS manual for instruction. The facility failed to include R35's fluid restriction for staff guidance on the comprehensive care plan. The facility reported a census of 92 residents with 22 selected for review. Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for four of the 22 residents reviewed. Resident (R)37 for use of support hose, R35 for fluid restriction, R78 for type of music, TV shows and religious preferences and R242 for shaving preferences. Findings included: - Review of Resident (R) 37's medical record revealed diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear, chronic kidney disease, congestive heart failure (a condition with low heart output and the body becomes congested with fluid), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The resident required extensive assistance of staff for dressing and personal hygiene. The Cognitive Loss Care Area Assessment (CAA), dated 07/25/23, assessed the resident's risk factors of skin breakdown, weight loss and fluid imbalance. The ADL (Activity of Daily Living) Functional/Rehabilitation CAA dated 07/25/23 did not trigger. The Care Plan reviewed 03/20/24, instructed staff the resident had a functional deficit with ADLs due to dementia(progressive mental deterioration characterized by confusion and memory failure).The resident required moderate assistance with dressing. The care plan instructed staff to ensure the resident wore appropriate footwear, as she preferred tennis shoes. The care plan lacked the resident's preference for wearing support hose. Interview, on 03/25/24 at 02:10 PM, with a family member revealed R37 preferred to wear support hose and had multiple pairs of them in her drawers. The family member stated the resident often does not have them on and she assists R37 in putting them on when visiting the resident. Observation, on 03/26/24 at 11:38 AM, revealed Certified Medication Aide (CMA) M ambulated with the resident to the bathroom. The resident lacked support hose. Interview with CMA M at that time revealed the night shift washed the support hose and dried them on the towel rack in the bathroom, and they were wet this morning, but dry at this time. CMA M did not know the resident had several pairs of the compression hose in her drawers. Observation revealed several pairs of support hose in her drawer beneath the closet. Interview, on 03/28/24 at 10:00 AM, with Administrative Nurse D, confirmed the resident preference for support hose was not on the care plan, and not listed as a Task for certified staff to complete. The facility policy Standards of Care and Care Planning Practice dated 04/01/23, instructed staff the care plan should reflect resident centered items that are unique to that resident's care. The facility failed to include R37's preference for wearing support hose in her comprehensive care plan to promote a sense of well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R)78's electronic medical record (EMR) included a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Modification of the admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. It was very important for her to listen to music she liked, participate in religious services and do her favorite activities. She required total staff assistance with transfers, locomotion on and off the unit, and she had impaired range of motion (ROM) on bilateral (both) upper and lower extremities. The Activities Care Area Assessment (CAA), dated 08/06/23, documented the resident was at risk for decreased socialization and worsening depression. The facility would encourage active participation in facility functions to engage in sensory stimulation. The Quarterly MDS, dated 01/23/24, documented the staff assessment for cognition revealed the resident was independent with daily decision making. She was dependent on staff for all activities of daily living (ADL). The care plan for activities, revised 08/01/23, instructed staff the resident was dependent on staff for participation in activities. Her favorite activities included visiting, watching group activities, watching TV and listening to music. Review of the resident's Activities admission Data Collection, dated 08/01/23, documented it was very important for her to listen to the music she liked, participate in religious services and to do her favorite activities. The primary respondent for the assessment was the resident. Review of the resident's Activities readmission Data Collection, 02/21/24, lacked activity preferences. Review of the facility's activity calendar revealed an activity of morning music would occur every morning at 09:30 AM and religious services would occur each Sunday morning at 09:30 AM and 11:00 AM. Review of the resident's EMR, from 03/01/24 through 03/27/24, revealed she participated in a social on three occasions and had visitors on two occasions. No other activities documented. On 03/26/24 at 08:14 AM, Certified Nurse Aide (CNA) T and Certified Medication Aide (CMA) MM entered the resident's room to prepare the resident for the day. The resident's room lacked a device to listen to music and her TV was not turned to a music station. On 03/27/24 at 09:48 AM, the resident sat in her wheelchair in the commons area facing the TV. The TV, which was tuned to a soap opera, had no volume. On 03/28/24 at 09:01 AM, the resident sat in her wheelchair in her room with CNA X. The TV was turned off and no music played in the resident's room. On 03/28/24 at 09:01 AM, the resident stated she prefers to listen to rap music. She stated she was a Baptist but had not been able to participate in a Baptist service for a long time. On 03/26/24 at 03:09 AM, CNA PP stated she was unsure of what the resident liked to watch on TV but staff would put her in the commons area in front of the TV so she was able to watch whatever was on at that time. On 03/27/24 at 08:14 AM, CNA T stated the resident's family would turn the TV on to a music station when they visited, but CNA T was unsure of what music the resident preferred. On 03/28/24 at 07:38 AM, Activity Staff Z stated the staff were responsible for activities in the green houses. On 03/28/24 at 09:01 AM, CNA X stated she was unsure of what music the resident preferred. On 03/28/24 at 09:51 AM, Administrative Nurse D stated the staff were to do the activities in the green houses. Administrative Nurse D was unsure of how church services were set up for the green houses. The facility policy for Resident Rights, dated 10/2022, included: The resident has the right to choose which activities they wish to participate in, including social, religious and community activities. The facility failed to implement an ongoing resident centered activity program for this dependent resident. The facility reported a census of 92 residents with 22 residents selected for review which included six residents reviewed for activities. Based on observation, interview, and record review, the facility failed to ensure appropriate activities for five Residents (R)7, R20, R33, R37, and R78, of the six residents reviewed for activities. Findings included: - Review of Resident (R) 7's medical record, revealed diagnoses that included 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) and major depressive disorder (major mood disorder). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The resident rated books, music, animals, and group activities as very important. The Activities Care Area Assessment (CAA), dated 10/23/23, did not trigger. The Care Plan reviewed 01/26/24, instructed staff to provide an activity program that was meaningful and of interest and provide opportunities for exercise and physical activity. Staff to plan activities during optimal times when pain and stiffness are abated. Review of the task Activities for the past 30 days revealed only two entries for active participation on 03/04/24 for social, and 03/22/24 for musical. Review of the March Activity Calendar indicated the following activities available: On 03/25/24 at 09:30 AM, chair exercises, 03:00 PM, UNO a card game, and 04:30 PM Bingo. On 03/26/24 at 09:30 AM, Noodle ball, at 03:00 PM- cards, and 06:00 PM -Table Talk. On 03/27/24 at 09:30 AM, Chair Yoga, at 03:00 PM- Bible study, and 06:00 PM- World Travel. On 03/28/24 at 10:00 AM- Bingo, and at 10:30 AM - group exercises. On 03/29/24 at 09:30 AM - Coffee Social, and at 03:00 PM --[NAME] in Corner, and at 06:00 PM- Residents Choice. On 03/30/24, Saturday at 09:00 AM -bingo, at 03:00 PM -manicures, and at 06:00 PM- Movie of Choice. On 03/31/24 Sunday at 09:00 Mass TV, 11:00 AM- First United Methodist church , and at 06:00 PM - Name Five. Observation on 03/25/24 at 03:00 PM, revealed lack of the activity UNO. Observation, on 03/26/24 at 09:30 AM, revealed lack of Noodle Ball and at 03:00 PM lack of cards being offered. Observation on 03/27/24 at 10:00 AM revealed lack of Chair Yoga and at lack of Bible Study and 03:00 PM being offered. Interview, on 03/25/24 at 12:17 PM, with R7 revealed she usually just watched TV in her room. She stated she usually just sat around, and the only activity was bingo once a week. Interview, on 03/26/24 at 07:35 AM, with Certified Medication Aide(CMA/CNA) M revealed staff did not have time to do any activities. Interview, on 03/26/24 at 07:54 AM, with Activity Staff Z, revealed the evening staff should do activities. Interview, on 03/27/24 at 03:10 PM, with CMA /CNA N, revealed evening staff did not provide activities and lacked tools/supplies to provide residents with activities Interview, on 03/27/24 at 03:30 PM, with CMA Q, revealed on nice days staff should encourage residents to go outside on the patio and often have cook outs. CMA Q revealed few structured activities provided. Interview, on 03/28/24 at 10:20 AM, with Administrative Staff A, confirmed activities in the Greenhouses have been an issue. The facility policy for Resident Rights, dated 10/2022, included: The resident has the right to choose which activities they wish to participate in, including social, religious and community activities. The facility failed to provide activities to the residents of this facility to increase their sense of well-being. - Review of Resident (R)20's medical record revealed diagnoses that included deep vein thrombosis (DVT- blood clots) in the right and left leg, heart disease, diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion) and unstageable pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction and the wound is covered by a layer of dead tissue). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a BIMS score of nine, which indicated moderate cognitive impairment. The resident had no impairment in her upper or lower extremities, dependent on staff for Activities of Daily Living (ADL). R20 rated having books, newspaper, and magazines to read, listening to music, having animals around, keep up with the news, and do favorite activities as very important. The Activities Care Area Assessment (CAA), dated 02/05/24, did not trigger. The Care Plan reviewed 02/21/24, instructed staff the resident had little, or no activity involvement related to disinterest and resident wishes. The resident's preferred activities include bingo, crocheting, and adult coloring books. The resident preferred TV channels include news, Hallmark, Discovery, [NAME], and home decorating channels. Observation, on 03/26/24 at 09:45 AM, revealed the resident seated in her wheelchair in her room. Certified Medication Aide (CMA) XXX and CMA Y assisted R20 to pivot transfer into her bed. The TV was on a shopping channel and CMA XXX or CMA Y did not ask the resident regarding her preference for the channel. The resident's embroidery supplies were out of her reach. Observation, on 03/27/24 at 09:20 AM, revealed the resident's television was on the shopping channel. Interview, on 03/26/24 at 10:09 AM, with R20, revealed she likes to read and embroider. R20 stated she would enjoy a book club. R20 stated she enjoyed watching old movies on TV. Interview, on 03/26/24 at 07:54 AM, with Activity Staff Z, revealed the evening staff should do activities. Interview, on 03/27/24 at 02:55 PM, with Certified Nurse Aide QQ, revealed the residents usually do not want to attend activities, but thought someone does bingo for the residents. Interview, on 03/27/24 at 02:56 PM with CNA YYY, revealed she provided one on one visits with the residents and the residents liked getting their nails done, but there were no structured activities as she did not think the residents would participate. Interview, on 03/28/24 at 10:20 AM, with Administrative Staff A, confirmed activities in the Greenhouses have been an issue. The facility policy for Resident Rights, 10/2022, included: The resident has the right to choose which activities they wish to participate in, including social, religious and community activities. The facility failed to provide activities to the residents of this facility to increase their sense of well-being. - Review of Resident (R)33's medical record revealed diagnoses that included heart failure, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain ), and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The resident rated doing favorite activities and go outside when the weather was good as very important. The Activities Care Area Assessment (CAA) dated 05/06/23 did not trigger. The Care Plan reviewed 02/16/24, instructed staff to encourage the resident to participate in activities of her choice and provide opportunities for social interaction. Review of the March Activity Calendar indicated the following activities available: On 03/25/24 at 09:30 AM -chair exercises, at 03:00 PM- UNO a card game, and 04:30 PM- Bingo. On 03/26/24 at 09:30 AM- Noodle ball, at 03:00 PM- cards, and 06:00 PM -Table Talk. On 03/27/24 at 09:30 AM - Chair Yoga, at 03:00 PM- Bible study, and 06:00 PM- World Travel. On 03/28/24 at 10:00 AM- Bingo and at 10:30 AM - group exercises. On 03/29/24 at 09:30 AM - Coffee Social, at 03:00 PM- [NAME] in Corner, and at 06:00 PM- Residents Choice. On 03/30/24 - Saturday at 09:00 AM -bingo, at 03:00 PM- manicures, and at 06:00 PM- Movie of Choice. On 03/31/24- Sunday at 09:00- Mass TV, at 11:00 AM -First United Methodist church , and at 06:00 PM - Name Five. Interview on 03/25/24 at 12:50 PM with R33, revealed the facility provided bingo once a week and would like to participate in more frequent bingo games. R33 stated she would also like to play cards. Observation on 03/25/24 at 03:00 PM, revealed lack of the activity UNO provided to the residents. Observation, on 03/26/24 at 09:30 PM revealed lack of Noodle Ball and at 03:00 PM lack of cards offered to the residents. Observation on 03/27/24 at 10:00 AM, revealed lack of Chair Yoga, and at 03:00 PM, Bible Study was not offered to the residents. Interview on 03/25/24 at 12:50 PM with R33, revealed the facility provided bingo once a week and would like to participate in more frequent bingo games. R33 stated she would also like to play cards. Interview, on 03/26/24 at 07:35 AM, with Certified Medication Aide( CMA) M revealed staff did not have time to do activities. Interview, on 03/26/24 at 07:54 AM, with Activity Staff Z, revealed the evening staff should do activities. Activity Staff Z stated the facility provided one bingo game per week. Interview, on 03/26/24 at 02:20 PM, with Licensed Nurse G, revealed the resident only came out of her room for bingo. Interview, on 03/28/24 at 10:20 AM, with Administrative Staff A, confirmed activities in the Greenhouses have been an issue. The facility policy for Resident Rights, 10/2022, included: The resident has the right to choose which activities they wish to participate in, including social, religious and community activities. The facility failed to provide activities to the residents of this facility to increase their sense of well-being. - Review of Resident (R) 37's medical record revealed diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. R37 rated music, animals and doing favorite activities as very important. The resident required moderate/partial assistance for mobility. The Activities Care Area Assessment (CAA), dated 07/25/23, did not trigger. The Cognitive Loss/Dementia CAA dated 07/25/23, assessed the resident with risk factors that included decreased socialization and need to encourage active participation in facility functions. The Care Plan, reviewed 03/20/24, instructed staff to provide the resident with materials for individual activities as desired. The resident likes knitting/crocheting, puzzles, some reading material and simple coloring. The resident preferred educational programs and game shows. The resident enjoys arts/crafts, bingo card games, baking, group discussions and was independent on staff with activity participation. Review of the Task tab Activities in the electronic medical record for the last 30 days, revealed an entry on 03/04/24 for social and on 03/22/24 for music. No other activity participation provided. Observation, on 03/25/25 at 02:20 PM, revealed the resident sleeping in her recliner in her room. Review of the March Activity Calendar indicated the following activities available: On 03/25/24 at 09:30 AM -chair exercises, at 03:00 PM- UNO a card game, and 04:30 PM -Bingo. On 03/26/24 at 09:30 AM -Noodle ball, at 03:00 PM- cards, and 06:00 PM- Table Talk. On 03/27/24 at 09:30 AM -Chair Yoga, at 03:00 PM- Bible study, and 06:00 PM- World Travel. On 03/28/24 at 10:00 AM Bingo, and at 10:30 AM group exercises. On 03/29/24 at 09:30 AM Coffee Social, and at 03:00 PM [NAME] in Corner, and at 06:00 PM Residents Choice. On 03/30/24 Saturday at 09:00 AM bingo, at 03:00 PM manicures, and at 06:00 PM Movie of Choice. On 03/31/24 Sunday at 09:00 Mass TV, 11:00 AM First United Methodist church , and at 06:00 PM Name Five. Observation on 03/25/24 at 03:00 PM, revealed lack of the activity UNO. Observation, on 03/26/24 at 09:30 revealed lack of Noodle Ball and at 03:00 PM lack of cards. Observation on 03/27/24 at 10:00 AM revealed lack of Chair Yoga and at lack of Bible Study and 03:00 PM. Interview, on 03/25/24 at 02:10 PM, with a family member revealed the facility did not provide many activities. Interview, on 03/26/24 at 07:35 AM, with Certified Medication Aide (CMA) M revealed staff did not have time to do activities. Interview, on 03/26/24 at 07:54 AM, with Activity Staff Z, revealed the evening staff should do activities. Interview, on 03/27/24 at 03:10 PM, with CMA N, revealed evening staff did not provide activities and lacked tools for providing them. Interview, on 03/27/24 at 03:30 PM, with CMA Q, revealed on nice days staff should encourage residents to go outside on the patio and would have cook outs. CMA Q revealed few structured activities as residents do not want to attend. CMA Q stated R37 did attend bingo games. Interview, on 03/28/24 at 10:20 AM, with Administrative Staff A, confirmed activities in the Greenhouses have been an issue. The facility policy for Resident Rights, 10/2022, included: The resident has the right to choose which activities they wish to participate in, including social, religious and community activities. The facility failed to provide activities to the residents of this facility to increase their sense of well-being.

The facility reported a census of 92 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the resident kitchenette, on 03/25/24 at 11:07 AM, the following areas of concern were noted in the kitchen of greenhouse 1202: 1. The inside of the toaster had a heavy build-up of crumbs. 2. The top of the stove had dried-on food debris. 3. A large plastic container of corn chips lacked a lid and there were corn chips on the floor. 4. The deep freeze had food debris on the bottom. 5. The silverware drawer contained wet silverware and food debris. 6. There were multiple greasy fingerprints on the hood of the range. During a tour of the kitchenette of the first floor, on 03/25/24 at 01:00 PM, the following areas of concern were noted: 1. The resident refrigerator contained a can of an opened energy drink which was unlabeled and undated. 2. The sink had a brownish substance on the back rim up against the wall. 3. The trash can had dried-on food debris and lacked a lid. During an initial tour of the kitchen, on 03/26/24 at 07:49 AM, the following areas of concern were noted: 1. The reach-in refrigerator racks had an extremely heavy build-up of a black substance in between the front lip of six white, plastic-covered racks. 2. The top of the ice machine and the oven contained a layer of dust. 3. A white, four-tiered cart, used to dry clean dishes, had ground in dirt and debris into the four plastic tiers and the handles of the cart, causing them to be discolored. 4. Ten knives plastic handles were deeply grooved and had ground in dirt and debris causing the handles to be discolored. The plastic container holding the knives contained food debris. 5. Three plastic containers holding spatulas, tongs and divider bars contained food debris in the bottom of the closed containers. 6. The inside of the microwave had dried-on food debris. 7. Two shelves over the cold cart had a layer of dust. 8. The shelf on the steam table, used to cut food for resident's consumption, had deep cuts causing the surface to be discolored and uncleanable. 9. Three doors of the cold cart had a large amount of ground-in food debris in the rubber seal of the doors. During a tour of the kitchen in green house 1212, on 03/25/24 at 10:55 AM, the following areas of concern were noted: 1. Two open cans of 2-cal (a nutritionally complete, high-calorie formula designed to meet the needs of people with increased protein and calorie requirements) were partially used and undated. 2. There was a mug of a milky substance was undated. 3. There was a plastic bag of cucumbers, undated. The cucumbers had a slimy appearance. 4. There were two pitchers of juice, undated. 5. Two cartons of juice concentrate to be used within 48 hours of thawing, lacked date. On 03/25/24 at 10:50 AM, Dietary staff DD stated the staff should date foods when opened. On 03/28/24 at 10:07 AM, Dietary staff DD stated the staff were responsible for keeping the kitchens and kitchenettes clean and sanitary. The facility policy for Food Safety Requirements, reviewed 01/2024, included: It is the policy of the facility to provide safe and sanitary storage, handling and consumption of all foods. The food service workers are responsible to adhere to the food safety requirements. The facility failed to prepare and serve food under sanitary conditions for the residents of the facility appropriately to prevent the potential for food borne bacteria.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R)78's electronic medical record (EMR) revealed a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Modification of admission Minimum Data Set (MDS), dated 08/06/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of thee, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and was incontinent of bowel. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/06/23, did not trigger. The Quarterly MDS, dated 01/23/24, documented the staff assessment for cognition revealed the resident was independent with daily decision making. She was dependent on staff for all ADLs and was always incontinent of bowel. The care plan for ADLs, dated 08/01/23, instructed staff the resident required assistance with all ADLs. Review of the resident's EMR, from 03/01/24 through 03/27/24, revealed the resident was dependent on staff for bowel incontinence and dressing. On 03/26/24 at 08:14 AM, Certified Nurse Aide (CNA) T and Certified Medication Aide (CMA) MM entered the resident's room to get her ready for the day. The staff completed peri-care due to the resident being incontinent of bowel. The staff then applied a clean brief without changing gloves. CNA T then began to dress the resident, putting her hand through the sleeve of the resident's clean shirt, without changing her gloves. On 03/26/24 at 08:14 AM, CNA T confirmed she had not changed her gloves after performing peri-care following the incontinent BM before she placed a new brief on the resident and began to dress her. CNA T stated she should have changed her gloves but had forgotten. On 03/26/24 at 08:19 AM, CMA MM stated she should have changed her dirty gloves before helping to put a clean brief on the resident. On 03/28/24 at 09:51 AM, Administrative Nurse D stated it was the expectation for staff to change their gloves after providing peri-care and before putting on a clean brief or assisting a resident to dress. The facility lacked a policy regarding changing gloves following peri-care. The facility failed to use appropriate hand hygiene after performing peri-care for this dependent resident. - Review of Resident (R)242's electronic medical record (EMR) included a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated 01/15/24, documented the staff assessment for cognition revealed severe impairment. He was dependent on staff for all ADLs. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 01/15/24, documented the resident was dependent on staff for toileting. The Medicare 5-Day MDS, dated 03/16/24, documented the staff assessment for cognition revealed severe impairment. He was dependent on staff for all ADLs. The indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care plan, revised 03/25/24, instructed staff to position the catheter bag and tubing below the level of the bladder. Review of the resident's EMR revealed the following physician's order: Indwelling urinary catheter for neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), 03/20/24. On 03/26/24 at 01:15 PM, Certified Medication Aide (CMA) NN entered the room to empty the resident urinary catheter. CMA NN drained the urine into a graduate (a vessel used to measure liquids). CMA NN then emptied the urine into the toilet, filled the graduate half-way with water from the resident's bathroom faucet to rinse, poured the rinse water into the toilet then placed the graduate upside down on the back of the toilet on top of paper towels up against the resident's tooth brush, tooth paste and shaving cream. On 03/26/24 at 01:15 PM, CMA NN stated the staff kept the graduate on the back of the toilet with the rest of the resident's things all the time. On 03/27/24 at 01:38 PM, Administrative Nurse D stated the staff should not place the graduate up against the resident's toothbrush and toothpaste. The facility policy for Urinary Catheter Care, dated 02/2017, included: Staff shall use standard precautions while performing urinary catheter cares with residents. The facility failed to use appropriate standard precautions while performing catheter care for this dependent resident with a urinary catheter. The facility reported a census of 92 residents with 22 included in the sample. Based on observation, interview, and record review, the facility failed to ensure infection control techniques for Resident (R)9, regarding oxygen (O2) tubing/cannula storage, for R60, related to urinary catheters and perineal care, R242, related to storage of soiled catheter collection device stored next to personal care items of toothbrush and toothpaste, and R78, related to incontinence cares, to prevent the spread of infections in the facility. Findings included: - R9's physician orders revealed the following diagnoses that included chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Review of the Quarterly MDS dated [DATE], revealed a BIMS score of 15. R9 received oxygen (O2). The care plan dated 03/17/2023 revealed the resident had COPD and staff were to give oxygen therapy as ordered by the physician. Observation on 03/25/24 at 11:45 AM, revealed Certified Nursing Assistant (CNA) UU entered the resident's room to assist the resident to lunch. CNA UU removed R9's O2 cannula and placed the tubing and nasal cannula directly on the bed. The room lacked a storage container for the O2 cannula. CNA UU removed a trash filled bag out of the trash can, reached into the trash can and obtained a new trash bag out and placed R9's cannula into the trash bag, and laid the cannula back onto the bed. No hand hygiene completed between removing the trash and handling R9's cannula. Observation revealed a second nasal cannula stored directly on R9's walker and was not stored in a container. CNA UU applied the opened, unbagged nasal cannula to R9 and assisted R9 to the dining room. Observation on 03/26/24 at 12:10 PM, CNA SS entered the resident's room to assist the resident to the dining room. She removed R9's O2 cannula and placed the cannula/tubing directly on the bed and placed a magazine on top of the cannula. CNA SS removed O2 tubing/cannula from the walker and placed it on the resident. That cannula was not in a storage bag and was wrapped around the back of the walker with the cannula having contact with the top of the O2 tank. On 03/25/24 at 11:50 AM, CNA UU reported the resident's O2 cannula and tubing should be in a box but did not see one in her room. The resident's walker should have a bag to contain the O2 when not in use. On 03/26/24 at 12:10 PM, CNA SS reported she was not sure what to do with the O2, so she just put it on the bed and laid something on top of it so it would not slide off on the floor. She was unaware anything had to be on the walker for the O2 tubing to be stored in. On 03/26/24 at 12:20 PM, Licensed Nurse (LN) I reported everyone on O2 should have a three-compartment cart in their room for the O2. She also reported all walkers or wheelchairs that use O2 should have bags with the resident's name and date on it and changed weekly. Observation revealed LN I went into R9's room and found the O2 cart, in a closet behind a wheelchair, with piled clothing and blankets that covered the O2 cart. LNI removed the cart from the closet and placed it into R9's room to be utilized. The facility's policy for oxygen, lacked care of the tubing and cannulas. The facility failed to ensure good infection control techniques by the failure to store oxygen (O2) tubing and nasal cannula in a sanitary manner when not in use. - Resident (R) 60's signed physician orders dated 11/03/23 revealed the following diagnoses included neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and a history of urinary tract infection (infection of any part of the urinary system). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident was dependent on staff for all daily cares and used a wheelchair for mobility. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) and was incontinent of bowel. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 11/03/23 revealed staff were to provide assistance to clean and dry the resident for bowel needs and the resident had an indwelling urinary catheter. Observation on 03/25/24 at 12:10 PM, revealed Certified Nursing Assistant (CNA) V emptied the resident's catheter. CNA V donned gloves and retrieved a graduated pitcher from the bathroom and removed the tubing from the catheter bag spigot. She drained the catheter bag and placed the tubing into the spigot of the drainage bag without cleansing the spigot. CNA V failed to remove her soiled gloves and CNA V and CNA UU transferred the resident from a full body mechanical lift to the bed. The resident had a bowel movement and required incontinence cares. CNA UU provided perineal cares and grabbed disposable wipes from the container with the soiled gloves. CNA V and CNA UU failed to remove their soiled gloves and placed a clean brief under the resident. CNA UU then went into the bathroom with the soiled gloves on, retrieved moisture barrier, and applied moisture barrier to the resident. With soiled gloves on, the brief was placed and fastened, and staff positioned the resident onto his side with positioning devices and placed positioning devices under his legs. CNA V then removed her gloves. CNA UU emptied the trash and then removed her gloves. Both CNA's left the resident's room without washing their hands. On 03/25/24 at 12:30 AM, CNA V reported she would usually use alcohol when emptying a catheter but thought there was no available alcohol in the resident's bathroom, so just did not use it. On 03/25/24 at 12:32 PM, CNA UU reported she should have changed her gloves during the incontinent care. On 03/28/24 at 08:00 AM, Administrative Nurse D reported she expected her staff to maintain good hand hygiene with personal care. Staff should change their gloves between dirty and clean. Staff with the clean gloves should handle the wipes and hand to the aide doing the perineal care. When emptying the catheter, gloves are required along with alcohol to the tubing to clean the tubing, to prevent urinary tract infections (UTI's). Hand washing and proper usage of gloves and disinfecting the tubing is a must. The facility's policy for Urinary Catheter Care, dated 02/2017, included: Staff shall use standard precautions while performing urinary catheter cares with residents. Review of the facility's policy for Standards of Care dated 04/01/23, revealed all staff are to maintain standard precautions when providing care to a resident. The facility failed to ensure good infection control techniques by the failure to change gloves between dirty and clean while performing peri-care for R60 and the failure to properly clean the catheter spigot when emptying R 60's indwelling urinary catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 87 residents. The sample included 23 residents with one resident reviewed for choices. Based on observation, interview, and record review, the facility failed to provide choices for Resident, (R)30 related to food. Findings included: - Review of the Resident (R) 30's undated Physician Orders, revealed diagnoses included, dry mouth, gastroesophageal reflux (backflow of stomach contents to the esophagus), and type 2 diabetes mellitus (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], documentation included the resident's Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. She reported feeling down. The resident interview regarding preferences revealed she thought it was somewhat important to have snacks available between meals. She received a mechanically altered and therapeutic diet. The Communication Care Area Assessment (CAA), dated 03/10/22, identified risk factors which included mood decline, weight loss, and behavioral issues. The CAA, noted to proceed to Care Plan, to decrease risk for mood decline, behaviors, and monitoring dietary intake and hydration status. The Care Plan, (CP), dated 03/18/22, directed staff the resident was independent with set up for eating. The facility should provide her alternate food according to her preference if she did not like the featured meal of the day. She liked almost all foods except tuna. On 05/03/22 at 08:11 AM, the resident stated she was not happy and that the residents were told what they can and cannot eat. She does not have a choice. The resident stated the evening before she was served a cold plate of tuna salad, with pasta salad and when she asked for an alternate meal, she was told they did not have anything else. She described the meal's appearance as looking like they dumped a can of tuna on a salad. On 05/04/22 at 12:30 PM, observation of the resident's lunch included chicken strips, buttered carrots, watermelon and mashed potatoes. She fed herself 100%. On 05/05/22 at 12:15 PM, observation of the resident's meal included lasagna, broccoli floret, carrot and raisin salad, and garlic bread sticks. She fed herself 100%. The resided stated the food was delicious and confirmed she received what she ordered. On 05/03/22 at 03:34 PM, Certified Medication Aide (CMA) TT, reported staff were universal workers (worked all areas of patient care, dietary, nursing, laundry, and housekeeping). The staff dish the food out to the residents sitting in the dining room and then serve the resident's that were in their rooms. The facility has a list of alternative meals that included chicken strips, hamburger patties, or staff could make breakfast if they do not like what is on the menu. Resident's dislikes are posted in the kitchen. The food comes from the assisted living kitchen and the staff in the greenhouses cook it or heat it up. Some staff are lazy and do not look at the resident's food choices or preferences. CMA TT confirmed the resident does not like tuna and the supper meal for Monday, 05/02/22, was tuna casserole and pasta salad. She stated the staff should have checked the diet card for the resident's dislikes and offered an alternative. On 05/03/22 at 04:14 PM, Certified Nurse Aide (CNA) MM reported she worked everywhere including the kitchen. She reported she got complaints about the food from the residents frequently. CNA MM stated she did not always give the resident what they were serving on the menu, she would cook them what they want. Sometimes, the residents ask for stuff we do not have. On 05/04/22 at 11:50 AM, Licensed Nurse (LN) G, stated that nursing staff were universal staff. He confirmed that not everybody can cook. Staff need to know how to prepare the food, but some don't. The facility should have alternates for main menu and offer them to residents who do not want the items on the main menu. On 05/05/22 at 01:12 PM, Administrative Nurse E, reported the nursing staff worked as universal staff and worked in the kitchen and prepared food. The main menu was posted, and an alternative menu was available to the residents who did not want the main meal. She expected staff to offer alternatives to the residents that did not want the items on the main menu. The facility policy Resident's Rights, lacked address for alternate food choices. The facility failed to provide choices for this resident, related to food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of the Resident's (R) 18 Physician Orders, dated 03/10/22 revealed diagnosis which included chronic respiratory failure and sleep apnea (breathing stops during sleep). The admission Minimum Data Set (MDS) dated [DATE], documentation included the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. She reported trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy for two to six days of the look back period. She required extensive assistance of staff with activities of daily living (ADLs) for bed mobility and transfers. The resident used Oxygen. The Quarterly MDS, dated 02/17/22, documented changes which included the resident required supervision of staff for transfers, and limited assistance for walking. The Care Area Assessment (CAA), dated 05/19/22, documentation did not address the use of oxygen. The Care Plan, (CP), dated 02/16/22, directed staff the resident with altered respiratory status/difficulty breathing related to sleep apnea and chronic respiratory failure. The oxygen setting for the concentrator was set for three liters via nasal cannula. The care plan did not include maintenance of oxygen tubing, concentrator filter, humidifier bottle, distilled water nor storage of cannula/tubing when not in use. Additionally, the care plan did not address the use nor maintenance of the Continuous Positive Air Pressure (CPAP) machine and/or mask and tubing storage when not in use. Review of the Physician's Order, dated 03/10/22, documented an order initiated on 02/04/22 to change the humidifier bottle once weekly. Wipe down the concentrator and clean the filter. Change the oxygen cannula/tubing, once weekly on Saturday and as needed. Please assist the elder in placing C-pap on at bedtime, initiated 05/25/2021. Review of the Treatment Administration Record, (TAR), dated 03/01/22 through 05/02/22, documentation revealed the oxygen humidifier and tubing changes, clean concentrator filter signed out as done on 03/5/22, 03/12/22, 03/19/22, 03/26/22, 04/02/22, 04/09/22, and 04/23/22. Staff failed to document/ sign on 04/16/22 and 04/30/22, On 05/03/22 at 10:01 AM, the resident stated her brother put water in the oxygen bottle, as the staff do not take care of the oxygen. The jug sitting on the floor only had a little water left in it so they will need to get me more. The staff have not changed the tubing more than three times this year, if that many times. She reported she never had a bag to put her CPAP in and verified she used it every night. She would use the oxygen on during the day, but never had a bag for it either. On 05/03/22 at 10:27 AM, the resident had her oxygen cannula and tubing in place with oxygen at three liter per minute via nasal cannula. The oxygen tubing date was 02/22/22, the humidifier bottle was not labeled, a partially empty unlabeled jug of distilled water sat directly on the floor. There was not a storage bag present for storing the cannula and tubing when not in use. The concentrator filter had a thick layer of dust. The CPAP hose hung across the bed rail without having a bag present for storage when not in use. On 05/03/22 at 04:14 PM, Certified Aide (CNA) stated the nurse should change the tubing and humidifier bottle every two weeks. There should be a bag to store the tubing and mask when the oxygen and CPAP were not in use. The storage bags should be dated. Additionally, she reported the distilled water was to fill the humidifier bottle on the oxygen concentrator and should be stored in the bathroom off the floor. The distilled water should be dated when opened. On 05/04/22 at 09:36 AM, CNA M, confirmed the above findings. Additionally, she confirmed there was two jugs of distilled water directly on the floor by the concentrator, neither labeled and one partially empty. She stated she was not aware an oxygen concentrator had a filter that needed to be cleaned. She reported she thought the tubing and cannulas were changed two times a week by the nurse, but she did not know. On 05/04/22 at 11:50 AM, Licensed Nurse G reported, staff should change the oxygen tubing monthly. He was not aware of the system in this facility for changing out the tubing or cleaning the concentrator filter. The tubing should be labeled when changed. Night shift usually changes it out. The resident uses her CPAP at night, but was unaware where staff should store oxygen when not in use. In addition, he was unaware of the system for changing out the oxygen tubing or the humidifier bottle. On 05/05/22 at 09:26 AM, Licensed Nurse (LN) H reported staff should change the oxygen tubing and humidifier bottles weekly. The tubings should be stored in a labeled bag when not in use. Night shift staff change the tubing/ humidifier bottles/ nebulizer tubings. The resident's CPAP mask and hose should be stored in a labeled bag when not in use. On 05/09/22 at 10:20 AM, Administrative Nurse D stated nurses should change the oxygen cannulas/tubing weekly and as needed. The tubing, humidifier bottles should be labeled with the date when changed. The tubing for oxygen and CPAP should be stored in a labeled bag when not in use. Additionally, the nurse should document on the TAR when tubing, humidifier, and concentrator filters are changed and cleaned. The facility undated policy for Elder Directed Care Plans, documentation included .it is the policy of this facility to provide an individualized, interdisciplinary plan of care for all elders that is appropriate to the elder's needs, strengths, and limitations. The facility failed to develop and implement a plan of care related to the use of oxygen and CPAP for this resident. for respiratory equipment. The facility reported a census of 87 residents with 23 residents selected for review. Based on observation, interview and record review, the facility failed to develop comprehensive care plans for three residents. Resident (R)18 and 68 for oxygen maintenance, and R27 for restorative cares. Findings included: - Review of Resident (R)27's electronic medical record (EMR), under the Med Diag (Diagnosis) tab, included a diagnosis of muscle weakness. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She required extensive assistance of two staff for transfers, her balance was not steady, and she had impairment on one side of her lower extremities. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment, dated 02/28/22, documented the resident had impaired balance and transition during transfers. The care plan would be initiated to maintain current ADL status and functional ability. The care plan for ADLs, revised 02/24/22, instructed staff the resident had self -care performance deficit. The resident required two staff for transfers with the use of a mechanical lift. The care plan lacked staff instruction for restorative cares or range of motion (ROM) exercises. On 05/05/22 at 08:34 AM, the resident sat in her wheelchair in her room watching TV. Her feet rested on the foot pedals of her wheelchair. The resident demonstrated how she was unable to straighten her right leg with her knee at a 45- degree angle. On 05/03/22 at 11:00 AM, the resident stated she had not been able to straighten her right knee since before her admission. The contracture had not gotten worse, it was the same as when she admitted to the facility. The resident stated she'd asked the staff about therapy or restorative care to help loosen her leg, but staff had told her she could not receive restorative care as she was on hospice. On 05/09/22 at 09:38 AM, Licensed Nurse (LN) L stated the resident had a contracture to her right knee but did not receive restorative care. LN L was unsure of who was responsible for the care plans. On 05/05/22 at 09:02 AM, Administrative Nurse E stated the facility only had a part-time restorative aide. The resident would need to be evaluated by therapy for her to receive restorative services and that had not been done because the resident was currently on hospice. The contracture was something that should be included on the care plan. The facility policy for Elder Directed Care Plans, undated, included: It was the policy of the facility to provide an individualized plan of care for all elders that was appropriate to the elder's needs, strengths and limitations. The facility failed to develop an individualized comprehensive plan of care for this dependent resident with a contracture. - Review of Resident (R)68's Physician Order Sheet, dated 03/16/22, revealed diagnoses that included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness,) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain,) and atrial fibrillation (rapid, irregular heartbeat.) The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function and received oxygen therapy. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/13/22, assessed the resident required assistance with ADLs due to generalized weakness and decreased functional ability. The Care Plan, revised 04/08/22, instructed staff the resident received hospice services, which provided equipment and supplies. The Care Plan, instructed staff to monitor for respiratory distress/decreased respirations due to pain medications. The Care Plan lacked instruction for oxygen therapy and maintenance of equipment. A Physician's Order, dated 04/07/22, instructed staff to administer oxygen at two to five liters per minute per nasal cannula as needed for air hunger. Observation, on 05/02/22 through 05/05/22 revealed the resident's oxygen concentrator contained oxygen tubing draped over the top of the concentrator attached to a half full humidifier canister. The oxygen tubing contained a piece of tape with the date 04/21/22. Observation, on 05/09/22 revealed the oxygen concentrator in the resident's closet with the oxygen tubing draped over the top of the concentrator attached to the half full humidifier canister. The oxygen tubing contained a piece of tape dated 04/21/22. Interview, on 05/09/22 at 09:30 AM, with the resident, revealed she did not have difficulty breathing and placed the concentrator in her closet today. Interview, on 05/09/22 at 09:45 AM, with Certified Medication Aide (CMA) SS, confirmed the resident had an order for oxygen as needed on the Treatment Administration Record (TAR), but lacked instruction on changing the tubing/humidifier canister. CMA SS thought the resident used the oxygen once. Interview, on 05/09/22 at 9:55 AM, with Administrative Nurse E, revealed she would expect the care of the oxygen equipment to be documented on the TAR and in the care plan and would expect staff to change the oxygen tubing weekly. The facility policy for Elder Directed Care Plans, undated, included: It was the policy of the facility to provide an individualized plan of care for all elders that was appropriate to the elder's needs, strengths and limitations. The facility failed to include this resident's as needed use of oxygen on the care plan to ensure management and assessment of the resident's oxygen equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 87 residents with 23 residents sampled, including one resident reviewed for restorative services. Based on observation, interview, and record review, the facility failed to provide restorative services for one sampled Resident (R)27 to maintain or prevent decline in range of motion (ROM) ability. Findings included: - Review of Resident (R)27's electronic medical record (EMR), under the Med Diag (Diagnosis) tab, included a diagnosis of muscle weakness. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She required extensive assistance of two staff for transfers, her balance was not steady, and she had impairment on one side of her lower extremities. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment, dated 02/28/22, documented the resident had impaired balance and transition during transfers. The care plan would be initiated to maintain current ADL status and functional ability. The care plan for ADLs, revised 02/24/22, instructed staff the resident had self -care performance deficit. The resident required two staff for transfers with the use of a mechanical lift. Review of the resident's EMR lacked documentation of the resident having a contracture (a permanent shortening of muscle, tendon, or scar tissue producing deformity or distortion) to her right knee. Documentation lacked evidence of a restorative plan for the resident. On 05/05/22 at 08:34 AM, the resident sat in her wheelchair in her room watching TV. Her feet rested on the foot pedals of her wheelchair. The resident demonstrated how she was unable to straighten her right leg with her knee at a 45- degree angle. On 05/03/22 at 11:00 AM, the resident stated she had not been able to straighten her right knee since before her admission. The contracture had not gotten worse, it was the same as when she admitted to the facility. The resident stated she'd asked the staff about therapy or restorative care to help loosen her leg, but staff had told her she could not receive restorative care as she was on hospice. On 05/04/22 at 03:02 PM, Certified Nurse Aide (CNA) O stated the resident was on hospice. CNA O stated the resident did not receive restorative care. On 05/04/22 at 12:02 PM, CNA N stated the resident did not receive restorative care because she was on hospice. CNA N confirmed the resident had a contracture to her right knee. On 05/09/22 at 09:38 AM, Licensed Nurse (LN) LL stated the resident had a contracture to her right knee but did not receive restorative care. On 05/05/22 at 09:02 AM, Administrative Nurse E stated the facility only had a part-time restorative aide. The resident would need to be evaluated by therapy for her to receive restorative services and that had not been done because the resident was currently on hospice. The facility policy for Restorative Nursing, revised 05/17, included: The facility will provide restorative care for residents requiring contracture prevention and management, including passive range of motion (PROM), active range of motion (AROM) and splint/brace assistance. The facility failed to provide restorative services for this dependent resident in order to maintain or prevent decline in her ROM ability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 87 residents with 23 selected for review including two residents reviewed for pain management. Based on interview and record review, the facility failed to order one resident's narcotic (class of medication used to treat moderate to severe pain) medication in a timely manner, resulting in four missed scheduled doses and an increased pain level, for Resident (R)63. Findings included: - The Order Summary Report, dated 04/07/22, for Resident (R)63, included diagnoses of neuralgia (nerve pain), pain in unspecified joint, pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral (area of the lower back near the spine region), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS), dated [DATE], assessed R63 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. She frequently had pain or hurting in the last five days of the assessment period rated as an 8 on the 0-10 pain scale, where zero equals no pain and ten equals the worst possible pain. The pain made it hard for her to sleep at night and limited her day-to-day activities. She received scheduled pain medication, as needed pain medication, and non-medication intervention for pain. The Pain Care Area Assessment, dated 04/20/22, revealed R63 complained of pain during the pain interview and had pain related to her recent surgery, pressure ulcer, therapy, mobility, and had a history of pain. The physician was to be immediately notified if there was no pain relief from the current regimen. The Care Plan, dated 04/13/22, included a problem dated 04/30/22 which revealed R63 had acute/chronic pain related to surgical debridement (procedure to remove debris or infected/dead tissue from a wound) of sacrum, pressure ulcer, neuralgia (severe pain due to damaged nerves), osteoarthritis and to administer analgesics per orders. The staff were to notify the physician if interventions were unsuccessful or if current complaint of pain was a significant change from her past experience of pain. R63 preferred to have her pain controlled by medication as prescribed by the physician. Additionally, a problem was added to the care plan, dated 05/02/22, indicating R63 was on pain medication therapy, to administer the analgesic (pain reliever) as ordered by the physician. A fax sheet, dated 04/26/22, from the wound clinic to the facility revealed a request for the facility to contact the primary care physician, as R63 requests to have her as needed pain medications be given/provided throughout the night as ordered so she can stay on top of her pain. The electronic medical record (EMR), included an order dated 04/27/22, for hydrocodone-acetaminophen (narcotic analgesic), 10-325 milligrams (mg), give one tablet, by mouth, every four hours, for pain. A previous order, dated 04/14/22, was to give hydrocodone-acetaminophen, every four hours, while awake. The Medication Reorder Form, for the hydrocodone-acetaminophen, 10-325 mg, had a date of 05/01/22. The individual count sheet, for the hydrocodone-acetaminophen, 10-325 mg, revealed staff administered the last dose on the individual medication packet on 05/01/22 at 06:00 PM. The next count sheet, revealed on 05/02/22 at 02:36 PM, the facility received 60 tabs of the hydrocodone-acetaminophen from the pharmacy, and then staff administered the medication after the medication was available. The count sheet lacked what time the staff administered the first dose given on 05/02/22. The electronic Medication Administration Record, (eMAR), dated 05/2022, revealed R63 missed doses of the scheduled hydrocodone-acetaminophen at the following times: 1. On 05/01/22 at 10:00 PM. 2. On 05/02/22 at 02:00 AM. 3. On 05/02/22 at 06:00 AM. 4. On 05/02/22 at 10:00 AM, at which time her pain level rose to a 9 on the 0-10 pain scale. The eMAR, dated 05/2022, revealed the next time R63 received her narcotic pain medication was on 05/02/22 for the 02:00 PM scheduled dose. The Progress Notes, dated 05/02/22, revealed the hydrocodone-acetaminophen was Not in stock. The staff provided Tylenol (analgesic for mild pain) on 05/02/22 at 05:44 AM and was effective and again at 10:53 AM and was ineffective. On 05/03/22 at 10:01 AM, R63 stated, yesterday they did not order pain medication for me and I went half a day without pain medication, the staff had to wait for it to come in. I get the medication every four hours. Finally, Licensed Nurse (LN) I brought it to me immediately when it came in. I guess she put a big note in my chart to make sure there was enough pain medication to get me by, I do not think they ordered the medication. The medication is scheduled every four hours, but sometimes I have to ask for it because I know they are Super busy. On 05/03/22 at 01:45 PM, Certified Medication Aide (CMA) T stated when a medication gets down to seven pills remaining, there is a sticker that is pulled off of the medication card and placed on a fax form and sent to the pharmacy. If staff send the paper to the pharmacy by 10:00 AM, the pharmacy can fill the medication the same day. On 05/05/22 at 08:43 AM, CMA RR stated that when a medication gets down to five or seven tablets left, staff pull the sticker off the medication card and place it on a reorder sheet and fax the sheet to the pharmacy. The process is the same for narcotic medication scheduled every four hours. If the pharmacy required a script from the physician to fill the medication, the pharmacy would notify the physician. On 05/05/22 at 09:01 AM, Administrative Nurse D stated the process for reordering medication included pulling the sticker off the medication card, placing on the reorder form, and fax it to the pharmacy, or the nurse could call and request a refill. If it is a scheduled narcotic every four hours, the CMA should alert the charge nurse before the medication gets down to six pills, and alert the nurse right away if the medication was not in stock. On 05/05/22 at 09:15 AM, Consultant pharmacy staff GG stated R63's script for the hydrocodone-acetaminophen was filled on 05/02/22. The pharmacy received the request for refill with the medication sticker on it at 05/01/22 at 09:17 PM. The facility should request a refill at least 24 hours or even two days before the medication would run out to give them a chance to get a script from the physician so they could refill the medication. On 05/05/22 at 09:59 AM, R63 stated she had just received a pain pill, it was brought separately from the other pills, she had to ask if it was in the cup of pills, as they have to get that medication elsewhere than her room medication cabinet. R63 stated on 05/01/22 when my pain medication ran out, the staff did offer her Tylenol, she thought she took it but was not for sure, it did not really help much anyway. On 05/09/22 at 10:53 AM, LN I stated R63 ran out of her pain medication once for her on a weekend, the pain medication had not been reordered, and should have been on Wednesday before going into the weekend, or if there were seven pills left on the count sheet. With R63 getting the medication every four hours, seven pills was not soon enough to reorder the medication, and it should be reordered when there are 12 pills left. The staff offered Tylenol to her when she ran out of the hydrocodone. LN I offered to call the on call physician to get something for her pain out of the emergency kit, but the resident reported it would be fine until the morning, but we encouraged her to let us know if the pain got worse. LN I talked to therapy about not seeing her until her pain medication came in, which she received the medication on 05/02/22 at 02:42 PM. R63 received Tylenol that morning, but it was not effective, and the staff repositioned her and changed the dressing to her bottom, and Occupational Therapy did some bed exercises with her. Once the staff situated R63 she was comfortable after that. I would expect the staff to order her medication timely, so it does not run out. The facility policy Medication Ordering and Receiving from Pharmacy, dated 04/2020, revealed the policy was for medications and related products were received from the dispensing pharmacy on a timely basis. If a medication was not automatically refilled by the pharmacy, repeat medications (refills) were to be ordered three to five days in advance of need, as directed by the pharmacy order and delivery schedule, to assure and adequate supply was on hand. The refill order was to be called in, faxed, sent electronically, or otherwise transmitted to the pharmacy. When available and legible, the pharmacy label (including bar code if used) was to be pulled and transmitted to the pharmacy. The facility failed to provide this resident pain management for her acute/chronic pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 87 residents with five selected for review of unnecessary medications. Based on observation, interview and record review, the facility and consulting pharmacist failed to identify the need for baseline and subsequent assessment for extrapyramidal side effect of antipsychotic medications at the initiation of Seroquel (antipsychotic medication used to treat certain mental/ mood conditions)and periodically thereafter during therapy to ensure the resident did not experience adverse effects of this antipsychotic medication. Findings included: - Review of Resident (R)70's Physician Order Sheet, dated 03/16/22, revealed diagnoses included vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbance. The quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit and continuous inattention, disorganized thinking, and altered level of consciousness. The resident received hospice services. The Behavior Symptoms Care Area Assessment (CAA), dated 10/12/21, assessed the resident was physically and verbally abusive to staff and other residents with wandering, yelling and cursing. The resident was resistant to care. The Psychotropic Drug Use CAA, assessed the resident used psychotropic medications to manage the resident's psychiatric illness. The Care Plan, revised 02/13/22, instructed staff the resident used antianxiety medications and to report adverse effects of the medications. The Care Plan lacked interventions for the use of antipsychotic medications. A Physician's Order, dated 03/22/22, instructed staff to administer topical (on the skin) Seroquel (an antipsychotic medication) 25 milligrams (mg), twice a day, for increased anxiety and behaviors. Review of the resident's electronic records lacked an assessment for extrapyramidal or abnormal involuntary movement scale (AIMS). Observation, on 05/04/22 at 12:47 PM, revealed the resident seated in a recliner (with foot rest elevated) in the common living area. The resident attempted to climb out of the recliner, and CNA Q assisted the resident to transfer into her wheelchair and took the resident to the bathroom. Interview, on 05/04/22 at 03:00 PM, with Licensed Nurse (LN) HH, revealed the resident did have multiple behaviors in the evenings and at night, often staying up all night wandering. Interview, on 05/09/22 at 10:30 AM, with LN LL, revealed when a resident needed an assessment for extrapyramidal (a group of symptoms that may occur due to antipsychotic medication) side effects of antipsychotic medications the electronic medical record system should trigger the task on the dashboard for staff to complete. Interview, on 05/09/22 at 12:25 PM, with Administrative Nurse E, confirmed the facility failed to complete a baseline assessment for extrapyramidal side effect of antipsychotic medications at the start of Seroquel therapy on 03/22/22 or subsequently. Interview, on 05/09/22 at 01:30 PM, with Consultant Pharmacist II, confirmed she would expect the facility to complete a baseline assessment for extrapyramidal side effect of antipsychotic medications at the start of antipsychotic therapy and periodically during therapy. Consultant Pharmacist II confirmed lack of recommendation for the assessment upon review of the resident's medications on 03/31/22 and 04/30/22. The facility lacked a policy for assessment for assessment of extrapyramidal side effect of antipsychotic medications. The consulting pharmacist and facility failed to complete a baseline assessment for extrapyramidal side effect of antipsychotic medications at the initiation of Seroquel and periodically thereafter during therapy to ensure the resident did not experience adverse effects of this antipsychotic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Physician Order Sheet (POS), dated 03/16/22, for Resident (R)45, documented a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. He had rejection of care one to three days of the assessment period and took an antianxiety (a medication or other intervention that inhibits anxiety) medication seven of the seven days of the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 03/23/22, documented the pharmacist consultant would review medications monthly and the physician would review medications with each visit. The quarterly MDS, dated 03/10/22, documented the resident had a BIMS score of three, indicating severe cognitive impairment. He had inattention and disorganized thinking behavior which fluctuated and verbal behavior and other behavioral symptoms not directed towards others one to three days. He received an antianxiety medication seven of the seven days of the look back period. The care plan, updated 04/05/22, for polypharmacy, instructed staff the pharmacist would review and follow-up with the Ativan (an antianxiety medication), as indicated. Review of the resident's electronic medical record (EMR), under the Orders tab, included the following: Ativan 0.5 milligrams (mg), every (Q) four hours, as needed (PRN), for restlessness and agitation, ordered, 03/14/22. On 05/04/22 at 07:44 AM, Licensed Nurse (LN) J and Certified Medication Aide (CMA) SS entered the resident's room to provide cares. The resident was restless, but cooperative with staff as they toileted and dressed him. On 05/05/22 at 02:30 PM, the resident sat in the commons area of the unit. The resident continually attempted to stand up from his chair per self. Staff responded quickly to the resident to assist him to sit back down. Staff gave the resident activities to do in an attempt to redirect him. On 05/04/22 at 07:44 AM, CMA SS stated, the resident takes Ativan due to agitation. He has a PRN Ativan that he takes also. CMA SS stated the PRN antianxiety medications needed to be reordered every 14 days and the nurse took care of that. On 05/04/22 at 08:03 AM, LN J stated the resident receives PRN Ativan for agitation. On 05/09/22 at 08:56 AM, LN K stated the resident had an order for PRN antianxiety. Before giving the medication, staff will attempt non-medication interventions to try to calm the resident down. All PRN antianxiety medications need to have an automatic 14 day stop date unless there is documentation by the doctor to continue the medication for a longer period of time. On 05/09/22 at 09:55 AM, Administrative Nurse E stated PRN antianxiety medications should be reordered every 14 days unless the resident was on hospice. This resident was currently on hospice but did not have any stop date on the PRN Ativan. Administrative Nurse E stated she had contacted the hospice nurse who will be coming in to put a stop date on the medication. The facility policy for Medication Regimen Review, created 11/17, included: PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, then he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. The facility failed to obtain a stop date for the PRN antianxiety medication. The facility reported a census of 87 residents with five residents selected for review for unnecessary medications. Based on observation, interview and record review, the facility failed to assess for extrapyramidal (a group of symptoms that may occur due to antipsychotic medication) side effects for one of the five sampled residents (R)70 and failed to ensure as needed psychotropic medications did not exceed 14 day use without physician re-evaluation and specified duration for three of the five sampled residents (R) 70, 68 and 45. Findings included: - Review of Resident (R)70's Physician Order Sheet, dated 03/16/22, revealed diagnosis included vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbance. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit and received seven days of antidepressant and antianxiety medications during the seven day look-back period. The Behavior Symptoms Care Area Assessment (CAA), dated 10/12/21, assessed the resident was physically and verbally abusive to staff and other residents with wandering, yelling and cursing. The resident was resistant to care. The Psychotropic Drug Use CAA,dated 10/12/21, assessed the resident used psychotropic medications to manage the resident's psychiatric illness. The quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit and continuous inattention, disorganized thinking, and altered level of consciousness. The resident received hospice services . The Care Plan, revised 02/13/22, instructed staff the resident used antianxiety medications and to report adverse effects of the medications. A Physician's Order, dated 04/22/22, instructed staff to administer lorazepam (a medication for anxiety) 0.5 milligrams (mg,) topically (on the skin,) every two hours, as needed, for anxiety and/or restlessness. A Physician's Order, dated 04/23/22, instructed staff to administer lorazepam, 0.5 mg, topically, every four hours, as needed, for anxiety and/or restlessness. Interview, on 05/04/22 at 08:00 AM, with Certified Nurse Aide(CNA) Q, revealed the resident cooperated for bathing this morning, but often the resident resisted care. Observation, on 05/04/22 at 12:47 PM, revealed the resident seated in a recliner (with foot rest elevated) in the common living area. The resident attempted to climb out of the recliner, and CNA Q assisted the resident to transfer into her wheelchair and took the resident to the bathroom. Interview, on 05/04/22 at 03:00 PM, with Licensed Nurse (LN) HH, revealed the resident did have multiple behaviors in the evenings and at night, often staying up all night wandering. Interview, on 05/09/22 at 09:55 AM, with Administrative Nurse E, revealed as needed antianxiety medications should be ordered for 14 days and then for six months if the resident was on hospice and the orders for lorazepam should indicate this. The undated policy Medication Regimen Review, instructed staff that orders for as needed psychotropic medications are limited to 14 days unless the prescribing practitioner believed it was appropriate to extend the order and must document the rational and indicate the duration for the as needed order. The facility failed to ensure this resident's as needed lorazepam did not exceed the 14-day limitation for physician reevaluation for extension and duration of therapy to ensure the resident did not experience adverse effects of the psychotropic medication. - Furthermore, review of resident (R)70's Physician Order Sheet, dated 03/16/22, revealed diagnoses included vascular dementia V(a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbance. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit and received seven days of antidepressant and antianxiety medications during the seven day look-back period. The Behavior Symptoms Care Area Assessment (CAA), dated 10/12/21, assessed the resident was physically and verbally abusive to staff and other residents with wandering, yelling and cursing. The resident was resistant to care. The Psychotropic Drug Use CAA, assessed the resident use psychotropic medications to manage the resident's psychiatric illness. The quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit and continuous inattention, disorganized thinking, and altered level of consciousness. The resident received hospice services. The Care Plan, revised 02/13/22, instructed staff the resident used antianxiety medications and to report adverse effects of the medications. The Care Plan lacked interventions for the use of antipsychotic medications. A Physician's Order, dated 03/22/22, instructed staff to administer topical (on the skin) Seroquel (an antipsychotic medication) 25 milligrams (mg), twice a day, for increased anxiety and behaviors. Review of the resident's electronic records lacked an assessment for extrapyramidal or abnormal involuntary movement scale (AIMS). Observation, on 05/04/22 at 12:47 PM, revealed the resident seated in a recliner (with foot rest elevated) in the common living area. The resident attempted to climb out of the recliner, and CNA Q assisted the resident to transfer into her wheelchair and took the resident to the bathroom. Interview, on 05/04/22 at 03:00 PM, with Licensed Nurse (LN) HH, revealed the resident did have multiple behaviors in the evenings and at night, often staying up all night wandering. Interview, on 05/09/22 at 10:30 AM, with LN LL, revealed when a resident needed an assessment for extrapyramidal (a group of symptoms that may occur due to antipsychotic medication) side effects of antipsychotic medications the electronic medical record system should trigger the task on the dashboard for staff to complete. Interview, on 05/09/22 at 12:25 PM, with Administrative Nurse E, confirmed the facility failed to complete a baseline assessment for extrapyramidal side effect of antipsychotic medications at the start of Seroquel therapy on 03/22/22 or subsequently. Interview, on 05/09/22 at 01:30 PM, with Consultant Pharmacist II, confirmed she would expect the facility to complete a baseline assessment for extrapyramidal side effect of antipsychotic medications at the start of antipsychotic therapy and periodically during therapy. The facility lacked a policy for assessment for assessment of extrapyramidal side effect of antipsychotic medications. The facility failed to complete a baseline assessment for extrapyramidal side effect of antipsychotic medications at the initiation of Seroquel and periodically thereafter during therapy to ensure the resident did not experience adverse effects of this antipsychotic medication. - Review of Resident (R)68's Physician Order Sheet, dated 03/16/22, revealed diagnoses that included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness,) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain,) and atrial fibrillation (rapid, irregular heartbeat.) The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function. The Psychotropic Drug Use Care Area Assessment (CAA), dated 04/13/22, assessed the resident used psychotropic medications to manage psychiatric illness/condition. The Care Plan, revised 04/08/22, instructed staff the resident received antianxiety medications and to monitor for adverse effects. A Physician's Order, dated 04/07/22, instructed staff to administer Ativan (an antianxiety psychotropic medication) 0.5 milligrams (mg) every four hours, as needed for shortness of breath. Observation, on 05/04/22, at 11:44 AM, revealed the resident ambulating in the hallway with Certified Medication Aide (CMA) SS. The resident's had noticeable tremors but ambulated with a slow steady gait. Interview, on 05/04/22 at 11:50 AM with CMA SS, revealed the resident received hospice services and included the resident to have multiple medications changed. Interview, on 05/09/22 at 09:55 AM, with Administrative Nurse E, revealed as needed antianxiety medications should be ordered for 14 days and then for six months if the resident was on hospice and the orders for lorazepam should indicate this. The undated policy Medication Regimen Review, instructed staff that orders for as needed psychotropic medications are limited to 14 days unless the prescribing practitioner believed it was appropriate to extend the order and must document the rational and indicate the duration for the as needed order. The facility failed to ensure this resident's as needed lorazepam did not exceed the 14-day limitation for physician reevaluation for extension and duration of therapy to ensure the resident did not experience adverse effects of the psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 87 residents with 23 selected for review, including five reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to change the oxygen tubing for Resident (R)73, failed to change the oxygen tubing for R18 and to clean the concentrator and filter, failed to change the oxygen tubing for R68, failed to date the oxygen tubing, humidifier bottle and tubing, nebulizer tubing and store those items in a sanitary manner when not in use as well as the nebulizer kit after cleansing and allowing to air dry for R335, and failed to date the oxygen tubing and nebulizer tubing and kit when changed and to store items in a sanitary manner when not in use for R72. These practices increased the risk of these five residents for developing a respiratory infection. Findings included: - The Discharge Summary, for Resident (R)72, included a diagnosis of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], for Resident (R)72, assessed her with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition. R12 had shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat. She required the use of oxygen and had a diagnosis of COPD. The Baseline Care Plan, dated 04/20/22, included R72 required oxygen via a nasal cannula at four liters per minute continuously. The Care Plan, dated 05/03/22, revealed R72 required oxygen therapy at four liters via nasal cannula, monitor for signs and symptoms of respiratory insufficiency, and give aerosol medications as ordered. The electronic medical record (EMR), included these orders on 04/19/22: 1. Oxygen at four liters continuous via a nasal cannula. 2. 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 (3) milligrams (mg)/three milliliters (mL), one vial, inhale orally, every six hours, as needed, for COPD. The electronic Medication Administration Record, dated 05/2022, revealed the staff administered a breathing treatment three times on 05/02/22. A new order, dated 05/04/22 at 08:01 PM, instructed the staff to change the oxygen cannula/tubing and humidifier bottle once weekly on Saturday during the second shift and as needed. This was 15 days after R72 admitted to the facility. The order lacked when to change out the nebulizer tubing/kit. On 05/03/22 at 07:50 AM, observed R72 in her room with oxygen in place at four liters per a nasal cannula per the oxygen concentrator. The concentrator did not have a humidifier bottle in place. A nebulizer mask kit stored in the drawer of the bedside table, connected and not stored in a sanitary manner. The nebulizer tubing and kit and the oxygen tubing lacked a date when the staff changed it. On 05/03/22 at 10:40 AM, observed a nasal cannula hanging from the handle of the portable oxygen bottle cart with the nasal prongs in direct contact with the handle of the regulator. The nasal cannula lacked a date the staff changed the tubing. There were no changes to the nebulizer mask kit from prior observation. On 05/04/22 at 10:23 AM, R72 was in her room, nasal cannula in place and lacked a date the staff changed the tubing. The nebulizer kit was stored on the holding spot on the machine and connected. On 05/05/22 at 12:24 PM, Certified Medication Aide (CMA) RR, stated the oxygen tubing, humidifier bottle, and nebulizer kit were to be changed once a week and dated when changed. After the staff administer a nebulizer treatment, it is expected to rinse it out, wipe it out, then put it in a basket, disassembled. It should not be left out after use. On 05/05/22 at 12:36 PM, CMA RR confirmed with observation that R72's oxygen tubing connected to the concentrator and the portable oxygen bottle lacked a date the staff changed the tubing. The nasal cannula connected to the portable bottle was coiled and hanging from the handle of the cart. CMA RR stated the tubing should be in a bag, then removed the tubing and placed in a fabric bag. Furthermore, the kit should be rinsed and wiped out then reassembled so it would be ready when she needed a treatment. The kit lacked a date the staff changed the tubing. On 05/05/22 at 12:40 PM, R72 stated that sometimes the staff clean it and leave it lay out on a towel in the bathroom by the sink. On 05/09/22 at 11:28 AM, Administrative Staff D stated the oxygen tubing and the nebulizer tubing/kit should be changed weekly and was on the MAR to prompt the staff to do so. The staff were educated regarding this on 03/16/22 and 04/20/22. When staff change the items then it should include a date. When the items were not in use, the tubing should be stored in a black mesh bag. After staff administer a nebulizer treatment, staff should wash the kit with soap and water, rinse, and set the items out to dry. Staff should not wipe the nebulizer mask and medication cup of the kit after rinsing and should place the items on a clean paper towel each time. Storage of the kit to dry next to the sink could place the kit at risk for contamination. The facility policy Cleaning Respiratory Equipment, dated 05/01/17, instructed the staff to replace masks and/or cannulas used within seven days and PRN when obviously contaminated. When not in used, store masks and cannula in plastic bags labeled with the resident's name and date. For small volume nebulizers, replace every 48-72 hours. This includes hand-held nebulizers for medication. Rinse with water and air dry between treatments on the same resident. For humidification addressed prefilled humidifier bottles only which instructed following manufacturer's instructions, usually every seven to ten days. The purpose policy was to provide a safe and healthy environment for residents and to minimize or prevent the spread of infections. The facility failed to date the oxygen and nebulizer tubing/kit when changed and failed to store in a sanitary manner when not in use, increasing the risk of R72 of developing a respiratory infection. - The Discharge Summary, dated 04/25/22, for Resident (R)335, included diagnoses of acute respiratory failure with hypoxia (abnormal deficiency in the concentration of oxygen in arterial blood) and aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). The admission Minimum Data Set, (MDS), dated [DATE], assessed R335 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. He had shortness of breath or trouble breathing with exertion and required the use of oxygen. The Baseline Care Plan, dated 04/27/22, included a diagnosis of aspiration pneumonia and required oxygen at one liter per nasal cannula to keep oxygen saturations above 90% (percent). The comprehensive Care Plan, dated 04/25/22, included a problem dated 05/02/22, which revealed R335 was on antibiotic therapy related to a respiratory infection. An additional problem, dated 04/29/22, revealed R335 had chronic respiratory failure and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and required oxygen via a nasal cannula at one to two liters as needed. The electronic medical record (EMR) included the following orders on 04/25/22: 1. Oxygen to keep saturation 90-94%, lowest flow possible, one to two liters. 2. DuoNeb (respiratory inhalant medication used to treat COPD) solution, 0.5-2.5 (3) milligrams (mg)/three milliliters (mL), inhale orally, via nebulizer, every three times a day for hypoxemia and every four hours as needed for shortness of breath. 3. Budesonide (steroid medication) suspension 0.5 mg/mL, one application, inhale orally, two times a day. The EMR, contained additional orders, dated 04/26/22: 1. Change the humidifier bottle once weekly on Sunday during the day shift and as needed, start on 05/01/22. 2. Change the oxygen cannula/tubing once weekly on Sunday during the day shift, to start on 05/02/22. On 05/02/22 at 03:46 PM, R335's nebulizer tubing was on the floor, the oxygen tubing and humidifier connected to the oxygen concentrator lacked a date the staff changed the tubing and the humidifier bottle. On 05/03/22 at 11:02 AM, observed R335's nebulizer tubing was hanging off the bedside table. The humidifier bottle and oxygen tubing connected to the concentrator lacked a date the staff changed the tubing and the humidifier bottle. On 05/04/22 at 07:54 AM, R335 was resting in his bed without oxygen in place. The nasal cannula connected to the concentrator was on the floor beside his bed and lacked a date the staff changed the tubing. The humidifier bottle continued to lack a date the when staff changed the bottle. The tubing from the nebulizer was dangling between the bedside table and the wall and lacked a date the staff changed the tubing. On 05/04/22 at 07:57 AM, observed Certified Medication Aide (CMA) T replace the nasal cannula that had been on the floor with a new one. CMA T did not date the new nasal cannula. On 05/04/22 at 08:49 AM, CMA T prepared the nebulizer treatment for R335, she removed the nebulizer kit from paper towels located in the bathroom on the counter right next to the sink. She connected the administration kit to the tubing that was dangling between the bedside table and the wall. On 05/04/22 at 09:06 AM, CMA T disconnected the nebulizer tubing from the administration kit and placed the tubing directly on the bedside table. Next, CMA T disassembled the kit and rinsed the kit with water without gloves on and placed the kit on the paper towels that she previously removed the kit from. CMA T confirmed the kit and tubing lacked a date the staff changed the tubing, but it did display on the Medication Administration Record when to be changed, and did not know the frequency, and the tubing does not get stored in a bag when not in use. On 05/04/22 at 10:55 AM, CMA T observed disconnecting the nasal cannula from the extension tubing connected to the concentrator and draped the extension tubing across the overbed table and the end dangled over the table. The extension tubing fell to the floor when the resident exited the room. CMA T picked up the extension tubing, placed the tubing back onto the bedside table. On 05/04/22 at 11:05 AM CMA T stated she had never seen a bag to store the tubing in when not in use. On 05/04/22 at 11:06 AM, observed a round hairbrush with hair present in the bristles laying on the paper towel within an inch of the nebulizer mask right next to the sink. The paper towels were located to the right of the sink counter next to the mirror above the sink, which could cause contamination to the nebulizer kit when moving hands from sink after washing to paper towel location. On 05/04/22 at 01:50 PM CMA T stated the staff store the nebulizer kit at the sink and was at risk for getting water splashed on it during handwashing and when getting paper towels, and new paper towels should be used each time after rinsing the kit. On 05/05/22 at 12:24 PM CMA RR stated the oxygen tubing, humidifier bottle, and nebulizer kit were to be changed once a week and dated when changed. After the staff administer a nebulizer treatment, it is expected staff to rinse the nebulizer kit out, wipe it out, then put it in a basket, disassembled. It should not be left out after use. CMA RR confirmed the oxygen tubing, humidifier bottle, and nebulizer kit lacked a date. On 05/09/22 at 11:28 AM, Administrative Staff D stated the oxygen tubing and the nebulizer tubing/kit should be changed weekly and was on the MAR to prompt the staff to do so. The staff had been educated regarding this on 03/16/22 and 04/20/22. When staff changed the items then it should include a date. When the items were not in use, the tubing should be stored in a black mesh bag. After staff administer a nebulizer treatment, staff should wash the kit with soap and water, rinse, and set the items out to dry. Staff should not wipe the nebulizer mask and medication cup of the kit after rinsing and should place the items on a clean paper towel each time. Storage of the kit to dry next to the sink could place the kit at risk for contamination. The facility policy Cleaning Respiratory Equipment, dated 05/01/17, instructed the staff to replace masks and/or cannulas used within seven days and PRN when obviously contaminated. When not in used, store masks and cannula in plastic bags labeled with the resident's name and date. For small volume nebulizers, replace every 48-72 hours. This includes hand-held nebulizers for medication. Rinse with water and air dry between treatments on the same resident. For humidification addressed prefilled humidifier bottles only which instructed following manufacturer's instructions, usually every seven to ten days. The purpose policy was to provide a safe and healthy environment for residents and to minimize or prevent the spread of infections. The facility failed to date the oxygen and nebulizer tubing/kit when changed for this resident and failed to store the items in a sanitary manner when not in use, increasing the risk of R335 of developing a respiratory infection. - Review of the Resident's (R) 18 Physician Orders, dated 03/10/22 revealed diagnosis which included chronic respiratory failure and sleep apnea (breathing stops during sleep). The admission Minimum Data Set (MDS) dated [DATE], documentation included the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. She reported trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy for two to six days of the look back period. She required extensive assistance of staff with activities of daily living (ADLs) for bed mobility and transfers. The resident used Oxygen. The Quarterly MDS, dated 02/17/22, documented changes which included the resident required supervision of staff for transfers, and limited assistance for walking. The Care Area Assessment (CAA), dated 05/19/22, documentation did not address the use of oxygen. The Care Plan, (CP), dated 02/16/22, directed staff the resident with altered respiratory status/difficulty breathing related to sleep apnea and chronic respiratory failure. The oxygen setting for the concentrator was set for three liters via nasal cannula. The care plan did not include maintenance of oxygen tubing, concentrator filter, humidifier bottle, distilled water nor storage of cannula/tubing when not in use. Additionally, the care plan did not address the use nor maintenance of the Continuous Positive Air Pressure (CPAP) machine and/or mask and tubing storage when not in use. Review of the Physician's Order, dated 03/10/22, documented an order initiated on 02/04/22 to change the humidifier bottle once weekly. Wipe down the concentrator and clean the filter. Change the oxygen cannula/tubing, once weekly on Saturday and as needed. Please assist the elder in placing C-pap on at bedtime, initiated 05/25/2021. Review of the Treatment Administration Record, (TAR), dated 03/01/22 through 05/02/22, documentation revealed the oxygen humidifier and tubing changes, clean concentrator filter signed out as done on 03/5/22, 03/12/22, 03/19/22, 03/26/22, 04/02/22, 04/09/22, and 04/23/22. Staff failed to document/ sign on 04/16/22 and 04/30/22, On 05/03/22 at 10:01 AM, the resident stated her brother put water in the oxygen bottle, as the staff do not take care of the oxygen. The jug sitting on the floor only had a little water left in it so they will need to get me more. The staff have not changed the tubing more than three times this year, if that many times. She reported she never had a bag to put her CPAP in and verified she used it every night. She would use the oxygen on during the day, but never had a bag for it either. On 05/03/22 at 10:27 AM, the resident had her oxygen cannula and tubing in place with oxygen at three liter per minute via nasal cannula. The oxygen tubing date was 02/22/22, the humidifier bottle was not labeled, a partially empty unlabeled jug of distilled water sat directly on the floor. There was not a storage bag present for storing the cannula and tubing when not in use. The concentrator filter had a thick layer of dust. The CPAP hose hung across the bed rail without having a bag present for storage when not in use. On 05/03/22 at 04:14 PM, Certified Aide (CNA) stated the nurse should change the tubing and humidifier bottle every two weeks. There should be a bag to store the tubing and mask when the oxygen and CPAP were not in use. The storage bags should be dated. Additionally, she reported the distilled water was to fill the humidifier bottle on the oxygen concentrator and should be stored in the bathroom off the floor. The distilled water should be dated when opened. On 05/04/22 at 09:36 AM, CNA M, confirmed the above findings. Additionally, she confirmed there was two jugs of distilled water directly on the floor by the concentrator, neither labeled and one partially empty. She stated she was not aware an oxygen concentrator had a filter that needed to be cleaned. She reported she thought the tubing and cannulas were changed two times a week by the nurse, but she did not know. On 05/04/22 at 11:50 AM, Licensed Nurse G reported, staff should change the oxygen tubing monthly. He was not aware of the system in this facility for changing out the tubing or cleaning the concentrator filter. The tubing should be labeled when changed. Night shift usually changes it out. The resident uses her CPAP at night, but was unaware where staff should store oxygen when not in use. In addition, he was unaware of the system for changing out the oxygen tubing or the humidifier bottle. On 05/05/22 at 09:26 AM, Licensed Nurse (LN) H reported staff should change the oxygen tubing and humidifier bottles weekly. The tubings should be stored in a labeled bag when not in use. Night shift staff change the tubing/ humidifier bottles/ nebulizer tubings. The resident's CPAP mask and hose should be stored in a labeled bag when not in use. On 05/09/22 at 10:20 AM, Administrative Nurse D stated nurses should change the oxygen cannulas/tubing weekly and as needed. The tubing, humidifier bottles should be labeled with the date when changed. The tubing for oxygen and CPAP should be stored in a labeled bag when not in use. Additionally, the nurse should document on the TAR when tubing, humidifier, and concentrator filters are changed and cleaned. The facility policy for Cleaning Respiratory Equipment, dated 05/01/2017, documentation included . Replace masks and/or cannula used by an individual resident within seven days and as needed (PRN) when obviously contaminated. When not in use, store masks and cannula in plastic bags labeled with the resident's name and date. Clean oxygen concentrator filter weekly. The facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice. - Review of Resident (R)73's electronic medical record (EMR), under the Med Diag (Diagnosis) tab, included a diagnosis of chronic obstructive pulmonary disease [(COPD) progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing.] The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She used oxygen. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 11/01/21, documented the resident had memory and recall deficits. The quarterly MDS, dated 04/16/22, documented the resident had a BIMS score of six, indicating severe cognitive impairment and she used oxygen. The care plan, dated 03/27/22, instructed staff the resident had a diagnosis of COPD. The resident was to have her oxygen settings at 2 liters (L) by nasal cannula (NC), per minute, continuously. Review of the resident's EMR, under the Orders tab, included an order to change the oxygen cannula and tubing weekly and as needed (PRN). Documentation showed staff completed this task on a weekly basis. On 05/02/22 at 04:13 PM, the resident's oxygen concentrator sat in her room. The oxygen tubing, dated 03/26/22, was on top of the resident's bed side table. The resident was in the dining room, in her wheelchair, with an oxygen tank with oxygen tubing dated 04/23/22. On 05/03/22 at 08:17 AM, the resident's oxygen concentrator sat in her room. The oxygen tubing, dated 03/26/22, was on top of the resident's bed side table. The resident was in the dining room, in her wheelchair, with an oxygen tank with oxygen tubing dated 04/23/22. On 05/04/22 at 03:02 PM, Certified Nurse Aide (CNA) O stated the resident used her oxygen at all times. The resident used the oxygen concentrator whenever she was in her bed. The resident was unable to put the oxygen on herself. On 05/05/22 at 09:53 AM, CNA N stated the resident required her oxygen to be on at all times. The resident would use the oxygen concentrator in her room when she was in bed and the oxygen tank when she was out of her room. CNA N confirmed the date of 03/26/22 on the oxygen tubing. On 05/04/22 at 02:09 PM, Licensed Nurse (LN) L stated staff were to change the oxygen tubing every week. Either the nurse or the Certified Medication Aide (CMA) could change the tubing. Staff document this on the treatment administration sheet (TAR). On 05/09/22 at 09:38 AM, LN LL stated the CMAs would change the oxygen tubing on the resident's oxygen concentrators each week during the evening shift. Staff should put the date on the tubing when putting on new tubing. On 05/09/22 at 09:55 AM, Administrative Nurse E stated staff were to change the oxygen tubing every week and document on the TAR. Staff were to date the tubing with the date it was changed. The facility policy for Cleaning Respiratory Equipment, revised 05/01/17, included: Replace masks and/or cannulas used by an individual resident within seven days and as needed (PRN) when obviously contaminated. The facility failed to change the oxygen tubing for this dependent resident who used oxygen continuously, in a timely manner. - Review of Resident (R)68's Physician Order Sheet, dated 03/16/22, revealed diagnoses that included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness,) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain,) and atrial fibrillation (rapid, irregular heartbeat.) The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function and received oxygen therapy. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/13/22, assessed the resident required assistance with ADLs due to generalized weakness and decreased functional ability. The Care Plan, revised 04/08/22, instructed staff the resident received hospice services, which provided equipment and supplies. The Care Plan, instructed staff to monitor for respiratory distress/decreased respirations due to pain medications. The Care Plan lacked instruction for oxygen therapy and maintenance of equipment. A Physician's Order, dated 04/07/22, instructed staff to administer oxygen at two to five liters per minute per nasal cannula as needed for air hunger. Observation, on 05/02/22 through 05/05/22 revealed the resident's oxygen concentrator contained oxygen tubing draped over the top of the concentrator attached to a half full humidifier canister. The oxygen tubing contained a piece of tape with the date 04/21/22. Observation, on 05/09/22 revealed the oxygen concentrator in the resident's closet with the oxygen tubing draped over the top of the concentrator attached to the half full humidifier canister. The oxygen tubing contained a piece of tape dated 04/21/22. Interview, on 05/09/22 at 09:30 AM, with the resident, revealed she did not have difficulty breathing and placed the concentrator in her closet today. Interview, on 05/09/22 at 09:45 AM, with Certified Medication Aide (CMA) SS, confirmed the resident had an order for oxygen as needed on the Treatment Administration Record (TAR), but lacked instruction on changing the tubing/humidifier canister. CMA SS thought the resident used the oxygen once. Interview, on 05/09/22 at 9:55 AM, with Administrative Nurse E, revealed she would expect the care of the oxygen equipment to be documented on the TAR and would expect staff to change the oxygen tubing weekly. The facility policy Infection Control, revised 05/01/17, instructed staff to replace the cannula within seven days and store in a plastic bag labeled with the resident's name and date. The facility failed to maintain this resident's oxygen cannula/tubing/humidifier canister in a sanitary manner to prevent the spread of infection.

The facility reported a census of 87 residents. Based on record review and interview, the facility failed to ensure nursing staff followed the principles of antibiotic stewardship in a proactive manner to ensure residents received antibiotics in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance. The facility failed to track and trend infections and causative microorganisms throughout the facility and failed to compile antibiotic use data for prescribing practitioners. Findings included: - Review of the Antibiotic Log, revealed the following areas of concerns: April 2021: One unsampled resident with a wound infection treated with an antibiotic for 14 days without location of wound or causative organism. May 2021: Three unsampled residents with urinary tract infections (UTIs) treated with antibiotics, all without indication of causative organisms. June 2021: One unsampled resident identified with MRSA(methicillin resistant streptococcus aureus) treated with Vancomycin (antibiotic) and lacked source of the MRSA or need for isolation. This same resident was treated with Cefepime and Doxycycline (antibiotics.) One unsampled resident with community acquired MRSA infection and wound infections was treated with Clindamycin, Levaquin and Doxycycline (antibiotics) and lacked wound location or onset date of therapy or resolution. July 2021: One unsampled resident with UTI treated with Methenamine (antibiotic.) One unsampled resident treated for Infection with Vancomycin and lacked a causative organism. One unsampled resident treated for Infections with Bactrim DS (antibiotic) and lacked causative organism. August 2021: One unsampled resident treated with Bactrim DS (antibiotic), and lacked onset date, causative organism or diagnosis. One unsampled resident treated with Cefdinir (antibiotic) lacked diagnosis or causative organism. September 2021: Ten residents with UTIs, all treated with antibiotics, all lacked causative organisms. One unsampled resident with prophylaxis (action taken to prevent disease) antibiotic for UTI. One unsampled resident with an infection to her port (intravenous access site) treated with antibiotic and lacked causative organism and determination if facility acquired. October 2021: One unsampled resident for unknown diagnosis/organism treated with Invanz (antibiotic) for unknown diagnosis/organism. One unsampled resident treated with Hiprex (antibiotic) with an unknown diagnosis/organism. One unsampled resident treated with piperacillin/tazobactam (antibiotics) lacked diagnoses/organism. Four unsampled residents with UTIs all treated with antibiotics and lacked causative organisms. One unsampled resident with C Diff (clostridium difficile) treated with Vancomycin and lacked if isolation precautions instituted. November 2021: Five unsampled residents with UTIs, and no causative organism indicated. One unsampled resident treated with Acyclovir, and lacked diagnoses/ causative organism. One unsampled resident treated with Trimethoprim (antibiotic) indefinitely for chronic UTI and lacked causative organism. December 2021: Ten unsampled residents treated with antibiotics for UTIs with no causative organisms indicated. One unsampled resident treated with Zithromax (antibiotic) lacked causative organism/diagnoses and same resident treated with Erythromycin (antibiotic) for Allergies. One unsampled resident treated with Keflex (antibiotic), lacked onset date, organism, diagnosis and stop date. One unsampled resident treated with Cephalexin (antibiotic) for UTI for 10 days, then treated with Augmentin (antibiotic) for 10 days and lacked diagnoses causative /organisms. January 2022: Six unsampled residents treated with antibiotics for UTI, lacked causative organisms. February 2022 , three unsampled residents treated with antibiotics for UTIs, lacked causative organisms. One unsampled resident treated for Infection lacked diagnosis/ causative organisms treated with Cefalexin (antibiotic.) March 2022, Five unsampled resident treated with antibiotics for UTI, lacked causative organisms. April/May 2022: One unsampled resident treated for UTI with Keflex(antibiotic) for seven days followed by seven days of Cefdinir (antibiotic), lacked causative organism. Five other unsampled residents treated with antibiotics for UTI's lacked causative organisms. Two unsampled resident treated with antibiotics, lacked diagnosis/organism. Interview, on 05/09/22 at 11:30 AM, with Administrative Nurse D, confirmed incomplete data collection for tracking/trending of causative microorganisms/ diagnoses, and determination of antibiotic appropriateness as evidenced in the Antibiotic Logs provided. The facility policy Infection Prevention and Control Program revised 05/20/17 instructed staff to utilize a system of surveillance for identifying, reporting, investigating and preventing infections. Antibiotic Stewardship will be implemented as part of the overall infection prevention and control program. Antibiotic use protocols and a system to monitor antibiotic use will be implemented. The facility failed to ensure principles of antibiotic stewardship to ensure residents received antibiotics in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner. The facility failed to track and trend infections and causative microorganisms throughout the facility and failed to compile antibiotic use data for prescribing practitioners.

The facility census totaled 92 residents with three residents reviewed for beneficiary notices. Based on record review and interview the facility failed to notify Resident (R)5 in advance of Medicare Part A (skilled) services ending on 10/14/20 per the Centers for Medicaid/Medicare Services (CMS) regulation. Findings included: - Review of R5's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed his Medicare Part A skilled services episode started on 08/31/20 and the last covered day of Part A service as 10/14/20. Review of Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage, (SNFABN) signed on 10/15/20 revealed R5's coverage ended 10/14/20, but the facility did not have the resident sign the form until 10/15/20. Interview with Social Services staff C on 02/11/21 at 12:31 PM revealed the SNFABN for R5 was signed by the resident a day after coverage ended, and the form should have been completed 48-72 hours before the resident coverage ended. Review of Medicare Claims Processing Manual, revised 03/08/19, revealed the facility was to issue the written notice far enough in advance the beneficiary could make a rational, informed decision or before the procedure is initiated. The facility failed to provide R5 written notification of the SNFABN prior to the end of the Medicare Part A stay.

The facility census totaled 92 residents, with three residents reviewed for falls. Based on observation, interview, and record review, the facility failed to effectively evaluate Resident (R) 45's causal factors for falls and enact appropriate interventions related to the identified causal factors. Findings included: - Review of R45's pertinent diagnoses from 01/12/21 Physicians Orders Diagnosis electronic medical records (EMR) revealed: atrial fibrillation (A-FIB, a rapid, irregular heartbeat), presence of a cardiac pacemaker (an implanted device to regulate the beating of the heart), hypertension (HTN, elevated blood pressure), Alzheimer's (a progressive mental deterioration characterized by confusion and memory failure), benign prostatic hyperplasia (BPH, a non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections). A review of the 10/01/20 admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of eight, indicating moderately impaired cognition. R45 had no rejections of care noted and required extensive two-person assistance for transfers, one-person assistance for walking in his room, and toileting. R45's unsteady gait required the use of a walker/wheelchair. No falls noted for the review period. Review of the 12/22/20 Quarterly MDS revealed a BIMS of six, indicating severely impaired cognition. R45 had no rejection of care noted and required extensive two-person assistance for transfers and toileting, supervision two-person assistance for walking in the room. R45's unsteady gait required the use of a walker/wheelchair. He experienced two or more non-injury falls and two or more injury falls since the last MDS. Review of the 10/01/20 Cognitive Care Area Assessment (CAA) revealed R45's continued to show forgetfulness by trying to get up on his own and indicated a risk for falls. Review of the 10/01/20 ADL CAA revealed the resident's unsteady gate made it challenging to perform transitions between bed, chair and scooter. During the assessment period, he received extensive assistance with walking and toileting. Review of the 10/01/20 Falls CAA revealed, see the Cognitive and ADL CAAs - same information applies. Review of 12/15/20 Morse Fall Assessment revealed resident at high risk for falls. The facility did not provide a fall assessment before the 12/15/20 date as requested on 02/17/21. Review of Care Plan, revised 01/14/21, revealed R45 was alert and oriented to surroundings, forgetful, and might make poor/unsafe decisions. Review of ADL Care Plan, revised 01/14/21, revealed he ambulated/transferred with a four-wheeled walker with standby assistance. For toilet use, R45 required contact guard assistance (1 staff minimum assistance). The resident slept in his recliner. Review of Bowel and Bladder Care Plan, revised 01/14/21, revealed he experienced occasional bladder incontinence and wore briefs. Staff encouraged and provided good peri-care. Review of Fall Prevention Care Plan, last revised 01/14/21, revealed staff was to complete visual checks while performing rounds, remind R45 to call for assistance, monitor for any gait or balance changes, assist with walking, transferring, and showering, provide reminder signs to encourage soft-touch call light usage, physical therapy consulted for strengthening, a lamp by the bedside, and a one-way glider which staff was to check stability and function daily. Review of 09/25/20 to 09/27/20 Voiding Diary revealed resident averaged toilet use/incontinence every three to four hours while awake but lacked an assessment of the voiding diary. The facility failed to provide a more recent voiding diary as requested on 02/17/21. Review of 10/02/20 at 08:35 AM Progress Note revealed R45 required one-person assistance with walker and gait belt. The resident stated, I do not remember you telling me to call for help after he went to the bathroom himself, and staff told him he needed to call for help. Review of 10/05/20 at 09:10 AM Progress Note revealed he required one to two-person assistance with a gait belt for transfers/toileting, and he continued to be non-compliant with call light. Review of Fall Investigations revealed R45 had a total of six falls from 12/04/20 to 01/08/21. Review of Fall Investigation dated 12/04/20 at 07:15 PM revealed R45 had an unwitnessed fall in the bathroom after showering and toileting himself. Staff listed contributing factors as inadequate footwear and showering by himself. Facility staff identified the fall's casual factors as the amount of assistance R45 required and implemented the intervention of having R45 call for assistance when he felt weak and needed assistance. Review of Fall Investigation dated 12/08/20 at 09:50 PM revealed R45 had an unwitnessed fall in his room while attempting to walk to the bathroom unassisted. Staff identified contributing factors as R45 having weakness while walking to the bathroom. Facility staff identified the causal factor as got weak in the knees, and the interventions implemented were to have R45 call for assistance with walking, increase monitoring R45 for signs and symptoms of COVID-19 (viral disease), completion of a voiding diary, and ensuring one staff member assistance with walking. Review of Fall Investigation dated 12/14/20 at 06:20 AM revealed R45 had an unwitnessed fall in the room after sliding out of the recliner. Staff listed contributing factors as COVID-19 and sliding out of the recliner. The staff did document that R45 had been incontinent of urine at the time of the fall. Facility staff identified the fall's causal factor as slid out of the recliner and implemented using brightly colored reminders for R45 to utilize the new soft-touch call light. Review of Fall Investigation dated 12/15/20 at 05:30 AM revealed R45 had an unwitnessed fall in his room when attempting to transfer and toilet himself. Staff listed contributing and causal factors as weakness from COVID-19 and needing to utilize the restroom. The facility then implemented leaving R45's door open at all times, changing to a manual recliner, keeping the call light within reach, and utilizing a hi/low bed. Review of Fall Investigation dated 12/18/20 at 05:30 AM revealed R45 had an unwitnessed fall in his room while attempting to walk to the bathroom independently. Staff listed contributing factors as a recent COVID-19 infection which increased his weakness and confusion. Staff documented R45 had loose stool spilling from his brief upon staff's arrival. The facility staff listed the causal factor as medical/mental/toileting status and implemented scheduled toileting during the night, continued education about utilizing the call light, and signage to remind R45 to use the call light. Review of Fall Investigation dated 01/08/21 at 06:15 PM revealed R45 had an unwitnessed fall in his room when he slipped out of his recliner. The Fall Investigation did not identify causal factors or interventions. Observation of R45 on 02/11/21 at 07:53 AM revealed the resident in his room seated in his recliner with his eyes closed and call light in place. At 07:59 AM, Certified Nurse Aide (CNA) E entered the resident room with the resident's breakfast. At 08:24 AM, Licensed Nurse (LN) H in the resident room did not prompt/encourage the resident to the toilet. At 08:59 AM, CNA D walked by the resident room, and she asked him if he needed to use the restroom. The resident stated he could do it alone, and CNA D reminded the resident that he needed assistance and asked again if he needed to go now, and he responded no. The resident did no exhibit anger or other disruptive response to the CNA's question. Observation of resident on 02/16/21 at 10:45 AM revealed the resident in his room with the room door closed. Upon entering the room after knocking, R45 was standing with his walker by the window with oxygen tubing located under his feet and the walker. R45 reported he went to the bathroom and needed a new shirt, so he got one and put it on. CNA E then entered the room and assisted R45 back to the recliner. Interview on 02/11/21 at 10:45 AM with CNA D revealed R45's fall risk is high, and he had a few falls in the facility. Some interventions included signs on the door to remind him to use his call light and walker, but he would not remember. She stated that he usually called to go to the restroom, but staff checked on him and offered to the toilet often because he did experience incontinence. Interview on 02/16/21 at 10:49 AM with CNA E revealed that she felt staff encouraging R45 with a toileting plan every two to four hours would be beneficial for this resident because he cannot remember to use his call light as directed. Interview with LN F on 02/16/21 at 11:26 PM she stated that R45 had fallen a lot because he refused to use his call light. She indicated the interventions for his falls included staff encouraging the use of the soft call light and reminders, frequent checks on the resident, and keeping his door open for safety. She then stated, I think a toileting schedule would be beneficial, and after looking at his voiding diary, every two hours would be appropriate during the day. She then indicated that the fall risk meetings did not include the nursing staff, including CNAs, that worked with the resident. She then stated, That would help find better interventions and root causes, and probably would have noticed the need for a toileting schedule/plan for him sooner if regular care staff were invited to give input. Interview on 02/16/21 at 08:00 AM with Administrative Nurse B revealed she stated, It seemed that while awake, R45 voided pretty regularly. She then indicated that a toileting plan would be beneficial based on looking at his BIMs, voiding diary, and his history of falls in the facility because of his confusion. She reported the voiding diary should have an assessment of the findings. The fall risk meeting staff had been so focused on COVID-19 they had overlooked a toileting plan as an intervention. Review of the revised 2019 Fall Management Program policy revealed the policy's purpose was to provide an individualized assessment to minimize and prevent future falls and injuries from falls and identify causative information and trends useful in preventing future falls. The care plan would include individualized interventions designed to decrease the potential for falls. If the resident continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident's falling and re-evaluate current interventions' continued relevance. The facility failed to identify causal factors and implement interventions based on the causal factors to prevent R45 from falling.

The facility census totaled 92 residents with four reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure that Resident (R)45 oxygen humidifier (device used to humidify supplemental oxygen) and oxygen tubing was maintained. Findings included: - Review of resident (R) 45 pertinent diagnoses from 01/12/21 physicians orders diagnosis electronic medical records (EMR) revealed: atrial fibrillation (A-FIB, a rapid, irregular heartbeat), presence of cardiac pacemaker (an implanted device to regulate the beating of the heart), Alzheimer's (a progressive mental deterioration characterized by confusion and memory failure). Review of the 10/01/20 admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of eight, indicating moderately impaired cognition. He required oxygen therapy. Review of the 12/22/20 Quarterly MDS revealed a BIMS of six, indicating severely impaired cognition. He required oxygen therapy. Review of Care Plan, revised 01/14/21 revealed R45 required continuous oxygen per nasal cannula (NC). Staff were to monitor/assess for signs and symptoms of decreased oxygenation and checked oxygen (O2) saturations. Review of Physician Orders dated 02/01/21 revealed R45 required O2 at 2 liters per minute via nasal canula continuously for shortness of breath. Observation on 02/09/21 at 01:26 PM revealed R45s O2 tubing connected to the concentrator and the humidifier did not contain any liquid and cracks were noted in the plastic of the humidifier container. Interview with Licensed Nurse (LN) F on 02/09/21 at 01:26 PM revealed the O2 tubing was replaced every two weeks, but she was unsure when the humidifier needed changed/filled. Interview on 02/16/21 at 08:00 AM with Administrative Nurse B revealed every Saturday the nurses on first shift change out the O2 tubing and humidifier bottles. Review of revised 02/16/21 Infection Control Cleaning Respiratory Equipment policy revealed the facility replaced cannula used by an individual resident within seven days and as needed (PRN) when obviously contaminated. Staff were to replace humidifiers according to manufacturer's instructions, usually every seven to ten days and follow the schedule and intervals specified in this procedure. The facility failed to ensure R45s humidifier and oxygen tubing was maintained for his use.