The facility identified a census of 120 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to notify Resident (R) 1's representative of care plan changes and/or results. This deficient practice had the risk of miscommunication between R1, their representative, and the facility. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of heart failure (HF-a condition with low heart output and the body becomes congested with fluid), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (cerebrovascular accident [CVA]/stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, and seizures. The Significant Change Minimum Data Set (MDS) dated 11/06/24, documented a Brief Interview for Mental Status was not conducted due to R1 rarely or never understood. R1 had coughing or choking during meals or when swallowing medications. R1 had weight loss. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 11/11/24, documented R1 experienced strokes and seizures and other medical and physical complications including dysphasia (a condition that affects your ability to produce and understand spoken language). The Nutrition CAA dated 11/12/24, documented R1 had impaired nutrition related to weight loss and poor appetite. R1 needed set-up assistance and cueing and staff placed items in reach of R1's left hand. R1's Care Plan dated 03/22/19, documented R1 had impaired cognitive function related to CVA and directed the facility to communicate with R1 and her representative regarding R1's capabilities and needs. R1's EMR revealed the following: A Communication/Visit with Physician note on 09/06/24 at 05:04 PM, documented that staff notified R1's provider of her seizure activity. The provider gave a new order to restart Lacosamide (medication used to treat seizures) 250 milligrams (mg) daily. R1's clinical record lacked evidence the facility notified R1's representative of her seizure activity and new medication order. A Health Status note on 09/07/24 at 01:08 PM, documented R1 had two short seizures that shift. R1 came out of the seizures quickly and seemed to return to her normal self shortly after. R1's clinical record lacked evidence the facility notified R1's representative of her seizure activity. A Provider/Practitioner note on 10/21/24 at 06:49 PM, documented R1 had diffuse (throughout) wheezing (breathing with a whistling or rattling sound in the chest) in all lung fields. R1 had a chest x-ray completed and the results were pending at the time of the visit. The provider ordered levofloxacin 500 mg daily if the chest x-ray showed pneumonia (inflammation of the lungs). R1's clinical record lacked evidence that the facility notified R1's representative of the order for a chest x-ray or the plan of care in case of pneumonia. A Health Status note on 10/22/24 at 09:13 AM, documented R1's provider ordered a chest x-ray on 10/21/24 due to respiratory symptoms. The x-ray results showed R1's lungs were free of infiltrates (substances that are not normally present in the lungs, but instead build up in the lung tissue) with no pleural effusion (abnormal accumulation of fluid in the lungs) or pneumothorax (accumulation of air and blood in the area around the lungs). R1's clinical record lacked evidence the facility notified R1's representative of the chest x-ray results. A Communication/Visit with Physician note on 10/23/24 at 09:27 AM, documented R1 had an open area to her sacrum (large triangular bone/area between the two hip bones) from shearing/pressure. R1 had weight loss and the facility placed R1 in a different wheelchair with a new cushion. The facility notified the registered dietitian and R1's provider. R1's clinical record lacked evidence the facility notified R1's representative of the open area to her sacrum, weight loss, and the new wheelchair. A Health Status note on 10/26/24 at 10:34 AM, documented R1 had a mild seizure episode and staff noted R1 stared for a couple of seconds then responded to her name. R1's clinical record lacked evidence the facility notified R1's representative of R1's seizure activity. A Provider/Practitioner note on 11/01/24 at 11:53 PM, documented the provider discussed R1's weight loss and sacral wound with her representative. On 11/19/24 at 12:07 PM, R1 sat in a Broda (specialized wheelchair with the ability to tilt and recline) at a dining room table and ate spaghetti. On 11/19/24 at 10:52 AM, R1's representative stated the facility did not notify her about changes. She stated she found out in a provider visit a few weeks ago that the facility treated R1 for pneumonia. R1's representative stated the facility did not notify her about the Broda chair. On 11/19/24 at 01:42 PM, Administrative Nurse E stated as a nursing intervention, the facility changed R1 to a new wheelchair for her weight loss and open sacral area. She stated R1's provider talked to her representative about the new wheelchair and documented it in a provider note. On 11/19/24 at 01:46 PM, Licensed Nurse (LN) G stated she notified families and representatives of medication changes, physical changes such as sickness, or any new orders for testing such as x-rays then again with the results. LN G stated most of R1's seizures lasted less than a minute, but the facility sent her out for significant seizures. She stated she did not notify R1's representative after each seizure but she might if R1 had more than one per day. LN G stated she notified representative notifications in the progress notes including attempts to call the representative. She stated the facility notified resident representatives if a resident changed to a Broda chair. On 11/19/24 at 02:09 PM, LN G stated she notified a resident's representative before the end of her shift except for emergencies then she notified their representative right away. On 11/19/24 at 02:26 PM, Administrative Nurse D stated the facility notified the resident's representative for weight loss and medication changes. She stated she expected staff to notify the resident's representative of any changes, as soon as possible that day. Administrative Nurse D stated staff documented notifications in the progress notes, and she expected staff to document attempts at notifying representatives. She stated staff should have notified R1's representative about the Broda chair. She stated R1's representative responded better when talking to the provider and R1's provider notified R1's representative about the Broda chair. Administrative Nurse D stated she expected staff to notify the resident's representative and provider after seizures and document the notification in the progress notes. The facility's Notification of Changes policy, last revised 12/04/23, directed the facility to immediately inform the resident, their physician, and their representative of a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly. The facility failed to notify R1's representative of the plan of care changes and/or results. This deficient practice had the risk of miscommunication between R1, their representative, and the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R209's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, dependence on a wheelchair, dementia (progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The admission Minimum Data Set (MDS) dated [DATE] was in progress. R209's Care Area Assessment (CAA) was in progress. R209's baseline Care Plan dated 11/28/23 lacked who was the hospice provider, how to contact the hospice provider, the frequency of hospice visits, the hospice provided supplies and/or medications, or how communication was to be collaborated between the facility and the hospice provider. Observation on 12/06/23 on 12:10 PM R209 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) next to his bed. R209 was asleep in the Broda chair. He had several days of facial hair growth noted. The call light was on the bedside table behind R209's Broda chair, outside his reach. Observation on 12/11/23 on 12:54 PM R209 sat in a Broda chair next to his bed. R209 was asleep in the Broda chair. He had several days of facial hair growth noted. The call light was on the floor next to R209's Broda chair, outside his reach. On 12/12/23 at 02:40 PM, Administrative Nurse D stated she expected all residents to have access to the call light while in bed The facility did not provide a policy related to accommodation of needs. The facility failed to ensure R60 had a call light within reach. This placed the resident at risk for impaired care. The facility identified a census of 114 residents. The sample included 23 residents with three residents reviewed for accommodation of needs. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 60 and R209 each had a call light within reach. This placed the residents at risk for impaired care. Findings included: - R60'S Electronic Medical Record (EMR), under the Diagnoses tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R60's Quarterly Minimum Data Set [MDS] dated 10/27/23 recorded a Brief Interview for Mental Status (BIMS) score of zero which indicated severe cognitive impairment. The MDS recorded R60 had impairment of both upper and lower extremities on both sides. The MDS recorded R60 required substantial to maximal assistance to roll left and right. R60's Care Plan documented a problem on 08/26/22 and revised on 10/25/23 which documented R60 fell on [DATE], 12/20/22, 02/22/23, 05/20/23, 07/24/23, and 10/25/23. The plan directed staff were to ensure a safe environment, provide a wider mattress when available, and a body pillow. On 12/06/23 at 01:37 PM R60 had a flat pad call light in the upper left corner of his low air loss mattress. R60 laid in bed, rolled to the far right. The call light was out of reach. On 12/07/23 at 07:20 AM R60 laid in bed on his right side on the right side of the bed facing the wall. His flat pad call light was placed in the upper left corner of his bed, behind and above and out of reach. On 12/07/23 at 09:31 AM R60 remained in bed on his right side with his flat pad call light at the left corner of bed out of reach. On 12/11/23 at 07:24 AM R60 laid in bed, on his right side. His bed was in the lowest position. His flat pad call light sat on the bedside table perpendicular to the head of R60's bed, out of reach of the resident. The facility failed to ensure staff provided R60 his call light within easy reach. This deficient practice placed R60 at increased risk for falls and unmet needs. On 12/12/23 10:07 AM Licensed Nurse (LN) H stated staff ensure R60's bed is always in the low position in order to prevent falls. She stated R60 had falls in the past and used a fall mat though he was currently on palliative care and does not fall as much. LN H stated R60 had a flat call light that he was able to use. She said the Certified Nurse's Aides (CNA) were good about making sure they placed the resident's call light where he could reach, and she expected the CNA to ensure the resident always had his call light available. On 12/12/23 at 02:40 PM, Administrative Nurse D stated she expected all residents to have access to the call light while in bed. The facility did not provide a policy related to accommodation of needs. The facility failed to ensure R60 had a call light within reach. This placed the resident at risk for impaired care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 114 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan for Resident (R) 209 related to his bathing preferences. This deficient practice placed R209 at risk of impaired care related to uncommunicated care needs. Findings included: - R209's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, dependence on a wheelchair, dementia (progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The admission Minimum Data Set (MDS) dated [DATE] was in progress. R209's Care Area Assessment (CAA) was in progress. R209's Care Plan dated 11/28/23 documented the resident required (specify bathing options [reclining shower chair, drop seat shower chair, shower gurney, bed bath]; staff assist; cueing [specify], etc.). The Care Plan lacked person centered direction for R209. Observation on 12/06/23 on 12:10 PM R209 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) next to his bed. R209 was asleep in the Broda chair. He had several days of facial hair growth noted. The call light was on the bedside table behind R209's Broda chair, outside his reach. On 12/12/23 at 09:53 AM Certified Nurse Aide (CNA) O stated the CNAs had access to the [NAME] (nursing tool that gives a brief overview of the care needs of each resident) but not the plan of care. CNA O stated not sure what day or shift R209 received his bath. CNA O stated R209 had not been at the facility very long and hospice provided R209's bath. On 12/12/23 at 11:53 AM Licensed Nurse (LN) G stated the nurses had access to the care plan but not the CNA's. LN G stated they had access to the [NAME] which populated from the information from the plan of care. LN G stated R209's bathing preference should be listed on the plan of care. On 12/12/23 at 02:41 PM Administrative Nurse D stated each resident was asked at the time of their admission what was their preference for bathing such as the time of day, frequency, and type of bath. Administrative Nurse D stated that information was placed on the resident's care plan within 48 hours, which populated onto the [NAME]. Administrative Nurse D stated the CNAs had access to the [NAME]. The facility's Care Plan dated 11/01/23 documented baseline care plan would Include instructions needed to provide effective and person- centered care of the resident that met professional standards of quality care. A baseline care plan would be developed upon admission according to federal and state regulations. This plan of care would be modified to reflect the care currently required/provided for the resident. The care plan would emphasize the care and development of the whole person ensuring that the resident would receive appropriate care and services. It would address the relationship of items or services required and facility responsibility for providing these services. The facility failed to develop a person-centered baseline care plan for R209 related to his bathing preferences. This deficient practice placed R209 at risk of impaired care related to uncommunicated care needs.

The facility identified a census of 114 residents. The sample included 23 residents with five residents review for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 60's Care Plan was revised to include his use of insulin (hormone that lowers the level of glucose in the blood). This placed R60 at risk for complications related insulin use due to uncommunicated care needs. Findings included: - R60'S Electronic Medical Record (EMR), under the :Diagnoses tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R60's Quarterly Minimum Data Set [MDS] dated 10/27/23 recorded a Brief Interview for Mental Status (BIMS) score of zero which indicated severe cognitive impairment. The MDS recorded R60 received injections and insulin for days of the observation period. The MDS recorded R60 received multiple high-risk medication during the observation period which included an antianxiety medication (medication used to treat anxiety), an antidepressant (class of medications used to treat depression) an antipsychotic (class of medications used to treat major mood disorders) and a hypoglycemic (medication used to lower blood glucose). R60's Care Plan documented a problem on 01/08/20 which recorded the resident had DM. The plan documented intervention dated 01/08/20 which directed staff a licensed nurse would provide foot & nail care and staff referred to a podiatrist for complications. It directed staff to inspect R60's feet daily for open areas, sores, pressure areas, blisters, edema or redness and report abnormalities to the nurse. staff were to ensure R60's socks/hosiery were clean and dry and make sure that his socks/shoes were not too tight. R60's Care Plan lacked direction or interventions related to his insulin use. R60's EMR, under the Orders tab, recorded a Physician's Order dated 08/31/21 for Accu-check (point of care test to assess blood glucose levels) at meals (AC) and at bedtime (HS). Notify the physician for a blood glucose reading greater than 400 milliliters (ml) per deciliter (dL) or less than 70 mm/dL related to DM. R60's EMR recorded a Physician's Order dated 08/10/22 for insulin aspart solution (fast action insulin) inject subcutaneously (under the skin) as per sliding scale: if [blood glucose] 0-150 mm/dL give zero units; 151 - 200 mm/dL give four 4 units; 201 - 250 mm/dL give eight units; 251 - 300 mm/dL give 12 units; 301 - 350 mm/dL give 16 units. Call physician if blood glucose over 351 mm/dL., subcutaneously with meals related to DM. Hold the morning (AM) dose if resident does not eat breakfast. Review of R60s October 2023 Medication Administration Record/Treatment Administration Record [MAR/TAR] /dL at 05:00 PM on 10/26/23436 mm/dL on 10/23/23 at 05:00 PM and a blood glucose of 51 mm/dL at 05:00 PM on 10/26/23. An eAdmin Note dated 10/06/23 at 04:44 PM documented the nurse administered the maximum dose of 16 units (insulin). The nurse held dinner R60's until his blood glucose deceased . At 05:59 PM the nurse notified the physician and received an order for more insulin. An eAdmin Note dated 10/23/23 at 06:12 PM documented the maximum scale was administered. The note lacked evidence the physician was notified. R60's EMR lacked evidence the physician was notified of the blood glucose of 51 mm/dL on 10/26/23. R60 November 2023 MAR/TAR recorded blood glucose levels of 392 mm/dL at 05:00 PM on 11/10/23, and 381 mm/dL at 05:00 PM on 11/27/23. An eAdmin Note dated 11/10/23 at 04:35 PM documented R60's blood glucose was 392 mm/dL and the nurse administered 16units of insulin. The note recorded food and drink were held, and one hour later R60's blood glucose was 216 mm/dL. The note lacked evidence R60's physician was notified. An eAdmin Note dated 11/27/23 at 04:39 PM documented the maximum scale was administered. The note lacked evidence the physician was notified. On 12/07/23 at 02:20 PM, R60 sat in his wheelchair at a dining table and drank a can of cola through a straw. On 12/12/23 at 02:40 PM, Administrative Nurse D stated she expected nursing staff to follow the physician's orders exactly as the order was written. She stated if the order directed staff to notify the physician for specific parameters, she expected the staff to follow the order and document the notification in the resident's record. Administrative Nurse D said each residents care plan included the necessary information staff need to provide care. Administrative Nurse D stated all nurses had access and ability to review care plans. The facility's Care Plan dated 11/01/23 documented the facility would develop a comprehensive care plan using an interdisciplinary team approach. A comprehensive care plan would include measurable objectives and timeframes that met a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The care plan would emphasize the care and development of the whole person ensuring that the resident would receive appropriate care and services. It would address the relationship of items or services required and facility responsibility for providing these services. The facility failed to ensure R60's Care Plan was revised to include his use of insulin. This placed R60 at risk for complications related insulin use due to uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 114 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to provide consistent bathing for Resident (R) 7 and R209. This deficient practice had the risk for poor hygiene, skin infections, decreased self-esteem and impaired dignity. Findings included: - R7's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hearing loss, intellectual disabilities, major depressive disorder (major mood disorder which causes persistent feelings pf sadness) and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE] documented a staff interview R7's long term memory was ok, short-term memory was ok and some difficulty in new situations. The MDS documented that R7 required extensive assistance of one staff member for activities of daily living (ADLs). The Quarterly MDS dated 09/08/23 documented a staff interview revealed R7's short term memory was ok, long-term memory was ok, and she was consistent/reasonable with decision making. The MDS documented that R7 required limited assistance of one staff member for ADLs. R7's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 06/26/23 documented R7 required assistance with her ADLs. R7's Care Plan dated 04/29/19 documented R7 preferred a whirlpool two times weekly. She preferred a female staff member and needed assistance with shaving and nail care weekly. Review of the EMR under Documentation Survey Reports tab for bathing reviewed for the following dates for R7 from 09/01/23 to 12/07/23 (98 days) documented three Whirlpool (W) on 09/04/23, 09/21/23, and 10/16/23. Did not Occur (DO) was documented one time on 09/14/23. Not Applicable was documented four times on10/02/23, 10/30/23, 11/02/23, and 12/04/23. Resident Refused was documented two times on 11/16/23 and 11/30/23. The clinical record revealed two refusals for bathing. Observation on 12/11/23 at 09:25AM R7 sat in her wheelchair alone in the hallway. Her clothes were soiled with food from breakfast. On 12/12/23 at 12:22 PM Certified Nurse Aide (CNA) P stated R7 did refuse her bath at times and the staff would reapproach her at different times. CNA P stated the staff offered her alternative bathing. CNA P stated staff charted the baths or the refusals in the EMR. CNA P stated staff would check the bath list or [NAME] (nursing tool that gives a brief overview of the care needs of each resident) to know which resident was due for a bath. On 12/12/23 at 12:28 PM Licensed Nurse (LN) I stated R7 refused her whirlpool at times. LN I stated different staff offered to bathe R7. LN I stated staff documented bathing the EMR. On 12/12/23 at 02:41 PM Administrative Nurse D stated each resident was asked at the time of their admission what was their preference for bathing such as the time of day, frequency, and type of bath. Administrative Nurse D stated that information was placed on the resident's care plan within 48 hours, which populated onto the [NAME]. Administrative Nurse D stated the assistant director of nursing ensured the new residents were placed on the bath list on their preferred days. Administrative Nurse D stated most of the resident received a bath two times weekly. Administrative Nurse D stated the nursing staff should chart every shift the care that was provided. The facility's Bathing policy dated 08/29/23 documented the facility was to promote cleanliness and general hygiene. To stimulate circulation of the skin. To promote comfort, relaxation, and well-being. To observe resident's condition. To assist resident with personal care. To promote safety for the resident in the bath. The facility failed to provide consistent bathing for R7. This deficient practice placed R7 at risk for complications related to poor hygiene and impaired dignity. - R209's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, dependence on a wheelchair, dementia (progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The admission Minimum Data Set (MDS) dated [DATE] was in progress. R209's Care Area Assessment (CAA) was in progress. R209's Care Plan dated 11/28/23 documented the resident required (specify bathing options [reclining shower chair, drop seat shower chair, shower gurney, bed bath]; staff assist; cueing [specify], etc.). The Care Plan lacked person centered direction for R209. Review of the EMR under Documentation Survey Reports tab for bathing reviewed for the following dates for R209 from 11/28/23 to 12/10/23 (13 days) lacked documentation of a bath was provided for R209. The clinical record lacked a refusal of care. Observation on 12/06/23 on 12:10 PM R209 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) next to his bed. R209 was asleep in the Broda chair. He had several days of facial hair growth noted. The call light was on the bedside table behind R209's Broda chair, outside his reach. On 12/12/23 at 09:53 AM Certified Nurse Aide (CNA) O stated the charge nurse made the assignment every morning and assigned the baths. CNA O stated he was not sure what day or shift R209 received his bath. CNA O stated R209 had not been at the facility very long and hospice provided R209's bath. On 12/12/23 at 11:53 AM Licensed Nurse (LN) G stated the nurse mangers updated the bath list with any new admissions. LN G checked the bath list to check what days R209 was to be bathed. LN G stated R209 was scheduled on Monday evening shift, usually the resident received a bath two times a week. LN G stated she was not sure what days hospice provided R209's additional bathing. On 12/12/23 at 02:41 PM Administrative Nurse D stated each resident was asked at the time of their admission what was their preference for bathing such as the time of day, frequency, and type of bath. Administrative Nurse D stated that information was placed on the resident's care plan within 48 hours, which populated onto the [NAME]. Administrative Nurse D stated the assistant director of nursing ensured the new residents were placed on the bath list on their preferred days. Administrative Nurse D stated most of the resident received a bath two times weekly. Administrative Nurse D stated the nursing staff should chart every shift the care that was provided. The facility's Bathing policy dated 08/29/23 documented the facility was to promote cleanliness and general hygiene. To stimulate circulation of the skin. To promote comfort, relaxation, and well-being. To observe resident's condition. To assist resident with personal care. To promote safety for the resident in the bath. The facility failed to provide consistent bathing for R209. This deficient practice placed R209 at risk for complications related to poor hygiene and impaired dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 114 residents. The sample included 23 residents with one resident reviewed for. Based on observation, record review, and interviews, the facility failed to follow a physician order for daily weights to monitor for fluid overload for Resident (R) 97. This deficient practice placed R97 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R97's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), muscle weakness, need for assistance with personal care, and history of falls. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented that R97 required partial/moderate assistance moving from a sitting position to standing. The MDS documented R97 received a diuretic (medication to promote the formation and excretion of urine) during the observation period. R97's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/16/23 documented R97 had displayed memory loss. R97's Care Plan dated 05/30/23 documented nursing staff would monitor R97 based on clinical practice guidelines or clinical standards of practice related to diuretic use. The Care Plan lacked direction related to daily weight monitoring for fluid overload. Review of the EMR under Orders tab revealed physician orders: Lasix (diuretic) oral tablet 40 milligram (mg) give one tablet by mouth daily for CHF dated 09/08/23. Daily weights every day dated 09/11/23. Review of R97's Medication Administration Record (MAR) from 09/11/23 to 12/06/23 (87 days) lacked evidence staff measured and recorded R97's weight) on following dates 09/14/23, 09/28/23, 09/30/23, 10/18/23, 10/22/23, 10/23/23, 10/25/23, 10/27/23, 10/28/23, 10/30/23, 11/02/23, 11/03/23, 11/05/23, 11/09/23, 11/13/23, 111/20/23, 11/21/23, 11/22/23, 11/23/23, 11/25/23, 11/30/23, and 12/05/23. The clinical record lacked documentation of physician notification of daily weight was not obtained. Observation on 12/07/23 at 07:59 AM R97 sat in her wheelchair at the dining room table with non-skid socks on her lower extremities and drank her coffee. On 12/12/23 at 09:00 AM Certified Medication Aide (CMA) R stated the nurse would let the staff know which residents needed a daily weight obtained. CMA R stated the staff would notify the nurse of the of the weight. On 12/12/23 at 11:53 AM Licensed Nurse (LN) G stated R97 was a daily weight for CHF. LN G stated the physician should be notified of any weight gain of two pounds or more in day or five pounds in a week. LN G was unaware that R97's daily weight did not have a weight parameter when the physician was to be notified. LN G stated she was not aware of R97 every refusing to be weighed. On 12/12/23 at 02:41 PM Administrative Nurse D stated daily weights should have parameter of gain or loss when the physician would be notified. Administrative Nurse D stated the charge was responsible to monitor daily weights. The facility's Physician/Practitioner Orders policy dated 03/29/23 documented to provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. To provide a procedure that facilitates the timely and accurate process of physician/practitioner orders. Physician/practitioner orders are a critical component to providing quality care to residents. Accurate processing of physician/practitioner orders are important. The nursing services and health information management (HIM) departments each have responsibilities for processing physician/practitioner orders in a timely and accurate manner. Teamwork and communication between the two departments is essential. Once the order is entered into PCC, depending on order category, the order would populate the appropriate electronic administration documentation location within the application. The facility failed to follow a physician order for daily weights to monitor weight gain for fluid overload for R97. This deficient practice placed R97 at risk of adverse side effects for unnecessary medication or complications related to fluid overload.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 114 residents. The sample included 23 residents with seven reviewed for accidents. Based on observation, record review, and interviews, The facility failed to provide consistent Roam Alert (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) functionality checks on Residents (R) 25's Roam Alert band. This deficient practice placed the resident at risk for elopement. The facility additionally failed to prevent avoidable accidents during R33's Hoyer (full body lift) lift transfers resulting in minor injuries and failed to utilize R87's care planned Hoyer lift while transferring her to her bed resulting in a non-injury fall. These deficient practices placed the residents at risk for preventable accidents and injuries. Findings included: - The electronic medical record (EMR) for R25 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), needs for assistance for personal cares, Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), history of falls, and abnormalities of gait/mobility. R25 Annual Minimum Data Set (MDS) completed 11/15/23 noted a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The MDS indicated she was independently mobile with staff supervision while walking. The MDS noted she had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) but no wandering behaviors at the time of assessment. R25's Cognitive Loss Care Area Assessment (CAA) completed 11/17/23 noted a BIMS score of four. The CAA noted she usually had confusion, disorientation, forgetfulness. The CAA listed her goal was to maintain her current level of function. R25's Fall CAA indicated she was at risk for falls related to her medical diagnoses and history. The CAA noted therapy services were initiated to improve her gait during walking. R25's Care Plan initiated 12/16/22 indicated she had potential for elopement related to her medical diagnoses. The plan noted she had a Wander Guard placed on her walker to Alert staff to her movements. The plan instructed staff check for functionality every shift to ensure its working order. A review of R25's Physician's orders revealed an order dated 09/02/23 instructed staff to check her Roam Alert placement every night shift. A review of R25's Treatment Administration Report (TAR) indicated the placement of the Roam Alert bracelet was being completed lacked documentation showing the functionality was tested. The facility Roam Alert logs located on the Cozy Cottage unit indicated R25's Roam Alert Functionality had not been tested since 10/27/23. Licensed Nurse (LN) PP verified that the checks were not completed for the resident. She stated maybe the residents on the locked unit were only being checked by the night shift. On 12/07/23 at 09:23AM R25 walked through the fireplace social area. Her Roam Alert bracelet was fastening under the front strap of her walker. On 12/12/23 at 11:30 Certified Nurses Aid (CNA) M stated the placement of the Roam Alerts were check daily by direct care staff, but the function was checked by the night staff. He stated they had a wand that tested the bands to see if they worked. On 12/12/23 at 02:30 Administrative Nurse D stated all residents with Roam Alert devices should be check nightly for placement and functionality. She stated the logs were kept on the secured unit and night shift should be checking and logging the checks. She stated each unit had binders with at-risk resident pictures. She stated staff should check the placement of the bands each shift and keep eyes on resident's that wander. The facility's Elopement policy revised 07/11/23 indicated the facility will monitor all residents at risk for elopement will be closely monitored. The policy noted staff will follow each resident's individualized care interventions as well as facility wide processes. The facility did not provide a policy related to Roam Alert systems. The facility failed to provide consistent functionality checks on R25's Roam Alert bands. This deficient practice placed the resident at risk for elopement. - The electronic medical record (EMR) for R33 documented diagnoses of 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), dysphagia (swallowing difficulty), muscle weakness, and abnormalities of gait/posture. R33 Quarterly Minimum Data Set (MDS) completed 11/10/23 noted a Brief Interview for Mental Status (BIMS) score of seven indicating severe cognitive impairment. The MDS indicated she was dependent for staff assistance for all Activities of Daily Living (ADLs) except eating. The MDS noted she had a history of verbal aggression. R33's Delirium Care Area Assessment (CAA) and Cognitive Loss CAA completed 08/22/23 indicated she had impaired cognitive function related to her medical diagnoses. The CAA noted she had impaired memory recall and trouble sleeping. The CAA indicated her goal was to maintain her current level of functioning. R33's Activities of Daily Living (ADLs) CAA completed 08/22/23 indicated she required extensive assistance with her ADLs. The CAA indicated she was not always aware of her needs but asks to go to restroom. The CAA indicated she required a Hoyer lift for transfers. The CAA indicated her goal was to maintain her current level of functioning. R33's Behaviors CAA completed 10/22/23 indicated she had a history of verbal behaviors with a diagnosis of anxiety, depression, and delusions. The CAA noted she had increased frustration when extra noise was present. The CAA indicated her goal was to maintain her current level of functioning. R33's Care Plan initiated 07/05/20 indicated she was at risk for decreased physical mobility, ADL performance, and communication related to her medical diagnoses. The plan noted she had a communication deficit related to confusion, hearing deficits, and delusions (07/05/20). The plan encourage staff to allow R33 to express her thoughts and use techniques which enhanced interactions (decrease background noise, keep conversation simple). The plan noted she required assistance from two staff members for toileting, transfers, and bathing. The plan noted she required a total lift for transfers and a Sit-to-stand lift for toileting. The plan indicated she had grief and loss related to her husband's passing in March 2022. The plan indicated she had loss support through counseling and therapy services to support emotional stability (04/06/22). R33's EMR revealed Health Status note dated 11/22/23 indicating R33's left hand got caught in a Hoyer lift sling during a transfer in the shower room. The note indicated her hand slipped multiple times. The note identified bruising on her left thumb and hand. R33's EMR revealed a Progress Note dated 07/10/23 that indicated she obtained a small cut to her right lower back while being lowered into her Broda chair (specialized wheelchair with the ability to tilt and recline). The noted indicated the areas was cleansed and a Band-aid was applied. An Occupational Therapy note completed 07/13/23 indicated R33's Broda chair was adjusted to support her leg, hip, and back positioning. On 12/07/23 at R33 sat at the fireplace social area. R33 asked to be moved to her room. R33 stated she did not remember the incident but remember being rushed to go to bed. She stated CNA LL was rude to her and got her bed when she wanted to go. She couldn't remember if two staff were present that evening but had received injuries before when being transferred. On 12/12/23 at 11:24AM Certified Nurse's Aide (CNA) M stated R33 always required a Hoyer lift for transfers. He stated staff had to make sure she kept her hands positioned safely because she would move around a lot during transfers. He stated staff received Hoyer lift training while orienting with the facility. He stated two staff should assist during the transfer with the lift. He stated one person lifts the resident while to other maneuvers the resident. On 12/12/23 at 11:50AM Licensed Nurse (LN) J stated staff should check the resident's positioning while using the lift to prevent injuries from occurring. She stated the resident's hands should be positioned over their chest and not near the sling or machine. On 12/12/23 at 02:41PM Administrative Nurse D stated staff have been re-educated on sling use and proper positioning. She stated occupational therapy was consulted to adjust R33 chair to prevent positional injuries from occurring during transfer. She stated two staff were expected to completed Hoyer transfers and ensure the residents safety. The facility's Restorative_ Identifying Decline in Activities of Daily Living policy revised 12/16/22 indicated the facility would assess and develop to ensure ADLs are carried out in a consistent and safe manner based on each resident's needs and care planned interventions. The facility's Fall Prevention and Management policy revised 03/29/23 indicated staff were to follow the appropriate preventative interventions documented in the care plan, [NAME], or physician's orders to prevent falls. The facility failed to prevent avoidable accidents during R33's Hoyer lift transfers resulting in minor injuries. This deficient practice placed R33 at risk for preventable injuries and falls. - The Medical Diagnosis section within R87's Electronic Medical Records (EMR) included diagnoses of cognitive communication disorder, type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), morbid obesity (severely overweight), acute kidney failure, and need for assistance with personal care. R87's Significant Change Minimum Data Set (MDS) completed 11/10/23 noted a Brief Interview for Mental Status (BIMS) score of 10 indicating mild cognitive impairment. The MDS indicated she required substantial/maximal assistance for transfers, toileting, bathing, and dressing. The MDS indicated she used a manual wheelchair for mobility. The MDS indicated she had no falls since admission. R87's Activities of Daily Living (ADL) Care Area Assessment (CAA) completed 11/14/23 indicated she required extensive assistance for her ADLs. The MDS noted she started hospice services and needed a total lift for transfers. R87's Fall CAA completed 11/14/23 indicated she was at risk for falls related to her medications. Poor safety awareness, and medical diagnoses. The CAA encouraged staff to provide a consistent care routine and anticipate her needs. R87's Care Plan initiated 10/20/23 indicated she had an ADL self-care deficit related to her medical diagnoses and cognitive impairment. The plan noted she required staff assistance for toileting, bathing, bed mobility, personal hygiene, and transfers. The plan noted she required a total lift (Hoyer) with a large high back sling for all transfers (10/20/23). A review of R87's EMR revealed an Incident note dated 12/03/23 indicating she fell while being transported from the restroom by staff. The note indicated she was transported with a Sit-to-stand lift and slipped off the lift. The note indicated staff lowered her to the floor. The note indicated she had no injuries from the fall. A review of a Fall Investigation completed 12/03/23 indicated a Sit-to-stand lift was used for her transfers and staff were educated to use the total (Hoyer) lift. On 12/06/23 at 08:00AM R87 sat in her wheelchair as she ate her breakfast. R87 report no concerns with her care and reported she was receiving hospice services. On 12/12/23 at 10:41AM Certified Nurse's Aide (CNA) M indicated R87 required a total lift due to her declining health and weakness. He stated all staff had access to each resident's [NAME] (nursing tool that gives a brief overview of the care needs of each resident) and should review each resident's transfer requirements before caring for them. On 12/12/23 at 11:50AM Licensed Nurse (LN) J indicated R87 transferred with a total lift and was too weak to use the Sit-to-stand lift. On 12/12/23 at 02:41PM Administrative Nurse D stated R87'S Care Plan indicated she needed a total lift for transfers since 10/20/23. She stated she expected staff to follow the care plan interventions. She stated all staff were required to receive training on mechanical lifts before working at the facility. She stated the facility held frequent training sessions if patterns or concerns were found with certain care areas. The facility's Restorative_ Identifying Decline in Activities of Daily Living policy revised 12/16/22 indicated the facility would assess and develop to ensure ADLs are carried out in a consistent and safe manner based on each resident's needs and care planned interventions. The facility's Fall Prevention and Management policy revised 03/29/23 indicated staff were to follow the appropriate preventative interventions documented in the care plan, [NAME], or physician's orders to prevent falls. The facility failed to utilize R87's care planned Hoyer lift while transferring her to her bed resulting in a non-injury fall. This deficient practice placed R87 at risk for preventable accidents and injuries.

The facility identified a census of 114 residents. The sample included 23 residents with two reviewed for incontinence management and urinary catheters. Based on observation, record review, and interviews, the facility failed to provide individualized incontinence interventions based on Resident (R)55's significant status change. The facility additionally failed to provide consistent monitoring of urinary catheter care for R101. This deficient practice placed the residents at risk for complications related to incontinence and/or urinary tract infections (UTIs). Findings Included: - The Medical Diagnosis section within R55's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), Recent fracture (Bone Break) of the left femur (large leg bone), dementia (progressive mental disorder characterized by failing memory, confusion), and cognitive communication deficit. R55's Significant Minimum Data Set (MDS) completed 11/10/23 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated she was always incontinent of urine and occasionally incontinent of bowel with no toileting program. The MDS noted she required partial to moderate assist with toileting and substantial/maximal assist with toileting transfers. R55's Urinary Incontinence Care Area Assessment completed 10/24/23 indicated she was incontinent and required assistance from staff to toileting. The CAA noted she had limited mobility due to here left hip fracture and required incontinence briefs. R55's Activity of Daily Living (ADL) CAA completed 10/24/23 noted she had a functional decline in her ADLs and required assistance with toileting. R55's Care Plan initiated 10/17/23 indicated she had bladder incontinence related to dementia and the aging process. The plan noted she required incontinence brief and check and change for incontinence. The plan noted she had resolved urinary tract infections related to her incontinence. The plan failed to address her bowel incontinence and peri-care. A review an Incident Report dated 10/06/23 indicated R55 indicated R55 had a major injury fall while toileting herself in the shower room. The plan noted she was independent mobile and able to toilet herself at the time of her fall. The report noted she was hospitalized with a left femur fracture. A review of R55's EMR revealed no incontinence screening to identify her specific needs or recommended interventions. The facility was unable to provide a toileting trial as requested on 12/12/23. On 12/07/23 at 02:23PM R55 sat in her room. R55 was smelled of urine. R55 reported she required assistance with toileting and often had issue with bladder episodes. On 12/12/23 at 11:00AM Certified Nurses Staff (CNA) M stated all resident were on a two-hour check and change and provided peri-care. He stated R55 recently had a fall and her need levels changed. On 12/12/23 at 11:45AM Licensed Nurse (LN) J stated R55 was on a check and change and would often let staff know when she needed assistance. She stated R55 had an ADL decline after her recent leg fracture which required her need more assistance. She stated R55 was incontinent of both bowel and bladder. On 12/12/23 at 02:30PM Administrative Nurse D stated all residents are screened upon admission for incontinence and provided care planned interventions. She stated residents in need of more individualized interventions would have a bladder trail completed, two hour toileting, and individualized interventions depending on the reason and type of incontinence. A review of the facility's Bowel and Bladder Incontinence policy 08/22/23 indicated the facility would appropriately screen and implement individualized toileting interventions. The policy indicated the facility will continue ongoing evaluations of the effectiveness of the interventions in place. The facility will provide treatment to help each resident maintain the highest level of function. The facility failed to provide individualized incontinence interventions based on R55's significant status change. This deficient practice placed both residents at risk for complications related to incontinence. - The electronic medical record (EMR) for R101 documented diagnoses of hemiplegia & hemiparesis (weakness and paralysis on one side of the body), retention of urine (a condition where an individual is unable to completely empty the bladder), hypertension (HTN- elevated blood pressure), and cerebral infarction (stroke). The Significant Change Minimum Data Set (MDS) for R101 dated 10/27/23 documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. R101 had impairment to both upper and lower extremities on one side. R101 was dependent on staff for toileting. R101 required the use of an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 11/14/23 for R101 documented she needed a foley catheter due to urine retention. The Catheter Care Plan revised 05/18/23 for R101 directed staff to monitor/record/report to the health care provider signs and symptoms of a urinary tract infection (UTI - an infection in any part of the urinary system). The care plan directed staff to perform catheter care by the certified nurse aide (CNA) every shift and ensure the catheter was anchored to the thigh with a catheter secure device. Staff was directed to report unusual observations/conditions to nurse. The Orders tab of the EMR documented an Order Summary for R101 documented a physician's order dated 05/18/23 to check anchor placement daily on day shift. The Orders tab of the EMR documented an Order Summary for R101 documented a physician's order dated 05/18/23 to empty catheter bag every shift and as needed. The Orders tab of the EMR documented an Order Summary for R101 documented a physician's order dated 08/03/23 to insert an indwelling foley catheter to dependent drainage. Change every night shift every 28 days for urinary retention. Review of R101's September 2023 Documentation Summary Report documented toileting/catheter care/output was performed/documented on 25 of 88 opportunities. Review of R101's October 2023 Documentation Summary Report documented toileting/catheter care was performed/documented on 12 of 63 opportunities that month. Review of R101's November 2023 Documentation Summary Report documented toileting/catheter care was performed/documented on 36 of 90 opportunities that month. Review of R101's December 2023 Documentation Summary Report documented toileting/catheter care was performed/documented on 25 of 34 opportunities for the month. On 12/11/23 at 01:09 PM R101 sat in her wheelchair in her room watching tv. Her left hand/wrist had a splint present and resting on an arm support on the wheelchair. R101's catheter bag was present on the left side of wheelchair with a dignity bag noted. On 12/12/23 at 11:41 AM Certified Medication Aide (CMA)/CNA R stated the aide was responsible for catheter cares. CMA R stated the aide should document each shift the amount of urine emptied and report any changes noted to the color or smell along with any resident complaints to the nurse. On 12/12/23 at 10:50 AM Licensed Nurse (LN) G stated that typically only when a resident initially got a catheter would staff document the output. LN G stated the aides recorded the amount of urine emptied each shift in their point of care (POC). LN G stated the aides should report any changes noted during the catheter care to the nurse. On 12/12/23 at 02:45 PM Administrative Nurse D stated the aides provided the catheter care for residents and should chart in POC the amount of urine that was emptied from the catheter bag each shift or anytime catheter care was performed. Administrative Nurse D stated the aides should also report any changes noted in urine color or smell to the charge nurse. The facility policy Catheter: Care, Insertion and Removal, Drainage Bags, Irrigation, Specimen last revised 04/25/22 documented the purpose for catheter care was to continuously monitor urinary output and maintain correct urinary drainage. Catheter care would be completed with morning and bedtime cares and as needed. If a resident was on Intake and Output measure urine volume and record in POC. The facility failed to ensure staff provided appropriate treatment and services, including monitoring urine output (including amount, color, odor) for R101. who had an indwelling catheter. This placed R101 at risk for infection and further urinary problems.

The facility identified a census of 114 residents. The sample included 23 residents with five residents review for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities with Resident (R) 60's insulin (hormone that lowers the level of glucose in the blood). This placed R60 at risk for complications related to insulin use. Findings included: - R60'S Electronic Medical Record (EMR), under the Diagnoses tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R60's Quarterly Minimum Data Set [MDS] dated 10/27/23 recorded a Brief Interview for Mental Status (BIMS) score of zero which indicated severe cognitive impairment. The MDS recorded R60 received injections and insulin for days of the observation period. The MDS recorded R60 received multiple high-risk medication during the observation period which included an antianxiety medication (medication used to treat anxiety), an antidepressant (class of medications used to treat depression) an antipsychotic (class of medications used to treat major mood disorders) and a hypoglycemic (medication used to lower blood glucose). R60's Care Plan documented a problem on 01/08/20 which recorded the resident had DM. The plan documented intervention dated 01/08/20 which directed staff a licensed nurse would provide foot & nail care and staff referred to a podiatrist for complications. It directed staff to inspect R60's feet daily for open areas, sores, pressure areas, blisters, edema or redness and report abnormalities to the nurse. staff were to ensure R60's socks/hosiery were clean and dry and make sure that his socks/shoes were not too tight. R60's Care Plan lacked direction or interventions related to his insulin use. R60's EMR, under the Orders tab, recorded a Physician's Order dated 08/31/21 for Accu-check (point of care test to assess blood glucose levels) at meals (AC) and at bedtime (HS). Notify the physician for a blood glucose reading greater than 400 milliliters (ml) per deciliter (dL) or less than 70 mm/dL related to DM. R60's EMR recorded a Physician's Order dated 08/10/22 for insulin aspart solution (fast action insulin) inject subcutaneously (under the skin) as per sliding scale: if [blood glucose] 0-150 mm/dL give zero units; 151 - 200 mm/dL give four 4 units; 201 - 250 mm/dL give eight units; 251 - 300 mm/dL give 12 units; 301 - 350 mm/dL give 16 units. Call physician if blood glucose over 351 mm/dL. Hold the morning (AM) dose if resident does not eat breakfast. Review of R60s October 2023 Medication Administration Record/Treatment Administration Record [MAR/TAR] /dL at 05:00 PM on 10/26/23436 mm/dL on 10/23/23 at 05:00 PM and a blood glucose of 51 mm/dL at 05:00 PM on 10/26/23. An eAdmin Note dated 10/06/23 at 04:44 PM documented the nurse administered the maximum dose of 16 units (insulin). The nurse held dinner R60's until his blood glucose deceased . At 05:59 PM the nurse notified the physician and received an order for more insulin. An eAdmin Note dated 10/23/23 at 06:12 PM documented the maximum scale was administered. The note lacked evidence the physician was notified. R60's EMR lacked evidence the physician was notified of the blood glucose of 51 mm/dL on 10/26/23. Review of R60's CP Medication Regimen Review (MRR) dated 11/06/23 lacked evidence the CP identified and reported the above irregularities. R60's November 2023 MAR/TAR recorded blood glucose levels of 392 mm/dL at 05:00 PM on 11/10/23, and 381 mm/dL at 05:00 PM on 11/27/23. An eAdmin Note dated 11/10/23 at 04:35 PM documented R60's blood glucose was 392 mm/dL and the nurse administered 16units of insulin. The note recorded food and drink were held, and one hour later R60's blood glucose was 216 mm/dL. The note lacked evidence R60's physician was notified. An eAdmin Note dated 11/27/23 at 04:39 PM documented the maximum scale was administered. The note lacked evidence the physician was notified. Review of R60's CP MRR dated 12/04/23 revealed the CP documented no recommendations. On 12/07/23 at 02:20 PM, R60 sat in his wheelchair at a dining table and drank a can of cola through a straw. On 12/12/23 10:07 AM Licensed Nurse (LN) H stated if R60's blood glucose were high or low, or outside of the parameters, the nurses passed that information in report. LN H stated if R60's blood glucose was on the lower side, like 90 mm/dL, she would try to encourage juice. If R60's blood sugar were 51, she would call the physician, to get orders, right away. LN H said R60's blood glucose did occasionally get higher in the evenings. LN H reviewed R60's insulin order and stated the orders for insulin at maximum dose was for a blood glucose reading of 300-350 mm/dL and if the blood glucose was higher, she would call the physician for orders since the order did not specify to give the 16 units if over 350 mm/dL. LN H stated all physician notifications should be documented in the EMR. On 12/12/23 at 02:40 PM, Administrative Nurse D stated she expected nursing staff to follow the physician's orders exactly as the order was written. She stated if the order directed staff to notify the physician for specific parameters, she expected the staff to follow the order and document the notification in the resident's record. Administrative Nurse D said the CP reports were faxed to several key staff in the facility and the staff then reviewed the recommendations with the physician and noted any orders or changes. Administrative Nurse D stated she expected the CP to identify and report irregularities associated with the use of insulin and indicated the facility's CP typically did review all relevant measurements associated with medication use. The facility policy Medication: Drug Regimen Review- R/S, LTC dated 02/10/23 documented the drug regimen review (DRR), an important piece of medication management, was vital to reducing medication errors. By verifying, clarifying and reconciling medications at each point of care, pharmacists and nurses played a vital role in improving health care. The DRR would identify the following: Review of medications to assure that doses and duration are appropriate to each resident's clinical condition, age and comorbidities; Monitoring of medications for efficacy and adverse consequences; Potential medication irregularities and response to these irregularities; Medication-related errors; Gradual dose reduction and lowering costs. The facility failed to ensure the CP identified and reported irregularities with R60's insulin. This placed R60 at risk for complications related to insulin use.

The facility identified a census of 114 residents. The sample included 23 residents with five residents review for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 60 received his insulin (hormone that lowers the level of glucose in the blood) as ordered by the physician and failed to ensure blood glucose levels outside of physician ordered parameters were reported to the physician as ordered. This placed R60 at risk for complications related to insulin use. Findings included: - R60'S Electronic Medical Record (EMR), under the Diagnoses tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R60's Quarterly Minimum Data Set [MDS] dated 10/27/23 recorded a Brief Interview for Mental Status (BIMS) score of zero which indicated severe cognitive impairment. The MDS recorded R60 received injections and insulin for days of the observation period. The MDS recorded R60 received multiple high-risk medication during the observation period which included an antianxiety medication (medication used to treat anxiety), an antidepressant (class of medications used to treat depression) an antipsychotic (class of medications used to treat major mood disorders) and a hypoglycemic (medication used to lower blood glucose). R60's Care Plan documented a problem on 01/08/20 which recorded the resident had DM. The plan documented intervention dated 01/08/20 which directed staff a licensed nurse would provide foot & nail care and staff referred to a podiatrist for complications. It directed staff to inspect R60's feet daily for open areas, sores, pressure areas, blisters, edema or redness and report abnormalities to the nurse. staff were to ensure R60's socks/hosiery were clean and dry and make sure that his socks/shoes were not too tight. R60's Care Plan lacked direction or interventions related to his insulin use. R60's EMR, under the Orders tab, recorded a Physician's Order dated 08/31/21 for Accu-check (point of care test to assess blood glucose levels) at meals (AC) and at bedtime (HS). Notify the physician for a blood glucose reading greater than 400 milliliters (ml) per deciliter (dL) or less than 70 mm/dL related to DM. R60's EMR recorded a Physician's Order dated 08/10/22 for insulin aspart solution (fast action insulin) inject subcutaneously (under the skin) as per sliding scale: if [blood glucose] 0-150 mm/dL give zero units; 151 - 200 mm/dL give four 4 units; 201 - 250 mm/dL give eight units; 251 - 300 mm/dL give 12 units; 301 - 350 mm/dL give 16 units. Call physician if blood glucose over 351 mm/dL., subcutaneously with meals related to DM. Hold the morning (AM) dose if resident does not eat breakfast. Review of R60's October 2023 Medication Administration Record/Treatment Administration Record [MAR/TAR] /dL at 05:00 PM on 10/26/23436 mm/dL on 10/23/23 at 05:00 PM and a blood glucose of 51 mm/dL at 05:00 PM on 10/26/23. An eAdmin Note dated 10/06/23 at 04:44 PM documented the nurse administered the maximum dose of 16 units (insulin). The nurse held dinner R60's until his blood glucose deceased . At 05:59 PM the nurse notified the physician and received an order for more insulin. An eAdmin Note dated 10/23/23 at 06:12 PM documented the maximum scale was administered. The note lacked evidence the physician was notified. R60's EMR lacked evidence the physician was notified of the blood glucose of 51 mm/dL on 10/26/23. R60's November 2023 MAR/TAR recorded blood glucose levels of 392 mm/dL at 05:00 PM on 11/10/23, and 381 mm/dL at 05:00 PM on 11/27/23. An eAdmin Note dated 11/10/23 at 04:35 PM documented R60's blood glucose was 392 mm/dL and the nurse administered 16units of insulin. The note recorded food and drink were held, and one hour later R60's blood glucose was 216 mm/dL. The note lacked evidence R60's physician was notified. An eAdmin Note dated 11/27/23 at 04:39 PM documented the maximum scale was administered. The note lacked evidence the physician was notified. On 12/07/23 at 02:20 PM, R60 sat in his wheelchair at a dining table and drank a can of cola through a straw. On 12/12/23 10:07 AM Licensed Nurse (LN) H stated if R60's blood glucose were high or low, or outside of the parameters, the nurses passed that information in report. LN H stated if R60's blood glucose was on the lower side, like 90 mm/dL, she would try to encourage juice. If R60's blood sugar were 51, she would call the physician, to get orders, right away. LN H said R60's blood glucose did occasionally get higher in the evenings. LN H reviewed R60's insulin order and stated the orders for insulin at maximum dose was for a blood glucose reading of 300-350 mm/dL and if the blood glucose was higher, she would call the physician for orders since the order did not specify to give the 16 units if over 350 mm/dL. LN H stated all physician notifications should be documented in the EMR. On 12/12/23 at 02:40 PM, Administrative Nurse D stated she expected nursing staff to follow the physician's orders exactly as the order was written. She stated if the order directed staff to notify the physician for specific parameters, she expected the staff to follow the order and document the notification in the resident's record. The facility policy Medication: Administration Including Scheduling and Medication Aides-R/S, LTC dated 03/29/23 documented medications were administered to the resident according to the Six Rights. All employees passing medications were familiar with action and adverse reactions of medications. The facility failed to ensure R60 received his insulin as ordered by the physician and failed to ensure blood glucose levels outside of physician ordered parameters were reported to the physician as ordered. This placed R60 at risk for complications related to insulin use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 114 residents. The sample included 23 residents with two residents reviewed for hospice services. Based on observation, record review and interview, the facility failed to establish a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for Resident (R) 47 and R202. The facility failed to ensure that R47 and R202's written plan of care included both the most recent hospice plan of care and a description of the services furnished by both the facility and hospice. This placed R47 and R202 at risk of decline and/or from maintaining the highest practicable physical, mental, and psychosocial well-being. Findings included: - The electronic medical record (EMR) for R47 documented diagnoses of sequalae of cerebral infarction (conditions produced after the acute phase of an illness or injury due to a stroke), altered mental status (-a change in mental function that stems from illnesses, disorders and injuries affecting your brain), major depressive disorder with psychotic behaviors (-a mental disorder in which a person has depression along with loss of touch with reality), and a 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 left buttock. The admission Minimum Data Set (MDS) dated 10/09/23 for R47 documented a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R47 was dependent of staff for toileting and required substantial/maximal staff assist with self-care. R47 utilized a manual wheelchair for mobility. The Pressure Ulcer Care Area Assessment (CAA) dated 10/13/23 for R47 documented R47 had a blister to her heel. R47 had a pressure relieving mattress, a chair cushion and a moisture associated skin damage (MASD- inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva or mucous) which was being treated. The Terminal Prognosis Care Plan for R47 initiated 12/04/23 directed staff to assess residents coping strategies. The care plan directed staff to consult with the health care provider and social services to have hospice care for the resident in the facility. Staff was to encourage a support system of family and friends. Staff was directed to review the resident's' advance care planning choices and assist other to respect choices. R47's Care Plan lacked a care area for hospice services that directed staff on who the hospice provider was, how to contact the hospice provider, the hospice provided supplies and/or medications, or how communication was to be collaborated between the facility and the hospice provider. A verbal Physician's Order dated 11/21/23 directed hospice services due to sequelae of cerebral infarction. On 12/07/23 at 08:33 AM, R47 rested in bed on her left side, bed in low position, the call light was with reach. On 12/12/23 at 11:41 AM, Certified Medication Aide (CMA)/Certified Nurse Aide (CNA) R stated the nursing staff would let the aides know when a resident entered on hospice services as well as it showed on a resident's dashboard in the EMR. CMA R stated the [NAME] (nursing tool that gives a brief overview of the care needs of each resident) listed when a resident was on hospice. CMA R stated she was not certain what supplies/medications hospice provided or how often hospice came to visit R47. On 12/12/23 at 10:50 AM Licensed Nurse (LN) G stated the facility did not have a hospice book for each resident. LN G stated when a resident was placed on hospice, the hospice provider came in to do an assessment with the resident and provided the facility with the plan of care as well as a list of supplies hospice would provide. LN G stated after a hospice visit, the facility was provided with a printed summary of the visit that would then be given to medical records to be scanned. LN G stated she believed that R47's care plan had information about hospice on it but was not certain without looking at the care plan herself. On 12/12/23 at 02:48 PM Administrative Nurse D stated that the facility did not keep a hospice book for each resident. Administrative Nurse D stated typically when a resident was placed on hospice services the nursing staff would be notified. Administrative Nurse D stated hospice provided the facility with the plan of care, the list of supplies and medications that were provided. Administrative Nurse D stated the care plan for R47 documented on 12/04/23 that she was on hospice care. Administrative Nurse D stated on R47's profile in the EMR documented who the hospice provider was. The Hospice and Nursing Facility Services Agreement dated 09/01/23 documented: Hospice would furnish and/or assume financial responsibility for medication, and any durable medical equipment (DME) and supplies that were needed for management of each resident' terminal illness. Hospice would deliver to the facility medications for each resident to be administered by the facility. Hospice and the facility shall communicate with one another regularly and as needed for each hospice patient. Each party shall document the communication in its respective clinical records to ensure that the needs of the resident were met 24 hours per day. The facility nurse responsibilities included coordination with hospice staff in the implementation and update of the joint plan of care; administration of medication; supervision of facility DME; notify hospice of change in condition of the resident; communication with hospice nurse regarding needs for medication refills, new medications, x-ray, lab studies, therapy, consults and supplies. The facility failed to establish a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day for R47. The facility failed to ensure, that R47's written plan of care included both the most recent hospice plan of care, a description of the services furnished by the facility, and the contact and address information for the hospice provider. This placed R47 at risk of decline and/or maintaining the highest practicable physical, mental, and psychosocial well-being.- R209's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, dependence on a wheelchair, dementia (progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The admission Minimum Data Set (MDS) dated [DATE] was in progress. R209's Care Area Assessment (CAA) was in progress. R209's baseline Care Plan dated 11/28/23 lacked who was the hospice provider, how to contact the hospice provider, the frequency of hospice visits, the hospice provided supplies and/or medications, or how communication was to be collaborated between the facility and the hospice provider. R209's clinical record lacked documentation of communication between the facility and the hospice provider. Observation on 12/06/23 on 12:10 PM R209 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) next to his bed. R209 was asleep in the Broda chair. He had several days of facial hair growth noted. The call light was on the bedside table behind R209's Broda chair, outside his reach. On 12/12/23 at 11:41 AM, Certified Medication Aide (CMA) R stated the nursing staff would let the aides know when a resident entered on hospice services as well as it showed on a resident's dashboard in the EMR. CMA R stated the [NAME] (nursing tool that gives a brief overview of the care needs of each resident) listed when a resident was on hospice. CMA R stated she was not certain what supplies/medications hospice provided or how often hospice came to visit R47. On 12/12/23 at 10:50 AM Licensed Nurse (LN) G stated the facility did not have a hospice book for each resident. LN G stated when a resident was placed on hospice, the hospice provider came in to do an assessment with the resident and provided the facility with the plan of care as well as a list of supplies hospice would provide. LN G stated after a hospice visit, the facility was provided with a printed summary of the visit that would then be given to medical records to be scanned. LN G stated she was not sure that R209's care plan had information related to hospice on it but was not certain without looking at the care plan herself. On 12/12/23 at 02:48 PM Administrative Nurse D stated that the facility did not keep a hospice book for each resident. Administrative Nurse D stated typically when a resident was placed on hospice services the nursing staff would be notified. Administrative Nurse D stated hospice shared the care plan with facility care plan. Administrative Nurse D stated hospice information should be added to the resident's care plan within 48 hours after being admitted on to hospice services. Administrative Nurse D stated the care plan would not always contain the items provided by the hospice provider, frequency of visits, or the medication covered by the hospice provider. Administrative Nurse D stated these things were subject to change at any time. Administrative Nurse D stated those things were communicated to the nursing staff during the hospice visits. The Hospice and Nursing Facility Services Agreement dated 09/01/23 documented: Hospice would furnish and/or assume financial responsibility for medication, and any durable medical equipment (DME) and supplies that were needed for management of each resident' terminal illness. Hospice would deliver to the facility medications for each resident to be administered by the facility. Hospice and the facility shall communicate with one another regularly and as needed for each hospice patient. Each party shall document the communication in its respective clinical records to ensure that the needs of the resident were met 24 hours per day. The facility nurse responsibilities included coordination with hospice staff in the implementation and update of the joint plan of care; administration of medication; supervision of facility DME; notify hospice of change in condition of the resident; communication with hospice nurse regarding needs for medication refills, new medications, x-ray, lab studies, therapy, consults and supplies. The facility failed to establish a communication process, including how the communication would be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day for R209. The facility failed to ensure, that R209's written plan of care included both the most recent hospice plan of care, a description of the services furnished by the facility, and the contact and address information for the hospice provider. This placed R209 at risk of decline and/or maintaining the highest practicable physical, mental, and psychosocial well-being.

The facility identified a census of 114 residents. The sample include 23 residents. Based on observation, record review, and interviews, the facility failed to provide consistent activities for Resident (R) 7 and the other cognitively impaired residents who resided outside of the locked unit. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom. Findings included: - On 12/11/23 at 09:50 a group of cognitively impaired residents sat in the fireplace social area. The residents were not alerted or invited to attend the scheduled 10:00AM. The residents did not attend the planned activity event from 10:00AM to 11:00AM. On 12/11/23 at 10:00AM the facility held a Name that Christmas song activity. The activity provided snacks for the residents as they listened for the mystery Christmas songs played. At 10:33AM R7 () wheeled herself down the hall and into the activities room. R7 wheeled herself around the room and residents attending the event. R7 wheeled herself to the front of the room by the activities staff. Staff did not invite R7 to the game or provide her with a snack. R7 then wheeled herself to the adjoined chapel area and sat in the dark. At 10:45AM R7 wheeled herself out of the activity room and to the vending machine room. R7 sat in the vending machine room until 12:33PM. On 12/11/23 at 01:24PM R84, R41, R66, R100, and R309 (all cognitively impaired residents) sat at the fireplace social area. The listed residents sat in the common area with their eyes closed. They were not asked if they would like to attend the scheduled Bingo game at 02:00 PM. The residents missed the Bingo events. Residents remained in the seated area with minimal interactions or engagement from staff. No activities were offered or provided to the residents. On 12/12/23 at 09:50AM R309 sat by the fireplace common area. Activities Staff Z began escorting residents to the activities room for Christmas Ornament Painting event. R309 was not asked by staff if she wanted to attend the event and was left in the area with several other residents. At 10:10AM the event began and R309 was still at the fireplace sitting area. R309 stated she wanted to attend the event. 12/11/23 at 02:30PM Certified Nurse Aid M stated staff were expected to communicate with the resident the scheduled activities and ask them if they prefer something else. He stated staff should be offering options to the residents like attending activities, social hour, television, and games. He stated cognitively impaired resident should receive sensory activities. On 12/12/23 at 11:22AM Activities Staff Z stated she R7 usually was anxious during the events and would often have to leave due to disruptions. She stated the activities calendars are given out to all the residents and posted on the bulletin board. She stated impaired residents are provided with painting activities on one-one basis. She stated a lot of the more cognitively impaired residents don't like to attend the social events or activities. She stated every should be asked to attend or invited. She stated R7 liked to paint, color, and watch others. She stated the activities provided for each resident was charted in the EMR. On 12/12/23 at 02:30PM Administrative Nurse D stated all resident should be invited to the activity events. She stated it is the resident's choice not to attend but the activities should include everyone. She stated staff should provide engagement and offer activities if the resident did not want to go to the scheduled events. A review of the facility's Activities indicated the facility was responsible for providing beneficial activities that meet each resident's needs, interest, and functional level. The policy noted the activities should build community, spirituality, and cognitive opportunities for the residents. The facility failed to provide consistent activities for the cognitively impaired residents who did not reside on the locked unit. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 114 residents. The facility had three medication rooms and seven medication carts. Based on observation, record review and interview the facility failed to ensure accurate labeling of medications to facilitate consideration of precautions and safe administration of medications in accordance with professional standards. The facility failed to ensure safe and secure storage of medications. This deficient practice created a risk for adverse side effects and ineffective medication administration. Findings included: - On 12/06/23 during the initial tour, the Exam Room was unlocked. Inspection of the room revealed an unlocked medication refrigerator with multiple boxes of Covid-19 vaccine and multiple does of pneumococcal vaccine. The refrigerator contained one vial of opened but undated tuberculin serum The November temperature log was posted on the refrigerator and the temperatures stopped at 11/27/23 with no further evidence staff assessed temperatures after 11/27/23. There was no December log present. On 12/06/23 at 07:29 AM observation of the nurse's cart in 300 hall outside room [ROOM NUMBER] revealed an opened Admelog insulin lispro (a fast-acting insulin) pen opened and no open and discard date noted for R38. A Toujeo (long-acting) insulin pen was opened and undated for R38. A glargine (long-acting) insulin pen for R109 was opened and undated. There was multiple expired vials of B12 injection dated 09/20/23. On 12/06/23 at 07:50 AM the 300 Hall Cart contained Systane gel open with no dates or resident name. There was an albuterol (a medication used to relax the muscles around the airways so they open up and you can breathe more easily) 90 mcg inhaler with resident name blacked out opened on 09/7/23. The shift medication count log on Ridges 300 noted 10 opportunities where the narcotic count was not done in December 2023. On 12/06/23 at 11:08 AM during inspection of the medication room for 200 hall it was noted that medication refrigerator temperature logs for the month of December were missing entries for dates of December 1, 2023, through December 4, 2023. A bottle of liquid lorazepam (a sedative medication used to treat anxiety disorders) for R94 was opened and not dated (label missing from bottle). On 12/06/23 at 07:29 AM Licensed Nurse (LN) L stated the insulin should be labeled and dated and all expired medications should be removed from cart. LN L took the insulin pens and expired medication and stated they would be discarded. On 12/06/23 at 07:35 LN K stated the Systane drops she believed was R27's as her son brought them from home. On 12/06/23 at 11:08 AM LN G stated the medication refrigerator temperature logs was to be completed by the night shift nurse every night. On 12/12/23 at 02:41 PM Administrative Nurse D stated staff should ensure that medication/exam rooms be kept locked and secured, as well as refrigerators being secured. Administrative Nurse D stated her expectation was for her staff to date insulin pen when opened with open date and expiration date on label. Administrative Nurse D stated medications should be discarded when expired. Administrative Nurse D stated she had been working with her two Assistant Director of Nursing (ADON) on educating staff on discarding medications, ensuring medications had an open date, and the importance of completing the narcotic count at the end of each shift. The facility policy Medication Acquisition Receiving Dispensing and Storage revised 03/02/23 documented: medications would be stored in a locked medication cart, drawer, or cupboard. The location would routinely check for expired medications and necessary disposal would be done in accordance with regulations. Refrigerators holding medications would be kept between 36 degrees Fahrenheit (F) and 46 degrees F. Medication rooms would be kept between 59 degrees F and 86 degrees F. Refrigerator temperature was to be checked once in the morning and once in the evening. Controlled drugs would be reconciled at least daily through an appropriate system of records of receipt and disposition. Medications brought into the facility by the resident or family members were used only upon written order by the attending physician. The facility policy Medication: Insulin Administration, Insulin Pens revised 04/26/23 documented Insulin pens containing multiple doses of insulin are meant for use on a single person only and should never be used for more than one person, even when the needle was changed. Insulin pens must be clearly labeled with the name or other identifiers to verify that the correct pen was used on the correct person. Verify provider order, the expiration date, and the number of days the pen had been open. The facility failed to ensure accurate labeling of medications to facilitate consideration of precautions and safe administration of medications in accordance with professional standards. The facility failed to ensure safe and secure storage of medications. This deficient practice created a risk for adverse side effects and ineffective medication administration.

The facility identified a census of 114 residents. The sample included 23 residents. Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices. This placed the residents at risk for transmission of infectious disease. Findings included: - Observation On 12/06/23 during the initial tour, the Exam Room was unlocked. The room had a bin of hair products including clippers and a hairbrush with gray hairs in it. The brush was in with the clippers, on the counter, and was unlabeled with any resident name or room number. The desk-type chair in the exam room had short gray hairs all over the seat surface. The handwashing sink in the exam room was not equipped with paper towels for drying. Observation on 12/06/23 at 07:12 AM an unidentified staff member walked down the hall with no mask. The staff member held a piece of paper up to her face to cover her mouth and nose. Observation on 12/06/23 at 09:06 AM two sit to stand lifts and a Hoyer (total body mechanical lift) sat in the hallway and all three- of the lifts had debris and were visibly soiled. Observation on 12/06/23 at 07:23 AM an ice cooler sat on the 300 halls next to fish tank. The inside of the ice cooler had black particles or debris mixed with scant amount of melted ice. Observation on 12/06/23 at 07:30 AM a laundry cart with residents' clothes on the rack sat uncovered and unattended in the hallway. A pillow, a lap blanket, and a clothes hanger sat on the handrail behind a chair in hallway alcove. Observation on 12/06/23 at 07:40 AM the unlocked clean linen room had clean linen stored uncovered in the room with a walking frame and wheelchair also stored in room. The walking frame was visibly soiled. Bumper pads stored on the lowest shelf hung off and touched the floor. Observation on 12/07/23 at 08:38 AM staff pushed Resident (R) 101 from the dining room in her wheelchair with her catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) bag dragging on the floor under the wheelchair. Observation on 12/07/23 at 02:29 PM a large bag of trash sat on the floor in the hallway outside the bath/spa room unattended. Observation on 12/11/23 at 07:30 AM R81's catheter bag with amber colored urine rested on the floor. Observation on 12/12/23 at 08:39 AM R81's catheter bag with amber colored urine rested on the floor next to his bed. Observation on 12/12/23 at 11:13 AM Certified Nurse Aide (CNA) Q parked the Hoyer (total mechanical lift) lift in hallway after use and failed to disinfect the lift before walking away to enter another room. On 12/12/23 at 09:00 AM Certified Medication Aide (CMA) R stated a catheter bag should never touch the floor and all lifts should be disinfected between each use. CMA R stated trash bags should never be stored on the floor., CMA R stated only clean linen should be stored in the clean linen room and the personal clothes cart should be covered when in the halls. On 12/12/23 at 11:53 AM Licensed Nurse (LN) G stated staff should disinfect the shared lifts between each use. LN G stated she was not sure if the lifts where routinely cleaned. LN G stated trash bags should never be left on the floor in the hallways and catheter bags should never touch the floor. LN G the clean linen cart should always be covered when in the hallway. LN G stated only clean linens should be stored in the clean linen room. On 12/12/23 at 02:43 PM Administrative Nurse D stated the lifts should be disinfected between each use and open unattended trash bags should never be stored on the floor in the hallways. Administrative Nurse D stated Sani-wipes should never be within reach of the residents. Administrative Nurse D stated nothing other than clean linens should be stored in the clean linen room. Administrative Nurse D stated clean linen carts should be covered when in the hallways. Administrative Nurse D stated catheter bag should not be placed on the floor. The facility's Infection Prevention and Control Program policy dated 10/21/22 documented the facility would establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Appropriate employees would integrate state-specific regulations from the location's state health department or regulatory agency into their infection control procedures. Appropriate employees would include the infection preventionist at the rehabilitation/skilled care location. The procedures would be reviewed by the QAPI committee, quality improvement team or safety committee as applicable to each setting. Infection control policies and procedures would be communicated to employees by location leaders via memos, emails, in-services, and ongoing training, as appropriate. The infection prevention and control program would be accessible to employees and reviewed and updated by the infection prevention specialist or designee at least annually based on the facility assessment and infection prevention risk assessment. The facility failed to implement appropriate infection control practices. This placed the residents at risk for transmission of infectious disease.

The facility identified a census of 114 residents with one kitchen and two main dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to cleanliness of the kitchen/dining room equipment, clean ventilation, equipment storage, hygienic serving practices, and food storage. This placed the residents at risk for food borne illness. Finding Included- - On 12/06/23 at 07:02AM an initial walkthrough of the kitchen was completed. An inspection of the air conditioning vents above the food warming station, stove/grill, food prep table, sink, and clean plates storage revealed layered debris/dust covering the vents. An inspection of the spice storage shelf revealed spilled spice particles covering the bottle and shelf. An inspection of the wet condiment shelf revealed sticky residue underneath the honey, vanilla, and vinegar bottles. An inspection of the storage area outside the kitchen revealed a buffet table with piles of clean cloth napkins covering the top of the buffet table exposed to the environment. An inspection of refrigerator number two revealed a package of opened pancakes with no opened date. An inspection of refrigerator number three revealed a measuring container with slimy yellowish liquid substance with no label or date. An inspection of the clean bowel/plate storage rack revealed them to be stored upward with nothing covering them. An inspection of the 300 Hall nutrition fridge revealed an unlabeled/undated paper plate wrapped in a plastic bag, an open container of apple juice with no open date, a brown square unidentifiable food item with no label or date and an opened small container of milk which lacked a date opened or name. On 12/06/23 at 11:45AM an inspection of lunch service revealed multiple staff repeatedly adjusting their face masks during meal service without completing hand hygiene. Dietary Staff CC carried drinks while touching the drinking surface of the glass with her bare hands. Further observation revealed a white PVC storage bin heavily soiled with old food and debris. An uncovered, wheeled bin contained clean place mats and napkins was pushed against the trash can and touched the soiled storage bin. Dietary Staff CC wore her mask with her mouth exposed. On 12/06/23 at 12:03PM Dietary staff CC stated clean surfaces should not be in contact with soiled surfaces. She stated the trash can should not touch the clean linen carts but was not sure if the clean linen should have been covered. On 12/06/23 at 12:30PM Dietary Staff BB stated staff were expected to clean and wipe down the storage bin and cart after use or when they became soiled. She stated all food and items stored should be labeled and dated in the refrigerators. She stated maintenance was coming to clean the vents above to kitchen area and they were responsible for maintaining them. She stated staff were expected to complete hand hygiene during meal service and should not be touching their masks. She stated the bowl and plate cart was usually covered with a dome when not in use. A review of the facility's Food Services and Nutrition policy 11/27/23 indicated the facility would promote a system that identified proper service, cleaning, and food storage. The policy noted all surfaces within the dining room and kitchen were to be cleaned and sanitized per professional standards. The policy indicated food would be label/dated and stored in a manner that is safe and maintains nutrition value. The policy indicated staff were to ensure safe food handling practices to prevent cross-contamination and food-borne illness. The policy indicated staff should complete hand hygiene in between touching surfaces related to direct food preparation, handling, and serving. The policy noted all kitchen ad dining equipment be stored in a manner that prevent soiling or contamination of clean items. The facility failed to follow sanitary dietary standards related to cleanliness of the kitchen/dining room equipment, clean ventilation, equipment storage, hygienic serving practices, and food storage. This placed the residents at risk for food borne illness.

The facility reported a census of 114 residents. Five Certified Nurse Aide's (CNA) were sampled for prevention of abuse, neglect, and exploitation training. Based on record review and interview the facility failed to provide evidence of the required prevention of abuse, neglect, and exploitation training for one of the five CNAs that were sampled. This placed the residents at risk for abuse. Findings included: - Employee record review of CNA OO revealed the facility failed to provide evidence that CNA OO received the required abuse, neglect, and exploitation training. On 12/11/12 at 02:24 PM Administrative Nurse D stated she contacted CNA OO and asked him to come in and complete the required education. On 12/12/23 at 02:41 PM Administrative Nurse D stated Consultant II oversaw and tracked the compliance and education requirements/hours for the employees at the facility. Administrative Nurse D stated it was also her responsibility to make sure employees were up to date on required training. An education policy was not provided by the facility. The facility failed to provide evidence of the required prevention of abuse, neglect, and exploitation training for one of the five CNAs that were sampled. This placed the residents at risk for abuse.

The facility had a census of 114 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure two of the five CNA staff reviewed had the required 12 hours of in-service education which included dementia (progressive mental disorder characterized by failing memory, confusion) care training. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included: - Review of the facility's in-service records revealed the following: CNA OO, hired on 11/30/05, had 1.75 hours of in-service in the past 12 months. Review of trainings for CNA OO for past year lacked evidence of the required education on the topic of dementia. CNA QQ, hired on 08/31/16, had 6.59 hours of in-service in the past 12 months. Review of trainings for CNA QQ for past year lacked evidence of the required education on the topic of dementia. On 12/11/12 at 02:24 PM Administrative Nurse D stated she contacted CNA OO and asked him to come in and complete the required education. On 12/12/23 at 02:41 PM Administrative Nurse D stated Consultant II oversaw and tracked the compliance and education requirements/hours for the employees at the facility. Administrative Nurse D stated it was also her responsibility to make sure employees were up to date on required training. Administrative Nurse D stated dementia training was done annually through an online learning center and the facility offered hands on/in-person training as well. An education policy was not provided by the facility. The facility failed to ensure two of the five CNA staff reviewed had the required 12 hours of in-service education and dementia care training. This placed the residents at risk for decreased quality of life and/or inadequate care.

The facility reported a census of 108 residents with 22 sampled including one reviewed for an indwelling catheter. Based on observation, interview, and record review the facility failed to promote dignity when staff failed to provide a privacy bag for the indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) drainage bag for Resident (R) 22. This placed R22 at risk for impaired dignity and psychosocial wellbeing. Findings included: - Review of 22's Physician Order Sheet documented the following diagnoses of hydronephrosis (swelling of a kidney due to a build-up of urine) and obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow). The 05/28/21 admission Minimum Data Set (MDS) documented a staff assessment indicated long and short-term memory problem with severely impaired cognition. R22 had an indwelling catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/28/21 documented the resident had a permanent indwelling urinary catheter in place on admission. The Care Plan dated 02/14/21 revealed staff assisted R22 with catheter care every shift and more often as needed. On 02/07/21 at 01:06 PM observed R22 in bed with an indwelling catheter drainage bag hung on the side of her bed with no privacy covering. On 02/08/22 at 08:27 AM observed R22 in bed with an indwelling catheter drainage bag hung on the side of her bed with no privacy covering. On 02/09/22 at 03:57 PM observed R22 in bed with an indwelling catheter drainage bag hung on the side of her bed next to the privacy covering bag hung on the side of the bed. On 02/08/22 at 03:21 PM Certified Nurse Aide (CNA) H revealed a resident with a catheter would have a leg strap in place, a privacy cover, and it would always be kept below the bladder. On 02/09/22 at 07:36 AM CNA J revealed she expected the catheter drainage bag to always be in a privacy bag. On 02/09/22 at 07:53 AM Licensed Nurse (LN) I revealed any resident with a catheter would need to have a privacy bag covering the drainage bag while in bed or up in a chair. Upon entrance into R22's room LN I stated the catheter drainage bag should be in a privacy bag. Interview on 02/09/22 at 09:02 AM with Administrative Nurse B revealed she expected staff to cover all catheter drainage bags with a dignity bag. Review of the facilities Resident Dignity policy revised on 10/19/21 documented that staff were to maintain the dignity of all residents. The facility failed to promote dignity for R22 when staff did not provide a privacy bag for her indwelling catheter drainage bag while in bed.

The facility reported a census of 108 residents with 22 sampled including one for an indwelling catheter. Based on observation, interview, and record review the facility failed to provide safe, sanitary, and hygienic catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care by allowing Resident (R) 22's indwelling catheter drainage bag to touch the floor. This placed the resident at risk for improper catheter care. Findings included: - Review of 22's Physician Order Sheet documented the following diagnoses: hydronephrosis (swelling of a kidney due to a build-up of urine) and obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow). The 05/28/21 admission Minimum Data Set (MDS) documented a staff assessment indicated long and short-term memory problem with severely impaired cognition. R22 had an indwelling catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/28/21 documented the resident had a permanent indwelling urinary catheter in place on admission. The Care Plan dated 02/14/21 revealed staff assisted R22 with catheter care every shift and more often as needed. On 02/08/22 at 10:15 AM observed R22 in bed with an indwelling catheter drainage bag lying on the floor under her bed. On 02/08/22 at 03:21 PM Certified Nurse Aide (CNA) H revealed a resident with a catheter would have a leg strap in place and it would always be kept below the bladder and off the floor. On 02/09/22 at 07:36 AM CNA J revealed she expected the catheter drainage bag to not be on the floor. On 02/09/22 at 07:53 AM Licensed Nurse (LN) I revealed staff should not place resident's catheter drainage bags on the floor. Interview on 02/09/22 at 09:02 AM with Administrative Nurse B revealed she expected staff to keep all catheter drainage bags off the floor at all times. Review of the facilities Catheter Care, Insertion, and Removal, Drainage Bags, Irrigation, Specimen policy revised on 05/27/21 instructed staff that catheter tubing should never be allowed to touch the floor. The facility failed to provide safe, sanitary, and hygienic catheter care for R22.

The facility reported a census of 108 residents with 22 sampled with three residents reviewed for respiratory care. Based on observation, interview, and record review the facility failed to provide safe and sanitary care for oxygen tubing to help prevent the development and transmission of diseases and infections for one Resident (R) 63. This placed R63 at risk for infections. Findings Included: - R63's Electronic Health Record (EHR) under the medical diagnosis tab documented the diagnosis of hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood). The 07/02/21 admission Minimum Data Set (MDS) documented R63 had a Brief Interview for Mental status (BIMS) score of 15, indicating intact cognition, with no use of oxygen noted. The 02/02/21 Care Plan documented R63 had altered respiratory status. Staff were to monitor R63 for signs or symptoms of acute respiratory insufficiency and respiratory infection. R63 had oxygen (O2) therapy, as needed (PRN). The EHR documented a Physician Order on 12/04/21 for albuterol sulfate (bronchodilator- works by relaxing and opening air passages to the lungs) nebulization (electrically powered machine that turns liquid medication into a mist) solution 2.5 milligrams (mg)/milliliter (ml). On 12/29/21 R63 had an order for oxygen (O2) therapy PRN, O2 tubing care, and level of O2 to be used. On 02/08/22 at 03:42 PM observation revealed R63's O2 mask for nebulized medication sat with no barrier on the countertop, and her O2 tubing laid on the floor next to the concentrator with no storage bag noted on the concentrator. On 02/09/22 at 07:57 AM, observation revealed R63's O2 mask for nebulized medication sat on her rocking chair with no barrier and with no bag for storage. On 02/10/22 at 08:29 AM Certified Medication Aid (CMA) L revealed that O2 and nebulizer tubing and masks should be stored in a plastic bag when not in use. On 02/10/22 at 11:10 AM Licensed Nurse (LN) I stated all nebulizer as well as O2 tubing and masks should be stored in a plastic bag when not in use. On 02/10/22 at 09:15 AM Administrative Nurse B confirmed all tubing should be kept in a storage bag on the back of the concentrator when not in use. Nebulizer tubing should be stored the same with the dates on both. Review of the facility's Oxygen Administration, Safety, Mask Types policy revised 05/19/21 documented when oxygen was not in use, store cannula, face mask, or face tent and tubing in a zip-lock bag/plastic bag secured to oxygen cylinder or concentrator. The facility failed to provide respiratory care consistent with professional standards of practice for R63.

The facility reported a census of 108 residents with 22 sampled including one for dialysis care. Based on observation, record review, and interview the facility failed to monitor Resident (R) 258's dialysis (procedure where impurities or wastes were removed from the blood) treatments appropriately by not sending or collecting the dialysis communication forms. This placed the resident at risk for complications and health decline. Findings include: - Review of Resident (R) 258's Physician Order Sheet documented the diagnosis of end stage (a terminal disease because of irreversible damage to vital tissues or organs) renal (kidney) disease (ESRD). The 11/29/21 admission Minimum Data Set (MDS) documented R258 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The resident required staff assistance with all her activities of daily living (ADLs) except eating which she could do with some set up help. R258 required dialysis. The 11/29/21 ADL Functional/Rehab Care Area Assessment (CAA) documented R258 had ESRD and received dialysis three times a week. The 12/06/21 Care Plan documented R258 went to dialysis three times a week and staff were to follow protocol for assessments. The Electronic Health Record (EHR) documented a Physician Order on 11/15/21 for staff to prepare and collect the dialysis communication forms with vital signs, weights before and after process, and any other notes from dialysis or facility. The EHR lacked dialysis communication forms for the following dates: 12/03/21, 12/06/21, 12/15/21, 12/17/21, 12/24/21, 12/27/21, 12/29/21, 12/31/21, 01/05/22, 01/17/22, 01/21/22, 02/04/22, and 02/07/22. On 02/08/22 at 03:20 PM R258 sat in her room watching tv and looked out the window following dialysis with staff assessing shunt dressing on her leg and obtaining vital signs. On 02/08/22 at 01:40 PM Licensed Nurse (LN) K stated that it was the nurses' responsibility to send and gather the dialysis communication form for residents on dialysis. On 02/10/22 at 11:10 AM LN I stated that R258 required dialysis three times a week, the staff sent dialysis communication sheets with her, and the sheets were to be collected when she returned. On 02/10/22 at 09:15 AM Administrative Nurse B confirmed the missing documents and stated she expected the staff to send and collect the dialysis communication forms. The facilities Dialysis Services policy revised on 09/17/21 instructed staff to monitor the resident receiving dialysis. The facility failed to prepare and collect the dialysis communication forms for R258 as ordered.

The facility reported a census of 108 residents. Based on observation, record review and interview, the facility failed to store food in accordance with professional standards for food service safety, when kitchen observation revealed numerous expired food items. This placed the residents who received meals from the facility kitchen at risk for foodborne illness. Findings included: - On 02/07/22 at 08:15 AM, during initial tour of the main kitchen revealed the following items were expired: House Recipe Quick Grits (five containers, expired on 01/15/22) Thickened Cranberry Cocktail 46 ounce container (one container, expired on 01/18/22) light molasses one gallon container (three containers, expired on 12/22/17) Potato Pearls 29.3 ounce box (six boxes, expired on 11/06/21) Carnation Breakfast Essentials Pack (19 packs, expired on 09/09/21), Gelatin Mix Assorted Flavors three ounce pack (11 packs, with expiration dates of 06/2018, 07/2018, 08/2018, and 01/2021) Drink Mix Assorted Flavors 1.27 ounce pack (30 packs, with expiration dates of 12/2020 and 01/2021) Mousse Mix Assorted Flavors nine ounce pack (13 packs, with expiration dates on 06/2020 and 07/2020) lemonade drink mix 24 ounce pack (two packs, undated) French's Crisp Fried Onions (one package, opened and expired on 06/12/21) Interview with Certified Dietary Manager (CDM) C on 02/07/22 at 09:00 AM revealed items were used on a first in, first out basis. CDM C expected the dietary staff members to follow this process and dispose of expired items. CDM C also expected the dietary staff members to use food items within 30 days that did not have a listed expiration date. The 05/03/21 Date Marking-Food and Nutrition policy documented all food items would be discarded when the container or package did not bear a date and/or when the food item was beyond the use by or expires on date. The facility failed to store food in accordance with professional standards for food service safety when observations revealed expired food in the facility kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 136 residents. The sample included 29 residents. Based on observations, record reviews, and interviews, the facility failed to clearly identify the expressed choices to initiate or withhold resuscitative measures (restoration to life or consciousness of one apparently dead, or whose respirations had ceased) by maintaining a Do Not Resuscitate (DNR) (an order to withhold resuscitative measures) advance directive for Resident (R) 79, signed by R79 or her representative. Findings included: - R79's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a staff assessment revealed moderate impairment in decision making. The MDS documented R79 required extensive assistance of one staff member for Activities of Daily Living (ADL). The Quarterly MDS dated 01/24/20 documented a staff interview revealed R79 had moderately impaired decision making. The MDS documented R79 required extensive assistance of two staff members for ADL's. The ADL Care Area Assessment (CAA) dated 11/08/19 documented R79 required assistance with her ADL's. The care plan lacked interventions to direct staff regarding R79's code status. The EMR documented a physician order dated 06/05/18 for a DNR. Review of the EMR for R79 lacked a signed DNR form by her or her representative. Observation on 03/03/20 at 08:59 AM R79 propelled herself in the wheelchair in the hallway toward the dining room for breakfast. Her right lower extremity was on her foot pedal. During an interview on 03/05/20 at 10:45 AM Licensed Social Worker X stated when a resident was transferred to the hospital the original DNR form was sent with the resident to the hospital. Upon return from the hospital a new DNR form was signed by the resident or designated power of attorney (a resident's legal representative). During an interview on 03/05/20 at 01:50 PM with Licensed Nurse (LN) I stated staff know a resident's code status by looking in the code status books kept in the nurse's charting office and from the resident's EMR. LN I did not find R79's signed DNR form in the code status book in the Meadows nurses' office. LN I stated R79 would be a Full Code if found unresponsive. During an interview on 03/05/20 at 02:57 PM Administrative Nurse D stated every unit had a code status book where the DNR forms could be located. Administrative Nurse D stated code status was reviewed every care plan conference. The Advance Care Planning and Advanced Directives policy with revision date of 04/16 lacked documentation related to the DNR form in the medical record and availability to nursing staff. The facility failed to maintain a copy of the DNR advanced directive, signed by R79, her legal representative, or the physician., which had the potential to deny her expressed wishes to initiate with resuscitative measures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 136 residents. The sample included 29 residents, with three residents sampled for hospitalization. Based on observations, record reviews, and interviews the facility failed to issue a written notification of discharge which indicated the reason for hospitalization for Resident (R) 96 and R7. Findings included: - The Diagnoses tab of R96's electronic medical record (EMR) documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), kidney disease, and hyperkalemia (greater than normal amount of potassium in the blood). The admission Minimum Data Set dated 02/03/20 documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. She required limited staff assistance of one person with her Activities of Daily Living (ADL). The Care Area Assessment for Communication dated 02/03/20 documented R96 spoke clearly and made her needs known. She heard others if background noise was decreased. The ADL care plan revised 02/05/20 documented R96 had a self-care performance deficit related to renal failure and needed assistance with ADL's. A Progress Note dated 02/10/20 in R96's EMR documented she was transferred to the hospital for evaluation of a critical potassium lab level. R96's EMR lacked documentation of a written notification of discharge which indicated the reason for transfer and location where R96 was being transferred. On 03/03/20 at 01:57 PM R96 was observed in her room. A staff member knocked on her door and entered her room. The staff member pushed R96 in her wheelchair to the nurses' cart in the hallway. On 03/05/20 at 10:09 AM Licensed Nurse (LN) H stated no written notice was sent to the family when a resident is transferred to the hospital. The family was called. On 03/05/20 at 10:41 AM Social Services X stated written notice was sent to the family when a resident was transferred to the hospital. The notice was scanned into the EMR. On 03/05/20 at 12:09 PM Social Services X stated she did not find the written notice of hospitalization mailed to the family of R96 for the hospital transfer dated 02/10/20 so she had not done it. On 03/05/20 at 01:40 PM LN G stated no written notice was sent to a resident's family when a resident was transferred to the hospital. On 03/05/20 at 02:56 PM Administrative Nurse D stated written notification was sent to a resident's family when they were transferred to the hospital and a copy was scanned into the resident's EMR. The facility policy Discharge and Transfer revised September 2017 documented the facility notified the resident, and/or representative of the transfer and the reason for the transfer in writing and in a language and manner they understood. The facility failed to provide written notification of the reason and location for the transfer to the hospital for R96 or her representative. - R7's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and hypertension (high blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a staff interview revealed R7 had severely impaired decision making. The MDS documented R7 required extensive assistance of two staff members for Activities of Daily Living (ADLs). The Quarterly MDS dated [DATE] documented a staff interview revealed R7 had severely impaired decision making. The MDS documented R7 required total assistance of two staff members for ADL's. The Cognitive Loss Care Area Assessment (CAA) dated 04/02/19 documented R7 was non-verbal most of the time. The Care Plan dated 01/26/18 directed staff R7 understood consistent, simple, and direct sentences. Under the Progress Note tab dated 11/20/19 at 02:47 PM documented R7 was transported to the hospital related to difficulty breathing and was admitted . The EMR lacked documentation in the nurses note of written notification to resident or representative. Observation on 03/03/20 at 09:44 AM R7 laid on her back with her blanket pulled up to her chest, eyes closed, no distress noted, and call light pinned to blanket. On 03/05/20 at 10:09 AM Licensed Nurse (LN) H stated no written notice was sent to the family when a resident is transferred to the hospital. The family was called. On 03/05/20 at 10:41 AM Social Services X stated written notice was sent to the family when a resident was transferred to the hospital. The notice was scanned into the EMR. On 03/05/20 at 12:09 PM Social Services X stated she did not find the written notice of hospitalization mailed to the family of R96 for the hospital transfer dated 02/10/20 so she had not done it. On 03/05/20 at 01:40 PM LN G stated no written notice was sent to a resident's family when a resident was transferred to the hospital. On 03/05/20 at 02:56 PM Administrative Nurse D stated written notification was sent to a resident's family when they were transferred to the hospital and a copy was scanned into the resident's EMR. The facility policy Discharge and Transfer revised September 2017 documented the facility notified the resident, and/or representative of the transfer and the reason for the transfer in writing and in a language and manner they understood. The facility failed to provide written notification of the reason and location for the transfer to the hospital for R7 or her representative.

The facility reported a census of 136 residents. The sample included 29 residents. Based on interviews and record reviews, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for anticoagulant (medications used to decrease the coagulation time of the blood) use for Resident (R) 41. Findings included: - The Diagnoses tab of R41's electronic medical record (EMR) documented diagnoses of personal history of other venous thrombosis (potentially life threatening blood clot, usually in the legs) and embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) and long term (current) use of anticoagulants (a medication to prevent the formation of blood clots). The Quarterly MDS dated 12/24/19 revealed R41 received an anticoagulant seven days during the assessment period. The care plan dated 07/15/19, resolved 10/10/19 revealed R41 was on anticoagulant therapy related to history of deep vein thrombosis and directed facility staff to monitor R41's condition based on clinical practice guidelines or clinic standards of practice related to the use of Eliquis (apixaban-an anticoagulant) The Orders tab of the EMR documented R41 had an order for apixaban 5 milligrams (mgs.) two times a day with a start date of 07/04/19. The order was discontinued on 09/05/19. Observation on 03/03/20 at 02:06 PM revealed R41 attended resident council meeting with surveyors. R41 sat in her wheelchair and was active answering questions. On 03/09/20 at 10:45 AM, Administrative Nurse E stated she looked at the Medication Administration Record (MAR) for medications when completing MDS assessments and she knew which drugs were anticoagulants. The facility policy Assessment (MDS) last revised December 2019 directed a registered nurse to coordinate and conduct the assessment with appropriate participation of other team members. The results of the assessments were used to develop, review, and revise the residents' comprehensive care plans. The facility failed to accurately document that R41 was not on an anticoagulant during the assessment period. This had the potential of ineffective identification of her care plan needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 136 residents with a sample size of 29 which included four residents reviewed for urinary catheter use. Based on observations, interviews and record reviews the facility failed to care for the urinary catheter (tube inserted into the bladder to drain urine into a collection bag) in a manner to prevent urinary tract infections for Resident (R)122 and R27. Findings included: - The Diagnoses tab of R122's electronic medical record (EMR) documented diagnoses of urinary tract infection (an infection in any part of the urinary system), multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), and neuromuscular dysfunction of bladder (nerve damage of the bladder). The Significant Change Minimum Data Set (MDS), dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four which indicated severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. The resident had an indwelling catheter. Review of the Quarterly MDS dated 01/24/20 revealed a BIMS score of eight which indicated moderately impaired cognition. R122 required extensive assistance of two staff for transfers and toileting. The ADL (Activities of Daily Living)/Functional Rehabilitation Care Area Assessment (CAA), dated 02/12/2020, revealed R122 required staff assistance with ADL's. The Urinary Incontinence and Indwelling Catheter CAA, dated 02/12/2020, revealed R122 required a catheter to empty his bladder. The indwelling catheter worked better since he was less mobile. Review of the Catheter Care Plan, revised on 02/20/2020, revealed staff was directed to perform catheter care every shift. The Order Tab of the EMR documented an order to insert indwelling catheter 16 French (FR)/5 cubic centimeters (cc) dated 02/10/20. The order lacked documentation for catheter care. Review of Catheter Care under Documentation Survey Report in the EMR from 02/20/20 through 03/04/20 revealed lack of documentation catheter care was done for R122 every shift. The record revealed the placement of the catheter occurred on 02/10/20. The EMR also lacked documentation of catheter care eight shifts in February 2020 after 02/20/20 and three shifts from 03/01/20 through 03/04/20. On 03/04/20 at 07:15 AM R122 sat in the dining room in his wheelchair. R122's catheter was in a dignity bag under the seat of his wheelchair. On 03/05/20 at 10:09 AM Certified Nurse Aide (CNA) M stated catheter care was done by aides or nurses. It was done each time a resident toileted, first thing in the morning or whenever care was done. She said catheter care was documented by the aides in the EMR. On 03/05/20 at 10:15 AM Licensed Nurse (LN) H stated catheter care was done at least once a shift by aides or nurses. It was documented in the EMR. On 03/05/20 at 12:10 PM LN J stated catheter care should be done every shift and documented under tasks in the EMR. Blank spaces in the documentation meant the catheter care was not done. On 03/05/20 at 02:56 PM Administrative Nurse D stated catheter care was done at least once a shift. The catheter care was documented in the kiosk. The task was assigned to the aides, but anyone could perform catheter care. If there were blank spaces in the documentation someone did not document, so it was not done. The facility policy Catheter revised December 2019 lacked documentation for care of the urinary catheter. The facility failed to ensure facility staff documented R122's catheter care to ensure the resident received the appropriate care and services to prevent catheter related urinary tract infections. - R27's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), major depression disorder (major mood disorder), and neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R27 required extensive assistance of two staff members for Activities of Daily Living (ADL). The MDS documented R27 had an indwelling catheter during the look back period. The Quarterly MDS dated 12/13/19 documented R27 was independent with decision making. The MDS documented R27 was totally dependent of two staff members for ADL's. The MDS documented R27 had an indwelling catheter during the look back period. The Urinary, Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 04/11/19 documented R27 had an indwelling catheter due to his neurogenic bladder. The Care Plan dated 12/22/19 directed staff to provide catheter care every shift for R27. The Physician Order Sheet (POS) under the Orders tab revealed an order dated 02/18/20 to change Foley catheter (an indwelling catheter) 16 French (FR)/5 cubic centimeters (cc) bulb every 14 days. The POS lacked an order for catheter care. Review of Catheter Care under Documentation Survey Report in R27's EMR from 12/22/19 through 03/04/20 revealed the lack of documentation of catheter care eight shifts out of 30 shifts in December 2019, 18 shifts out of 93 shifts in January 2020, 16 shifts out 87 shifts in February 2020 and five shifts out of 12 in March 2020. Observation on 03/03/20 at 02:27 PM R27 sat in an electric wheelchair in the therapy room, his catheter was attached to the wheelchair in a privacy bag. On 03/05/20 at 10:09 AM Certified Nurse Aide (CNA) M stated catheter care was done by aides or nurses. It was done each time a resident toileted, first thing in the morning or whenever care was done. She said catheter care was documented by the aides in the EMR. On 03/05/20 at 10:15 AM Licensed Nurse (LN) H stated catheter care was done at least once a shift by aides or nurses. It was documented in the EMR. On 03/05/20 at 12:10 PM LN J stated catheter care was done every shift and documented under tasks in the EMR. Blank spaces in the documentation meant the catheter care was not done. On 03/05/20 at 02:56 PM Administrative Nurse D stated catheter care was done at least once a shift. The catheter care was documented in the kiosk. The task was assigned to the aides, but anyone could perform catheter care. If there were blank spaces in the documentation someone did not document, so it was not done. The facility policy Catheter revised December 2019 lacked documentation for care of the urinary catheter. The facility failed to ensure facility staff documented R27's catheter care to ensure R27 received the appropriate care and services to prevent catheter related urinary tract infections.

The facility identified a census of 136 residents. The sample included 29 residents. Six residents were reviewed for nutrition. Based on observations, record reviews, and interviews, the facility failed to address a significant weight loss for Resident (R) 56 Findings included: - The Diagnoses tab of R56's electronic medical record (EMR) documented diagnoses of hypertension (high blood pressure) and type two diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Significant Change MDS dated 02/21/20 documented R56 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. She required extensive assistance of one to two staff members for most of her Activities of Daily Living (ADLs), and set-up and supervision assistance with eating. The MDS recorded R56 had weight loss. The Care Area Assessment (CAA) for Nutrition dated 01/24/20 documented R56 had a high body mass index (BMI) (measure of body fat based on height and weight) and recent weight loss. R56's appetite was fair, and she didn't always let staff know if didn't like what was served. The Nutrition care plan revised on 02/19/20 documented R56 had a recent unplanned weight loss. She was to be referred to the Registered Dietician and the Nutrition Risk Committee. She was to be provided nutritional supplement as ordered, weighed weekly, and labs monitored. The Care Plan lacked interventions related to resident's food likes or dislikes. The EMR, under the Weight tab, revealed a weight dated on 01/08/20 of 253 pounds (lbs.) and a weight of 230 lbs. dated 02/05/20, which indicated a 23 lbs. and 9.09% weight loss in one month. The EMR lacked any documentation the physician was notified of the 23 lb./9.09% weight loss. Observation on 03/04/20 at 08:00 AM R56 sat in her wheelchair in the main dining room. She consumed 100% of breakfast after staff set it up. During an interview on 03/05/20 at 01:44 PM Certified Medication Aide (CMA) S stated the staff was informed of weight loss or other changes concerning the residents in shift report. During an interview on 03/05/20 at 01:50 PM Licensed Nurse (LN) I stated if she noted a weight loss for a resident, she notified the MDS coordinator. During an interview on 03/05/20 at 02:57 PM Administrative Nurse D stated weights were obtained monthly and weekly for residents that are at a nutritional risk. The MDS coordinators reviewed the monthly and weekly weights. The registered dietician came weekly and reviewed the at-risk residents monthly. During an interview on 03/05/20 at 03:40 PM Administrative Nurse E stated she reviewed the monthly weights for R56. Administrative Nurse E stated R56 had not fallen into the significant weight loss parameter set by the policy. The Weight and Height policy with a revision date of 10/17 documented residents that are at nutritional risk were weighed weekly. If a resident's weight varied more than three percent, the resident was reweighed, and the weight was documented. A significant weight change was defined as five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days. The facility failed to identify and place intervention for R56's significant weight loss, which had the potential for physical complications related to nutritional deficits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 136 residents. The sample contained 29 residents. Based on observations, interviews, and record reviews, the facility failed to ensure the use of standard infection control precautions (infection prevention practices which include but are not limited to hand hygiene and use of gloves) while performing wound care for Resident (R)24's right buttock 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). Findings included: - The Diagnoses tab of R24's electronic medical record (EMR) documented diagnoses of non-pressure chronic ulcer of buttock with fat layer exposed and pressure ulcer of sacral region (bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone), stage 3. The Annual Minimum Data Set (MDS) dated [DATE] revealed R24 was at risk for pressure ulcers, had moisture associated damage to skin, and had pressure relieving devices for bed and wheelchair. Observation on 03/03/20 at 10:44 AM revealed Licensed Nurse (LN) J walked into R24's room with LN K for a dressing change to R24's right buttock. LN J and LN K performed hand hygiene, then put on gloves and provided privacy. LN K rolled R24 onto her left side so LN J could assess the wound. R24 laid on an incontinence pad with no underwear or incontinence brief on, incontinence pad had scant (barely sufficient or adequate) drainage (the removal of fluids and/or gases from a body part) on it where the wound laid open against it. LN J stated resident had loose stools recently and they cannot keep a dressing on long. LN J cleaned R24's perineal area (the area of soft tissue covering the muscles and ligaments of the pelvic floor between the vagina and the anus in women and between the scrotum and the anus in men) with hygiene wipes, removed gloves, performed hand hygiene, then donned new gloves. LN J cleansed wound with normal saline and gauze three times. LN K laid R24 onto her back onto the soiled incontinence pad with wound exposed. LN J removed gloves, performed hand hygiene, and donned clean gloves then put Medihoney (medical honey that aides in wound healing) onto a folded piece of gauze. LN K rolled R24 over onto her left side again, so her buttocks were exposed to LN J. LN J applied Medihoney gauze to the wound and secured with medical tape. Soiled incontinence pad removed then LN K placed linens in a plastic bag and covered R24 with blanket. Both LN J and LN K performed hand hygiene before exiting room. Interview with LN J on 03/05/30 at 12:28 PM revealed LN J stated R24 is incontinent of urine. LN J stated R24's incontinence was the reason for her skin issues. Her skin looked good when she had an indwelling catheter. Interview with LN J on 03/05/30 at 12:28 PM revealed LN J stated R24 is incontinent of urine. LN J stated R24's incontinence was the reason for her skin issues. Her skin looked good when she had an indwelling catheter. The facility policy Infection Preventionist, last revised December 2019, directed the facility to continually monitor employee infection control practices, ensuring aseptic technique is used when appropriate, and work to prevent infections common to the rehabilitation/skilled care location. The facility failed to ensure use of standard infection control practices when performing wound care for R24. This deficient practice had the potential for transmission and/or development of infections among the residents and staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 136 residents. The facility 300 hall had 59 residents. Based on observation, and interview the facility failed to ensure a safe environment free of accidents for 14 of the 59 residents who were cognitively impaired and independently mobile that resided on the 300 hall. Findings included: - An observation on 03/03/20 at 07:30 AM revealed a clear plastic container that contained new and unused lancets (a device the used a sharp needle to prick the skin to obtain a blood sample) and a glucometer (an instrument used to calculate blood glucose). The container was sitting on a bedside table unattended in the hallway near room [ROOM NUMBER]. An observation on 03/03/20 at 10:05 AM revealed the clear plastic container with new lancets and the glucometer was still sitting on a bedside table unattended in the hallway near room [ROOM NUMBER]. An observation on 03/04/20 at 08:36 AM revealed a clear plastic container that contained new and unused lancets and a glucometer sitting on top of a bedside table out in the main hallway of the 300 hall. Interview of Certified Medication Aide (CMA) R on 03/05/20 at 01:54 PM stated she kept the lancets and glucometer in a plastic container in the bottom drawer of the medication cart. She would not leave it on a table in the hallway unattended. Interview of Licensed Nurse (LN) L on 03/03/20 at 10:05 AM stated that the container of lancets on the bedside table in the hallway was there so the items would be available to use when needed. Interview of LN G on 03/0520 at stated that the lancets and glucometer should be kept in the bottom drawer of the medication cart when not being used. Interview of Administrative Nurse D on 03/05/20 at 02:56 PM stated that supplies used for obtaining blood sugars such as lancets and the glucometer should be stored in the medication cart when not being used. The facility failed to provide a policy for storage of lancets. The facility failed to ensure a safe environment that was free of possible accidents for 14 residents who resided on 300 hall, when the facility failed to store lancets appropriately. This deficient practice had the potential to cause harm to 14 cognitively impaired and independently mobile residents.

The facility identified a census of 136 residents. The sample included 29 residents. Based on record reviews, observations and interviews the facility failed to complete annual performance reviews for the Certified Nurse's Aides (CNAs). Findings included: - Review of the CNA Training Hours Report by Employee records from April 2019 through February 2020 lacked documentation for annual performance reviews for the CNAs. On 03/05/20 at 01:34 PM CNA N stated she had worked in facility about two years. She received competency skills demonstration testing when she was hired, but none since hire. She was told a while back she had to do a perineal care (washing the genitals and anal area) demonstration but, this was not completed. On 03/05/20 at 02:58 PM Administrative Nurse D stated competency skills demonstration testing was done on all new employees. The skills testing was only done when the facility noticed a problem during spot checks or when trends were noted and not on an annual basis. The facility's Competency Validation Process-Clinical Skills policy dated December 2019 documented competency validation of clinical skills was required and completed annually, at a minimum, and more often when training needs were identified. The facility failed to complete annual CNA performance reviews. This had the potential to ensure the residents were provided with competent care for the prevention of accidents and possible complications in their health.

The facility identified a census of 136 residents. The facility had one kitchen. Based on observations, interview, and record review, the facility failed to ensure safe and sanitary storage of food for residents related to opened and undated food items in the facility freezer. Findings included: - During initial tour of the facility's kitchen on 03/02/20 at 07:30 AM an observation of the main kitchen freezer revealed one opened and undated bag of tater tots, one bag of opened and undated pork patties, one bag of opened and undated french fries, and one opened and undated bag of peas and carrots. The pork patties and peas and carrots were open to the air. During an interview on 03/05//20 at 7:07 AM Dietary Staff (DS) BB stated staff performed spontaneous checks of the contents in the freezer at least two times per week. He stated packages were dated when opened by the staff member who received the delivery. He stated opened, unsealed, and undated packages of food were discarded. The facility's Food/Supply Storage Policy revised August 2019 included guidelines to ensure refrigerated and frozen food were properly stored, but it did not directly address the labeling and storage of opened foods. The facility failed to follow safe and sanitary storage of food, which had the potential of unpalatable and unsafe food for residents.