**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 98 residents. The sample included three residents reviewed for weight loss. Based on record review, observation, and interview, the facility failed to monitor the effectiveness of weight loss interventions after a significant weight loss for Resident (R)1. This deficient practice placed R1 at risk for further loss and malnutrition. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab documented diagnoses of need for assistance with personal care, difficulty in walking, dysphagia (swallowing difficulty), paralysis (the loss of muscle function, sensation, or both) of vocal cords and larynx, and iron deficiency. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required setup or clean-up assistance with meals but was independent with eating. R1 weighed 173 pounds upon admission. The Five day Scheduled MDS dated 07/26/24 documented a BIMS score of 15 which indicated intact cognition. R1 required supervision or touching assistance on one staff providing verbal cues and or touching/steadying assistance with eating. R1 weighed 160 pounds. The Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 06/20/24 documented R1 had weakness and required assistance with ADLs. Staff were directed to assist with R1's ADLs. R1 was able to feed himself. The Nutrition CAA dated 06/20/24 documented R1 had a therapeutic diet with no added salt. R1's Care Plan dated 07/22/24 documented R1 was able to feed himself after staff assistance setting his meal up. The plan documented R1 was offered the diet as prescribed to him and the registered dietitian (RD) would consult as needed. Staff were directed to monitor for changes in R1's intake pattern and report changes as needed. R1 was to be provided snacks and beverages during and in between meals. R1 was to be encouraged to weigh per facility protocols. Staff were directed to monitor for significant weight gain or loss and to notify the medical director. R1's Order Summary retrieved 08/28/24 recorded the following orders: Diet order for no added salt (NAS) diet, regular texture with thin consistency dated 07/30/24. Ensure Enlive (a liquid supplement designed to help rebuild strength and energy in patients recovering from illness, injury, and surgery) two times a day for a supplement dated 07/30/24 (discontinued on 08/01/24). Daily weights-notify provider for a gain of over three pounds in 24 hours or more than five pounds in seven days every dayshift dated 07/30/24. Review of R1's Tasks for snacks for the last 30 days documented snacks were given on 08/12/24, 08/16/24, 08/18/24, 08/19/24, 08/20/24, 08/25/24, and 08/26/24 with no other snack intakes documented during the last 30 days. Review of R1's Tasks for amount eaten for the last 30 days documented meals eaten for lunch and dinner on 08/12/24, breakfast and dinner on 08/16/24, dinner on 08/18/24, lunch on 08/19/24, lunch on 08/20/24, dinner on 08/22/24, lunch and dinner on 08/25/24, and lunch and dinner on 08/26/24 with no other meal intakes documented during the 30 days look back. R1's Nutrition Risk Assessment dated 06/18/24 documented R1 reported a weight loss of 25 pounds from recent surgery and a previous liquid diet. R1 spoke of wanting a chocolate Ensure for a snack with breakfast. R1 reported he disliked breakfast compared to other meals and felt hungry. R1 was educated on weight gain, eating meals, and drinking water throughout the day. R1's EMR was documented on 06/21/24 at 05:15 PM the Behavioral Note documented R1 stated he wanted to start drinking Ensure twice a day at 10:00 AM and 02:00 PM and R1 only wanted chocolate shakes. At 10:00 AM staff attempted to give R1 his requested Ensure to which R1 refused stating he did not order it. R1 failed to recall he had seen his physician and requested the Ensure drinks and did not want them anymore. R1's Nutrition Risk Assessment dated 07/26/24 documented R1 was at risk for malnutrition. R1 had supplemental Ensure Enlive twice a day at 10:00 AM and 02:00 PM. It was recommended R1 trial a Thrive (Gluten-free, protein-rich ice cream, packed with 24 vitamins and natural prebiotics) cup for weight maintenance. R1's August 2024 Medication Administration Record/Treatment Administration Record (MAR/TAR) documented R1 received Ensure Enlive twice daily but lacked a record of the intake amount of the supplement the resident consumed. A review of R1's Task: Snacks intake record for the last 30 days documented snacks were given on 08/12/24, 08/16/24, 08/18/24, 08/19/24, 08/20/24, 08/25/24, and 08/26/24 with no other snack intakes documented during the last 30 days. Review of R1's Task:Amount Eaten intake record for amount eaten for the last 30 days documented meals eaten for lunch and dinner on 08/12/24, breakfast and dinner on 08/16/24, dinner on 08/18/24, lunch on 08/19/24, lunch on 08/20/24, dinner on 08/22/24, lunch and dinner on 08/25/24, and lunch and dinner on 08/26/24 with no other meal intakes documented during the 30 days look back. On 08/28/24 at 12:48 PM R1 laid in his bed with his blankets up to his chest. R1 stated that lunch was ok, but the staff always took a long time to get him a beverage with his meal. R1 revealed that a lot of the time he had finished his meal before staff would bring him a beverage. On 08/29/24 at 12:56 PM, R1 lay in his bed visiting with his family. R1 reported that he had not received his lunch tray until after 12:30 and then when it had arrived it was a chicken burrito with beans. R1 stated he could not eat the chicken in the burrito or the beans due to both being too hard for him to chew. R1 revealed he was able to eat the burrito around the outside. R1 stated he was given a strawberry Ensure but he did not like it and could not consume it. R1 stated he had not seen the RD in quite a while. R1 went on to say that staff often left his tray of food on the bedside table when he was sleeping, and the staff did not attempt to alert him the food was there. R1 stated that staff often left the room without checking to see if he needed help cutting up his food or if he needed anything else. On 08/29/24 at 03:15 PM, Certified Nurse's Aide (CNA) M stated that that the CNA staff weighed residents, but she was unsure which residents were at risk for weight loss. CNA M stated staff charted the percentage eaten for the meals into the point of care charting system. On 08/29/24 at 03:24 PM Licensed Nurse (LN) G stated the MDS and plan of care informed the staff which residents needed assistance with eating and if the residents required assistance with meals, there was an assisted dining room set up where the staff assisted those residents. LN G stated that if a resident was triggering for weight loss, he would check with the physician to see if a resident needed a supplement or more assistance eating. The facility's Weight Change Investigation policy revised in May 2023 documented that weight change investigations would be initiated with the following: a significant weight change of 5% or more in one month. Once the weight change investigations were completed, the dietician and physician would be contacted for interventions. Interventions would be updated on the resident's chart if appropriate, and the resident or resident's representative would be notified of the interventions. The facility failed to consistently monitor the effectiveness of interventions, including intake amounts for meals, snacks, and nutritional supplements, after a significant weight loss for R1. This deficient practice placed R1 at risk for continued weight loss and malnutrition.

The facility identified a census of 98 residents which included ten residents reviewed for transfers to another room in the facility for the convenience of staff. Based on observations, interviews, and record review, the facility failed to inform Residents (R) 1, R2, R3, R4, R5, R6, R7, R8, and R9 in writing of the impending room change in order to create a hall to group skilled residents. This placed the residents at risk for impaired resident rights and decreased psychosocial well-being. Findings included: - R9's Electronic Medical Record (EMR) recorded a Family Communication Note dated 07/23/24 at 11:10 AM that documented R9 (Brief Interview for Mental Status [BIMS] score of 15 which indicated intact cognition), discussed moving rooms on 07/33/24. R9 was agreeable to a new room. On 08/01/24 at 12:30 PM R9's Notification of Room Change located under the Evaluations tab documented the reason for the room change was a transfer from post-acute to long-term care. Administrative Staff C spoke with R9 and R9's family member on 07/22/24 regarding the move. R3's EMR recorded a Family Communication Note dated 07/23/24 at 12:53 PM that documented R3 (BIMS score of three which indicated severely impaired cognition) was spoken to on 07/23/24 related to changing rooms. R3 stated she was 'OK' with changing rooms if R3's representative was ok with the change. On 08/01/24 at 12:08 PM R3's Notification of Room Change located under the Evaluations tab documented the reason for the room change was R3 being transferred to long-term care from the post-acute unit. Administrative Staff C placed calls to R3's family member on 07/19/24 and 07/22/24 and finally spoke with R3's family member on 07/23/24 regarding the move. R2's EMR recorded a Family Communication Note dated 07/23/24 at 02:15 PM that documented R2 (BIMS score of one which indicated severely impaired cognition) was visited on 07/19/24 regarding changing rooms. R2's representative was also spoken with related to R2's room move and was agreeable to the room picked for R2. On 08/01/24 at 12:16 PM, R2's Notification of Room Change located under the Evaluations tab documented the reason for the room change was to transfer from the post-acute care to long-term care. Administrative Staff C spoke with R2 and R2's representative on 07/19/24 regarding the move. R5's EMR recorded a Family Communication Note dated 07/24/24 at 05:53 PM that documented R5's (BIMS score of 15) family member was given a compassionate ear related to R5's change in rooms. On 08/01/24 at 12:25 PM R5's Notification of Room Change located under the Evaluations tab documented the reason for the room change was to transfer from post-acute to long-term care. Administrative Staff C spoke with R5 and R5's family member on 07/19/24 regarding the move. R6's EMR recorded an Other Note dated 07/25/24 at 10:46 AM that documented R6 (BIMS score of 15) would be taken to see the room R6 would move into by unidentified administrative staff. On 08/01/24 at 12:33 PM R6's Notification of Room Change located under the Evaluations tab documented the reason for the room change was to transfer to long-term care from post-acute care. Administrative Staff C spoke with R6 on 07/19/24 regarding the move. R1's EMR documented a Notification of Room Change dated 08/01/24 at 12:41 PM that documented the reason for the room change was to transfer to long-term care from post-acute care. Administrative Staff C spoke with R1 and R1's family representative on 07/05/24 regarding the move. R7's EMR recorded a Notification of Room Change dated 08/02/24 at 12:37 PM that documented the reason for the room change was to transfer from the post-acute. R4's EMR noted a Notification of Room Change dated 08/05/24 at 12:20 PM, that documented the reason for the room change was to transfer from the post-acute care unit to long-term care. Administrative Staff B spoke with R4's family on 08/05/24 regarding the move. R8's EMR recorded a Notification of Room Change dated 08/05/24 at 12:53 PM that documented the reason for the room change was to transfer from the post-acute care unit to long-term care. Administrative Staff B spoke with R8's family representative and R8 regarding the move. The list of residents provided by the facility via electronic mail on 08/21/24 documented that were recently moved from P hall documented staff spoke with R1 regarding changing rooms and R1's family representative, R2 and R2's family representative, R3 and R3's family representative, R4's family representatives, R5 and R5's family representative, R6, R7 and R7's family representative, R8's family representative, and R9 and R9's family representative to move to a different room. On 08/28/24 at 12:48 PM R1 (BIMS score of 15) lay in his bed with his blankets up to his chest. R1 stated that he knew he was moved for a reason but R1 he could not remember why. On 08/28/24 at 01:40 PM, R6 sat in her wheelchair in her room painting on an easel. R6 stated she was not asked but was told she was moving and the room she was in would be used for dialysis (a procedure where impurities or wastes were removed from the blood). R6 further stated she did not want to move because she would lose her shower. R6 revealed that she had not gotten anything in writing and only remembered hearing about it through word of mouth. R6 revealed she was disappointed with the room move. On 08/28/24 at 02:12 PM, R5 appeared well-groomed and clean. R5 sat in her wheelchair watching the television. R5 stated she was told she had to move that the new owners wanted the hallway she used to live on for acute care and that everyone on that hall had to move. R5 revealed she had not received a letter about the move and was not told she could stay if she did not want to move. R5 stated she cried and felt very unhappy about the move. R5 stated she had lived in the facility for over two and a half years, and it was quite upsetting. On 08/29/24 at 03:09 PM, R9 lay in bed with a clean blanket draped over him up to his chest with his arms and hands laid on top of the blanket. R9 stated that he had no option to stay in his old room. R9 revealed that the room move was heard through word of mouth and that neither he nor his family member had received written notice of the room change. R9 stated that if he would thought he could have stayed in his old room, he would have fought it and put up a stink. R9 stated he felt like a number or an object and wished he could have stayed in his old room. On 08/28/24 at 01:15 PM, R1's representative stated neither he nor R1 had received written notification about the room move. R1's representative stated they were not given an option to stay in the room R1 had been in. R1's representative stated that R1 and he chose that room due to it being smaller and that way he would not end up with a roommate. R1's representative stated that the residents and residents' family members were fearful that the bigger rooms with be doubled up with more than one resident in the room. On 08/28/24 at 01:35 PM, R2's representative stated that he had been told that R2 needed to move rooms. R2's representative stated the facility had taken good care of R2 and R2 was not up out of bed so R2's representative had no concerns with the room move. R2's representative verified he had not been informed of the move in writing. On 08/28/24 at 02:10 PM, R7's representative stated she was told that R7's old room was going to be used for therapy. R7's representative stated it took multiple family members making numerous statements to get R7 moved to a room where R7's wheelchair would fit through the bathroom door. On 08/28/24 at 02:21 PM, R3's representative stated that she was told that R3 had to move and that the incoming company wanted everyone moved off of the hall that R3 was on, and the new company wanted to use that hall for rehabilitation. R3's representative stated that she had not received anything in writing explaining the room move, nor was R3 staying in the old room even an option. R3's representative stated if R3 could have stayed in the old room, R3's representative would have wanted that. On 08/29/24 at 02:29 PM, R8's representative stated that the room move happened and there was no choice to be able to stay in R8's current room. R8's representative further revealed that she had received nothing in writing related to the room move. R8's representative stated that R8's room was chosen because it is small because the family was fearful that the bigger rooms in the building were going to be doubled up. On 08/29/24 at 03:15 PM, Certified Nurse Aide (CNA) M stated that the room moves happened so that the P hallway where the resident previously lived, could be made into a rehabilitation hall. On 08/29/24 at 03:24 PM License Nurse (LN) G stated that the room moves occurred so that residents that were being skilled were all in one location. The facility's Room Moves policy revised in April 2024, documented that when it is decided by the facility administrator or per resident request of a room move, guest services/social services or designee would call the family and inform the resident of the room move if time allows. If time does not allow (urgent isolation need or new admission entered building early) or the facility is unable to inform the resident/family of the room move for any number of reasons (resident is on appointment, outside facility, in dialysis, etc.) facility would inform resident/family at earliest possible availability. If a resident is alert and oriented times three, the facility can notify the resident only. If a resident is not alert and oriented times three, then the facility should notify the Power of Attorney (POA) or representative. The facility failed to inform R1, R2, R3, R4, R5, R6, R7, R8, and R9 in writing of the impending room change in order to create a hall to group skilled residents. This placed the residents at risk for impaired resident rights and decreased psychosocial well-being.

The facility identified a census of 83 residents. The sample included 18 residents with one reviewed for self-administration of medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)53 was safe to self-administer her medications. This deficient practice placed R53 at risk for unidentified medication complications and administration errors. Findings Included: -The Medical Diagnosis section within R53's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and obstructive uropathy (structural blockage within the urinary tract blocking urine flow). R53's Quarterly Minimum Data Set (MDS) completed 06/07/24 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she was dependent on staff assistance for toileting, bathing, transfers, bed mobility, dressing, and personal hygiene. The MDS indicated she had an indwelling urinary catheter (a tube inserted into the bladder to drain urine). R53's Urinary Catheter Care Area Assessment (CAA) completed 08/17/23 indicated she had a suprapubic urinary catheter (a catheter that enters the bladder through a surgically created hole in the abdomen) related to obstructive uropathy. The plan noted she required staff monitoring for the catheter ostomy site. The CAA instructed staff to provide catheter care and monitor her for urinary tract infections. R53's Functional Abilities CAA completed 08/17/23 revealed she required total staff assistance for bathing, dressing, grooming, personal hygiene, toileting, transfers, and bed mobility. R53's Care Plan initiated 06/04/24 indicated she required assistance with her daily activities of daily living (ADLs). The plan indicated she required staff assistance for toileting, bathing, transfers, bed mobility, and dressing. The plan indicated she had impaired memory, decision-making, and comprehension. The plan lacked documentation indicating she could self-administer her medication safely. R53's EMR under Physician's Orders lacked an order related to medication self-administration. On 07/17/24 at 11:30 AM, upon request, the facility provided a Medication Self-Administration Evaluation completed on 04/09/24. The evaluation noted R53 was deemed unable to safely self-administer her medications. On 07/15/24 at 08:01 AM, R53 sat upward in her bed. Her bed was elevated to the highest position. R53's bedside table was pulled over her lap. Her table contained a cup of water, and two small plastic pill cups filled with numerous medications. She stated she was taking her morning pills. Staff were not present in the room. On 07/17/24 at 10:20 AM Licensed Nurse (LN) J stated R53 should not be taking her medications unsupervised. She stated some residents prefer to eat their meals before taking the medications, but the medication should not left in the room unsupervised. On 07/17/24 at 12:20 PM Administrative Nurse D stated no residents in the facility were currently able to self-administer their own medications. She stated R53 needed supervision while taking her medications and staff were expected to remove the medication from the room upon leaving. The facility's Self-Administration of Medications policy revised 12/2017 indicated the facility will ensure each resident's safety related to the administration of medication. The policy indicated the facility will complete ongoing assessments of individuals identified as safe for self-administration. The policy indicated care planned interventions will be provided to identify the appropriate education and supervision for the administration. The facility failed to ensure R53 was safe to self-administer her medications. This deficient practice placed R53 at risk for unidentified medication complications and administration errors.

The facility identified a census of 83 residents with 18 residents included in the sample. Based on interview and record review the facility failed to issue Center for Medicare/Medicaid Services (CMS) Notification of Medicare Non-Coverage Form 10123 (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R)139. This failure placed the resident at risk for decreased autonomy and impaired decision-making. Findings included: - A review of R139's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 04/10/24 and ended on 04/27/24. R139 did not remain in the facility for custodial care. R139's clinical record lacked evidence of a NOMNC issued for this Medicare Part A episode. On 07/16/24 at 11:40 AM AM Administrative Staff A stated the facility was unable to find the NOMNC issued to R139. The facility did not provide a policy for beneficiary notification. The facility failed to ensure a NOMNC was provided at the end of skilled services for R139. This failure placed the residents at risk for decreased autonomy and impaired decision-making.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 83 residents. The sample included 18 residents with four residents sampled for transfer and discharge. Based on observations, record review, and interview the facility failed to provide a written notice of transfer as soon as practicable to Resident (R) 13 and R56 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R13 and R56. Findings included: - The electronic medical record (EMR) for R13 documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated 07/28/23 documented a Brief Interview for Mental Status (BIMS) score of five which indicated severely impaired cognition. R13 required extensive assistance from two staff for activities of daily living (ADLs). The Quarterly MDS dated 04/26/24 for R13 documented a BIMS score of eight that indicated moderately impaired cognition. R13 utilized a walker and a wheelchair for mobility. R13 required partial to moderate assistance with upper body dressing and substantial to maximal assistance with toileting, bathing, lower body dressing, and personal hygiene. The Discharge MDS dated 08/18/23 for R13 documented a discharge to an acute hospital with a return anticipated. An Entry MDS dated 08/23/23 for R13 documented a reentry from an acute hospital. The Discharge MDS dated 03/09/24 for R13 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated 03/12/24 documented a reentry to the facility from an acute hospital. The Discharge MDS dated 04/16/24 for R13 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated 04/19/24 for R13 documented a reentry to the facility from an acute hospital. The ADL Care Area Assessment dated 08/07/23 for R13 documented he was alert and oriented with episodes of confusion. R13 was able to communicate his needs. R13 needed assistance with ADLs. R13 was able to walk with a walker but would forget it at times. R13 had lower extremity weakness and was at risk for falls. R13's Care Plan dated 04/19/24 directed staff would support R13's plan to stay long term. Staff was directed to assist R13 with adjustments to the facility and routines. A Nursing Note dated 08/18/23 at 03:28 PM for R13 documented him having increased thirst and shortness of air. Staff called R13's physician who ordered the resident to be sent out to the hospital for evaluation. R13's Nurse's Progress Note dated 03/09/24 at 05:27 PM documented R13 was observed in the recliner shaking and trembling. R13 stated he was cold. R13 stated he was not hungry. R13 was noted to be responding to staff inappropriately to questions. Staff called R13's physician and notified him of R13's symptoms and received orders to send R13 to the hospital for evaluation. R13's family was called and notified of the transfer. R13's Nurse's Progress Note dated 04/16/24 at 05:32 PM documented R13 was noted to be shaking. The nurse obtained his vital signs with a noted oxygen saturation of 87 percent (%). At 05:00 PM R13 was noted to be vomiting. R13's physician was notified, and an order was received to send the resident out for evaluation at the hospital. R13's family was notified. R13's Nurse's Progress Note dated 04/16/24 at 07:09 PM documented R13 was admitted to the hospital for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). The facility was unable to provide, as requested, the required written notification of transfer or discharge for R13's facility-initiated discharge to the hospital on [DATE], 03/09/24, or 04/16/23. On 07/15/24 at 11:50 AM R13 propelled himself in his wheelchair to the dining area and visited with other residents in the area. On 07/16/24 at 01:41 PM, R13 rested in a recliner in the commons area with a blanket covering his body and head. On 07/16/24 at 03:22 PM Administrative Staff A stated that only nursing notes had documentation of the discharge. Administrative Staff A stated that the nurses were responsible for notifying the family when a resident was sent out the to hospital but could not state for fact if a written notification or transfer was sent to the resident's representative. On 07/17/24 at 12:27 PM Administrative Nurse D stated that the floor nurses were responsible for notifying the family representative when a resident was sent to the hospital. Administrative Nurse D stated to her knowledge a formal written notification of transfer was not sent to the representative and that the representative would only receive a phone call when a resident was sent out to the hospital. The facility did not have a policy regarding written notification of transfer and or discharge. The facility failed to provide written notice of transfer as soon as practicable to R13 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R13. - The electronic medical record (EMR) for R56 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), atrial fibrillation (a rapid, irregular heartbeat), and 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). The Significant Change Minimum Data Set (MDS) for R56 dated 05/23/24 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R56 had impairment on one side of his upper and lower extremities. R56 used a walker to assist with mobility. R56 required partial to moderate assistance from staff for functional abilities. R56 had a history of falls. The Discharge MDS dated 11/25/23 for R56 documented a discharge to an acute hospital with a return anticipated. The Discharge MDS dated 01/15/24 for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated 01/19/24 for R56 documented a reentry to the facility from an acute hospital. The Discharge MDS dated 02/18/24 for R56 documented a discharge to an acute hospital with a return anticipated. The Discharge MDS dated 04/06/24 for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated 04/09/24 for R56 documented a reentry to the facility from an acute hospital. The Discharge MDS dated 05/02/24 for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated 05/16/24 for R56 documented a reentry to the facility from an acute hospital. R56's Functional Abilities Care Area Assessment (CAA) dated 05/28/24 documented R56 sustained recent fractures to the face and leg and required assistance with activities of daily living (ADLS). R56 was able to feed himself with setup assistance. R56 was at risk for future falls. R56's Care Plan dated 05/16/24 directed staff that R56 planned to make the community a long-term home through the next review period. Staff was to support R56's plan to stay long-term. Staff was directed to assist R56 with referrals, as needed, to meet goals for discharge. R56's Nurse's Progress Note dated 11/25/23 at 11:03 AM documented the resident was assessed by the physician in the facility at that time due to tremors and delayed responses. R56's physician ordered R56 to be sent out to the hospital for evaluation. Staff called R56's daughter to notify her of the transfer. R56's Nurse's Progress Note dated 01/15/24 at 12:02 PM documented R56 complained of a headache and requested Imitrex (a medication used to treat migraines and cluster headaches). Staff notified R56's physician of his condition. R56 requested staff to call his daughter to notify her of his condition, and R56's daughter requested that R56 go to the hospital to be evaluated. R56's physician was notified, and the resident was transferred to the hospital. R56's Nurse's Progress Note dated 02/18/24 at 02:44 PM documented that staff noted R56 presented with some confusion and had put his shirt on inside out and on backward. Staff was called by R56's daughter and she requested that the nurse see R56 due to him being confused when she had called him. Staff checked on R56 again noting R56 with his arms and leg frequently jerking. R56 was unaware of the time. Staff called the on-call practitioner, and an order was received to send the resident to be evaluated at the hospital. R56's daughter was called and notified of the transfer. R56's 04/06/24 at 05:16 PM Nurse's Progress Note documented staff noted R56 to be confused and very disoriented. R56's family requested resident be sent out to the hospital. Staff called the on-call doctor, and an order was received to send the resident out to the hospital. R56's 05/02/24 at 06:04 PM Nurse's Progress Note documented R56's daughter had called the facility to notify staff that R56 was on the floor. Staff went to R56's and entered his room and found the resident on the floor in front of his dresser. R56 had noted blood coming from his nose and around his head. Staff immediately called 911. R56 stated he had turned his call light on for the staff to come get his dinner tray. R56 stated he got up from his recliner when the call light had not been answered and walked with the tray to a chair, then walked back to his recliner and attempted to turn around and fell. Emergency medical services (EMS)personnel arrived at the facility and assessed R56. R56 was transported out to the hospital. The facility was unable to provide as requested the required written notification of transfer/discharge for R56's discharges on 11/25/23, 01/15/24, 02/18/24, 04/06/24, and 05/02/24. On 07/16/24 at 08:45 AM R56 sat in the main lobby of the facility with his walker in front of him. R56 stated he was just waiting to go to his appointment this morning. On 07/16/24 at 03:22 PM Administrative Staff A stated that only nursing notes had documentation of the discharge. Administrative Staff A stated that the nurses were responsible for notifying the family when a resident was sent out to the hospital but could not state for fact if a written notification or transfer was sent to the resident's representative. On 07/17/24 at 12:27 PM Administrative Nurse D stated that the floor nurses were responsible for notifying the family representative when a resident was sent to the hospital. Administrative Nurse D stated to her knowledge a formal written notification of transfer was not sent to the representative and that the representative would only receive a phone call when a resident was sent out to the hospital. The facility did not have a policy regarding written notification of transfer and or discharge. The facility failed to provide written notice of transfer as soon as practicable to R56 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R56.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 83 residents. The sample included 18 residents with four residents sampled for transfer and discharge. Based on observations, record review, and interview the facility failed to provide a bed hold notice with the required information to Resident (R) 13 and R56 and/or to their family representative when transferred to the hospital. This deficient practice placed R13 and R56 at risk for impaired ability to return to the facility or his same room. Findings included: - The electronic medical record (EMR) for R13 documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated 07/28/23 documented a Brief Interview for Mental Status (BIMS) score of five which indicated severely impaired cognition. R13 required extensive assistance from two staff for activities of daily living (ADLs). The Quarterly MDS dated 04/26/24 for R13 documented a BIMS score of eight that indicated moderately impaired cognition. R13 utilized a walker and a wheelchair for mobility. R13 required partial to moderate assistance with upper body dressing and substantial to maximal assistance with toileting, bathing, lower body dressing, and personal hygiene. The Discharge MDS dated 08/18/23 for R13 documented a discharge to an acute hospital with a return anticipated. An Entry MDS dated 08/23/23 for R13 documented a reentry from an acute hospital. The Discharge MDS dated 03/09/24 for R13 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated 03/12/24 documented a reentry to the facility from an acute hospital. The Discharge MDS dated 04/16/24 for R13 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated 04/19/24 for R13 documented a reentry to the facility from an acute hospital. The ADL Care Area Assessment dated 08/07/23 for R13 documented he was alert and oriented with episodes of confusion. R13 was able to communicate his needs. R13 needed assistance with ADLs. R13 was able to walk with a walker but would forget it at times. R13 had lower extremity weakness and was at risk for falls. R13's Care Plan dated 04/19/24 directed staff would support R13's plan to stay long term. Staff was directed to assist R13 with adjustments to the facility and routines. A Nursing Note dated 08/18/23 at 03:28 PM for R13 documented him having increased thirst and shortness of air. Staff called R13's physician who ordered the resident to be sent out to the hospital for evaluation. R13's Nurse's Progress Note dated 03/09/24 at 05:27 PM documented R13 was observed in the recliner shaking and trembling. R13 stated he was cold. R13 stated he was not hungry. R13 was noted to be responding to staff inappropriately to questions. Staff called R13's physician and notified him of R13's symptoms and received orders to send R13 to the hospital for evaluation. R13's family was called and notified of the transfer. R13's Nurse's Progress Note dated 04/16/24 at 05:32 PM documented R13 was noted to be shaking. The nurse obtained his vital signs with a noted oxygen saturation of 87 percent (%). At 05:00 PM R13 was noted to be vomiting. R13's physician was notified, and an order was received to send the resident out for evaluation at the hospital. R13's family was notified. R13's Nurse's Progress Note dated 04/16/24 at 07:09 PM documented R13 was admitted to the hospital for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). The facility was unable to provide, as requested, evidence a bed hold notice was provided to R13 when he was discharged to the hospital on [DATE], 03/09/24, or 04/16/23. On 07/15/24 at 11:50 AM R13 propelled himself in his wheelchair to the dining area and visited with other residents in the area. On 07/16/24 at 01:41 PM, R13 rested in a recliner in the commons area with a blanket covering his body and head. On 07/16/24 at 03:22 PM Administrative Staff A stated that the social worker had been typically responsible for providing the bed hold to the resident and the representative. Administrative Staff A stated that the facility had not had a social worker for nearly a month, but he had not been able to find any record of bed holds for R13's hospitalizations. The facility policy Bed- Holds and Returns last revised in December 2017 documented at the time of transfer for hospitalization, the nursing facility must provide to the residents and or resident representatives a written notice which specifies the duration for the bed hold. Residents may return to and resume residence in the community after hospitalization. Prior to a transfer, written information would be given to the residents and the resident's representative that explained in detail the duration of the bed hold. The reserve bed payment policy as indicated by the state plan and the details of the transfer (per the Notice of Transfer). The facility failed to provide a bed hold notice to R13 and his representative when transferred to the hospital. This deficient practice placed R13 at risk for impaired ability to return to the facility or his same room. - The electronic medical record (EMR) for R56 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), atrial fibrillation (a rapid, irregular heartbeat), and 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). The Significant Change Minimum Data Set (MDS) for R56 dated 05/23/24 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R56 had impairment on one side of his upper and lower extremities. R56 used a walker to assist with mobility. R56 required partial to moderate assistance from staff for functional abilities. R56 had a history of falls. The Discharge MDS dated 11/25/23 for R56 documented a discharge to an acute hospital with a return anticipated. The Discharge MDS dated 01/15/24 for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated 01/19/24 for R56 documented a reentry to the facility from an acute hospital. The Discharge MDS dated 02/18/24 for R56 documented a discharge to an acute hospital with a return anticipated. The Discharge MDS dated 04/06/24 for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated 04/09/24 for R56 documented a reentry to the facility from an acute hospital. The Discharge MDS dated 05/02/24 for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated 05/16/24 for R56 documented a reentry to the facility from an acute hospital. R56's Functional Abilities Care Area Assessment (CAA) dated 05/28/24 documented R56 sustained recent fractures to the face and leg and required assistance with activities of daily living (ADLS). R56 was able to feed himself with setup assistance. R56 was at risk for future falls. R56's Care Plan dated 05/16/24 directed staff that R56 planned to make the community a long-term home through the next review period. Staff was to support R56's plan to stay long-term. Staff was directed to assist R56 with referrals, as needed, to meet goals for discharge. R56's Nurse's Progress Note dated 11/25/23 at 11:03 AM documented the resident was assessed by the physician in the facility at that time due to tremors and delayed responses. R56's physician ordered R56 to be sent out to the hospital for evaluation. Staff called R56's daughter to notify her of the transfer. R56's Nurse's Progress Note dated 01/15/24 at 12:02 PM documented R56 complained of a headache and requested Imitrex (a medication used to treat migraines and cluster headaches). Staff notified R56's physician of his condition. R56 requested staff to call his daughter to notify her of his condition, and R56's daughter requested that R56 go to the hospital to be evaluated. R56's physician was notified, and the resident was transferred to the hospital. R56's Nurse's Progress Note dated 02/18/24 at 02:44 PM documented that staff noted R56 presented with some confusion and had put his shirt on inside out and on backward. Staff was called by R56's daughter and she requested that the nurse see R56 due to him being confused when she had called him. Staff checked on R56 again noting R56 with his arms and leg frequently jerking. R56 was unaware of the time. Staff called the on-call practitioner, and an order was received to send the resident to be evaluated at the hospital. R56's daughter was called and notified of the transfer. R56's 04/06/24 at 05:16 PM Nurse's Progress Note documented staff noted R56 to be confused and very disoriented. R56's family requested resident be sent out to the hospital. Staff called the on-call doctor, and an order was received to send the resident out to the hospital. R56's 05/02/24 at 06:04 PM Nurse's Progress Note documented R56's daughter had called the facility to notify staff that R56 was on the floor. Staff entered R56's room and found the resident on the floor in front of his dresser. R56 had noted blood coming from his nose and around his head. Staff immediately called 911. R56 stated he had turned his call light on for the staff to come get his dinner tray. R56 stated he got up from his recliner when the call light had not been answered and walked with the tray to a chair, then walked back to his recliner and attempted to turn around and fell. Emergency medical services (EMS)personnel arrived at the facility and assessed R56. R56 was transported out to the hospital. The facility was unable to provide, as requested, evidence a bed hold notice was provided to R56 when he was discharged to the hospital on [DATE], 01/15/24, 02/18/24, 04/06/24, and 05/02/24. On 07/16/24 at 08:45 AM R56 sat in the main lobby of the facility with his walker in front of him. R56 stated he was just waiting to go to his appointment this morning. On 07/16/24 at 03:22 PM Administrative Staff A stated that the social worker had been typically responsible for providing the bed hold to the resident and the representative. Administrative Staff A stated that the facility had not had a social worker for nearly a month, but he had not been able to find any record of bed holds for R5613's hospitalizations. The facility policy Bed- Holds and Returns last revised in December 2017 documented at the time of transfer for hospitalization, the nursing facility must provide to the residents and or resident representatives a written notice which specifies the duration for the bed hold. Residents may return to and resume residence in the community after hospitalization. Prior to a transfer, written information would be given to the residents and the resident's representative that explained in detail the duration of the bed hold. The reserve bed payment policy as indicated by the state plan and the details of the transfer (per the Notice of Transfer). The facility failed to provide a bed hold notice to R56 and his representative when transferred to the hospital. This deficient practice placed R56 at risk for impaired ability to return to the facility or his same room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body) with 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), hypertension (HTN-elevated blood pressure, and obesity. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented R11 had an impairment of the extremities on one side. The MDS documented R11 needed set-up and clean-up assistance with eating. R11's ADL Functional/Rehabilitation potential Care Area Assessment (CAA) dated 11/29/23 documented that R11 had a history of right-sided hemiparesis. R11 required extensive to total staff assistance with dressing, bathing, grooming, personal hygiene, and oral care. The MDS documented R11 could feed himself most of the time after the meal was set up. R11's Care Plan date 05/01/24 documented that nursing staff was to assist R11 with meals, placing utensils and cups to the left side for easier reach. R11's plan of care documented nursing staff were to assist R11 with eating if he needed help. On 07/16/24 at 08:34 AM R11 sat in a reclined wheelchair. R11 was eating breakfast that consisted of hot cereal and mandarin oranges. During the observation, R11's spoon was on the floor so R11 was eating his mandarin oranges and hot cereal with his fingers. The nursing staff did not check on R11, who ate in his room by himself. On 07/16/24 at 11:05 PM, Certified Nurse's Aide (CNA) N stated all the nursing staff could check on R11. CNA N stated she would change R11's shirt and ensure he had enough to eat. On 07/16/24 at 12:06 PM Licensed Nurse (LN) H stated nursing should check on R11 more often while he was eating and help him if needed. On 07/17/24 at 12:29 PM, Administrative Nurse D stated staff should check on the residents who eat in their rooms and help if they need assistance. The facility's Assistance with Meals policy revised 11/2019 documented it was the facility's policy that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. The facility failed to ensure R11 received supportive care and services to promote and maintain his quality of life and highest practicable ADL ability when the facility did not ensure R11 had assistance and monitoring while eating. This deficient practice placed the resident at risk for decreased abilities and independence. The facility identified a census of 83 residents. The sample included 18 residents with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide assistance for Resident (R)10 and R11 during mealtimes to promote and maintain their highest practicable abilities. This deficient practice placed both residents at risk for impaired nutrition and a decline in their ADLs. Findings Included: - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), left-sided hemiparesis (weakness and paralysis on one side of the body), and insomnia (difficulty sleeping). R10's Quarterly Minimum Data Set (MDS) completed 06/05/24 noted a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment. The MDS indicated she had one-sided impairment of her upper and lower extremities. The MDS indicated she required substantial to maximal assistance for transfers, bed mobility, dressing, toileting, bathing, and personal hygiene. The MDS indicated she required set-up and clean-up assistance for meals. R10's Functional Abilities Care Area Assessment completed 09/29/23 indicated she was at risk for a decline in her ADLs related to her medical diagnoses. The CAA indicated she required extensive assistance with dressing, bathing, toileting, bed mobility, transfers, and grooming. The CAA noted she required set-up assistance for meals. The CAA noted she used a wheelchair for mobility. The CAA noted she used her right arm and right leg to propel herself. R10's Care Plan initiated on 12/27/23 indicated she had impaired memory, decision, and comprehension related to her dementia diagnosis. The plan indicated she required assistance with her ADLs related to her left-sided hemiparesis. The plan indicated she couldn't walk and used her wheelchair for ambulation. The plan indicated she couldn't use her left arm due to weakness and staff were to place all needed items, food utensils, drinks, and food towards her right side for easier reach so she could feed herself. The plan instructed staff to provide finger foods and cut her food up before serving. On 07/15/24 at 12:01 PM, R10 sat in the E Hall dining room. R10 sat in her wheelchair with her left arm draped across her chest. Two other residents at the table were served their meals but R10 had no food or drink. R10's food and drink were served to her 20 minutes after her peers' meals. R10's peers left the dining room, and she was left alone at the table. R10 sat at the table for 20 minutes alone with no staff or peer interaction. Staff failed to engage and provide interaction throughout R10's meal. R10's drink was not touched during her meal. The staff did not cue her to drink during her meal. On 07/16/24 at 12:05 PM R10 arrived in the dining room and awaited her lunch. At 12:20 PM R10 was served a whole hamburger on a bun and fries. R10 stared at her burger and fries but did not eat it. At 12:44 PM Dietary Staff CC entered the dining hall and asked R10 why she was not eating her meal. Dietary Staff CC then cut up R10's burger for her and she began to eat her meal. R10's water was placed on the left side of her table. R10 attempted several times to reach her water with her right arm but could not. R10 repositioned her wheelchair and stretched outward to finally get her water. On 07/17/24 at 10:20 AM Certified Nurse's Aide (CNA) O stated she felt a lot of the residents had to wait longer for assistance with ADLs because some of the residents with higher acuity (requiring more assistance for care) often took priority. She stated that R10 did require more prompting and cueing due to her dementia. She stated that R10 had left-sided weakness and required items to be placed on her right side. On 07/17/24 at 10:35 AM Licensed Nurse (LN) J stated the resident should be served at the same time but some of the meals were required to come out later depending on what the residents ordered. She stated staff should remain in the dining room to assist the residents with eating. She stated staff should engage with the residents and ensure their needs were met during meal service. On 07/17/24 at 12:32 AM Administrative Nurse D stated staff were expected to provide assistance to all the residents who need it during meal service. She stated the residents should not be left in the dining room to eat alone. She stated all staff had access to the care plan and should know what level of assistance was needed. She stated R10's meal and drinks should be placed toward her right side due to her left-sided weakness. The facility's Assistance with Meals policy revised 11/2019 indicated all residents were encouraged to eat in the dining room for socialization. The policy indicated residents that who required assistance with meals should be provided help as needed. The policy indicated staff will maintain supervision of the residents, engage in cueing, and provide guidance during meals. The facility failed to provide ADL assistance for eating for R10 during mealtime to promote R10s highest practicable ability and independence. This deficient practice placed R10 at risk for impaired nutrition and a decline in ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 83 residents. The sample included 18 residents with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 11 and R80's bilateral lower extremities to prevent pressure ulcers. This placed R11 and R80 at increased risk for pressure ulcer development. Findings Included: -R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body) with 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), hypertension (HTN-elevated blood pressure, obesity, and lymphedema (swelling caused by accumulation of lymph) The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented R11 had an impairment to one side. The MDS documented R11 had a Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) or greater pressure area or scar over a bony prominence or non-removable dressing or device. The MDS documented R11 was at risk for pressure ulcers. The MDS documented R11 needed substantial to maximal assistance to roll from right to left. R11's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 11/29/23 documented R11 required staff to assist with turning and repositioning every two hours while in his bed and wheelchair. R11 had a pressure-reducing mattress and a pressure-reducing wheelchair cushion. R11 had no skin breakdown noted. The CAA documented R11 had lymphedema in his bilateral extremities. R11's Care Plan dated 05/01/24 documented that staff was to keep pressure off his left elbow and bilateral heels as much as possible. Staff were to monitor for any signs of pressure injury, and report to the physician. R11's plan of care documented that staff were to observe R11's skin for redness; staff were to use pillows to float R11's heels while he was in bed. The Braden Scale (a scale for predicting pressure sore risk) dated 01/29/24 documented a score of thirteen which indicated a moderate risk for pressure wounds. On 07/16/24 at 07:34 AM R11 lay on his bed on his back. R11's heels were directly on the mattress. R11 did not have a pillow to float his heels. On 07/17/24 at 07:01 AM R11 laid on his bed on his back. R11's heels were directly on his mattress. R11 did not have a pillow to float his heels. On 07/16/24 at 07:55 AM Certified Nursing Aide (CNA) N stated she had noticed R11's heels were not floated She stated she was going to give him a bed bath and get him up for breakfast. CNA N stated she was aware his heels were to be placed on a pillow; she was able to see each resident's information on R11's plan of care. On 07/16/24 at 08:33 Licensed Nurse (LN) H stated she was aware R11's heel should be floated, but she was not assigned to that hall. LN H stated all nursing staff have access to the care plan and can see what is needed for each resident. On 07/17/24 at 12:29 PM Administrative Nurse D stated nursing should follow the care plan, Medication Administration Record (MAR), and the Treatment Administration Record (TAR). She stated if heels should be floated nursing was responsible for ensuring the task was done. The facility's Prevention of Pressure Injuries Protocol revised on 01/2018 documented that pressure injury was usually formed when a resident remains in the same position for an extended period causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. The facility failed to ensure that pressure-reducing measures were placed on R11 to prevent pressure ulcers. This placed R11 at increased risk for pressure ulcer development. - R80's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body) with cerebrovascular accident (CVA-stroke- the 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), hypertension (HTN-elevated blood pressure, dysphagia (swallowing difficulty), weakness, depression (a mood disorder that causes a persistent depression feeling of sadness and loss of interest), and renal failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes) The Quarterly Minimum Data Set (MDS) dated 06//19/24 R80 documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented R80 was at risk for developing pressure ulcers. The MDS documented R80 was dependent on staff for all activities of daily living (ADLs). The MDS documented R80 has a pressure-reducing chair and bed. R80's Care Plan dated 07/10/24 documented R80 was at risk for pressure ulcers and other related injuries. R80's plan of care documented staff was to help her keep her heels off the mattress using pillows as R80 would allow. R80's plan of care documented staff to apply heel protectors as ordered. R80's Braden Scale for Prediction Pressure Sore Risk dated 07/10/24 was not complete. R80's EMR under the Orders tab dated 11/12/23 revealed the following physician orders: nursing was to apply Tubi-grips (elasticated tubular bandage designed to provide tissue support in treating strains, sprains, soft tissue injuries, general edema, and tissue protection) to her right lower extremity for swelling. R80's EMR under the Orders tab dated 02/24/24 revealed the following physician's order: Boot to the right lower extremity for heel protector. On 07/15/24 at 011:44 AM R80 sat in her recliner, R80's flat call light, and her arm splint laid on her bed out of reach. R80's boot was not applied to R80's right lower extremity. R80's boot laid on the floor by R80's bed. On 07/16/24 at 07:01 AM R80 laid in her bed on her back. R80's heels lay directly on her mattress. R80's heels were not floating, and there were no pillows under her feet. R80's EMR under nursing Treatments documented no refusals. On 07/17/24 at 010:50 AM Certified Nurse's Aide (CNA) M stated she was unsure if R80 needed Tubi-grips and a boot or brace. She stated she would assume the resident needed the boot since it was lying on the floor. CNA M stated she was not able to see the plan of care, she did not have a login for the computer system. On 07/17/24 at 10:55 Licensed Nurse (LN) I stated if there was an order for boots and Tubi-grips they should be applied as ordered. LN I stated, nursing was responsible for the Tubi-grips and the boots for R80. On 07/17/24 at 12:09 PM, Administrative Nurse D stated if the care plan or Medication Administration Record or the Treatment Administration Record directed to apply boots or Tubi-grips, the devices should be applied. The facility's Prevention of Pressure Injuries Protocol revised on 01/2018 documented that pressure injury was usually formed when a resident remains in the same position for an extended period causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. The facility failed to ensure pressure-reducing measures were placed on R80 to prevent pressure ulcers. This placed R80 at increased risk for pressure ulcer development.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 83 residents. The sample included 18 residents with two residents reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and urinary tract infection (UTI-an infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for Resident (R) 11 with an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) when the facility failed to prevent the drainage bag tubing from resting on the floor and failed to practice good hand hygiene during catheter care. These deficient practices placed R11 at risk for catheter-related complications. Findings included: - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body) with 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), hypertension (HTN-elevated blood pressure, and obesity. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented R11 had an impairment of the extremities on one side. The MDS documented R11 was dependent on staff for all toileting hygiene. R11's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 11/29/23 documented R11 had bilateral nephrostomy (a passage maintained by a tube or splint) with a diagnosis of kidney stones and obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). R11 was being treated for UTI with intravenous (IV-administered directly into the vein) antibiotics. The CAA documented that staff would help with emptying urine from nephrostomy collection bags. R11 was encouraged to drink fluids. R11's Care Plan date 05/01/24 documented that R11 had an indwelling Foley catheter and a history of UTIs. R11 had a healing surgical wound where his nephrostomy tubes were removed. R11's plan of care documented nursing staff was to empty urine from the drainage bag every shift and as needed (PRN). R11's plan of care documented nursing staff was to keep the drainage bag below the level of his bladder and off the floor. Staff were to secure tubing to R11's leg using a catheter strap. R11's EMR under the Orders tab revealed the following physician's order: Cranberry extract 200 milligrams (mg) capsule, give one capsule by mouth every day for UTI prophylactic dated 05/02/24. R11's EMR under the Orders tab revealed the following physician's order for catheter care: empty the Foley bag every shift, record output, and report any urine abnormalities dated 05/02/24. R11's EMR under the Orders tab revealed the following physician's order: 16 French Foley catheter for obstructive uropathy, dated 05/09/24. R11's EMR under the Orders tab revealed the following physician's order: Flush the catheter with 60 milliliters (ml) of normal saline everyday shift to prevent catheter complications dated 06/18/24. R11's EMR under the Orders tab revealed the following physician's order: Omnicef (antibiotic) give 300 mg cap twice daily, morning and evening for seven days for UTI dated 07/11/24. On 07/16/24 at 08:34 AM R11 sat in a reclined wheelchair. R11 was eating breakfast that consisted of hot cereal and mandarin oranges. R11's catheter tubing laid on the floor under his wheelchair. 0n 07/17/24 at 08:15AM R11 laid in his bed. CNA M donned gloves, preparing to get R11 up in his wheelchair for breakfast. CNA M placed R11's catheter bag and tubing on his bed. CNA M did not don her personal protective equipment (PPE) or perform any hand hygiene. R11 was on enhanced barrier precautions (EBP). CNA M rolled R11 to the wall, she removed his brief, R11's brief had bowel movement in it. CNA M wiped cleaned R11's backside with wipes, CNA M used a wet soapy washcloth to finish cleaning R11, and dried R11's backside with a towel. CNA M doffed her gloves, did not perform hand hygiene, and doffed her gloves. CNA M washed R11's front peri area with a wipe and used the same towel to try R11's front peri/catheter area. CNA rolled R11 from side-to-side securing clothing and Hoyer (total body mechanical lift) sling. Administrative Nurse E came to R11's room to help with the transfer of Hoyer. Administrative Nurse E and CNA M donned gloves but Administrative Nurse E and CNA M did not perform hand hygiene or don gowns for EHB precautions. Administrative Nurse E held R11's catheter bag, and CNA M transferred R 11. CNA M pushed Hoyer to the hallway and walked away. On 07/16/24 at 11:05 PM, Certified Nurse's Aide (CNA) N stated there should be no part of the catheter tubing touching the floor. CNA stated she was able to search each person's plan of care when she logged into her computer to document. On 07/16/24 at 12:06 PM, Licensed Nurse (LN) G stated R11's catheter tubing should never touch the floor; it could add to complications of UTI. On 07/17/24 at 12:29 PM, Administrative Nurse D stated staff should ensure catheter tubing was off the floor; staff should practice good hand hygiene during catheter and peri-care. The facility's Catheter Care, Urinary policy revised 12/2017 documented that staff should use standard precautions when handling or manipulating the drainage system. The facility failed to provide appropriate treatment for R11 with an indwelling catheter when the facility failed to prevent the drainage bag tubing from resting on the floor and failed to practice good hand hygiene during catheter care. These deficient practices placed these residents at risk for catheter-related complications and further UTIs.

The facility identified a census of 83 residents. The sample included 18 residents with one resident reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care services. Based on observation, record review, and interviews, the facility failed to provide Resident (R)73 with dementia-related care and practices during her mealtimes. This deficient practice placed the R73 at risk for impaired quality of life. Findings Included: - The Medical Diagnosis section within R73's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), hypertension (high blood pressure), and dementia. R73's Annual Minimum Data Set (MDS) completed 05/08/24 noted a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The MDS indicated she was dependent on staff assistance for toileting, bathing, transfers, bed mobility, dressing, and personal hygiene. The MDS indicated she required staff assistance with meal set-up and clean-up. R73's Dementia Care Area Assessment (CAA) completed 05/16/24 indicated she had memory impairment related to her cognitive loss. The CAA noted she had difficulty hearing but could make her needs known. R73's Care Plan initiated on 06/04/24 indicated she had impaired memory, decision-making, and comprehension related to her dementia diagnoses. The plan indicated she required a Hoyer lift (full-body mechanical lift) and two staff for transfers. The plan noted she required staff assistance with bed mobility, toileting, dressing, and personal hygiene. The plan indicated she needed encouragement and cues to participate in groups and activities. The plan indicated she preferred to wake up at 07:00 AM and would need to be invited to group activities. The plan instructed staff to seat her near other residents to allow her to visit. The plan indicated she had depression. The plan noted R73 required set-up assistance and cueing from staff during meals. On 07/15/24 at 07:10 AM R73 was brought to the E Hall dining and positioned next to the rear table facing the unused kitchenette. R73 was alone in the dining room with no provided music or entertainment. R73 was not offered or provided a drink while she sat in the dining room. R73 repeatedly yelled out All right and okay but no staff or residents were in the area to engage with her. On 07/16/24 at 07:05 AM R73 was brought out to the E Hall dining room and positioned facing the unused kitchenette. R73 was alone in the dining room with no provided music or entertainment. R73 was not offered or provided a drink while she sat in the dining room alone. R73 repeatedly yelled out All right and okay but no staff or residents were in the area to engage with her. At 07:50 AM R44 (a severely cognitively impaired resident) was brought into the dining hall and positioned directly across from R73. Neither resident was offered food or drink as staff again left the dining room with both residents alone. On 07/16/24 at 12:03 AM R73 was wheeled into the dining room E Hall dining room and positioned at the rear table facing the unused kitchenette. R73 was not offered food or drink. R73 repeatedly yelled out All right and Okay but the staff did not talk to her. R73 sat in the dining room while other resident ate their meals. At 12:41 PM Certified Nurse's Aide (CNA) O entered the dining hall and placed R73 and R44's meal trays on the table. CNA O completed hand hygiene and sat down at the table. CNA O flipped the dome covers off both meal trays and prepped R44's meal for her to eat without talking to her. CNA O put a spoonful of R44's food and held it up to her mouth but did not ask her if she wanted a bite. CNA O continued to provide assisted bites without talking or explaining to R73 what she was doing or if she wanted a bite. At 12:50 PM CNA stopped feeding R44 and engaged in a personal conversation with Dietary Staff CC at the assisted table. Upon completion of R73's meal, CNA O briskly wheeled R73 to her room without talking to her. On 07/17/24 at 10:05 AM Certified Nurse's Aide (CNA) O stated the resident should be offered drinks and entertainment while waiting for their meals. She stated staff were expected to talk to the residents while assisting them. She stated the facility held annual in-services for dementia care. She stated residents should not be left unsupervised or alone. She stated the higher acuity residents sometimes take more time than others and often have staff running back and forth. On 07/17/24 at 12:20 PM Administrative Nurse D stated staff were expected to offer drinks, music, television, games, puzzles, and other activities to the residents. She stated the residents should never be left alone or with no one to socialize with. She stated staff should never discuss personal issues or hold conversations in front of the residents. She stated staff focus should be on the residents and what their care needs were. She stated the facility had annual training for dementia care exercises to familiarize staff with how to talk to residents with dementia. The facility's Memory Support' policy revised 05/2025 indicated staff will continue to provide supervision and supportive care to individuals with cognitive impairment. The policy indicated individualized interventions will be implemented and adjusted to address changes in each resident's condition. The facility failed to provide R73 with dementia-related care and practices during her mealtimes. This deficient practice placed the R73 at risk for unmet care needs to maintain their highest practicable level of functioning.

The facility identified a census of 83 residents. The sample included 18 residents with four residents sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure that Resident (R)11, R43, and R80 had call lights to call for assistance. The facility further failed to provide footrests for R72's wheelchair. This deficient practice left these residents at risk for impaired care due to unmet care needs. Findings included: - On 07/15/24 at 09:33 AM, R80's call light lay in the middle of her bed. R80 sat in her recliner and the call light was out of her reach. On 07/15/24 at 09:45 AM R43's call light was wrapped around her bed rail, R43 was in her Broda chair (specialized wheelchair with the ability to tilt and recline). R43's call light was out of her reach. On 07/16/24 at 12:09 PM, R11's call light was wrapped around his bed rail. R11 was in his wheelchair eating lunch. R11's call light was out of his reach. On 07/15/24 at 11:48 AM R72 was pushed to the dining room without foot pedals, R72 was pushed fast and her heels hit the floor and bounced back up before staff parked her wheelchair at the dining room table. On 07/16/24 at 11:05 PM, Certified Nurse's Aide (CNA) N stated pedals should be placed on wheelchairs if staff is going to propel the chairs. CNA N stated all call lights should be either on the resident or within the resident's reach. On 07/17/24 at 11:15 PM, Licensed Nurse (LN) I stated all residents should have their pedals on their wheelchairs if staff were pushing them. LN I stated all staff were responsible for call lights being placed where the residents can reach them. On 07/10/24 at 12:29 PM in an interview, Administrative Nurse D stated staff should never push residents without pedals, and call lights should always be within the residents' reach. The facility's Accommodation of Needs policy revised on 12/2017 documented the community's environment and staff behaviors are directed toward assisting the resident in maintaining and or achieving independent functioning, dignity, and well-being. The facility failed to ensure R11, R43, and R80 had call lights for use and failed to provide footrests for R72's wheelchair. This deficient practice placed the residents at risk for impaired care due to unmet care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body) with 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), hypertension (HTN-elevated blood pressure, and obesity. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented R11had an impairment to one side. The MDS indicated R11 had therapy during the observation period. R11's Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 11/29/23 documented R11 had right-sided hemiparesis. R11 required extensive to total staff assistance with dressing, bathing, grooming, personal hygiene, and oral care. R11's Care Plan dated 05/01/24 documented staff to keep R11's fingernails trimmed and the palm of his right hand clean. The plan of care documented staff was to apply a rolled washcloth in R11's right hand as needed. R11's plan of care dated 06/06/24 documented that staff was to apply the right resting hand splint in the morning for approximately eight hours, staff may remove the splint for showers and hand hygiene, then reapply at nighttime. On 07/16/24 at 08:34 AM R11 was sitting up in a reclined wheelchair. R11 was eating breakfast with his left hand, which consisted of hot cereal and mandarin oranges. R11 did not have a splint on his right hand or a rolled washcloth in his right hand. On 07/17/24 at 08:22 AM R11 sat in his reclined wheelchair watching TV. R11 did not have a rolled washcloth in his right hand, or a splint on his right hand. On 07/17/24 at 11:05 AM, Certified Nurse's Aide (CNA) M stated she was not able to see what the plan of care for R11 was and said she was trained by a staff CNA. CNA M stated she was an agency and had been logged out of the facility's system. CNA M stated she had not taken the time to get a new login. CNA M stated she would put the rolled washcloth in R11's right hand. On 07/17/24 at 11:36 AM Licensed Nurse (LN) I stated she was able to see the plan of care for all residents. LN I stated all splints should be applied. On 07/17/24 at 12:29 PM, Administrative Nurse D stated the splints or devise should be on the Medication Administration Record (MAR), or the Treatment Administration Record (TAR), and nursing staff were responsible for ensuring they were applied as ordered or care planned. The facility's Restorative Nursing-Range of Motion Program policy revised 12/17 documented the residents who have or were at risk of having difficulty with ROM were assessed by nursing or therapy for a restorative nursing range of motion program to promote independence and quality of life by improving or maintaining functional ROM. The facility failed to ensure R11's right hand splint or a rolled washcloth was placed in R11's right hand, to prevent his contractures from worsening. This deficient practice left R11 at risk for further decline and decreased range of motion ROM or mobility. The facility identified a census of 83 residents. The sample included 18 residents with five reviewed for range of motion (ROM) and positioning. Based on observation, record review, and interviews, the facility failed to ensure Residents(R)73 and R44's care planned arm bolsters (specialized devices used for positioning and support) were utilized on their Broda chairs (specialized wheelchair with the ability to tilt and recline). The facility additionally failed to ensure R75 and R11's hand splints were implemented as ordered. This deficient practice placed the residents at risk for a decline in ROM and contractures (abnormal permanent fixation of a joint). Findings Included: -The Medical Diagnosis section within R73's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), hypertension (high blood pressure), and dementia (a progressive mental disorder characterized by failing memory, confusion). A review of R73's Annual Minimum Data Set (MDS) completed 05/08/24 noted a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The MDS indicated she was dependent on staff assistance for toileting, bathing, transfers, bed mobility, dressing, and personal hygiene. The MDS indicated she required staff assistance with meal set-up and clean up. R73's Dementia Care Area Assessment (CAA) completed 05/16/24 indicated she had memory impairment related to her cognitive loss. The CAA noted she had difficulty hearing but could make her needs known. R73's Pressure Injury CAA completed 05/16/24 indicated she was at risk for skin breakdown. The CAA noted she required turning and repositioning every two hours. The CAA noted she used a pressure reduction mattress and wheelchair seat cushion. R73's Care Plan initiated on 06/04/24 indicated she had impaired memory, decision-making, and comprehension related to her dementia diagnoses. The plan indicated she required a Hoyer lift (full-body mechanical lift) and two staff for transfers. The plan noted she required staff assistance with bed mobility, toileting, dressing, and personal hygiene. The plan indicated she used a Broda chair for comfort and positioning. The plan indicated her Broda chair had arm bolsters for positioning. The plan indicated R73 had fragile skin and bruised easily. R73's EMR under Physician's Order revealed no orders related to her arm bolsters. R73's EMR under physical or occupational therapy notes lacked documentation related to her arm bolsters. On 07/15/24 at 07:13 AM R73 was wheeled into the E Hall dining room. R73 was positioned at the rear table facing the empty kitchenette. R73 had geri-sleeves (sleeves placed over arms and legs to protect from injuries) on but her Broda lacked the arm bolsters. On 07/17/24 at 10:03 AM R73 sat in her Broda chair. R73's Broda chair lacked the arm bolsters. On 07/17/24 at 10:05 AM Certified Nurse's Aide (CNA) O stated she had been in the facility for almost a year and R73's chairs had been switched out. She stated she was not sure what arm bolsters were. She stated didn't remember her having arm bolsters attached to her chair. She stated all staff had access to the care plans and could review the preventative interventions. She stated she would report issues or concerns to the nurse for clarification. She stated she would place pillows, cushions, or apply splints if she was aware that the resident required the supportive devices. On 07/17/24 at 10:25 AM Licensed Nurse (LN) J stated the direct care staff or nurses could apply the bolster directly to the chairs based on the orders from the Treatment Administration Report (TAR). She stated she was not sure about R73's arm bolsters. On 07/17/24 at 12:28 PM, Administrative Nurse D stated she expected supportive devices to be listed on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) for the nurse to sign off and be responsible for the application or placement of the devices. The facility's Accommodation of Needs policy the facility will ensure the availability and appropriate placement of assistive devices that promote positioning, safety, independence, and dignity. The policy indicated the individual needs and preferences of each resident will be accommodated while maintaining health and safety. The facility failed to implement R73's arm bolsters to her Broda chair as care planned. This deficient practice placed R73 at risk for a decline in ROM and contractures. - R44's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral infarction (stroke - the 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), dysphagia (swallowing difficulty), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and severe protein-calorie malnutrition. The Significant Change Minimum Data Set (MDS) dated [DATE] documented R44 had severely impaired cognition. The MDS documented R44 was dependent on staff assistance for positioning. The Quarterly MDS dated 06/05/24 documented R44 had severely impaired cognition. The MDS documented that R44 was dependent on staff assistance for positioning. R44's Pressure Ulcer Care Area Assessment (CAA) dated 01/09/24 documented she required repositioning. R44's Care Plan dated 12/13/23 documented that staff would reposition R44 as needed when up in her Broda chair (specialized wheelchair with the ability to tilt and recline). The plan of care documented that staff would place arm bolsters (specialized devices used for positioning and support) in her Broda chair for positioning. On 07/15/24 at 08:10 AM R44 sat upright in her Broda chair. R44's chair did not have arm bolsters. On 07/15/24 at 11:48 AM Certified Nurse Aide (CNA) O pushed R44 into the dining room in her Broda chair. The chair did not have arm bolsters in place. On 07/16/24 at 07:50 AM R44 sat in her Broda chair at the dining room table. R44 did not have arm bolsters on her Broda chair. On 07/17/24 at 10:05 AM, Certified Nurse Aide (CNA) O stated she would place pillows, cushions, or apply splints if she was aware that the resident required supportive devices. CNA O stated she was not sure what arm bolsters were. CNA O stated she was not aware of R44's need for arm bolsters. CNA O stated she had not seen any bolsters for R44 in the past four months that she had taken care of R44. On 07/17/24 at 10:16 AM, agency Licensed Nurse (LN) J stated she was not aware that R44 was care planned to have an arm bolster in her Broda chair for support and positioning. On 07/17/24 at 12:28 PM, Administrative Nurse D stated she expected supportive devices to be listed on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) for the nurse to sign off and be responsible for the application or placement of the devices. The facility's Accommodation of Needs policy last revised 12/2017 documented the facility would ensure the availability and appropriate placement of assistive devices that promote positioning, safety, independence, and dignity. The policy indicated the individual needs and preferences of each resident would be accommodated while maintaining health and safety. The facility failed to ensure R44's supportive devices were provided for positioning. This deficient practice left R44 at risk for discomfort and a decrease in mobility. - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiplegia (paralysis of one side of the body) affecting the right side, chronic pain, and lack of coordination. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented R75 was dependent on staff assistant for dressing, transfers, and mobility. The MDS documented R75 had functional limitations of range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) of her upper and lower extremities on one side. The Quarterly MDS dated 0612/24 documented a BIMS score of four which indicated severely impaired cognition. The MDS documented that R75 had functional limitations of ROM of her upper and lower extremities on one side. The MDS documented R75 was dependent on staff assistance for her activities of daily living. R75's Pressure Ulcer Care Area Assessment (CAA) dated 12/29/23 documented she required the assistance of the staff for repositioning. R75's Care Plan dated 03/26/24 documented that staff would ensure the hand splint was on her right hand at all times except for showers and hand hygiene for contractures. R75's EMR under the Orders tab revealed the following physician orders: Right-hand splint on at all times, except for shower and hand hygiene per therapy dated 03/26/24. A review of R75's Treatment Administration Record from 07/01/24 to 07/15/24 documented she had her right-hand splint in place 27 out of 30 opportunities including the morning and evening of 07/15/24. On 07/15/24 at 11:13 AM R75 sat in her high back wheelchair asleep in the common area. R75's right lacked a right-hand splint, her right-hand fingers were bent inward, and her right arm rested tightly across her chest area. On 07/16/24 at 07:24 AM R75 sat in her high-back wheelchair in the common area asleep. R75's right hand lacked her hand splint. On 07/16/24 at 01:00 PM, Certified Nurse Aide (CNA) P stated R75 had not worn her right-hand splint at least for the past three months. CNA P stated the splint had caused bruises and discomfort for R75. On 07/16/24 at 01:06 PM, Licensed Nurse (LN) G stated R75 had refused her right-hand splint a few times in the past two or three weeks. LN G stated therapy was aware that R75 had refused to wear her splint. On 07/17/24 at 12:29 PM, Administrative Nurse D stated the splints or device should be on the Medication Administration Record (MAR), or the Treatment Administration Record (TAR), and nursing staff were responsible for ensuring they were applied as ordered or care planned. The facility's Restorative Nursing-Range of Motion Program policy revised 12/17 documented the residents who have or were at risk of having difficulty with ROM were assessed by nursing or therapy for a restorative nursing range of motion program to promote independence and quality of life by improving or maintaining functional ROM. The facility failed to ensure R75 received services and treatment for her multiple contractures to prevent an avoidable reduction of ROM and/or mobility. This deficient practice left R75 at risk for further decline and decreased ROM.

The facility identified a census of 83 residents. The sample included 18 residents with eight medication carts, four treatment carts, and three medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in seven of the eight medication carts and four of the four treatment carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - On 07/15/24 at 07:12 AM the medication cart on C-hall was unlocked and unattended in the hallway. The medication cart contained plastic cups in the top drawer with unlabeled pills in the cups. On 07/15/24 at 07:16 AM the medication cart on B-hall was unlocked and unattended in the hallway. On 07/15/24 at 07:20 AM the treatment carts on F-hallway and G-hall were unlocked and unattended in the hallway. On 07/15/24 at 07:20 AM the medication cart on G-Hall was unlocked and unattended in the hallway. On 07/15/24 at 07:21 AM the treatment cart on E hall was unlocked and unattended in the hallway. On 07/15/24 at 07:22 AM the mediation cart on C-hall was unlocked and unattended in the hallway. On 07/16/24 at 07:12 AM the medication cart and the treatment cart on E-hall were unlocked and unattended in the hallway. On 07/16/24 at 07:34 AM the treatment cart on A-hall was unlocked and unattended in the hallway. On 07/16/24 at 06:50 AM the treatment cart on P-hall was unlocked and unattended in the hallway. On 07/17/24 at 07:37 AM the medication cart on A-hall was unlocked and unattended in the hallway. On 07/15/24 at 07:20 AM, agency Licensed Nurse (LN) K stated the medication carts should stay locked unless the cart was in view. On 07/15/24 at 07:22 AM LN H stated the carts should be locked at all times, and the computer should be off when not in use. On 07/16/24 at 07:12 AM LN J stated the medication cart and the treatment cart should always be locked when not in use. On 07/17/24 at 12:28 PM, Administrative Nurse D stated she expected the nurses to keep the medication carts and the treatment carts locked when not in use. The facility's Storage of Medications policy last reviewed 01/2024 documented the facility would store all drugs and biological in a safe, secure, and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals would be locked when not in use, and trays or carts used to transport such items would not be left unattended if open or otherwise potentially available to others. The facility failed to properly store medications which could potentially cause adverse consequences or ineffective treatment to the affected residents.

The facility identified a census of 83 residents and 13 residents who were on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to the handling of soiled laundry, storage of oxygen tubing while not in use, and hand hygiene during catheter (a tube inserted into the bladder to drain urine) care. The facility further failed to follow EBP. These deficient practices placed the residents at risk for infectious diseases. Included Findings: - On 07/15/ 24 at 07:40 AM Resident (R) 51 had a portable oxygen tank with a nasal cannula (a hollow tube used to deliver supplemental oxygen) that was not in use near the entrance of her room. The nasal cannula hung over the portable oxygen tank, there was not a sanitary container for storage of the cannula. On 07/15/24 at 09:07 AM R33's nasal cannula was wrapped around the arm of the wheelchair in her room. The nasal cannula was not stored in a sanitary container. On 07/15/24 at 09:46 AM, an unidentified staff member walked off the E-hallway with unbagged linens pressed up against her upper body. On 07/16/24 at 03:38 PM, a dirty tub of white clothing was in a yellow tub marked dirty laundry. The yellow tub of soiled clothing sat next to clean laundry that was hanging on a rack and hung partly into the soiled bin in the washing area of the laundry room. 0n 07/17/24 at 08:15 AM R11 laid in his bed. Certified Nurse Aid (CNA) M donned two pairs of gloves, preparing to get R11 up in his wheelchair for breakfast. CNA M placed R11's catheter bag and tubing on his bed. CNA M did not don her gown for the EBP nor perform any hand hygiene prior to donning the gloves. CNA M rolled R11 to the wall, removed his brief, and there was bowel movement in the brief. CNA M wiped R11's backside with wipes. Wearing the same gloves, CNA M used a wet soapy washcloth to finish cleaning R11 and dried R11's backside with a towel. CNA M doffed her gloves, did not perform hand hygiene, and donned a clean pair of gloves. CNA M washed R11's front peri area with a wipe and used the same towel to try R11's front peri/catheter area. CNA M rolled R11 from side to side, securing clothing and Hoyer (total body mechanical lift) sling. CNA M doffed her gloves and left the room to get help with R11s transfer. Administrative Nurse E arrived at R11's room to help with the transfer using the Hoyer. Administrative Nurse E and CNA M donned gloves but neither Administrative Nurse E nor CNA M performed hand hygiene before donning gloves and neither wore a gown for EBP. Administrative Nurse E held R11's catheter bag, and CNA M transferred R11. CNA M pushed the Hoyer to the hallway without sanitizing it and walked away. On 07/17/24 at 02:19 PM a laundry tub marked dirty laundry sat in the dirty part of the laundry room without a lid. There was clothing hanging on top of the basket. Dietary Staff BB stated the clothes hanging were clothing that was going to be given away. He stated the facility had nowhere else to store the clothing. Dietary Staff BB stated the dirty clothes tubs should have had lids. On 07/17/24 at 12:29 PM Administrative Nurse D stated staff are trained on hand hygiene when they are hired, and agency staff have a check-off sheet when they come aboard that includes hand hygiene. She stated oxygen tubing should always be stored in a container when not in use. Administrative D stated staff would know what PPE to wear when taking care of a resident, by the guide provided to them inside the resident's room, with the PPE. The facility's policy for Peri Care, Enhanced Barrier Precautions, and Laundry and Linen documented, that the facility was to provide cleanliness and comfort to the resident to prevent infections skin irritation, and to observe the resident's skin condition. The enhanced barrier precautions documented the community will fully implement the precautions during high-contact resident care activities when caring for residents at risk. The laundry and linen policy directs to separate soiled and clean linen and perform hand hygiene after handling soiled linen and before handling clean linen. The facility failed to follow sanitary infection control standards related to the handling of soiled laundry, hand hygiene storage of oxygen tubing while not in use, catheter care, and EBP. These deficient practices placed the residents at risk for infectious diseases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 90 residents. The sample included 18 residents with one resident reviewed for self-administration of medications. Based on observations, record reviews, and interviews, the facility failed to ensure safe and appropriate self-administration of medication for Resident (R) 47. This placed the resident at risk for unnecessary medication side effects and self-administration errors. Findings included: - R47's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R47 required extensive assistance of one staff member for activities of daily living (ADL). The MDS documented R47 required physical assistance of one staff member for bathing activity. The MDS documented R47 had received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) for three days, antibiotic (class of medication used to treat bacterial infections) for four days, antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) for five days, antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and an opioid (a class of medication used to treat pain) for six days during the look back period. R47's Cognitive Loss Care Area Assessment (CAA) dated 01/20/23 documented R47 had moderate cognitive loss. R47's Care Plan dated 01/24/23 directed staff to administer medication as ordered and monitor for side effects. The care plan lacked documentation or direction for R47's ability for self-administration of medications. R47's clinical record lacked an assessment for self-administration of medications. On 03/14/23 at 01:22 PM R47 laid on the bed with personal items on the bed. A plastic cup which contained pills sat on the bedside table within R47's reach. On 03/20/23 at 02:30 PM Licensed Nurse (LN) H stated R47 was not able to self-administer her own medication and medication should never be left at her bedside at any time. On 03/20/23 at 04:49 PM Administrative Nurse E stated only a few residents were able to self-administer their own medication. Administrative Nurse E stated the nursing staff would complete an assessment to determine if a resident was safe to be able to self-administer medications. Administrative Nurse E stated R47 was not able to self-administer her medication and medication should never be left at her bedside at any time. The facility's Self-Administration of Medications policy last revised December 2017 documented residents had the right to self-administer medication if the interdisciplinary team had determined that it was clinically appropriate and safe for the resident to do so. As part of the evaluation, the nursing associates would assess each resident's mental and physical abilities, to determine whether self-administrating medications was clinically appropriate for the resident. The facility failed to ensure safe and appropriate self-administration of medications for R47 who was cognitively impaired. This deficient practice placed the resident at risk for unnecessary medication side effects and self-administration errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 90. The sample included 18 residents with one resident reviewed for notification of changes. Based on observation, record review and interview, the facility failed to notify Resident (R)30 and/or his family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) of a significant change in skin condition when R30 developed a pressure ulcer (a 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) during his stay at an acute hospital which was identified when R30 readmitted to the facility. This deficient practice placed the resident at risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of peripheral vascular disease (PVD - abnormal condition affecting the blood vessels), hypertension (HTN -elevated blood pressure), and heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). The Annual Minimum Data Set (MDS) dated [DATE] documented R30 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R30 required extensive assistance of one staff for activities of daily living (ADL). The MDS documented R30 had no unhealed pressure ulcers during the look back period. The Quarterly MDS dated 01/18/23 documented R30 had a BIMS score of 13 which indicated intact cognition. R30 required extensive assistance of one staff for his ADL. The MDS documented no unhealed pressure ulcers during the look back period. The ADL Care Area Assessment (CAA) dated 05/16/22 documented R30 required limited to extensive assistance with bathing, dressing, grooming and personal hygiene. R30 could shave himself and do oral care after set up. R30 was able to feed himself. R30 required assistance with bed mobility with cues to use bilateral enabler bars. R30 ambulated with staff assistance using a walker and gait belt mostly in his room with help. Staff assisted R30 with transfers using a gait belt. R30 also used a wheelchair and self-propelled most of the time, staff assisted him as needed. R30 has a history of left total knee arthroplasty (TKA-total knee replacement) with multiple revisions and lower extremity weakness. R30 needed help with toileting. R30 was alert and oriented with a BIMS score of 13. R30 was forgetful at times. The Pressure Ulcer CAA dated 05/15/22 documented R30 required extensive assistance with bed mobility, off-loading and repositioning. R30 had urinary incontinence and occasional bowel incontinence. R30 was checked for incontinence approximately every two hours. R30 had a pressure reduction mattress to his bed and a cushion to his wheelchair. R30 currently had no pressure ulcers. A Braden scale (an assessment used to predict pressure sore risk) score was 16 indicating he was at high risk for pressure injury. R30 had a wound on the left thigh with treatment ordered. R30 has noted edema (swelling). Review of the EMR under ID Notes tab revealed: A Nurses Note dated 03/08/23 04 :17 PM documented R30 readmitted to the facility with a pressure ulcer inside his bilateral buttocks. Review of Skin Evaluation Form dated 03/09/23 at 11:42 AM documented a pressure ulcer length of 6.5 centimeters (cm), width 6.0cm. and depth 0.1cm. R30's clinical record lacked documentation his DPOA was notified of the pressure injury. The facility lacked a policy for notifying of changes. The facility failed to notify R30 and/or his family/DPOA of a significant change in skin condition when R30 developed a pressure ulcer during his stay at an acute hospital which was indentified upon readmission to the facility This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R30.

The facility identified a census of 90 residents. The sample included 18 residents with one resident reviewed for abuse and mistreatment. Based on observation, record review, and interviews, the facility failed to identify an allegation of abuse, and report to the State Agency, when Resident (R) 40 told the Hospice nurse he received rough treatment from staff, and the Hospice nurse then informed the facility Director of Nursing (DON). This placed the resident at risk for unidentified and ongoing abuse and /or neglect. Findings Included: - The Medical Diagnosis section within R40's Electronic Medical Records (EMR) included diagnoses of pulmonary fibrosis (scarring of the lungs), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (major mood disorder). A review of R40's Quarterly Minimum Data Set (MDS) dated 10/19/22 recorded a Brief Interview for Mental Status (BIMS) of 10 which indicated moderate cognitive impairment. The MDS indicated R40 was totally dependent on two staff for bed mobility and transfers. The MDS indicated he was totally dependent on one staff for personal hygiene, toileting, dressing, and bathing. The MDS documented R40 had a history of rejecting cares. A review of R40's Quarterly MDS dated 01/04/23 noted a BIMS score of three indicating severe cognitive impairment. The MDS indicated he was totally dependent on two staff for bed mobility and transfers. The MDS indicated he was totally dependent on one staff for personal hygiene, toileting, dressing, and bathing. The MDS indicated R40 had a history of rejecting cares. A review of R40's Activities of Daily Living (ADL) Care Area Assessment (CAA) completed 05/05/22 indicated R40 required extensive to total assistance from staff for bathing, dressing, grooming, personal hygiene, and oral care. The CAA indicated he required a Hoyer lift (total body mechanical lift) for transfers and relied on staff to propel him in his wheelchair. R40's Cognitive Impairment CAA completed 05/05/22 indicated R40 had mild cognitive impairment. R40's Behavioral CAA was not triggered. A review of R40's Care Plan revised 06/23/22 for cognitive impairment noted he had impaired ability to make decisions and comprehend. The care plan noted staff would orient R40 daily with activities and routines. R40's Care Plan for ADL initiated on 06/23/22 indicated he required a Hoyer lift for transfers and two-person assist for all transfers. The plan noted he used a Broda chair (specialized wheelchair with the ability to tilt and recline) for mobility with staff assistance. A review of an Incident Report dated 08/21/22 indicated direct care staff found R40 hanging off his bed, attempting to reach items on the floor. The note indicated the Certified Nurse Aide (CNA) identified R40 had bleeding wounds and then placed R40 back in bed. The report indicated the CNA did not notify nursing staff of R40's injuries and left him in bed. The report indicated another direct care staff member found R40 and reported that incident to the nurse. R40's care plan lacked interventions related to his injuries or his mechanism of injury. The report indicated the CNA received counseling on failing to report skin injuries to the nurse. The CNA completed in-service for abuse, neglect, and exploitation. A review of R40's Hospice Communication form on 11/14/22 from the Hospice nurse revealed R40 reported to hospice that the weekend staff called R40 obstinate and were rough with him. The facility could not provide an investigation into the 11/14/22 allegation of abuse. On 03/16/23 at 08:30AM R40 sat in his bed and watched television. R40 reported he could not remember falling out of bed or staff being rough with him. He reported he was upset about having his feeding tube and stated he attempted to pull it out in the past. He reported he felt safe in the facility. On 03/19/23 at 10:41AM R40's representative reported that she was notified by the hospice nurse on Saturday, 11/12/22, that R40 was roughed up by staff during cares. She reported R40 could be difficult to work with and was easily confused due to his cognitive impairment. She stated she believed that R40 attempted to hit staff due to them being rough with him. On 03/19/22 at 10:58AM Consultant Licensed Nurse (LN) I reported when she talked with R40 on 11/14/22, he informed her that staff were rough with him during cares over the weekend. She reported that R40 had not made previous claims to her about the incident and she felt like R40 was not confused or disoriented at the time of the complaint. She stated that she reported the complaint to the facility's Social Service Director and Director of Nursing. On 03/20/23 at 10:50AM Social Service X stated she was not aware of an allegation related to staff being rough with R40 during cares. She stated she would have immediately reported it and investigated if notified. On 03/20/23 at 11:01AM Administrative Staff B reported she believed R40 was confused and reported the previous incident that occurred on 08/21/22. She stated that she believed he was remembering a previous incident and confused. She did not investigate it as a possible separate incident or report it due to her thought the incident was a connected event to the August incident. She stated the facility assumed it was the same incident they had already investigated and was not aware of Hospice reporting any new allegation but stated she would contact hospice to confirm. She stated the hospice communication notes would have been reviewed daily by the nurses and interdisciplinary team (IDT). She stated staff were provided annual training related to abuse, neglect, and exploitation. She stated she also provided educational in-services and floor training to all staff. On 03/20/23 at 11:10AM Administrative Nurse D reported that she was informed by Hospice that staff were rough with R40 in November of 2022. Administrative Nurse D reported she believed R40 was referring to the incident that occurred on 08/21/23. She stated that if hospice had notified her of possible abuse she would have investigated as a separate event and reported the event to the State Agency. She stated that staff (including hospice) were expected to report all abuse allegations. A review of the facility's Abuse Prevention policy revised 06/2020 noted the facility's residents had the right to be free from abuse, neglect, misappropriation, and exploitation. The policy indicated the facility would screen, educate , and implement protective measures to prevent resident abuse. The policy indicated that all witnessed or suspected abuse will be reported and investigated. The policy indicated that facility will respond quickly to protect the alleged victim and the integrity of the investigation. The policy instructed the facility to report all alleged abuse to the investigating state agency. The facility failed to ensure incidents of alleged abuse were identified as allegations and reported, as required, to the State Agency. This placed the resident at risk for unidentified and ongoing abuse and /or neglect.

The facility identified a census of 90 residents. The sample included 18 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to investigate an allegation of staff to resident abuse when Resident (R)40 reported rough treatment from direct care staff. This placed R40 at risk for ongoing and/or unidentified abuse and mistreatment. Findings Included: - The Medical Diagnosis section within R40's Electronic Medical Records (EMR) included diagnoses of pulmonary fibrosis (scarring of the lungs), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (major mood disorder). A review of R40's Quarterly Minimum Data Set (MDS) dated 10/19/22 recorded a Brief Interview for Mental Status (BIMS) of 10 which indicated moderate cognitive impairment. The MDS indicated R40 was totally dependent on two staff for bed mobility and transfers. The MDS indicated he was totally dependent on one staff for personal hygiene, toileting, dressing, and bathing. The MDS documented R40 had a history of rejecting cares. A review of R40's Quarterly MDS dated 01/04/23 noted a BIMS score of three indicating severe cognitive impairment. The MDS indicated he was totally dependent on two staff for bed mobility and transfers. The MDS indicated he was totally dependent on one staff for personal hygiene, toileting, dressing, and bathing. The MDS indicated R40 had a history of rejecting cares. A review of R40's Activities of Daily Living (ADL) Care Area Assessment (CAA) completed 05/05/22 indicated R40 required extensive to total assistance from staff for bathing, dressing, grooming, personal hygiene, and oral care. The CAA indicated he required a Hoyer lift (total body mechanical lift) for transfers and relied on staff to propel him in his wheelchair. R40's Cognitive Impairment CAA completed 05/05/22 indicated R40 had mild cognitive impairment. R40's Behavioral CAA was not triggered. A review of R40's Care Plan revised 06/23/22 for cognitive impairment noted he had impaired ability to make decisions and comprehend. The care plan noted staff would orient R40 daily with activities and routines. R40's Care Plan for ADL initiated on 06/23/22 indicated he required a Hoyer lift for transfers and two-person assist for all transfers. The plan noted he used a Broda chair (specialized wheelchair with the ability to tilt and recline) for mobility with staff assistance. A review of an Incident Report dated 08/21/22 indicated direct care staff found R40 hanging off his bed, attempting to reach items on the floor. The note indicated the Certified Nurse Aide (CNA) identified R40 had bleeding wounds and then placed R40 back in bed. The report indicated the CNA did not notify nursing staff of R40's injuries and left him in bed. The report indicated another direct care staff member found R40 and reported that incident to the nurse. R40's care plan lacked interventions related to his injuries or his mechanism of injury. The report indicated the CNA received counseling on failing to report skin injuries to the nurse. The CNA completed in-service for abuse, neglect, and exploitation. A review of R40's Hospice Communication form on 11/14/22 from the Hospice nurse revealed R40 reported to hospice that the weekend staff called R40 obstinate and were rough with him. The facility could not provide an investigation into the 11/14/22 allegation of abuse. On 03/16/23 at 08:30AM R40 sat in his bed and watched television. R40 reported he could not remember falling out of bed or staff being rough with him. He reported he was upset about having his feeding tube and stated he attempted to pull it out in the past. He reported he felt safe in the facility. On 03/19/23 at 10:41AM R40's representative reported that she was notified by the hospice nurse on Saturday, 11/12/22, that R40 was roughed up by staff during cares. She reported R40 could be difficult to work with and was easily confused due to his cognitive impairment. She stated she believed that R40 attempted to hit staff due to them being rough with him. On 03/19/22 at 10:58AM Consultant Licensed Nurse (LN) I reported when she talked with R40 on 11/14/22, he informed her that staff were rough with him during cares over the weekend. She reported that R40 had not made previous claims to her about the incident and she felt like R40 was not confused or disoriented at the time of the complaint. She stated that she reported the complaint to the facility's Social Service Director and Director of Nursing. On 03/20/23 at 10:50AM Social Service X stated she was not aware of an allegation related to staff being rough with R40 during cares. She stated she would have immediately reported it and investigated if notified. On 03/20/23 at 11:01AM Administrative Staff B reported she believed R40 was confused and reported the previous incident that occurred on 08/21/22. She stated that she believed he was remembering a previous incident and confused. She did not investigate it as a possible separate incident or report it due to her thought the incident was a connected event to the August incident. She stated the facility assumed it was the same incident they had already investigated and was not aware of Hospice reporting any new allegation but stated she would contact hospice to confirm. She stated the hospice communication notes would have been reviewed daily by the nurses and interdisciplinary team (IDT). She stated staff were provided annual training related to abuse, neglect, and exploitation. She stated she also provided educational in-services and floor training to all staff. On 03/20/23 at 11:10AM Administrative Nurse D reported that she was informed by Hospice that staff were rough with R40 in November of 2022. Administrative Nurse D reported she believed R40 was referring to the incident that occurred on 08/21/23. She stated that if hospice had notified her of possible abuse she would have investigated as a separate event and reported the event to the State Agency. She stated that staff (including hospice) were expected to report all abuse allegations. A review of the facility's Abuse Prevention policy revised 06/2020 noted the facility's residents had the right to be free from abuse, neglect, misappropriation, and exploitation. The policy indicated the facility would screen, educate, and implement protective measures to prevent resident abuse. The policy indicated that all witnessed or suspected abuse will be reported and investigated. The policy indicated that facility will respond quickly to protect the alleged victim and the integrity of the investigation. The policy instructed the facility to report all alleged abuse to the investigating state agency. The facility failed to ensure incidents of alleged staff to resident abuse and/or mistreatment were fully investigated by the facility. This placed the resident at risk for ongoing abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 90. The sample included 18 residents. Two sampled residents were reviewed for hospitalization. Based on observation, record review and interview, the facility failed to provide written notice of transfer with the required information to Resident (R)30 and R4 and/or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R30 and R4. Findings included: - The electronic medical record for R30 documented diagnoses of peripheral vascular disease (PVD - abnormal condition affecting the blood vessels), hypertension (HTN-an elevated blood pressure), and heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). The Annual Minimum Data Set (MDS) dated [DATE] documented R30 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R30 required extensive assist of one staff for activities of daily living (ADL). The Quarterly MDS dated 01/18/23 documented R30 had a BIMS score of 13 which indicated intact cognition. R30 required extensive assistance of one staff for his ADL. The ADL Care Area Assessment dated documented R30 required limited to extensive assistance with bathing, dressing, grooming and personal hygiene. R30 could shave himself and do oral care after setting up. R30 was able to feed himself. R30 required assist with bed mobility with cues to use bilateral enabler bars. R30 ambulated with staff assistance using a walker and gait belt mostly in his room with help. Staff assisted R30 with transfers using a gait belt. R30 also used a wheelchair and self-propels most of the time, staff assist him as needed. R30 has a history of left total knee arthroplasty (TKA-total knee replacement) with multiple revisions and lower extremity weakness. R30 needed help with toileting. R30 was alert and oriented with a BIMS score of 13. R30 was forgetful at times. The Cardiovascular Care Plan dated 06/09/22 directed staff to provide medications and treatments per physician's orders and monitor for side effects. Staff was to monitor vital signs as ordered and as needed. Report abnormalities to the physician. Staff was to monitor for signs/symptoms of cardiovascular complications. Staff to apply wraps to lower extremities as ordered. Staff was to check his circulation each shift. Staff to monitor for changes in respiratory pattern such as, new, or increased shortness of breath, new or increased wheezing, abnormal breath sounds, new or increased periods of not breathing. Review of R30 EMR under the ID Notes documented: A Nursing Note on 06/04/22 at 10:44 AM R30 was sent by ambulance to the emergency room for evaluation and was admitted to the hospital. A Nursing Note on 02/28/23 at 05:07 PM R30 was sent by ambulance to the emergency room for evaluation and was admitted to the hospital. A Nursing Note on 03/11/23 at 09:45 AM R30 was sent by ambulance to the emergency room for evaluation and was admitted to the hospital. R30's clinical record lacked evidence the facility provided a written notification of discharge which contained the required information to R30 or R30's DPOA. On 03/20/23 at 05:17 PM Social Services X stated the facility notified the family/DPOA by phone of a resident's transfer from the facility to the hospital but had never provided written notification of the transfer. The facility policy Transfer or Discharge, preparing a Resident for last revised 11/2022 documented the social worker, or designee, was responsible for: informing the resident, or his or her representative (in writing) of the facility's readmission appeal rights, bed-holding policies. Informing the resident, his or her representative of their right to appeal the decision to be discharged off Medicare skilled services, in accordance with the Medicare Claims Processing Manual. Informing the resident, or his or her representative of the estimated financial responsibility if they wish to continue receiving Medicare skilled services that may not be paid for by Medicare, in accordance with the Medicare Claims Processing Manual. A copy of the notice shall be provided to the Office of the State Long-Term Care Ombudsman. The facility failed to provide written notice of transfer with the required information to R30 and/or to their family/DPOA in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R30. - The electronic medical record (EMR) for R4 documented diagnoses of pressure ulcer (a 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), hypertension (HTN- an elevated blood pressure), chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing chronic kidney disease), and chronic kidney disease (CKD-when your kidneys are damaged and can't filter blood the way they should). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R4 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. R4 required extensive to total assistance of two staff for activities of daily living (ADL). R4 used pressure reducing devices for her bed and chair. R4's Cognitive Loss Care Area Assessment (CAA) dated 01/17/23 documented R4 had mild cognitive loss. R4's Care Plan dated 03/01/23 documented R4 required assistance of two staff members with the use of Hoyer lift (total body mechanical lift used to transfer residents) for transfer. Review of R30 EMR under the ID Notes documented: A Nursing Note on 12/12/22 at 01:43 AM documented R4 was sent by ambulance to the emergency room for evaluation and was admitted to the hospital. A Nursing Note on 12/27/22 at 06:57 AM documented R4 was sent by ambulance to the emergency room for evaluation and was admitted to the hospital. A Nursing Note on 01/17/23 at 10:57 AM documented R4 was sent by ambulance to the emergency room for evaluation and was admitted to the hospital. A Nursing Note on 02/13/23 at 01:50 PM documented R4 was sent by ambulance to the emergency room for evaluation and was admitted to the hospital. On 03/15/23 at 10:32 AM R4 laid on the bed with her eyes closed; the TV was on in the room. On 03/20/23 at 05:17 PM Social Services X stated the facility notified the family/DPOA by phone of a resident's transfer from the facility to the hospital but had never provided written notification of the transfer. The facility policy Transfer or Discharge, preparing a Resident for last revised 11/2022 documented the social worker, or designee, was responsible for: informing the resident, or his or her representative (in writing) of the facility's readmission appeal rights, bed-holding policies. Informing the resident, his or her representative of their right to appeal the decision to be discharged off Medicare skilled services, in accordance with the Medicare Claims Processing Manual. Informing the resident, or his or her representative of the estimated financial responsibility if they wish to continue receiving Medicare skilled services that may not be paid for by Medicare, in accordance with the Medicare Claims Processing Manual. A copy of the notice shall be provided to the Office of the State Long-Term Care Ombudsman. The facility failed to provide written notice of transfer with the required information to R4 and/or to their family/DPOA in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity or a delay for healthcare service for R4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -The Medical Diagnosis section within R60's Electronic Medical Records (EMR) included diagnoses of history of falls, rhabdomyolysis (breakdown of damaged skeletal tissue), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), insomnia (inability to sleep), and dysphagia (swallowing difficulty). A review of R60's admission Minimum Data Set (MDS) dated 01/25/23 indicated a Brief Interview for Mental Status (BIMS) of 13 indicating intact cognition. The MDS indicated she required total assistance with all activities of daily living (ADL) from one to two staff. A review of R60's Care Area Assessment (CAA) completed indicated R60 required assistance with bathing, grooming, dressing, personal hygiene, oral care, and bed mobility. The CAA noted she was forgetful with a BIMS of 13. The CAA indicated she required a Hoyer lift (total body mechanical lift used to transfer residents) for transfers and relied on staff to propel her in his wheelchair. R60's Care Plan revised 01/30/23 indicated she required Hoyer lift and two-person assist for all transfers. The plan noted she used a wheelchair and staff assist for mobility as needed. The plan noted she required extensive assistance from one staff during bathing and preferred to take showers. R60's Care Plan indicated she had Clostridium difficile (C-diff- contagious bacteria characterized by foul smelling frequent bowel movements) on 03/07/23. The plan indicated she would complete the antibiotic course and have ongoing infection monitoring for ongoing sign/symptoms of infection and medication side effects. A review of R60's Bathing Lookback reports between 01/18/23 through 03/20/23 revealed she received four bathing opportunities (1/25, 1/28, 2/14, and 2/28). The report did not document any refusals of care for R60. On 03/14/23 at 08:01AM R60 sat in her room, in her wheelchair, next to her bedside table. R60 was unsure when her last shower occurred and reported she did not think she received showers consistently. R60's hair was uncombed and greasy. R60 was in isolation for C-diff. and her room smelled like urine. On 03/14/23 at 01:35PM staff propelled R60 down A Hall towards the C-Hall nursing station. R60's hair was damp and combed. On 03/20/23 at 01:59 PM Licensed Nurse (LN) G stated there was a bath schedule posted in the nurse's station for the staff can review and agency staff was given a [NAME] (tool that gives a brief overview of each resident) sheet with that information. LN G stated if a resident was to refuse their bath, then after several approaches by the certified nurse aide (CNA), the nurse would talk with the resident to find out why they had refused the bath. LN G stated if the resident continued to refuse their bath, then the CNA would document the refusal in POC. LN G stated the assistant director of nursing did audit bathing to prevent a resident missing bathing on a frequent occasion. On 03/20/23 at 04:49 PM Administrative Nurse E stated the bath list was posted in the nurse's station by room number. Administrative Nurse E stated the staff would document in POC if a resident was to refuse their bath. Administrative Nurse E stated she would audit the showers from shower sheets to the POC charting and stated the documentation in POC was correct. On 03/20/23 at Administrative Staff B reported that R60 was placed on isolation starting on 03/16/23. She stated that R60 could exit her room as long as she was not having explosive diarrhea or vomiting. She stated she may attend activities, church, eat in the dining hall, or be transported to other rooms in the facility as long as she does not have those symptoms. The facility's Bath, Bathing, Shower and personal Hygiene policy date approved 02/20/23 referred to Quality of Life- Self Determination policy last revised 12/20/21 documented each resident chose activities, schedules and healthcare that was consistent with their interest, values, assessments and plans of care including personal care needs, such as bathing methods. The facility failed to provide consistent bathing opportunities for R60, who had an infectious disease. This deficient practice place her at risk for infections and decreased psychosocial wellbeing. The facility identified a census of 90 residents. The sample included 18 residents with two residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interview, the facility failed to ensure bathing was provided for two residents who required assistance from staff to complete the care. This deficient practice placed Resident (R) 47 and R60 at risk for impaired psychosocial wellbeing, potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices. Findings included: - R47's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R47 required extensive assistance of one staff member for ADL. The MDS documented R47 required physical assistance of one staff member for bathing activity. The MDS documented R47 received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) for three days, antibiotic (class of medication used to treat bacterial infections) for four days, antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) for five days, antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and opioid (a class of medication used to treat pain) for six days during the look back period. R47's Cognitive Loss Care Area Assessment (CAA) dated 01/20/23 documented R47 had moderate cognitive loss. R47's Care Plan dated 01/24/23 directed staff to assist R47 with bathing on alternate days of hospice bath days and honor R47's wishes. Review of the EMR under Point of Care (POC) under daily charting look back report for R47 reviewed from 12/01/22 to 12/28/22 (28 days) revealed two baths/showers on 12/23/22 and 12/27/22. Activity did not Occur on six days on 12/07/22, 12/09/22, 12/21/22, 12/22/22, 12/24/22, and 12/28/22. Review from 01/13/23 to 03/14/23 (61 days) revealed one shower/baths on 01/19/23. Activity did not Occur was documented 25 days on 01/14/23, 01/16/23, 01/17/23, 01/23/23, 01/30/23, 02/01/23, 02/04/23, 02/07/23, 02/10/23, 02/13/23, 02/14/23, 02/17/2, 02/18/23, 02/19/23, 02/20/2, 02/21/23, 02/24/23, 02/27/23, 02/28/23, 03/03/23, 03/05/23, 03/09/23, 03/13/23, and 03/14/23. The clinical record lacked documentation R47 refused a shower/bath. On 03/15/23 at 03:17 PM R47 laid on the bed working on a laptop computer. R47's hair was uncombed and R47 wore the same shirt as the previsou day. On 03/20/23 at 01:59 PM Licensed Nurse (LN) G stated there was a bath schedule posted in the nurse's station for the staff can review and agency staff was given a [NAME] (tool that gives a brief overview of each resident) sheet with that information. LN G stated if a resident refused their bath, then after several approaches by the certified nurse aide (CNA), the nurse talked with the resident to find out why they had refused the bath. LN G stated if the resident continued to refuse their bath, then the CNA would document the refusal in POC. LN G stated the assistant director of nursing did audit bathing to prevent a resident missing bathing on frequent occasions. On 03/20/23 at 02:20 PM CNA M stated there was bath schedule at each nurse's station that staff can review at the beginning of their shift. CNA M stated staff would report to the charge nurse if a resident refused their bath and document in POC. On 03/20/23 at 04:49 PM Administrative Nurse E stated the bath list was posted in the nurse's station by room number. Administrative Nurse E stated the staff would document in POC if a resident was to refuse their bath. Administrative Nurse E stated she would audit the showers from shower sheets to the POC charting and stated the documentation in POC was correct. The facility's Bath, Bathing, Shower and personal Hygiene GUIDE TO POLICY date approved 02/20/23 referred to Quality of Life- Self Determination policy last revised 12/20/21 documented each resident chose activities, schedules and healthcare that was consistent with their interest, values, assessments and plans of care including personal care needs, such as bathing methods. The facility failed to ensure a shower/bath was provided for R47, who required physical assistance with bathing, which had the potential to cause impaired psychosocial wellbeing, skin breakdown and/or skin complications due to poor personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 90 residents. The sample included 18 residents. Based on observations, record review, and interviews, the facility failed to provide bowel monitoring as ordered by a physician for Resident (R) 6 who received opioid (medications used to treat pain). This deficient practice placed the resident at risk for constipation (difficulty passing stools) and physical complications. Findings included: - R6's Electronic Medical Record (EMR) documented diagnoses of chronic pain syndrome and dementia (progressive mental disorder characterized by failing memory, confusion) with mood disturbance. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of ten which indicated moderate cognitive impairment. R6 required extensive assistance with two staff for bed mobility and dressing; total dependence with two staff for transfers and toileting; and supervision with setup help for eating. R6 was always incontinent (lack of voluntary control over urination or defecation) of urine and bowel movements. R6 received opioid medications seven days in the seven-day lookback period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/07/22, documented R6 had moderate cognitive loss. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 12/07/22, documented R6 required extensive to total assistance with dressing, grooming, personal hygiene, incontinent care, bed mobility, and oral care. The Care Plan dated 12/13/22, documented R6 had dementia and needed assistance with daily ADL care. The Care Plan directed staff assisted R6 with bed mobility, oral care, grooming, personal hygiene, and dressing. The Care Plan dated 12/13/22, documented R6 was incontinent of bowel and bladder and directed staff checked her for incontinence every two hours. The Care Plan dated 12/13/22, documented R6 had a potential for complications from constipation/opioid use and directed staff to give scheduled medications as ordered, monitor to make sure she had a bowel movement at least every three days; and give as needed (PRN) medications, monitor for effectiveness, and report concerns to her medical doctor. R6's EMR documented the following medication orders: an order with a start date of 06/30/22 for morphine (opioid pain medication) extended release 15 milligrams (mg) twice a day for pain; an order with a start date of 07/18/22 for bisacodyl (laxative- medication used to treat constipation) 10 mg daily PRN for constipation; an order with a start date of 07/31/22 for docusate sodium (stool softener) 100 mg twice a day for constipation; an order with a start date of 08/03/22 for staff to document if R6 had a bowel movement or if she did not; an order with a start date of 08/22/22 for Miralax 8.5 gram (G) dissolved in six to eight ounces (oz) of water twice a day for constipation with instructions to hold for loose stools; and an order with a start date of 11/19/22 for morphine solution 20 mg/milliliter, give one milliliter at 03:00 PM daily for pain. R6's EMR documented a physician's order an order with a start date of 08/03/22 which ordered staff to document if R6 had a bowel movement, or if she did not. R6's EMR revealed a lack of evidence of bowel monitoring on 11/17/22, 11/18/22, 12/14/22 to 12/21/22, 12/23/22 to 12/25/22, 01/05/23 to 01/07/23, 01/09/23, 01/17/23 to 01/23/23, 01/27/23 to 01/30/23, 02/01/23 to 02/10/23, and 02/24/23 to 02/26/23. On 03/15/23 at 10:30 AM, R6 laid in bed and rested, she appeared comfortable. On 03/20/23 at 01:58 PM, Licensed Nurse (LN) G stated Certified Nurse Aides (CNA) charted bowel movements and she reviewed bowel movement monitoring herself. She stated if a resident had not had a bowel movement in more than three days, the resident received a PRN medication and if there were no results, she would have looked at the standing orders or call the doctor. On 03/20/23 at 02:37 PM, CNA M stated if he worked three days in a row, he knew if a resident had a bowel movement. He stated bowel movements were charted in Point of Care (POC- CNA EMR system) and he could see in the chart if a resident had not had a bowel movement in more than three days. On 03/20/23 at 04:49 PM, Administrative Nurse E stated the nurses ran a bowel movement report during the shift and if a resident had not had a bowel movement in six shifts or three days, they received a PRN medication. If the resident did not have a PRN laxative then the nurse reached out to the doctor. The facility's Administering Medications policy, last revised December 2021, directed medications were administered in accordance with the orders. The facility's Restorative Nursing- Toileting Program policy, last revised May 2021, directed residents who were incontinent were assessed by nursing and/or therapy for a toileting program to promote independence and quality of life by maintaining or improving a resident's continence. The policy did not address bowel monitoring. The facility failed to provide bowel monitoring as ordered by a physician for R6 who received opioids routinely and was at risk for constipation. This deficient practice had the risk for constipation and physical complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 90 residents. The sample included 18 residents with two residents reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure staff implemented infection control practices during wound care for Resident (R) 4 who received antibiotics to treat a wound infection. This deficient practice placed R4 at risk of delayed healing, ongoing infection, and worsening of her wound. Findings included: - The electronic medical record (EMR) for R4 documented diagnoses of osteomyelitis (local or generalized infection of the bone and bone marrow) of vertebra (bone of the spinal column) and sacral (large triangular bone between the two hip bones), pressure ulcer, hypertension (HTN- an elevated blood pressure), chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing chronic kidney disease), and chronic kidney disease (CKD-when your kidneys are damaged and can't filter blood the way they should). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R4 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. R4 required extensive to total assistance of two staff for activities of daily living (ADL). R4 was at risk for pressure ulcers. R4 used pressure reducing devices for her bed and chair. The Pressure Ulcer Care Area Assessment (CAA) dated 01/17/23 for R4 documented she required extensive assistance with turning and repositioning. R4's Braden scale (an assessment used to identify the risk of pressure wounds) score of 12 indicating she was at risk for pressure injury. R4 had a low air loss mattress to her bed and a cushion for her chair. R4's heels were kept off the mattress using foot pillows or regular pillows to float her heels. R4 had a stage three pressure (full thickness wound that extends past all layers of skin into the fat tissue) wound prior to her hospitalization. The pressure ulcer was surgically debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) at the hospital and noted to be a stage four (a deep wound that reaches the muscles, ligaments, or even bone) after the procedure. R4 has a history of not wanting to lay down much during the day and tended to lay on her back when in bed. R4 had extra pillows to help position her and keep pressure off the coccyx/sacral (small triangular area at the base of the spine) area. R4 had vitamin and Juven supplements (a supplement used to support wound healing) ordered. R4 had a new gastrostomy tube (G-tube- a tube inserted through the belly that brings nutrition directly to the stomach) places and a new colostomy (a surgical procedure in which a piece of the colon was diverted to an artificial opening in the abdominal wall). R4's Care Plan dated 02/21/23 documented R4 required assistance with bed mobility, had incontinence with risk for pressure ulcers. Staff was directed to complete Braden scale per facility protocol; do weekly head to toe skin assessment. Staff was to check skin during cares and bathing for signs of redness, rash, skin tears, open areas, blisters, dark discolored areas on skin and report to charge nurse for further skin assessment if skin issues were observed each shift. Staff was to assist with turning and repositioning when R4 was in her bed and wheelchair approximately every two hours. Staff was to check R4 for incontinence approximately every two hours to keep her skin clean and dry each shift. Staff was to ensure R4 had a wheelchair cushion each shift. Staff was to use pillows to floats R4's heels while in bed and encourage use. R4 was to have an air mattress for her bed and check air pressure each shift and as needed to ensure mattress was inflated to proper setting. R4 had a stage four pressure ulcer on the sacral area. R4 was resistant to recommendations to off load at times and had numbness from the waist down with risk for infection, and complications. Staff was to do treatments as ordered. Staff was to monitor R4 for signs/symptoms of further infection. Staff was to monitor for healing or worsening of wound and report concerns to the physician. Staff was to encourage R4 to lay down between meals. Staff was to keep pressure off the affected areas as much as possible. Encourage her to allow staff to reposition her on left and right sides approximately every two hours while in bed and use extra pillows to help position her when off-loading approximately every two hours. Review of the EMR under Physician Orders tab revealed physician orders: Aztreonam (antibiotic used to treat bacterial infection) inject one gram intravenous (administered through a vein directly into the blood stream) every 12 hours for wound infection dated 02/22/23 and end date of 04/01/23. Santyl (a sterile enzymatic debriding ointment) 250 unit/gram (gm) ointment apply a nickel thick layer mixed with triple antibiotic ointment (used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) fill wound bed with gauze daily for wound care started 03/02/23. Triple antibiotic 3.5-400-5000 ointment apply nickel thick layer mixed with Santyl to wound bed daily for wound care dated 03/03/23. On 03/16/23 at 01:14PM R4 had wound care provided by Licensed Nurse (LN) H. LN H put gloves on, and placed the clean wound care items on the bedside table without providing a clean barrier. He then assisted with repositioning R4 and removed her soiled dressings. LN H placed the soiled dressings in trash and removed his gloves. LN H put on new gloves without performing hand hygiene in between glove change and sprayed wound cleanser onto R4's wound. LN H dried the wound with three gauze pads and changed his gloves without performing hand hygiene. LN H mixed ointment together with a Q-tip and applied to ointment to the bed of the wound. LN H again replaced his gloves without completing hand hygiene in between changes. LN H then packed the wound with gauze and applied a dressing to cover it. LN H placed R4's nourishment drink next to her wound care dressing and restarted her tube feeding without performing hand hygiene. On 03/20/23 at 03:20PM LN G reported that she would provide a barrier when handling wound care items or any clean items used for the residents. She stated she would always wash her hands before, during, and after cares provided to the residents. She stated she would always perform hand hygiene in between changing gloves. On 03/20/23 at 04:02PM Administrative Staff B reported staff were expected to complete hand hygiene in between gloves changes for all cares. She stated that she held education in-services and training to improve infection control practices for the facility. She stated that staff were expected to foam in and foam out of rooms, complete hand hygiene frequently, and ensure infections were not being spread by completing cares for residents. A review of the facility's Wound Care policy revised 01/2022 indicated that infection control practices will be implemented into wound care and dressing changes. The policy noted all materials will be prepared and placed on a sterile field. The policy noted that hand hygiene will occur during preparation, between glove changes, and after cares are provided. The facility failed to ensure ensure staff implemented infection control practices during wound care for R4 who received antibiotics to treat a wound infection. This deficient practice placed R4 at risk of delayed healing, ongoing infection, and worsening of her wound.

The facility identified a census of 90 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure foot pedals were used for Resident (R) 67 and R11, when staff pushed residents in their wheelchairs. This deficient practice placed these residents at risk of avoidable accidents. Findings included: - On 3/16/23 at 12: 00 PM Certified Nurse Aide (CNA) O pushed R67 in a wheelchair with no foot pedals into the dining room. R67's feet slid along the floor. R67 stomped her feet onto the floor while staff propelled her forward and attempted to stop her wheelchair in the middle of the dining room. On 03/16/23 at 12:05 PM CNA N pushed R11 in a wheelchair with no foot pedals into the dining room as R11's feet slid along on the floor. On 03/20/23 at 01:59 PM Licensed Nurse (LN) G stated all residents who were in a wheelchair and pushed by staff should have foot pedals on their wheelchair to prevent a fall or injuries that could occur if they flipped out of their wheelchairs. LN G stated all the residents had foot pedals for their wheelchairs. On 03/20/23 at 03:29PM CNA M stated foot pedals should be used whenever a resident needed propelled by a staff member, or when a resident had a chance that their feet might possibly drag on the ground and the resident was not able to hold their feet up. On 03/20/23 at 05:12 PM Administrative Nurse E stated foot pedals should be used any time a resident that required staff assistance with being propelled around the facility; residents should also have foot pedals any time they leave the building. The facility did not provide a policy related to use of foot pedals. The facility failed to ensure staff used foot pedals on the wheelchairs when staff pushed R67 and R11 in the wheelchair. This deficient practice placed R67 and R11 at risk for accidents and related injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R6's Electronic Medical Record (EMR) documented diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), unspecified dementia (progressive mental disorder characterized by failing memory, confusion), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), seizures (violent involuntary series of contractions of a group of muscles), chronic pain syndrome, and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Annual Minimum Data Set (MDS) dated 12/07/22 documented a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. R6 had no behaviors noted. R6 complained of occasional pain rated highest of two out of ten in the last five days of the assessment period. R6 received antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression), antipsychotics (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions), anticoagulants (medication used to prevent blood from thickening or clotting), and opioids (medication used to relieve pain) seven days in the seven-day lookback period. The Psychotropic (any drug that affects brain activities associated with mental processes and behavior) Drug Use Care Area Assessment (CAA) dated 12/07/2022, documented R6 was taking multiple psychotropic medications for bipolar, psychosis, and depression. The Cognitive Loss Dementia CAA dated 12/07/2022, documented R6 had moderate cognitive loss. The Care Plan dated 12/13/2022, documented that R6 took antipsychotic medication for bipolar, psychosis and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) with risk for side effects. The Care Plan dated 12/13/22, documented R6 received scheduled pain medication for chronic pain, joint pain, and diagnosis of brain tumor with a risk for increased pain. The Care Plan directed staff gave scheduled pain medications as ordered, monitored for increased pain and uncontrolled pain, and consulted with her medical doctor for further evaluation and treatment. The Care Plan dated 12/13/22, documented R6 received medications for diagnosis of hypertension with risk for elevated blood pressure. The Care Plan directed staff administered medications per medical doctor order; monitored vital signs per facility protocol or as ordered; and monitored for complaints of headache, nosebleed, shortness of breath, fatigue, and feeling faint. The Care Plan dated 12/13/22, documented R6 had a seizure disorder with a risk for complications and directed staff monitored labs per orders and informed physician of results. R6's EMR documented an order with a start date of 10/30/21 for metoprolol succinate (antihypertensive medication) 25 milligrams (mg) every day for hypertension with instructions to hold and notify medical doctor if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 110 millimeters of mercury (mmHg) or heart rate (HR) was less than 60 beats per minute (bpm); an order with a start date of 05/04/22 for Depakote 500 mg every 12 hours for seizures; an order with a start date of 10/06/22 for Voltaren 1% topical gel applied to right knee and low back twice a day, no dosage noted; and an order with a start date of 01/17/23 for lorazepam intensol (antianxiety medication) 2 milligrams per milliliter (mg/ml) every two hours as needed for anxiety disorder. A review of R6's Medication Administration Record (MAR) for January 2023 revealed metoprolol was given outside of ordered parameters on 01/07/23, 01/08/23, 01/11/23, 01/12/23, 01/21/23, and 01/29/23. A review of R6's MAR for February 2023 revealed metoprolol was given outside of ordered parameters on 02/01/23, 02/08/23, 02/09/23, 02/10/22, 02/22/23, 02/24/23, 02/27/23, and 02/28/23. A review of R6's MAR for 03/01/23 to 03/16/23 revealed metoprolol was given outside of ordered parameters on 03/02/23, 03/05/23, 03/06/23, and 03/12/23. R6's medical record lacked an order for valproic acid (Depakote) laboratory test. Upon request, the facility provided the last valproic acid laboratory results which was completed on 03/31/21. Review of R6's medical record lacked documentation the PRN lorazepam intensol had a 14 day stop date or physician's rationale for extended use. Review of the Medication Regimen Reviews (MRR) for November 2022 through February 2023 lacked evidence the CP identified and reported metoprolol given outside of ordered parameters, laboratory monitoring for Depakote, dosing instructions for Voltaren gel, and a 14-day stop date for PRN lorazepam and/or rationale for extended usage. On 03/15/23 at 10:30 AM, observation revealed R6 was in her room resting in bed. She appeared comfortable. On, 03/20/2023 at 01:58 PM Licensed Nurse (LN) G stated antihypertensives were held if the vital signs were outside parameters and were charted in the MAR if it was held. She stated she rechecked the blood pressure before discarding the medication. LN G stated valproic acid laboratory test orders were given by the doctors if the system did not generate it. She stated if the resident was on hospice, the laboratory test would still need done but it was up to the doctor and family. LN G stated medications should have all had dosages and Voltaren came with a dosage card. She stated she called and verified dosage if the order did not have a dosage. She stated that most of the PRN medications like lorazepam would have a 14 day stop date. LN G stated that if they found a PRN medication, like lorazepam, without a 14 day stop date, that they would report it to the provider. On, 03/20/23 at 04:49 PM Administrative Nurse E stated if a medication did not have a dosage on it, the computer would not complete the order. She stated Voltaren was sometimes put in as 1% and the facility reviewed those orders the next day and corrected them to add the dosage. Administrative Nurse E stated the doctors decided when laboratory tests were completed for medications and hospice residents still received laboratory tests if ordered by a physician. She stated she expected staff to hold blood pressure medications if the vitals were outside of parameters, then notify the physician. Administrative Nurse E stated that PRN medications, such as lorazepam, should have an automatic stop date. On 03/21/23 at 02:00 PM, Consultant GG stated she reviewed every resident's chart but tried to wait for the previous month's MRR to return from the physician. She stated she would not write a recommendation for a Depakote level if it was being used for mood or behaviors and she reviewed medications for dosage and location of creams/gels. Consultant GG stated she reviewed vital signs for antihypertensive medication and if the medication was held. She stated PRN antianxiety medications should have had a stop date. The facility's Medication Regimen Review for Nursing policy, last revised September 2019, directed the pharmacist reported any irregularities to the attending physician, the facility's Medical Director, and Director of Nursing, and the reports were acted upon in a manner that meets the needs of the residents. The facility's Behavioral Assessments, Intervention and Monitoring policy dated 12/2019 documented the community will comply with regulatory requirements to the use of medications to manage behavioral changes. The facility's Administering Medications policy, last revised December 2021, directed medications were administered in accordance with the orders. The facility failed to ensure the CP identified and reported the lack of laboratory monitoring for Depakote for two years, antihypertensive medication given outside parameters, a lack of dosing instructions for Voltaren gel, and a lack of a 14-day stop date for a PRN antianxiety medication and/or physician's rationale for extended use for R6's. This deficient practice placed R6 at risk for unnecessary medications and adverse medication side effects. - The electronic medical record for R65 documented diagnoses of hypertension (elevated blood pressure), and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R65 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderately impaired cognition. R65 required extensive assistance of one staff for her activities of daily living (ADLS). R65 received an anti-psychotic medication (a medication used to treat mental/mood disorders) seven of seven days during the lookback period. The Psychotropic Drug Use CAA dated 10/12/22 for R65 documented Risperidone (antipsychotic medication) was ordered for psychosis/hallucinations (sensing things while awake that appear to be real, but the mind created). R65 continued to have problems with hallucinations at times. The Anti-Psychotic Medication Care Plan dated 10/12/22 for R65 directed staff to give medications as ordered and monitor for side effects. Staff was to monitor for target behaviors/symptoms and document per facility policy. Staff was to consult with the physician for gradual dose reduction/discontinuing medication per protocol. The Physician's Order, dated 12/13/2022, documented an order for Risperidone 0.25 mg to be given at bedtime for hallucinations. Review of the Medication Regimen Reviews (MRR) for December 2022 through February 2023 lacked evidence the CP identified and reported an inappropriate diagnosis for the Risperidone usage for R65. On, 03/20/23 at 02:51 PM, R65 rested in her bed, awake. On, 03/20/2023 at 01:58 PM Licensed Nurse (LN) G stated that is an antipsychotic did not have an appropriate diagnosis that she would call and clarify with the doctor or go through the chart to see if there was a correct diagnosis. She stated that if she was unable to find a diagnosis, then she would contact the doctor to get the order clarified. On, 03/20/23 at 04:49 PM Administrative Nurse E stated that some appropriate diagnoses for antipsychotic medication use could be bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), or schizophrenia (a serious mental disorder in which people interpret reality abnormally); however, she stated that it will sometimes depend on the doctor as to what diagnosis is assigned for the medications use. She reported being unsure if there was a benefit/risk analysis done before using antipsychotics for off label reasons. On 03/21/23 at 02:00 PM, Consultant GG stated she reviewed every resident's chart but tried to wait for the previous month's MRR to return from the physician. She stated she made recommendations for an appropriate diagnosis for antipsychotic medications. The facility's Medication Regimen Review for Nursing policy, last revised September 2019, directed the pharmacist reported any irregularities to the attending physician, the facility's Medical Director, and Director of Nursing, and the reports were acted upon in a manner that meets the needs of the residents. The facility's Behavioral Assessments, Intervention and Monitoring policy dated 12/2019 documented the community will comply with regulatory requirements to the use of medications to manage behavioral changes. The facility failed to ensure the CP identified and reported an inappropriate indication for use for R65's anti-psychotic medication Risperidone that was used to treat her hallucinations. This placed the resident at risk for side effects and unnecessary antipsychotic medication use. The facility identified a census of 90 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported a lack of an appropriate diagnosis for antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) medication usage. The facility failed to ensure the CP identified and reported the lack of laboratory monitoring for R6 who was on Depakote (medication used to treat seizures) for two years, antihypertensive (medications used to treat high blood pressure) medication given outside parameters for R6, a lack of dosing instructions for Voltaren (topical pain reliever medication) gel for R6, and a lack of a 14-day stop date for a PRN (as needed) antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication for R6; the facility failed to ensure the CP identified and reported an inappropriate diagnosis for antipsychotic medication usage for R65. This deficient practice had the risk for unnecessary medication use and unwarranted physical complications for the affected residents. Findings included: - R47's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R47 required extensive assistance of one staff member for activities of daily (ADL). The MDS documented R47 required physical assistance of one staff member for bathing activity. The MDS documented R47 had received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) for three days, antibiotic (class of medication used to treat bacterial infections) for four days, antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) for five days, antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and opioid (a class of medication used to treat pain) for six days during the look back period. R47's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/20/23 documented R47 received several psychotropic medications on a regular basis. R47's Care Plan dated 01/24/23 directed nursing staff to administer medication as ordered, monitor for behaviors and side effects of medications given. Review of the EMR under Orders tab revealed physician orders: Quetiapine fumarate (antipsychotic) 300 milligrams (mg) give two tablets (600mg) by mouth at bedtime for insomnia (inability to sleep)/depression dated 02/06/23. Review of the Monthly Medication Review (MMR) provided by the facility, performed by the CP, reviewed from March 2022 through February 2023 failed to address the lack of appropriate indication for antipsychotic medication. On 03/14/23 at 01:22 PM R47 laid on the bed with personal items on the bed. A plastic cup which contained pills sat on the bedside table within R47's reach. On 03/20/23 at 01:59 PM Licensed Nurse (LN) G stated she does not see the MMR's. LN G stated she would clarify the diagnosis with physician if she noted an inappropriate diagnosis for antipsychotic medication. On 03/20/23 at 04:49 PM Administrative Nurse E stated the CP comes monthly to review the clinical record of each resident. Administrative Nurse E stated the CP should review for appropriate diagnosis for antipsychotic medications and was not sure if the CP reviewed bowel movements. On 03/21/23 at 02:00 PM CP GG stated she reviewed each resident clinical record monthly. CP GG stated she does make recommendation to the physician for appropriate use of antipsychotic medication. The facility's Procedure: Medication Regimine Review for Nursing policy last revised September 2019 documented the medication regimen of each resident was reviewed by a licensed pharmacist according to Federal, State, and local regulations as well as current standards of practice. The pharmacist would report any irregularities to the attending physician, the facility's medical director, and the director of nursing, and then the reports are acted upon in a manner that meets the needs of the resident. The facility failed to ensure the CP identified and reported a lack of an appropriate indication for antipsychotic medication usage. This deficient practice had the risk for unnecessary medication use and physical complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R6's Electronic Medical Record (EMR) documented diagnoses of chronic pain syndrome, essential hypertension (high blood pressure), seizures, and dementia (progressive mental disorder characterized by failing memory, confusion) with mood disturbance. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. R6 required extensive assistance with two staff for bed mobility and dressing; total dependence with two staff for transfers and toileting; and supervision with setup help for eating. R6 complained of occasional pain rated highest of two out of ten in the last five days of the assessment period. R6 received anticoagulant (medication used to prevent blood from thickening or clotting) and opioid medications seven days in the seven-day lookback period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/07/22, documented R6 had moderate cognitive loss. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 12/07/22, documented R6 required extensive to total assistance with dressing, grooming, personal hygiene, incontinent care, bed mobility, and oral care. The Care Plan dated 12/13/22, documented R6 had dementia and needed assistance with daily ADL care. The Care Plan directed staff assisted R6 with bed mobility, oral care, grooming, personal hygiene, and dressing. The Care Plan dated 12/13/22, documented R6 received scheduled pain medication for chronic pain, joint pain, and diagnosis of brain tumor with a risk for increased pain. The Care Plan directed staff gave scheduled pain medications as ordered, monitored for increased pain and uncontrolled pain, and consulted with her medical doctor for further evaluation and treatment. The Care Plan dated 12/13/22, documented R6 received medications for diagnosis of hypertension with risk for elevated blood pressure. The Care Plan directed staff administered medications per medical doctor order; monitored vital signs per facility protocol or as ordered; and monitored for complaints of headache, nose bleed, shortness of breath, fatigue, and feeling faint. The Care Plan dated 12/13/22, documented R6 had a seizure disorder with a risk for complications and directed staff monitored labs per orders and informed physician of results. R6's EMR documented an order with a start date of 10/30/21 for metoprolol succinate (antihypertensive medication) 25 milligrams (mg) every day for hypertension with instructions to hold and notify medical doctor if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 110 millimeters of mercury (mmHg) or heart rate (HR) was less than 60 beats per minute (bpm); an order with a start date of 05/04/22 for Depakote 500 mg every 12 hours for seizures; an order with a start date of 10/06/22 for Voltaren 1% topical gel applied to right knee and low back twice a day, no dosage noted. A review of R6's Medication Administration Record (MAR) for January 2023 revealed metoprolol was given outside of ordered parameters on 01/07/23, 01/08/23, 01/11/23, 01/12/23, 01/21/23, and 01/29/23. A review of R6's MAR for February 2023 revealed metoprolol was given outside of ordered parameters on 02/01/23, 02/08/23, 02/09/23, 02/10/22, 02/22/23, 02/24/23, 02/27/23, and 02/28/23. A review of R6's MAR for 03/01/23 to 03/16/23 revealed metoprolol was given outside of ordered parameters on 03/02/23, 03/05/23, 03/06/23, and 03/12/23. R6's medical record lacked an order for valproic acid (Depakote) laboratory test. Upon request, the facility provided the last valproic acid laboratory results which was completed on 03/31/21. On 03/15/23 at 10:30 AM, R6 laid in bed and rested, she appeared comfortable. On 03/20/23 at 01:58 PM, Licensed Nurse (LN) G stated antihypertensives were held if the vital signs were outside parameters and were charted in the MAR if it was held. She stated she rechecked the blood pressure before discarding the medication. LN G stated valproic acid laboratory test orders were given by the doctors if the system did not generate it. She stated if the resident was on hospice, the laboratory test would still need done but it was up to the doctor and family. LN G stated medications should have all had dosages and Voltaren came with a dosage card. She stated she called and verified dosage if the order did not have a dosage. On 03/20/23 at 04:49 PM, Administrative Nurse E stated if a medication did not have a dosage on it, the computer would not complete the order. She stated Voltaren was sometimes put in as 1% and the facility reviewed those orders the next day and corrected them to add the dosage. Administrative Nurse E stated the doctors decided when laboratory tests were completed for medications and hospice residents still received laboratory tests if ordered by a physician. She stated she expected staff to hold blood pressure medications if the vitals were outside of parameters then notify the physician. The facility's Administering Medications policy, last revised December 2021, directed medications were administered in accordance with the orders. The facility failed to ensure antihypertensive medications were not given outside of ordered parameters, failed to provide laboratory monitoring for Depakote medication usage, and failed to ensure Voltaren gel had dosing instructions for R6. This deficient practice had the risk for unnecessary medication use and unwarranted physical complications. The facility identified a census of 90 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to provide bowel monitoring for Resident (R) 47, who received opioid (medication used to relieve pain) medications; failed to ensure antihypertensive (medications used to treat high blood pressure) medications were not given outside of parameters for R6; failed to provide laboratory monitoring for R6 who received Depakote (medication used to treat seizures) for two years, and failed to ensure Voltaren (topical pain reliever medication) gel had dosing instructions for R6. This deficient practice had the risk for unnecessary medication use and unwarranted physical complications for the affected residents. Findings included: - R47's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R47 required extensive assistance of one staff member for activities of daily living (ADL). The MDS documented R47 required physical assistance of one staff member for bathing activity. The MDS documented R47 had received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) for three days, antibiotic (class of medication used to treat bacterial infections) for four days, antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) for five days, antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and opioid (a class of medication used to treat pain) for six days during the look back period. R47's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/20/23 documented R47 received several psychotropic medications on a regular basis. R47's Care Plan dated 01/24/23 directed nursing staff to administer medication as ordered, monitor for behaviors and side effects of medications given. Review of the EMR under Point of Care (POC) under daily charting look back report for R47 bowel movement documentation from reviewed from 12/01/22 to 12/28/22 (28 days) revealed no bowel movement documented from 12/07/22 to 12/12/22 (6 days) and 12/24/22 to 12/28/22 (5 days). Review from 01/13/23 to 03/14/23 (61 days) revealed no bowel movement documented from 01/23/23 to 01/29/23 (7 days), 01/31/23 to 02/03/23 (4 days), 02/05/23 to 02/09/23 (5 days), 02/11/23 to 02/20/23 (10 days), and 02/22/23 to 03/08/23 (15 days). Review of R47 s Medication Administration Record from 12/01/22 to 03/14/23, no as needed laxatives was documented as given. Review of the EMR under Physician Orders tab revealed physician orders: Dulcolax suppository laxative (medication used to stimulate or facility evacuation of the bowels) 10 milligrams (mg) give one suppository rectally daily as needed for constipation dated 01/12/23. Magnesium citrus solution (lemon) (laxative) 1.745gram (gm)/30 milliliters (ml) give 30ml by mouth daily as needed for constipation dated 01/12/23. Polyethylene glycol (laxative) 3350 (bulk) powder one packet by mouth twice a day as needed for constipation dated 01/12/23. Fleet enema [sodium phosphates] (laxative) 19-7 gm/11 19-7 gm/1 give rectally every day as needed for constipation dated 01/12/23. Lactulose (laxative) 10 gm/15 mL oral solution give 15gm by mouth three times a day as needed for constipation dated 02/02/23. On 03/14/23 at 01:22 PM R47 laid on the bed with personal items on the bed. A plastic cup which contained pills sat on the bedside table within R47's reach. On 03/20/23 at 01:59 PM Licensed Nurse (LN) G stated she reviewed the resident's chart to find out when their last bowel movement was, at the start of each shift. LN G stated the bowel movements are documented in the point of care (POC) which was reviewed in the resident's clinical record. On 03/20/23 at 04:49 PM Administrative Nurse E stated the charge nurse would run a report at the start of their shift of residents with no documented bowel movement for three days of six shifts and administer any as needed laxatives or notify the physician. The facility was unable to provide a policy related to bowel monitoring. The facility failed to provide bowel monitoring for R47 who received opioid medication. This deficient had the risk for unnecessary medication use and physical complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The electronic medical record for R65 documented diagnoses of hypertension (elevated blood pressure), and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R65 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderately impaired cognition. R65 required extensive assistance of one staff for her activities of daily living (ADLS). R65 received an anti-psychotic medication (a medication used to treat mental/mood disorders) seven of seven days during the lookback period. The Psychotropic Drug Use CAA dated 10/12/22 for R65 documented Risperidone (antipsychotic medication) was ordered for psychosis/hallucinations (sensing things while awake that appear to be real, but the mind created). R65 continued to have problems with hallucinations at times. The Anti-Psychotic Medication Care Plan dated 10/12/22 for R65 directed staff to give medications as ordered and monitor for side effects. Staff was to monitor for target behaviors/symptoms and document per facility policy. Staff was to consult with the physician for gradual dose reduction/discontinuing medication per protocol. The Physician's Order, dated 12/13/2022, documented an order for Risperidone 0.25 mg to be given at bedtime for hallucinations. On, 03/20/23 at 02:51 PM, R65 was observed resting in her bed, awake. On, 03/20/2023 at 01:58 PM Licensed Nurse (LN) G stated that is an antipsychotic did not have an appropriate diagnosis that she would call and clarify with the doctor or go through the chart to see if there was a correct diagnosis. She stated that if she was unable to find a diagnosis, then she would contact the doctor to get the order clarified. On, 03/20/23 at 04:49 PM Administrative Nurse E stated that some appropriate diagnoses for antipsychotic medication use could be bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), or schizophrenia (a serious mental disorder in which people interpret reality abnormally); however, she stated that it will sometimes depend on the doctor as to what diagnosis is assigned for the medications use. She reported being unsure if there was a benefit/risk analysis done before using antipsychotics for off label reasons. The facility's Behavioral Assessments, Intervention and Monitoring policy dated 12/2019 documented the community will comply with regulatory requirements to the use of medications to manage behavioral changes. The facility failed to ensure an adequate indication for use for R65's anti-psychotic medication Risperidone that was used to treat her hallucinations. This placed the resident at risk for side effects and unnecessary antipsychotic medication use. - R6's Electronic Medical Record (EMR) documented diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), unspecified dementia (progressive mental disorder characterized by failing memory, confusion), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), seizures (violent involuntary series of contractions of a group of muscles), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Annual Minimum Data Set (MDS) dated 12/07/22 documented a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. R6 had no behaviors noted. R6 received antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression), antipsychotics (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions), anticoagulants (medication used to prevent blood from thickening or clotting), and opioids (medication used to relieve pain) seven days in the seven-day lookback period. The Quarterly MDS dated 09/21/2022, documented a BIMS score of 10 which indicated moderate cognitive impairment. R6 had no behaviors noted. R6 received antidepressants, antipsychotics, anticoagulants, and opioids seven days in the seven-day lookback period. The Psychotropic (any drug that affects brain activities associated with mental processes and behavior) Drug Use Care Area Assessment (CAA) dated 12/07/2022, documented R6 was taking multiple psychotropic medications for bipolar, psychosis, and depression. The Cognitive Loss Dementia CAA dated 12/07/2022, documented R6 had moderate cognitive loss. The Care Plan dated 12/13/2022, documented that R6 took antipsychotic medication for bipolar, psychosis and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) with risk for side effects. The Physician's Order, dated 01/17/23, directed staff to administer lorazepam intensol (antianxiety medication) 2 milligrams per milliliter (mg/ml) every two hours as needed for anxiety disorder. Review of R6's medical record lacked documentation the PRN lorazepam intensol had a 14 day stop date or physician's rationale for extended use. On 03/15/23 at 10:30 AM, observation revealed R6 was in her room resting in bed. She appeared comfortable. On, 03/20/2023 at 01:58 PM Licensed Nurse (LN) G stated that most of the PRN medications like lorazepam would have a 14 day stop date. LN G stated that if they found a PRN medication, like lorazepam, without a 14 day stop date, that they would report it to the provider. On, 03/20/23 at 04:49 PM Administrative Nurse E stated that PRN medications, such as lorazepam, should have an automatic stop date. The facility's Behavioral Assessments, Intervention and Monitoring policy dated 12/2019 documented the community will comply with regulatory requirements to the use of medications to manage behavioral changes. The facility failed to ensure a 14 day stop date or physician's rationale for extended use for R6's PRN psychotropic medication, placing the resident at risk to receive unnecessary psychotropic medications and adverse medication side effects. - The electronic medical record for R142 documented diagnoses of hypertension (elevated blood pressure), type 2 diabetes mellitus (DM when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood), and tremors (a neurological disorder that causes shaking movements in one or more parts of your body, most often in your hands). The admission Minimum Data Set (MDS) dated [DATE] documented R142 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R142 required extensive assistance of one staff for her activities of daily living (ADL). R142 received antipsychotic medications seven days, antianxiety and hypnotic (a class of medications used to induce sleep and treat insomnia) medications one day in the seven-day look back period. The Psychotropic Drug Use CAA dated 03/21/23 documented R142 was admitted on scheduled Abilify (aripiprazole: an anti-psychotic medication used to treat certain mental/mood disorders). R142 also had as needed alprazolam (a medication used for anxiety and panic disorders). The Anti-anxiety Care Plan dated 03/12/23 documented R142 was taking medication for her involuntary jerking of the left hand/arm. Staff was to administer the mediation as ordered and monitor for side effects. Staff was to consult with the physician for medication review and dose reduction. The Physician's Order, dated 03/02/2023, directed staff to administer alprazolam (antianxiety medication) 0.5 milligrams (mg) three times a day as needed for sleep/anxiety. Review of 142's medical record lacked documentation the PRN alprazolam had a 14 day stop date or physician's rationale for extended use. On, 03/15/23 at 10:45 AM R142 exercised at her physical therapy appointment. On, 03/20/2023 at 01:58 PM Licensed Nurse (LN) G stated that most of the PRN medications like alprazolam would have a 14 day stop date. LN G stated that if they found a PRN medication, like alprazolam, without a 14 day stop date that they would report it to the provider. On, 03/20/23 at 04:49 PM Administrative Nurse E stated that PRN medications, such as alprazolam, should have an automatic stop date. The facility's Behavioral Assessments, Intervention and Monitoring policy dated 12/2019 documented the community will comply with regulatory requirements to the use of medications to manage behavioral changes. The facility failed to ensure the physician implemented an appropriate 14-day stop date or an appropriate rationale for continued use and duration for PRN alprazolam for R142. This deficient practice left R142 at risk for unnecessary medication administration and possible adverse side effects. The facility identified a census of 90 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure Resident (R)47 and R65 had an appropriate diagnosis for antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) medication use and failed to ensure an as needed (PRN) antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication had a 14-day stop date for R6 and R142. This deficient practice had the risk for unnecessary medication use and physical complications for the affected residents. Findings included: - R47's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R47 required extensive assistance of one staff member for activities of daily living (ADL). The MDS documented R47 required physical assistance of one staff member for bathing activity. The MDS documented R47 had received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) for three days, antibiotic (class of medication used to treat bacterial infections) for four days, antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) for five days, antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and opioid (a class of medication used to treat pain) for six days during the look back period. R47's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/20/23 documented R47 received several psychotropic medications on a regular basis. R47's Care Plan dated 01/24/23 directed nursing staff to administer medication as ordered, monitor for behaviors and side effects of medications given. Review of the EMR under Orders tab revealed physician orders: Quetiapine fumarate (antipsychotic) 300 milligrams (mg) give two tablets (600mg) by mouth at bedtime for insomnia (inability to sleep)/depression dated 02/06/23. R47's clinical record lacked physician documentation of clinical indication and rationale for use of antipsychotic without an appropriate diagnosis for a person with dementia. On 03/20/23 at 01:59 PM Licensed Nurse (LN) G stated she would clarify the diagnosis with physician if she noted an inappropriate diagnosis for antipsychotic medication. On 03/20/23 at 04:49 PM Administrative Nurse E stated the CP should review for appropriate diagnosis for antipsychotic medications. Administrative Nurse E stated the facility had approached the physician related to appropriate diagnosis or documentation for risk verse benefit of antipsychotic medication orders. The facility's Behavioral Assessments, Interventions and Monitoring policy last revised December 2019 documented residents would receive behavioral healthcare and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. The facility failed to ensure the physician documented a clinical justification for use of antipsychotic medication for R47 who has a diagnosis of dementia, which had the potential of unnecessary psychotropic medication administration thus leading to possible harmful side effects.

The facility identified a census of 90 residents. The facility identified one resident positive for Clostridium difficile (C-diff- contagious bacteria characterized by foul smelling frequent bowel movements). Based on observations, record review, and interviews, the facility failed to follow transmission-based precautions related to isolation practices for Resident (R)60 (mildly cognitively impaired resident) and failed to perform adequate infection control practices including hand hygiene practices during wound care for R4. The deficient practice placed both residents at risk for the spread of infectious diseases and delayed healing. Findings Included: - A review of the facility's Infection Control Log revealed one resident on isolation precautions for March 2023; R60 for C-Diff. A review of R60's Electronic Medical Record (EMR) revealed she was placed isolation precautions related to C-diff and started Vancomycin (strong medication used to treat resistant bacterial infections) for ten days. R60's isolation was continued on 03/17/22 due to ongoing loose stool and positive test result. On 03/14/23 at 08:01 AM R60 sat in her room. An isolation cart sat next to her entry door with personal protective equipment (PPE) supplies (gloves, gowns, masks, and face shields). R60's room contained two bio-hazard containers for trash and linen. A sign posted on top of the isolation box instructed isolation precautions in place due to a suspected or confirmed infectious agent. The sign instructed staff to see nurse before entry. On 03/14/23 at 01:35PM staff propelled R60 down A Hall towards the C-Hall nursing station. R60's hair was damp and combed. R60 backed into a space by the fish tank area next to R1. R1 attempted to converse with R60 before an unidentified staff female member moved R60 back to her room. R60's room still had the isolation cart and signs in place. On 03/15/23 at 12:25PM Licensed Nurse (LN) J reported R60 was still on isolation but could go onto the unit as long as she was not having diarrhea or symptoms of C-diff. She stated that staff were still required to wear full PPE when performing ADL cares for R60. On 03/20/23 at Administrative Staff B reported that R60 was placed on isolation starting on 03/16/23. She stated that R60 could exit her room as long as she was not having explosive diarrhea or vomiting. She stated she may attend activities, church, eat in the dining hall, or be transported to other rooms in the facility as long as she does not have those symptoms. She stated that staff were expected clean the room, clean to dirty surfaces, disinfect to room based on recommended infection control agent method and follow PPE requirements each time a care is provided. A review of the facility's Clostridium Difficle (C-diff) policy revised 12/2021 noted that preventative measures will be taken to prevent the occurrence of C-diff infections among residents and precautions will be taken while caring for residents with C-Diff . The policy indicated C-diff will be considered in residents with acute diarrhea (three or more unformed stools within 24 hours) or abdominal pain. The policy noted primary reservoirs for C-diff were infected people and surfaces. The policy noted that any activity that involved contact between the resident's hand and/or mouth or instruments may provide opportunities for transmission. The policy indicated residents suspected with C-diff will be placed on contact isolation (act of separating a sick individual with a contagious disease from healthy individuals). The policy noted staff will maintain proper PPE (gowns and gloves) will be maintained by staff while providing cares for the resident. The policy indicated staff will maintain vigilant hand hygiene using soap and water during cares for the resident. The policy indicated enhanced environmental cleaning will be completed including the use of Environmental Protective Agency (EPA) registered germicidal agents effective against C-diff spores. The policy indicated special attention to will be provided to disinfecting items of potential fecal soiling (bed, railings, chairs, railings, room fixtures) using approved disinfecting agent recommended for C-diff spores. The policy indicated residents suspected of C-diff will be verified by a positive cytotoxin assay. The policy indicated testing of asymptomatic residents or repeated testing would not be completed. The policy noted that residents that remained asymptomatic (diarrhea free) for 48 hours can be removed from precautions. The policy indicted all residents will be monitored for dehydrations related to diarrhea. The facility failed to ensure consistent isolation precautions were followed related to R60's C-diff infection. This deficient practice placed R60 at risk for the spread of infectious diseases and delayed healing. -On 03/16/23 at 01:14PM R4 had wound care provided by Licensed Nurese (LN) H in her room. LN H put gloves on and placed the clean wound care items on the bedside table without providing a clean barrier. He then assisted with repositioning R4 and removed her soiled dressings. LN H placed the soiled dressings in trash and removed his gloves. LN H put on new gloves without performing hand hygiene in between glove change and sprayed wound cleanser onto R4's wound. LN H dried the wound with three gauze pads and changed his gloves without performing hand hygiene. LN H mixed ointment together with a Q-tip and applied to ointment to the bed of the wound. LN H again replaced his gloves without completing hand hygiene in between changes. LN H then packed the wound with gauze and applied a dressing to cover it. LN H placed R4's nourishment drink next to her wound care dressing and restarted her tube feeding without performing hand hygiene. On 03/20/23 at 03:20PM LN G reported that she would provide a barrier when handling wound care items or any clean items used for the residents. She stated she would always wash her hands before, during, and after cares provided to the residents. She stated she would always perform hand hygiene in between changing gloves. On 03/20/23 at 04:02PM Administrative Staff B reported staff are expected to completed hand hygiene in between gloves changes for all cares. She stated that the she holds education in-services and training to improve infection control practices for the facility. She stated that staff are expected to foam in and foam out of roam, completed hand hygiene frequently, and ensure infections are not being spread by completing cares for residents. A review of the facility's Wound Care policy revised 01/2022 indicated that infection control practices will be implemented into wound care and dressing changes. The policy noted the all materials will be prepared and placed on a sterile field. The policy noted that hand hygiene will occur during preparation, between glove changes, and after cares are provided. The facility failed to practice hand hygiene during wound care for R4. The deficient practice placed R4 at risk for the spread of infectious diseases and delayed healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 96 residents. The sample included 20 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to notify the physician of elevated blood sugar levels outside the physician ordered parameters for one of five sampled residents, Resident (R) 60. Findings included: - R60's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact) and no behaviors. The MDS documented R60 transferred and walked without staff assistance, and received insulin injections seven days a week. The Diabetic Care Plan, dated 06/29/21, directed staff to check R60's blood sugars as ordered by the physician, monitor for signs and symptoms of hyperglycemia (more than normal amount of sugar in the blood), and notify the physician of abnormal blood sugars and changes in condition. The Physician's Order, dated 02/28/21, directed staff to check R60's blood sugar levels before meals and at bedtime, and notify the physician of blood sugars greater than 400 milligrams per deciliter (mg/dl). Review of R60's June 2021 Medication Administration Record (MAR) recorded the following blood sugar levels greater than 400 mg/dl and lack of physician notification: 06/26/21 at 08:40 PM - 482 mg/dl. Review of R60's July 2021 MAR recorded the following blood sugar levels greater than 400 mg/dl and lack of physician notification: 07/12/21 at 11:06 AM - 403 mg/dl 07/20/21 at 08:43 PM - 431 mg/dl 07/21/21 at 07:29 PM - 441 mg/dl 07/25/21 at 09:24 PM - 443 mg/dl 07/26/21 at 07:39 AM - 402 mg/dl 07/28/21 at 09:27 PM - 425 mg/dl 07/29/21 at 08:38 PM - 465 mg/dl Review of R60's August 1-2, 2021 MAR recorded the following blood sugar levels greater than 400 mg/dl and lack of physician notification: 08/01/21 at 07:14 AM - 401 mg/dl. On 07/29/21 at 08:44 AM, observation revealed R60 walked independently with a walker in the hall and conversed with several other residents and staff. On 07/29/21 at 09:56 AM, Licensed Nurse (LN) G stated staff should check R60's blood sugar levels as ordered by the physician, assess R60 when blood sugars were elevated, and notify the physician for elevated blood sugars greater the 400 mg/dl. On 08/02/21 at 10:02 AM, Administrative Nurse D stated staff should check R60's blood sugar levels as ordered by the physician, assess the resident when blood sugars were elevated, and notify the physician of blood sugar levels greater than 400 mg/dl. The facility's Guidelines for Notifying Health Care Providers policy, dated December 2020, directed staff to notify the physician of abnormal vital signs or monitoring assessments as ordered by the physician. The facility failed to notify the physician of R60's elevated blood sugar levels outside the physician ordered parameters, placing the resident at risk for continued elevated blood sugars and adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R90's admission MDS, dated 04/15/21, recorded the resident required extensive assistance of one to two staff with ADLs and impaired functional range of motion of one side of lower extremities. The MDS recorded the resident at risk for pressure ulcers, no pressure ulcers, surgical wound, and application of ointment/medication other than to feet. The Quarterly MDS, dated 07/07/21, recorded R90 required limited to extensive assistance of one or two staff for ADLs, one or more unhealed pressure ulcers Stage I or higher, one unstageable pressure ulcer, surgical wound, and received surgical and pressure ulcer care. The Activities of Daily Living CAA, dated 04/22/21, documented R90 underwent an open reduction and internal fixation (ORIF- type of surgery used to stabilize and heal broken bones) for a left ankle fracture, wore a support boot, and had been discharged to the facility for skilled services. The Pressure Ulcer Care Plan, dated 04/09/21, directed staff to see physician orders for treatment. The Physician's Order, dated 05/14/21, directed staff to cleanse the resident's left ankle and second toe with normal saline, pat dry, apply Silvagel (gel used to treat pressure ulcers of partial to full thickness wounds) to wound bed, cover with foam dressing, daily, and as needed. The Physician's Order, dated 06/03/21, directed staff to place Xeroform to left inner foot and first metatarsal toe (long bone in the foot, and is palpable along the distal outer edges of the feet) head. The Physician's Order, dated 06/17/21, directed staff to wrap the resident's toes to knees with Ace (stretchable bandage) wrap daily. The Physician's Order, dated 06/18/21, directed staff to apply Silvagel to the resident's left inner ankle and apply a double thick 4 x 4 gauze pad to surgical wound area daily. The Physician's Order, dated 07/04/21, directed staff to apply Silvagel to the resident's second toe and cover with a foam dressing daily. Review of the resident's June 2021 TAR lacked documentation staff completed part or all of the resident's wound care or wrapping the leg on the following days: 06/01/21 06/05/21 06/09/21 06/10/21 06/14/21 06/17/21 06/18/21 06/20/21 06/24/21 06/28/21 06/29/21 Review of the resident's July 2021 TAR lacked documentation staff completed part or all of the resident's wound care or wrapping the lower leg on the following days: 07/02/21 07/04/21 07/05/21 07/06/21 07/09/21 07/10/21 07/12/21 07/14/21 07/16/21 07/18/21 07/19/21 07/21/21 07/22/21 The Interdisciplinary Team Note (IDT), dated 04/29/21 at 07:03 PM, recorded the physician ordered to apply a thin layer of Silvagel to left shin, cover with Xeroform and foam dressing. The order directed staff to fully cover left second toe wound with skin prep and apply folded 4 x 4 gauze dressing to surgical site, wrap with Kerlix from toes to knee, and cover with Ace wrap. The IDT Note, dated 05/13/21 at 05:43 PM, documented the physician ordered to cleanse wounds with normal saline, pat dry, apply Silvagel to wound bases, and cover with foam dressing to left ankle and second toe daily. The IDT Note, dated 06/03/21 at 06:04 PM, documented the physician noted no changes to left inner ankle and second left toe. The note further documented a new area of concern to left inner foot and ordered to cleanse area with normal saline, pat dry, apply Xeroform, and cover with foam dressing daily. On 07/29/21 at 01:59 PM, observation revealed LN K removed the old dressings, cleansed area to left toe, inner left ankle, and surgical wound with normal saline, patted dry with gauze, applied Silvagel to wound beds, and covered with foam dressing. LN K then placed 4 x 4 gauze folded in half over the surgical site, wrapped Kerlix from toes to above surgical site on lower left leg, then finished with Ace wrap to cover the Kerlix gauze. LN K stated the facility's wound team made weekly rounds with the physician to assess wounds for changes, obtained measurements, and documented in the electronic medical record. On 08/02/21 at 10:15 AM, Administrative Nurse D verified staff should follow the physician orders for treatments and the electronic treatment record should be signed when treatments were completed. Administrative Nurse D verified she was unable to find any further documentation related to the unsigned orders in the TAR. On 08/02/21 at 11:06 AM, Administrative Nurse F stated staff should document in the treatment record when they have completed the treatments. The facility's Wound Care/Dressing Change policy, dated December 2017, documented the following information should be recorded in the resident's medical record with the date and time the care was given, the name and title of individual performing the wound care, and any changes to the wound. The facility failed to complete R90's wound treatments as ordered, placing the resident at risk for delayed wound healing. The facility had a census of 96 residents. The sample included 20 residents, with six reviewed for pressure ulcers (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). Based on observation, record review, and interview, the facility failed to consistently complete wound treatment as ordered for three of six sampled residents, Resident (R) 62, R90, and R64. Findings included: - R62's admission Minimal Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, locomotion on and off the unit, limited staff assistance with personal hygiene, and supervision with eating. The MDS documented the resident had one unhealed Stage I (intact skin with nonblanchable redness of a localized area, usually over a bony prominence) pressure ulcer, one Stage III (full thickness tissue loss with exposed subcutaneous fat and some slough (dead skin) pressure ulcer, and one Stage IV (full thickness skin loss with exposed bone, tendon, or muscle, slough or eschar (dead skin) may be present) pressure ulcer. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 03/22/21, documented the facility admitted the resident with several deep tissue injuries (purple or maroon localized are of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and one healing Stage I pressure area. The CAA documented the wound team and physician continued to treat the resident's wounds. The Pressure Ulcer Care Plan, dated 03/16/21, instructed staff to keep the resident's bed linens wrinkle free and not use excess pads, observe skin for redness and breakdown during routine cares, place a cushion in the resident's wheelchair, and off load his heels in bed using pillows as he allowed. The care plan further directed staff to provide physician ordered treatments, place a low air loss mattress on the resident's bed, report concerns to the physician, keep pressure off affected areas as much as possible, and encourage the resident to allow treatments to affected areas. The Physician's Order, dated 07/19/21, instructed staff to cleanse the wound at the base of the resident's right great toe and side of right foot with normal saline, pat dry, apply Xeroform (sterile non-adherent (nonstick) wound dressing), cover with foam dressing, and change dressing daily on the night shift. Review of the July 2021 Treatment Administration Record (TAR) lacked documentation staff completed physician ordered wound treatment on 07/19/21 and 07/20/21. On 07/29/21 at 09:24 AM, observation revealed Licensed Nurse (LN) H provided proper treatment to the resident's wounds. On 07/28/21 at 12:15 PM, LN H stated the resident occasionally refused his wound treatment. If he did, LN H re-approached him later. LN H stated staff should document when wound treatments were completed on the TAR. On 08/02/21 at 10:15 AM, Administrative Nurse D verified staff should follow the physician orders for treatments and sign the resident's electronic TAR when they have completed his wound treatment. Administrative Nurse D verified she was unable to find any further documentation related to the unsigned treatment orders. The facility's revised Wound Care/Dressing Change policy, dated December 2017, documented staff should review and verify physician orders for procedure and document the following in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition 6. All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure and any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. 9. Document physician and family notification of refusal. 10. The signature and title of the person recording the data. The facility failed to consistently complete R62's physician ordered dressing changes, placing the resident at risk for delayed wound healing. - R64's Significant Change MDS, dated 06/21/21, documented the resident had a BIMS score of 11, indicating moderately impaired cognition. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, dressing, toilet use, limited staff assistance with walking in room and corridor, personal hygiene, and supervision with eating. The MDS documented the resident had one unhealed Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead skin). May also present as an intact or open/ruptured serum-filled blister) pressure ulcer, pressure reducing device for chair and bed, on a turning repositioning schedule, and received nutritional interventions for the pressure ulcer. The MDS documented the resident received pressure ulcer care, application of non-surgical dressings, and treatment for a foot wound infection. The Pressure Ulcer CAA, dated 06/21/21, directed staff to cue/assist the resident to reposition every two hours when sitting in a recliner and when in bed. The CAA documented the resident used a pressure reduction mattress and instructed staff to keep the resident's heels off the mattress using pillows as she allowed. The Pressure Ulcers/Skin Prevention Care Plan, dated 06/23/21, documented the resident sat in her recliner most of the day and directed staff to cue the resident to change position due to risk for pressure ulcers. The care plan instructed staff to observe the resident's skin for redness and promptly report to the nurse observed skin breakdown during routine checks. The care plan instructed staff to place a pressure reduction mattress on the resident's bed, float her heels with pillows when in bed, consult with physician at first signs of skin breakdown for early treatment, and provide wound treatments as physician ordered. The Physician's Order, dated 0701/21, instructed staff to cleanse the resident's left great toe wound, pat dry, apply Xeroform, and cover with foam dressing, daily. Review of the June 2021 TAR lacked documentation staff changed the resident's dressing on the following days: 06/06/21 06/08/21 06/13/21 On 07/27/21 at 04:30 PM, observation revealed LN J provided wound dressing change to R62's left outer foot and great toe wounds. On 08/02/21 at 10:15 AM, Administrative Nurse D verified staff should follow the physician orders for treatments and sign the resident's electronic TAR when they have completed her wound treatment. Administrative Nurse D verified she was unable to find any further documentation related to the unsigned treatment orders. The facility's revised Wound Care/Dressing Change policy, dated December 2017, documented staff should review and verify physician orders for procedure and document the following in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition 6. All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure and any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. 9. Document physician and family notification of refusal. 10. The signature and title of the person recording the data. The facility failed to consistently complete R62's physician ordered dressing changes, placing the resident at risk for delayed wound healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R73's Physician Order Sheet (POS), dated 06/28/21, documented diagnoses of congestive heart failure (condition with low heart output and the body becomes congested with fluid) and cardiomyopathy (heart disease). R73's Quarterly MDS, dated 06/02/21, recorded the resident had a BIMS score of 14, indicating intact cognition and required extensive assistance of one staff for all ADLs except eating, which she was independent. The MDS recorded the resident received antipsychotic, antidepressants, anti-anxiety, anticoagulants, opioids, and antibiotics (class of medication used to treat bacterial infections). The Blood Pressure Care Plan, dated 06/28/21, directed staff to administer medications as ordered to ensure blood pressure remained stable and below 150/90 millimeters of Mercury (mmHg), monitor for side effects such as hypotension (low blood pressure), headache, weakness, nausea, vomiting, dizziness, and constipation, and monitor vital signs as ordered. The Cardiovascular Disease Care Plan, dated 06/28/21, directed staff to monitor vital signs as ordered, check pulse before administering metoprolol (medication used to treat high blood pressure) as this medication may cause bradycardia (low heartbeat, less than 60 beats per minute (bpm), and report any abnormalities to the physician. The Constipation Care Plan related to Opioid Use, dated 06/28/21, directed staff to administer medications as ordered, monitor to ensure the resident had a bowel movement at least every three days, administer as needed medications and monitor for effectiveness, and report concerns to the resident's physician. The Physician's Order, dated 04/06/21, directed staff to administer the resident metoprolol succinate ER 25 mg by mouth every morning for hypertension. Hold and notify physician if systolic blood pressure (SBP) less than 110 mmHg or heartrate less than 60 bpm. The Medication Regimen Reviews, dated March 2021-June 2021, failed to identify blood pressures and pulses out of physician ordered parameters. Review of R73's April 2021 Electronic Medication Administration Record, (EMAR) lacked blood pressure and pulse monitoring prior to the administration of metoprolol succinate on the following dates: 04/08/21 04/12/21 04/13/21 04/17/21 04/18/21 04/21/21 04/22/21 04/27/21 Review of R73's May 2021 EMAR, lacked blood pressure and pulse monitoring prior to the administration of metoprolol succinate on the following dates: 05/01/21 05/02/21 05/05/21 05/06/21 05/10/21 05/15/21 05/19/21 05/20/21 05/29/21 Review of R73's May 2021 Electronic Medical Record-Bowel Movements (EMR) documented bowel movements on the following days: 05/10/21 (at least 10 days) 05/11/21 05/21/21 (9 days without a bowel movement) Review of R73's June 2021 EMR Bowel Movements documented bowel movements on the following days: 06/30/21 (39 days without a bowel movement) Review of R73's July 2021 EMR Bowel Movements documented bowel movements on the following days: 07/01/21 07/09/21 (7 days without a bowel movement) 07/10/21 07/15/21 (4 days without a bowel movement) 07/17/21 07/23/21 (5 days without a bowel movement) 07/28/21 (4 days without a bowel movement) 07/29/21 On 07/29/21 08:26 AM, observation revealed Certified Medication Aid (CMA) S obtained the resident's vitals signs and then administered the resident's medications. Observation revealed the resident swallowed her medications without difficulty. On 08/02/21 at 02:35 PM, Administrative Nurse D stated she expected the Consultant Pharmacist to review bowel monitoring and medications, and note if the blood pressures and pulses were not being documented. The facility's Medication Regimen Review for Nursing policy, dated September 2019, documented the medication regimen of each resident is reviewed by a licensed Pharmacist according to Federal, State, and Local regulations as well as current standards of practice. The pharmacist reports any irregularities to the Attending Physician, the facility's Medical Director and Director of Nursing, and these reports are acted upon in a manner that meets the needs of the residents. The facility's Consultant Pharmacist failed to identify R73's missing blood pressures and pulses prior to the administration of metoprolol succinate, and lack of bowel movements, placing the resident at risk for adverse side effects from medications. - R90's Quarterly MDS, dated 07/07/21, recorded the resident had moderate cognitive impairment, required limited to extensive assistance of one or two staff for activities of daily living (ADLs), always incontinent of urine and always continent of bowel. The MDS recorded R90 received antidepressant (class of medications used to treat mood disorders and relieve symptoms of abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), antianxiety (class of medications that calm and relax people with excessive mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, nervousness, or tension), diuretic (medication to promote the formation and excretion of urine ), and opioid (narcotic pain medication) pain medication. The Medication Care Plan, dated 04/21/21, documented the resident had potential for drug related complications related to antidepressant and antianxiety medication use. The care plan directed staff to observe, document, and report to the medical doctor as needed signs or symptoms of drug related complications. Review of the June 2021 Bowel Movement Record documented the resident had a bowel movement on the following days: 06/23/21 06/24/21 Review of the July 2021 Bowel Movement Record documented the resident had a bowel movement on the following days: 07/29/21 (34 days without a bowel movement) The April - June 2021 Pharmacy Review Progress Notes lacked documentation related to bowel function. On 07/28/21 at 09:41 AM, observation revealed R90 sat in a wheelchair in her room working with therapy weights. On 08/02/21 at 12:44 PM, Administrative Nurse D reported bowel movement charting had been poor due to use of agency staff and staff should ensure that the resident was having a bowel movement every third day. On 08/02/21 at 02:35 PM, Administrative Nurse D stated she expected the Consultant Pharmacist to review bowel monitoring and medications, and note if the blood pressures and pulses were not being documented. The facility's Medication Regimen Review policy, dated September 2019, directed the facility's Consultant Pharmacist to identify and report irregularities in the residents' medication regimen to the facility's Medical Director and Director of Nursing. The facility's Consultant Pharmacist failed to identify R90's lack of bowel movements, placing the resident at risk for adverse side effects from medications. - R87's admission MDS, dated 07/17/21, recorded the resident had severe cognitive impairment, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), other behavioral symptoms not directed toward others, which significantly interfered with R87's participation in activities or social interactions, and intruded on the privacy or activity of others. The MDS recorded the resident required limited staff assistance with ADLs, always incontinent of bladder and occasionally incontinent of bowel, received scheduled pain, antianxiety, and antidepressant medications. The Activity of Daily Living Care Area Assessment (CAA), dated 07/17/21, recorded the resident required staff assistance with toileting, at risk for further incontinence, and received medications for depression and anxiety. The Medication Care Plan, dated 07/20/21, documented potential drug related complications associated with antidepressant, antipsychotic, and antianxiety medications. The care plan directed staff to observe, document, and report to the medical doctor as needed for signs and symptoms of drug related complications. Review of the July 2021 Bowel Movement Record documented the resident had no bowel movements the entire month. (31 days) The Pharmacy Review Progress Note, dated 07/19/21, lacked documentation related to bowel function. On 07/29/21 at 02:10 PM, observation revealed the resident smiled and visited with staff. On 08/02/21 at 12:44 PM, Administrative Nurse D reported bowel movement charting had been poor due to use of agency staff and staff should ensure that the resident was having a bowel movement every third day. On 08/02/21 at 02:35 PM, Administrative Nurse D stated she expected the Consultant Pharmacist to review bowel monitoring and medications, and note if the blood pressures and pulses were not being documented. The facility's Medication Regimen Review policy, dated September 2019, directed the facility's Consultant Pharmacist to identify and report irregularities in the residents' medication regimen to the facility's Medical Director and Director of Nursing. The facility's Consultant Pharmacist failed to identify R87's lack of bowel movements, placing the resident at risk for adverse side effects from medications. - R21's Quarterly MDS, dated 05/05/21, documented the resident has severe cognitive impairment, required extensive to total dependence on one or two staff for ADLs, and always incontinent of bladder and bowel. The MDS further documented the resident received scheduled pain, anticoagulant (having the effect of retarding the coagulation of the blood), opioid, and diuretic medications. The Activity of Daily Living CAA, dated 02/10/21, recorded R21 dependent on one to two staff for ADLs and always incontinent of bladder and bowel. The Medication Care Plan, dated 05/05/21, recorded the resident had diseases and conditions that were treated with medications. The care plan directed staff to see current medication orders and warnings associated with current medications. Review of the May 2021 Bowel Movement Record documented the resident had no bowel movements the entire month. (at least 31 days) Review of the June 2021 Bowel Movement Record documented the resident had a bowel movement on the following days: 06/08/21 06/11/21 06/23/21 (12 days without a bowel movement) Review of the July 2021 Bowel Movement Record documented the resident had a bowel movement on the following days: 07/07/21 (13 days without a bowel movement) 07/22/21 (14 days without a bowel movement) The Pharmacy Review Progress Note, dated 07/19/21, lacked documentation related to bowel function. On 07/29/21 at 09:16 AM, observation revealed resident watched TV until staff assisted the resident to his room to check him for incontinence. On 08/02/21 at 12:44 PM, Administrative Nurse D reported bowel movement charting had been poor due to use of agency staff, and staff should ensure that the resident was having a bowel movement every third day. On 08/02/21 at 02:35 PM, Administrative Nurse D stated she expected the Consultant Pharmacist to review bowel monitoring and medications and note if the blood pressures and pulses were not being documented. The facility's Medication Regimen Review policy, dated September 2019, directed the facility's Consultant Pharmacist to identify and report irregularities in the residents' medication regimen to the facility's Medical Director and Director of Nursing. The facility's Consultant Pharmacist failed to identify R21's lack of bowel movements, placing the resident at risk for adverse side effects from medications. The facility had a census of 96 residents. The sample included 20 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to identify blood sugar levels for Resident (R) 60 out of physician ordered parameters, monitor blood pressures and pulses for R73, and monitor bowel movements for R21, R87, R73, and R90. Findings included: - R60's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact) and no behaviors. The MDS documented R60 transferred and walked without staff assistance, and received insulin injections seven days a week. The Diabetic Care Plan, dated 06/29/21, directed staff to check R60's blood sugars as ordered by the physician, monitor for signs and symptoms of hyperglycemia (more than normal amount of sugar in the blood), and notify the physician of abnormal blood sugars and changes in condition. The Physician's Order, dated 02/28/21, directed staff to check R60's blood sugar levels before meals and at bedtime, and notify the physician of blood sugars greater than 400 milligrams per deciliter (mg/dl). Review of R60's June 2021 Medication Administration Record (MAR) recorded the following blood sugar levels greater than 400 mg/dl and lack of physician notification: 06/26/21 at 08:40 PM - 482 mg/dl. Review of R60's July 2021 MAR recorded the following blood sugar levels greater than 400 mg/dl and lack of physician notification: 07/12/21 at 11:06 AM - 403 mg/dl 07/20/21 at 08:43 PM - 431 mg/dl 07/21/21 at 07:29 PM - 441 mg/dl 07/25/21 at 09:24 PM - 443 mg/dl 07/26/21 at 07:39 AM - 402 mg/dl 07/28/21 at 09:27 PM - 425 mg/dl 07/29/21 at 08:38 PM - 465 mg/dl Review of R60's August 1-2, 2021 MAR recorded the following blood sugar levels greater than 400 mg/dl and lack of physician notification: 08/01/21 at 07:14 AM - 401 mg/dl. Review of R60's Monthly Medication Regimen Review, dated 07/31/21, recorded the Consultant Pharmacist had not identified any irregularities in the resident's medication regimen. On 07/29/21 at 08:44 AM, observation revealed R60 walked independently with a walker in the hall and conversed with several other residents and staff. On 08/02/21 at 10:02 AM, Administrative Nurse D stated the Consultant Pharmacist had not identified or reported the inadequate monitoring of R60's elevated blood sugars and the lack of physician notification for blood sugars outside the physician ordered parameters. The facility's Medication Regimen Review policy, dated September 2019, directed the facility's Consultant Pharmacist to identify and report irregularities in the residents' medication regimen to the facility's Medical Director and Director of Nursing. The facility's Consultant Pharmacist failed to report the inadequate monitoring of R60's elevated blood sugars, placing the resident at risk for continued elevated blood sugars and adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 96 residents. The sample included 20 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor blood sugars for Resident (R) 60, bowel movements for R21, R73, R87, and R90, and blood pressures and pulses for R73. Findings included: - R73's Physician Order Sheet (POS), dated 06/28/21, documented diagnoses of congestive heart failure (a condition with low heart output and the body becomes congested with fluid) and cardiomyopathy (heart disease). R73's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required extensive assistance of one staff for all activities of daily living (ADLs) except eating, which she was independent. The MDS recorded the resident received antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions), antidepressants (class of medication used to treat mood disorders and relieve symptoms of abnormal exaggerated feelings of sadness, worthlessness and emptiness), anti-anxiety (class of medication that calms and relaxes people with excessive apprehension, uncertainty and irrational fear, nervousness, or tension), anticoagulants (class of medications that help prevent blood clots), opioids (class of medications used to treat severe pain), and antibiotics (class of medication used to treat bacterial infections). The Blood Pressure Care Plan, dated 06/28/21, directed staff to administer medications as ordered to ensure blood pressure remained stable and below 150/90 millimeters of Mercury (mmHg), monitor for side effects such as hypotension (low blood pressure), headache, weakness, nausea, vomiting, dizziness, and constipation, and monitor vital signs as ordered. The Cardiovascular Disease Care Plan, dated 06/28/21, directed staff to monitor vital signs as ordered, check pulse before administering metoprolol (medication used to treat high blood pressure) as this medication may cause bradycardia (low heartbeat, less than 60 beats per minute (bpm), and report any abnormalities to the physician. The Constipation Care Plan related to Opioid Use, dated 06/28/21, directed staff to administer medications as ordered, monitor to ensure the resident had a bowel movement at least every three days, administer as needed medications and monitor for effectiveness, and report concerns to the resident's physician. The Physician's Order, dated 04/06/21, directed staff to administer the resident metoprolol succinate ER 25 milligrams (mg) by mouth every morning for hypertension. Hold and notify physician if systolic blood pressure (SBP) less than 110 mmHg or heartrate less than 60 bpm. The Medication Regimen Reviews, dated March 2021 - June 2021, failed to identify blood pressures and pulses out of physician ordered parameters. Review of R73's April 2021 Electronic Medication Administration Record (EMAR), lacked blood pressure and pulse monitoring prior to the administration of metoprolol succinate on the following dates: 04/08/21 04/12/21 04/13/21 04/17/21 04/18/21 04/21/21 04/22/21 04/27/21 Review of R73's May 2021 EMAR lacked blood pressure and pulse monitoring prior to the administration of metoprolol succinate on the following dates: 05/01/21 05/02/21 05/05/21 05/06/21 05/10/21 05/15/21 05/19/21 05/20/21 05/29/21 Review of R73's May 2021 Electronic Medical Record-Bowel Movements (EMR) documented bowel movements on the following days: 05/10/21 (at least 10 days) 05/11/21 05/21/21 (9 days) Review of R73's June 2021 EMR-Bowel Movements documented bowel movements on the following days: 06/30/21 (39 days) Review of R73's July 2021 EMR Movements documented bowel movements on the following days: 07/01/21 07/09/21 (7 days) 07/10/21 07/15/21 (4 days) 07/17/21 07/23/21 (5 days) 07/28/21 (4 days) 07/29/21 On 07/29/21 08:26 AM, observation revealed Certified Medication Aide (CMA) S obtained the resident's vitals signs and then administered the resident's medications. The resident was able to take her medications without difficulty. On 08/02/21 at 11:00 AM, Licensed Nurse (LN) I stated the facility did not have a bowel protocol. The nurses talked to the residents and relied on them to let staff know if they were not having bowel movements. The nurses assessed bowel sounds, any abdominal distention, or nausea. If there was a problem then we proceeded from there. On 08/02/21 at 12:05 PM, CMA R stated before she administered any blood pressure medications she checked the resident's blood pressure and pulse to make sure they were okay and then administered the medications if there were no problems. If the blood pressure and pulse were too low then CMA R held the medication and let the nurse know. All of the vital signs are charted in the EMAR. On 08/02/21 at 12:05 PM, LN H stated the computer prompted the user to enter the vital signs prior to administration so all vital signs should be performed prior to administration of any blood pressure medications with parameters. On 08/02/21 at 02:35 PM, Administrative Nurse D stated the facility did not have a bowel protocol. For the independent residents staff ask them if they have had a bowel movement. Our nurses review the bowel documentation and if it is determined that a resident may not have had a bowel movement for a period of time then the nurses assess the resident for discomfort, lack of appetite, nausea, abdominal distention, and then start reviewing the residents as needed (PRN) medications, and contact the doctor to see how he wants to proceed. Administrative Nurse D stated she expected the nurses to review the bowel movements for the residents, document and review all vital signs for abnormalities as physician ordered, and chart in the EMAR. Upon request, the facility was unable to provide a policy regarding bowel protocol. The facility's Documentation of Medication Administration policy, dated December 2019, documented the community shall maintain a medications administration record to document medications administered and reason why medications are withheld or not administered. The facility failed to monitor R73's blood pressures, pulses, and bowel movements as physician ordered, placing the resident at risk for adverse side effects. - R90's Quarterly MDS, dated 07/07/21, recorded the resident had moderate cognitive impairment, required limited to extensive assistance of one or two staff for ADLs, always incontinent of urine and always continent of bowel. The MDS recorded R90 received antidepressant, antianxiety, diuretic, opioid pain medications. The Medication Care Plan, dated 04/21/21, documented the resident had potential for drug related complications related to antidepressant and antianxiety medication use. The care plan directed staff to observe, document, and report to the medical doctor as needed signs or symptoms of drug related complications. Review of the June 2021 Bowel Movement Record documented the resident had a bowel movement on the following days: 06/23/21 06/24/21 Review of the July 2021 Bowel Movement Record documented the resident had a bowel movement on the following days: 07/29/21 (34 days) The April - June 2021 Pharmacy Review Progress Notes lacked documentation related to bowel function. On 07/28/21 at 09:41 AM, observation revealed R90 sat in a wheelchair in her room working with therapy weights. On 08/02/21 at 12:44 PM, Administrative Nurse D reported bowel movement charting had been poor due to use of agency staff and staff should ensure that the resident was having a bowel movement every third day. On 08/02/21 at 02:35 PM, Administrative Nurse D stated the facility did not have a bowel protocol. Upon request, the facility was unable to provide a policy regarding bowel protocol. The facility failed to document and monitor R90's bowel movements, placing the resident at risk of constipation and possible bowel obstruction. - R87's admission MDS, dated 07/17/21, recorded the resident had severe cognitive impairment, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), other behavioral symptoms not directed toward others, which significantly interfered with R87's participation in activities or social interactions, and intruded on the privacy or activity of others. The MDS recorded the resident required limited staff assistance with ADLs, always incontinent of bladder and occasionally incontinent of bowel, received scheduled pain, antianxiety, and antidepressant medications. The Activity of Daily Living Care Area Assessment, dated 07/17/21, recorded the resident required staff assistance with toileting, at risk for further incontinence, and received medications for depression and anxiety. The Medication Care Plan, dated 07/20/21, documented potential drug related complications associated with antidepressant, antipsychotic, and antianxiety medications. The care plan directed staff to observe, document, and report to the medical doctor as needed for signs and symptoms of drug related complications. Review of the July 2021 Bowel Movement Record documented the resident had no bowel movement the entire month. (31 days) The Pharmacy Review Progress Note, dated 07/19/21, lacked documentation related to bowel function. On 07/29/21 at 02:10 PM, observation revealed the resident smiled and visited with staff. On 08/02/21 at 12:44 PM, Administrative Nurse D reported bowel movement charting had been poor due to use of agency staff and staff should ensure that the resident was having a bowel movement every third day. On 08/02/21 at 02:35 PM, Administrative Nurse D stated the facility did not have a bowel protocol. Upon request, the facility was unable to provide a policy regarding bowel protocol. The facility failed to document and monitor R87's bowel movements, placing the resident at risk of constipation and possible bowel obstruction. - R21's Quarterly MDS, dated 05/05/21, documented the resident had severe cognitive impairment, required extensive to total dependence on one or two staff members for ADLs, and always incontinent of bladder and bowel. The MDS further documented the resident received scheduled pain, anticoagulant (having the effect of retarding the coagulation of the blood), opioid, and diuretic medications. The Activity of Daily Living CAA, dated 02/10/21, recorded R21 dependent on one to two staff for ADLs and always incontinent of bladder and bowel. The Medication Care Plan, dated 05/05/21, recorded the resident had diseases and conditions that were treated with medications. The care plan directed staff to see current medication orders and warnings associated with current medications. Review of the May 2021 Bowel Movement Record documented the resident had no bowel movements the entire month. (at least 31 days) Review of the June 2021 Bowel Movement Record documented the resident had a bowel movement on the following days: 06/08/21 06/11/21 06/23/21 (12 days) Review of the July 2021 Bowel Movement Record documented the resident had a bowel movement on the following days: 07/07/21 (13 days) 07/22/21 (14 days) The Pharmacy Review Progress Note, dated 07/19/21, lacked documentation related to bowel function. On 07/29/21 at 09:16 AM, observation revealed the resident watched TV until staff assisted the resident to his room to check him for incontinence. On 08/02/21 at 12:44 PM, Administrative Nurse D reported bowel movement charting had been poor due to use of agency staff and staff should ensure that the resident was having a bowel movement every third day. On 08/02/21 at 02:35 PM Administrative Nurse D stated the facility did not have a bowel protocol. Upon request, the facility was unable to provide a policy regarding bowel protocol. The facility failed to document and monitor R21's bowel movements, placing the resident at risk of constipation and possible bowel obstruction. - R60's Quarterly MDS, dated 06/16/21, documented the resident had a BIMS score of 13 (cognitively intact) and no behaviors. The MDS documented R60 transferred and walked without staff assistance and received insulin injections seven days a week. The Diabetic Care Plan, dated 06/29/21, directed staff to check R60's blood sugars as ordered by the physician, monitor for signs and symptoms of hyperglycemia (more than normal amount of sugar in the blood), and notify the physician of abnormal blood sugars and changes in condition. The Physician's Order, dated 02/28/21, directed staff to check R60's blood sugar levels before meals and bedtime, and notify the physician of blood sugars greater than 400 milligrams per deciliter (mg/dl). Review of R60's June 2021 Medication Administration Record (MAR) recorded the following blood sugar levels greater than 400 mg/dl and lack of physician notification: 06/26/21 at 08:40 PM - 482 mg/dl Review of R60's July 2021 MAR recorded the following blood sugar levels greater than 400 mg/dl and lack of physician notification: 07/12/21 at 11:06 AM - 403 mg/dl 07/20/21 at 08:43 PM - 431 mg/dl 07/21/21 at 07:29 PM - 441 mg/dl 07/25/21 at 09:24 PM - 443 mg/dl 07/26/21 at 07:39 AM - 402 mg/dl 07/28/21 at 09:27 PM - 425 mg/dl 07/29/21 at 08:38 PM - 465 mg/dl Review of R60's August 2021 MAR recorded the following blood sugar levels greater than 400 mg/dl and lack of physician notification: 08/01/21 at 07:14 AM - 401 mg/dl On 07/29/21 at 08:44 AM, observation revealed R60 walked independently with a walker in the hall and conversed with several other residents and staff. On 07/29/21 at 09:56 AM, LN G stated staff checked R60's blood sugar levels as ordered by the physician, assessed R60 when blood sugars were elevated, and notified the physician for elevated blood sugars greater the 400 mg/dl. On 08/02/21 at 10:02 AM, Administrative Nurse D stated staff should check R60's blood sugar levels as ordered by the physician, assess the resident when blood sugars were elevated, and notify the physician of blood sugar levels greater than 400 mg/dl. The facility's Medication Administration policy, dated December 2019, directed staff to monitor the effectiveness of medications and report ineffective or undesired responses to medications to the physician. The facility's Diabetes Mellitus policy, dated December 2019, directed staff to check blood sugar levels as ordered by the physician, assess residents with abnormal blood sugars, and notify the physician. The facility failed to adequately monitor R60's blood sugar levels, placing the resident at risk for continued elevated blood sugar levels and associated side effects.

The facility had a census of 96 residents. The sample included 20 residents. Based on observation and interview, the facility failed to identify and remove expired medications in one of three medication rooms. Finding included: - On 07/27/21 at 08:40 AM, observation during initial tour of the facility revealed the B Hall medication room contained one bottle of Calcium 600 milligrams (mg) 150 tablets with an expiration date of 06/2021 and two bottles of Children Ibuprofen Oral Suspension 120 milliliters (ml) with expiration date of 05/2021. On 07/27/21 at 08:41 AM, Administrative Nurse E verified the Calcium tablets expired 06/2021 and Children's Ibuprofen expired 05/2021. Administrative Nurse E removed and disposed the items and stated expired medications should not be left in the medication room for use. The facility's Labeling of Medication Containers policy, dated August 2021 documented medications maintained in the community shall be properly labeled in accordance with state and federal regulations. Expired medications to be destroyed per protocol for medication destruction, label for each floor stock medication shall include all necessary information including the expiration date. The facility failed to remove expired medication in one of three medication storage rooms, placing the residents at risk for receiving ineffective medications.