The facility reported a census of 29 residents. Based on the observation, interview, and record review, the facility failed to ensure a safe environment at the front entrance of the facility and failed to ensure a sanitary environment in staff and visitor areas throughout the facility. This deficient practice had the risk of impaired health and safety.Findings included: - On 07/23/25 at 08:15 AM, the front door entrance to the facility revealed a large, rubberized rug covering the sloped walkway from the parking lot to the entrance of the facility. On 07/23/25 at 08:20 AM, an environmental tour with Administrative Staff A, Maintenance Staff U, and Housekeeping V revealed multiple areas throughout the facility of a black, white, yellow, and/or green substance on the walls, floors, and ceilings, including the following areas:The public restroom on the Southwest wing.The soiled and clean laundry area on the Northwest wing.,The central corridor included the kitchen area.The smoking lounge and medical records storage area are on the Southeast wing. On 07/23/25 at 10:40 AM, an additional tour of the facility service area with Administrative Staff A, Administrative Nurse D, Maintenance U, and Housekeeping V revealed multiple areas of the substance in the boiler room, laundry, and HVAC room. On 07/24/25 at 01:30 PM, the surveyor stumbled on the large rubberized rug upon leaving the building with Administrative Staff A. Administrative Staff A pulled back the large rubberized rug to reveal a large hole in the underlying cement and commented that was the reason why the rug was there, to cover the hole so residents, staff, and visitors did not trip and fall due to the crumbling cement at the entrance to the facility. On 07/23/25 at 12:10 PM, Licensed Nurse (LN) G said the floors in the records room had black spots for months. He reported that a lot of staff have complained of headaches and sore throats for weeks. On 07/23/25 12:35 PM, Certified Nurse Aide (CNA) N reported that in the recent past, there was a leak in the ceiling on the southwest hallway while it was raining outside, and there was a bucket placed underneath to catch the water. She reported a musty smell from the back hallway. On 07/23/25 03:55 PM, Administrative Staff A said that the decision to evacuate residents and restrict visitors and staff from areas within the facility would have to be made by corporate. He confirmed the above findings and stated that the environmental staff systematically cleaned all visible surfaces of all the affected and unaffected rooms and inspected for additional mold growth. On 07/24/25 at 12:30 PM, Administrative Staff A confirmed the above findings and reported that facility staff inspected the facility and identified all the rooms on the Southwest hallway, all of the rooms but one on the Northwest hallway, all the rooms but two on the Southeast hallway, and one room on the Northeast hallway were contaminated with mold. Administrative Staff A said he informed Consultant GG on 07/21/25 about the environmental concern and was told not to test the substance to verify presence or absence of mold due to the facility's obligation to treat if testing was positive for mold. Administrative Staff A said the leadership team held a tabletop exercise related to emergency preparedness and identified the best course of action was to evacuate the residents until the environmental concern could be appropriately treated. Administrative Staff A said on the evening of 07/21/25, Consultant GG toured the facility with Administrative Staff A, and Administrative Staff A pointed out the areas of concern in the hallways. Administrative Staff A said he presented the decision by the leadership team to evacuate the residents to Consultant GG and reported he was instructed by Consultant GG to instruct other members of the leadership team to stay in their lane and resume their assigned jobs. Administrative Staff reported that on the morning of 07/22/25, the leadership team met but had not received additional instructions from Consultant GG to evacuate the residents and instead received instructions to have the housekeeping staff spray all visible surfaces with Virex. Administrative Staff A further stated that 15 of the staff reported not feeling well in the days leading up to the discovery of the mold. The facility policy Infection Management Process, dated 11/2023, did not address mold treatment and or removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 14 residents selected for review, which included one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide grooming for one Resident (R)5 in a manner of his choosing. Findings included: - Review of Resident (R) 5's medical record revealed diagnoses that included schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and pneumonia (inflammation of the lungs), due to SARS (severe acute respiratory syndrome) due to COVID. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The resident had no impairment in upper or lower extremities but required set up assistance for personal hygiene. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/11/24, assessed R5 required partial assistance with hygiene due to illness. The Quarterly MDS, dated 08/01/24, assessed the resident with a BIMS score of five, which indicated severe cognitive impairment. R5 had no impairment in upper or lower extremities and required substantial to maximal assistance with personal hygiene. The Care Plan reviewed 07/19/24, instructed staff R5's ability to perform ADL varied and staff advised to offer assistance for ADLs and daily shaving. Observation, on 09/17/24 at 04:42 PM, revealed the resident seated in his wheelchair in the dining room. R5 had several days worth of facial hair, overgrown sideburns and eyebrows, hair in his ears and nose, and fingernails approximately ¼ inch in length. Observation, on 09/18/24 at 01:26 PM, revealed the R5 positioned in his bed. R5 had several days' worth of facial hair, overgrown sideburns and eyebrows, hair in his ears and nose, and fingernails approximately ¼ inch in length. R5 stated he did not think his electric razor worked properly and he tried to use fingernail clippers but could not cut his fingernails. Interview with Certified Nurse's Aide (CNA) N, reported he needed assistance with grooming, and this was usually done on bath days, which were Sundays and Thursdays. Interview, on 09/18/24 at 02:53 PM, Social Service Staff X reported he was in the process of finding a beautician to provide grooming services to the resident and did not know when the last time the resident received grooming services. Social Service Staff X stated he would investigate the problem with R5's electric razor. Interview, on 09/19/24 at 08:30 AM, with Administrative Nurse D, revealed she would expect staff to provide grooming services to R5 per the standard of practice. The facility failed to provide a policy for grooming. The facility failed to provide grooming services for R5 who required assistance with personal hygiene which included facial hair removal and fingernail trimmings to maintain himself in a dignified manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 14 residents sampled for review. Based on observation, interview, and record review, the facility failed to complete an accurate Significant Change Minimum Data Set (MDS), dated [DATE], as required, for Resident (R)83, regarding falls. Findings included: - Review of Resident (R)83's electronic medical record (EMR) included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident had no limitation in functional range of motion (ROM), used a wheelchair for mobility and had one non-injury fall and one injury (except major) fall since the prior assessment. The Fall Care Area Assessment (CAA), dated 01/25/24, lacked information regarding the resident's falls. The Modification of Significant Change MDS, dated 01/11/24, documented the staff assessment for cognition revealed severe impairment. He was dependent on staff for mobility, had no limitation in ROM, and had two non-injury falls and one injury (except major) fall since the prior assessment. The care plan, revised 01/02/24, instructed staff the resident could be impulsive. Staff were to ensure his room was free from clutter and not leave him alone in the wheelchair while in his room. Staff were to ensure he wore geri-sleeves (a protective covering on his arms) to help prevent injuries. Review of the resident's EMR revealed multiple Fall Assessments which placed the resident at a high risk for falls, dated: 01/22/24, 01/07/24, 12/28/23 and 12/08/23. On 09/19/24 at 11:36 AM, Administrative Nurse D confirmed the falls CAA for this resident lacked fall information. The facility used the Resident Assessment Instrument (RAI) for the accurate completion of MDSs. The facility failed to complete an accurate Significant Change MDS, dated [DATE], for this resident with a history of falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to review and revise the care plan for one Resident (R)3, related skin tear prevention. This deficient practice placed R3 at risk for repeated skin tears. Findings included: - Review of Resident (R)3's undated Physician Orders, (POS) documentation included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) right hand, diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (high blood pressure), sleep apnea (absence of breathing during sleep), gout (inflammation of the joints) , anxiety disorder, (mental or emotional disorder characterized by reactions of apprehension, uncertainty and irrational fear), and pain. The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The resident demonstrated verbal and physical behavioral symptoms directed towards others during the look back period. He had functional limitation in active range of motion of upper and lower extremities on both sides of his body. The resident reported almost constant pain. The clinical skin assessment identified the resident was at risk for pressure ulcer injury (PU) and was without identified skin treatments. He received anticoagulant (blood thinners) and opioids. (narcotic pain medication). The Quarterly MDS, dated [DATE], revealed changes which included a BIMS score of 09, indicating further decline in moderate cognitive impairment. He received application of nonsurgical dressings (with or without topical medications) other than to feet. The Functional Abilities and Mobility Care Area Assessment (CAA) dated 01/29/24, documentation included he had cerebral palsy. The resident was not ambulatory, (able to walk) and confined to his bed He was totally dependent on staff for his activities of daily living (ADLs) due to his contractures (abnormal permanent fixation of a joint or muscle) to upper and lower extremities. His finger/hand contractures put him at risk of spills of liquids/foods and used an adaptive cup for his coffee. The Care Plan dated 07/27/24, directed staff the resident required staff assistance with ADL's related to his physical limitations. He used two bilateral (both) position bars at the head of his bed (HOB) to assist with his bed mobility. He was at risk for skin breakdown and staff should encourage him to wear long sleeved shirts to help protect his arms from skin tears. The care plan included the following interventions, with corresponding initiation dates for interventions related the treatment and prevention of skin tears to the resident's arms: 1. On 01/21/2020, use caution with hand placement while transfers with full body lift. 2. On 03/02/23, the resident sits at a small table by himself in the dining room. The staff to assist the resident when leaving the dining room to remove him from the table to decrease the likelihood so of him scrapping his extremities against the table. 3. On 05/16/23, related to a small skin tear to his right forearm - offer arm protectors/long sleeves and if the resident refused, skin tear noted in a scarred area of his arm. The care plan lacked an intervention for treatment of a current left hand skin tear. Additionally, the care plan lacked an updated revision to interventions to prevent further skin tears to the resident's skin tear to the resident's arm and interventions to prevent further injuries to his arms. Review of R 3's Physician Orders dated 09/12/24 through 09/09/17/24, documentation revealed the resident lacked an order for a skin tear. Review of R3's Progress Note, dated 09/12/2024 at 6:14 PM, documentation included the resident was in the dining room. He had his left hand under the table, pulled his left hand out from under the table, and hit his left hand on the edge of the table. The skin tear measured 0.8 centimeters (cm) by 0.8 cm by 0.1 cm. The skin tear cleansed, and transparent dressing applied. On 09/17/24 at 01:37 PM, R3 laid in his bed on his right side that faced the window. He yelled out he wanted to be turned over to face the wall. The bed had bilateral grab bars at the head of the bed. He stuck his left arm through the grab bar on the right side of the bed. He had a red discolored area with scarring on his lower arms with a transparent adhesive dressing on his left lower arm. The dressing was dated 09/15/24. The edges of the wound were approximated six to seven inches with clotted brown blood approximately six to seven inches in length. Certified Nurse Aide (CNA) M entered the room and repositioned the resident towards the wall. On inquiry, she reported the resident had a table in the dining room where he sits alone, and he bumped his arm on the table and the facility changed his table. CNA M confirmed the care plan provided the staff with guidance on how to give care to the resident. Identified causes of injury should have an immediate intervention addressed in the care plan to prevent further injuries. On 09/18/24 at 01:45 PM, the resident sat in the wheelchair at the nurse's station. The left top of his right hand had a clear dressing dated 09/15/24. The left hand with red area with intermittent blue areas that extended approximately two inches above his wrist to the knuckles. Administrative Nurse E verified the date of the dressing as 09/15/24. On 09/19/24 at 11:12 AM, Administrative Nurse E confirmed the above findings. Upon review of the resident's electronic medical record (EMR) revealed the lack of a physician's order or on R3's Treatment Administration Record (TAR) for the existing skin tear. He reported the staff that identified the existence of the skin tear should have assessed the area to include measurements, initiated an immediate intervention to prevent further injury and updated the care pan to guide the staff in providing care to prevent further injury and promote healing. On 09/18/24 at 01:57 PM, CNA O reported the skin tear on his hand was due to hitting it on the dining room table and staff removed the table. On 09/19/24 at 09:02 AM, Administrative Nurse D stated when a resident received a skin tear, the nurse should assess and initiate an investigation to determine the cause and/or contributing factors. The immediate intervention should be implemented to prevent further injury. An intervention should be documented in the care plan. He hit his arm on the table which caused a skin tear, so staff turned the table around, but he continued to use the same table. She verified the facility failed to update the care plan to alert the staff of a change in resident care to prevent further skin care. On at 09/19/24 at 09:18 AM, CNA OO verified she saw the resident sustain the existing skin tear on his left hand. She reported the resident was in the dining room sitting at the old style 60s type table with metal trim around the edge of the table. She reported she attempted to obtain his blood pressure and he hit his hand under the table which caused a skin tear. On 09/19/24 at 11:19 AM, Administrative Nurse D verified a small table with the metal edge/trim remained in the dining room and should be removed to prevent injury to residents of the facility. She confirmed the resident had reoccurring skin tears due to the resident use of the table. The facility should have removed the table and communicated with the staff by updating the care plan. The facility policy Wound Prevention and Management, dated 2018, documentation included the staff develop interventions to providing guidelines for optimal care to promote healing for residents with all identified kin alteration. The plan of care will address problems, goals, and interventions directed towards prevention skin integrity concern. The facility failed to review and revise the care plan for one Resident (R)3, related skin tear prevention. This deficient practice placed R3 at risk for repeated skin tears.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents. The sample included 14 residents, with one resident sampled for skin condition, not related to pressure ulcer/injury. Based on observation, interview, and record review, The facility failed to ensure that Resident (R)3 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices and provide adequate treatment and monitoring of one cognitively impaired, dependent resident's skin condition, to ensure resolution of multiple reoccurring skin areas and prevention of further injury. Findings included: - Review of Resident (R)3's undated Physician Orders, (POS) documentation included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) right hand, diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (high blood pressure), sleep apnea (absence of breathing during sleep), gout (inflammation of the joints) , anxiety disorder, (mental or emotional disorder characterized by reactions of apprehension, uncertainty and irrational fear), and pain. The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The resident demonstrated verbal and physical behavioral symptoms directed towards others during the look back period. He had functional limitation in active range of motion of upper and lower extremities on both sides of his body. The resident reported almost constant pain. The clinical skin assessment identified the resident was at risk for pressure ulcer injury (PU) and was without identified skin treatments. He received anticoagulant (blood thinners) and opioids. (narcotic pain medication). The Quarterly MDS, dated [DATE], revealed changes which included a BIMS score of 09, indicating further decline in moderate cognitive impairment. He received application of nonsurgical dressings (with or without topical medications) other than to feet. The Functional Abilities and Mobility Care Area Assessment (CAA) dated 01/29/24, documentation included he had cerebral palsy. The resident was not ambulatory, (able to walk) and confined to his bed He was totally dependent on staff for his activities of daily living (ADLs) due to his contractures (abnormal permanent fixation of a joint or muscle) to upper and lower extremities. His finger/hand contractures put him at risk of spills of liquids/foods and used an adaptive cup for his coffee. The Care Plan dated 07/27/24, directed staff the resident required staff assistance with ADL's related to his physical limitations. He used two bilateral (both) position bars at the head of his bed (HOB) to assist with his bed mobility. He was at risk for skin breakdown and staff should encourage him to wear long sleeved shirts to help protect his arms from skin tears. The care plan included the following interventions, with corresponding initiation dates for interventions related the treatment and prevention of skin tears to the resident's arms: 1. On 01/21/2020, use caution with hand placement while transfers with full body lift. 2. On 03/02/23, the resident sits at a small table by himself in the dining room. The staff to assist the resident when leaving the dining room to remove him from the table to decrease the likelihood so of him scrapping his extremities against the table. 3. On 05/16/23, related to a small skin tear to his right forearm - offer arm protectors/long sleeves and if the resident refused, skin tear noted in a scarred area of his arm. The care plan lacked an intervention for treatment of a current left hand skin tear observed. Additionally, the care plan lacked an updated revision to interventions to prevent further skin tears to the resident's skin tear to the resident's arm and interventions to prevent further injuries to his arms. Review of R 3's Physician Orders dated 09/12/24 through 09/09/17/24, documentation revealed the resident lacked an order for a skin tear. Review of R3's Progress Note, dated 09/12/2024 at 6:14 PM, documentation included the resident was in the dining room. He had his left hand under the table, pulled his left hand out from under the table, and hit his left hand on the edge of the table. The skin tear measured 0.8 centimeters (cm) by 0.8 cm by 0.1 cm. The skin tear cleansed, and transparent dressing applied. On 09/17/24 at 01:37 PM, R3 laid in his bed on his right side that faced the window. He yelled out he wanted to be turned over to face the wall. The bed had bilateral grab bars at the head of the bed. He stuck his left arm through the grab bar on the right side of the bed. He had a red discolored area with scarring on his lower arms with a transparent adhesive dressing on his left lower arm. The dressing was dated 09/15/24. The edges of the wound were approximated six to seven inches with clotted brown blood approximately six to seven inches in length. Certified Nurse Aide (CNA) M entered the room and repositioned the resident towards the wall. On inquiry, she reported the resident had a table in the dining room where he sits alone, and he bumped his arm on the table and the facility changed his table. CNA M confirmed the care plan provided the staff with guidance on how to give care to the resident. Identified causes of injury should have an immediate intervention addressed in the care plan to prevent further injuries. On 09/18/24 at 01:45 PM, the resident sat in the wheelchair at the nurse's station. The left top of his right hand had a clear dressing dated 09/15/24. The left hand with red area with intermittent blue areas that extended approximately two inches above his wrist to the knuckles. Administrative Nurse E verified the date of the dressing as 09/15/24. On 09/19/24 at 11:12 AM, Administrative Nurse E confirmed the above findings. Upon review of the resident's electronic medical record (EMR) revealed the lack of a physician's order or on R3's Treatment Administration Record (TAR) for the existing skin tear. He reported the staff that identified the existence of the skin tear should have assessed the area to include measurements, initiated an immediate intervention to prevent further injury and updated the care pan to guide the staff in providing care to prevent further injury and promote healing. Administrative Nurse E stated the staff failed to provide the expected care and follow-up related to the resident with repeated skin tears as they should. On 09/18/24 at 01:57 PM, CNA O reported the skin tear on his hand was due to hitting it on the dining room table and staff removed the table. On 09/19/24 at 09:02 AM, Administrative Nurse D stated when a resident received a skin tear, the nurse should assess and initiate an investigation to determine the cause and/or contributing factors. The immediate intervention should be implemented to prevent further injury. The physician should be notified, and the Nurse should put an order in the EMR, open a risk event, then determine a root cause. Staff reported the dining room had a metal strip underneath and he hit his hand on it. An intervention should be documented in the care plan. He hit his arm on the table which caused a skin tear, so staff turned the table around, but he continued to use the same table. She verified the facility failed to update the care plan to alert the staff of a change in resident care to prevent further skin care. On at 09/19/24 09:18 AM, CNA OO verified she saw the resident sustain the existing skin tear on his left hand. She reported the resident was in the dining room sitting at the old style 60s type table with metal trim around the edge of the table. She reported she attempted to obtain his blood pressure and he hit his hand under the table which caused a skin tear. On 09/19/24 at 11:19 AM, Administrative Nurse D verified a small table with the metal edge/trim remained in the dining room and should be removed to prevent injury to residents of the facility. She confirmed the resident had reoccurring skin tears due to the resident use of the table. The facility should have removed the table and communicated with the staff by updating the care plan. Administrative Nurse D reported the nurse should have put an order in for treating the skin tear to make nursing staff was aware of the treatment and follow-up care. The facility policy Wound Prevention and Management, dated 2018, documentation included the staff develop interventions to providing guidelines for optimal care to promote healing for residents with all identified kin alteration. The plan of care will address problems, goals, and interventions directed towards prevention skin integrity concern. The facility failed to ensure R3 received treatment and care to provide adequate treatment and monitoring of one cognitively impaired, dependent resident's skin condition, to ensure resolution of multiple reoccurring skin areas and prevention of further injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 14 residents sampled, including five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor one Resident (R)11 for use of antipsychotic medications (drugs used to treat psychosis-related conditions and symptoms). Findings included: - Review of Resident (R)11's electronic medical record (EMR) revealed a diagnosis of schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He received antipsychotic medication (drugs used to treat psychosis-related conditions and symptoms) during the assessment period. The Psychotropic Drug Care Area Assessment (CAA), dated 01/11/24, documented the resident received antipsychotic medications daily. The Quarterly MDS, dated 07/04/24, documented the resident had a BIMS score of 14, indicating intact cognition. He received antipsychotic medications during the assessment period. The care plan, revised 06/13/24, instructed staff the resident received antipsychotic medications. Review of the resident's EMR, revealed the following Dyskinesia Identification System scores (DISCUS-an assessment tool that monitors for tardive dyskinesia (TD-an involuntary movement disorder) in residents who take antipsychotic medications) which revealed a score of zero, indicating no involuntary movements: 09/17/24, 01/10/24 and 10/10/23. Review of the resident's EMR, revealed the following physician's order: Risperidone (an antipsychotic medication), 1 milligram (mg), by mouth (po), twice daily (BID), for schizophrenia, ordered 08/06/24. Review of the resident's EMR revealed the following recommendations made by Consultant Staff GG: On 05/13/24, Consultant Staff GG made a recommendation for the facility to complete a DISCUS (a tool used to evaluate the severity of dyskinesia [inability to execute voluntary movements]) assessment at least Q six months, due to the resident's use of antipsychotic medication. Consultant Staff GG documented the facility last completed a DISCUS assessment on 01/10/24. On 07/13/24, Consultant Staff GG made a recommendation for the facility to complete a DISCUS assessment at least every (Q) six months, due to the resident's use of antipsychotic medication. Consultant Staff GG documented the facility last completed a DISCUS assessment on 01/10/24. On 09/19/24 at 11:36 AM, Administrative Nurse D stated she was currently working on Consultant Staff GG's recommendations. Admistrative Nurse D confirmed staff should complete the DISCUS assessments every six months and the resident had not had one completed for over eight months. The facility lacked a policy regarding the completion of DISCUS assessments. The facility failed to monitor this resident, who received antipsychotic medications, for use of his antipsychotic medications.

The facility reported a census of 29 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment on four of five resident halls. Findings included: - During an environmental tour on 09/19/24 at 11:26 AM with Housekeeping/Maintenance Staff U, the following areas of concern were noted: 1. One resident room on the northeast hall had a strong urine odor. 2. The shower room on the northeast hall had rust around the drain and contianed a large amount of loose hair. A clean linen cart, stored in the shower room and containg clean linen, was uncovered. The handrails on each side of the toilet were loose. 3. The beauty shop on the central hall had a large glob of cut hair in the drain of the sink. 4. The laundry room's handwashing sink contained dead bugs and small pieces of trash. 5. A shower room on the southeast hall had a toilet riser resting directly on the floor next to the toilet. The covebase underneath the handwashing sink was peeling from the floor and the wall leading into the shower corner was in poor repair with peeling and broken tile. On 09/19/24 at 11:30 AM, Maintenance/Housekeeping Staff U confirmed these areas of concern needed to be corrected. The facility policy for Housekeeping, Laundry and Maintenance, undated, included: The goals of Housekeeping and Maintenance are to follow accepted practices and procedures of good institutional housekeeping. The facility failed to maintain a clean, cmfortable and homelike environment on four of five resident halls for the residents of the facility. The facility reported a census of 29 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment on four of five resident halls. Findings included: - During an environmental tour on 09/19/24 at 11:26 AM with Housekeeping/Maintenance Staff U, the following areas of concern were noted: 1. One resident room on the northeast hall had a strong urine odor. 2. A shower room on the northeast hall had rust around the drain and contained a large amount of loose hair. A clean linen cart, stored in the shower room and containing clean linen, was uncovered. The handrails on each side of the toilet were loose. 3. The beauty shop on the central hall had a large glob of cut hair in the drain of the sink. 4. The laundry room's handwashing sink contained dead bugs and small pieces of trash. 5. A shower room on the southeast hall had a toilet riser stored directly on the floor next to the toilet. The cove base underneath the handwashing sink was peeling from the floor and the wall leading into the shower corner was in poor repair with peeling and broken tile. On 09/19/24 at 11:30 AM, Maintenance/Housekeeping Staff U confirmed these areas of concern needed to be corrected. The facility policy for Housekeeping, Laundry and Maintenance, undated, included: The goals of Housekeeping and Maintenance are to follow accepted practices and procedures of good institutional housekeeping. The facility failed to maintain a clean, comfortable, and homelike environment on four of five resident halls for the residents of the facility.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to provide annual performance reviews for certified nurse aides and certified medication aides as required. Findings included: - Review of the Certified Nurse Aide (CNA)/Certified Medication Aide (CMA) employee records revealed the following areas of concern: CNA Q employee record revealed a hire date of 06/08/23 and lacked a signed evaluation. CNA O employee record revealed a hire date of 03/14/23 and lacked a signed evaluation. CNA/CMA NN employee record revealed a hire date of 08/24/06 and lacked an evaluation. CNA P employee record revealed a hire date of 08/18/1999 and lacked an evaluation. CNA MM employee record revealed a hire date of 01/12/23 and lacked an evaluation. Interview, on 09/19/24 at 08:30 AM, with Administrative Nurse D, confirmed the above and stated she would have expected annual evaluations on each certified staff member to be completed in a timely manner and at least annually. The facility did not provide a policy for completion of annual evaluations. The facility failed to ensure certified nursing staff received annual evaluations to ensure competency and identification of training needs as required.

The facility reported a census of 29 residents. Based on observation, interview, and record review, the facility failed to prepare, store, and serve food under sanitary conditions, to the residents of the facility. Findings Included: - During a facility tour on 09/19/24 at 09:59 AM, with Administrative Staff A, revealed the following concerns in the ice room: 1. The wood shelving unit utilized to stack dishes and glasses with loose chunks of dirt on the shelves where plates and glasses were stored upside down in direct contact with the shelving. On 09/19/24 at 10:00 AM, Administrative Staff A confirmed the above findings and verified the ice machine/storage room needed housekeeping and maintenance to clean and repair the room to ensure a safe and sanitary environment for residents and staff of the facility. He reported he was not aware of who was responsible for the cleaning and if the dishes and/or glasses were utilized for food service. He verified the ice room was where staff provided ice for the residents of the facility. On 09/19/24 at 10:10 AM, Dietary staff BB reported she thought housekeeping was responsible for cleaning the ice room, the dietary staff do not clean or maintain that area. She stated the kitchen and nursing staff get ice for the residents and staff from the ice room and dietary staff often use plates and glasses stored for holiday dinners as does activities staff. The facility stored excess dishware in the ice machine room. On 09/19/24 at 10:15 AM, Housekeeping staff W stated dietary staff was responsible for the cleaning of the ice machine room and was not on the housekeeping cleaning schedule. Additionally, on 09/19/24 at 11:20, the following concerns were identified during the environmental tour with Housekeeping Staff V and Maintenance staff U: 1. An opened box of 1000 foam cups stored directly on the floor of the southeast storage room. 2. An opened box of 1000 Hot/cold insulated bowls stored directly on the floor of the southeast storage room. 3. An opened box of 1000 cup lids stored directly on the floor of the southeast storage room. On 09/19/24 at 11:20 AM, Maintenance Staff U reported dietary staff should store supplies used for food service off the floor on appropriate racks to ensure sanitary conditions for food service. On 09/19/24 at 11:37 AM, Dietary staff BB verified the above findings. She reported the shipment of dietary supplies arrived the previous day and the dietary staff tried to get the supplies out of the kitchen. She stated the staff should have stored the boxes of plates, cups, and lids on racks to maintain sanitation for the use with food service. The undated facility policy Dietary Services lacked address of storage for dietary supplies and dishware to ensure sanitary food service. The facility failed to prepare, store, and serve food under sanitary conditions, to the residents of the facility.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on four dates between 07/01/23 and 09/30/23, and six dates between 10/01/23 and 12/31/23. Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for Fiscal year (FY), Quarter 4, 2023 (07/01/23 and 09/30/23) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 07/01/23 , Saturday (SA), On 07/15/23, SA, On 07/30/23, Sunday (SU), On 07/31/23, Monday (MO), Review of the Payroll Base Journal (PBJ) Staffing Data Report for Fiscal year (FY), Quarter 1, 2024 (10/01/23 and 12/31/23) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 10/13/23, Friday (FR), On 11/25/23, Saturday (SA), On 12/03/23, Sunday (SU), On 12/14/23, Thursday, (TH), On 12/27/23, Wednesday, (WE), and On 12/31/23, SU, On 09/19/24 at 01:41 PM, interview with Administrative Nurse D revealed as far as she knew, the PBJ was submitted correctly and stated the facility had 24-hour licensed nurse coverage and did not know why the PBJ indicated the above dates in question. The facility policy for Benefits Improvement Protection Act (BIPA) Nurse Staff Posting, revised 12-2019, instructed staff to post the actual hours worked for licensed and unlicensed nursing staff. The facility lacked a policy for submission of the PBJ to CMS. The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to licensed nursing staffing information when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on four dates between 07/01/23 and 09/30/23 and six dates between 10/01/23 and 12/31/23.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to track and trend infections to prevent the spread of infections amongst the residents. Findings included: - Review of the Infection Control logbook, revealed the tab for August 2024 and September 2024 lacked data. The Tab for June 2024 contained documentation's of two wound infections, three urinary tract infections and two oral infections. The logbook lacked culture reports to determine causative organisms for the infections. Interview, on 08/18/24 at 02:30 PM, with Administrative Nurse E, revealed he documented the infections on the facility on a map of the resident rooms to determine trends by type of infections. He stated the facility did have an electronic monitoring program but did not know the components of the program or how to load the data. Administrative Nurse E stated the facility experienced a COVID outbreak in July 2024, when four residents tested positive for COVID, and then staff developed COVID also. The facility had no cases of COVID at this time. Interview, on 09/19/24 at 09:00 AM, with Administrative Nurse D revealed she would expect the staff to track and trend infections in the facility and utilize the electronic data collection tool in the facility system. The facility policy Antibiotic Use Protocol, dated 11/2023 and Antibiotic Stewardship instructed staff to monitor for infections and provide the necessary instruction to staff for management of residents with infections. The facility failed to monitor infections in the facility to determine trends in causative organisms and types of infections to prevent the spread of infections.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to ensure staff adhered to the principles of antibiotic stewardship through monitoring for the appropriate use of antibiotics prescribed for residents to prevent antibiotic resistance and spread of multidrug resistant organisms within the facility. Findings included: - A physician's order, dated 07/26/24, instructed staff to administer to Resident (R)5 Cefdinir (an antibiotic that treats a wide range of bacteria) 300 milligrams, (mg) twice a day for five days for Health Maintenance. Interview, on 08/18/24 at 02:30 PM, with Administrative Nurse E, revealed he lacked training in the facility's computerized infection monitoring system. Interview, on 09/18/24 at 12:43 PM, with Administrative Nurse D, revealed the R5 had COVID in July 2024, and was in acute care for pneumonia and subsequently returned to the facility with the order for the antibiotic. Administrative Nurse D confirmed the lack of completion of the computerized infection monitoring system and lack of antibiotic stewardship for the residents of the facility. The facility policy Antibiotic Use Protocol, dated 11/2023 and Antibiotic Stewardship dated 11/23, instructed staff to monitor for infections and provide the necessary instruction to staff for management of residents with infections. Staff to monitor antibiotic use in the facility. The facility failed to provide ongoing antibiotic stewardship to ensure appropriate antibiotic use for the residents of the facility to prevent antibiotic resistance and the spread of multi drug resistant organisms.

The facility reported a census of 29 residents. Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for residents and staff of the facility. Findings included: - During facility tour on 09/19/24 at 09:59 AM, with Administrative Staff A revealed the following concerns in the ice room: 1. The floor covered with black grime build up at the entrance directly in front of the ice machine, throughout the floor. 2. The wood shelving unit utilized to stack dishes and glasses with loose chunks of dirt on the shelves where plates and glasses were stored upside down in direct contact with the shelving. 3. Used crumpled paper towels laid directly on the floor. 4. The walls had missing paint on the edges of the wall. 5. The floor was unsanitizable due to missing paint/sealant directly in front of the ice machine. On 09/19/24 at 10:00 AM, Administrative Staff A confirmed the above findings and verified the ice machine/storage room needed housekeeping and maintenance to clean and repair the room to ensure a safe and sanitary environment for residents and staff of the facility. He reported he was not aware of who was responsible for the cleaning and repair of the ice room/storage area as there were multiple new staff additions in each. On 09/19/24 at 10:10 AM, Dietary staff BB reported she thought housekeeping was responsible for cleaning the ice room, the dietary staff do not clean or maintain that area. She stated the kitchen and nursing staff get ice for the residents and staff from the ice room and dietary staff often use plates and glasses stored for holiday dinners as does activities. Additionally, the facility stored excess dishware in the ice machine room. On 09/19/24 at 10:15 AM, Housekeeping staff W stated the dietary staff was responsible for the cleaning of the ice machine room and was not on the housekeeping cleaning schedule. The facility lacked a policy to address the maintenance and cleaning of the ice machine/storage room. The facility failed to ensure a safe and sanitary environment for residents and staff of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 23 residents with 14 residents sampled, including one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to one Resident (R)2, when he reported the need to urinate and the staff told him to urinate in his brief. Findings included: - The electronic medical record (EMR), for Resident (R)2, included a diagnosis of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He required extensive assistance of two staff for toileting and was frequently incontinent of bladder. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment CAA), dated 03/03/22, documented the resident required extensive to total assistance with toileting. The quarterly MDS, dated 11/17/22, documented the resident had a BIMS score of 15, indicating intact cognition. He required total assistance of two staff for toileting and was always incontinent of bladder. The incontinence care plan, revised 08/24/22, instructed staff the resident was able to express the need for toileting but due to physical disabilities was unable to take himself to the bathroom and required staff assistance. Review of the EMR, from 11/07/22 through 12/05/22, revealed documentation that the resident required total assistance of one to two staff for toileting and was incontinent of bladder at all times. On 12/06/22 at 07:17 AM, Certified Nurse Aides (CNA) M and N entered the resident's room to get him ready for the day. Staff N asked the resident if he needed to urinate in which the resident replied he did. CNA N instructed the resident to urinate in his brief, which the resident did. Staff made no offer of a urinal to the resident. On 12/05/22 at 11:47 AM, the resident stated he usually knew when he needed to urinate or have a bowel movement (BM). Staff always told him to go in his brief instead of offering a urinal or a bed side commode (BSC). On 12/06/22 at 07:17 AM, CNA M stated the resident did not use a urinal because it was not on his care plan. The resident required the hoyer lift (a full-body mechanical lift) for transfers and the lift would not fit into the bathroom. At times, the staff would use the BSC, but there was not one in the resident's room at that time. On 12/06/22 at 07:17 AM, CNA N stated the staff have the resident urinate in his brief because the hoyer lift will not fit into the bathroom. The resident was not care planned to use a urinal. On 12/08/22 at 09:02 AM, Administrative Nurse D stated staff should not ask residents to go to the bathroom in their brief as that would be a dignity issue. Residents who are able to feel the sensation to urinate should be offered a urinal. The facility lacked a policy for dignity. The facility failed to show respect and dignity to this dependent resident when he reported the need to urinate and the staff instructed him to urinate in his brief.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 23 residents with 14 residents sampled, including one resident reviewed for Activities of Daily Living (ADL). Based on observation, interview and record review, the facility failed to ensure one Resident (R)2 had a clean face and clothing. Findings included: - Review of Resident (R)2's electronic medical record (EMR), included a diagnosis of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He required extensive assistance of two staff for dressing. The Activities of Daily Living Functional/Rehabilitation Potential (ADL) Care Area Assessment (CAA), dated 03/03/22, documented the resident required extensive to total assistance with dressing. The quarterly MDS, dated 11/17/22, documented the resident had a BIMS score of 15, indicating intact cognition. He required total assistance of two staff for dressing. The care plan for ADLs, revised 08/24/22, instructed staff the resident required extensive assistance of one to two staff for dressing. Review of the resident's EMR, from 11/07/22 through 12/05/22, documented the resident required extensive to total staff assistance for dressing. On 12/06/22 at 08:26 AM, the resident propelled self in the wheelchair out of the dining room. The resident had egg on his face and down the front of his shirt. On 12/06/22 at 09:22 AM, the resident sat in his wheelchair in the front commons area. The resident continued to have dried egg on his face and down the front of his shirt. On 12/06/22 at 01:05 PM, the resident continued to have dried egg on his face as well as the front of his shirt. On 12/05/22 at 11:47 AM, the resident stated he almost always has dried food on his face and his clothing. On 12/06/22 at 07:17 AM, Certified Nurse Aide (CNA) M stated the resident feeds himself at meals. Staff should clean the residents faces and ensure they have on clean clothes, at all times. On 12/06/22 at 07:17 AM, CNA N stated staff should wash residents faces when they are dirty and change their clothes when they have food on them. On 12/06/22 at 08:32 AM, Licensed Nurse (LN) G stated the staff should ensure the residents faces and clothing are clean at all times. On 12/08/22 at 09:02 AM, Administrative Nurse D stated it was the expectation that residents' clothing and faces be clean at all times. The facility policy for Empowering Residents through Activities of Daily Living (ADL), undated, included: Staff shall help residents attain or maintain their highest level of physical and psychosocial well-being as possible. The facility failed to ensure this dependent resident had clean clothing and adequate staff assistance with cleaning his face.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 23 residents with 14 selected for review which included three residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to provide position change in a timely manner for one Resident (R)4 of the three residents reviewed for pressure ulcers. Findings included: - Review of Resident (R)4's Physician Order Sheet, dated 10/03/22, revealed diagnoses included Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with moderate cognitive impairment, required extensive assistance of two for bed mobility toilet use. The resident was dependent on staff for transfer and personal hygiene. The resident had no current pressure ulcers and was at risk for pressure ulcer development and had a pressure reducing device for her chair and bed and was on a turning/repositioning program. The resident had impairment in functional range of motion on one side of the upper and lower extremities. The resident was always incontinent of bowel and bladder. The Quarterly MDS, dated 10/20/22, assessed the resident with moderate cognitive impairment. The resident was dependent on two staff for bed mobility, transfer, toilet use and personal hygiene. The resident had no current pressure ulcers and was at risk for pressure ulcer development and had a pressure reducing device for her chair and bed and was on a turning/repositioning program. The resident had impairment in functional range of motion on one side of the upper and lower extremities. The resident was always incontinent of bowel and bladder. The Pressure Ulcer Care Area Assessment (CAA), dated 04/28/22, assessed the resident was at risk for pressure ulcer development due to bowel and bladder incontinence and required extensive assistance with bed mobility. The resident was on a turn and reposition schedule every two hours. The Care Plan reviewed 10/26/22, instructed staff to turn and reposition the resident every two hours and as needed. Observation, on 12/06/22 at 07:15 AM, revealed the resident seated in her Broda chair (a type of chair that provides distribution of pressure areas to help prevent skin breakdown.) Observations continued every 15 minutes and as follows: At 08:09 AM, Certified Nurse Aide (CNA) Q, placed shoes on the resident and propelled her to the dining room. At 09:00 AM, CNA N propelled the resident to her room and positioned her in front of the TV without repositioning the resident's torso. At 11:45 AM, CNA Q propelled the resident to the dining area for the noon meal without repositioning the resident. At 12:45 PM, CNA N propelled the resident back to her room and placed her in front of the TV without repositioning the resident. Interview, at that time with CNA Q revealed staff would transfer the resident back to bed when the residents in the dining room were taken to their rooms. At 01:45 PM, CNA Q and N, transferred the resident back to bed with the mechanical lift. CNA Q removed the resident's incontinence brief and observed the resident was incontinent of urine. The resident's left buttocks had and area of redness approximately three by two centimeters. Licensed Nurse (LN) G observed the area of redness and stated she noticed it three weeks ago. LN G applied moisture barrier cream. LN G stated the resident was at risk for pressure ulcers and staff should lay the resident down at least every two hours to provide incontinence care and repositioning. Interview, on 12/08/22 at 01:31 PM, with Administrative Nurse D revealed she observed the resident's buttocks on 12/07/22 and thought the skin looked better with application of zinc oxide barrier cream to the resident's perineal area and buttocks. Administrative Nurse D stated staff should reposition and check the resident for incontinence at least every two hours. The facility policy Wound Prevention and Management, revised 12/2022, instructed staff to provide repositioning to meet the individual resident's needs. The facility failed to provide the timely planned repositioning assistance for this dependent resident with redness on her buttocks and at risk for the development of pressure ulcers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 23 residents with 14 residents sampled, including six residents reviewed for restorative services. Based on observation, interview, and record review, the facility failed to provide restorative services for one of the six sampled Residents (R)7, to maintain or prevent decline in range of motion (ROM) ability. Findings included: - Review of Resident (R)7's electronic medical record (EMR) included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. He required extensive assistance of two staff for toilet use and extensive assistance of one staff for bed mobility, transfers, dressing and personal hygiene. He had no impairment in functional range of motion (ROM) and received no restorative cares during the assessment period. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/23/22, documented the resident required staff assistance with ADLs. The restorative nursing program care plan, dated 10/23/22, instructed staff to do active ROM to the resident's bilateral (both sides) upper and lower extremities, work on transfers and ambulation, six times per week for 15 minutes. Review of the resident's EMR, from 11/07/22 through 12/05/22, revealed no restorative cares completed with the resident. On 12/07/22 at 09:14 AM, consultant staff II stated the staff do not walk with the resident anymore. On 12/06/22 at 09:36 AM, Certified Nurse Aide (CNA) N stated the staff do not do ROM with the resident or walk with him on the day shift. The restorative aide used to do those things, but that staff member was no longer at the facility. On 12/06/22 at 03:34 PM, CNA O stated the resident does not get ROM on the evening shift. CNA O confirmed the staff did not walk with the resident to meals. On 12/06/22 at 02:30 PM, Licensed Nurse (LN) G stated the facility did not have a restorative aide at this time. On 12/08/22 at 09:02 AM, Administrative Nurse D stated the facility had not had a restorative aide for several weeks and restorative cares were not being done. Administrative Nurse D stated if a resident had a restorative plan on their care plan it should be getting done and was not. The facility policy for Restorative Program, revised 12/2022, included: The facility shall develop a restorative nursing program which was resident driven and specific to maintain the resident's highest level of functioning and which motivates the resident to perform at their best ability. The facility failed to provide this dependent resident with restorative services as planned to maintain or prevent decline in his ROM ability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 23 residents with 14 residents sampled, including three residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure appropriate interventions following falls for one Resident (R)19 and failed to ensure appropriate safety measures were utilized with one R2, regarding foot placement while in the wheelchair. Findings included: - The electronic medical record (EMR), for Resident (R)2, revealed a diagnosis of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. He required extensive assistance of one staff for locomotion on the unit and used a wheelchair for mobility. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/03/22, documented the resident required extensive staff assistance for locomotion on the unit. The quarterly MDS, dated 11/17/22, documented the resident had a BIMS score of 15, indicating intact cognition. He required supervision of two staff for locomotion on the unit with the use of his wheelchair. The ADL care plan, revised 08/24/22, instructed staff the resident currently used a manual wheelchair, for locomotion, which staff propelled. Review of the resident's EMR, from 11/07/22 through 12/05/22, revealed the resident required limited to total assistance of one staff for locomotion in his wheelchair on the unit. On 12/05/22 at 12:25 PM, the resident propelled himself out of the dining room in his wheelchair. He wore protective, padded boots to his bilateral bare feet, which drug along directly on the floor underneath his wheelchair. On 12/06/22 at 07:34 AM, Certified Nurse Aide (CNA) M propelled the resident from his room to the dining room in his wheelchair. The resident wore padded boots to his bilateral bare feet, which drug along direct on the floor underneath his wheelchair. On 12/05/22 at 12:25 PM, Certified Medication Aide (CMA) R stated the resident's feet would not stay on the foot pedals of his wheelchair. Staff did not know what to do about the problem. On 12/06/22 at 08:28 AM, CMA S stated the resident's feet would fall of the wheelchair foot pedals all of the time. CMA S confirmed staff would propel the resident in his wheelchair with his feet dragging underneath. On 12/06/22 at 08:32 AM, Licensed Nurse (LN) G stated she was unsure of what could be done to keep the resident's feet on his wheelchair foot pedals. On 12/08/22 at 09:02 AM, Administrative Nurse D stated resident's feet should stay on the wheelchair foot pedals while they are propelled by staff. If a resident's feet were dragging underneath the wheelchair it could cause the resident to flip out of the wheelchair. The facility lacked a policy for wheelchair safety. The facility failed to ensure appropriate safety measures were utilized to keep his feet from directly dragging along on the floor, while propelling this dependent resident in his wheelchair, to prevent accidents. - The electronic medical record (EMR), for Resident (R)19, included a muscle weakness (weak muscles). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. He required limited assistance of one staff for locomotion on the unit with the use of a walker. His balance was not steady and was only able to stabilize with human assistance. He had one injury fall, non-major since admission. The Care Area Assessment (CAA) for Falls, dated 08/04/22, documented the resident had balance problems. The quarterly MDS, dated 11/03/22, documented the resident had a BIMS score of 5, indicating severe cognitive impairment. He required limited assistance of one staff for locomotion on the unit with the use of a walker. His balance was not steady, and he was only able to stabilize with human assistance. The resident had two or more non-injury falls since the previous assessment. The care plan for falls, revised 11/03/22, instructed staff to ensure the resident wore non-skid socks or shoes while ambulating. Staff were to prompt the resident to toilet every two hours and keep his walker in front of him while he was in his recliner. Staff were to give stand by assistance with ambulation. Review of the residents EMR, revealed staff assessed the resident to be at a high risk for falls on 11/12/22, 11/10/22 and 08/01/22. Review of the residents EMR, revealed the resident had a non-injury fall in his room on 10/27/22. The EMR lacked an intervention for this fall to prevent further falls. Review of the residents EMR, revealed the resident had a fall in the front commons area 11/10/22. The EMR lacked an intervention for this fall, to prevent further falls. Review of the residents EMR, revealed an injury, not major, fall in the resident's room [ROOM NUMBER]/27/22. The EMR lacked an intervention for this fall. On 12/05/22 at 08:47 AM, the resident sat in the dining room with his walker in front of him. He wore non-skid shoes. On 12/06/22 at 12:30 PM, the resident sat in the front commons area. His walker was within his reach, and he wore appropriate footwear. On 12/06/22 at 03:00 PM, Licensed Nurse (LN) G stated when a resident had a fall, a new intervention needed to be initiated immediately by the nurse on duty. The intervention would then need to be added to the care plan. On 12/08/22 at 09:02 AM, Administrative Nurse D stated interventions should be initiated immediately following a resident fall. The facility policy for Falls Management, revised 12/2022, included: After a fall, the licensed nurse was to initiate a new intervention to reduce any injuries associated with falls. The resident plan of care was to be reviewed and revised with each fall occurrence and new interventions implemented. The facility failed to initiate appropriate interventions following this dependent resident's falls, to prevent further accidents.

- The Physician Order Sheet (POS), dated 09/14/22, documented Resident (R)8 had a diagnosis of bipolar disease (major mental illness that caused people to have episodes of severe high and low moods). Review of the resident's electronic medical record (EMR) revealed a physician order for Abilify (an antipsychotic medication), 10 milligrams (mg), by mouth (po) every day (QD), for Bipolar disorder, ordered on 09/14/17. The pharmacist recommendation, dated 08/01/22, requested the physician consider a gradual dose reduction (GDR) for the Abilify 10 mg, which the resident had taken since 09/2017. The facility lacked a physician response for the recommendation. The facility failed to act upon the pharmacist recommendation for the resident's medication and GDR, from 08/01/22 through current 12/08/22, a period of over four months. Interview on 12/08/22 at 10:45 AM, with Administrative Nurse E, revealed she would expect the Director of Nursing to follow up on pharmacy recommendations, however the current Director of Nursing had been hired three weeks ago, and she was unable to locate the previous Director of Nursing's follow ups to the pharmacy recommendations. The consulting pharmacist was not available for interview. The facility lacked a policy for follow up on pharmacy recommendations for the residents' medication monthly reviews. The facility failed to follow up on pharmacy recommendations to ensure this resident did not experience adverse effects of medications. The facility reported a census of 23 residents with six selected for review for unnecessary medications. Based on observation, interview and record review, the facility failed to follow up on pharmacy recommendations for three of the six residents reviewed. (Resident (R)22, R17 and R8). Findings included: - Review of Resident (R)22's medical record, revealed a Physician's Order, dated 10/05/22 instructed staff to administer Risperdal (an antipsychotic) 0.5 milligrams (mg) twice a day for delirium. The pharmacy recommendations for 10/05/22, requested an appropriate diagnosis for the for the use of Risperdal 0.5 mg twice a day. Review of R17's medical record, revealed a Physician's Order, dated 09/23/22, instructed staff to apply Lidocaine 4% patch topically every night shift for polyarthritis and Lidocaine patch 4% topically one time a day for polyarthritis. Review of the October, November, and December 2022 Medication Administration Record (MAR) revealed entries for the Lidocaine 4% patch for application every night shift and day shift and lacked instructions for removal. The pharmacy recommendation dated 10/05/22 advised staff the Lidocaine patch may remain in place for no more than 12 hours per 24-hour period. Interview, on 12/08/22 at 10:30 AM, with Administrative Nurse E, revealed staff were actually removing the patch at night, not applying it. Administrative Nurse E stated she would expect the MAR to indicate removal time. Interview on 12/08/22 at 10:45 AM, with Administrative Nurse E, revealed she would expect the Director of Nursing to follow up on pharmacy recommendations, however the current Director of Nursing had been hired three weeks ago, and she was unable to locate the previous Director of Nursing's follow ups to the pharmacy recommendations. The consulting pharmacist was not available for interview. The facility lacked a policy for follow up on pharmacy recommendations. The facility failed to follow up on pharmacy recommendations to ensure these residents did not experience adverse effects of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 23 residents with six selected for review for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure staff monitored extrapyramidal (a movement disorder caused by medications), effects of antipsychotic medications (class of medications used to treat psychosis, and other mental emotional conditions) for three of the six Residents (R)22, 6 and 17. Findings included: - Review of Resident (R) 22's Physician's Order Sheet, dated 10/03/22, revealed diagnoses included anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit and received two days of antipsychotic medications during the seven-day look back period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 10/06/22, assessed the resident received antipsychotic and antianxiety medications with increased risk for falls. The resident diagnoses included delirium, dementia, and anxiety disorder. The Care Plan reviewed 10/23/22, instructed staff to allow the resident to express her emotions without judgement or criticism. The resident received antipsychotic with black box warning which included altered mental status tardive dyskinesia, dysrhythmias, and increased mortality in elderly with dementia. The care plan lacked instruction for monitoring for tardive dyskinesia. A Physician's Order, dated 10/05/22, instructed staff to administer Risperdal 0.5 mg twice a day for delirium, then daily beginning 10/10/22 through 10/16/22. Review of medical record revealed lack of an assessment for extrapyramidal side effects of antipsychotic medications such as the Dyskinesia Identification System Condensed User Scale (DISCUS) or Abnormal Involuntary Movement Scale (AIMS). Interview, on 12/08/22 at 02:45PM, with Administrative Nurse E, confirmed lack of DISCUS assessment for this resident, and stated she would expect staff to complete one upon admission, upon initiation of a new antipsychotic medication and with significant changes. The facility lacked a policy for assessment of extrapyramidal effects of antipsychotics. The facility failed to monitor for adverse effects of antipsychotic medications for this resident with dementia. - Review of Resident (R)6's Physician Order Sheet, dated 10/03/22, revealed diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness,) psychotic disorder (any major mental disorder characterized by a gross impairment in reality testing) and lymphedema (swelling caused by accumulation of lymph). The Annual Minimum Data Set, dated 07/07/22, assessed the resident with moderately impaired cognitive function. The resident required extensive assistance of two staff for bed mobility toileting, personal hygiene and was dependent on two staff for transfers. The resident had no impairment in range of motion in upper or lower extremities. The resident was always continent of bowel and bladder. The Cognitive Loss Care Area Assessment, (CAA), dated 07/02/22, assessed the resident had anxiety and depressed mood, overactive bladder. The resident was able to make herself understood but was at risk for impaired comprehension with a decline in cognition. The resident required extensive to total assist with activities of daily living. The Psychotropic Drug Use CAA, dated 07/02/22, assessed the resident received antipsychotic, antidepressants and anxiolytics and was a t risk for impaired comprehension and functional mobility and/or self-care. The Care Plan, reviewed 09/28/22, instructed staff the resident received antipsychotic, antidepressants, and anxiolytics. These medications put the resident at increased risk for side effects/adverse reactions. Staff instructed to allow the resident to express her emotions without judgement or criticism. Staff informed the resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created). The Physician's Order, dated 04/08/21, instructed staff to administer Seroquel (an antipsychotic), 50 milligrams(mg), daily, for delusional disorder. Review of the medical record revealed a Dyskinesia Identification System Condensed User Scale (DISCUS) completed on 10/08/21 with a score of 4(a score >5 indicated need for further evaluation), 03/03/22 score of 0 and 04/07/22 score of 0. No further DISCUS found in the medical record (eight months). Observation, on 12/06/22 at 07:34 AM, revealed the resident alert to name and place, sitting in her chair in her room. The resident responded to questions appropriately. The resident had slight tremors noted in her extremities and head. Interview, on 12/08/22 at 02:45PM, with Administrative Nurse E, confirmed lack of DISCUS assessment for this resident, and stated she would expect staff to complete one upon admission, upon initiation of a new antipsychotic medication and with significant changes. The facility lacked a policy for assessment of extrapyramidal effects of antipsychotics. The facility failed to monitor for adverse effects of this resident's antipsychotic medication. - Review of Resident (R)17's Physician Order Sheet, dated 09/27/22, revealed diagnoses included major depressive disorder, and anxiety. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function. The resident received seven days of antipsychotic medications during the seven- day look-back period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 09/29/22, assess the resident received psychotropic medications which included antipsychotics and antidepressants. The resident had an anxiety disorder and hallucinations and essential tremors. The Care Plan, reviewed 10/23/22, instructed staff the resident received antipsychotic medications with black box warnings which included tardive dyskinesia (movement disorder). A Physician's Order, dated 09/29/22 instructed staff to administer quetiapine fumarate (an antipsychotic medication) 50 milligrams (mg) three times a day related to major depressive disorder and anxiety. Review of the resident's medical record revealed lack of an assessment for extrapyramidal side effects of antipsychotic medications such as the Dyskinesia Identification System Condensed User Scale (DISCUS) or Abnormal Involuntary Movement Scale (AIMS). Interview, on 12/08/22 at 02:45PM, with Administrative Nurse E, confirmed lack of DISCUS assessment for this resident, and stated she would expect staff to complete one upon admission, upon initiation of a new antipsychotic medication and with significant changes. The facility lacked a policy for assessment of extrapyramidal effects of antipsychotics. The facility failed to monitor for adverse effects of antipsychotic medications for this resident.

The facility reported a census of 23 residents. Based on observation and interview the facility failed to document the open date on insulin pens for two residents, Resident (R)5 and R11, to ensure medication quality and potency. Findings included: - Observation on 12/05/22 at 12:14 PM, revealed Licensed Nurse (LN) H administered 30 units of Novolog insulin to Resident (R)5. The insulin pen lacked an open date. R5's Levemir pen also lacked an open date. Observation, on 12/05/22 at 12:20 PM, revealed R11's Novolog pen lacked an open date. Interview at that time with LN N revealed staff should date the insulin pens when opened for the first dose and confirmed the above three pens had been used. Interview, on 12/6/22 at 10:30 AM, with Administrative Nurse E, revealed she would expect staff to date insulin pens when first opened so staff could determine the expiration date of the insulin. The facility utilized the guide Diabetes Injectable Medications which indicated Novolog must be used within 28 days after opening and Levemir must be used within 42 days after opening. The facility failed to document the open date for these two residents with three insulin pens to ensure the quality and potency of the insulin.

The facility reported a census of 23 residents. Based on observations and interviews, the facility failed to provide a clean, comfortable, home-like environment on three of four hallways, the living room, and in the dining/activity room. Findings included: - During initial tour of the northeast hall of the facility, on 12/5/22 at 08:30 AM, the following items/area noted in need of housekeeping/maintenance services: The entrance/threshold to a resident's room revealed an accumulation of grime and dirt along the threshold and in the corners of the room. The room also contained a very foul urine odor present. In this resident's bathroom a brown discoloration in the caulking surrounded the toilet base. In another resident's bathroom a black box sat by the sink which held a pillow with a cloth cover over it. A shelf holding resident toiletries held a thick layer of dust build-up under the toiletries. Across the back of the bathroom sink rested silverware and straws. On 12/07/22 at 08:30 AM, an environmental tour with housekeeping/maintenance supervisor U, revealed the following items/areas of concern: The northeast and southeast hallways contained multiple areas of cracked linoleum along the halls. The entrances/thresholds to the resident rooms/bathrooms, on these two halls, contained a build-up of grime and visible dirt. These halls lower halves of the walls contained dirty faded carpets. At that time Staff U reported he was told, It is original to the building when it was built in the 60's. Furthermore, both hallways contained a strong urine odor on all days of the survey. The northeast hallway had various sized areas of peeling wallpaper border, at the chair rail level, that was peeling off the wall. The resident living room contained piles of boxes directly on the floor, some empty and some with Christmas decorating supplies, and two boxes with puzzles. These scattered boxes remained present in the living room on all days of the survey. On the northeast hall, outside of a resident's room sat a bag with adult incontinent briefs directly on the floor. On the southeast hall, the men's tub room ceiling held an air vent surrounded with a black substance around it. The activity room, on the countertop by the handwashing sink sat an unlabeled, partially empty Doctor Pepper bottle on the countertop on both 12/06/22 and 12/07/22. During this tour, on the southwest hall, a resident reported to Certified Medication Aide (CMA) S that her heater had not been working and CMA S informed environmental/maintenance employee U of the resident's complaint. He stated: It has to drop to a specific temperature, so if you want it at 73, put it at 75 or 76. On 12/08/22 at 09:00 AM, on the southeast hall, a resident's bathroom, from the toilet seat down to the floor, contained a brown substance smeared down the front of it. The facility policy titled Resident Room Daily Cleaning Procedures contained the following: Clean outside toilet tanks and stool, lid, seat, etc. Using your micro-fiber frame and handle attach the blue pad to the Velcro frame and proceed to clean the resident room floor. Outline the baseboards including the washroom area and work your way to the center of the room, working your way out to the hallway. Mop baseboards six inches out from edges. Drag your mop against baseboards daily as to prevent soil build-up. The facility failed to provide adequate housekeeping/maintenance services to maintain a clean, neat and orderly environment in these areas for the residents on those halls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The electronic medical record (EMR), for Resident (R)19, included a muscle weakness (weak muscles). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. He required limited assistance of one staff for locomotion on the unit with the use of a walker. His balance was not steady and was only able to stabilize with human assistance. He had one injury fall, non-major since admission. The Care Area Assessment (CAA) for Falls, dated 08/04/22, documented the resident had balance problems. The quarterly MDS, dated 11/03/22, documented the resident had a BIMS score of 5, indicating severe cognitive impairment. He required limited assistance of one staff for locomotion on the unit with the use of a walker. His balance was not steady, and he was only able to stabilize with human assistance. The resident had two or more non-injury falls since the previous assessment. The care plan for falls, revised 11/03/22, instructed staff to ensure the resident wore non-skid socks or shoes while ambulating. Staff were to prompt the resident to toilet every two hours and keep his walker in front of him while he was in his recliner. Staff were to give stand by assistance with ambulation. Review of the residents EMR, revealed staff assessed the resident to be at a high risk for falls on 11/12/22, 11/10/22 and 08/01/22. Review of the residents EMR, revealed the resident had a non-injury fall in his room on 10/27/22. The EMR lacked an intervention for this fall to prevent further falls. Review of the residents EMR, revealed the resident had a fall in the front commons area 11/10/22. The EMR lacked an intervention for this fall, to prevent further falls. Review of the residents EMR, revealed an injury, not major, fall in the resident's room [ROOM NUMBER]/27/22. The EMR lacked an intervention for this fall. On 12/05/22 at 08:47 AM, the resident sat in the dining room with his walker in front of him. He wore non-skid shoes. On 12/06/22 at 12:30 PM, the resident sat in the front commons area. His walker was within his reach, and he wore appropriate footwear. On 12/06/22 at 03:00 PM, Licensed Nurse (LN) G stated when a resident had a fall, a new intervention needed to be initiated immediately by the nurse on duty. The intervention would then need to be added to the care plan. On 12/08/22 at 09:02 AM, Administrative Nurse D stated interventions should be initiated immediately following a resident fall by the nurse on duty. After the nurse initiated the intervention, they should update the care plan. The facility lacked a policy for care plans. The facility failed to update the care plan for this dependent resident following two falls. - Review of Resident (R)7's electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating moderately impaired cognition. The MDS inaccurately documented the resident did not use oxygen (O2) while a resident. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/23/22, documented the resident required limited to extensive assistance with ADLs. The care plan, revised 10/23/22, lacked staff instruction on care of the oxygen tubing. Review of the resident's EMR revealed a physician's order for Oxygen 2 liters (L) per nasal cannula (NC), as needed (PRN) for shortness of breath, ordered 11/09/22. On 12/05/22 at 03:13 PM, the resident had undated oxygen tubing in his room. On 12/06/22 at 09:15 AM, the resident's oxygen tubing remained undated. On 12/06/22 at 09:36 AM, Certified Nurse Aide (CNA) N stated she was not sure who was responsible for changing the oxygen tubing on residents' oxygen concentrators. On 12/06/22 at 03:34 PM, CNA O stated the resident used oxygen while in his room. CNA O stated the night shift would change the oxygen tubing on all residents' concentrators weekly. On 12/06/22 at 02:30 PM, Licensed Nurse (LN) G stated oxygen and the care of the equipment should be included on the care plan. On 12/08/22 at 09:02 AM, Administrative Nurse D stated oxygen tubing should be included on the care plan. The facility lacked a policy for care plans. The facility failed to update the care plan with instructions for care of the oxygen that this dependent resident used. - The electronic medical record (EMR), for Resident (R)2, included a diagnosis of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He required extensive assistance of two staff for toileting and was frequently incontinent of bladder. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/03/22, documented the resident required extensive to total assistance with toileting. The quarterly MDS, dated 11/17/22, documented the resident had a BIMS score of 15, indicating intact cognition. He required total assistance of two staff for toileting and was always incontinent of bladder. The incontinence care plan, revised 08/24/22, instructed staff the resident was able to express the need for toileting but due to physical disabilities was unable to take himself to the bathroom and required staff assistance. The care plan lacked instruction on the use of a urinal. Review of the EMR, from 11/07/22 through 12/05/22, revealed documentation that the resident required total assistance of one to two staff for toileting and was incontinent of bladder at all times. Review of the EMR, revealed the lack of a bladder assessment. On 12/06/22 at 02:30 PM, Licensed Nurse (LN) G stated if a resident was able to use a urinal, staff should offer him one. On 12/08/22 at 09:02 AM, Administrative Nurse D stated nurses were able to update the care plans. A urinal should absolutely be on the care plan for this resident since he was able to tell when he needed to urinate. The facility lacked a policy for care plans. The facility failed to update the care plan with instructions that the resident could use a urinal for urination instead of just being incontinent. The facility reported a census of 23 residents with 14 selected for review. Based on observation, interview, and record review the facility failed to review and revise the care plans for five of the residents reviewed. Resident (R)16 and R7 for lack of oxygen therapy, R18 for use of protective foot device, R 19 for fall interventions, R2 for lack of urinal for toileting, Findings included: - Review of Resident (R)18's Physician Order Sheet, dated 10/03/22, revealed diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin,) cerebral infarction (stroke), dementia (progressive mental disorder characterized by failing memory, confusion) and diabetic foot ulcer. The Annual Minimum Data Set (MDS). Dated 10/20/22, assessed the resident had severely impaired cognitive function, required extensive assistance of two person for bed mobility and dependent on staff for transfers. The resident had a diabetic foot ulcer and was at risk for pressure ulcers and had pressure relieving devices in his bed and chair and was on a turning and repositioning plan. The Pressure Ulcer Care Area Assessment (CAA), dated 10/20/22, assessed the resident required extensive assistance from staff for bed mobility. The resident was a risk for pressure injury and had a chronic diabetic wound to his right foot. The Care Plan, reviewed 10/23/22 instructed staff to turn and reposition the resident at least every two hours and as needed. Staff were to inform the nurse when the dressing becomes soiled, wet, or falls off. Staff instructed to turn and reposition the resident every two hours. The care plan lacked interventions for wearing protective boots to his feet. A Physician's Order dated 06/27/22, instructed staff to wash the resident's right foot ulcer with betadine and cover with gauze over an aperture pad (with central cut out) and secure with gauze wrap and apply a padded boot one time a day for diabetic foot ulcer. A Physician's Order, dated 12/05/22, instructed staff to cleanse the resident's diabetic foot ulcer with wound cleanser and apply iodosorb gel (a medicated gel to aide in absorbing drainage and covering the wound bed) to the wound bed and cover with a protective dressing daily. Observation, on 12/06/22 at 08:30 AM, revealed the resident asleep in bed. The resident did not have protective boots on his feet. Observation, on 12/06/22 at 08:53AM, revealed Certified Nurse Aide (CNA) M and N, prepared the resident for breakfast, and transferred the resident with a mechanical lift into his wheelchair. Staff propelled the resident to the dining room. The resident did not have protective boots on his feet. Observation, on 12/06/22 at 10:15 AM, revealed CNA M and N transferred the resident from his wheelchair to his recliner and elevated the footrest. The resident did not have protective boots on his feet. Interview, on 12/06/22 at 10:20 AM, with CNA M, revealed she thought the resident wore his protective boots when in bed. Observation, on 12/06/22 at 01:24 PM, revealed the resident seated in his recliner with his feet elevated on the footrest. The resident did not have protective boots on his feet. Observation, on 12/06/22 at 02:24 PM, revealed Licensed Nurse (LN) G, prepared to do dressing change to the resident's right foot diabetic ulcer. LN G did not sanitize the resident's bedside table and placed the wound care supplies on a paper towel on the overbed table. LN G donned gloves and removed the dressing. The resident's wound had been treated at a specialty wound clinic on 12/05/22. The wound was open and dark red in color approximately 3 by 2 centimeters (cm). With same gloves, LN G proceeded to cleanse the wound with the wound cleanser. LN G removed her gloves but did not perform hand hygiene. LN G donned a new pair of gloves and applied the iodosorb cream to the wound and applied an absorbent dressing and wrapped the wound with gauze. Interview, on 12/06/22 at 02:40 PM, with LN G, revealed she did not know when the resident should wear the protective boots. Interview, on 12/07/22 at 10:30 AM, with Administrative Nurse D, revealed she thought the resident wore the boots when in bed and this should be on the care plan. The facility lacked a policy for reviewing and revising the care plan. The facility failed to review and revise this resident's care plan to include use of protective foot devices for treatment of his diabetic foot ulcer. - Review of Resident (R)16's Physician Order Sheet, dated 10/03/22, revealed diagnoses included chronic respiratory failure. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function, required extensive assistance with bed mobility transfer, dressing and toilet use. The resident had functional impairment in range of motion in both sides of his upper extremities. The resident utilized oxygen therapy. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential (CAA), dated 10/27/22, assessed the resident required extensive assistance for bed mobility transfer, locomotion, dressing toilet use, bathing, and personal hygiene. The resident had acute/chronic respiratory failure with hypercapnia pneumonia, and anxiety disorder. The Care Plan, reviewed 11/19/22, lacked interventions for oxygen use. A Physician's Order, dated 09/27/22 instructed staff to administer oxygen at two liters per minute to keep the oxygen saturations (the amount of oxygen in the blood) above 90% and for shortness of breath as needed. Observation, on 12/05/22 at 09:00AM, revealed the resident positioned in his chair with the oxygen set at two liters/minute. The oxygen tubing lacked a date, and the humidifier water bottle lacked water and the bottle also lacked a date. Interview, on 12/08/22 at 03:00 PM, with Administrative Nurse E, revealed she would expect staff to change the oxygen tubing as directed on the MAR/TAR. Administrative Nurse E stated she did not know if use of oxygen was on the care plan. The facility lacked a policy for review and revising care plans. The facility staff failed to review and revise this resident's care plan to include care for oxygen therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident's (R)2's electronic medical record (EMR), revealed a diagnosis of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He required extensive assistance of one staff for locomotion on the unit with the use of a wheelchair. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/03/22, documented the resident required extensive to total assistance of one staff on the unit and was at risk for complications from immobility. The quarterly MDS, dated 11/17/22, documented the resident had a BIMS score of 15, indicating intact cognition. He required supervision of two staff for locomotion on the unit with the use of his wheelchair. The care plan for ADLs, revised 08/24/22, instructed staff the resident required staff assistance with ADLs due to physical limitations. The resident used a manual wheelchair which staff would propel, at times. Review of the resident's EMR from 11/07/22 through 12/05/22, revealed the resident required limited to total assistance of one staff for locomotion on the unit with the use of a wheelchair. Review of the resident's EMR from 11/07/22 through 12/05/22, lacked a treatment order for a skin abrasion (shallow scrape on the skin) to the resident's left second toe. On 12/05/22 at 11:48 AM, the resident sat in the dining room awaiting lunch. The resident had an open abrasion to his second toe on his left foot which lacked a dressing. On 12/05/22 at 12:25 PM, the resident propelled himself from the dining room out into the hall using his hands in his wheelchair. His bilateral bare feet with podus boots (protective booties) were dragging the floor underneath the wheelchair. The front left wheel of the wheelchair rubbed against the resident's left second toe where he had an open abrasion. On 12/06/22 at 08:28 AM, Certified Medication Aide (CMA) S stated the resident's feet would fall off of his foot pedals a lot. CMA stated she was unaware the resident had an abrasion to his left second toe. On 12/06/22 at 07:34 AM, Certified Nurse Aide (CNA) M stated the resident's feet would not stay on the foot pedals of his wheelchair. CNA M was unaware the resident had an open area to his second left toe. On 12/06/22 at 08:32 AM, Licensed Nurse (LN) G stated she was unaware of the resident having a skin issue on his toe. There was no order for treatment in his record. LN G stated she would notify the physician and get an order at that time. On 12/08/22 at 09/02 AM, Administrative Nurse D stated all skin issues should have a treatment order. The nurse would be responsible for adding the treatment order to the Treatment Administration Record (TAR) to ensure the skin area was treated and monitored until healed. The facility policy for Skin Condition, dated 12/2015, included: The staff will document a description of any new skin findings and obtain a physician's order for the care and treatment of the wound. All responsible parties, including the physician and wound nurse, will be notified of any newly identified or worsening skin conditions. The facility failed to obtain an order for treatment for this dependent resident with a skin abrasion. - Review of Resident (R)19's electronic medical record (EMR), revealed a diangosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. He required limited assistance of one staff for ADLs and used a walker for locomotion. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/04/22, documented the resident required limited assistance with ambulation with the use of a walker. The quarterly MDS, dated 11/03/22, documented the resident had a BIMS score of five, indicating severe cognitive impairment. He required limited assistance of one staff for ADLs and used a walker for locomotion. The care plan, revised 11/03/22, instructed staff the resident required assistance with ADLs due to physical limitations. Review of the resident's EMR, from 11/07/22 through 12/05/22, lacked staff instructions on treatment for the resident's right wrist. Review of the resident's progress notes, included a note, dated 11/11/22, which included: The resident had a skin tear to his right forearm. On 12/05/22 at 09:54 AM, the resident had an undated, dirty bandage to his right wrist area. On 12/05/22 at 03:21 PM, the undated, dirty bandage remained in place to the resident's right wrist area. On 12/06/22 at 03:00 PM, Licensed Nurse (LN) G gathered supplies to change the dressing on the resident's right wrist/forearm area. When LN G removed the undated bandage, there was a large amount of thick purulent (thick, milky) drainage from the wound. LN G treated the area and placed a new dressing. On 12/06/22 at 03:30 PM, LN G stated the area to the resident's right wrist/forearm lacked any treatment orders. She was unaware the resident had a skin issue due to not seeing a treatment for the wound in his EMR. LN G stated she called the physician and received an order to treat and added the new order to the resident's EMR. On 12/08/22 at 09:02 AM, Administrative Nurse D stated any new skin issues should be added to the resident's EMR so the areas can be treated and monitored for healing and/or complications. The facility had not obtained an order for this resident's skin tear and the nurses had not monitored the area. The facility policy for Skin Condition, dated 12/2015, included: The staff will document a description of any new skin findings and obtain a physician's order for the care and treatment of the wound. All responsible parties, including the physician and wound nurse, will be notified of any newly identified or worsening skin conditions. The facility failed to obtain an order for treatment and failed to monitor the skin tear for signs or symptoms of healing and/or complications for this dependent resident. The facility reported a census of 23, with 14 residents selected for review which included four for review of skin wounds. Based on observation, interview and record review, the facility failed to provide appropriate skin wound treatments for the four sampled residents with wounds, Residents (R ) 2, R18, R19, and R10. Furthermore, the facility failed to ensure assistance for proper body alignment while up in a chair for one sampled resident R6, to ensure quality of care for all five of these sampled residents. Findings included: - Review of Resident (R)10's Physician Order Sheet, dated 08/02/22, revealed diagnoses included multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), venous insufficiency, non-pressure chronic ulcer of the left and right thigh, and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed the resident with normal cognition. The resident had no unhealed pressure ulcers but was at risk for pressure ulcers and had open lesions. The resident was incontinent of bladder and always continent of bowel. The Annual (MDS), dated [DATE], assessed the resident with normal cognitive function. The resident required extensive assistance of two staff for bed mobility, dressing and personal hygiene. The resident was dependent on staff for transfer and toilet use. The resident had no unhealed pressure ulcers but did have open lesions. The Pressure Ulcer Care Area Assessment (CAA), dated 09/15/22, assess the resident had a no pressure chronic ulcer to his left and right thigh and required extensive to dependent assistance with all activities of daily living. The resident had a wheelchair cushion and a pressure reducing mattress to decrease the resident of pressure injury. The Care Plan, reviewed 09/21/22, instructed staff the resident required total assistance of two staff for toileting, dressing bathing and hygiene and staff to encourage the resident to lay down and sit to side to off load wounds. The resident was at risk for developing pressure ulcers due to incontinence and limited mobility. Staff instructed that resident wore incontinence briefs and was on a two-hour check and change. The resident had moisture associated skin damage to his right posterior thigh and staff were to apply treatment as indicated. The Physician's Order, dated 11/29/22, instructed staff to cleanse the right thigh wound and left coccyx wound with wound cleanser, and apply collagen powder and Triad paste (a type of medicated cream that adheres to the wound bed to aide in healing) to the wound bed and apply triad paste around the wound. Interview, on 12/05/22 at 09:30 AM, with Licensed Nurse (LN) I, revealed the resident had MRSA (methicillin resistant staphylococcus aureus a highly contagious bacteria) in his thigh wound and was on isolation for this. Observation, on 12/05/22 at 09:30 AM, revealed an isolation precaution sign posted on the door to the resident's room. Observation, on 12/06/22 at 10:43 AM, revealed the resident positioned in bed on his right side. Licensed Nurse (LN) G positioned the dressing supplies directly on the resident's bedside table without sanitizing or placing a barrier. LN G donned gloves and removed the dressing to the resident's right lower buttock. The dressing had red and yellow drainage on it. This wound was open approximately 3 by 2 centimeters (cm) and red in color. With the same gloved hands, LNG cleansed the open right thigh wound and closed left thigh wound with wound cleanser and the same gauze sponge. With the same gloved hands, LNG obtained scissors and tape from her pocket. LN G applied the triad paste, to the right thigh wound and left thigh would with the same gloved hands but did not locate the collagen powder for the wound. LN applied a dressing with tape to the resident's right thigh. Interview, on 12/08/22 at 09:04 AM, with Administrative Nurse D, revealed she would expect staff to sanitize hands in between gloving, and to change gloves after removing a dressing and donning a clean pair to cleanse the wound and apply the ordered treatment. The facility policy Hand Hygiene, instructed staff to help prevent the development and transmission of communicable diseases and infections to perform hand hygiene between glove changes during care or procedures. The facility failed to provide sanitary dressing change to this resident's right and left thigh wounds to prevent the spread of infection. - Review of Resident (R)18's Physician Order Sheet, dated 10/03/22, revealed diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin,) cerebral infarction (stroke), dementia (progressive mental disorder characterized by failing memory, confusion) and diabetic foot ulcer. The Annual Minimum Data Set (MDS). Dated 10/20/22, assessed the resident had severely impaired cognitive function, required extensive assistance of two person for bed mobility and dependent on staff for transfers. The resident had a diabetic foot ulcer and was at risk for pressure ulcers and had pressure relieving devices in his bed and chair and was on a turning and repositioning plan. The Pressure Ulcer Care Area Assessment (CAA), dated 10/20/22, assessed the resident required extensive assistance from staff for bed mobility. The resident was a risk for pressure injury and had a chronic diabetic wound to his right foot. The Care Plan, reviewed 10/23/22 instructed staff to turn and reposition the resident at least every two hours and as needed. Staff were to inform the nurse when the dressing becomes soiled, wet, or falls off. Staff instructed to turn and reposition the resident every two hours. The care plan lacked interventions for wearing protective boots to his feet. A Physician's Order dated 06/27/22, instructed staff to wash the resident's right foot ulcer with betadine and cover with gauze over an aperture pad (with central cut out) and secure with gauze wrap and apply a padded boot one time a day for diabetic foot ulcer. A Physician's Order, dated 12/05/22, instructed staff to cleanse the resident's diabetic foot ulcer with wound cleanser and apply iodosorb gel (a medicated gel to aide in absorbing drainage and covering the wound bed) to the wound bed and cover with a protective dressing daily. Observation, on 12/06/22 at 08:30 AM, revealed the resident asleep in bed. The resident did not have protective boots on his feet. Observation, on 12/06/22 at 08:53AM, revealed Certified Nurse Aide (CNA) M and N, prepared the resident for breakfast, and transferred the resident with a mechanical lift into his wheelchair. Staff propelled the resident to the dining room. The resident did not have protective boots on his feet. Observation, on 12/06/22 at 10:15 AM, revealed CNA M and N transferred the resident from his wheelchair to his recliner and elevated the footrest. The resident did not have protective boots on his feet. Interview, on 12/06/22 at 10:20 AM, with CNA M, revealed she thought the resident wore his protective boots when in bed. Observation, on 12/06/22 at 01:24 PM, revealed the resident seated in his recliner with his feet elevated on the footrest. The resident did not have protective boots on his feet. Observation, on 12/06/22 at 02:24 PM, revealed Licensed Nurse (LN) G, prepared to do dressing change to the resident's right foot diabetic ulcer. LN G did not sanitize the resident's bedside table and placed the wound care supplies on a paper towel on the overbed table. LN G donned gloves and removed the dressing. The resident's wound had been treated at a specialty wound clinic on 12/05/22. The wound was open and dark red in color approximately 3 by 2 centimeters (cm). With same gloves, LN G proceeded to cleanse the wound with the wound cleanser. LN G removed her gloves but did not perform hand hygiene. LN G donned a new pair of gloves and applied the iodosorb cream to the wound and applied an absorbent dressing and wrapped the wound with gauze. Interview, on 12/06/22 at 02:40 PM, with LN G, revealed she did not know when the resident should wear the protective boots. Interview, on 12/07/22 at 10:30 AM, with Administrative Nurse D, revealed she thought the resident wore the boots when in bed. Administrative Nurse D stated staff should ensure a sanitized area for dressing supplies and should sanitize their hands in between glove changes. The facility policy Hand Hygiene, instructed staff to help prevent the development and transmission of communicable diseases and infections to perform hand hygiene between glove changes during care or procedures. The facility policy Wound Prevention and Management, instructed staff to document interventions on the care plan. The facility failed to provide a sanitary dressing change for this dependent resident's diabetic foot ulcer and failed to clarify/apply the padded protective boots to his feet as ordered by the physician on 06/27/22, to prevent further decline. - Review of Resident (R)6's Physician Order Sheet, dated 10/03/22, revealed diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness,) psychotic disorder (any major mental disorder characterized by a gross impairment in reality testing), and lymphedema (swelling caused by accumulation of lymph). The Annual Minimum Data Set, dated 07/07/22, assessed the resident with moderately impaired cognitive function. The resident required extensive assistance of two staff for bed mobility toileting, personal hygiene and was dependent on two staff for transfers. The resident had no impairment in range of motion in upper or lower extremities. The resident was always continent of bowel and bladder. The Cognitive Loss Care Area Assessment, (CAA), dated 07/02/22, assessed the resident had anxiety and depressed mood, overactive bladder. The resident was able to make herself understood but was at risk for impaired comprehension with a decline in cognition. The resident required extensive to total assist with activities of daily living. The ADL (Activity of Daily Living) Functional/Rehabilitation CAA, dated 07/02/22, assessed the resident required extensive assistance with bed mobility, dressing, toileting and personal hygiene, and dependence on staff for transfers, locomotion, and bathing. The 'Care Plan reviewed 09/28/22, instructed staff the resident utilized a Broda chair for locomotion and needed assistance of one staff for locomotion. The resident required extensive assistance of two staff for toileting. The resident required a mechanical lift for transfers. Staff instructed to place a wedge to assist her in sitting upright. Observation, on 12/06/22 at 07:34 AM, revealed the resident seated in her Broda chair, slumped to the left with her left arm and shoulder off the back and arm of the chair. The resident lacked a positioning wedge on her left side. Interview with the resident at that time revealed she was uncomfortable leaning with her arm extending off the arm of the chair and was unable to reposition herself or move her left arm up. Observation, on 12/06/22 at 08:13 AM, revealed Certified Nurse Aide Q, propelled the resident to the dining room for breakfast. The resident leaned to the left but was able to feed herself with cueing. Observation continued every 15 minutes through 10:30 AM, at which time the resident remained slumped to the left in her Broda chair (a specialized chair for pressure prevention). CNA Q pulled the resident up in her chair by the lift sling which was positioned under the resident. CNA Q placed a wedge under the resident's left side, Observation on 12/26/22 at 1:39 PM, revealed the resident sitting in her Broda chair leaning to the left, with left arm off the arm of the chair and extending downward. Observation on 12/06/22 at 01:58 PM, revealed CNA Q and N transferred the resident into bed with the mechanical lift. Observation, on 12/07/22 at 09:30 AM, revealed the resident positioned in her Broda chair leaning with her left shoulder off center with her left arm off the arm of the chair and dropping towards the floor. The resident did have a wedge in place but was ineffective in maintaining the resident in an upright posture. Interview, on 12/07/22 at 09:53 AM, with Consulting Therapy Staff GG, confirmed the resident leaned to the left, and staff did not place the positioning wedge in the proper position as indicated by the pictures in the resident's room. Therapy Staff GG stated the resident needed to be positioned and centered in the chair to assist with upright posture. Interview, on 12/07/22 at 01:36 PM, with Administrative Nurse D, revealed the resident should be repositioned at least every two hours and as needed. Administrative Nurse D stated she would expect staff to use the proper positioning devices to keep the resident as upright as possible. The facility policy Positioning, Mobility and Range of Motion Critical Element Pathway, undated, instructed staff to ensure the resident is properly positioned in a wheelchair or recliner to maintain proper body alignment. The facility failed to ensure staff transferred this resident into her Broda chair to maintain upright and centered posture and utilized positioning devices in an effective manner to maintain upright and anatomical positioning as much as possible for the resident comfort and wellbeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The electronic medical record (EMR), for Resident (R)2, included a diagnosis of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He required extensive assistance of two staff for toileting and was frequently incontinent of bladder. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/03/22, documented the resident required extensive to total assistance with toileting. The quarterly MDS, dated 11/17/22, documented the resident had a BIMS score of 15, indicating intact cognition. He required total assistance of two staff for toileting and was always incontinent of bladder. The incontinence care plan, revised 08/24/22, instructed staff the resident was able to express the need for toileting but due to physical disabilities was unable to take himself to the bathroom and required staff assistance. Review of the EMR, from 11/07/22 through 12/05/22, revealed documentation that the resident required total assistance of one to two staff for toileting and was incontinent of bladder at all times. Review of the EMR, revealed the lack of a bladder assessment. On 12/06/22 at 07:17 AM, Certified Nurse Aides (CNA) M and N entered the resident's room to get him ready for the day. Staff N asked the resident if he needed to urinate in which the resident replied he did. CNA N instructed the resident to urinate in his brief, which the resident did. Staff made no offer of a urinal to the dependent resident. On 12/05/22 at 11:47 AM, the resident stated he usually knew when he needed to urinate or have a bowel movement (BM). Staff always told him to go in his brief instead of offering a urinal or a bed side commode (BSC). On 12/06/22 at 07:17 AM, CNA M stated the resident did not use a urinal because it was not on his care plan. The resident required the hoyer lift (a full-body mechanical lift) for transfers and the lift would not fit into the bathroom. At times, the staff would use the BSC, but there was not one in the resident's room at that time. On 12/06/22 at 07:17 AM, CNA N stated the staff have the resident urinate in his brief because the hoyer lift will not fit into the bathroom. The resident was not care planned to use a urinal. On 12/08/22 at 09:02 AM, Administrative Nurse D stated staff should not ask residents to go to the bathroom in their brief as that would be a dignity issue. Residents who are able to feel the sensation to urinate should be offered a urinal. The facility policy for Incontinence Management, revised 12/2017, included: The purpose of the policy was to restore or maintain the resident's bowel and bladder function. The facility failed to ensure this dependent resident was able to maintain his bladder function by with the failure to offer a urinal when the resident reported the need to urinate. The facility reported a census of 23 residents with 14 selected for review which included four residents reviewed for bowel and bladder incontinence. Based on observation, interview and record review, the facility failed to provide a toileting program for one of the four sampled Residents (R)2 and failed to provide toileting/personal hygiene opportunities to three of four sampled residents (R 10, R 6 and R4) to prevent urinary tract infections. Findings included: - Review of Resident (R)10's Physician Order Sheet, dated 08/02/22, revealed diagnoses included multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), venous insufficiency, non-pressure chronic ulcer of the left and right thigh, and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed the resident as always incontinent of bowel and bladder. The Annual MDS), dated [DATE], assessed the resident with normal cognitive function. The resident required extensive assistance of two staff for bed mobility, dressing and personal hygiene. The resident was dependent on staff for transfer and toilet use. The resident was assessed as always continent of bowel and bladder. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 09/15/22, assessed the resident was incontinent of urine and was totally dependent on staff for toileting. He required check and change every two hours and as needed. He had a chronic ulcer to his left and right thigh and used a mechanical lift for transfers. The Care Plan, reviewed 09/21/22, instructed staff the resident required total assistance of two staff for toileting, dressing bathing and hygiene and staff were to encourage the resident to lay down and sit to the side to off load wounds. The resident was at risk for developing pressure ulcers due to incontinence and limited mobility. Staff instructed that the resident wore incontinence briefs and was on a two- hour check and change. The resident did not alert staff of the need to be changed. Staff were to provide peri care as needed with incontinence episodes. The resident had moisture associated skin damage to his right posterior thigh and staff were to apply treatment as indicated. Observation, on 12/06/22 at 10:50 AM, revealed the resident positioned in bed. Certified Nurse Aide (CNA) N applied an incontinence brief and layered pad for incontinence. Licensed Nurse (LN) G and CNA N transferred the resident with a mechanical lift into his wheelchair. Interview, on 12/06/22 at 12:50 PM, with CNA N, revealed the resident was incontinent of urine but would tell staff when he was wet. Observation continued, on 12/06/22 at intervals and revealed staff assisted the resident to go outside to smoke, and brought his lunch to him, but staff did not offer the resident a toileting opportunity. Observations continued through 12/06/22 at 02:54 PM at which time the resident was seated in his wheelchair in his room. CNA O and CNA MM removed a urine-soaked pad while the resident was seated in his wheelchair. Staff did not provide peri care. CNA O stated the resident did not usually lay down for peri care, or position changes and so staff did not ask him if he wanted to. CNA O thought this was on his care plan. Interview, on 12/07/22 at 12:14 PM, with the resident revealed he would lay down during the day and no one talked to him about laying down to change his brief or sitting up too long in his chair. Interview. On 12/07/22 at 01:49 PM, with CNA NN, revealed the resident was incontinent of urine and would notify staff when he was wet. Interview, on 12/07/22 at 01:38 PM, with Administrative Nurse D, revealed she thought the resident was continent of urine, but could tell staff when he was wet. Administrative Nurse D stated staff should lay the resident down to provide peri care, but he often refused. The facility policy Incontinence Management Policy, revised 12/2017, instructed staff to assess the resident to identify a history and pattern of bowel and bladder function. Staff instructed to review the individualized bowel and bladder program and revise as needed. The facility failed to ensure sanitary and timely incontinence hygiene care for this dependent resident to prevent urinary tract infections. - Review of Resident (R)6's Physician Order Sheet, dated 10/03/22, revealed diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness,) psychotic disorder (any major mental disorder characterized by a gross impairment in reality testing), and lymphedema (swelling caused by accumulation of lymph). The Annual Minimum Data Set, dated 07/07/22, assessed the resident with moderately impaired cognitive function. The resident required extensive assistance of two staff for bed mobility toileting, personal hygiene and was dependent on two staff for transfers. The resident had no impairment in range of motion in upper or lower extremities. The resident was always continent of bowel and bladder. The Cognitive Loss Care Area Assessment, (CAA), dated 07/02/22, assessed the resident had anxiety and depressed mood, overactive bladder. The resident was able to make herself understood but was at risk for impaired comprehension with a decline in cognition. The resident required extensive to total assist with activities of daily living. The ADL (Activity of Daily Living) Functional/Rehabilitation CAA, dated 07/02/22, assessed the resident required extensive assistance with bed mobility, dressing, toileting and personal hygiene, and dependence on staff for transfers, locomotion, and bathing. The 'Care Plan reviewed 09/28/22, instructed staff the resident utilized a Broda chair for locomotion and needed assistance of one staff for locomotion. The resident required extensive assistance of two staff for toileting. The resident required a mechanical lift for transfers. Observation, on 12/06/22 at 07:34 AM, revealed the resident seated in her Broda chair in her room. The resident's room smelled of urine, and the resident's bed contained urine-soaked sheets. Interview with the resident at that time, revealed staff did not always check on her in a timely manner and she had urinary incontinence. Interview, on 12/06/22 at 07:40 AM, with Administrative Nurse D, revealed staff should remove the urine-soaked sheets. Observation, on 12/06/22 at 08:13 AM, revealed Certified Nurse Aide Q, propelled the resident to the dining room for breakfast. Observation continued every 15 minutes through 10:30 AM, at which time the resident remained slumped to the left in her Broda chair (a specialized chair for pressure prevention). CNA Q pulled the resident up in her chair by the lift sling which was positioned under the resident. CNA Q did not offer the resident a toileting/personal hygiene opportunity. Observation continued through 12/06/22 at 01:58 PM, at which time CNA Q and N transferred the resident into bed with the mechanical lift. The resident's brief was saturated with urine. The resident's Broda chair smelled of urine. CNA Q and N provided peri care to the resident but did not sanitize the Broda chair. Observation, on 12/06/22 at 03:46 PM, revealed CNA O and CNA MM, provided incontinence care to the resident. CNA O stated at that time the resident was on a two-hour check and change for incontinence. Interview, on 12/07/22 at 01:36 PM, with Administrative Nurse D, revealed the resident should be checked and changed every two hours and staff needed to encourage fluids as she had a strong urine odor. The facility policy Incontinence Management Policy, revised 12/2017, instructed staff to assess the resident to identify a history and pattern of bowel and bladder function. Staff instructed to review the individualized bowel and bladder program and revise as needed. The facility failed to evaluate this resident's urinary incontinence and provide an individualized toileting program to maintain or improve her bladder functioning ability. - Review of Resident (R)4's Physician Order Sheet, dated 10/03/22, revealed diagnoses included Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with moderate cognitive impairment, required extensive assistance of two for bed mobility toilet use. The resident was dependent on staff for transfer and personal hygiene. The resident had no current pressure ulcers and was at risk for pressure ulcer development and had a pressure reducing device for her chair and bed and was on a turning/repositioning program. The resident had impairment in functional range of motion on one side of the upper and lower extremities. The resident was always incontinent of bowel and bladder. The Quarterly MDS, dated 10/20/22, assessed the resident with moderate cognitive impairment. The resident was dependent on two staff for bed mobility, transfer, toilet use and personal hygiene. The resident had no current pressure ulcers and was at risk for pressure ulcer development and had a pressure reducing device for her chair and bed and was on a turning/repositioning program. The resident had impairment in functional range of motion on one side of the upper and lower extremities. The resident was always incontinent of bowel and bladder. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 04/28/22, assessed the resident as incontinent of bowel and bladder and required extensive to total assistance for toileting and personal hygiene. The Care Plan, reviewed 10/26/22, instructed staff to check/change/reposition the resident every two hours and provide peri care. Observation, on 12/06/22 at 07:15 AM, revealed the resident seated in her Broda chair (a type of chair that provides distribution of pressure areas to help prevent skin breakdown.) Observations continued every 15 minutes and included the following: At 08:09 AM, Certified Nurse Aide (CNA) Q, placed shoes on the resident and propelled her to the dining room. At 09:00 AM, CNA N propelled the resident to her room and positioned her in front of the TV without a toileting/personal hygiene opportunity. At 11:45 AM, CNA Q propelled the resident to the dining area for the noon meal without offering a toileting/personal hygiene opportunity. At 12:45 PM, CNA N propelled the resident back to her room and placed her in front of the TV without providing toileting/personal hygiene. Interview, at that time with CNA Q revealed staff would transfer the resident back to bed when the residents in the dining room were taken to their rooms. At 01:45 PM, CNA Q and N, transferred the resident back to bed with the mechanical lift. CNA Q removed the resident's incontinence brief and observed the resident was incontinent of urine. The resident's left buttocks had and area of redness approximately three by two centimeters. Licensed Nurse (LN) G observed the area of redness and stated she noticed is three weeks ago. LN G applied moisture barrier cream. LN G stated the resident was at risk for pressure ulcers and staff should lay the resident down at least every two hours to provide incontinence care and repositioning. Interview, on 12/08/22 at 01:31 PM, with Administrative Nurse D revealed she observed the resident's buttocks on 12/07/22 and thought the skin looked better with application of zinc oxide barrier cream to the resident's perineal area and buttocks. Administrative Nurse D stated staff should reposition and check the resident for incontinence at least every two hours. The facility policy Incontinence Management Policy, revised 12/2017, instructed staff to assess the resident to identify a history and pattern of bowel and bladder function. Staff were instructed to review the individualized bowel and bladder program and revise as needed. The facility failed to provide toileting and personal hygiene opportunities in a timely manner for this dependent resident at risk for pressure ulcers and urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 23 residents with 14 residents sampled including four residents reviewed for respiratory. Based on interview, record review, and observation, the facility failed to provide appropriate respiratory services for the four sampled residents included; the failure to ensure oxygen (O2) tubing was dated for three Residents (R)7, R 8 and R 16, failed to ensure staff cleaned the continuous positive airway pressure (CPAP) mask and hosing daily for R 2, and failed to ensure the humidifier bottle contained distilled water for R 16. Findings included: - Review of Resident (R)2's electronic medical record (EMR), revealed a diagnosis of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He used oxygen (O2) and a continuous positive airway pressure (CPAP) while a resident. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/03/22, documented the resident had contractures (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). The quarterly MDS, dated 11/17/22, documented the resident had a BIMS score of 15, indicating intact cognition. The MDS inaccurately documented the resident did not use a CPAP while a resident. The care plan for respiratory, revised 08/24/22, instructed staff to change the CPAP filters every Sunday night and to clean the mask and head gear daily. Staff were to clean the CPAP tubing daily on the day shift. Review of the resident's EMR revealed documentation of staff completing the task of rinsing the tubing and mask every day shift. On 12/05/22 at 11:48 AM, the resident's CPAP mask rested directly on top of the bedside table and lacked a barrier. The CPAP mask and hose remained connected. On 12/06/22 at 07:17 AM, Certified Nurse Aide (CNA) M and CNA N got the resident up for the day. Staff removed his CPAP mask and rested it on the bedside table, without a barrier. Staff failed to rinse the mask and hose at that time. On 12/06/22 at 09:22 AM, the CPAP mask and hose remained connected and rested directly on the bedside table next to the resident's bed. On 12/06/22 at 08:28 AM, Certified Medication Aide (CMA) S stated staff clean the resident's CPAP mask and hosing on Sunday nights. On 12/06/22 at 07:17 AM, CNA M stated staff on the night shift will clean the CPAP mask before putting the resident to bed. They did not clean the mask or the tubing on day shift. On 12/06/22 at 03:34 PM, CNA O stated the day shift would clean the CPAP mask and hosing when they got the resident up in the morning, though CNA O was not sure how often the staff cleaned the mask and hosing. On 12/06/22 at 08:32 AM, Licensed Nurse (LN) G stated staff cleaned the CPAP mask and hosing every night before putting the resident to bed. The resident was to wear the CPAP at all times while sleeping. On 12/08/22 at 09:02 AM, Administrative Nurse D stated staff should clean the CPAP mask and tubing every morning when the resident woke up. The facility policy for Administration of Oxygen, undated, included: Nursing staff shall be adequately trained in the handling of respiratory equipment. The facility failed to ensure the staff cleaned the CPAP mask and hose daily for this dependent resident, placing him at an increased risk of a respiratory infection. - Review of Resident (R)7's electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating moderately impaired cognition. The MDS inaccurately documented the resident did not use oxygen (O2) while a resident. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/23/22, documented the resident required limited to extensive assistance with ADLs. The care plan, revised 10/23/22, lacked staff instruction on care of the oxygen tubing. Review of the resident's EMR revealed a physician's order for Oxygen 2 liters (L) per nasal cannula (NC), as needed (PRN) for shortness of breath, ordered 11/09/22. On 12/05/22 at 03:13 PM, the resident had undated oxygen tubing in his room. On 12/06/22 at 09:15 AM, the resident's oxygen tubing remained undated. On 12/06/22 at 09:36 AM, Certified Nurse Aide (CNA) N stated she was not sure who was responsible for changing the oxygen tubing on residents' oxygen concentrators. On 12/06/22 at 03:34 PM, CNA O stated the resident used oxygen while in his room. CNA O stated the night shift would change the oxygen tubing on all residents' concentrators weekly. On 12/06/22 at 02:30 PM, Licensed Nurse (LN) G stated she was unsure of who changed the oxygen tubing in the facility. On 12/08/22 at 09:02 AM, Administrative Nurse D stated oxygen tubing should be changed out on Sunday nights and PRN. Oxygen tubing should be dated at the time it was changed. The facility policy for Administration of Oxygen, undated, included: Nursing staff shall be adequately trained in the handling of respiratory equipment. The facility failed to maintain this dependent resident's oxygen tubing with the date at the time it was changed, to prevent respiratory infections, making it unclear how long the tubing had been in use. - Review of Resident (R)8's Physician Order Sheet (POS), included a diagnosis of acute respiratory failure (loss of pulmonary function). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He used oxygen (O2) while a resident. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/11/22, documented the resident required extensive assistance with ADLs. The quarterly MDS, dated 11/10/22, documented the resident had a BIMS score of 15, indicating intact cognition. He used oxygen while a resident. The care plan for respiratory, revised 11/02/22, instructed staff the resident had the potential for respiratory distress. Staff were to change the oxygen tubing weekly. On 12/05/22 at 07:43 AM, The resident rested on his back in bed. He had his oxygen on with the tubing undated. On 12/05/22 at 03:09 PM, the resident's oxygen tubing remained undated. On 12/06/22 at 09:36 AM, Certified Nurse Aide (CNA) N stated she was not sure who was responsible for changing the oxygen tubing on resident's oxygen concentrators. On 12/06/22 at 03:34 PM, CNA O stated the night shift would change the oxygen tubing on all resident's concentrators weekly. On 12/06/22 at 02:30 PM, Licensed Nurse (LN) G stated she was unsure of who changed the oxygen tubing in the facility. On 12/08/22 at 09:02 AM, Administrative Nurse D stated oxygen tubing should be changed out on Sunday nights and PRN. Oxygen tubing should be dated at the time it was changed. The facility policy for Administration of Oxygen, undated, included: Nursing staff shall be adequately trained in the handling of respiratory equipment. The facility failed to maintain this dependent resident's oxygen tubing at the time it was changed with the date, to prevent respiratory infections, making it unclear how long the tubing had been in use. - Review of Resident (R)16's Physician Order Sheet, dated 10/03/22, revealed diagnoses included chronic respiratory failure. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function, required extensive assistance with bed mobility transfer, dressing and toilet use. The resident had functional impairment in range of motion in both sides of his upper extremities. The resident utilized oxygen therapy. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential (CAA), dated 10/27/22, assessed the resident required extensive assistance for bed mobility transfer, locomotion, dressing toilet use, bathing, and personal hygiene. The resident had acute/chronic respiratory failure with hypercapnia pneumonia, and anxiety disorder. The Care Plan, reviewed 11/19/22, lacked interventions for oxygen use. A Physician's Order, dated 09/27/22 instructed staff to administer oxygen at two liters per minute to keep the oxygen saturations (the amount of oxygen in the blood) above 90% and for shortness of breath as needed. The September, October, and November 2022 Medication Administration Record/Treatment Administration Record (MAR/TAR) lacked indication for oxygen usage. Observation, on 12/05/22 at 09:00AM, revealed the resident positioned in his chair with the oxygen set at two liters/minute. The oxygen tubing lacked a date, and the humidifier water bottle lacked water and the bottle also lacked a date. Observation, on 12/06/22 at 11:08 AM, revealed the resident resting in bed. The oxygen tubing and canula (section of tubing going directly into the nostrils) lay directly on the floor. Interview, on 12/06/22 at 11:15AM, with Licensed Nurse (LN) G, revealed the tubing should be dated and picked up the oxygen tubing and attempted to sanitize the cannula with an alcohol swab. LNG, then decided to provide a new tubing and cannula. Interview, on 12/08/22 at 09:30AM, with Administrative Nurse D, revealed she would expect staff to change the oxygen tubing as directed on the MAR/TAR. Interview, on 12/08/22 at 03:00 PM, with Administrative Nurse E, revealed she would expect staff to change the oxygen tubing as directed on the MAR/TAR. The facility policy for Oxygen Policies- Administration of Oxygen, undated, instructed staff to follow the training in handling of oxygen equipment and administration and medical use of oxygen. The facility lacked a policy for changing oxygen tubing and maintaining humidification of oxygen. The facility staff failed to provide and monitor this resident's oxygen tubing and humidification in a sanitary manner to prevent the spread of infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - A narcotic count of the medication room emergency medication kits (e-kits), with Administrative Nurse D, on 12/07/22 at 06:54 AM, revealed the Controlled Medication Inventory (a sheet used to keep count of narcotic medications) sheets lacked any nurses' signatures since 11/23/22. One e-kit contained the following medications: 1. Ten Hydrocodone (an opioid pain medication) 5 milligrams (ml)/Acetaminophen (APAP) 325 mg. 2. Five Hydrocodone 7.5 mg/APAP 325 mg. 3. Five Hydrocodone 10 mg/APAP 325 mg. The refrigerated e-kit contained the following medications: 1. One insulin (a hormone produced in the pancreas) aspart (a short-acting insulin) pen. 2. One insulin garligen (a long-acting insulin) pen. 3. One lupro (a short-acting insulin) insulin pen. 4. One levemir (a long-acting insulin) insulin pen. 5. Lorazepam (an antianxiety medication) 2 mg/milliliter (ml), injection 1 ml vial. 6. Lorazepam oral concentrate 2 mg/ml, 30 ml bottle. 7. Promethazine (medication used to prevent and treat nausea and vomiting) 25 mg suppositories (a solid medical preparation in a roughly conical or cylindrical shape, designed to be inserted into the rectum or vagina to dissolve), two suppositories. On 12/07/22 at 06:54 AM, Administrative Nurse D stated she was unaware the e-kits were in the medication room. The facility policy for Medication Storage and Labeling, undated, included: Staff will maintain sufficiently detailed records of receipt and disposition of controlled medications were maintained to enable an accurate reconciliation. The facility failed to ensure an accurate adequate system for monitoring and reconciliation narcotic medications to prevent misappropriation of resident medications in two e-kits in the medication room. The facility reported a census of 23 residents. The sample of 14 included six reviewed for medications. Based on observation, interview, and record review, the facility failed to ensure an accurate adequate system for monitoring and reconciliation of narcotic medications, to prevent misappropriation of resident medications from two emergency medication kits (e-kits) in the medication room. Furthermore, the facility failed to administer Prednisone as ordered by the physician for one Resident (R) 76 of the six residents reviewed for medications. Findings included: - Review of Resident (R)76's medical record, revealed the resident admitted to the facility on [DATE]. Physician Order Sheet, dated 10/19/22, revealed diagnoses included pulmonary hypertension (elevated blood pressure in the arteries of the lungs), chronic respiratory failure, chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic kidney disease and atrial fibrillation (rapid, irregular heartbeat). The resident was transferred to acute care on 10/14/22 for acute bradycardia (slowed pulse) and hypotension (low blood pressure) per the Acute Care admission Note, dated 10/14/22. The resident transferred back to the facility on [DATE]. The resident was transferred to acute care on 10/20/22 for acute pulmonary edema per the Acute Care admission Note, dated 10/20/22 and returned to the facility on [DATE] and expired on 10/26/22. A Physician's Order, dated 10/11/22, instructed staff to administer Prednisone (a medication given to decrease inflammation) 10 milligrams (mg), take six tabs daily, decrease by one tab (10mg) daily. A Physician's Order, dated 10/17/22 instructed staff to administer Prednisone 10 mg, take six tabs (60 mg), daily, and decrease by 10 mg daily. Review of the October 2022 Medication Administration Record, revealed the following: Physician's order date, 10/11/22, Prednisone tablet 10 mg, give six tablets by mouth, one time a day, related to acute and chronic respiratory failure until 10/12/22. The administration documentation area was blank, indicating the staff failed to administer the medication. Order date, 10/11/22, Prednisone tablet, 10 mg, give five tablets, by mouth, one time a day related to acute and chronic respiratory failure until 10/13/22. The administration documentation was blank Order date, 10/11/22, Prednisone tablet, 10 mg, give four tablets, by mouth, one time a day related to acute and chronic respiratory failure until 10/14/22, with the administration given. (The resident transferred to acute care 10/14/22 and returned 10/17/22.) Order date, 10/17/22, Prednisone 10 mg, give two tablets, by mouth, three times a day, for one day, related to acute and chronic respiratory failure with the administration time 08:00 PM on 10/18/22, 08:00 AM on 10/19/22, and 12:00 PM on 10/19/22. The administration documentation for 10/18/22 was blank and two administrations slots for 10/19/22 at 08:00 AM and 12:00 PM indicated to see Nurse Notes. Order date, 10/17/22, Prednisone 10 mg, give one tablet, five times a day, for one day, related to acute and chronic respiratory failure. The administration time was set for 10/19/22 at 05:00PM and 09:00PM; 10/20/22 at 08:00 AM, 11:00 AM, and 02:00PM. The administration on 10/19/22 at 05:00 PM was blank. The administration 10/19/22 at 09:00 PM indicated staff administered the medication. The administration times on 10/20/22 indicated to see nurses' note. The resident was transferred to acute care on 10/20/22 for acute pulmonary edema per acute care admission note dated 10/20/22. Interview on 12/08/22 at 09:45 AM, with Certified Medication Aide (CMA) T, revealed she remembered the resident had nausea at times and she reported that to the charge nurse. She stated she did not administer the ordered Prednisone due to the resident's nausea but did not remember what dates that occurred. Interview, on 12/08/22 at 10:30 AM, with Administrative Nurse E, revealed the pharmacy sent Prednisone in two separate bubble packs, and staff may have used doses from the 10/22/22 bubble pack for the 10/17/22 orders. Administrative Nurse E confirmed staff did not consistently administer the Prednisone as ordered and she would expect staff to notify the physician for clarification as per Standard of Practice. The lacked a policy for following physician orders. The facility failed to ensure this resident, with multiple admissions to acute care, received Prednisone as ordered by the physician. The facility failed to clarify the physician's orders for prednisone. - Observation, on 12/06/22 at 10:30 AM, revealed the medication room contained two boxes of resident medications without pharmacy processing forms. The medication room counter contained multiple stacks of medication for return to the pharmacy with processing forms. The narcotic safe box for return contained multiple narcotic medications for destruction. This box contained a card of 62 doses of Lorazepam (a medication used for anxiety) without the narcotic count record. Interview, on 12/06/22 at 10:30 AM, with Administrative Nurse D, confirmed the medications in the medication room needed to be processed and returned to the pharmacy, but did not have time to complete this task for all the medications. Administrative Nurse D confirmed the 62 doses of Lorazepam should have the narcotic count record. The facility policy Medication Storage and Labeling dated 10/2022, instructed staff to maintain record of receipt and disposition of controlled medications to enable accurate reconciliation. Staff instructed to maintain medication record in an orderly manner. The facility failed to maintain medications for return to pharmacy, expired medications in an orderly manner, and failed to ensure a narcotic count record was attached to the Lorazepam for destruction, to prevent missing residents' narcotic medications.

The facility reported a census of 23 residents. Based on observation, interview, and record review, the facility failed to administer influenza vaccines in a timely manner to the 19 residents who consented to the administration of the vaccine. Findings included: - Observation, on 12/06/22 at 10:00 AM revealed four boxes of high dose influenza vaccine with procurement date of 10/20/22 in the medication room refrigerator. Review of the 23 influenza 2022 consent forms revealed four residents declined the vaccine. Interview, on 12/07/22 at 05:45 PM, with Consulting Medical Staff HH, revealed influenza vaccine should be administered by mid-October to provide protection to the residents. Interview, on 12/08/22 at 11:23 AM, with Administrative Nurse E, revealed the facility did not administer the influenza vaccine to the 19 residents that wanted the flu vaccine as of this date. The facility policy Resident Immunization, revised 12/2018, instructed staff that it was especially important to have an established and effective resident immunization program. Staff to offer all residents the influenza vaccine annually. The facility failed to administer the influenza vaccine to the 19 residents that requested the vaccine in a timely manner for optimal influenza protection.

The facility reported a census of 23 residents. Based on observations and interviews, the facility failed to provide a sanitary environment in the facility hospitality storage room, a soiled utility room, a women's tub room, and in the laundry. Findings included: - On 12/7/22 at 08:30 AM, during a facility tour with housekeeping and maintenance supervisor U, the following items/areas revealed of concern: The hospitality room, now used for storage, had a plugged in, empty deep freezer. The deep freezer had visible dirt and dust build-up on both the inside and outsides. Employee/maintenance employee U reported using this area as a COVID supply storage room. The soiled utility room in the northeast hall by the nurses' station had no usable sinks. Instead, there was cardboard taped over both sides of a double sink. There was also a strong foul potent odor of urine in this soiled utility room. In addition, there were uncovered barrels for trash and dirty laundry. Housekeeping/maintenance employee U reported the staff emptied the barrels at 8, 10, and at the end of the day. The women's tub room in the northwest hallway had a note on the door documenting that the room was closed. Environmental/maintenance employee U reported it as closed due to an old survey because of the of the floors. On the floor of the shower room, there was a pair of resident's jeans, visibly soiled underwear, and a pair of socks. A towel rested directly on the floor at the shower entrance. On 12/8/22 at 09:00 AM, observation in the laundry room revealed a small white residential washer with peeling paint around the lid. The fabric dispenser cup on the top of the inside of the machine held visible food particles. The top right side of the washer contained a smear of an unknown brown substance. Two industrial sized washers had noted rust along the lower portion of the machines. The clean side of the laundry had a clean, folded resident blanket on a bottom shelf, which hung out directly on the floor. The clean linen cart to deliver clean linens, had visible brown smears and dust build-up. A biohazard bag contained linens and tied shut sat directly on the floor of the laundry room. Housekeeping employee V reported certified nurse aid N had brought it in and put it on the floor. The facility's policy for Housekeeping, Laundry, and Maintenance states all isolation linen must be placed in a biohazard bag inside a properly-labeled container. The facility did not provide a policy on cleaning of these non-resident usage areas as requested on 12/12/2022. The facility failed to ensure adequate housekeeping/maintenance services to maintain a clean and sanitary environment in these areas.

The facility reported a census of 23 residents. The facility failed to equip corridors with firmly secured handrails on each side of one of three resident hallways, to ensure resident safety. Findings included: - On 12/7/22 at 08:30 AM, observation of the rigid plastic handrail along the north side of the northeast corridor, revealed the handrail contained clear, plastic tape applied from the top to the bottom of the seam in the plastic. The handrail easily pulled away from the wall at the east end, making it unsecure and unsafe for resident/visitors use. On 12/8/22 at 02:00 PM, interview with Administrative Staff A, explained the facility staff completed monthly checks of all of the facility handrails and Administrative Staff A was unaware of any loose railings. The facility lacked a policy on equipping secure handrails in resident hallways. The facility failed to ensure secure handrails on one of three resident hallways making it unsafe for residents/visitors of the facility.

The facility reported a census of 23 residents and 12 residents that required two-person assistance with activities of daily living, which included bed mobility and transfers. Based on observation, interview and record review, the facility failed to provide adequate staffing to meet the needs of the residents. Findings included: - Review of the Daily Staff Posting, (a document that records the actual hours worked by each nursing staff) from 10/03/22 through 11/28/22, revealed the facility staffed the third shift (10:00 PM to 06:00 AM) with one Licensed Nurse (LN) and one Certified Nurse Aide (CNA) on 14 of these days. Interview, on 12/05/22 at 08:00 AM, with Administrative Nurse D, revealed she worked as charge nurse on multiple shifts and did not have time to train for her administrative role and did not have time to process the medications for return to the pharmacy which were in the medication room in two large boxes (see F755). Interview on 12/05/22 at 09:44 AM, with anonymous alert normal cognitive status resident revealed she had a fall and had her call light on, but staff did not come for quite a while. Interview, on 12/05/22 at 10:22 AM, with alert anonymous resident with normal cognitive status, revealed staff took over an hour to respond to his call light, resulting in bowel incontinence. Interview, on 12/08/22 at 07:30 AM, with Licensed Nurse (LN) J, revealed several of the resident's required two-person assistance for cares, and with one nurse and one CNA to work from 10:00 PM to 06:00AM, it could be difficult to complete tasks especially if an emergency situation occurred. Interview, on 12/08/22 at 11:35 AM, with Administrative Nurse E, revealed the Director of Nursing frequently worked as the charge nurse and did not have time to complete the infection tracking and trending logs or administer influenza vaccines. Interview, on 12/08/22 at 12:10 PM, with Administrative Staff A, revealed the facility utilized agency staff frequently to fill staffing positions. Review of the Facility Assessment, dated 07/26/22, revealed it instructed staff to determine what resources were necessary to provide person centered care and services the residents required. The facility failed to provide adequate staffing to meet the needs of the residents of the facility.

The facility reported a census of 23 residents. Based on interview and record review the facility failed to complete an annual performance review at least once every 12 months for two of four Certified Nurse Aides (CNA) reviewed, CNA OO and CNA P, to identify further education needs, to provide cares to the residents of the facility. Findings included: - The facility identified four staff as employees over a year in the facility. Review of these four employee personnel files, revealed the following concerns: 1. Certified Nurse Aide (CNA) OO, hired 11/18/21, lacked an annual performance review in her personnel file. 2. CNA P, hired 08/01/89, lacked an annual performance review in her personnel file. On 12/08/22 at 12:30 PM, Administrative Staff A stated all employees should have an annual performance review completed. Not all employees have had their annual evaluations this year. The facility lacked a policy for the completion of the required employees annual evaulations. The facility failed to complete annual performance reviews for these two CNAs, who had been an employee for over one year, to identify further areas of education needs, to provide cares to the residents of the facility.

The facility reported a census of 23 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary kitchen for food storage, preparation, and serving to the residents of the facility. Findings included: - On 12/07/22 at 01:36 PM, Dietary staff DD cleaned the dining room tables following lunch with a bucket of soapy water. The water lacked a chemical for disinfection to properly sanitize the residents' tables. On 12/07/22 at 01:36 PM, Dietary staff DD stated they only use soapy water to clean the dining room tables following a meal. The facility does not use any type of chemical in the water and do not spray the tables with any chemical after being wiped down with the soapy water. On 12/07/22 at 01:36 PM, Dietary Staff BB stated the staff should first wash the dining room tables with soapy water and then spray them with Virex (a disinfecting spray) and allow to air dry. The facility policy for Dining Room Tables, undated, included: Staff shall wipe the dining room table down with hot, soapy water and allow to air dry. Staff shall then spray the tables with Virex (a disinfectant spray) and it let stand for ten minutes. The facility failed to ensure the dining tables were disinfected properly for all residents of the facility. - During an environmental tour of the kitchen on 12/07/22 at 01:40 PM, the following areas of concern were noted: 1. Four large skillets lacked the protectant non-stick coating on the cooking surface, making them unable to be sanitized. 2. Three small skillets lacked the protectant non-stick coating on the cooking surface, making them unable to be sanitized. 3. Six cutting boards contained large, deep grooves, making them unable to be sanitized. On 12/07/22 at 01:40 PM, Dietary staff BB, confirmed the skillets and cutting boards were unable to be sanitized. The facility lacked a policy for the upkeep and cleaning of cooking pans and cutting boards. The facility failed to ensure a clean, sanitary kitchen for the residents of the facility.

- On 12/06/22 at 08:53 AM, Licensed Nurse (LN) G put a dressing on Resident (R)2's second toe on his left foot. LN G used hand sanitizer and put on gloves. LN G then cleansed the area with wound cleanser sprayed onto the wound and patted it dry with four by four gauze pads. LN G applied an antibiotic cream to the wound and covered it with a bandaide. LN G failed to remove her gloves, to use hand sanitizer and apply new, clean gloves after cleansing the wound and before applying the antibiotic cream and applying the bandaide. On 12/06/22 at 08:53 AM, LN G stated she should have washed her hands and changed gloves after cleansing the wound and before applying the medicated cream and a bandaide but did not. On 12/08/22 at 09:02 AM, Administrative Nurse D stated staff should change their gloves after cleaning a wound and before applying a clean dressing. The facility policy Hand Hygiene, instructed staff to help prevent the development and transmission of communicable diseases and infections to perform hand hygiene between glove changes during care or procedures. The facility failed to ensure appropriate hand hygiene while caring for a wound on this dependent, highly susceptible resident, to prevent infections. - On 12/06/22 at 03:00 PM, Licensed Nurse (LN) G gathered supplies to treat a skin tear on Resident (R)19's right wrist/forearm. LN G placed the gathered supplies directly on top of the treatment cart without a barrier. On 12/06/22 at 03:00 PM, LN G stated she had not put down a barrier for the supplies when she placed them on top of the treatment cart and she should have. On 12/08/22 at 09:02 AM, Administrative Nurse D stated staff should use a barrier for dressing supplies and not place them directly on top of the treatment cart. The facility lacked a policy for the use of a barrier for treatment supplies. The facility failed to ensure appropriate barrier usage while caring for a wound on this dependent, highly susceptible resident, to prevent infections. The facility reported a census of 23 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program to prevent the spread of infections amongst the residents of the resident when they failed to ensure staff wore face masks in a manner to cover their nose and mouth; failed to ensure trash and linen were contained in isolation barrels in one resident's room and bagged soiled isolation laundry without containment in the laundry processing room in a sanitary manner. The facility failed to ensure sanitary dressing change for two residents (R)2 and R19 to prevent the spread of infections amongst the residents. Findings included: - Interview, on 12/05/22 at 09:30 AM, with Licensed Nurse H, revealed resident (R)10 was in isolation for MRSA (methicillin resistant staphylococcus aureus a highly contagious bacteria) for a wound on his lower thigh. Observation, on 12/06/22 at 02:54 PM, revealed Certified Nurse Aide O and MM, provided incontinence care to R10 and placed their used isolation gowns in a red isolation barrel containing trash with isolation gowns cascading down the outside of the barrel. The resident's laundry and bed linen overflowed directly onto the floor from the red bag lined laundry basket. CNA O and MM stated the previous shift should empty the barrels when the shift ends. CNA O and MM did not empty the barrels or laundry basket at that time. Observation, on 12/06/22 at 03:19 PM, revealed Housekeeping Staff W, cleaned R10's room, and stated the nursing staff emptied the trash and laundry and Staff W did not empty the overflowing laundry or overflowing trash at that time. Observation, on 12/08/22 at 11:24 AM, revealed the dirty side of the laundry room floor contained a red biohazard bag of soiled laundry from R10 in isolation for MRSA. One washing machine contained food-like substance in the rinse dispenser and a smear of a brown substance on the top side of the washer. The clean linen delivery cart had a brown substance on the right side and visible accumulation of grime on the bottom of the cart. Laundry staff V confirmed the above areas of concern. The facility policy Infection Management Process, dated 10/2022, instructed staff that use of red bagging required proper handling and disposal as biohazard products. The facility policy Housekeeping, Laundry and Maintenance undated, instructed staff to bag the isolation laundry in the resident's room and take immediately to the laundry. Laundry staff to sort and place the isolation laundry in a washer and process. The facility failed to ensure staff handled the isolation laundry and trash in a manner to prevent the spread of infection. - Observation, on 12/06/22 at 08:30 AM, revealed Certified Nurse Aide (CNA) Q assisted feeding resident (R)15 in the common dining room with her face mask positioned beneath her nose. CNA Q pulled the mask up over her nose and proceeded to continue to feed the resident without performing hand hygiene. The facility policy Hand Hygiene, instructed staff to help prevent the development and transmission of communicable diseases and infections to perform hand hygiene between glove changes during care, or procedures. The facility failed to ensure staff wore their masks in an effective manner and perform hand hygiene to prevent the spread of infection to the residents of the facility.

The facility reported a census of 23 residents. Based on observation, interview and record review, the facility failed to ensure staff applied principles of antibiotic stewardship through tracking and trending of infections to ensure residents received effective and appropriate treatment with antibiotics to prevent adverse effects. Findings included: - Review of the Infection Surveillance and Analysis log for tracking and trending of infections and use of antibiotics revealed the logs were incomplete for causal analysis, mapping trends and precautions taken, for the logs from April through November 2022. Furthermore, staff did proactively document on the December 2022 log. Interview, on 12/08/22 at 11:35 AM, with Administrative Nurse E, revealed she would expect the Infection Preventionist to complete the logs to determine trends in infections, ensure the residents received appropriate antibiotics and determine adherence to McGeer's criteria (a set of criteria for determining infections) for compliance with the principles of antibiotic stewardship. The facility Antibiotic Use Protocol, revised 12/2018, instructed staff the Director of Nursing or designated staff to record antibiotic usage and infections on the Infection Surveillance and Analysis log to track, analyze and conduct root cause analysis. The facility failed to monitor adherence to the principle of antibiotic stewardship by tracking and trending infections and to determine appropriate antibiotic use, for the residents of the facility from April through December 2022. The facility failed to monitor antibiotic use rates and microorganism prevalence through analysis of the surveillance records as required.

The facility reported a census of 23 residents. Based on interview and record review, the facility failed to report COVID-19 outbreak status of the facility and mitigating actions to responsible parties as required. Findings included: - Interview, on 12/05/22 at 12:36 PM, with family member JJ, revealed she did not receive notice of the COVID-19 outbreak in November 2022, other than a sign posted on the facility door. Interview, on 12/07/22 at 03:28 PM, with Administrative Nurse E, revealed a COVID-19 outbreak began 10/27/22 with positive staff at which time the facility began outbreak testing of staff and residents twice a week. The last positive staff was 11/04/22 and the last positive resident was 11/08/22. The facility failed to notify responsible parties of the outbreak/mitigating actions during that time, other than posting a sign on the door of the facility informing visitors that the facility had positive COVID-19 cases. The facility policy Checklist for Controlling COVID-19 in LTC Facility, revised 09/27/22, instructed staff to prepare and distribute/mail notifications to families, residents, and responsible parties a letter of notification of positive resident(s) and actions taken by the facility. The facility failed to notify responsible parties of the COVID-19 outbreak status and mitigating actions as required.

The facility reported a census of 21 residents, with 14 residents sampled for review. Based on observation, interview and record review, the facility failed to honor one of one Resident (R) 20 preferences related to choices of going outside to visualize his preferred surroundings. Findings included: - The signed Physician Order Sheet for Resident (R)20, dated 07/21/21, documented the resident had diagnosis of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), and pain. The annual Minimum Data Set, dated 03/25/21, documented R20's Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. The resident required one staff assistance for locomotion. He used a wheelchair for mobility. It was very important for the resident to do his favorite activities, and it was very important to go outside to get fresh air when the weather permitted. The ADL (activity of daily living) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 04/12/21, revealed the resident required staff assistance with locomotion. The resident was unable to ambulate. The activity care plan, dated 05/14/15, identified R20 was able to go on outings of his choice and was able to ride around in his scooter when the weather was warm. However, his ADL care plan documented he was currently using a manual wheelchair with staff assistance. In addition, the care plan guided staff to allow the resident to make as many choices as he was able. The last completed Elopement Risk Assessment, dated 07/19/19, documented R20 is not at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff). On 07/15/21 at 08:04 AM, the resident in his wheelchair. He reported he would like to go out front and watch the traffic and planned on discussing this matter with the administrator as it was a nice day. On 07/14/21 at 01:37 PM, R20 stated he used to enjoy sitting outside the front, watching the cars drive by. He wanted to sit outside the front of the building because that has a view of the main road with the cars. He had a fall A long time ago, when his electric wheelchair went off the curb as he navigated back towards the building. Since that time, staff instructed him to sit on the patio. The patio situated on the side of the building facing a side street. The side view had more buildings and less cars. The resident reported he wanted to have a choice regarding where he was able to sit outside, but staff refused to allow him to go out front because they treated him like A little kid. On 07/19/21 at 11:57 AM, Certified Nursing Assistant (CNA) M reported the resident could sit on the side patio but was not allowed to sit out front. CNA M agreed there were more cars and things to look at in the front area. CNA M stated the nurse decided whether he could sit in the front area. She notified the Administrator and the Director of Nursing of his request to sit out front in the past, but no staff had been assigned to sit with him out front. They offer the patio because there is staff that sits on the patio, and no staff to be able to sit with the resident in the front area. On 07/19/21 at 12:02 PM, Licensed Nurse (LN) G reported the resident had requested to sit out in the front area, however, he experienced a fall A long time ago and was no longer allowed to outside the front. On 07/19/21 at 12:07 PM, Administrative Staff A reported staff allowed the resident out in the front area in the past, and he enjoyed sitting under a shade tree by the driveway. He experienced a fall two years ago, when staff left him on the sidewalk, and the resident attempted to get to the driveway area to sit under the shade tree. The resident would require staff supervision to be able to sit out in the front area, and staff has not sat outside the front area with him. On 07/19/21 at 05:05 PM, CNA N stated R20 could go outside with another person but not by himself. She has not taken the resident outside. On 07/20/21 at 01:18 PM, Administrative Nurse D stated R20 rolled off the sidewalk several years ago and fell. There were a few other residents allowed to go out and sit at the front area if they were physically able to do so themselves. The resident was not at risk for elopement, but he would require supervision. The facility was unable to provide a policy regarding choices. The facility failed to honor this alert and oriented resident, that required staff assistance for locomotion and was not at risk for elopement, preferences related to choices of going outside to visualize his preferred surroundings.

The facility reported a census of 21 residents, with 14 residents sampled that included five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure the consultant pharmacist identified irregularities related to monitoring the resident's blood pressure parameters for Resident (R)10, when staff administered the resident's blood pressure medication out of the prescribed parameters. Findings included: - The signed Physician Order Sheet (POS), for Resident (R)10, dated 07/09/21, revealed the following diagnoses: cerebral infarction (damage tissue in the brain due to a loss of oxygen), atrial fibrillation (rapid, irregular heart beat), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and hypertension (elevated blood pressure). The physician's order included: Start date, 05/17/21, Diltiazem CD (medication used to treat elevated blood pressure), 240 milligrams (mg), by mouth, one time a day, related to hypertension (elevated blood pressure). Hold the medication if the systolic (measures the force of blood against your artery walls as your ventricles pushing blood to the rest of your body) blood pressure less than 90/60 or the resident's heart rate less than 60. Start date, 05/20/21, Metoprolol Tartrate (medication used to treat elevated blood pressure), 50 mg, by mouth, at bedtime, related to hypertension. Hold the medication if the resident's blood pressure- less than 90/50. Review of the resident's MAR (medication administration record), from 05/17/21 to 07/20/21, revealed staff administered the resident's Diltiazem CD medication, outside of the ordered parameters as follows: On 05/24/21, the resident's blood pressure was 105/57. Staff failed to hold the medication as ordered. On 05/25/21, the resident's blood pressure was 90/54. Staff failed to hold the medication as ordered. On 06/02/21, the resident's blood pressure was 102/54. Staff failed to hold the medication as ordered. On 06/24/21, the resident's blood pressure was 104/55. Staff failed to hold the medication as ordered. Review of the resident's MAR from 05/20/21 to 07/20/21, revealed staff administered the resident's Metoprolol Tartrate, outside the ordered parameters as follows: On 06/15/21, the resident's blood pressure was 93/49. Staff failed to hold the medication as ordered. On 06/29/21, the resident's blood pressure was 90/46. Staff failed to hold the medication as ordered. On 07/04/21, the resident's blood pressure was 101/56. Staff failed to hold the medication as ordered. On 07/13/21, the resident's blood pressure was 104/59. Staff failed to hold the medication as ordered. The pharmacy review's from 04/01/21 through 07/20/21 lacked documentation related to the identification when staff administered the resident's blood pressure medications when the blood pressure was out of the physician's ordered parameter. On 07/20/21 at 02:40 PM Administrative Nurse D advised the pharmacist visited monthly to review the resident's EMAR (electronic medical records) and should complete the pharmacy recommendations that included monitoring for medication parameters. On 07/21/21 09:58 AM, Consultant GG, advised that she does come to the facility twice a month and also reviewed the resident's EMAR off-site for recommendations that included monitoring of parameters for medications. The facility lacked a policy for pharmacist to review the out of parameter medications. The facility failed to ensure the consultant pharmacist identified irregularities related to monitoring the resident's blood pressure parameters for this resident when staff administered her hypertensive medication when out of the ordered parameters.

The facility reported a census of 21 residents, with 14 residents sampled that included five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure one of the five sampled residents remained free as possible of unnecessary medication usage for Resident (R)10, with anti-hypertensive medication and the failure to hold the resident's medication when the resident's blood pressure was out of the physician ordered parameters. Findings included: - The signed Physician Order Sheet (POS), for Resident (R)10, dated 07/09/21, revealed the following diagnoses: cerebral infarction (damage tissue in the brain due to a loss of oxygen), atrial fibrillation (rapid, irregular heart beat), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and hypertension (elevated blood pressure). The physician's order included: Start date, 05/17/21, Diltiazem CD (medication used to treat elevated blood pressure), 240 milligrams (mg), by mouth, one time a day, related to hypertension (elevated blood pressure). Hold the medication if the systolic (measures the force of blood against your artery walls as your ventricles pushing blood to the rest of your body) blood pressure less than 90/60 or the resident's heart rate less than 60. Start date, 05/20/21, Metoprolol Tartrate (medication used to treat elevated blood pressure), 50 mg, by mouth, at bedtime, related to hypertension. Hold the medication if the resident's blood pressure- less than 90/50. Review of the resident's MAR (medication administration record), from 05/17/21 to 07/20/21, revealed staff administered the resident's Diltiazem CD medication, outside of the ordered parameters as follows: On 05/24/21, the resident's blood pressure was 105/57. Staff failed to hold the medication as ordered. On 05/25/21, the resident's blood pressure was 90/54. Staff failed to hold the medication as ordered. On 06/02/21, the resident's blood pressure was 102/54. Staff failed to hold the medication as ordered. On 06/24/21, the resident's blood pressure was 104/55. Staff failed to hold the medication as ordered. Review of the resident's MAR from 05/20/21 to 07/20/21, revealed staff administered the resident's Metoprolol Tartrate, outside the ordered parameters as follows: On 06/15/21, the resident's blood pressure was 93/49. Staff failed to hold the medication as ordered. On 06/29/21, the resident's blood pressure was 90/46. Staff failed to hold the medication as ordered. On 07/04/21, the resident's blood pressure was 101/56. Staff failed to hold the medication as ordered. On 07/13/21, the resident's blood pressure was 104/59. Staff failed to hold the medication as ordered. On 07/20/21 at 02:40 PM Administrative Nurse D verified staff administered the resident's Diltiazem CD medication and Metoprolol Tartrate medications out of the physician ordered parameters. Administrative Nurse D reported the facility lacked a medication administration policy for following physician orders. The facility lacked a policy related to following parameters set for blood pressure medications. The facility failed to ensure this resident who required medication for her elevated blood pressure, remained free as possible of unnecessary medication, when staff administered the resident's blood pressure medication out of the prescribed parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 21 residents. The facility had 25 medications administration opportunities for seven residents with four medication errors. The facility experienced a 16% medication error rate, based on observation, interview and record review, when the facility administered medications inappropriately to two residents (R15 and R21) of the seven residents observed. The facility failed to ensure R15 remain free of medication error due to diuretic medications administered simultaneously when the physician orders instructed staff to provide 30 minutes between diuretic medication administration, and R21 remain free of medication errors, related to medication inhalation. The facility failed to ensure a medication error rate of less than 5%, with 25 opportunities and four med errors, which created a 16% medication error rate. Findings included: - Record review of the Physicians Order Sheet (POS), for Resident (R) 21, dated 07/13/21, documented the following orders: Start date, 06/08/21, Bumetanide (diuretic medication to promote the formation and excretion of urine),2 milligram (mg), by mouth, one time a day, related to edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Start date, 06/08/21 Metolazone (diuretic medication to promote the formation and excretion of urine),5 mg, by mouth, one time a day, related to edema. Give 30 minutes prior to Bumetanide. On 07/19/21 at 09:45 AM, Certified Medication Aide, (CMA) R, administered Bumetanide 2 mg (milligrams) and Metolazone 5 mg to R21. Staff failed to administer the Metolazone 30 minutes before the Bumetanide, as ordered. On 07/19/21 at 09:45 AM, CMA R advised that she administered Bumetanide 2 mg and Metolazone 5 mg together to R 21. On 07/19/21 at 10:42 AM, Administrative Nurse D verified the physician order for Metolazone 5 mg was to be administered 30 minutes prior to Bumetanide 2 mg. Administrative Nurse D verified CMA R failed to administer Metolazone 5 mg and Bumetanide 2 mg according to the physician's orders. Furthermore: Record review of the Physicians Order Sheet (POS) for Resident (R) 15, dated 06/14/21, included the following orders: Start date, 11/26/20, Symbicort Aerosol 80-4.5 MCG (microgram), inhale two puffs orally, two times a day, related to influenza (disease caused by virus infecting the respiratory tract), due to identified Novel Influenza A virus with other respiratory manifestations. Rinse mouth with water and spit (the water) back into the cup after use. Start date, 10/17/20, Ventolin (medication used to treat wheezing and shortness of breath caused by breathing problems) inhale two puffs, orally, three times a day, to acute pulmonary edema. Observation, on 07/14/21 at 10:31 AM, CMA S failed to shake the inhalation canister. CMA S administered 2 consecutive puffs of Symbicort inhaler without allowing the resident a breath between each puff of medication. CMA S gave the resident a drink of water, without instructions to rinse her mouth and spit the water back into a cup, as ordered. CMA S then administered two puffs of the Ventolin inhaler without allowing the resident a breath between each puff of medication. According to www.mysimbicort.com, the manufacturer's instructions for use documented to shake the inhaler well for 5 seconds right before each use. The resident should fully exhale, then breath in deeply and slowly through the mouth while pressing firmly and fully on the top of the counter on the Symbicort inhaler to release the medicine. Hold the breath for about 10 seconds, or for as long as comfortable . shake the Symbicort inhaler again for 5 seconds and repeat .After administration, rinse the mouth with water, Spit out the water. Do not swallow it (water). According to www.ventolin.com, the manufacturer's instructions for use documented to hold the breath for about 10 seconds, or for as long as it is comfortable, and breath out slowly. Wait one minute, [NAME] the inhaler again, and repeat the steps. On 07/14/21 at 05:33 PM, Administrative Staff A verified the expectation of staff included to shake the inhaler canisters well before administration. Staff should administer the inhalation medications separately, and staff should ensure the residents' mouth should be rinsed after steroid inhaler. The facility failed to provide a policy related to diuretic administration. Furthermore, the facility's policy for Oral Inhalations, dated 05/16, revealed for staff to press down on the inhaler once to release medication as res starts to breathe in slowly through the mouth over three to five seconds. Do not spray more than one puff at a time. If another puff of the same or different medication required, follow the manufacturer's product information for administration including the acceptable wait time between inhalations. For steroid inhalers, provide the resident with a cup of water and instruct him/her to rinse their mouth and spit the water back into a cup. The facility failed to ensure a medication error rate of less than 5%, with 25 opportunities and four med errors, which created a 16% medication error rate.