**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 76 residents. The sample included three residents reviewed for medications. Based on record review and interviews, the facility failed to ensure staff accurately transcribed orders from the hospital on admission and failed to follow the physician's orders for Resident (R) 1. This deficient practice placed R1 at risk for unwarranted physical complications and less-than-therapeutic effects related to medication use. Findings included: - R1 admitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted to the facility on [DATE], and discharged home 01/24/24. R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness and Hashimoto's encephalopathy (a rare disease that involves impaired brain function and is a steroid-responsive acute or subacute encephalopathy characterized by autoimmune thyroiditis [autoimmune disorder where the immune system attacks the thyroid gland] associated with elevated levels of antithyroid antibodies). The admission Minimum Data Set (MDS) dated 01/15/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Functional Abilities Care Area Assessment (CAA) dated 01/23/24, documented R1 had a decline in activities of daily living (ADLs) from her previous level of functioning related to multiple hospitalizations with the most recent due to head pressure, slurred speech, vision changes, confusion, hallucinations, and urinary tract infection. R1's Care Plan last revised 01/23/24, documented R1 had a cerebral vascular accident (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and Hashimoto's encephalopathy. The care plan documented an intervention, dated 01/10/24, that directed staff to give medications as ordered by the physician and monitored/documented side effects and effectiveness. R1's EMR revealed a Discharge Order Report dated 12/27/23, that documented an order for prednisone 10 milligrams (mg) in the morning. R1's EMR lacked evidence the prednisone order from 12/27/23 was entered and administered. R1's EMR revealed a Consultation Report on 12/28/23 that documented R1 recently admitted to the facility and the medication review process revealed the following discrepancies on the admission orders: there was an order for prednisone, but there was no current order in THE EMR. Recommendation to consider clarifying the medication orders and communicate with the prescriber and pharmacy as appropriate. The Notes tab of R1's EMR revealed the following: A Physician Progress Note on 12/28/23 at 11:08 AM, documented R1 had chronic steroid use and Hashimoto's encephalopathy with a plan to continue prednisone 10 mg. A Physician Progress Note on 01/02/24 at 04:30 PM, documented R1 had chronic steroid use and Hashimoto's encephalopathy with a plan to continue prednisone 10 mg. R1's EMR revealed Consult Notes on 01/05/24 at 01:06 PM that documented R1 had not been receiving her daily prednisone that past week and there was a concern that given her recurrent hospitalization, it was related to a relapse of Hashimoto's encephalopathy. The note documented that it was not unheard of as there were case reports with relapsing symptoms, however, it was presumed to be only present in about 10 to 15 percent of cases. The note documented R1 had poor sleep over the past several days which was also an area of concern in previous hospitalizations leading to ongoing confusion. That could have been a stronger contributor to her current presentation. The note documented from an encephalopathy picture, R1 did not have true confusion at that time, provided a good history, and performed extremely well on bedside cognitive testing. The facility's investigative report, dated 01/08/24, documented R1 was admitted to the facility on [DATE] and had a BIMS score of 14. R1 had a history of Hashimoto's encephalopathy. The nurse practitioner (NP) noted a change in condition and spoke to R1 and her representative about possible options to evaluate symptoms. The NP, R1, and her representative agreed to further evaluation at the emergency department (ED) to rule out infection or worsening Hashimoto's encephalopathy. The NP reviewed R1's chart and repeated a medication reconciliation on 01/04/24 at approximately 04:05 PM and it was noted that prednisone was not currently on the Medication Administration Record (MAR). Upon investigation, it was discovered that prednisone was missed on the admission orders by the admitting nurse, the second nurse, and the interdisciplinary team (IDT). A pharmacy recommendation was received on 12/28/23 stating that there were discrepancies on the admission orders which involved an order for prednisone but no current order in the chart. According to the hospital physician's note on 01/04/24, the probability of R1's Hashimoto's encephalopathy relapsing was only 10 to 15 percent. It was also noted that R1 had poor sleep over the last several days which had been an area of concern in previous hospitalizations leading to ongoing confusion. From an encephalopathy picture, she did not have true confusion at that time, provided a good history, and performed extremely well on bedside cognitive testing. On 01/30/24 at 01:23 PM, Administrative Nurse E stated when a resident is admitted to the facility, the nurse and aide help the resident settle. She stated the floor nurse put in the admission orders and the nurse manager helped. Every morning, the nurse managers reviewed the orders when they did chart review. Administrative Nurse E stated when the provider visits, the nurse on duty reviews the notes for new orders, and any new orders the provider puts in, show up in red in the chart. She stated the night nurses double-check the new orders. On 01/30/24 at 01:31 PM, Licensed Nurse (LN) G stated admission orders were done by the nurse or nurse managers. She stated the nurses double-checked the admission orders and the managers checked after that. LN G stated the providers put orders in and the nurse confirmed any pending orders. On 01/30/24 at 01:42 PM, Administrative Nurse D stated when a resident was admitted , the nurse received orders from the hospital and verified them with the provider. The admitting nurse transcribed the orders into the system, a second nurse reviewed them, and IDT reviewed them after that. Administrative Nurse D stated when a provider visited, some of them put their own orders in and some gave verbal orders. She stated the nurse reviewed the orders but not the provider's progress notes because they visited so often. Administrative Nurse D stated the pharmacy sent recommendations to the nurse managers, herself, and the administrator. Between those people, the recommendations were reviewed and sent to the physician. She stated staff saw what the recommendation was and if it was something they could address, they updated it, initialed, dated it, and uploaded the recommendation into the miscellaneous tab of the EMR. On 01/30/24 at 01:54 PM, Administrative Nurse F stated when she received a pharmacy recommendation, she did not sign her name until it was completed in the EMR. She stated she wanted to say that was what she did with R1's recommendation from 12/28/23 but it did not get put in. Administrative Nurse F stated when she received an admission pharmacy recommendation, she printed it off, verified the order with the hospital discharge orders, and made sure the provider did not put a note in not wanting the medication. Once she did that, she put the order in the EMR per the discharge orders, confirmed it in the EMR, signed the recommendation, and put a nurse's note in that it was completed. The facility's Reconciliation of Medications on Admission/re-admission and Monthly Orders policy, last revised in March 2019, directed medication reconciliation reduced medication errors and enhanced resident safety during the admission/transfer process by identifying the medications the resident needed and administering without interruption, the correct dosages and routes. The policy directed the facility used an approved medication reconciliation form or other record to list all medications from the medication history, the discharge summary, the previous MAR, and the admitting orders. The facility reviewed the list carefully to determine if there were any discrepancies, conflicts, or severe drug-to-drug interactions. The facility's Physician Visits policy, last revised in April 2013, directed the attending physician performed relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. The facility's Medication Regimen Review (MRR) Policy, dated July 2018, directed medication regimen reviews were completed upon admission, and completed MRR reports were sent to the medical director, director of clinical services, and healthcare provider to review the recommendations. The facility failed to ensure staff accurately transcribed orders from the hospital on admission and failed to follow the physician's orders for R1. This deficient practice placed R1 at risk for unwarranted physical complications and less-than-therapeutic effects related to medication use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 76 residents. The sample included three residents reviewed for medications. Based on record review and interviews, the facility failed to address the admission medication regimen review for Resident (R) 1 when the Consultant Pharmacist (CP) found irregularities with her admission orders. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use for R1. Findings included: R1 admitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted to the facility on [DATE], and discharged home 01/24/24. R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness and Hashimoto's encephalopathy (a rare disease that involves impaired brain function and is a steroid-responsive acute or subacute encephalopathy characterized by autoimmune thyroiditis [autoimmune disorder where the immune system attacks the thyroid gland] associated with elevated levels of antithyroid antibodies). The admission Minimum Data Set (MDS) dated 01/15/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Functional Abilities Care Area Assessment (CAA) dated 01/23/24, documented R1 had a decline in activities of daily living (ADLs) from her previous level of functioning related to multiple hospitalizations with the most recent due to head pressure, slurred speech, vision changes, confusion, hallucinations, and urinary tract infection. R1's Care Plan last revised 01/23/24, documented R1 had a cerebral vascular accident (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and Hashimoto's encephalopathy. The care plan documented an intervention, dated 01/10/24, that directed staff to give medications as ordered by the physician and monitored/documented side effects and effectiveness. R1's EMR revealed a Discharge Order Report dated 12/27/23, that documented an order for prednisone 10 milligrams (mg) in the morning. R1's EMR lacked evidence the prednisone order from 12/27/23 was entered and administered. R1's EMR revealed a Consultation Report on 12/28/23 that documented R1 recently admitted to the facility and the medication review process revealed the following discrepancies on the admission orders: there was an order for prednisone, but there was no current order in THE EMR. Recommendation to consider clarifying the medication orders and communicate with the prescriber and pharmacy as appropriate. The Notes tab of R1's EMR revealed the following: A Physician Progress Note on 12/28/23 at 11:08 AM, documented R1 had chronic steroid use and Hashimoto's encephalopathy with a plan to continue prednisone 10 mg. A Physician Progress Note on 01/02/24 at 04:30 PM, documented R1 had chronic steroid use and Hashimoto's encephalopathy with a plan to continue prednisone 10 mg. R1's EMR revealed Consult Notes on 01/05/24 at 01:06 PM that documented R1 had not been receiving her daily prednisone that past week and there was a concern that given her recurrent hospitalization, it was related to a relapse of Hashimoto's encephalopathy. The note documented that it was not unheard of as there were case reports with relapsing symptoms, however, it was presumed to be only present in about 10 to 15 percent of cases. The note documented R1 had poor sleep over the past several days which was also an area of concern in previous hospitalizations leading to ongoing confusion. That could have been a stronger contributor to her current presentation. The note documented from an encephalopathy picture, R1 did not have true confusion at that time, provided a good history, and performed extremely well on bedside cognitive testing. The facility's investigative report, dated 01/08/24, documented R1 was admitted to the facility on [DATE] and had a BIMS score of 14. R1 had a history of Hashimoto's encephalopathy. The nurse practitioner (NP) noted a change in condition and spoke to R1 and her representative about possible options to evaluate symptoms. The NP, R1, and her representative agreed to further evaluation at the emergency department (ED) to rule out infection or worsening Hashimoto's encephalopathy. The NP reviewed R1's chart and repeated a medication reconciliation on 01/04/24 at approximately 04:05 PM and it was noted that prednisone was not currently on the Medication Administration Record (MAR). Upon investigation, it was discovered that prednisone was missed on the admission orders by the admitting nurse, the second nurse, and the interdisciplinary team (IDT). A pharmacy recommendation was received on 12/28/23 stating that there were discrepancies on the admission orders which involved an order for prednisone but no current order in the chart. According to the hospital physician's note on 01/04/24, the probability of R1's Hashimoto's encephalopathy relapsing was only 10 to 15 percent. It was also noted that R1 had poor sleep over the last several days which had been an area of concern in previous hospitalizations leading to ongoing confusion. From an encephalopathy picture, she did not have true confusion at that time, provided a good history, and performed extremely well on bedside cognitive testing. On 01/30/24 at 01:23 PM, Administrative Nurse E stated when a resident is admitted to the facility, the nurse and aide help the resident settle. She stated the floor nurse put in the admission orders and the nurse manager helped. Every morning, the nurse managers reviewed the orders when they did chart review. Administrative Nurse E stated when the provider visits, the nurse on duty reviews the notes for new orders, and any new orders the provider puts in, show up in red in the chart. She stated the night nurses double-check the new orders. On 01/30/24 at 01:31 PM, Licensed Nurse (LN) G stated admission orders were done by the nurse or nurse managers. She stated the nurses double-checked the admission orders and the managers checked after that. LN G stated the providers put orders in and the nurse confirmed any pending orders. On 01/30/24 at 01:42 PM, Administrative Nurse D stated when a resident was admitted , the nurse received orders from the hospital and verified them with the provider. The admitting nurse transcribed the orders into the system, a second nurse reviewed them, and IDT reviewed them after that. Administrative Nurse D stated when a provider visited, some of them put their own orders in and some gave verbal orders. She stated the nurse reviewed the orders but not the provider's progress notes because they visited so often. Administrative Nurse D stated the pharmacy sent recommendations to the nurse managers, herself, and the administrator. Between those people, the recommendations were reviewed and sent to the physician. She stated staff saw what the recommendation was and if it was something they could address, they updated it, initialed, dated it, and uploaded the recommendation into the miscellaneous tab of the EMR. On 01/30/24 at 01:54 PM, Administrative Nurse F stated when she received a pharmacy recommendation, she did not sign her name until it was completed in the EMR. She stated she wanted to say that was what she did with R1's recommendation from 12/28/23 but it did not get put in. Administrative Nurse F stated when she received an admission pharmacy recommendation, she printed it off, verified the order with the hospital discharge orders, and made sure the provider did not put a note in not wanting the medication. Once she did that, she put the order in the EMR per the discharge orders, confirmed it in the EMR, signed the recommendation, and put a nurse's note in that it was completed. The facility's Reconciliation of Medications on Admission/re-admission and Monthly Orders policy, last revised in March 2019, directed medication reconciliation reduced medication errors and enhanced resident safety during the admission/transfer process by identifying the medications the resident needed and administering without interruption, the correct dosages and routes. The policy directed the facility used an approved medication reconciliation form or other record to list all medications from the medication history, the discharge summary, the previous MAR, and the admitting orders. The facility reviewed the list carefully to determine if there were any discrepancies, conflicts, or severe drug-to-drug interactions. The facility's Physician Visits policy, last revised in April 2013, directed the attending physician performed relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. The facility's Medication Regimen Review (MRR) Policy, dated July 2018, directed medication regimen reviews were completed upon admission, and completed MRR reports were sent to the medical director, director of clinical services, and healthcare provider to review the recommendations. The facility failed to address the admission medication regimen review for R1 when the CP found irregularities with her admission orders. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use for R1.

The facility identified a census of 76 residents. The sample included 18 residents with one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to ensure a dignified care environment for Resident (R) 47 related to her incontinence management. This deficient practice placed R47 at risk unnecessary embarrassment and decreased psychosocial wellbeing. Findings included: - On 12/14/23 at 02:05 PM an inspection of R47's room revealed a heavy urine smell. R47's room floor had a wet substance leading around the room and into the restroom. Parts of R47's floor had a dried / sticky substance covering it. On 12/18/23 at 12:34 PM R47 was in her room standing next to the closet in her room. R47 had a pair of white pants on the floor next to her recliner. R47 stated she just changed her pants and was going to lunch. R47 had a pile of clothing in her laundry basket. She reported she could do most things for herself but needed staff assistance from time to time. Staff were not in the room to assist her changing. R47 smelled of urine as she went to the dining room. On 12/19/23 at 12:31PM Certified Nurse Aid (CNA) stated she was not sure if R47 was incontinent, but all residents were checked on every three hours. She stated if a resident or their room smelled like bladder or bowel incontinence staff was to immediately ask the resident if they need assistance using the restroom and check them. She stated soiled clothing and linen should be immediately sent to the laundry services to be washed to prevent the room from smelling. At 12/19/23 at 01:08PM Administrative Nurse D stated staff should be assisting residents with incontinence and providing frequent toileting to prevent incontinent episodes. She stated if a resident or their rooms smells of urine the staff should assess them to ensure they were not incontinent. A review of the facility's Dignity policy revised 10/2022 indicated each resident shall be care for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem. The facility failed to ensure a dignified care environment for R47 related to her incontinence management. This deficient practice placed R47 at risk unnecessary embarrassment and decreased psychosocial wellbeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 76 residents. The sample included 18 residents with two residents reviewed for transfers. Based on observation, record review and interview, the facility failed to provide written notification of facility-initiated transfers with the required information to Resident R165 or their family/durable power of attorney (DPOA) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R165. Findings included: - The electronic medical record (EMR) for R165 documented diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure (a condition when your body does not have enough oxygen), and dependence on supplemental oxygen. The admission Minimum Data Set (MDS) dated 09/26/23 for R165 documented a Brief Interview for Mental Status (BIMS) score of 11 which indicated a moderately impaired cognition. R165 required partial/moderate to substantial/maximal staff assistance for functional abilities. R165 utilized the use of a wheelchair for mobility assistance. R165 required oxygen therapy while a resident. The Discharge MDS dated 11/19/23 for R165 documented a discharge to short term stay hospital. The Activities of Daily Living (ADL) Care Area Assessment dated 10/05/23 for R165 documented she was a long-term care resident due to heart failure. R165 was weak and had other co-morbidities that impaired her ability to perform ADL and personal cares. R165 was on oxygen and staff monitored her for oxygen needs as needed. The Respiratory Failure Care Plan last revised 11/25/23 directed staff to monitor for difficulty in breathing on exertion. Staff was to monitor/document changes in orientation, increased restlessness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and air hunger (form of respiratory distress characterized by gasping and labored breathing). Staff was to monitor for signs and symptoms of respiratory distress and report to physician. A Nursing Progress Report dated 11/19/23 at 11:17 PM for R165 documented it was reported that R165 was not feeling well that day. The nurse noted the resident was very weak, lethargic (an appearance of sluggishness, lack of energy) or less interactive. R165 was reassessed and was moaning and not opening eyes and did not respond to questions. The telehealth provider was notified and recommended the resident be sent to the hospital for further evaluation. R165's sister was notified of the change in condition. Emergency services was called and arrived at the facility around 11:00 PM and R165 was transported out of the facility at 11:20 PM. A Progress Note dated 11/20/23 at 03:57 PM documented R165 was admitted to the hospital due to pneumonia (inflammation of the lungs). A Progress Note dated 11/24/23 documented R165 readmitted after return from the hospital. The facility lacked written notification of transfer for R165's facility-initiated transfer to the hospital on [DATE]. On 12/18/23 at 12:01 PM staff propelled R165 in her wheelchair to the dining room for lunch. R165 had her supplemental oxygen on via nasal cannula (a hollow tube used to deliver supplemental oxygen) that was connected to a portable oxygen tank. R165 had no complaints at that time. On 12/19/23 at 02:29 PM Administrative Nurse F stated that the nurses initiated transfers for a resident when sent out to the hospital. Administrative Nurse F stated the nurse called the physician to get the order to send resident to the hospital. Administrative Nurse F stated the hospital was called to give report on the resident and then the family/representative would be called to notify of transfer to the hospital. Administrative Nurse F stated she was not aware that written notification of transfer had to be sent to the family/representative for hospital transfers. On 12/19/23 at 03:16 PM Administrative Nurse D stated she was unaware that a written notification of transfer was required to be sent to the family/representative upon transfer to the hospital. The facility policy Resident Transfer and Discharge last revised August 2023 documented: Prior to transfer or discharge of a resident, the resident and resident's representative should be notified in writing of the reason, effective date, the location to which the resident was transferred or discharged , a statement of the resident's appeal rights, the name, address, and telephone number of the office of the stated long-term care ombudsman. A copy of the notice should be sent to the representative of the Office of the State [NAME]-Term Care Ombudsman at the time the notice was provided to the resident and the resident representative, or as soon as practicable after an emergency transfer or discharge. The facility failed to provide written notification of transfer with the required information to R165 or their family/DPOA in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R165.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 76 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide a copy of the Bed Hold notice to Resident (R)63, or her representative, upon discharge to a hospital in November 2023. This deficient practice placed R63 at risk to not be allowed to return to their same room upon discharge from the hospital. Findings included: - R63's Electronic Medical Record documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), muscle weakness, difficulty walking and reduced mobility. R63's Entry Tracker documented she admitted on [DATE]. R63's Care Plan with an initiated date of 10/31/23 documented R63 had an activities of daily living (ADLs) self-care performance deficit. An eINTERACT SBAR Summary for Providers note dated 11/02/23, documented R63 had an unwitnessed fall in her room. The note further documented R63 was found on the floor on her left side with no injury at the time of assessment. A Nursing Progress Note dated 11/02/23, documented R63 developed a bruise to her left eyebrow and side of her head. The note further documented R63 was sent to the hospital for further evaluation per R63's daughter's request. The note documented R63 left the facility at 11:00 AM via Emergency Medical Services (EMS). R63's clinical record lacked evidence and the facility failed to provide evidence the resident or representative was provided a Bed Hold notice after discharge to a hospital. On 12/19/23 02:43 PM Social Services X stated she handled the written notice for transfers if a resident was being discharged home. She said the nurses were supposed to have completed the written notice for transfer and bed hold notifications if a resident discharged to a hospital. Social Services X stated if a resident was discharged to a hospital the notifications did not always make it onto the sheet, they used to track them to ensure they were done. On 12/19/23 at 03:17 PM Administrative Nurse D stated nurses completed notification of discharge and Bed Hold notifications when residents were discharged to the hospital. Administrative Nurse D stated nurse managers were responsible for following up to ensure Bed Hold notifications were being done. The facility provided Resident Bed-Hold policy dated 12/2008, documented residents may exercise their right to secure a bed-hold during hospitalization or therapeutic leave from the community in accordance with applicable state and federal laws, including the requirements of participation for states and long-term care facilities. A notice of the community's bed-hold policy should be provided at the times of a resident's transfer for hospitalization or therapeutic leave, or as soon as possible thereafter. The manner of providing the notice should be documented. The facility failed to provide a copy of the Bed Hold notice to R63, or her representative, upon discharge to a hospital in November 2023. This deficient practice placed R63 at risk to not be allowed to return to their same room upon discharge from the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 76 residents. The sample included 18 residents with one resident reviewed for baseline care plan. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan to include an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) for Resident (R) 115. This deficient practice placed R115 at risk of impaired care related to uncommunicated care needs. Findings included: - R115's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, disorder of kidney and ureter (duct that urine passes from the kidney to the bladder), femur (thigh bone) fracture (broken bone) of left leg, and encounter for fitting and adjustment of urinary device. The admission Minimum Data Set (MDS) was in progress. R115's Care Area Assessment (CAA) was in progress. R115's Baseline Care Plan dated 12/10/23 documented staff would provide catheter care per facility policy. R115's Care Plan dated 12/13/23 documented staff would place catheter drainage bag below the level of R115's bladder every shift related left femur fracture. The plan of care for R115 lacked reason for the indwelling catheter. R115's clinical record lacked evidence of catheter cares provided for the indwelling catheter. On 12/19/23 at 11:39 AM Certified Nurse Aide (CNA) P stated she had access to the [NAME] (nursing tool that gives a brief overview of the care needs of each resident) which would provide the information for each resident's care needs. On 12/19/23 at 11:52 AM Licensed Nurse (LN) J stated the admission nurse would start the baseline care plan which would include an information related an indwelling catheter care. LN J stated the baseline care plan would include the type of indwelling catheter and diagnosis for the catheter. LN J stated the care plan information was what information was on the [NAME] that directed the staff to meet the resident's individual care needs. On 12/19/23 at 03:15 PM Administrative Nurse D stated the baseline care plan was started on each resident at the time of admission. Administrative Nurse D stated the interdisciplinary team (IDT) would review the baseline plan of care to make revision and additions added to the plan of care from each department to develop a person-centered care plan for each resident. Administrative Nurse D stated the care plan information was what would build the information for the [NAME] for the staff to know what care was needed for each resident. The facility's Interim Care Plan Policy last revised 02/2023 documented an Interim baseline care plan would be developed for each resident within forty-eight (48) hours of admission to the skilled healthcare community. Within forty-eight (48) hours of admission to the skilled healthcare community, an interim baseline care plan would be developed which includes the minimum healthcare information necessary to care for the resident's immediate health and safety needs. The interim care plan would be developed by the admission nurse with the assistance of interdisciplinary team members. The Interim care plan would use but not be limited to, the resident's initial goals of care, physician's orders, dietary orders and instructions, therapy orders, resident cognitive, physical, and psycho-social needs. The Interim care plan would be person-centered and include services and treatments administered by the community. The interim care plan would be used until the completion of the comprehensive assessment and the comprehensive care plan is developed. The Interim Care Plan would be maintained and updated as needed until the Comprehensive Care Plan is developed. The facility failed to develop a person-centered baseline care plan to include an indication and type of indwelling catheter for R115. This deficient practice placed R115 at risk of impaired care related to uncommunicated care needs.

The facility identified a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide adequate care and services for activities of daily living (ADL) when staff failed to provide supervision with eating during meals for Resident (R)43. This deficient practice placed R43 at risk for complication related to aspiration (inhaling liquid or food into the lungs) and decline of overall abilities. Findings included: - The electronic medical record (EMR) for R43 documented diagnoses of hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing), cerebral infarction (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (condition with disordered or absent language function), and hemiparesis (muscular weakness of one half of the body). R43 Quarterly Minimum Data Set (MDS) completed 11/16/23 noted a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe impairment. The MDS indicated she required setup or clean-up assistance with her meals. The MDS indicated no swallowing disorders. The MDS indicated she was totally dependent on staff assistance for toileting, dressing, and bed mobility. The MDS indicated R43 was rarely or never understood. R43's Cognitive Loss Care Area Assessment (CAA) completed 06/15/23 indicated she was non-verbal and frequently lacked psychical responses or reactions to questions. The CAA noted she had a cognitive communication deficit related to her medical diagnoses. The CAA indicated staff will anticipate her care needs. R43's Functional Abilities CAA completed 06/15/23 indicated she had right sided hemiplegia, aphasia, and cognitive communication deficits. The CAA noted she had functional limitations in her range of motion. The CAA noted she had decreased independence and safety, right lower extremity weakness, and right facial drooping. The CAA noted she communicated by nodding her head when asked questions. The CAA noted she required extensive assistance from two staff related to toileting, personal hygiene, and bathing. The CAA noted she required supervision and set-up assistance during meals due to swallowing difficulties. R43's Care Plan initiated 06/23/23 indicated she was at risk for aspiration related to difficulty swallowing. The plan instructed staff to ensure she maintained an appropriate position during meals. The plan indicated she was to be served a regular diet with small bites/sips and provided distant supervision due to difficulty swallowing. On 12/18/23 at 12:43PM R43 sat in her bed with her bedside table pulled overlap. Staff delivered and prepped her meal. Staff then left the room with the door slightly propped open. R43 had bit sized meat and cut potatoes on her tray. R43 began eating her meal. From 12:45PM to 01:20PM no supervision or check-in was provided to R43 during her meal. On 12/19/23 at 07:20AM R43 ate her breakfast without staff supervision in her room with her door barely open. On 12/19/23 at 12:34PM Certified Nurse Aid (CNA) O reported that R43 liked to eat in her room but was not sure if she was at risk for aspiration. She stated she was not sure what distant supervision meant but thought maybe that staff should watch her from a distance. She stated all staff had access to the care plans and reviewed the interventions. On 12/19/23 at 01:05PM Licensed Nurse (LN) I stated R43 preferred to eat in her room due to not wanting to eat around the other residents. She stated R43 was aphasic (difficulty communicating) and got anxious (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) around large groups of residents. She was not sure what distant supervision meant but stated it had to do with risk of aspiration and staff should not stand close to her while she ate. On 12/19/23 at 03:16PM Administrative Nurse D stated residents at risk for aspiration should be monitored closely during meals. She was unsure what distant supervision meant but stated it may have had to do with R43's difficulty communicating her needs. A review of the facility's Supporting Activities of Daily Living policy revised 04/2022 indicated each resident would be provided with the care, services, and treatment as appropriate to safely maintain or improve their ability to carry out activities. The policy indicated each resident would receive the appropriate level of assistance to maintain hygiene, mobility, dining, toileting, and communication. The policy noted each resident's abilities will be monitored, measured, and tracked. The facility failed to provide adequate ADL cares when staff failed to provide supervision during meals for R43. This deficient practice placed R43 at risk for complication related to aspiration and overall decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 76 residents. The sample included 18 residents with four reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, The facility failed to provide consistent bathing opportunities for Residents (R)19, R13, and R37. This deficient practice placed the residents at risk for complications related to hygiene and infections and impaired psychosocial wellbeing. Findings included: - The electronic medical record (EMR) for R19 documented diagnoses of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), chronic kidney disease, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R19 Significant Change Minimum Data Set (MDS) completed 11/03/23 noted a Brief Interview for Mental Status (BIMS) score of 10 indicating mild cognitive impairment. The MDS noted she was totally dependent on staff for toileting, bathing, dressing, grooming, and transfers. The MDS indicated she was always incontinent of bowel and frequently incontinent of bladder with no toileting program. The MDS indicated she was at risk for developing pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and utilized pressure reducing devices (chair and bed) as preventative treatments. The MDS indicated she started hospice services. R19's Cognitive Loss Care Area Assessment (CAA) completed 11/03/23 indicated she displayed moderate cognitive impairment related to poor memory recall. The CAA noted staff were to provide cues and guidance. R19's Functional Abilities CAA completed 11/10/23 indicated she was at risk for potential decline of her ADL related to her prior level of function. The CAA noted she recently started hospice services. The CAA noted she was dependent on staff assistance for toileting, bathing, bed mobility, transfers, and personal hygiene. R19's Care Plan initiated 09/29/23 indicated she required assistant from staff for bed mobility, grooming, bathing, transfers, and personal hygiene. The plan noted she required a Hoyer (full body mechanical lift) lift and two staff for transfers. The plan noted staff were to provide a bed bath or sponge bath if R19 could not tolerate transferring. The plan indicated R19 preferred her bathing on Mondays and Thursdays during day shift. R19's plan indicated she began hospice services on 12/03/23 and was provided bathing opportunities as preferred by R19. R19's Documentation Survey Report from 11/01/2023 through 12/18/23 (48 days reviewed) indicated she received a bath on three occasions (11/09/23, 11/27/23, and 11/30/23) with no refusals documented. On 12/14/23 at 01:10PM R19 reported the facility was slow to get her up and had not given her a bath in weeks. She stated the only one who bathed her was hospice services because the facility staff repeatedly told her they didn't have enough staff. She stated since starting hospice services, the visiting nurse ensured she was bathed and provided hygiene care. R19 reported she preferred to be bathed more than twice weekly and did not understand why the facility could not do it. On 12/18/23 at 09:00AM R19 reported she received her bath from hospice but not from the facility over the previous week. On 12/19/23 at 12:31PM Certified Nurse Aid (CNA) O stated hospice comes to the facility twice weekly to provide R19 with bathing but was not sure if the facility was still providing her baths since hospice does it. She stated all bathing occurrences should be documented in the EMR even if the resident refused or was not available. She stated staff should provide bathing if residents want bathing on days outside of their regular days. She stated some days the facility was short on staff and resident cares were delayed as a result. On 12/19/23 at 12:55PM Licensed Nurse (LN) I stated R19 was heavily dependent on staff to complete her ADL. She stated R19 was on hospice and should have received her scheduled baths in addition to her extra baths provided by hospice. She stated the facility was often short on staff and the resident's requiring assistance for ADL or Hoyer lifts had to wait for staff. She stated all bathing should be documented in the EMR and reviewed by the interdisciplinary team if missed occurrences are found. On 12/19/23 at 03:17PM Administrative Nurse D stated all residents should be bathed per their scheduled days and hospice baths should be completed separately. She stated direct care staff were expected to document the bathing and nurse were expected to ensure the tasks were being completed. She stated the residents should never be told they could not have a bath or not enough staff were available. She stated she had not received concerns of resident not receiving baths. A review of the facility's Supporting Activities of Daily Living policy revised 04/2022 indicated each resident would be provided with the care, services, and treatment as appropriate to maintain or improve their ability to carry out activities. The policy indicated each resident would receive the appropriate level of assistance to maintain hygiene, mobility, dining, toileting, and communication. The policy noted each resident's abilities will be monitored, measured, and tracked. The facility failed to ensure R19 received consistent bathing opportunities from the facility in addition to the supplemental services provided by hospice. This deficient practice placed R19 at risk for complications related to hygiene and infections. - The electronic medical record (EMR) for R13 documented diagnoses of hypertension (elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid) and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated 05/24/23 documented R13 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R13 was total dependent on staff for bathing. R13 was at risk for developing a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). The Quarterly MDS dated 11/04/23 for R13 documented a BIMS score of 12 which indicated intact cognition. R13 was dependent on staff for all aspects of transfer and bathing activity. R13 utilized the use of a manual wheelchair to assist with mobility. R13's Activities of Daily Living (ADL) Care Plan last revised 10/19/23 directed staff that R13 needed assist of up to two staff members for transfers, toileting, and bathing. R13's preferred bath time was on Thursday and Sunday mornings. The Skin Integrity Care Plan last revised 10/7/23 directed staff to evaluate R13's skin condition on a daily and weekly basis. Staff was directed to keep R13's skin clean and dry and to use lotion on dry skin. Review of R13's Documentation Survey Report for the month of September 2023 with scheduled bath days on Thursday and Sunday revealed R13 lacked documentation for bathing on three opportunities (09/07/23, 09/24/23, and 09/28/23). Review of R13's Documentation Survey Report for the month of October 2023 with scheduled bath days on Thursday and Sunday revealed R13 lacked documentation for bathing on eight opportunities (10/01/23, 10/05/23, 10/08/23, 10/15/19, 10/22/23, 10/26/23, and 10/29/23). Review of R13's Documentation Survey Report for the month of November 2023 revealed R13 lacked documentation for bathing except on 11/30/23 which documented task as activity did not occur and not applicable. An Alert Note for R13 dated 11/13/23 at 11:40 AM by Licensed Nurse (LN) H documented there was no documented bath for greater than four days. The Certified Nurse Aide (CNA) was notified to give a bath. On 12/18/23 at 07:48 AM, R13 rested comfortably in her bed in her night gown, call light in reach, no signs of distress. On 12/19/23 at 10:06 AM CNA Q stated the nurse made out the list of daily baths at the beginning of the shift. CNA Q stated the aides charted in the bathing task when a bath was given and how much assistance was provided for a resident. CNA Q stated the unit normally had enough staff to provide bathing for the residents. CNA Q stated the aides should notify the nurse when a resident refused a bath or if the bath was not given. On 12/19/23 at 10:18 AM LN H stated each resident had baths scheduled per their preference. LN H stated she made out the list for daily baths and gave the list to the CNA's each morning. LN H stated the aides were to inform the nurse when a bath was refused or had not been given so the nurse could chart a progress note for the missed bath. On 12/19/23 at 03:15 PM Administrative Nurse D stated staff should always be documenting when a bath was given, missed, or refused. Administrative Nurse D stated residents were asked on admission about their bathing day preference. Administrative Nurse D stated the nurses should be going back to ask the resident if they refused a bath could be given later or the next day. The facility policy Supporting Activities of Daily Living (ADL) dated April 2022 documented: Residents should be provided with care, treatment, and services such that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs was unavoidable. Appropriate care and services should be provided for residents who were unable to carry out ADLs independently and in accordance with the plan of care including appropriate support and assistance with hygiene (bathing, grooming, and oral care). The facility failed to ensure consistent bathing was provided to dependent R13. This deficient practice placed R13 at risk for skin breakdown and possible injury/infection. This deficient practice placed the resident at risk of skin breakdown, infection, and impaired psychosocial wellbeing. - R37's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented bathing activity itself did not occur during the observation period. The Quarterly MDS dated 10/14/23 documented a BIMS score of six which indicated severely impaired cognition. The MDS documented that R37 required set up or clean up assistance for bathing activity during the observation period. R37's Activities of Daily Living Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 01/17/23 documented R37 was at risk of ADL decline related to dementia. R37's Care Plan dated 12/01/23 documented R37 required staff assistance with bathing/showering. The plan of care lacked documentation of R37's refusal of bathing/showering. The plan of care lacked person centered interventions for R37's lack of bathing/showering. Review of the EMR under Documentation Survey Reports tab for bathing reviewed for the following dates for R37 from 08/01/23 to 12/18/23 (140 days) documented seven Shower (S) on 08/05/23, 09/16/23, 11/08/23, 11/15/23, 11/22/23, 11/30/23, and 12/07/23. Activity Did Not Occur was documented nine times on 08/12/23, 08/19/23, 08/26/23, 08/30/23, 09/20/23, 10/25/23, 11/05/23, 12/04/23, and 12/18/23. The clinical record lacked documentation of R37's refusals for bathing. Observation on 12/19/23 at 01:06 PM R37 laid on her right side on the bed. R37's was uncombed and matted upward. On 12/19/23 at 12:35PM Certified Nurse's Aide (CNA) O stated R37 often refused cares and staff would have to approach her multiple times. CNA O stated refusals were documented in the EMR and the nurse was notified. CNA O stated all missed bathing would be offered on another day. She stated due to low staffing often caused delays in care for the residents. On 12/19/23 at 12:55PM Licensed Nurse (LN) I stated direct care staff would notify the nurses of refused cares and it would be documented in the EMR. LN I stated the facility was often short on staff and the resident's requiring assistance for ADLs or Hoyer (total body mechanical lift) lifts had to wait for staff. On 12/19/23 at 03:17PM Administrative Nurse D stated all residents should be bathed per their scheduled days and hospice baths should be completed separately. She stated direct care staff were expected to document the bathing and nurse were expected to ensure the tasks were being completed. She stated the residents should never be told they could not have a bath or not enough staff were available. She stated she had not received concerns of resident not receiving baths. The facility's Supporting Activities of Daily Living policy revised 04/2022 indicated each resident would be provided with the care, services, and treatment as appropriate to maintain or improve their ability to carry out activities. The policy indicated each resident would receive the appropriate level of assistance to maintain hygiene, mobility, dining, toileting, and communication. The policy noted each resident's abilities will be monitored, measured, and tracked. The facility failed to provide consistent bathing for R37. This deficient practice placed R37 at risk for complications related to poor hygiene and impaired dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure staff physician ordered daily weights were obtained and monitored for Resident (R) 164 who had congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). The facility also failed to ensure staff applied R52's thrombo-embolic deterrent (TED - a stocking that helps prevent blood clots and swelling in your legs) hose. This deficient practice placed R164 at risk for unwanted weight/fluid gain and R52 at risk for swelling and possible complications. Findings included: - The electronic medical record (EMR) for R164 documented diagnoses of hypertension (elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), and CHF. The admission Minimum Data Set (MDS) dated 11/24/23 documented R164 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R164 was dependent on staff for toileting, showering, and lower body dressing. R164 utilized a manual wheelchair for mobility. R164 was on a therapeutic diet. R164 received a diuretic (medication to promote the formation and excretion of urine) and an anticoagulant (a class of medications that thin the blood) medication. The Nutrition Care Area Assessment (CAA) dated 11/29/23 documented R164 had altered nutrition related to obesity (excessively overweight) and was on a therapeutic diet for CHF. R164 was to continue with weights as ordered, two-gram sodium diet to reduce water retention, aid blood pressure, and promote overall health. The Congestive Heart Failure Care Plan for R164 initiated on 11/21/23 directed staff to do weight monitoring as ordered. Staff was directed to obtain daily weight and notify physician if weight gain or loss of three pounds in 24 hours or five pounds in one week. Staff was to monitor/document/report to physician any signs/symptoms of CHF (swelling of legs and feet, shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake). The Orders tab of R164's EMR documented a physician's order dated 11/21/23 for a daily weight- notify physician or loss of three pounds in 24 hours or five pounds in one week related to CHF. Review of R164's November 2023 Medication Administration Record (MAR)/Treatment Administration Record (TAR) lacked evidence R164's daily weight was obtained and documented on seven of 10 opportunities. Review of R164's December 2023 MAR/TAR lacked evidence R164's daily weight was obtained and recorded on 12 of 18 opportunities. On 12/18/23 at 12:04 PM R164 sat in her wheelchair at the dining table. R164 was provided with a built-up plate and utensils to assist her with eating. R164 had two drinks provided with her meal. On 12/19/23 at 09:27 AM, Certified Nurse Aide (CNA) Q stated that daily weight was done by the aides and reported to the nurse to put into the MAR/TAR. CNA Q stated R164 was a daily weight. On 12/19/23 at 10:13 AM Licensed Nurse (LN) H stated the unit nurse made out a list of who was a daily weight and gave the list to the CNAs to obtain the weights. LN H stated the CNAs would then give the list of weights to the nurse to input into the MAR/TAR and the nurse should notify the physician of weight changes as needed. On 12/19/23 at 03:16 PM Administrative Nurse D stated she expected that a resident who was a daily weight would be weighed daily. Administrative Nurse D stated that the aides should be reporting the weights to the unit nurse for the nurse to chart and notify the physician as needed. The facility policy Weight and Height Policy last revised February 2018 documented: resident should be weighed upon admission/re-admission, weekly for three weeks, and as needed. Daily/weekly weight monitors - residents identified at risk should be weighed daily/weekly based on recommendations by the Interdisciplinary Team (IDT) or health care provider. Notify the health care provider and the resident and/or legal representative of any significant weight changes as indicated. The facility failed to ensure staff obtained a physician ordered daily weight for R164 who had CHF. This deficient practice placed R164 at risk for fluid overload and other possible complications. - R52's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and osteomyelitis (local or generalized infection of the bone and bone marrow). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R52 required partial/moderate assistance with moving from a sitting position to standing. The MDS documented R52 had an infection of her foot. The MDS documented R52 had a pressure reducing device on her bed and in her chair. The MDS documented R52 had received a diuretic (medication to promote the formation and excretion of urine) during the observation period. R52's Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 11/01/23 documented R52 was able to make her needs know to the staff. R52 required extensive assistance of one staff member for most of her ADLs. R52's Care Plan dated 10/20/23 documented staff would obtain R52's weight prior to breakfast daily and report results to the nurse. R52's EMR under Orders tab revealed physician orders: Furosemide (diuretic) oral Tablet 40 milligrams (mg) give 60mg by mouth two times a day related to CHF dated 10/20/23. R52's EMR revealed a physician Progress Note dated 10/23/23 with an order for daily weights for monitoring for heart failure. R97's EMR under Documentation Survey Report for daily weights reviewed from 10/20/23to 12/17/23 (59 days) lacked evidence staff measured and recorded R52's weight on following dates 10/20/23, 10/25/23, 10/31/23, 11/03/23, 11/10/23, 11/11/23, 11/12/23, 11/17/23, 11/25/23, 11/26/23, 12/1/23, 12/2/23, 12/3/23, 12/06/23, 12/09/23, 12/10/23, 12/12/23, 12/13/23, 12/14/23, 12/15/23, 12/16/23, and 12/17/23. The clinical record lacked documentation of physician notification of daily weight was not obtained. Observation on 12/18/23 at 12:12 PM R52 wheeled herself in a wheelchair to the dining room. On 12/19/23 at 11:39 AM Certified Nurse Aide (CNA) P stated the nurse assigned the daily weights, CNA P stated the CNAs usually obtain the weights and report the weight to the nurse. On 12/19/23 at 11:52 AM Licensed Nurse (LN) J stated the CNAs obtain the daily weights and report the weights to the charge nurse. LN J stated R52 was on a daily weight related to taking a diuretic medication daily. LN J stated the physician would be notified if the daily weight was not obtained and documented in the resident's EMR under the progress notes. On 12/19/23 at 03:15 PM Administrative Nurse D stated the CNAs obtain the weights and report the results to the charge nurse would document the weight in the resident's EMR. Administrative Nurse D stated the physician would be notified if a daily weight was not obtained and document the notification in the residents' EMR. The facility's Weight and Height Policy last revised 02/2018 documented daily/weekly weight monitors residents identified at risk would be weighed daily/weekly based on recommendations by the interdisciplinary team (IDT) or health care provider. The facility would notify the health care provider and the resident and/or legal representative of any significant weight changes as indicated. The facility failed to follow a physician order for daily weights to monitor weight gain for fluid overload for R52, who had CHF. This deficient practice placed R52 at risk of adverse side effects for unnecessary medication or complications related to fluid overload.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Diagnoses tab of R34's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), injury of lumber spinal cord, and difficulty in walking. The Quarterly Minimum Data Set (MDS) dated 11/14/23, documented R34 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. The MDS documented R34 used a wheelchair and required substantial assistance from staff for bathing and toileting. The MDS further documented R34 was dependent on staff to transition from seated to lying or lying to seated position and for chair to bed transfers. The Pressure Ulcer/Injury Potential Care Area Assessment (CAA) dated 10/28/23, documented R34 was at risk for skin breakdown due to weakness, decreased mobility, and incontinence. R34's Care Plan with an initiated date of 11/23/23, documented R34 had potential for impairment to skin integrity due to weakness, decreased mobility, pain, and incontinence. An intervention initiated on 10/23/23 directed staff to assist R34 with turning and repositioning as needed. A Physicians Order with a start date of 12/11/23, documented R34 was to have on pressure relief ankle foot orthotic boots (PRAFO-special boot which keeps the ankle and foot aligned to treat muscle weakness, imbalance and removes pressure from the back of the heel) while in bed, every shift. R34's EMR from 12/12/23 to 12/16/23 lacked documentation of refusal to wear the PRAFO boots. On 12/14/23 at 10:13 AM R34 slept in her room, in bed, without the PRAFO boots on. R34's PRAFO boots were on a chair across from her bed. On 12/19/23 at 12:05 PM Certified Nurse Aide (CNA) N stated if R34 had an order for the PRAFO boots to be on while bed, then R34 should have had them on even while she rested in bed during the day. On 12/19/23 at 12:25 PM Licensed Nurse (LN) H stated R34 should have had the PRAFO boots on while in bed. LN further stated in R34's case the PRAFO boots should probably have been on most of the time; however, when R34 was in bed the PRAFO boots should have been on her. On 12/19/23 at 03:17 PM Administrative Nurse D stated if R34 had an order for PRAFO boots to be on while in bed, then staff were expected to have placed them on R34 while she was in bed. The facility provided Skin Observation and Wound Prevention Protocol dated 03/2009 documented Charge nurses should observe the condition of the resident's skin on admission and on a routine basis. This system also provides a communication process for the nursing assistant to report residents with skin changes to the charge nurse. The facility failed to implement/ensure pressure reducing measures were in place for R34, who was at risk for pressure injuries. This placed R34 at increased risk for pressure/skin injuries. The facility identified a census of 76 residents. The sample included 18 residents with five residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure staff implemented appropriate infection control practices during wound care for Resident (R) 52, who had a history of a wound infection. The facility also failed to ensure pressure reducing measures were in place for R34. This deficient practice placed these residents at risk of development of pressure ulcers, of wound worsening and complications related to infections. Findings included: - R52's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and osteomyelitis (local or generalized infection of the bone and bone marrow). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R52 required partial/moderate assistance with moving from a sitting position to standing. The MDS documented R52 had an infection of her foot. The MDS documented R52 had a pressure reducing device on her bed and in her chair. R52's Pressure Ulcer Care Area Assessment (CAA) dated 11/01/23 documented R52 was monitored regularly by the physician for current wound. R52's Care Plan dated 10/21/23 documented staff would cleanse R52's wound on her right foot with wound cleanser, apply Skin-prep (liquid skin protectant) to peri-wound, apply drape to peri-wound. Cut black foam to fit wound and secure with drape. Change every Monday, Wednesday, Friday and as needed for wound care. R52's EMR under Orders tab revealed physician orders: Right foot wound: cleanse with wound cleanser, apply Skin-prep to peri-wound, apply drape to peri-wound. Cut black foam to fit wound and secure with drape. Change every Monday, Wednesday, Friday, and as needed for wound care and osteomyelitis dated 10/20/23. Cefazolin sodium (antibiotic) injection solution reconstituted two grams give two grams intravenously (directly into the blood stream via a vein) every morning and at bedtime for infection dated 12/16/23. Observation on 12/18/23 at 01:01 PM R52 sat in a recliner next to the bed with bilateral lower extremities elevated. Administrative Nurse E washed her hands in the bathroom, donned clean gloves, then unplugged the wound vac from the wound on R52's right foot, allowed the tubing from the wound-vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) drop onto the floor next to the recliner. Administrative Nurse E removed the dressing from R52's right foot, doffed her gloves then donned a clean pair of gloves and cleansed the wound without performing hand hygiene. Administrative Nurse E doffed gloves and with no hand hygiene preformed donned a clean pair of gloves and obtained photos of R52's wound on R52's phone. Administrative Nurse E doffed gloves again and donned a clean pair of gloves, without performing hand hygiene, and applied a dressing to R52's right foot wound. Administrative Nurse E cut the foam with scissors, then applied outer dressing. Administrative Nurse E removed the collection canister and tubing that rested on the floor and disposed of the items in the trash can. Administrative Nurse E connected a new collection canister to the wound vac and tubing to R52's right foot wound. On 12/19/23 at 11:52 AM Licensed Nurse (LN) J stated staff should always do hand hygiene during wound care and between gloves changes. On 12/19/23 at 02:30 PM Administrative Nurse E stated hand hygiene should be performed between glove changes, after providing care, and when hands were soiled. Administrative Nurse E stated the facility had an in-service over hand hygiene two weeks ago. The facility's Handwashing/Hand Hygiene policy last revised 11/2021 documented the facility considered hand hygiene the primary means to prevent the spread of infections. All associates would be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All associates would follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other associates, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for associates use to encourage compliance with hand hygiene policies. Center for Disease Control and Prevention (CDC) recommends using Alcohol Based Hand Sanitizer with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water during routine resident care. Before and after coming on duty; Before and after direct contact with residents; Before preparing or handling medications; Before performing any non-surgical invasive procedures; Before and after handling an invasive device (e.g., urinary catheters, IV access sites); Before donning sterile gloves; Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, etc.; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; After removing gloves; Before and after entering isolation precaution settings; Before and after assisting a resident with meals; and Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. The facility failed to ensure R52 was provided wound care following professional standards of infection control. This deficient practice placed R52 at risk of further infection and worsening of wounds.

The facility identified a census of 76 residents. The sample included 18 residents with five reviewed for bowel and bladder management and/or urinary catheter (tube inserted into the bladder to drain urine). Based on interviews, observations, and record review, the facility failed to identify changes in Resident (R) 47's bowel and bladder incontinence patterns and implement individualized toileting interventions. The facility additionally failed to ensure R115's indwelling catheter had an appropriate indication and physician's order to provide catheter and related care. This deficient practice placed both residents at risk for complications related to bladder management and incontinence. Findings included: - The electronic medical record (EMR) for R47 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (major mood disorder), and chronic kidney disease. R47 Significant Change Minimum Data Set (MDS) completed 11/27/23 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating mild cognitive impairment. The MDS indicated she required supervision or touch assistance for toileting, and lower body dressing. The MDS indicated she was occasionally incontinent of urine and frequently incontinent of bowel with no toileting program. R47's Cognitive Loss Care Area Assessment (CAA) completed 08/18/23 indicated she had dementia with cognitive communication deficits. The CAA indicated she was independent of all self-care activities prior to her hospitalization for her cerebral infarction. R47's Functional Abilities CAA completed 08/18/23 indicated she was at risk for a decline in her activities of daily living (ADLs) related to her medical diagnoses, weakness, and reduced mobility. The CAA noted she required limited staff assistance with her ADLs and personal care. R47's Urinary Incontinence CAA completed 08/18/23 indicated she was incontinent. The CAA instructed staff to provide toileting assistance related to her incontinence and monitor her for skin impairment. R47's Care Plan initiated 08/21/23 indicated she had a self-care performance deficit and required limited staff assistance for bed mobility, transfers, toileting, and hygiene. The care plan indicated she required assistance from one staff for transfers and ambulation to the bathroom. The plan indicated she had bowel and bladder incontinence and instructed staff to provide check/change assistance every three hours and directed staff to establish R47's voiding patterns. R47's EMR revealed a 72 Hour Toileting Log report completed 11/20/23 which noted no issues or analysis and provided no recommendations or possible interventions. A review of R47's Documentation Survey Report indicated she had multiple episodes of bowel and bladder incontinence noted on 11/24/23. A Nursing Quarterly Data Collection report completed 11/25/23 indicated R47 was continent of both bowel and bladder. The assessment was not completed due to her status being documented as continent. No recommendations were listed on the report. On 12/14/23 at 12:45 PM R47's resident representative stated R47 was recovering from a stroke that left her with difficulties communicating and remembering. She stated R47 was independent with her ADL, but her abilities had declined since her stroke. On 12/14/23 at 02:05 PM an inspection of R47's room revealed a heavy urine smell. R47's room floor had a wet substance leading around the room and into the restroom. Parts of R47's floor had a dried / sticky substance covering it. On 12/18/23 at 12:34 PM R47 was in her room standing next to the closet in her room. R47 had a pair of white pants on the floor next to her recliner. R47 stated she just changed her pants and was going to lunch. R47 had a pile of clothing in her laundry basket. She reported she could do most things for herself but needed staff assistance from time to time. Staff were not in the room to assist her changing. R47 smelled of urine as she went to the dining room. On 12/19/23 at 12:31PM Certified Nurse Aid (CNA) stated she was not sure if R47 was incontinent, but all residents were checked on every three hours. She stated if staff noticed changes in a resident's bathroom usage or increased episodes of incontinence, the nurse was notified. She stated R47 was more independent than other residents, but staff should notice if her clothing or room smelled like urine. At 12/19/23 at 12:55PM Licensed Nurse (LN) stated staff should be checking on R47 frequently and providing her with restroom breaks. She's stated R47 had issue with memory and may not know she was incontinent or not approach staff. She stated residents with sing of increased incontinence should be reassessed and provided interventions. At 12/19/23 at 01:08PM Administrative Nurse D stated all residents were screened upon admission for incontinence and given a 72-hour toileting trail. She stated the trail would show the patterns and help determine needed interventions. She stated a reassessment should be completed if signs of increased incontinence or changes occur with toileting. A review of the facility's Bowel and Bladder Management policy revised 08/2023 indicated the facility would complete a bowel and bladder assessment on each resident upon admission and provide individualized toileting programs for appropriate residents. The facility failed to identify changes in R47's increased incontinence patterns and implement individualized toileting interventions. This deficient practice placed R47 at risk for complications related to incontinence. - R115's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, disorder of kidney and ureter (duct that urine passes from the kidney to the bladder), femur (thigh bone) fracture (broken bone) of left leg, and encounter for fitting and adjustment of urinary device. The admission Minimum Data Set (MDS) was in progress. R115's Care Area Assessment (CAA) was in progress. R115's Baseline Care Plan dated 12/10/23 documented staff would provide catheter care per facility policy. R115's Care Plan dated 12/13/23 documented staff would place catheter drainage bag below the level of R115's bladder every shift related left femur fracture. The plan of care for R115 lacked reason for the indwelling catheter. R115's EMR under the Orders tab lacked a physician order for a foley catheter placement and the medical indication and catheter related care. R115's clinical record lacked evidence of catheter cares provided for the indwelling catheter. Observation on 12/19/23 at 09:34 AM R115 laid on the bed. Certified Nurse Aide (CNA) P entered R115's room, washed her hands, donned gloves, and explained the procedure to R115 for catheter care. CNA P removed two wipes from the package and placed the wipes on R115's right thigh. CNA P used one wipe to clean R115's foreskin and around the base of the penis. CNA P placed the soiled wipe on the bed between R115's legs. CNA P used the second wipe to clean the tip of R115's penis and wiped away from the tip of the penis down the tubing with the wipe. CNA P removed the soiled wipes and placed items into the trash can next to the bed. With the same gloves, CNA P assisted R115 onto his left side, provided peri-care, and placed a clean incontinent brief under R115. CNA P doffed her right-hand glove only, donned a clean glove without performing hand hygiene, then adjusted R115's clothes, and bedding, Wearing the same gloves, CNA P touched the bedside table, adjusted the abed height with a remote control and assisted R115 with repositioning on the bed. CNA P removed the soiled trash from R115's room. On 12/19/23 at 11:39 AM CNA P stated hand hygiene should be performed between glove changes. CNA P stated staff should change gloves after catheter care was completed. On 12/19/23 at 11:52 AM Licensed Nurse (LN) J stated staff should always do hand hygiene after peri-care or catheter care and between gloves changes. LN J stated there should always be a physician order for a resident to have an indwelling catheter and a diagnosis for that catheter. On 12/19/23 at 02:30 PM Administrative Nurse E stated hand hygiene should be performed between glove changes, after providing care, and when hands were soiled. Administrative Nurse E stated the facility had an in-service over hand hygiene two weeks ago. On 12/19/23 at 03:15 PM Administrative Nurse D stated the resident would need an order for indwelling catheter and diagnosis for the catheter. Administrative Nurse D stated catheter care was to be provided every shift. Administrative Nurse D stated the care plan should include the diagnosis and direction for care related to the indwelling catheter. Administrative Nurse D stated the care provided should be documented on the Treatment Administration Record (TAR). The facility's Urinary Catheter Care policy last revised 08/2023 documented staff would verify that there is a healthcare provider's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Use a washcloth with warm water and soap, or a disposable moist cloth to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth or disposable moist cloth with each cleansing stroke. With a clean washcloth, rinse with warm water or use a clean disposable moist cloth, using the above technique. Return foreskin to normal position. Dispose of used cloth(s) in designated container. Use a clean washcloth with warm water and soap, or a disposable moist cloth to cleanse and rinse the catheter from insertion site to approximately four inches outward. Dispose of used cloth(s) in designated container. Secure catheter utilizing a leg band. Check drainage tubing and bag to ensure that the catheter is draining properly. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry hands thoroughly. Reposition the bed covers. Make the resident comfortable. Place the call light within easy reach of the resident. Clean wash basin and return to designated storage area. Clean the bedside stand and/or overbed table. Return the overbed table to its proper position. Wash and dry hands thoroughly. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. The facility failed to ensure R115 had an appropriate indication for the ongoing use of an indwelling catheter. The facility further failed to ensure appropriate foley care orders were in place to direct nursing staff on foley catheter care for R115. This placed R115 at increased risk for catheter related complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 76 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations for physician documented rationale for the continued use of the antipsychotic medication (class of medications used to treat major mental conditions which cause a break from reality testing) for Resident (R) 37 were addressed by the physician. This deficient practice placed R37 at risk for unnecessary psychotropic medication and related complications. Findings included: - R37's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented bathing activity itself did not occur during the observation period. The MDS documented R37 received antipsychotic medication and antidepressant (class of medications used to treat mood disorders) medication for seven days during the observation period. The Quarterly MDS dated 10/14/23 documented a BIMS score of six which indicated severely impaired cognition. The MDS documented that R37 required set up or clean up assistance for bathing activity during the observation period. The MDS documented R37 received antipsychotic medication and antidepressant medication during the observation period. R37's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/17/23 documented R37 was at risk for adverse side effects from psychotropic medication ordered related to her diagnosis of dementia. R37's Care Plan dated 01/05/23 documented staff would consult with the physician to consider dose reduction at least every three months for psychotropic medications. Review of the EMR under Orders tab revealed physician orders: Olanzapine (antipsychotic) tablet five mg give one tablet by mouth at bedtime for dementia dated 07/25/23. R37's EMR under the Misc. tab the Monthly Medication Review (MMR) reviewed from January 2023 to October 2023 revealed recommendations for gradual reduction and physician documentation for risk versus benefits for the continued use of the antipsychotic medication for R37 with a diagnosis of dementia and Alzheimer's disease. R37's clinical record lacked a physician documented response to the MMR which included a rationale and risk versus benefits for the continued use of the antipsychotic medication with a diagnosis of dementia and Alzheimer's disease. Observation on 12/19/23 at 01:06 PM R37 laid on her right side on the bed. R37's hair was uncombed and matted upward. On 12/19/23 at 11:52 PM Licensed Nurse (LN) J stated the resident, or their representative would sign a consent for the use of psychotropic medications. LN J stated staff administered the medication as ordered by the physician for the diagnosis given by the physician. LN J stated the nurse managers, or the director of nurse would review pharmacy monthly recommendations. On 12/19/23 at 03:15 PM Administrative Nurse D stated for any psychotropic medication the physician was involved in the monitoring of the medication. Administrative Nurse D stated physician reviewed the diagnosis for each medication administered. Administrative Nurse D stated the monthly pharmacy recommendations were emailed to her and the nurse managers would make the changes. The facility's Medical regimen Review) MRR) Policy dated 07/2018 documented a drug regimen review was performed for each resident at the time admission, monthly thereafter and as indicated, based upon a resident's condition. This Medication Regimen Review (MRR) included, but was not limited to, time frames for different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. The facility failed to ensure the CP recommendations for physician documented rationale for the continued use of the antipsychotic medication for R37 were addressed by the physician. This deficient practice placed R37 at risk for unnecessary psychotropic medication and related complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 76 residents. The sample included 18 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 52. This deficient practice R52 at risk for unnecessary medication use and physical complications for the affected resident. Findings included: - R52's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and osteomyelitis (local or generalized infection of the bone and bone marrow). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R52 required partial/moderate assistance with moving from a sitting position to standing. The MDS documented R52 had an infection of her foot. The MDS documented R52 had a pressure reducing device on her bed and in her chair. R52's Pressure Ulcer Care Area Assessment (CAA) dated 11/01/23 documented R52 was monitored regularly by the physician for current wound. R52's Care Plan dated 10/20/23 documented staff would evaluate the effectiveness of R52's pain interventions and review for compliance, alleviating of symptoms, dosing schedules and her satisfaction with results, impact on functional ability and impact on cognition. Review of the EMR under Orders tab revealed physician orders: Voltaren external gel (anti-inflammatory class of medication used to reduce inflammation) one percent (%) (diclofenac sodium) (topical), apply to affected area every four hours as needed dated 11/21/23. The order lacked a dose. Observation on 12/18/23 at 12:12 PM R52 wheeled herself in a wheelchair to the dining room. On 12/19/23 at 11:39 AM Licensed Nurse (LN) J stated every medication should have a dosage to be administered as ordered by the physician. LN J stated if a medication lacked a dose to be administered, she would clarify the order with physician. LN J stated R52's Voltaren order lacked have a dose ordered for administration after she reviewed R52's Medication Administration Record (MAR). On 12/19/23 at 11:52 AM Administrative Nurse D stated she would except all medication orders would have a dose to be administered as ordered by the physician. Administrative Nurse D stated she would except the nurse would clarify the medication order with physician. The facility's Physician Medication Orders policy lasted revised 04/2021 documented medications would be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Orders for medications must include Name and strength of the drug; Quantity or specific duration of therapy; Dosage and frequency of administration; Route of administration if other than oral; and Reason or problem for which given. The facility failed to ensure dosing instructions for Voltaren gel for R52. This deficient practice placed R52 at risk for unnecessary medication use, side effects and physical complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 76 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication or documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of antipsychotic (class of medications used to treat major mental conditions which cause a break from reality testing) for Resident (R)115 and R37. This deficient practice placed these residents at risk for unnecessary psychotropic medication and related complications. Findings included: - R115's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, disorder of kidney and ureter (duct that urine passes from the kidney to the bladder), femur (thigh bone) fracture (broken bone) of left leg, and encounter for fitting and adjustment of urinary device. The admission Minimum Data Set (MDS) was in progress. R115's Care Area Assessment (CAA) was in progress. R115's Care Plan dated 12/11/23 documented staff would administer medication as ordered and monitor/document side effects and effectiveness. R115's Care Plan also documented the facility would consult with the pharmacy and physician to consider dose reduction, if clinically appropriate, and ongoing need for use. Review of the EMR under Orders tab revealed physician orders: Quetiapine fumarate (antipsychotic) oral tablet 25 milligrams (mg) give one tablet by mouth at bedtime for insomnia (inability to sleep) dated 12/09/23. R115's clinical record lacked a physician documented rationale which included the multiple unsuccessful attempts for nonpharmacological interventions and risk versus benefits for the continued use of the antipsychotic medication. Observation on 12/19/23 at 09:34 AM R115 laid on his back on the bed with the head of bed elevated. R115's catheter drainage bag was attached to the bed frame covered with a dignity bag. On 12/19/23 at 11:52 PM Licensed Nurse (LN) J stated the resident, or their representative would sign a consent for the use of psychotropic (alters mood or thought) medications. LN J stated staff administered the medication as ordered by the physician for the diagnosis given by the physician. On 12/19/23 at 03:15 PM Administrative Nurse D stated for any psychotropic medication the physician was involved in the monitoring of the medication. Administrative Nurse D stated physician reviewed the diagnosis for each medication administered. The facility's psychotropic Drug Management Policy policy last revised 10/2022 documented non-drug interventions would be implemented to the extent possible to assist the resident attain a satisfactory quality of life. To provide a therapeutic environment, use only those medications with a therapeutic benefit to the individual resident. Unnecessary drugs would be avoided. An unnecessary drug was any drug when used in excessive dose (including duplicate drug therapy, for excessive duration, without adequate monitoring, without adequate indications for its use, and/or in the presence of adverse consequences which indicate the dose would be reduced or discontinued. This can be one or in combination together. To avoid the use of unnecessary drugs and their associated adverse drug effects (ADEs), psychotropic medications would be used only after non-drug interventions alone have failed to manage behavioral symptoms associated with dementia and a medication was used to treat a specific condition as diagnosed and documented in the clinical record. This facility would monitor residents using psychotropic medications for efficacy and adverse reactions. Psychotropic is defined as any drug that affects brain activities associated with mental processes and behaviors. The facility failed to provide a physician documented rationale which included the multiple unsuccessful attempts for nonpharmacological interventions and risk versus benefits for the continued use of the antipsychotic medication for R115 for insomnia. This deficient practice placed him at risk for unnecessary psychotropic medication and related complications. - R37's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented bathing activity itself did not occur during the observation period. The MDS documented R37 received antipsychotic medication and antidepressant (class of medications used to treat mood disorders) medication for seven days during the observation period. The Quarterly MDS dated 10/14/23 documented a BIMS score of six which indicated severely impaired cognition. The MDS documented that R37 required set up or clean up assistance for bathing activity during the observation period. The MDS documented R37 received antipsychotic medication and antidepressant medication during the observation period. R37's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/17/23 documented R37 was at risk for adverse side effects from psychotropic (alters mood or thought) medication ordered related to her diagnosis of dementia. R37's Care Plan dated 01/05/23 documented staff would consult with the physician to consider dose reduction at least every three months for psychotropic medications. Review of the EMR under Orders tab revealed physician orders: Sertraline hci (antidepressant) tablet 100 milligrams (mg) give one tablet by mouth at bedtime related to depression dated 01/04/23. Mirtazapine tablet (antidepressant) 7.5mg give one tablet by mouth at bedtime for dementia dated 01/04/23. Olanzapine (antipsychotic) tablet five mg give one tablet by mouth at bedtime for dementia dated 07/25/23. R37's clinical record lacked a physician documented rationale which included the multiple unsuccessful attempts for nonpharmacological interventions and risk versus benefits for the continued use of the antipsychotic medication. Observation on 12/19/23 at 01:06 PM R37 laid on her right side on the bed. R37's hair was uncombed and matted upward. On 12/19/23 at 11:52 PM Licensed Nurse (LN) J stated the resident, or their representative would sign a consent for the use of psychotropic medications. LN J stated staff administered the medication as ordered by the physician for the diagnosis given by the physician. On 12/19/23 at 03:15 PM Administrative Nurse D stated for any psychotropic medication the physician was involved in the monitoring of the medication. Administrative Nurse D stated physician reviewed the diagnosis for each medication administered. The facility's psychotropic Drug Management Policy policy last revised 10/2022 documented non-drug interventions would be implemented to the extent possible to assist the resident attain a satisfactory quality of life. To provide a therapeutic environment, use only those medications with a therapeutic benefit to the individual resident. Unnecessary drugs would be avoided. An unnecessary drug was any drug when used in excessive dose (including duplicate drug therapy, for excessive duration, without adequate monitoring, without adequate indications for its use, and/or in the presence of adverse consequences which indicate the dose would be reduced or discontinued. This can be one or in combination together. To avoid the use of unnecessary drugs and their associated adverse drug effects (ADEs), psychotropic medications would be used only after non-drug interventions alone have failed to manage behavioral symptoms associated with dementia and a medication was used to treat a specific condition as diagnosed and documented in the clinical record. This facility would monitor residents using psychotropic medications for efficacy and adverse reactions. Psychotropic is defined as any drug that affects brain activities associated with mental processes and behaviors. The facility failed to provide a physician documented rationale which included the multiple unsuccessful attempts for nonpharmacological interventions and risk versus benefits for the continued use of the antipsychotic medication for R37 who has diagnosis of dementia and Alzheimer's disease. This deficient practice placed her at risk for unnecessary psychotropic medication and related complications.

The facility identified a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure physician ordered laboratory test results for Resident (R) 37 were included the clinical record. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R37's Electronic Medical Record (EMR) under the Orders tab revealed physician order: Complete Blood Count (CBC) laboratory test to be obtained monthly per physician order. Notify the physician of results dated 04/27/23. R37's EMR lacked laboratory tests obtained on 08/25/23, 09/25/23 and 10/25/23. On 12/19/23 at 03:15 PM Administrative Nurse D stated outside laboratory obtained the lab tests ordered by the physician. Administrative Nurse D stated the results were faxed to the facility and the physician was notified of the results, then the nurse would initial and dated the results. Administrative Nurse D stated the laboratory results were then sent to medical records, and scanned into the results are then scanned into the resident's EMR under the Misc. tab. Administrative Nurse D stated she was not sure what the time frame before the results were scanned into the resident's EMR, but she expected the results to scanned quickly to be reviewed by the physician and nurses. The facility's Electronic Medical Records policy last revised 06/2020 documented Electronic Medical Records may be used in lieu of paper records. The facility failed to ensure physician ordered laboratory test results for R37 were signed and included in the clinical record. This deficient practice could result in unnecessary tests and delayed treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 76 residents. The sample included 18 residents with five reviewed for influenza (highly contagious viral infection) and pneumococcal (type of bacterial infection) immunizations. Based on record review and interviews, the facility failed to provide pneumococcal vaccinations or informed refusals for Residents (R)13 and provide influenza vaccinations or informed refusals for R53. This deficient practice placed the residents at risk for complication related to infectious diseases. Findings included: - R13's clinical record lacked evidence indicating she or her representative was offered, consented, refused, or had received the pneumonia vaccination since her admission in 2019. R53's clinical record lacked evidence indicating she or her representative was offered, consented, refused, or had received the Influenza vaccination since her admission on [DATE]. On 12/19/23 at 02:23PM Administrative Nurse F stated she recently took over from the previous infection preventionist and the facility was catching up with all the infection control tasks. She stated each resident's immunizations should be reviewed upon admission and offered either at admission or during the next administration cycle. She stated the missing immunization consents would be completed and offered. A review of the facility's Influenza Immunization policy indicated all residents will be screened and offered immunizations. The policy noted resident and representative will be provided education related to the vaccinations and provided consent/declination opportunities. The policy indicated the documentation will be placed in the residents medical record for review. A review of the facility's Pneumococcal Immunization policy revised 05/2023 indicated the pneumococcal vaccination will be provided to residents over [AGE] years old or with medical indications. The policy noted the vaccination consent or declination will be completed and maintained in the medical records. The facility failed to provide pneumococcal vaccinations or informed refusals for R13 and provide influenza vaccinations or informed refusals for R53. This deficient practice placed the residents at risk for complication related to infectious diseases.

The facility reported a census of 76. Based on observations, record review, and interviews, the facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and impaired quality of life. Findings included: - A review of the facility's Resident Council Minutes from 12/2022 through 11/2023 indicated the council had recurring concerns with call light response times. The Resident Council Minutes for 01/2023 noted under new business concerns over call light response time. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 02/2023 noted under old business the previous call light concern was resolved and noted no other new/old concerns. No other issues were reported on the minutes. The Resident Council Minutes for 03/2023 noted long call light waits under new business concerns. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 04/2023 noted under old business the previous the long call light wait was better. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 05/2023 noted under old business the previous the long call light wait was resolved. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 06/2023 noted under new business concerns the Hoyer (full body mechanical lift) lifts were being left in the resident's rooms. The form did not list actions taken or resolutions provided. This issue was not addressed by the facility. No other issues were reported on the minutes. The Resident Council Minutes for 08/2023 noted long call light waits under new business concerns. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 09/2023 noted under old business the previous the long call light wait was resolved. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. On 12/18/23 at 02:00PM, the Resident Council reported ongoing concerns with staffing, call light response times, and activities of daily living not being completed. The council reported it took sometimes over 30 to 45 minutes for staff to respond to call lights. The council reported the facility staffing was lower on weekends and the wait times could go up to an hour. The council reported the facility was working on finding permanent staff and getting rid of agency staff. The council reported the Hoyer lifts were still being left in resident rooms. The council reported the staffing concerns were affecting bathing, toileting, activities, and meals. On 12/19/23 at 02:45PM Social Service X stated the concerns were directed to the appropriate department listed to resolve the issues or concerns. She stated the forms were signed off as resolved once the actions had been taken and improvement occurred. On 12/19/23 at 03:16PM Administrative Nurse D stated the facility was currently working to replace agency staff with more permanent staffing to improve resident care and response times. She reported call light response times was an ongoing issue and she felt it had improved recently. A review of the facility's Resident Council policy indicated the resident response form were to be utilized to track council concerns and facility resolution. The policy indicated the department related to any issue will be responsible for addressing the concerns. The facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and impaired quality of life.

The facility identified a census of 76 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representative to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Finding Included: - On 12/18/23 at 07:05AM an inspection of the facility revealed no designated grievance drop -box or alternative system available accessible to the residents and visitors of the facility to allow submission of grievances anonymously On 12/18/23 at 02:00PM, the Resident Council members reported they were not aware if the facility provided a way to complete an anonymous grievance. The council reported Social Services X was responsible for complaints or grievances. The council stated they would contact staff or social services. On 12/19/23 at 12:30PM Certified Nurses Aid (CNA) O reported she was not aware of an anonymous way the residents could report grievances other than giving staff the forms directly. She stated she was not aware of a drop box or secured area the forms could be placed anonymously by the residents or their representatives. On 12/19/23 at 01:05PM Social Services Staff X stated that facility had grievance forms at the front desk. She stated there was no drop box for the forms to be placed anonymously but staff could slide the forms under her door. A review of the facility's Grievance policy revised 10/2022 indicated the facility must enable each resident the right to file grievances verbally, orally, and anonymously to the designated officer, administrator, or staff member for review. The facility failed to implement a system to allow anonymous grievances. This deficient practice placed all the residents at risk for decreased psychosocial wellbeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 76 residents. The sample included 18 residents. Based on interview and record review, the facility failed to establish and maintain a system to ensure nursing staff maintained current cardiopulmonary resuscitation (CPR- a life-saving medical procedure that consists of chest compressions to allow oxygenated blood to circulate to vital organs, such as the brain and heart and artificial ventilation) certification for healthcare providers. This deficient practice placed all residents who desired CPR at risk for inadequate resuscitative measures. Findings included: - On [DATE] Licensed Nurse (LN) K's CPR certification had an issue date of [DATE] and a renew (expiration) date of 10/2023. On [DATE] at 03:43 PM Administrative Staff A stated LN K was a newer nurse and had previously worked at the facility as a Certified Nurse Aide. Administrative Staff A stated that LN K's CPR certification expired at the end of October. Administrative Staff A stated the facility had had not self-identified LN K's expired CPR certification. The facility failed to establish and maintain a system to ensure nursing staff maintained current CPR certification for healthcare providers. This deficient practice placed all residents who desired CPR at risk for inadequate resuscitative measures.

The facility identified a census of 76 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom. Findings included: - A review of the facility's Activity Calendar for September, October, and November 2023 was completed. The review revealed two consistent activities of movie matinee and activities connection as shown for both Saturday and Sundays. The calendar indicated church services were provided Sunday mornings. The calendar indicated the activity B-fit was provided by the therapy department on weekends. On 12/18/23 at 02:05PM, Resident Council members reported activities minimally occurred on weekends compare to the weekdays. The council reported due to the low staffing in the facility and limited activities provided, the resident usually watched television or wheeled themselves around to see each other. The council reported the facility did provide an Activities Connection basket that had crossword puzzles and coloring pages the residents could complete. The council reported they wanted the facility to provide more engagement activities like Bingo or interactive groups for the residents on the weekend. On 12/14/23 at 08:12AM Resident (R)216 sat in her room. She reported she was not aware the facility provided activity on the weekend. She stated she did attend some of the activities during the week. She reported she did not have a calendar in her room to know there were activities on Saturday and Sunday. An inspection of her room revealed no activity calendar. On 12/18/23 at 11:30AM the facility had a Caroling group singing next to the piano area for the 300 hallway residents. R19 reported she was not informed about the event and would have liked to see it. On 12/19/23 at 12:35PM Certified Nurses Aid (CNA) O stated some activities staff do come in on the weekends. She stated the residents were often provided with the activity connection stuff or therapy would come in the have exercise (B-fit) groups. She stated movies would be played on television. On 12/19/23 at 02:34 Activities Staff Z reported stated weekend activities were mainly one-one with the residents and completing activities assessments. She stated the facility was often staffed less on the weekends and residents were frequently provided solitary activities such as coloring, puzzle, and electronic tablets to play games. A review of the facility's Quality of Life policy revised 10/2021 indicated the residents will be provided and encourage to attend activities that meet each resident's interest, hobbies, worship, beliefs, and social needs. The facility failed to provide consistent activities for the residents during weekends. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom.

The facility identified a census of 76 resident. The facility had three medication storage rooms and five medication carts. Based on observation, record review and interview, the facility failed to ensure safe and secure storage of medications and biologicals. This deficient practice created a risk for adverse side effects and ineffective medication administration. Findings included: - On 12/14/23 at 09:25 AM the medication cart on the 300 hallway was left unsecured and unlocked in an area where residents were present. Licensed Nurse (LN) J came running out of a resident's room in the 300 hall when she realized she left the medication cart unlocked. On 12/14/23 at 09:45 AM the treatment cart in the 400 hall was left unsecured and unlocked. On 12/14/23 at 09:25 AM LN J stated the medication and treatment carts should be secured when not in use. On 12/19/23 at 03:16 PM Administrative Nurse D stated that the medication cart, medication room, and treatment carts should all be securely locked when staff was not using them. The facility policy Storage and Expiration of Medications, Biologicals, Syringes and Needles revised 01/01/13 documented the facility should ensure that all medications and biologicals, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors. The facility failed to ensure safe and secure storage of medications and biologicals. This deficient practice created a risk for adverse side effects and ineffective medication administration.

The facility identified a census of 78 residents. The sample included 18 residents. Based on record review, interviews, and observations, the facility failed to ensure sufficient staffing was provided to maintain the residents' physical and psychosocial wellbeing. This placed the residents at risk for impaired quality of life. Findings Included: - The Payroll Based Journaling (PBJ) report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2023 Quarter 1 and 3 indicated the facility had excessively low weekend staffing. Review of the facility's Resident Council Minutes from 12/2022 through 11/2023 indicated the council had recurring concerns with call light response times. (The complaint of slow call lights was not on the 01/23, 03/23, and 08/2023 council minutes). (Refer to F565) On 12/18/23 at 12:43PM R43 sat in her bed with her bedside table pulled overlap. Staff delivered and prepped her meal. Staff then left the room with the door slightly propped open. R43 had bit sized meat and cut potatoes on her tray. R43 began eating her meal. From 12:45PM to 01:20PM no supervision or check-in was provided to R43 during her meal. On 12/19/23 at 07:20AM R43 ate her breakfast without staff supervision in her room with her door barely open. Observation on 12/19/23 at 01:06 PM R37 laid on her right side on the bed. R37's was uncombed and matted upward. On 12/14/23 at 01:10PM Resident (R)19 reported the facility was slow to get her up and had not given her a bath in weeks. She stated the only one who bathed her was hospice services because the facility staff repeatedly told her they didn't have enough staff. She stated since starting hospice services, the visiting nurse ensured she was bathed and provided hygiene care. R19 reported she preferred to be bathed more than twice weekly and did not understand why the facility could not do it. (Refer to F677) On 12/18/23 at 02:00PM, the Resident Council reported ongoing concerns with staffing, call light response times, and activities of daily living not being completed. The council reported it took sometimes over 30 to 45 minutes for staff to respond to call lights. The council reported the facility staffing was lower on weekends and the wait times could go up to an hour. The council reported the facility was working on finding permanent staff and getting rid of agency staff. The council reported the staffing concerns were affecting bathing, toileting, weekend activities, and meals. On 12/18/23 at 03:30PM Administrative Staff A stated the facility was currently attempting to improve staffing by hiring more permanent staff and getting rid of agency staff. He said the facility currently had a performance improvement plan to address the low staffing and issues related to care concerns affected by staffing. On 12/19/23 at 12:34 Certified Nurse Aid (CNA) O stated weekend staffing was a struggle. She stated the weekend didn't have enough help to complete the assist the resident's need. She stated the residents usually must wait for staff from other units to come over to complete lifts and transfers that require more than one staff. She stated resident's baths get delay or pushed off to the next shift. On 12/19/23 at 01:04 Licensed Nurse I stated the facility has been low on staffing the units. She stated the facility was not looking at patient acuity and the needs of the residents when making assignment for the staff. She stated the lack of assistance made it hard to complete Hoyer (full body mechanical lift) lifts, transfers, bathing, toileting, and individualized care needs outside of the times when the nurse managers worked. She stated the lack of assistance caused residents to have to reschedule or wait long times for toileting and bathing. On 12/19/23 at 02:34 Activities Staff Z reported stated weekend activities were mainly one-one with the residents and completing activities assessment. She stated the facility was often staffed less on the weekends and residents were frequently provided solitary activities such as coloring, puzzle, and electronic tablets to play games. She was not sure why, but weekends have always been lightly staff compared to weekdays. She stated instead of having an activities staff for each unit (three units), one staff would work the weekend to cover all the units. (Refer to F679) On 12/19/23 at 02::45 Social Services X reported she had received a lot of grievances related to weekend staffing and reported them to the nursing department and administrator. She stated much of the focus was on slow call light times and staff response. She stated a social service staff is always working in the building seven days a week to meet with the residents and address their needs. On 12/19/23 at 03:16 Administrative Nurse D stated the facility was currently working to replace agency staff with more permanent staffing to improve resident care and response times. She reported call light response times was an ongoing issue and she felt it had improved recently. The facility failed to ensure sufficient staffing was provided to maintain the resident's physical and psychosocial wellbeing. This placed the residents at risk for impaired quality of life.

The facility identified a census of 76 residents. The facility identified one main kitchen and five satellite kitchenette areas. Based on observation, record review and interview, the facility failed to ensure kitchen staff appropriately sanitized a probe-type thermometer used to check food temperatures prior to meal service. The facility failed to ensure staff cleaned and maintained a satellite kitchen ice machine. This deficient practice left residents at risk for food borne illnesses and cross-contamination. Findings included: - During the initial tour of the facility on 12/14/23 shortly after 07:00 AM, the ice machine on the 400 hall had a brown gooey substance on the inside drain. The outside of the ice machine was visibly soiled. On 12/18/23 at 12:01 PM Dietary Staff DD prepared to check the temperature of the hot foods she placed on the steam table for meal service on the long-term care unit of the facility. Dietary Staff DD put on gloves without performing hand hygiene and grabbed a probe-type thermometer. Dietary Staff DD removed the cover of the probe and placed the probe end of thermometer into the metal container with the Salisbury steaks without sanitizing it first. Dietary Staff DD removed the probe from the steaks and then inserted the probe into the metal container that contained chicken breasts. Dietary Staff DD then removed the probe from the chicken breasts. Dietary Staff DD continued to check the temperature of each food item on the steam table (corn, Brussel sprouts, macaroni and cheese, mashed potatoes, and brown gravy) without sanitizing the probe of the thermometer after insertion into each food. On 12/18/23 at 12:05 PM Dietary Staff DD stated she did not have any of the sanitizing wipes to sanitize the thermometer probe and was not sure where to find them. On 12/19/23 at 08:51 AM Dietary Staff BB stated that the servers were expected to sanitize the thermometer after temperatures were obtained of each food item. Dietary Staff BB stated she would do some more education with her staff on proper procedure when checking the temperatures of the foods. Dietary Staff BB stated she expected the ice machines to be wiped down daily and cleaned weakly. Dietary Staff BB stated she would go over the policies and procedures again to re-educate her staff on the cleaning of the ice machines. The undated facility policy Food Temperatures documented: Foods should be served at proper temperatures to ensure food safety and palatability. Wash, rinse and sanitize a dial face, metal probe-type thermometer with an alcohol wipe. Re-sanitize the thermometer after each use. The undated facility policy Ice Machine documented: Sanitation of equipment- daily- wash the exterior of machine with hot water and detergent. Rinse with clean water and cloth. Use sanitizing solution and clean cloth to sanitize. Remove the drainage grate and tray and send through dishwasher. Allow drainage grate and tray to air dry and replace the drainage grate and tray. Store the ice scoop free from ice in a sanitary enclosed container. Document cleaning on the cleaning schedule. The facility failed to ensure kitchen staff appropriately sanitized the probe-type thermometer before and after obtaining each food temperature prior to service. The facility failed to ensure kitchen staff properly maintained and cleaned an ice machine used by staff for resident's drinks. This deficient practice had the potential for food borne illnesses and cross-contamination of food for the residents.

The facility identified a census of 76 residents. The sample included 18 residents. The facility identified two COVID-19 (highly contagious, potentially life-threatening respiratory virus) positive residents. Based on record review, observations, and interviews, the facility failed to ensure infection control standards were followed related to COVID-19 isolation precautions, clean supply/equipment storage, and hand hygiene during cares. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 12/14/23 at 07:05AM an unidentified staff member at the front desk wore her face mask around her chin while seated at the desk. The facility identified Residents (R)52 and R116 as positive for Covid-19. On 12/14/23 at 07:20AM an inspection of the clean linen rooms on the 300 and 400 halls revealed dirty vacuums stored next to the uncovered linen. [NAME] lift slings sat directly on the floor in both rooms. On 12/14/23 at 08:22AM R119's supplemental oxygen nasal cannula (oxygen mask supplying air to both nostrils) and oxygen tubing rested directly on the seat of her recliner. No storage bag was present for the cannula or tubing. On 12/14/23 at 09:18AM an inspection of R114 room revealed no signage indicating her droplet precautions or required personal protective equipment (PPE). An isolation cart was placed outside her room. On 12/14/23 at 12:22PM R114's nasal cannula and oxygen tubing laid directly on her unmade bed. On 12/14/23 at 12:38PM Certified Nurse Aide (CNA) M entered R116's room without wearing PPE. CNA M reported R116 was not on isolation and staff did not need to wear PPE. Licensed Nurse (LN) G came and stated R116 was on isolation precautions, and everyone was required to wear PPE upon entry to the room. On 12/14/23 at 03:44PM R215's unbagged nasal cannula and oxygen tubing rested on the floor next to her bed despite the storage bag was present. On 12/18/23 at 01:01PM Administrative Nurse E completed hand hygiene before providing wound care to R52. Administrative Nurse E unplugged the wound-vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) and removed R52's dressing. She changed her gloves but failed to complete hand hygiene in between glove change. Administrative Nurse E cleansed the wound and touched her personal phone during the cleansing. She again changed her gloves but failed to complete hand hygiene in between glove change. A new dressing was then applied to complete the wound care. On 12/18/23 at 01:14PM LN H prepared R1's medication administration through her feeding tube (tube for introducing high calorie fluids into the stomach). LN H failed to complete hand hygiene before preparing the medication, upon entering the room, or upon administering the medication using the feeding tube. She completed hand hygiene upon exiting the room after the administration was completed. On 12/19/23 at 09:34 AM R115 laid on the bed. CNA P entered R115's room, washed her hands, donned gloves, and explained the procedure to R115 for catheter care. CNA P removed two wipes from the package and placed the wipes on R115's right thigh. CNA P used one wipe to clean R115's foreskin and around the base of the penis. CNA P placed the soiled wipe on the bed between R115's legs. CNA P used the second wipe to clean the tip of R115's penis and wiped away from the tip of the penis down the tubing with the wipe. CNA P removed the soiled wipes and placed items into the trash can next to the bed. With the same gloves, CNA P assisted R115 onto his left side, provided peri-care, and placed a clean incontinent brief under R115. CNA P doffed her right-hand glove only, donned a clean glove without performing hand hygiene, then adjusted R115's clothes, and bedding. Wearing the same gloves, CNA P touched the bedside table, adjusted the bed height with a remote control and assisted R115 with repositioning on the bed. CNA P removed the soiled trash from R115's room. At 12/19/23 at 12:35PM CNA O stated staff were expected to complete hand hygiene before providing cares to residents and when visibly soiled. She stated oxygen tubing should be stored in a clean bag next to the machine or tank. She stated staff received training monthly on the online training service and in meetings about how to apply PPE and remove it. She stated only clean linen should be stored in the closest and slings should never be placed on the floor. At 12/19/23 at 01:05PM LN I stated hand hygiene should be completed before passing meals, medications, providing cares, and when soiled. She stated residents in isolation should have signage posted outside their rooms showing what PPE was required before entering. On 12/19/23 at 02:29PM Administrative Nurse F stated the facility routinely held in-service training related hand hygiene related to basic cares for residents. She stated hand hygiene should always be completed before providing direct contact care for the residents that included wound care, catheter care, medication administration, activities of daily living, and when assisting residents. Administrative Nurse E stated isolations signs and PPE carts should be posted outside the resident's door for isolation residents. She stated R116 was on isolation precautions and signs should have been posted outside her door. She stated posted signs identifying Covid-19 exposure were at the front door and main desk. She stated oxygen tubing and cannulas should be stored in their provided clean storage bag to prevent contamination or infections. A review of the facility's Standard Precautions policy revised 09/2022 indicated hand hygiene and prevention practices should be used regardless of a resident's diagnoses. The policy indicated hand hygiene should be performed before, during, and after direct contact with residents. The policy noted hand hygiene was to be completed after removal of PPE. The policy indicated soiled facility equipment should not be stored around or in the same area as clean equipment, clothing, linen, hygiene products, food, or furniture to prevent contamination. A review of the facility's Isolation policy revised 09/2022 indicated staff were follow were the appropriately indicated personal protective equipment outlined for residents in isolation precautions. The policy noted the facility will communicate and ensure staff are informed of the appropriate levels of precautions to prevent further spread infection. The policy indicated sings will be placed in visible areas to describe to level of precautions and PPE required. The facility failed to ensure infection control standards were followed related to COVID-19 and isolation precautions, clean supply/equipment storage, and hand hygiene during cares. This deficient practice placed the residents at risk for infectious diseases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 70 residents. The sample included 19 residents with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing services for one sampled resident, Resident (R) 62. This placed the resident at risk for poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R62 recorded diagnoses of femur fracture (broken thighbone), osteoarthritis (the breakdown of joint cartilage [flexible connective tissue] causing pain and stiffness), and hypertension (high blood pressure). R62's admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting and ambulation. The MDS further documented R62 required extensive assistance of one staff for bathing. The ADL Care Plan, dated 01/21/22, directed staff to provide R62 with a sponge bath when a full bath or shower could not be tolerated, promote dignity by providing privacy, and allow the resident sufficient time for dressing and undressing. The January 2022 Bathing Record documented R62 requested showers twice a week and documented he had not received a bath or shower during the following days: 01/21/22-02/03/22 (12 days) On 02/09/22 at 10:24 AM, observation revealed R62 unshaven and long fingernails with a brownish black substance underneath them. On 02/16/22 at 08:01 AM, observation revealed the resident had long fingernails with a brownish black substance underneath them. On 02/09/22 at 10:24 AM, R62 stated he had only had one shower since his admission on [DATE] and stated the facility did not have a good chair he could use while showering. On 02/16/22 at 10:35 AM, Certified Nurse Aide (CNA) N stated the resident sometimes refused his showers and the refusals are documented in his electronic record. CNA N further stated they do have shower sheets for resident's who refuse, they have the resident sign the sheet, and then the sheet was given to the nurse manager. On 02/16/22 at 10:49 AM, Licensed Nurse (LN) H stated the resident often refused his showers, the refusal should be documented in his electronic record, and verified she had not received any shower sheets regarding the resident refusals of his showers. On 02/17/22 at 03:00 PM, Administrative Nurse D stated the staff document if the resident refused showers and stated the resident should get two showers a week as requested. The facility's Activities of Daily Living policy, dated March 2018, documented resident would be provided with care, treatment and services as appropriate to maintain or improve their adl's. Residents who are unable to carry out activities of daily living independently, would receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. The facility failed to provide bathing for R62, placing the resident at risk for poor hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 70 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to provide supervision and assistance for one of four residents reviewed for accidents, Resident (R) 230 who was at risk for falls. This placed R230 at risk of injury. Findings included: - R230's Physician Order Sheet, dated 01/27/22, documented diagnoses of chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure, dependence on supplemental oxygen, chronic pain, dyspnea (difficulty breathing), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), repeated falls, lack of coordination, difficulty in walking, and urinary tract infection. The admission Minimum Data Set (MDS), dated [DATE], documented R230 had moderately impaired cognition, required supervision and limited assistance of one staff with bed mobility, transfers, walking in the corridor, and mobility on and off unit. The resident was not steady, but able to stabilize without staff assistance, and used a walker and wheelchair. The MDS further documented R230 had oxygen therapy while not a resident and while a resident, and received speech, occupational, and physical therapy. The Fall Care Area Assessment (CAA), dated 02/08/22, documented R230 was at risk for falls due to a history of falls, weakness, decreased mobility, and medication side effects. The Fall Care Plan, dated 02/09/22, documented the resident was at risk for falls due to a history of falls, weakness, decreased mobility, medication side effects and pain. The Fall Care Plan directed staff to provide R230 with a safe environment with cues and supervision. The COPD Care Plan, dated 02/09/22, directed staff to administer oxygen therapy as ordered by the physician and to monitor for signs and symptoms of acute respiratory insufficiency of anxiety, confusion, restlessness, and shortness of breath. The Physician Order, dated 01/27/22, documented respiratory order for oxygen at 2 Liters (L) per nasal cannula. The Physician Order, dated 01/28/22, directed staff to walk with R230 to and from the restroom. The Physician Visit Progress Note, dated 01/31/22, documented the resident had been seen in her room, alert and oriented with confusion noted. R230 sat without oxygen though she reportedly used continuously. The note further documented the provider did assist with placing the oxygen back on and the facility staff had a concern for elopement due to confusion. The Progress Note, dated 01/28/22 at 10:44 PM, recorded R230 was found wandering in the hall by the beauty shop. R230 had no shoes on, no walker, and was holding her oxygen tubing. The note further recorded R230 had been identified by her wristband, assisted back to her room, and staff would check on resident frequently. On 02/16/22 at 04:14 PM, observation revealed R230 sat in a chair in a commons area behind the chapel, outside of her unit. The resident was without oxygen, wheelchair or walker, and reported she planned to check into assisted living option for when she was discharged . The resident then ambulated to her unit holding onto the handrails. The resident walked past her room, stopping at other residents' doorways and looking into the rooms. She proceeded to walk to the farthest table in the dining room and sat briefly at a table. Staff approached the resident and provided her with a mask. R230 remained without oxygen, walker or wheelchair. On 02/16/22 at 04:18 PM, observation revealed R230 ambulated out of the dining room and she briefly spoke to the other residents at their doorways. She held on to the wall rails, leaned against the wall, and appeared short of breath. R230 then sat on the couch in the commons area of her unit with apparent shortness of breath and poor balance. Two staff members had been seated at the dining room tables as R230 passed through the dining room, left the table, and proceeded down another hall. On 02/16/22 at 04:24 PM, observation revealed R230 walking back to other resident's rooms, she entered rooms and spoke to the other residents briefly. The staff intercepted her in the commons area as she was having difficulty with walking and shortness of breath. The staff inquired what she was doing, asked her name, and directed her to a couch. R230 stated she was there to see her mother and incorrectly gave staff her name. Staff did not know the residents' name or what room she occupied. The surveyor gave information to staff of the residents' name and room number, and shared R230 needed a walker, and used oxygen. Staff retrieved her walker and placed it in front of her. The staff then returned to sitting at a dining room table. R230 commented she came to visit her mother, remained short of breath, anxious, talkative, and changed positions frequently on the couch. On 02/09/22 at 04:43 PM, staff from the dining room table approached R230, encouraged the resident to return to her room, and walked with her. R230 remained without oxygen therapy for 29 minutes. On 02/09/22 at 04:30 PM, License Nurse (LN) H stated staff at the dining room table had been agency staff, did not know the resident, and should have been supervising and assisting the resident with walking and use of oxygen to prevent falls. On 02/17/22 at 03:00 PM, Administrative Nurse D verified the resident should have been supervised, wearing her oxygen, and staff should be aware of the resident's needs and safety. The facility's Fall Prevention policy, dated October 2021, documents residents will be evaluated for the risk of falling so that intervention may be considered in order to promote resident safe, appropriate clinical and multidisciplinary assessment of falls. The interdisciplinary team will discuss the investigation and where reasonable and appropriate, modify the plan of care. The facility failed to provide supervision and assistance for R230, placing the resident at risk for decline and accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 70 residents. The sample included 19 residents, with one reviewed for urostomy (an artificial opening in an organ of the body) care. Based on observation, record review, and interview, the facility failed to provide urostomy care for one sampled resident, Resident (R) 178. This placed the resident at risk for inappropriate care and unecessary complications. Findings included: - The Electronic Medical Record (EMR) documented R178 had diagnoses of hypertension (high blood pressure), cellulitis (inflammation of the deepest layer of the connective tissue), and pain. R178's admission Minimum Data Set (MDS), dated [DATE] was in progress. The Urostomy Care Plan, dated 02/07/22, directed staff to change the appliance (bag) as needed, cleanse with soap and water, pat dry, apply skin prep (an antimicrobial skin cleanser), and appliance. The Urostomy Care Plan further directed staff to maintain universal precautions when providing resident care. The Urostomy Care Plan lacked documentation the resident would care for his urostomy without staff assistance and lacked documentation the resident would use his own urostomy supplies from home. The Physician's Order, dated 02/05/22 directed staff to change the urostomy appliance as needed, cleanse with soap and water, pat dry, apply skin prep and appliance. The Physicians Order, dated 02/08/22, directed staff to apply gentamicin sulfate cream (a topical antibiotic used to treat skin infections) 0.1%, one time a day every three days for urostomy care. The Nurse's Note, dated 02/04/22 at 04:34 PM, documented the resident was alert and oriented for person, place, time and situation, was skilled due to a fall at home, and had a urostomy for his bladder. The note further stated the urostomy bag leaked and needed changed after dinner. The Physician's Note, dated 02/07/22 at 10:35 AM, documented the resident was concerned with his urostomy care and that several certified nurse aides (CNA) and licensed nurses (LN) were not familiar with urostomy care and had to change the bag several times due to persistent leaking. The note further documented the skin prep that was used had left his skin sticky so the urostomy bag leaked and the resident had to replace the bag himself which was quite difficult. The Nurse's Note dated 02/14/22 at 08:16 AM, documented the gentamicin cream was used last night when the resident changed his urostomy bag. Review of the Treatment Administration Record for February 2022 lacked documentation staff assisted the resident with urostomy care. On 02/09/22 at 11:55 AM, observation revealed the resident seated in his room. He had a box of urostomy appliances and a mirror with a light attached to use when changing his urostomy bag. On 02/09/22 at 11:55 AM, R178 stated the staff had a hard time changing his urostomy bag and none of the staff on duty knew how to change the bag. R178 further stated he was unable to use the bags the facility had, so he had to use his own supply. R178 stated the first day they went through 11 bags and they cost $12.00 apiece. R178 stated he was providing his own urostomy care, had his daughter bring in his mirror with the light so he could see what he was doing, and he was not happy about it, but the staff didn't know how to change the bag correctly. On 02/16/22 at 08:09 AM, R178 stated he was discharged to home today and stated the staff had not helped him with his urostomy bag the whole time he was at the facility. R178 stated staff would hand him the supplies while he changed his own bag. On 02/16/22 at 10:50 AM, LN H stated staff should assist the resident with his urostomy care but the resident did not want to use the skin prep as ordered. LN H further stated she was unaware the resident was using his own bags, providing his own urostomy care was his choice, and should be documented in the care plan or in his medical record. On 02/17/22 at 03:12 PM, Administrative Nurse D stated staff should have assisted the resident with his urostomy care and that the facility would reimburse the resident if they found that he had to use his own supplies. The facility's Urostomy Care policy, dated October 2010, documented staff review the resident's care plan to assess for any special needs of the resident and assemble the equipment and supplies as needed. The policy further documented staff record the date and time the procedure was performed, name and title of who performed the procedure, the condition of the skin surrounding the stoma, and the type of appliance utilized. Staff documented all assessment data obtained during the procedure and how the resident tolerated the procedure and if the resident refused. The facility failed to assist R178 with his urostomy care as directed by the physician, placing the resident at risk for inappropriate care and unecessary complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 70 residents. The sample included 19 residents, with three reviewed for hydration. Based on observation, record review, and interview, the facility failed to monitor hydration status for one sampled resident, Resident (R) 69, who was on a physician ordered fluid restriction, and failed to establish a fluid restriction as ordered for R176. This placed the residents at risk for dehydration or fluid overload. Findings included: - The Electronic Medical Record (EMR), documented R69 had diagnoses of chronic kidney disease stage two (minor kidney damage), cirrhosis of the liver (liver damage), atrial fibrillation (irregular, rapid heart rate), hypertension (high blood pressure), and congestive heart failure (the heart doesn't pump blood as well as it should). R69's admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility and transfers and independent with eating. The Urinary Tract Infection Care Plan, dated 01/27/22, documented the resident was on a 2000 milliliters (ml) fluid restriction and directed clinical staff to provide 340 ml in the morning, 240 ml in the afternoon and 120 ml's of fluids at night. The Urinary Tract Infection Care Plan directed dining service staff to provide 720 ml at breakfast, 240 ml at lunch, and 240 ml's of fluid at dinner. The Dehydration Care Plan, dated 02/14/22, documented the resident had potential for dehydration or fluid deficit and had received intravenous fluids at times during her stay. The Dehydration Care Plan directed staff to notify the physician of any abnormal laboratory results, monitor her weights, and monitor for any signs or symptoms of decreased or no urine output, concentrated urine, strong odor, or cracked lips. The Physician's Order, dated 01/27/22, directed staff to implement a fluid restriction for R69 consisting of clinical staff to provide 340 ml in the morning, 240 ml in the afternoon and 120 ml's of fluids at night. The order directed dining service staff to provide 720 ml at breakfast, 240 ml at lunch, and 240 ml's of fluid at dinner. Review of the Medication Administration Record for January 2022 documented the following daily fluid totals: 01/26/22 - 240 ml 01/28/22 - 960 ml 01/31/22 - 1320 ml Review of R69's January 2022 Daily Fluid Intake lacked documentation of a daily fluid intake total. Review of the Medication Administration Record for February 2022 documented the following daily fluid totals: 02/01/22 - 930 ml 02/03/22 - 1080 ml 02/06/22 - 2140 ml 02/07/22 - 5097 ml 02/08/22 - 2097 ml 02/09/22 - 1090 ml Review of R69's February 2022 Daily Fluid Intake lacked documentation of a daily fluid intake total. On 02/10/22 at 08:17 AM, observation revealed three 12-ounce (oz) paper cups with lids on R69's bedside table. On 02/09/22 at 12:22 PM, R69 stated the staff tell her to drink more because her urine is darker and then they put her on a fluid restriction. R69 stated she is getting mixed messages from staff. On 02/10/22 at 08:25 AM, Certified Nurse Aide (CNA) N stated R69 was on a fluid restriction and wasn't sure how many ml's were in the resident's paper cups. CNA N further stated she just pours the fluid R69 hadn't drank into another paper cup and will tell the nurse how many cups are full of fluid. On 02/10/22 at 11:30 AM, Licensed Nurse (LN) J stated she goes into R69's room at mealtimes and looks to see how many cups of fluid R69 had been delivered. LN J stated she eyeballed the cups to see how much the resident had drank before staff took R69's meal tray with the fluids. On 02/16/22 at 10:50 AM, LN H stated the nurse was responsible for totaling up R69's daily fluid intake and that each cup of fluid was removed after each meal. LN H verified there were no daily fluid intake totals. On 02/16/22 at 02:29 PM, Consultant GG stated the computer program does not have a line to document the daily fluid intake totals but stated someone should monitor the fluid totals at the end of the shift. On 02/17/22 at 03:12 PM, Administrative Nurse D stated staff should monitor daily fluid totals to make sure R69 was not getting dehydrated or getting too many fluids. The facility's Fluid Restriction policy, dated October 2015, documented the fluid restriction policy was to provide adequate monitoring of residents with prescribing health care provider orders for a fluid restriction. The policy documented clinical services would determine the amount of daily fluid that would be provided by dining services and the amount of fluid provided by clinical services from the total amount of fluid per the health care provider order. Clinical services would monitor for signs and symptoms of dehydration and identify and develop or update the plan of care for those that are dehydrated or at risk of dehydration. The residents on a fluid restriction would be identified in the computer under the resident's profile and fluid intake should be documented in point click care. The facility failed to monitor hydration status for R69, who was on a physician ordered fluid restriction, placing the resident at risk for dehydration. - The Electronic Medical Record (EMR) documented R176 had diagnoses of congestive heart failure (a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and chronic respiratory failure (inability to effectively exchange carbon dioxide and oxygen). R176's admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance with bed mobility, dressing, transfers, toileting, and personal hygiene. The MDS further documented the resident was independent with eating. The Nutrition Care Plan, dated 01/28/22, documented the resident was on a 2000 milliliters (ml) fluid restriction and directed clinical staff to provide 340 ml in the morning, 240 ml in the afternoon and 120 ml's of fluids at night. The Nutrition Care Plan directed dining service staff to provide 720 ml at breakfast, 240 ml at lunch, and 240 ml's of fluid at dinner. The Preadmission Orders, dated 01/27/22, directed staff to limit the amount of the residents daily fluids to 2000 milliliters (ml). Review of the Medication Administration Record for January and February 2022 lacked documentation the resident was on a fluid restriction. On 02/10/22 at 08:15 AM, observation revealed the resident had two paper cups with lids on her bedside table. On 02/10/22 at 08:15 AM, R176 stated she thought she was supposed to be on a fluid restriction but no one had said anything about it to her. On 02/10/22 at 11:28 AM, Certified Nurse Aide (CNA) N stated R176 was not on a fluid restriction and that information would be on her CNA paperwork. On 02/10/22 at 11:30 AM, Licensed Nurse (LN) J stated there was only one resident on a fluid restriction and it was not R176. On 02/10/22 at 02:45 PM, Consultant GG stated R176 was supposed to be on a fluid restriction and verified it was missed upon admission. On 02/16/22 at 10:43 AM, LN H stated the admission nurse was responsible for the orders and the fluid restriction was missed when R176 was admitted to the facility. On 02/17/22 at 03:30 PM, Administrative Nurse D stated the admission nurse should have checked and made sure the fluid restriction order was on the MAR. The facility's Fluid Restriction policy, dated October 2015, documented the fluid restriction policy was to provide adequate monitoring of residents with prescribing health care provider orders for a fluid restriction. The policy documented clinical services would determine the amount of daily fluid that would be provided by dining services and the amount of fluid provided by clinical services from the total amount of fluid per the health care provider order. Clinical services would monitor for signs and symptoms of dehydration and identify and develop or update the plan of care for those that are dehydrated or at risk of dehydration. The residents on a fluid restriction would be identified in the computer under the resident's profile and fluid intake should be documented in point click care. The facility failed to implement R176's physician's ordered fluid restriction, placing the resident at risk for fluid overload.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 70 residents. The sample included 19 residents, with three reviewed for pain. Based on observation, record review, and interview, the facility failed to ensure that pain management was provided to one sampled resident, Resident (R) 62. This placed the resident at risk for pain and discomfort. Findings included: - The Electronic Medical Record (EMR) for R62 recorded diagnoses of femur fracture (broken thighbone), osteoarthritis (the breakdown of joint cartilage [flexible connective tissue] causing pain and stiffness), and hypertension (high blood pressure). R62's admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS further documented the resident had frequent pain and received pain medication. The Pain Care Plan, dated 02/02/22, directed staff to administer pain medication as ordered, anticipate R62's need for pain relief, provide interventions, and follow up for effectiveness of interventions. The Pain Care Plan directed staff to notify the physician if interventions were unsuccessful and if current complaint was a significant change from residents past experience of pain. The Physician's Order, dated 01/20/22, directed staff to apply biofreeze gel (a topical analgesic), four percent, apply topically to the back, every day and night shift for back pain. The Physician's Order, dated 01/21/22, directed staff to administer Tylenol (a mild pain medication), 325 milligrams (mg), two tablets by mouth, every 8 hours as needed for pain. The Physician's Order, dated 01/22/22, directed staff to apply a Lidocaine patch (a transdermal [adheres to the skin] patch used to relieve pain), four percent, apply to the right knee, daily for pain. Review of the Medication Administration Record for January 2022 documented Lidocaine patches were unavailable for the following days: 01/21/22 01/22/22 Review of the Medication Administration Record for February 2022 documented Lidocaine patches were unavailable for the following days: 02/05/22 02/11/22 02/12/22 02/13/22 On 02/16/22/at 08:01 AM observation revealed the resident seated in his wheelchair eating breakfast. On 02/16/22 at 10:49 AM, Licensed Nurse (LN) H stated the Lidocaine patches are always available through their central supply and stated some of the as needed nurse's may not know that information. On 02/16/22 at 01:45 PM, LN I stated the nurses are able to get the Lidocaine patches from the central supply. On 02/17/22 at 03:10 PM, Administrative Nurse D stated R62 should receive his pain patch as ordered. The facility's Pain Management policy, dated June 2020, documented the policy was to identify, treat and manage the resident's pain levels and provide a systematic approach to data collection using objective measurements of the pain level and effectiveness of the pain relief medication, pain management, needs to be addressed on the resident's care plan and monitored by the interdisciplinary team. The facility failed to provide pain management to R62, placing the resident at risk for further pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Electronic Medical Record (EMR), documented R69 had diagnoses of chronic kidney disease stage two (minor kidney damage), cirrhosis of the liver (liver damage), atrial fibrillation (irregular, rapid heart rate), hypertension (high blood pressure), and congestive heart failure (the heart doesn't pump blood as well as it should). R69's admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility and transfers. The MDS documented R69 received diuretic (medication to promote the formation and excretion of urine), antianxiety (medication that calm and relax people with excessive anxiety, nervousness, or tension), and antidepressant (medication used to treat mood disorders and relieve symptoms of depression) medications for four days of the look back period. The Hypertension Care Plan, dated 01/27/22, directed staff to administer antihypertensive (medication to lower blood pressure) medications as ordered and monitor for side effects, orthostatic hypotension (blood pressure dropping without change of position) and increased heart rate, give antihypertensive medication and obtain blood pressure readings as ordered. The Physicians Order, dated 01/27/22, directed staff to administer diltiazem hcl (antihypertensive medication), 30 milligrams (mg), three times a day. The staff were directed to hold the medication if R69's systolic blood pressure (sbp-the pressure caused by the heart contracting and pushing out the blood) was less than 110 beats per minute (bpm) or the diastolic blood pressure (dbp-the pressure in the arteries when the heart rests between beats) was less than 60 bpm. The Medication Administration Record (MAR) dated 01/29/22, documented R69's sbp was 106/64. The record documented the diltiazem medication was given. The MAR dated 02/07/22, documented R69's sbp was 108/66. The record documented the diltiazem medication was given. The MAR dated 02/09/22, documented R69's sbp was 109/64. The record documented the diltiazem medication was given. The MAR dated 02/15/22, documented R69's sbp was 108/70. The record documented the diltiazem medication was given. The MAR dated 02/16/22, documented R69's sbp was 104/60. The record documented the diltiazem medication was given. On 02/16/22 at 09:00 AM, observation revealed R69 in bed with her eyes closed. On 02/16/22 at 10:50 AM, Licensed Nurse (LN) H stated the nurses would often see R69's blood pressure was out of parameters, hold the medication, recheck the resident's blood pressure, and if it was within normal range, give R69 the medication. LN H stated the nurse should document they were rechecking the blood pressure and verified the nurse did not document she was rechecking the blood pressure, then giving the medication. On 02/16/22 at 01:37 PM, LN I stated she did not hold R69's medication when her sbp was out of parameters because she had read the order wrong. On 02/17/22 at 03:35 PM, Administrative Nurse D stated the nurse should hold the medication if R69's blood pressure was out of the ordered parameters. Upon request a policy for medication administration for out of parameter blood pressure was not provided by the facility. The facility failed to hold the diltiazem medication for R69's out of parameter sbp, placing the resident at risk for physical decline. The facility had a census of 70 residents. The sample included 19 residents with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold insulin (a hormone which regulates the amount of sugar in the blood) for Resident (R) 40 when blood sugars were lower than the physician ordered parameter, did not provide interventions when R22 had five days without a bowel movement, and did not hold blood pressure medication for R69 when blood pressures were out of the physician ordered parameters. This deficient practice placed three of six residents at risk for adverse side effects from medications. Findings included: - R40's Physician Order Sheet (POS), dated 02/09/22, documented a diagnosis of diabetes mellitus (an impairment in the way the body regulates and uses sugar as a fuel). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented R40 required supervision for eating, extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and total staff assistance for locomotion. The MDS documented R40 received insulin medication six days of the lookback period. The Diabetes Care Plan, dated 01/13/22, directed staff to provide medication as ordered, Glargine (long acting insulin) and Lispro (fast acting insulin), monitor for side effects and document effectiveness. The Diabetes Care Plan directed staff to obtain fasting blood sugar before meals and at bedtime as ordered by the doctor. Physician orders for insulin included: Glargine, 20 units at bedtime, Only IF AM (morning) glucose was above 130 mg/dL (milligrams per deciliter). Lispro, 7 units with meals, Only IF glucose was above 130 ml/dL and she was eating well. Review of the Medication Administration Record (MAR) revealed the following blood sugars below 130 ml/dL and Lispro insulin administered: 13 times 01/14/22 at 08:00 AM = 96 01/15/22 at 08:00 AM = 107 01/16/22 at 08:00 AM =121 01/19/22 at 05:00 PM = 113 01/21/22 at 08:00 and 11:00 AM = 109 01/22/22 at 11:00 AM =120 01/26/22 at 08:00 AM =95 02/01/22 at 08:00 AM = 100 02/04/22 at 08:00 AM = 100 02/07/22 at 05:00 PM = 128 02/08/22 at 08:00 AM = 121 02/15/22 at 08:00 AM = 114 On 02/10/22 at 08:35 AM, Licensed Nurse (LN) G obtained R40's blood sugar of 101 mg/dL and verified staff were to hold the Lispro insulin per physician orders. On 02/16/22 at 11:55 AM, Administrative Nurse D verified staff documented they administered the Lispro insulin even though the resident's blood sugar was below the physician ordered parameters. The facility's Insulin Administration policy, dated September 2014, documented staff must verify the type of insulin, dose, strength, and method of administration to assure that it corresponds with the order on the medication sheet and the health care provider's order. The facility failed to hold the insulin medication when R40's blood sugar was below 130 mg/dL per physician orders, which placed the resident at risk for adverse effects of the medication. - R22's Physician Visit Sheet, dated 01/12/22, documented diagnoses of dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and constipation (condition in which there is difficulty in emptying the bowels). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired decision-making skills. The MDS documented R22 required supervision for eating, walking in room, locomotion, and limited staff assistance with toileting, dressing, and transfers. The MDS documented R22 frequently incontinent of bowels. The Medication Care Plan, dated 01/06/22, directed staff to monitor medications for side effects of constipation and keep physician informed of any problems. R22 required staff assistance to use the toilet. The Medication Care Plan directed staff to record R22's bowel movement (BM) pattern each day, describe amount, color and consistency, encourage fluid intake with meal tray and offer between meal fluids. The Medication Care Plan documented R22 at risk for complications such as constipation related to decreased mobility and needed assist of one staff member for bed mobility, toileting and bathing. The Medication Care Plan directed staff to administer Miralax (laxative) as ordered and encourage R22 to sit on the toilet to evacuate her bowels if possible. The Physician Order, dated 12/02/20, directed staff to administer Miralax, 17 grams daily. On 12/18/20 the physician ordered Miralax 17 grams prn (as needed) every 24 hours. Review of R22's Electronic Medical Record revealed: No BM 02/08/22 through 02/12/22 (five days) and no PRN laxative administered, or record of nursing assessment related to bowels. 01/31/22 through 02/05/22 revealed no or small BMs (six days), no PRN laxative administered, or record of nursing assessment related to bowels. On 02/10/22 at 09:40 AM, observation revealed Licensed Nurse (LN) G administered Miralax 17 grams in water to the resident. On 02/10/22 at 01:57 PM, Certified Nurse Aide (CNA) M stated R22 had dementia and staff gently told her she needed to go to the bathroom and though she may argue at first, she would cooperate. On 02/16/22 at 11:55 AM, Administrative Nurse D verified staff were to investigate whether the resident had BMs if the BM report showed no BMs for three days. Administrative Nurse D stated if the resident had no BMs for three days, the nurse should assess bowel sounds, check for PRN treatments and provide the treatment. Administrative Nurse D verified staff provided no prn treatment in February and stated nursing should have notified the physician of the need to use PRN orders. The facility's Change of Condition policy, dated September 2019, stated when a resident is evaluated or assessed as having a change in condition, including constipation, the nurse would follow through in documenting notification of the healthcare provider and other licensed nurses in order to facilitate the appropriate plan of care. When a difference in the resident's usual physical, emotional, or cognitive patterns is noted the charge nurse would be notified. The licensed nurse would perform a comprehensive evaluation or assessment. The facility failed to adequately monitor the effectiveness of Miralax and provide treatment for the side effect of medications, placing R22 at risk for complications from constipation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 72. The sample included 21 residents. Based on observation, record reviews, and interviews, the facility failed to ensure Resident (R) 101 received the necessary care and services to maintain his highest practicable level of health and hygiene Findings included: - The Diagnoses tab of the electronic medical record (EMR) documented diagnoses of displaced fracture of base of neck of left femur (fracture of thigh bone) and unspecified dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] revealed R101's Brief Interview for Mental Status (BIMS) score was six. R101 required extensive one-person physical assistance with personal hygiene, toileting, and dressing. R101 required total assistance of one-person with bathing. R101 required supervision with one-person physical assistance with eating. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 03/23/2020 revealed resident required total assistance of up to two staff for bathing. R101 needed supervision and occasionally more assistance with eating during the assessment period related to eating not initiated. The Nutritional Status CAA dated 03/23/2020 revealed R101 had an increased risk for malnutrition and dehydration. R101 was on a puree diet due to swallow safety and coughed at meals which increased his risk of poor intake. The Care Plan initiated 03/17/2020 revealed R101 had a decline in his ADLs from his previous level of function due to recent hospitalization, after a fall with left hip fracture. The care plan directed staff to offer bathing assistance Wednesday and Friday evenings and as needed. The Care Plan initiated 03/18/2020 revealed R101 had a potential for aspiration and dysphagia (difficulty swallowing) and directed staff to supervise or assist R101 with oral intake as needed and needed help feeding. The Task tab of the EMR revealed a task for bathing on Wednesday and Friday. The documentation survey report documented a bed bath was given on 03/18/2020 then no bathing charted for 03/20/2020, 03/25/2020, 03/27/2020, and 04/01/2020. The bathing was charted as activity did not occur on 04/03/2020. The EMR lacked documentation for 23 out of 61 meals during R101's stay at the facility. The Weights/Vitals tab of the EMR revealed a 8.6 pound weight loss during R101's stay at the facility. In an interview on 08/06/2020 at 03:21 PM, Certified Nurse Aide (CNA) N stated tasks are done and documented prior to the end of the shift. If there was a blank on the task report the task was not done. She stated at 04:25 PM the CNAs assigned to that hall charted meal percentages and if they weren't charted then it wasn't done. In an interview on 08/06/2020 at 04:23 PM, Licensed Nurse (LN) I stated the CNAs knew the bathing schedule, if the resident refused then the nurse tried to see why the resident refused and tried to get resident to take a bath. CNAs charted the bathing. In an interview on 08/06/2020 at 02:54 PM, Administrative Nurse D stated she was not sure what a blank on the tasks meant. She stated bathing, eating, pain, skin issues showed up on the nurse's dashboard so if something was not charted then the nurse had to chart on it. She stated she reviewed the dashboard every morning to see what showed up and addressed it with the nurse managers. The Activities of Daily Living Care Documentation Policy last revised November 2018 directed ADL care not performed during a shift was reported to the manager on duty and to the incoming associates of the next shift. The facility failed to provide the necessary care and services related to bathing and eating per the care plan to R101. This placed the resident at risk for a decline in health status, hygiene and function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Diagnoses tab of the Electronic Medical Record (EMR) documented diagnoses of displaced fracture of base of neck of left femur (fracture of thigh bone), unspecified dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] revealed R101's Brief Interview for Mental Status (BIMS) score was six, which indicated severely impaired cognition. R101 required supervision with one-person physical assist with eating. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 03/23/2020 revealed R101 required supervision and occasionally more assistance with eating. The Nutritional Status CAA dated 03/23/2020 revealed R101 had an increased risk for malnutrition and dehydration. The Care Plan initiated 03/18/20 directed staff to encourage good nutrition and hydration in order to promote healthier skin. The Task tab of the EMR directed staff to offer fluids three times a day. The documentation survey report revealed 28 scheduled fluid times were not documented and there were 12 fluid times documented as not offered. In an interview on 08/06/2020 at 09:41 PM, Anonymous reporter TT stated a family member of R101 reported to her that when resident discharged from facility, he smelled, was dirty, had food in his beard, wasn't shaved, hair was greasy, and had significant weight loss. Upon review of lab results from hospital admission on [DATE] provided by Anonymous reporter TT, R101 had BUN 31, creatinine 1.3, lactic acid 6.2. Anonymous reporter TT reported R101 was admitted to hospital on [DATE] with urinary tract infection (infection in any part of your urinary system including kidneys, ureters, bladder, and urethra) and pneumonia (inflammation of the lungs). In an interview on 08/06/2020 at 02:54 PM, Administrative Nurse D stated she expected staff to chart fluids weren't offered if they weren't. She stated she expected staff to offer fluids during usual cares and if the resident that normally accepts fluids, declines then she expected staff to assess why they refused for possible change. In an interview on 08/06/2020 at 04:23 PM, Licensed Nurse (LN) I stated residents were given fresh ice water every shift. He stated the CNAs have a report sheet that showed resident's fluid preferences and if they were thickened liquids. In an interview on 08/06/2020 at 04:25 PM, Certified Nurse Aide (CNA) N stated residents are offered fluids a few times throughout the shift unless on a fluid restriction. She stated she took cups of water to the resident's room to offer fluids. The Hydration Program Policy last revised October 2019 documented residents should drink at least eight to ten eight-ounce glasses of total fluids each day, at least four of the total eight to ten glasses should be water. The facility failed to offer fluids and document fluid intake for R101 which had the potential for unwarranted physical complications due to decreased fluid intake. The facility identified a census of 72 residents. The sample included 21 residents. Based on interviews, observations, and record reviews the facility failed to record the percentages of meals eaten for one of four Residents, (R)44. The facility also failed to record the amount of fluid consumed by one resident (R99) on a fluid restriction for R101 who was to be monitored closely for fluid intake due to dehydration. Findings included: - R44's electronic medical record (EMR) documented diagnoses of cellulitis (skin infection caused by bacteria characterized by heat, redness, and swelling) of both legs and congestive heart failure (a condition with low heart output and the body becomes congested with fluid). The 07/27/20 admission Minimum Data Set documented a Brief Interview for Mental Status core of 15, which indicated intact cognition. She required limited to extensive staff assistance with her Activities of Daily Living. She had sustained a weight loss of five percent or more in the last month or more than 10 percent in the last six months and was not on a physician prescribed weight loss program. She held food in her mouth at times. The 07/29/20 Nutritional Status Care Area Assessment documented R44 had a weight loss of 8.9 percent since her admission on [DATE]. She was on a modified textured diet to ensure safe swallowing. The Care Plan revised on 07/31/20 documented R44 was on a modified textured diet and had a weight loss of 8.9% since admission. The staff assisted in meeting her extensive food preferences. Nutritional supplements had been added to her medications. The Nutrition Risk Review on 07/27/20 documented R44 was very particular on the food she liked, and the staff worked with her to get as many types of food as she wanted. The EMR documented R44 weighed 127.8 pounds on 07/21/20 and 112.6 pounds on 08/05/20 The EMR lacked documentation for the percentages of meals eaten for: Two of three meals on 07/23/20 and 07/24/20, 07/27/20, 07/29/20, 07/30/20, 08/01/20 and 08/04/20. One of three meals on 07/25/20. Three of three meals on 07/26/20, 08/02/20, and 08/03/20. On 08/05/20 at 07:30 AM R44 sat in her room as she watched television. She stated she had little appetite in the last few months but, thought it was improving. She used to like cheese but had lost her taste for it. She didn't like meat unless it was in goulash. She never liked eggs before but, she did like the facility's poached eggs. On 08/05/20 at 12:30 PM R44 ate lunch in the dining room. She was not noted to have trouble chewing or swallowing. She asked for several extra food items which the staff brought to her. On 08/06/20 at 01:45 PM Certified Nurse Aide (CNA) M stated the CNAs documented the percentages of meals eaten on everyone. On 08/06/20 at 02:00 PM Licensed Nurse H stated the CNAs documented the percentages of meals eaten by the residents. On 08/06/20 at 02:31 PM Administrative Nurse D stated meal percentages eaten are documented by the CNAs and are cross checked by the nurses. The facility's Routine Clinical Documentation policy dated January 2018 documented all services routinely provided to the resident are documented in the resident's record The CNAs documented the amount eaten by the residents. The facility failed to ensure the percentages of meals eaten by R44. This failure had the potential for the inability of the facility staff to properly evaluate the reason for her substantial weight loss. - R99's electronic medical record (EMR) documented diagnoses of chronic kidney disease and atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). The EMR documented an admission date of 08/03/20. The Care Plan dated 08/04/20 documented R99 was on a 2,000 milliliter per day fluid restriction. The EMR documented an order for a 2,000 mls. per day fluid restriction dated 08/03/20. The EMR, reviewed 08/03/20 through 08/05/20, lacked documentation for fluid R99 had consumed from 08/03/20 through 08/05/20. On 08/05/20 at 09:42 AM R99 sat upright in his bed. He became short of air with his speech. He stated he felt short of air when he did anything. On 08/06/20 at 01:45 PM Certified Nurse Aide M stated fluid restrictions are broken down to the amount given for each meal in the Tasks function of the EMRs. There is also a chart which indicated the amount of fluid in each type of glass provided by the facility. Each staff member was responsible for the documentation of the amount of fluid they noted the resident drank. On 08/05/20 at 02:00 Licensed Nurse H stated fluid restrictions were noted on the residents' Medication/Treatment Administration Record (MAR/TAR). She asked the CNAs how much fluid the resident received which she added to the amount she gave the resident, prior to the daily prior to the daily total documented. On 08/06/20 at 02:31 PM Administrative Nurse D stated the dietician broke down the amount of fluid a resident, on a fluid restriction, received throughout the day. On 08/06/20 at 03:39 PM Administrative Nurse E stated she placed the fluid restrictions in a resident's care plan and on the MAR/TAR when an order was received. The facility's Fluid Restriction Policy dated October 2015 documented fluid intake was documented in the EMR. The facility failed to document the fluids R99 consumed. This had the potential for unwarranted side effects from possible fluid overload or dehydration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 72 residents. The sample included 21 residents. Based on record reviews and interviews, the facility failed to prevent a significant medication error when they failed to transcribe and administer Digoxin (a medication used to treat a rapid, irregular heartbeat) for Resident (R) 100. Findings included: - R100's signed Physician's Order Sheet (POS) dated [DATE], documented the diagnoses of coronary artery disease (abnormal condition that may affect the flow of oxygen from the heart) and atrial fibrillation (rapid, irregular heartbeat). The admission Minimum Data Set (MDS), dated [DATE], documented R100 required extensive assistance of one to two staff for all activities of daily living. The MDS documented R100 had a Brief Interview for Mental Status (BIMS) score of six, indicating moderately impaired cognition. The Digoxin Care Plan, dated [DATE], documented R100 would be free from signs/symptoms or complications of cardiac problems and instructed staff to administer medications as ordered. Review of R100's Electronic Health Record, dated [DATE] at 04:30 PM, documented R100 returned from the hospital. The POS, dated [DATE], instructed staff to administer Digoxin 0.125 micrograms (mcgs,) one tablet, by mouth, one time daily, for atrial fibrillation. The POS instructed staff to hold the medication for a heart rate below 60 beats per minute (BPM). Review of R100's Medication Administration Record (MAR), from [DATE] to [DATE], lacked documentation of Digoxin administration from [DATE], on return from the hospital, to [DATE], when R100 died. On [DATE] at 03:28 PM, the MAR documented a heart rate of 84 and irregular. The Physician's Progress Note dated [DATE] at 05:00 PM, documented R100 reported he did not feel well. On [DATE] at 09:30 AM, LN J stated each charge nurse was responsible for transcribing admission or readmission orders. On [DATE] at 02:05 PM, Administrative Nurse D confirmed the charge nurse responsible for transcribing the readmission orders for R100 failed to transfer the complete set of orders received from the hospital, upon discharge. Administrative Nurse D stated staff education was completed and a nurse manager was responsible for the safety measures currently in place. On [DATE] at 04:48 PM, Consultant GG stated R100's cause of death, listed on the death certificate, was atrial fibrillation. The facility's Medical Management Overview - Med One policy, dated 03/2019, documented the facility would administer medications as prescribed by the health care provider. The facility failed to administer Digoxin as prescribed by the health care provider placing R100 at risk for adverse reactions related to medication omission.

The facility reported a census of 72. The sample included 21 residents. Based on observation and interview the facility failed to ensure insulin pens (medication that regulated the amount of sugar in the blood) were properly dated in two of five medication carts. Findings included: - On 08/04/20 at 09:19 AM, on initial tour, observation of 100 Hall medication cart revealed two Lantus insulin pens (long acting insulin), one Levemir insulin pen (long acting insulin that worked several hours after administration) undated when opened and two Novolog (insulin that worked 15 minutes after injection) with no resident name or opened date. On 08/04/20 at 09:19 AM, observation of 200 Hall medication cart revealed one Levemir pen and one Novolog pen not dated when opened. A review of the manufacturer's instructions for Novolog insulin at https://fda.gov documented Novolog insulin should be discarded 28 days after opening, Lantus insulin discarded 28 days after opening, and Levemir insulin discarded 42 days after opening. On 08/04/20 at 09:20 AM, Licensed Nurse (LN) G stated nursing staff would normally date insulin pens when opened and the two Novolog pens contained no resident names or opened dates. On 08/06/20 at 02:43 PM, Administrative Nurse D stated she would expect insulin pens to be labeled with the resident's name and dated upon opening. The facility's Medication and Treatment - Storage policy, dated 10/2018, documented medications would be stored in accordance with the manufacturers' and states' regulations. The facility failed to properly label and store insulin pens. This deficient practice placed residents at risk for decreased medication effectiveness.