**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents of which one resident was reviewed for hospitalizations. Based on observation, record review, and interview, the facility failed to provide Resident (R) 28 with a bed hold policy as required. This placed the resident at risk of being unable to return to the facility in the same room or bed. Findings included: - R28's Electronic Medical Record (EMR) included diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (major mood disorder that causes persistent feelings of sadness), heart failure, disorder of bone, localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), acute kidney failure, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and bradycardia (low heart rate, less than 60 beats per minute). The Minimum Data Set (MDS) dated [DATE], documented R28 discharged from the facility with a return anticipated. The MDS, dated [DATE], documented an entry into the facility. The MDS, dated [DATE], documented a discharge from the facility with a return anticipated. The Progress Note dated 02/07/24 at 08:57 AM, documented R28's blood pressure (BP) was elevated. The resident reported her right arm was weak and numb. Her pupils were equal in size, and she had no facial drooping. Staff notified the physician and family of the condition and sent R28 by ambulance to the emergency room for evaluation and treatment. The Progress Note dated 02/12/24, documented R28 returned to the facility from the hospital. The Progress Note dated 04/12/24 at 01:06 PM, documented the facility was notified by the physician's office that R28 would be admitted to the hospital overnight or through the weekend to receive intravenous (IV-administered directly into the bloodstream via a vein) antibiotic treatment for an infection in her chin. The Progress Note dated 04/19/24 at 08:15 PM, documented R28 returned to the facility from the hospital. R28's clinical record lacked evidence the resident or their representative received a copy of the bed hold notice when R28 was sent to the hospital. Upon request, the facility was unable to provide evidence a bed hold notice was provided to R28 and/or her representative. On 10/23/24 at 09:22 AM, Administrative Staff A reported the residents are given a transfer bed hold policy when admitted to the facility, and the original was kept in the chart. Administrative Staff A stated the form explained the ten-day bed hold for Medicaid payer source and verified the resident or the resident's representative had not received one at the time of her discharges. The facility's Bed Hold Policy, dated 04/10/24, documented the facility must provide written information to the Resident and/or Resident Representative when transferring a resident to a hospital or allowing a resident to go on a therapeutic leave that specified the duration of the facility bed hold policy. The facility failed to provide R28 with a bed-hold policy which placed the resident at risk of being unable to return to the facility in the same room or bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 23's care plan with resident-centered intervention to prevent R23's falls and R24's care plan to prevent pressure ulcers. This placed R24 and R23 at risk for further falls and injuries related to uncommunicated care needs. Findings included: - R23's Electronic Medical Record (EMR) documented that R23 had diagnoses of a need for assistance with personal care, hyperproteinemia (abnormally high level of protein in the blood), hypertension (HTN-elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), insomnia (inability to sleep), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), dementia (a progressive mental disorder characterized by failing memory and confusion), a personal history of urinary tract infections, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and atherosclerosis (plaque build-up in the walls of arteries, causing them to thicken). The Significant Change Minimum Data Set (MDS) dated [DATE] recorded R23 had severe cognitive impairment, inattention, disorganized thinking continuously, physical behaviors and rejection of care one to three days during the look-back period, and other behavioral symptoms not directed toward others four to six days of the look-back period. R23 required partial to moderate assistance with eating, substantial to maximal assistance with dressing, personal hygiene, and bed mobility, and was dependent on toileting and transfers. The MDS further documented R23 was 61 inches tall and weighed 120 pounds (lbs.), weight loss or gain was negative or unknown, and R23 did not receive a therapeutic or mechanically altered diet. R23 had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and a skin tear. R23 had a pressure-reducing device for the chair and bed and required pressure ulcer care. The MDS further documented R23 had a fall in the last month and had a fracture related to the fall. R23 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), an antibiotic (a class of medications used to treat infections) and an opioid (a class of medications used to treat pain). The Fall Care Area Assessment (CAA), dated 09/11/24, documented R23 had a fall with a major injury on 09/01/24 and fractured her hip. R23 had a fall previously on 08/10/24 resulting in pelvic and rib fractures. R23 risks included confusion, one to two falls in the past three months, incontinence, balance difficulty (non-weight bearing status), use of wheelchair, medications, and diagnoses. The Fall Care Plan dated 06/26/24, documented R23 had a fall in the past six months at the previous facility and was a high risk for falls. R23 had intermittent confusion, was ambulatory, had poor balance and gait and required the use of a wheeled walker (frequently forgot to use it). R23 was incontinent. The plan directed staff to encourage and assist R23 to keep the walker with her when ambulating, as she often forgot to bring it with her. The plan directed that if a fall occurred, alert the nurse to assess for injury and determine and put interventions in place to prevent further falls. On 06/28/24 the care plan was updated to include staff were to encourage R23 to wear non-slip footwear when ambulating or transferring. The Fall Care Plan dated 09/19/24, documented R23 was non-weight bearing due to a left hip fracture, used a wheelchair for locomotion propelled by staff. R23's Care Plan dated 09/19/24, directed staff to lower the bed to the floor and place a rolled blanket or body pillow under the bottom sheet on the outer aspect of the bed to help define the edge of the bed. The Progress Note dated 06/08/24 at 09:00 PM, documented R23 went to bed shortly after 06:00 PM, reporting she was worn out and tired. When staff went to get her ready for bed, R23 was in the bathroom without her walker, and staff reminded her that she is to use the walker when she got up. The Progress Note dated 07/28/24 at 02:35 PM, documented R23 was found on her bathroom floor at 01:00 PM, lying on her left side and holding her right side rib area. Staff notified R23's representative and physician of the fall and sent R23 to the hospital by ambulance to be evaluated. The facility was unable to provide an investigation to identify causative factors for the 07/28/24 fall. The Progress Note dated 08/11/24 at 01:59 AM, documented R23 had an unwitnessed fall around 09:30 PM on 0810/24, with injuries noted during the skin assessment. Staff called the hospital to see if the physician needed to see R23 due to the noted fractures at that time. The physician's response was to monitor R23 for any increase in pain or uncontrolled pain and if any were observed, send R23 to the hospital. The facility was unable to provide an investigation to identify causative factors for the 08/11/24 fall. R23's Care Plan lacked intervention to prevent further falls. The Progress Note dated 09/01/24 at 07:42 PM, documented at approximately 07:15 PM, staff alerted the nurse that R23 was lying on her left side on the floor with her head against the door jamb of the bathroom. The walker, along with a water cup, was tipped over and there was no water under R23's feet. R23 had severe pain and was grasping her left hip and thigh area. Staff called Emergency Medical Services (EMS) and R23 was transferred to the hospital. The facility was unable to provide an investigation to identify causative factors for the 09/01/24 fall. The Progress Note dated 09/01/24 at 09:57 PM, documented the facility nurse received correspondence from the hospital that R23 had a non-surgical fracture to her hip and would stay in the hospital for a few days for pain management. The Progress Note dated 09/01/24, documented R23 had a laceration on her head that required three staples to close it. The Progress Note dated 09/05/24 at 03:30 PM, documented R23 had returned to the facility via EMS and was uncomfortable when repositioned. R23 had a large dark purple bruise to the left inner thigh, a skin tear to the left arm and a staple to the back of her head. R23 was non-weight bearing, had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag), and a urinary tract infection. The Progress Note dated 09/19/24, documented that R23 had a significant change due to a left hip fracture. She was non-weight bearing, required significant total assistance with self-care and mobility, and had uncontrolled pain on admission. R23 transferred using a mechanical lift, used a wheelchair for mobility propelled by staff, had a urinary tract infection, and several medication changes. The Progress Note dated 10/03/24 at 04:38 AM, documented the nurse checked R23's camera and noted she was not in her bed. The nurse found R23 in her recliner. Staff offered her the bathroom and R23 stated she had to go. R23 refused to let staff put her in a wheelchair, began screaming, and became combative. R23 had been incontinent of bowel, so she was gingerly ambulated to the bathroom where the staff was able to clean R23. Staff was then able to sit on her walker and transferred to her bed without difficulty. On 10/23/24 at 08:12 AM, observation revealed R23 in bed, bed in a low position. There was a black mat on the floor next to the bed, an air mattress on the bed, and there was no rolled pillow under the sheet. A camera faced the direction of her bed. On 10/24/23 at 08:10 AM, Certified Nurse Aide (CNA) M reported staff checked on the resident frequently. CNA M said R23 had a camera in the room so she could be visualized at the nurse's desk to prevent falls. On 10/24/24 at 08:15 AM, Licensed Nurse (LN) I stated the staff do frequent visual checks on R23. LN I confirmed R23 had a camera in the room to prevent falls. On 10/24/24 at 08:19 AM, Administrative Nurse E reported the staff nurses should update the care plan in the Activities of Living (ADL) book after each fall. Administrative Nurse E stated at the MDS interval, she tried to get the care plan updated in the EMR. Administrative Nurse E reported the nurses did the initial fall report and Administrative Nurse D did a further investigation for the root cause of the fall. On 10/24/24 at 08:27 AM, Administrative Nurse D stated the nurses fill out a fall investigation and are to include interventions to prevent further falls, which should be transferred to the ADL book and the EMR. Administrative Nurse D said that staff were instructed to check R23 more frequently with rounds at night shift, but this had not been added to the care plan. Administrative Nurse D verified a lack of fall interventions for R23's falls. The facility's Plan of Care policy dated 04/10/24, documented it is the policy of the facility that a plan of care be developed and maintained for each resident. The plan of care is a working tool that provides a profile of the needs of the individual resident, identifies the role of each service in meeting these needs, and the supportive measures each service will use to complement each other in accomplishing the overall goal of care. The plan of care shall be reviewed as necessary, but at least quarterly. The resident and/or the representative will be informed of the review date and encouraged to participate in the review. The facility failed to update R23's Care Plan with new interventions to prevent further falls, which placed the resident at risk for further injuries due to uncommunicated care needs. - R24's Electronic Medical Record (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (HTN-elevated blood pressure), heart failure, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), bradycardia (low heart rate, less than 60 beats per minute), fracture of the right femur (thigh bone), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R24 had severe cognitive impairment and verbal behaviors directed toward others which occurred one to three days of the lookback period. R24 had functional range of motion impairment of one side lower extremity, required substantial/maximal assistance with toileting, dressing, and transfers. R24 had occasional incontinence of urine. R24 received scheduled, as-needed, and non-medication interventions for pain. The MDS further documented no falls since the prior assessment or readmit. The MDS documented R24 had recent surgery to repair a fracture of the pelvis, hip, leg, knee, or ankle. R24 had a surgical wound and wound care. R24 received an antidepressant (a class of medications used to treat mood disorders), anticoagulant (a class of medications used to prevent the blood from clotting), diuretic (medication to promote the formation and excretion of urine), and opioid (a class of medication to treat pain). R24's Fall Care Plan dated 09/18/24, documented that R24 was admitted to the facility with a distal femur (thigh bone) fracture sustained from a fall before admission. R24 was a high risk for falls, required assistance with elimination, used a wheelchair, had numerous falls since admission during self-transfers, and did not remember she was unable to transfer independently. R24 was weight-bearing as tolerated due to a right hip fracture on 07/29/24. The care plan directed staff to ensure R24 had gripper socks or shoes on at all times when awake, ensure the call light was within reach, and ensure the video monitor was in place and turned on while R24 was in the room. The care plan further documented that if R24 was restless when in bed, offer and assist her to a recliner in the living room area. The Progress Note dated 02/12/24 at 04:01 PM, documented R24 admitted to the facility following a fall and fracture of her right hip at the previous facility which required surgical repair. R24 had a history of attempting to get out of bed to ambulate independently and a video monitor would be placed in the room. R24 would like to be as independent as possible. She had numerous falls since admission during self-transfers and did not remember she was unable to transfer independently or get up and walk independently> R24 needed to be reminded that it was unsafe for her to ambulate independently. The Progress Note dated 02/13/24 at 01:52 AM, documented R24 had a fall around 09:43 PM on 02/12/24. After going to bed, the staff were not able to observe R24 with the video monitor. Upon checking, staff found R24 sitting on a pillow, on the floor in front of her recliner. R24 reported she thought a family member was coming to see her, so she wanted to get up. R24 denied pain or injury. R24's clinical record lacked evidence a fall investigation was completed, and interventions implemented to prevent further falls after the 02/12/24. The Progress Note dated 03/09/24, documented on 03/05/24 at approximately 05:45 PM, a resident notified staff that R24 fell in her bathroom. R24 was found on the floor of the bathroom with the wheelchair to the left of the resident and wheels locked in place. R24 had a tennis shoe on the left foot and a gripper sock with a leg brace on the right foot. R24 reported she was trying to go to the bathroom. R24 reported her right leg was sore, but said it was sore all week. The note documented the fall intervention was for staff to assist R24 to the bathroom when finished with supper. R24's clinical record lacked evidence a fall investigation was completed falls after the 03/05/24. The Progress Note dated 03/11/24 at 01:15 PM, staff reported nursing R24 sitting on the floor in the hallway and the wheelchair was in the bathroom. R24 had been toileted after lunch and denied injury. The note documented R24 would be care planned not to be left alone in the wheelchair. The Fall Investigation Report/Root Cause Analysis dated 03/18/24, documented an intervention to toilet R24 after all meals then to rest in recliner. Staff were alerted at the morning meeting to keep watch when meals were over for R24 heading to her bathroom. On 03/15/24 R23's Care Plan was updated with an intervention that directed staff to assist R24 to the bathroom on the way back from supper to prevent her from attempting to transfer herself into the bathroom. The Progress Note dated 03/18/24 at 07:10 PM, documented R24 was found sitting on the floor yelling Help me and for further information see fall paperwork. The Fall Investigation Report/Root Cause Analysis Report dated 03/20/24, documented R24 attempted to transfer self to toilet and to directed to continue current interventions and anticipate needs. The Progress Note dated 03/21/24 at 11:18 AM, documented the physician's response to the fall from the previous evening was to consider scheduled toileting, and the care plan directed staff to take R24 to the bathroom after each meal and to assist R24 to the recliner afterwards. R24 was reminded to always ask for help when needed to use the restroom. The Progress Note dated 04/27/24 at 06:18 PM, documented at 05:28 PM R24 was found sitting in front of closest on the floor, reported pain in the left knee, reporting she fell on her knee, no swelling or deformity. R24 reported she tried to transfer herself out of the wheelchair to get pajamas and fell. The Fall Investigation Report/Root Cause Analysis dated 04/27/24, documented that R24 attempted a self-transfer, lost balance, and fell due to numbness and weakness in her legs. The intervention to prevent further falls was to set R23's pajamas out before supper so she could see them and not attempt to transfer herself. On 04/28/24 R23'sCare Plan was updated and directed staff to make sure to sit R24's in the bathroom where she could see them so she would not attempt to transfer herself and increase the risk of falls. The Progress Note dated 05/13/24, documented at 08:50 AM R24 had a non-injury fall and the incident report was completed. The Fall Investigation Report/Analysis Report dated 05/13/24, documented the cushion hung off the wheelchair and R24 slid to the floor. The intervention was to remove the cushion from the chair. The Progress Note dated 06/01/24 at 10:00 AM, documented that while at breakfast a visitor told staff R24 had fallen in the dining room. R24 had a bruise on her left hand from hitting it on her wheelchair. R24's family member stated the staff kept the wheelchair near her and locked so that when R24 attempted to transfer herself she had a stable chair to move to and would not slide out from underneath her. The Fall Report Form dated 06/01/24 documented that R24 fell in the dining room, had regular socks on, no gripper socks, the wheelchair was unlocked and was last toileted at 08:15 AM. Interventions were to place gripper socks on or put shoes on with regular socks. On 06/01/24 R23's Care Plan documented an intervention that directed staff to ensure R24 had gripper socks on when in bed or other non-slip footwear. This was a repeated intervention. The Progress Note dated 06/02/24 at 09:53 AM, documented at 09:33 AM, laundry personnel reported R24 had scooted out to the hallway on her buttocks trying to leave the room. No injuries were noted. The Fall Report Form dated 06/02/24 documented R24 sat in the hallway asking for help and stating she had tried to get up and fell, then scooted to the hallway. The intervention was to re-educate staff not to put R24 in a room by herself. The Progress Note dated 06/19/24 at 10:00 PM documented that R24 had an unwitnessed fall, was found sitting on the floor, and stated she had fallen out of her chair. The Fall Report Form dated 06/19/24, documented that several staff were present in the area of where R24 was sitting in a recliner and had a garbage can under the footrest, R24 crawled over the footrest and slid from the recliner to the floor. R24 was care planned as a one-person assist, gripper socks, unknown time of last toileted, and when not looking R24 reported she was trying to walk, and her legs got weak. The care plan was reviewed and updated to place gripper socks on and put shoes on with regular socks. The Progress Note dated 07/01/24 at 08:30 AM, documented that R24 fell to the floor in the dining room attempting to self-transfer and reported pain in her knees, which was not a new complaint. The Fall Report Form dated 07/01/24 documented that R24 tried to move over to a wheelchair and fell in the dining room. The wheelchair brakes were unlocked and out of reach. The intervention was to anticipate R24's needs and assist to a wheelchair as soon as R24 was done eating. The Progress Note dated 07/25/24 at 02:02 PM, documented R24 sitting in front of a chair on the floor. R24 reported she was getting up to go to the bathroom and fell. R24 had edema from the hip down to her ankle, with external rotation and shortening of the right leg. The call light was within reach, gripper socks were on and the video monitor was on as planned. R24 sent to the hospital via Emergency Medical Services (EMS). The Progress Note dated 07/26/24 at 03:12 PM, documented that staff spoke to the hospital nurse and reported R24 planned for surgery that day and possible discharge to the facility the following Monday. The Progress Note dated 07/29/24 at 05:00 PM documented that R24 had returned from the hospital and reported pain to the right hip a ten of a scale of one to ten. The Progress Note dated 09/16/24 at 10:46 PM, documented staff assisted R24 to the bathroom and placed in the recliner. R24 was found sitting on the floor after the nurse checked on another resident. R24 reported she had to go to the bathroom. Staff had reminded R24 she had just been there and R24 reported she knew that but she needed to go again. The Fall Report Form dated 09/16/24 documented that R24 fell in the lounge area/nurses' station, had severe cognitive impairment, was wearing gripper socks, and had been toileted between 9:50 PM and 10:00 PM, R24 reported she had to use the bathroom. The root cause was that R24 had an urgent stool and got up independently for the bathroom because she did not know her limitations and the intervention to decrease the stool softener. On 10/23/24 at 11:00 AM observation revealed Licensed Nurse (LN) G walking R24 from her bathroom to a recliner in the living room area and close to the nurses' station. After a few minutes, R24 became restless and attempted to get out of the recline. R24 reported to LN D that she needed to go to the bathroom. LN G asked R24 to wait a few minutes for assistance and reminded R24 that she had just been to the bathroom. R24 stated she knew that but needed to go again. Another staff came by the area and took R24 to the bathroom. On 10/24/24 at 08:10 AM Certified Nurse Aide (CNA)M, stated staff checked on R24 frequently and had a video monitor in the room to prevent R24 from falling. On 10/24/24 at 08:15 AM, Licensed Nurse (LN) E stated the staff do frequent visual checks, kept R24 in the living room area and had a video monitor in the room to prevent falls. On 10/24/24 at 08:19 AM, Administrative Nurse E reported the staff nurses should update the care plan in the Activities of Living (ADL) book after each fall. Administrative Nurse E at the MDS interval tried to get the care plan updated in the EMR. Administrative Nurse E reported the nurses do the initial fall report and Administrative Nurse D a further investigation for the root cause of the fall. On 10/24/24 at 08:27 AM, Administrative Nurse D stated the nurses fill out a fall investigation and are to include interventions to prevent further falls, which should be transferred to the ADL book and the EMR. Administrative Nurse D verified lack of interventions for R24's falls. The facility's Plan of Care policy dated 04/10/24, documented it is the policy of the facility that a plan of care be developed and maintained for each resident. The plan of care is a working tool that provides a profile of the needs of the individual resident, identifies the role of each service in meeting these needs, and the supportive measures each service will use to complement each other in accomplishing the overall goal of care. The plan of care shall be reviewed as necessary, but at least quarterly. The resident and/or the representative will be informed of the review date and encouraged to participate in the review. The facility failed to update R24's care plan with new interventions to prevent further falls which placed the resident at risk for further injuries due to uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents of which three were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to provide interventions to prevent a facility-acquired pressure ulcer to Resident (R) 23's heel upon her significant change in mobility. The facility further failed to ensure all interventions were implemented as directed to prevent wound worsening or promote healing. This placed the resident at risk of complications related to skin breakdown and wounds. Findings included: - R23's Electronic Medical Record (EMR) documented that R23 had diagnoses of a need for assistance with personal care, hyperproteinemia (abnormally high level of protein in the blood), hypertension (HTN-elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), insomnia (inability to sleep), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), dementia (a progressive mental disorder characterized by failing memory and confusion), a personal history of urinary tract infections, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and atherosclerosis (plaque build-up in the walls of arteries, causing them to thicken). The Significant Change Minimum Data Set (MDS) dated [DATE] recorded R23 had severe cognitive impairment, inattention, disorganized thinking continuously, physical behaviors and rejection of care for one to three days during the look-back period, and other behavioral symptoms not directed toward others four to six days of the look-back period. R23 required partial to moderate assistance with eating, substantial to maximal assistance with dressing, personal hygiene, and bed mobility, and was dependent on toileting and transfers. The MDS further documented R23 was 61 inches tall and weighed 120 pounds (lbs.), weight loss or gain was negative or unknown, and R23 did not receive a therapeutic or mechanically altered diet. R23 had a pressure ulcer and a skin tear. R23 had a pressure-reducing device for the chair and bed and required pressure ulcer care. The MDS further documented had a fall in the last month and had a fracture related to the fall. R23 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), an antibiotic (a class of medications used to treat infections) and an opioid (a class of medications used to treat pain). The Pressure Ulcer Care Area Assessment (CAA), dated 09/17/24, documented that R23 had a Stage 1 pressure ulcer (pressure wound which appears reddened, does not blanche, and may be painful but is not open) to her outer left ankle and a Stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) to the left heel which was noted the first week of her return to the facility from the hospital. Foam boots were applied and Skin- prep (liquid skin protectant) to the areas to prevent the worsening of her wounds and further skin breakdown. R23 had the potential for friction and shearing when transferring, required assistance with mobility due to a left hip fracture, and her nutrition was probably inadequate. The CAA further documented that R23 had a pressure-reducing mattress and cushion for her wheelchair. R23's Care Plan dated 06/26/24, documented R23 did not have skin issues on admission and was at mild risk for pressure ulcers. She had impaired sensory due to dementia and expressive aphasia (a disorder that affects the ability to communicate). She was occasionally incontinent of urine, nutrition was probably inadequate, and she had the potential for friction and shearing when transferring. The plan further documented that R23 would have a pressure-reducing mattress on her bed. The plan directed staff to prompt and assist R23 to use the toilet upon rising, every two to three hours while awake, at bedtime, at midnight, and 04:00 AM, and provide as-needed incontinent care to prevent skin breakdown. The plan further documented a nurse would assess R23's skin for bruising, redness, and open areas weekly and as needed, and during care staff to observe for skin changes; if any skin issues were noted the nurse would notify the physician and initiate appropriate interventions. R23's Physician Order dated 10/14/24, directed staff to cleanse the open area to the left heel with wound cleanser, pat dry, apply collagen (protein-derived wound treatment used to promote wound healing) to the area and cover with foam border dressing, and secure with tape if needed until resolved. The orders further directed staff to float heels with a pillow at all times while in bed and place a pillow behind the lower legs while in a wheelchair to prevent pressure to the left heel until the pressure sore was healed. The Progress Note dated 09/09/24 at 11:15 PM, noted the physician had been notified that R23 had a red spot to the outer left ankle and a blister area to the left heel, with treatment of Skin-prep to the areas until resolved. R23 was to wear foam boots to prevent further breakdown and the physician agreed with the plan and treatment. The Progress Note dated 09/10/24 at 02:30 PM, documented that R23 was six days following return from the hospital and was placed on an air mattress to prevent further breakdown to her coccyx (area at the base of the spine) area. The blister to the left heel was intact, Skin-prep was applied. The Progress Note dated 09/15/24 at 10:55 PM, documented R23's blister to the left heel to be open and the skin had pulled away, the area measured four centimeters (cm) in length and width. The area was cleansed and patted dry. Vaseline gauze and Telfa (nonstick gauze) dressings were applied to the area. The note further documented that the gel cushion sock was too tight and was left off to allow the foam boot to be put on. A fax was sent to the physician for notification and treatment was applied to the treatment record until a response was received. The Skin Evaluation Note dated 09/19/24, documented an opened blister to the left heel, with granulation (new tissue formed during wound healing) and sanguineous (bloody drainage) exudate (drainage). The dressing was saturated and the tissue was painful. The evaluation also included an open area to the coccyx. The Skin Evaluation Note dated 10/03/24, documented the left heel wound measured 2 cm in width and length, had minimal drainage, was cleansed well, and a foam-bordered dressing was applied to both areas. R23 had gel heel protectors on and continued with a pressure wound to the coccyx. The Skin Evaluation Note dated 10/10/24, documented a left heel area of 1.8 cm in length x 1.4 cm in width with granulation, serous drainage, and peri-wound (surrounding skin) skin fragile. R23 continued with a pressure wound to her coccyx which measured 1.5 cm in length and 0.2 cm in width. The Skin Evaluation Note dated 10/17/24, documented a dried blister open ulcer to the left heel measuring 1.5 cm in length, 1.5 cm in width, and 0.2 cm in depth. It had granulation tissue and serosanguineous drainage, which may have occurred due to treatment with collagen. The Skin Evaluation Note dated 10/18/24 documented the coccyx wound measured 1.2 cm in length, 0.2 cm in width, and 0.1 cm in depth; it had granulation. On 10/23/24 at 12:26 PM, observation revealed Certified Nurse Aide (CNA) M and CNA N providing grooming and transfer assistance for the midday meal and reported R23 would become physically aggressive until she was ready for help. Licensed Nurse (LN) H was also present for a dressing change to the coccyx area. The coccyx area was visualized and was no longer open. LN H reported the heel dressing was changed by the night shift nurse. Further observation revealed R23 had an air mattress on her bed. On 10/23/24 at 03:30 PM, observation revealed R23 sat in the living room commons area, in a wheelchair with a cushion on the seat. Her right leg was crossed over the left leg, and there was no pillow behind her legs on the wheelchair pedals. R23 was restless, folding and unfolding a blanket with a doll and moving and pulling at the lift straps. On 10/24/24 at 08:15 AM, LN E stated R23 required repositioning every two to three hours. LN E said R23 had an air mattress on the bed and had foam protective boots, but the boots did not seem to help so staff just floated R23's heels off the bed with pillows. On 10/24/24 at 08:27 AM, Administrative Nurse D verified that R23's plan of care had not been updated with interventions used to heal and prevent further skin breakdown. Administrative Nurse D stated that R23's heels should have been floated on pillows or used foam boots and was unsure when this was implemented. The facility's Prevention of Pressure Ulcers policy, dated 04/10/24, documented it was the policy of the facility to prevent and manage pressure ulcers to preserve or attain the highest level of skin integrity for all residents. All residents will be assessed by a licensed nurse for the risk potential of skin breakdown upon admission and quarterly. Those with high risk will be assessed every week by nursing in addition to taking preventative measures. The care plan team will develop individualized care plans implemented by the interdisciplinary team through the education of staff. The facility failed to provide interventions to prevent a facility-acquired pressure ulcer to R23's heel upon her significant change in mobility. The facility further failed to ensure all interventions were implemented as directed to prevent worsening or promote healing. This placed the resident at risk of complications related to skin breakdown and wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that Resident (R)14 lacked a stop date as required by the Center for Medicare and Medicaid Services (CMS) for the continued use of as-needed (PRN) Ativan (antianxiety medication). This placed R14 at risk for complications related to psychotropic (alters mood or thought) medication use beyond 14 days. Findings included: - R14'sElectronic Medical Record documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and recurrent major depressive disorder (MDD- mood disorder which causes persistent feelings of sadness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had short- and long-term memory problems with severely impaired decision-making. The MDS documented R14 had physical, verbal, and wandering behaviors and received antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), and opioid medications (a class of controlled drugs used to treat pain). R14's Care Plan, dated 07/03/24, documented R14 was at risk for adverse behaviors related to diagnoses of dementia and anxiety. R14 has noted anxiety and fidgeting daily, became loud and disrupted the living environment, and would often wheel her chair into other residents' space. R14 had an order for PRN Ativan for high anxiety and restlessness up to three times per day. The care plan directed staff to offer R14 hand towels to fold as a mode of distraction when she becomes anxious; offer her baby doll and or cat to take care of in an attempt to distract her from her anxiety and ask family to come sit with R14 when other means of non-pharmacological measures are ineffective. The plan directed if non-pharmacological measures were ineffective, give R14's ordered PRN Ativan or her PRN pain medication for her high levels of anxiety and restlessness and provide one-on-one with R14 with reassurance when she has increased anxiety. The Physician Order, dated 04/03/24, directed staff to administer Ativan 0.5 milligrams (mg) PRN every six to eight hours for anxiety or restlessness. The stop date was marked indefinite. The Consultant Pharmacist Medication Review, dated 04/15/24, requested an Ativan PRN risk versus benefit statement from the physician. The pharmacist did not request a stop date for the PRN Ativan and the physician did not respond to the recommendation. The Physician Order, dated 06/03/24, directed staff to administer Ativan 0.5 mg PRN every eight hours for anxiety or restlessness. The stop date was marked indefinite. The Consultant Pharmacist Medication Review, dated 08/06/24, requested an Ativan PRN risk versus benefit statement from the physician but did not request a stop date. The physician's response was no change, patient doing well on current dose and no stop date was ordered. On 10/22/24 at 03:00 PM, observation revealed R14 in her wheelchair at the nurse's desk talking and lightly pulling on a phone wire, taking the paper out of the copy machine, and reaching for whatever she could reach. R14 removed her shoes and socks, and staff reapplied them. On 10/23/24 at 01:40 PM, Administrative Nurse D verified the CP should have continued to follow through until the physician provided a stop date for the PRN Ativan. The facility's Pharmacy Consultant policy, dated 04/10/24, stated the consultant pharmacist would review each resident's medication regimen at least monthly and identify irregularities. The resident-specific irregularities would be recorded and reported to the DON, medical director, and prescriber as individual recommendations and in a summary report. Recommendations would be acted upon and documented by the facility staff and or the prescriber. The prescriber accepts and acts upon suggestions or rejects and should provide an explanation for disagreeing. Recommendations concerning medication therapy would be communicated in a timely fashion and placed in the resident's medical record. The timing of these recommendations should enable a response prior to the next medication regimen review. The facility failed to ensure the CP identified and reported that R14 lacked a stop date as required for the continued use of PRN Ativan. This placed R14 at risk for complications related to psychotropic medication use beyond 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain a stop date from the physician for the continued use of as-needed (PRN) Ativan (antianxiety Medication) for two residents, Resident (R) 14 and R25. This placed the residents at risk for complications related to psychotropic (alters mood or thought) medications and unnecessary medication. Findings included: - R14'sElectronic Medical Record documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and recurrent major depressive disorder (MDD- mood disorder which causes persistent feelings of sadness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had short- and long-term memory problems with severely impaired decision-making. The MDS documented R14 had physical, verbal, and wandering behaviors and received antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), and opioid medications (a class of controlled drugs used to treat pain). R14's Care Plan, dated 07/03/24, documented R14 was at risk for adverse behaviors related to diagnoses of dementia and anxiety. R14 has noted anxiety and fidgeting daily, became loud and disrupted the living environment, and would often wheel her chair into other residents' space. R14 had an order for PRN Ativan for high anxiety and restlessness up to three times per day. The care plan directed staff to offer R14 hand towels to fold as a mode of distraction when she becomes anxious; offer her baby doll and or cat to take care of in an attempt to distract her from her anxiety and ask family to come sit with R14 when other means of non-pharmacological measures are ineffective. The plan directed if non-pharmacological measures were ineffective, give R14's ordered PRN Ativan or her PRN pain medication for her high levels of anxiety and restlessness and provide one-on-one with R14 with reassurance when she has increased anxiety. The Physician Order, dated 04/03/24, directed staff to administer Ativan 0.5 milligrams (mg) PRN every six to eight hours for anxiety or restlessness. The stop date was marked indefinite. The Consultant Pharmacist Medication Review, dated 04/15/24, requested an Ativan PRN risk versus benefit statement from the physician. The pharmacist did not request a stop date for the PRN Ativan and the physician did not respond to the recommendation. The Physician Order, dated 06/03/24, directed staff to administer Ativan 0.5 mg PRN every eight hours for anxiety or restlessness. The stop date was marked indefinite. The Consultant Pharmacist Medication Review, dated 08/06/24, requested an Ativan PRN risk versus benefit statement from the physician but did not request a stop date. The physician's response was no change, patient doing well on current dose and no stop date was ordered. On 10/22/24 at 03:00 PM, observation revealed R14 in her wheelchair at the nurse's desk talking and lightly pulling on a phone wire, taking the paper out of the copy machine, and reaching for whatever she could reach. R14 removed her shoes and socks, and staff reapplied them. On 10/23/24 at 01:40 PM, Administrative Nurse D verified staff should have obtained a stop date for the PRN Ativan. She stated the pharmacist noted the order needed a specific duration. The facility's PRN Psychotropic Drug Use policy, dated 04/10/24, stated PRN use of a psychotropic drug was limited to 14 days unless the prescriber reviews or evaluates and documents the rationale for the extension. A duration for the PRN must be specified by the prescriber. The facility failed to obtain a 14-day stop date or a physician rationale for the continued use of PRN Ativan with a specified duration placing R14 at risk for unnecessary psychotropic medication. - R25's Electronic Medical Record documented diagnoses of heart failure, macular degeneration (progressive deterioration of the retina), and chronic pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R25 required staff assistance for dressing and mobility and received no psychotropic drugs. R25's Care Plan, dated 07/08/24, directed staff to introduce themselves when providing care as he had poor eyesight and explain all care and procedures before performing them. The Physician Order, dated 09/27/24, directed staff to administer Ativan 0.5 mg, every two hours as needed for restlessness or agitation, and did not include a stop date. On 10/23/24 at 03:14 PM, observation revealed R25 activated his call light as he sat in his recliner with his feet elevated and shoes on. Certified Nurse Aide (CNA) O answered and used a gait belt and walker to assist him to his feet and ambulate to the bathroom. On 10/23/24 at 01:40 PM, Administrative Nurse D verified the PRN Ativan should have a stop date. The facility's PRN Psychotropic Drug Use policy, dated 04/10/24, stated PRN use of a psychotropic drug was limited to 14 days unless the prescriber reviews or evaluates and documents the rationale for the extension. A duration for the PRN must be specified by the prescriber. The facility failed to obtain a 14-day stop date or a physician rationale for the continued use of PRN Ativan with a specified duration placing R25 at risk for unnecessary psychotropic medication.

The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to prepare food in a sanitary manner for two residents who requested a lettuce salad at mealtime. This placed the residents at risk for foodborne illness. Findings included: - On 10/24/24 at 11:55 AM, observation revealed Dietary Staff (DS) CC placed gloves on her hands and took a head of lettuce out of the refrigerator. DS CC then unwrapped the plastic wrap, and several layers of lettuce leaves, took the core out of the center, then went to the trash can, lifted the trash can lid, and threw away the discarded lettuce. DS CC then returned to the lettuce without changing gloves, chopped several small servings of lettuce, and placed the chopped lettuce into two small bowls. Upon inquiry, DS CC stated she had not changed her gloves following touching the trash can lid and preparing the lettuce. DS BB, who was also present, then took the two bowls, covered them with foil, and placed the bowls into the refrigerator. Upon questioning DS BB on the intent of placing the bowls of contaminated lettuce into the refrigerator, DS BB reported the bowls of lettuce were placed into the refrigerator and would be served to the residents when the residents were given their meals. Upon further inquiry regarding whether the contaminated lettuce should be served to the residents, DS BB removed the lettuce from the refrigerator and washed it in the sink, then placed the lettuce into two small bowls. The facility's Food Preparation and Handling policy, dated 04/10/24, documented that food items will be prepared using methods and techniques designed to preserve maximum nutritive value, enhance flavor, and be free of injurious organisms and substances. Gloves will be changed and hand washed between preparation of different food items and any time the gloves have been contaminated by any potentially soiled surface. The facility failed to prepare food in a sanitary manner for two residents who requested a lettuce salad at mealtime. This placed the two residents at risk for foodborne illness.

The facility had a census of 29 residents. The sample included 12 residents. Based on the interview and record review the facility lacked evidence the required committee members, including the Medical Director, attended the Quality Assurance Performance Improvement (QAPI) meetings quarterly. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - The facility's sign-in sheets for the QAPI meetings documented that the meetings were held quarterly but lacked evidence of the medical director's attendance for the period of May through September 2024. On 10/24/24 at 01:49 PM, Administrative Staff A verified the facility's medical director did not attend a QAPI meeting in the third quarter of 2024. The facility did not provide a policy. The facility failed to ensure the medical director attended QAPI meetings at least quarterly which placed residents at risk of decreased quality of care.

The facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide and promote dignity for Resident (R) 14 who had a indwelling catheter (a tube in bladder). This placed the resident at risk for embarrassment and impaired psychosocial wellbeing. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of urinary retention (difficulty urinating and completely emptying the bladder). The Quarterly Minimum Data Set (MDS) dated 03/19/23, documented the resident required extensive assistance with bed mobility, transfers and had a urinary catheter. The updated Urinary Catheter Care Plan, dated 03/30/23, instructed the staff to keep the urinary drainage bag covered. On 04/20/23 at 10:50AM, observation revealed R14 lying in bed. Further observation revealed a urinary drainage bag hanging on the side of the bed uncovered. On 04/24/23 at 09:48AM, observation revealed R14 lying in bed. Further observation revealed a urinary drainage bag hanging on the side of the bed uncovered. On 04/24/23 at 03:40PM, observation revealed R14 lying in bed. Further observation revealed a urinary drainage bag hanging on the side of the bed uncovered. On 04/25/23 at 07:40AM, observation revealed R14 lying in bed. Further observation revealed a urinary drainage bag hanging on the side of the bed uncovered. On 04/25/23 at 09:00AM, Administrative Nurse D verified the uncovered urinary catheter bag . Administrative Nurse D stated she expected staff to keep the urinary catheter bags covered. The facility's Dignity Policy, dated 03/27/17, stated it is the policy of the facility that all residents be treated with dignity and respect. Privacy of a resident's body is to be maintained. The facility failed to cover R14's urinary catheter bag, placing the resident at risk for embarrassment and decreased dignity.

The facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide foot care and services for Resident (R)13 which placed R13 at risk for pain in feet, and decreased mobility and quality of life. Findings included: - The Electronic Medical Record (EMR) documented R13 had diagnoses of osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a disease that destroys memory and other mental functions),and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). The Annual Minimum Data Set (MDS), dated 01/29/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R13 used a cane and required stand by assistance with ambulation. She had pain present and constant daily which limited daily activities. The Care Area Assessment Summary (CAA) for pain, dated 02/02/23, documented R13 had moderate pain to the bottom of her feet and did not receive scheduled medication for pain. The CAA recorded R13 was offered as needed acetaminophen (pain reliever medication) but R13 refused to take the medication. The Cognition Care Plan, dated 01/29/23, documented R13 had severe cognition and poor decision-making skills and required cues and prompting from staff for care. The Mobility Care Plan, dated 01/29/23, documented R13 used a cane and staff were to cue and remind R13 to use her cane when ambulating. The Pain Care Plan, dated 01/29/23, documented R13 had a history of leg cramps and complaints of foot pain with noted callous to bottom of both her feet. Staff were directed to monitor for pain, any increased agitation, moaning or grimacing and to notify the charge nurse. Staff were directed to provide as needed acetaminophen and to encourage R13 to elevate her legs when having pain. R13's primary care physician was to be notified of any increased pain. Review of the Weekly Nursing Assessment for the following dates, documented the same statement, Her feet hurt when she walks, has callouses on the bottom of both feet and are painful on 01/22/23, 01/31/23, 02/07/23, 02/14/23, 02/21/23, 02/28/23, 03/07/23, 03/14/23, 03/21/23, 03/28/23, 04/01/23, 04/08/23, 04/15/23. The Weekly Nursing Assessment lacked any documentation of the size of the callous on the bottom R13's feet or actions taken in response to the pain. Review of R13's medical record lacked documentation R13's physician had been notified of the foot pain and lacked evidence R13 was referred to podiatry for evaluations of the ongoing foot pain. On 04/20/23 at 02:40PM, observation revealed R13 sat on a loveseat in the living room area holding a doll. Further observation revealed R13 with her eyes closed. On 04/24/23 at 08:45 AM, observation revealed R13 ambulated with a cane from the dining room. R13 grimaced and moaned softly when she ambulated. On 04/24/23 at 11:50AM, observation revealed R 13 stood up from sitting on the love seat and used her cane, then ambulated to the dining room. R 13 moaned and stated to another resident my feet hurt. On 04/25/23 at 07:45 AM, observation revealed R13 ambulated down the 100 hallway with her cane to the therapy room (approximately 75 feet) with stand by assistance from Certified Nurse Aide (CNA) M. Further observation revealed R13 grimaced, and verbalized my feet are sore they hurt. CNA M informed R13 she needed to be weighed and then they were going to walk to the dining room for breakfast. On 04/25/23 at 07:50 AM, observation revealed R13 ambulated with her cane and stand by assistance from CNA M out of the therapy room. R13 grimaced and moaned softly when ambulating. R13 stated my feet hurt, and CNA M responded I am sorry your feet hurt but we need to go to breakfast. R13 ambulated approximately 100 yards to the dining room and sat on a dining chair. R13 closed her eyes and rocked back and forth after being seated on the chair. On 04/25/23 at 02:40PM, R13 ambulated to her room and sat down on a recliner chair. At the request of the surveyor, Licensed Nurse (LN) G, removed the resident's shoes and socks and assessed R13's feet. The outer aspect of the right foot had a 1.5 centimeter (cm) by 1 cm callous, and no open areas on the right foot. The outer aspect of the left foot had a 1cm by 1 cm callous, and no open areas to left foot. The left foot great toe had a long toe nail with edges curled into the skin. Administrative Nurse D was present and verified the need for toenail care for R13. L N G asked R13 if her feet hurt, and the resident responded yes they do, but my mom will make them better. On 04/25/23 at 07:55AM, CNA M verified R13 verbalized her feet hurt and had a difficult time ambulating. On 04/25/23 at 03:00PM, L N G verified R13 verbalized and grimaced in pain when ambulating. On 04/25/23 at 03:10PM, Administrative Nurse D verified R13 grimaced and complained of pain in both feet. Administrative Nurse D stated R13's toenails required trimming, and also confirmed the resident had not seen a podiatrist since November 2019. Upon request the facility did not provide a policy for foot care. The facility failed to provide care and services to maintain good foot health for R13, who had foot pain. This placed the resident at risk for impaired mobility, and diminished quality of life.

The facility had a census of 28 residents. The sample included 12 of which three residents were reviewed for pain. Based on observation, record review and interview the facility failed to recognize, evaluate, manage and treat the underlying cause of pain for Resident (R) 13. This placed the resident at risk for impaired mobility and diminished her quality of life. Findings included: - The Electronic Medical Record (EMR) documented R13 had diagnoses of osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a disease that destroys memory and other mental functions),and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). The Annual Minimum Data Set (MDS), dated 01/29/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R13 used a cane and required stand by assistance with ambulation. She had pain present and constant daily which limited daily activities. The Care Area Assessment Summary (CAA) for pain, dated 02/02/23, documented R13 had moderate pain to the bottom of her feet and did not receive scheduled medication for pain. The CAA recorded R13 was offered as needed acetaminophen (pain reliever medication) but R13 refused to take the medication. The Cognition Care Plan, dated 01/29/23, documented R13 had severe cognition and poor decision-making skills and required cues and prompting from staff for care. The Mobility Care Plan, dated 01/29/23, documented R13 used a cane and staff were to cue and remind R13 to use her cane when ambulating. The Pain Care Plan, dated 01/29/23, documented R13 had a history of leg cramps and complaints of foot pain with noted callous to bottom of both her feet. Staff were directed to monitor for pain, any increased agitation, moaning or grimacing and to notify the charge nurse. Staff were directed to provide as needed acetaminophen and to encourage R13 to elevate her legs when having pain. R13's primary care physician was to be notified of any increased pain. Review of the Medication Administration Record (MAR) documented R13 could receive acetaminophen 1000 milligrams (mg) by mouth (PO) every six hours as needed for pain and not to exceed 3000mg in 24 hours. Review of the MAR for January 2023, February 2023, March 2023 and April 1st to the 26 2023, revealed R13 received one dose of acetaminophen on 03/23/23. No other doses of acetaminophen were administered. Review of the Weekly Nursing Assessment for the following dates, documented the same statement, Her feet hurt when she walks, has callouses on the bottom of both feet and are painful on 01/22/23, 01/31/23, 02/07/23, 02/14/23, 02/21/23, 02/28/23, 03/07/23, 03/14/23, 03/21/23, 03/28/23, 04/01/23, 04/08/23, 04/15/23. The Weekly Nursing Assessment lacked any documentation of the size of the callous on the bottom R13's feet or actions taken in response to the pain. Review of R13's medical record lacked documentation R13's physician had been notified of the foot pain. On 04/20/23 at 02:40PM, observation revealed R13 sat on a loveseat in the living room area holding a doll. Further observation revealed R13 with her eyes closed. On 04/24/23 at 08:45 AM, observation revealed R13 ambulated with a cane from the dining room. R13 grimaced and moaned softly when she ambulated. On 04/24/23 at 11:50AM, observation revealed R 13 stood up from sitting on the love seat and used her cane, then ambulated to the dining room. R 13 moaned and stated to another resident my feet hurt. On 04/25/23 at 07:45 AM, observation revealed R13 ambulated down the 100 hallway with her cane to the therapy room (approximately 75 feet) with stand by assistance from Certified Nurse Aide (CNA) M. Further observation revealed R13 grimaced, and verbalized my feet are sore they hurt. CNA M informed R13 she needed to be weighed and then they were going to walk to the dining room for breakfast. On 04/25/23 at 07:50 AM, observation revealed R13 ambulated with her cane and stand by assistance from CNA M out of the therapy room. R13 grimaced and moaned softly when ambulating. R13 stated my feet hurt, and CNA M responded I am sorry your feet hurt but we need to go to breakfast. R13 ambulated approximately 100 yards to the dining room and sat on a dining chair. R13 closed her eyes and rocked back and forth after being seated on the chair. On 04/25/23 at 02:40PM, R13 ambulated to her room and sat down on a recliner chair. At the request of the surveyor, Licensed Nurse (LN) G, removed the resident's shoes and socks and assessed R13's feet. The outer aspect of the right foot had a 1.5 centimeter (cm) by 1 cm callous, and no open areas on the right foot. The outer aspect of the left foot had a 1cm by 1 cm callous, and no open areas to left foot. The left foot great toe had a long toe nail with edges curled into the skin. Administrative Nurse ) D was present and verified the need for toenail care for R13. L N G asked R13 if her feet hurt, and the resident responded yes they do, but my mom will make them better. On 04/25/23 at 07:55AM, CNA M verified R13 verbalized her feet hurt and had a difficult time ambulating. On 04/25/23 at 08:20AM, Certified Medication Aide (CMA) R verified she administered routine medications to R13 without difficulty or refusal On 04/25/23 at 09:50AMLN H verified R13 had an order for as needed acetaminophen for pain. On 04/25/23 at 03:00PM, LN G verified R13 verbalized and grimaced in pain when ambulating. On 04/25/23 at 03:10PM, Administrative Nurse D verified R13 grimaced and complained of pain in both feet, and acknowledged acetaminophen had not been administered except one time on 03/23/23. Administrative Nurse D said R13's toenails required trimming, and that no interventions were done to alleviate R13's pain. The facility's Pain Management Policy, dated 04/12/22, stated documentation is to be completed on resident's who are experiencing pain and assessment is to be completed. It is the responsibility of the clinical staff to assess and reassess the resident for pain. Expressions of pain can be verbal and non-verbal. Interventions are to be used to alleviate a resident's pain. Pharmacological interventions and non-pharmacological interventions are to be used to alleviate pain. Pain control for each resident experiencing pain to promote better quality of life. The facility failed to recognize, evaluate, manage and treat the underlying cause of pain for R13, who was severely cognitively impaired and had a history of pain and visible signs, and verbal complaints, of pain. This placed the resident at risk for impaired mobility, and diminished quality of life.

The facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to store food in accordance with professional standards for food service safety for the 28 residents who resided in the facility and received their food from the facility kitchen, when the facility failed to label and date freezer food items and failed to defrost a freezer. This placed the 28 residents at risk for foodborne illness. Findings included: - On 04/20/23 at 09:31 AM, observation in the kitchen dry storage room, revealed a silver freezer which had an unlabeled, undated loaf of banana bread wrapped in tin foil and an unlabeled, undated paper plate with cookie bars. On 04/20/23 at 09:31 AM, Certified Dietary Manager (CDM) BB verified the above finding, discarded the food items, and stated staff should label and date all food items stored in the freezer. On 04/24/23 at 10:30 AM, observation in the kitchen dry storage room revealed the white upright freezer had approximately one-half inch (in) of ice on four shelves extending from the front of the shelves to the back. The Monthly Cleaning Schedule, dated April 2023, listed the freezers should be cleaned on different weeks. On 04/24/23 at 12:00PM, CDM BB verified the finding and stated she was going to defrost the freezer but since the facility was moving to the new building soon, and getting a new freezer, she decided not to defrost the freezer. The facility's Food Storage Policy, revised 02/17/17, documented food should be dated with the received date to ensure timely use. The facility's Dietary Cleaning Procedures, revised 4/13/22, documented a cleaning schedule check list for daily, weekly, bimonthly, and monthly tasks would be developed and maintained in the dining services notebook. The procedure documented it was the responsibility of each staff member to check the lists at the beginning of the work period to identify the tasks that needed to be performed on that day. The facility failed to store food in accordance with professional standards for food service safety for the 28 residents who resident in the facility and received their food from the facility kitchen. This placed the 28 residents at risk for foodborne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents of which one was reviewed for activities of daily living (ADLs). The facility failed to perform 72-hour voiding diary on admission and failed to provide Resident (R) 29 with a toileting plan for incontinence when the resident was aware of the need to urinate. Findings included: - The Physician Order Sheet (POS), dated 07/06/21, documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The admission Minimum Data Set (MDS), dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score of 13 indicated intact cognition. The assessment documented the resident required one to two staff extensive assistance for all activities of daily living except for eating which he was independent. The assessment documented the resident was frequently incontinent of urine but always continent of bowel. The Continence Care Area Assessment (CAA), dated 06/14/21, documented the resident was frequently incontinent of urine and had functional urinary incontinence due to not being able to take himself to the toilet and requiring one to two extensive staff assistance to transfer to toilet and provide clean up care. The assessment documented the resident as able to use the urinal at night. He had not had a 72 -hour voiding diary due to extensive assistance for toileting. The Urinary Care Plan, dated 06/08/21, documented the care plan goal was to improve upon his current level of continence and directed staff to assist and encourage the resident to use the toilet for his urinary needs and to notify the nurse if a decline in continence was noted so an assessment could be completed. The facility was unable to provide a 72-hour voiding diary or a voiding plan. On 09/16/21 at 10:45 AM, the resident was in the day room putting a puzzle together and then self- propelled himself out of the door and asked a staff member to assist him to the bathroom. On 09/13/21 at 11:30 AM, R29 stated that he had to wait so long for someone to help him get to the bathroom and that he wet in his pants and it humiliated him because he could not get to the bathroom by himself when he had to go. R29 stated he turned the call light on and waited and waited and by the time they answered his call light, he was incontinent. R29 stated he took a water pill every day. On 09/14/21 at 01:45 PM, Certified Medication Aide (CMA) R stated the resident required two staff assistance with transfers and toileting and was able to tell them when he needed changed. On 09/14/21 at 02:47 PM, Licensed Nurse (LN) G stated the aides do the best they can to get to the call light in a timely manner but the resident received a diuretic that made him have to urinate frequently. LN G stated the resident was not on a voiding schedule. On 09/16/21 at 11:32 AM Certified Nurse Aide (CNA) N stated that when the resident called for assistance to go to the bathroom, the CNAs probably made it in time about fifty percent of the time for him to go to the bathroom without being incontinent, but the other fifty percent of the time he had already gone and it was just a matter of changing him. On 09/16/21 at 11:40 AM, Administrative Nurse E stated that if a resident was admitted and needed extensive assistance by two staff the facility does not perform a 72-hour voiding diary and that was the way they had done it for ten to fifteen years. Administrative Nurse E then stated that a voiding plan might help with his incontinence but he also took Lasix which can really inhibit a voiding plan. On 09/16/21 at 03:37 PM, Administrative Nurse D stated that doing a 72-hour voiding diary when the resident was on Lasix and needed two staff assistance with toileting, even when he knew when he had to go, would not work because a voiding diary had to be done every two hours and he would have to be willing to participate. Upon request, the facility did not provide a bowel and bladder policy. The facility's Baseline 48 Hour Care Plan policy, dated 08/14/20, stated a 72-hour voiding diary would be done on all incontinent residents that are admitted to the facility. The facility failed to initiate a 72-hour voiding diary on admission to use the information that it provided to place R29 on a voiding schedule to maintain the resident's dignity from being incontinent.

The facility had a census of 29 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to provide sanitary service during two meals in one of one facility dining rooms. Findings included: - On 09/13/21 at 11:52 AM, observation during the noon meal revealed Dietary Staff (DS) CC served residents beverages and touched rim or lip surface while handling the glasses. DS CC moved one resident's wheelchair for her, and then continued serving other residents' beverages, touching the lip surface with contaminated hands. Continued observation revealed DS CC unwrapped a straw and handled it with bare contaminated hands when putting it in the resident's glass. On 09/16/21 at 11:47 AM, observation in the dining room revealed DS DD used a cloth to wipe the floor using his foot to push it around. DS DD picked up the soiled cloth with bare hands, put it on the bottom of the beverage cart, and continued serving residents beverages without washing his hands. Further observation during the meal revealed DS BB handled residents' glasses very close to the top rim and when separating two glasses had two fingers inside one of the glasses. On 09/16/21 at 02:34 PM, DS BB verified staff are not to handle glasses by the lip surface and should have washed their hands after picking up the soiled cloth from the floor. Upon request, the facility did not provide a food handling policy. The facility failed to provide sanitary services during meals in one of one dining rooms, placing the residents who ate in the dining room at risk for infection.