Based on observation, interview, and record review, the facility failed to provide a reasonable accommodation of resident needs related to call lights for three (Resident (R) 21, R27, and R91) of six residents reviewed for environmental concerns. Call lights were out of reach and not accessible to residents, two of whom were verbally calling out for assistance. The findings include: Although requested, no policy regarding call lights was provided prior to exit from the facility. 1. Review of R21's admission Record found in the resident's electronic medical record (EMR) revealed the facility admitted the resident on 04/04/2023 with diagnoses including debility, coronary artery disease, and dementia. Review of R21's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/11/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3/15, indicating the resident was severely cognitively impaired. Further review of a quarterly MDS, with an ARD of 12/09/2024, revealed a BIMS was not completed due to the resident rarely being understood. Per the MDS, R21 was dependent (helper does all the effort) on staff for all activities of daily living (ADLs) and required substantial/maximal assist (helper does more than half the effort) for mobility performance. Review of R21's undated Comprehensive Care Plan (CCP) revealed the facility assessed R21 as at risk for falls. An intervention initiated on 04/29/2024 to prevent falls was to keep the resident's call light and frequently used personal items within reach. a. During an observation of R21's room on 01/26/2025 at 3:15 PM, R21 was lying in bed, with the head of the bed elevated slightly. R21 had a nightstand next to the bed above, and to the left, of R21's position in bed. An adaptive call light (wide-based touchpad with a cord which plugged into the call light switch) was sitting on top of the resident's nightstand. The adaptive call light was near the wall and behind the resident's supplies, out of the resident's reach. An interview was attempted with the resident; however, R21 was non-interviewable due to severe cognitive impairment. During an interview with Licensed Practical Nurse (LPN) 1 on 01/26/2025 at 3:20 PM, the nurse was notified that R21's adaptive call light was not within reach of the resident. LPN1 stated that all call lights should be within reach of the resident to ensure the resident's safety. Further observation on 01/26/2025 from 3:20 PM until 3:40 PM revealed that neither LPN1 nor any other staff entered R21's room to place the call light within the resident's reach. b. On 01/26/2025 at 5:08 PM, observation again revealed that R21's adaptive call light was on top of the resident's nightstand, out of the resident's reach. During an interview with State Registered Nurse Aide (SRNA) 3, on 01/26/2025 at 5:10 PM, she stated that R21's adaptive call light should be kept within reach of the resident. SRNA3 was uncertain as to why the adaptive call light was not within the resident's reach. She stated that keeping the call light within reach was important for the resident's safety and to prevent accidents. 2. Review of R27's admission Record revealed the facility admitted the resident on 05/23/2023 with diagnoses including mild cognitive impairment and osteoarthritis. Review of R27's Quarterly MDS, with an ARD of 01/22/2025 revealed the facility assessed the resident with a BIMS score of 13/15, indicating the resident was cognitively intact. Further review revealed R27 required partial to moderate assistance with most activities, including turning side to side in the bed and with bed to chair transfers. Review of R27's Care Plan, dated 05/24/2023, revealed the facility assessed the resident as at risk for falls and included the intervention of keeping the resident's call light in reach. Observation on 01/29/2025 at 5:09 PM revealed R27 in bed with her legs swung over the side of the bed, attempting to get up. Further observation revealed the resident's call light was tangled in her bed frame, out of the resident's reach. In continuous observation until 5:21 PM, R27 intermittently yelled for help, but there was no staff member in the hallway to hear her when she called out. Interview on 01/29/2025 at 5:21 PM with R27 revealed she could not find her call light. R27 stated she had screamed and cussed for help, but it didn't do any good. 3. Review of R91's admission Record revealed the facility admitted the resident on 01/18/2024 with diagnoses including unspecified dementia, mild intellectual disabilities, and abnormal posture. Review of R91's care plan, revised 02/08/2024, revealed the resident was at risk for falls. Approaches to prevent accidents included keep call light and frequently used personal items within reach. Observation on 01/26/2025 at 1:13 PM revealed the resident calling for help, stating he needed to be pulled up in bed. Further observation revealed R91's call light was sitting on a nightstand by the window, out of the resident's reach. During an interview with the Director of Nursing Services (DNS) on 02/03/2025 at 5:06 PM, she stated that staff were trained to keep call lights within reach of residents. The DNS stated it was her expectation that call lights were accessible to residents for their safety and well-being. She stated further that knowing that someone would return was crucial for the resident's sense of security. During an interview with the Executive Director (ED 1) on 02/03/2025 at 6:28 PM, she stated it was her expectation that call lights were within the resident's reach at all times to ensure the resident's safety.

Based on interview, record review, and facility policy review, the facility failed to develop a baseline care plan within 48 hours that included the minimum instructions needed to provide effective and person-centered care that met professional standards of quality care for one of 32 sampled residents (Resident (R) 93). The facility admitted R93 with pressure ulcers present; however, neither the identification nor treatment of R93's pressure ulcers were addressed on his baseline care plan. The findings include: Review of the facility's policy titled, Baseline Care Plan, revised 05/16/2024 revealed the baseline care plan will be developed within 48 hours of a resident's/patient's admission and will include the minimum healthcare information necessary to properly care for a resident/patient including, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy and social services, and PASARR (Pre-admission Screening and Resident Review) process recommendation, if applicable. Further review revealed the admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident/patient and resident/patient representative, if applicable. Additional review of the policy revealed interventions shall be initiated that address the resident's/patient's current needs including any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk; any identified needs for supervision, behavioral interventions, and assistance with activities of daily living; and any special needs such as for intravenous (IV) therapy, dialysis, or wound care. Review of the facility's policy titled, Wound Care, dated 05/30/2024 revealed it was the policy of the facility that those residents with impaired skin integrity were recognized by the care teams and residents of the facility have their skin assessed at admission/readmission. Review of R93's, Face Sheet revealed the facility admitted the resident on 12/24/2024 with diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, type 2 diabetes, and muscle weakness. Review of R93's, admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating the resident was cognitively intact. Review of R93's baseline care plan, Section 1N Nursing Services: Fall risk/interventions, wound, and medical needs such as cardiac, diabetes, and respiratory dated 12/26/2024 revealed the resident's pressure wounds were not addressed. In an interview with R93 on 01/26/2025 at 3:46 PM, he stated his pressure ulcers were present when he was admitted to the facility, and he developed them several months ago. In an interview with State Registered Nurse Aide (SRNA) 10 on 01/30/2025 at 3:29 PM, he stated R93 had pressure wounds present on admission. In an interview with Licensed Practical Nurse (LPN) 3 on 01/30/2025 at 4:54 PM, she stated R93 had pressure wounds, but they were present on admission. In an interview with the Assistant Director of Nursing (ADON) on 02/01/2025 at 4:11 PM, she stated the MDS nurse developed baseline care plans, and all baseline care plans were discussed daily in their morning meeting. In an interview with the MDS Nurse on 02/012025 at 4:59 PM, she stated nursing evaluated new admissions for information included on the baseline care plan. The MDS Nurse stated information was retrieved through interview and assessment. She further stated every care area was assessed, and if a resident was admitted with a pressure ulcer that should be included on the baseline care plan. She stated it was important that the baseline care plans were accurate, so staff ensured the best quality of care was provided and residents' needs were met. In an interview on 02/01/2025 at 7:15 PM with the Director of Nursing Services (DNS), she stated the purpose of a baseline care plan was it provided a basic outline of a resident's required care. She further stated a pressure ulcer present on admission was a care area included on their baseline care plan. The DNS stated it was important the baseline care plan was accurate, so residents received proper care based on their needs.

Based on observation, interview, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to provide care and treatment to prevent and/or treat urinary tract infections (UTI) in accordance with accepted standards of practice for two (Resident (R) 1 and R125) of seven sampled residents who had an indwelling urinary catheter. R1 and R125's catheter collection bags were not secured and were, instead, on the floor. In addition, the facility failed to take immediate action when R1 presented with indicators of a urinary tract infection. The findings include: Review of the facility's policy titled, Indwelling Catheter. revised 01/02/2024, revealed the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures. Additionally, the policy stated that care practices included recognition and assessment for complications and their causes and maintaining a record of any catheter related problems. Review of the Centers for Disease Control and Prevention [CDC] and Health Research and Educational Trust [HRET] Presentation, dated 2015, revealed catheter care essentials included use of a catheter securement device to anchor the catheter. Further review revealed catheter care included keeping the collection bag off the floor. Review of the CDC's Guideline for Prevention of Catheter Associated Urinary Tract Infections [CAUTI], dated 2009, revealed proper techniques for catheter maintenance included to maintain unobstructed urine flow and to keep the catheter and tube free from kinking. Further review revealed the collecting bag should always be kept below the level of the bladder and should not rest on the floor. 1. Review of R1's admission Record, found in the electronic medical record (EMR), revealed the facility admitted the resident on 07/14/2022 with diagnoses including end-stage renal disease, and uropathy (blockage in the urinary tract). Review of Physician Orders, dated 12/26/2024, revealed the resident had a urinary Foley catheter with tubing and drainage bag. Review of R1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/30/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. Further review of the MDS revealed the resident had an indwelling catheter. Observation in R1's room, on 01/28/2025 at 10:10 AM, revealed R1 was in bed. The resident's catheter collection bag was not secured to the bed and was observed lying flat on the floor. Continued observation revealed the catheter tubing was not anchored in any way. Upon examining the catheter tubing, it was noted to have streaks of white sediment. The urine collection bag contained approximately 250 milliliters (ml) of dark amber urine, which also had sediment present. During observation and interview with R1 on 01/28/2025 at 10:15 AM, R1 reported experiencing pain in her lower abdomen, which she believed was consistent with a UTI. She stated that she recently had been treated for a UTI but had experienced bladder spasms and pain with urination overnight. R1 stated that she informed the evening staff about her pain and communicated it to the nursing aide presently on duty. However, according to R1, staff had not addressed her concerns, and no nurse had come to assess her this morning. Review of R1's EMR revealed there was no documentation of R1's complaint of bladder spasms overnight, or the morning of 01/28/2025. In response to the resident's concerns, the State Survey Agency Surveyor informed Licensed Practical Nurse (LPN) 1, on 01/28/2025 at 10:40 AM, that R1 had complained of pain with urination and bladder spasms. LPN1 stated she would assess the resident immediately. Review of a Progress Note, dated 01/28/2025 at 3:18 PM, revealed new orders were received to obtain a urinalysis (UA) and culture and sensitivity (C&S) due to frequent urination and pain with urination. An additional Progress Note, dated 01/28/2025 at 5:02 PM, revealed that when R1's catheter was changed, per her request, the urine collection bag contained 300 milliliters (ml) of straw-colored urine with moderate sediment noted. Review of a Progress Note, dated 01/28/2025 at 8:13 PM, revealed a UA sample was obtained via the catheter tubing and sent to lab for testing. Review of the Progress Note, dated 01/29/2025 at 8:14 AM, revealed new orders for ceftriaxone injection (an antibiotic which kills bacteria) to be administered intramuscularly (in the muscle) for five days due to a UTI. During an interview with State Registered Nurse Aide (SRNA) 19 on 01/28/2024 at 10:24 AM, she stated R1 had an indwelling catheter, and the catheter collection bag always dark urine with sediment in it. SRNA19 confirmed she was aware of R1's dark urine and complaints of bladder spasms earlier in the shift. She stated she told one of the nurses but could not recall which nurse she told. During an interview with LPN1 on 01/28/2024 at 10:40 AM, she stated that R1 had just finished antibiotic therapy on 01/26/2025 to treat a UTI. The nurse stated she was not aware if the resident had been assessed for the antibiotic's effectiveness. She stated that despite rounding on the resident, she was unaware R1 was not feeling well. LPN1 stated that no one brought R1's concerns to her attention. Further interview revealed the catheter bags should not touch the floor due to the risk of causing an infection. During an interview with the Nurse Practitioner (NP) on 01/29/2025 at 7:30 AM, he stated R1 was recently treated for a UTI. The NP stated that he was not aware that the resident's UTI symptoms continued until he was notified yesterday, after the SSA intervention. The NP added that R1 had a history of recurring UTI's, and dysuria (discomfort, pain, or burning during urination). The NP stated that the nurses communicated changes in condition (CIC) by calling the provider. The NP stated that he would like the nurses to increase nursing documentation, as the providers reviewed all notes. He stated that while nurses chart by exception, this was inadequate, and that any changes in patients' (residents') conditions should be documented in the nursing notes. 2. Review of R125's admission Record revealed the facility admitted the resident on 01/27/2025 with diagnoses including adult failure to thrive and UTI. Review of R125's Baseline Care Plan, dated 01/27/2025, revealed a focus, initiated 01/27/2025, that the resident was at risk for infection/complications related to a suprapubic catheter in place due to obstructive uropathy. Interventions, dated 01/27/2024, included: suprapubic catheter care every shift and observe for symptoms of urinary tract infection. Further review revealed a focus area, initiated 01/27/2025, that R125 had a UTI. During an observation of R125 on 02/01/2025 at 4:50 PM, revealed the resident was in his wheelchair, resting with his eyes closed. R125's suprapubic catheter collection bag was not secured to the wheelchair and was observed lying flat on the floor near the back wheel. During an interview with SRNA12 on 01/30/2025 at 10:42 AM, she stated she was trained on catheter care, which included ensuring the tubing was not kinked, keeping the tubing below the bladder, and anchoring it to the bed or wheelchair. During an interview with SRNA13 on 01/30/2025 at 10:42 AM, she stated catheter care included ensuring the tubing was not kinked or looped and to keep the tubing below the bladder to prevent back up. She stated that the catheter collection bag should be anchored to the bed or wheelchair and never placed directly on the floor as it could put the resident at risk for infection. During an interview with the Infection Preventionist and Staff Development Nurse (IP/SD) on 02/01/2025 at 1:29 PM, she stated that the facility recently focused on catheter care and hygiene, observing aides as they practiced their skills to ensure competency and to provide guidance if necessary. She stated that catheter maintenance involved ensuring an unobstructed urine flow and keeping the catheter and tube free from kinks. The IP/SD stated the collecting bag should always be below the bladder level and not rest on the floor, explaining that this was important to prevent the risk of healthcare acquired infections (HAI), including UTIs. During an interview with the Assistant Director of Nursing (ADNS) on 02/01/2025 at 4:50 PM, she stated catheter bags should be anchored to the bed frame or wheelchair and never rest on the floor. The ADNS stated this was important to prevent UTIs. During an interview with the Executive Director (ED) on 02/01/2025 at 6:28 PM, she stated it was her expectation that staff follow facility policies and CDC guidelines to ensure the safety and well-being of the residents and to prevent the spread of infection.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure residents received appropriate treatment and services to prevent complications of enteral feeding for one (Resident (R) 62) of two sampled residents reviewed for tube feeding. After failing to receive all ordered nutrition and fluids via gastrostomy tube (g-tube), R62 was hospitalized with severe dehydration and hypernatremia (elevated blood sodium levels). The findings include: Review of the facility's policy Enteral Feeding, dated 01/02/2024, revealed the facility would ensure enteral feedings would be administered in accordance with current clinical standards of practice, with interventions to prevent complications. Review of R62's admission Record revealed the facility admitted the resident on 07/12/2023, with an original admission date of 04/14/2022. R62's diagnoses included epilepsy, vascular disorder of the intestine, dysphagia, and intellectual disabilities. Per the admission Record, the resident also had a diagnosis of gastrostomy, with an onset date of 10/16/2023. Observation on 01/26/2025 at 1:16 PM, revealed R62 resting with his eyes closed in bed. His bed was elevated. The resident was receiving an enteral feeding via g-tube of Vital 1.5 at 65 milliliters (ml) /hour by pump. Attempts to interview the resident were unsuccessful, due to the resident's cognition. Review of R62's Quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 11/14/2024 revealed the resident was assessed by the facility as severely cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of 1/15. Further review of the MDS revealed R62 was dependent (helper does all of the effort) for activities of daily living (ADLs). Review of R62's Comprehensive Care Plan [CCP], undated, revealed the facility identified R62 as being at risk for dehydration on 04/27/2022. Care plan interventions revised on 12/02/2024 included administer medications as ordered and observe for side effects, document intake, encourage and assist with fluid intake, notify physician if persistent symptoms of diarrhea, nausea, or vomiting, and observe for signs and symptoms of dehydration to include decreased urine output, concentrated urine, cracked lips. Review of the Physician Orders, dated 08/29/2024, revealed R62 was to receive Vital 1.5 enteral feed at 65 mL/h for 23 hours for a total of 1495 mL per day, via g-tube. Per the orders, the resident was to receive nothing by mouth (NPO). Additionally, there was an order dated 12/29/2023 for a water flush with 50 mL every two hours for a total of 600 mL per day. All nutrition was from enteral feeding. Record review revealed on 11/03/2024 an order for a stat (immediate) x-ray (medical imaging) of the resident's kidney, ureter, and bladder (KUB) was done for abdominal distention. However, review of R62's electronic medical record revealed no evidence from 10/22/2024 to 11/01/2024 of distention. On 11/06/2024 orders were received for a chest x-ray and blood work due to cough, congestion and confusion, although there was no corresponding documentation of the resident's condition. Review of a Hydration Risk Assessment - V2, dated 11/06/2024, revealed R62 scored an 11, which indicated the resident was at high risk for dehydration. Additionally, on 11/07/2024 at 1:11 AM, an order was obtained for Ativan (a medication used to treat anxiety) for agitation although there was no corresponding nursing documentation explaining the specifics of the resident's condition. Review of a Hydration Risk Assessment - V2, dated 11/06/2024, revealed R62 scored an 11, which indicated the resident was at high risk for dehydration. Review of an unsigned Physician Progress Note, dated 11/07/2024 at 11:22 AM, revealed R62 was seen for a routine examination. R62 was assessed as being alert, impaired at baseline. No cough or shortness of breath. The notes stated the resident did not appear to be in any distress or discomfort and staff had no concerns. Review of an Order Note, dated 11/08/2024 at 6:55 AM, revealed R62 was experiencing increased agitation and aggression. According to the note, the resident pulled out his feeding tube, colostomy bag, and Foley (brand of indwelling catheter). The note stated the Nurse Practitioner (NP) was notified and orders were obtained to increase the resident's anti-anxiety dosage. Review of a No Type Specified Note, dated 11/10/2024 at 9:10 PM, revealed R62 had an urinalysis that was positive for infection. An antibiotic (medication to kill bacteria) was ordered. Review of an Order Note, dated 11/15/2024 at 4:30 AM, revealed R62 experienced increased lethargy and altered mental status, elevated blood pressure, elevated pulse, and lungs sounds were noted with rhonchi (low-pitched, gurgling sounds) bilaterally. Per the note, R62 was difficult to arouse at this time. Additionally, R62 experienced increased behaviors and agitation and displayed aggression toward staff. According to the documentation, orders were obtained to send the resident out for evaluation. Review of the local Emergency Department's (ED) Hospital Medicine admission History and Physical, dated 11/15/2024, revealed the hospital physician stated the resident presented with confusion worse than his baseline. Per the record, the nursing home facility reported the resident had been treated for urinary tract infection recently and staff stated the resident had been sick for a week. The physician assessed R62 as very unkempt on arrival, clinically dry on exam, chronically ill appearing overall. According to the note, R62 was admitted for hypernatremia (increased sodium concentration in the blood). Further review of lab values taken in the ED revealed R62's was noted to be severely dehydrated with sodium levels at 164 milliequivalents per liter (mEQ/L) (normal value is between 135 and 145 mEQ/L). Review of a No Type Specified Note, dated 11/15/2024 at 9:10 PM, revealed the local hospital called the facility to inquire about the resident's condition on arrival to the ED. The note stated the caller asked about the resident being clinically dry on examination. The nurse stated in her note the reason was that R62 did not take fluids or meals by mouth and was a mouth breather. Review of the local hospital's Physician Discharge Summary, dated 11/22/2024, revealed R62's discharge diagnosis was hypernatremia with additional problems to include dehydration, and a urinary tract infection (UTI). Review of the recorded intake for tube feeding was reviewed for the two weeks prior to the resident's hospitalization for dehydration and hypernatremia. Based on physician orders, from 11/01/2024 to 11/14/2024, R62 should have received 16,800 mL of water flushes. However, review of the intake records for 11/01 - 11/14/2024, revealed the resident only received 12,200 mL (deficit of 4,600 ml.) In addition, based on physician orders, the resident should have received 20,944 mL of enteral feed. Review of the intake records for 11/01 - 11/14/2024 revealed R62 received only 13,045 mL over the course of the 14 days (deficit of 7899 mL). Review of nursing documentation indicated that the enteral feed was turned off during this time period on 11/06/2024 at 8:21 PM, 11/09/2024 at 5:01 AM, and 11/10/2025 at 5:21 AM, due to the resident vomiting or feelings of fullness. There was no evidence of how long the enteral feed was turned off each of these times. During an interview with Licensed Practical Nurse (LPN) 1 on 01/27/2025 at 4:55 PM, she stated she remembered that R62 had gone to the hospital but did not recall the specifics. She stated R62 has bouts of nausea and vomiting and could decline quickly. She stated his tube feed was turned off due to distention and nausea and vomiting. She stated prior to his admission to the hospital in November 2024, he also had bouts of diarrhea, which were being addressed. She stated she did not know why more information about the resident's symptoms was not documented but she thought it was communicated to the providers and nurses in shift report. LPN1 stated it was important to document any change in condition. An attempt to interview LPN5, who was the nurse on duty the day the resident was transferred to the hospital was unsuccessful, as the nurse no longer worked at the facility. During an interview with MDS Nurse 1 on 02/01/2025 at 4:55 PM, she stated that the nurses caring for R62 should have documented his decline and communicated this based on his symptoms. She stated that if R62 was not receiving tube feedings as ordered, he should have been evaluated to prevent dehydration and malnourishment. During an interview with the Nurse Practitioner (NP) on 01/29/2025 at 7:30 AM, he stated he was in the facility full time. The NP stated R62 was treated for a UTI, and then was transferred to the hospital for evaluation and admitted . The NP stated that nurses communicated changes in condition (CIC) by calling the provider. When interviewed about the lack of nursing documentation in the progress notes related to R62, he stated changes should be documented. The NP stated that he would like the nurses to increase nursing documentation as the providers review all notes. He stated that while nurses chart by exception, this was inadequate. He emphasized that any changes in patients' (residents') conditions should be documented in the nursing notes. During an interview with the Director of Nursing Services (DNS) on 01/27/2025 at 3:35 PM, she stated there should be documentation in the chart if nausea and vomiting occurred and the tube feeding needed to be stopped. The DNS stated that if the feeding was withheld, the nurse practitioner should be notified, as ensuring proper nutrition was important to the health of the resident. She stated that if an order was not carried out, nurses need to communicate with the physician or nurse practitioner to maintain continuity of care. The DNS stated that the nurse leaders audited progress notes from the past 24 to 72 hours and stated no issues were found with the nursing documentation. The Executive Director (ED1) was interviewed on 02/01/2025 at 9:30 AM about the resident's admission to the hospital for dehydration, UTI, and hypernatremia. ED 1 stated the reason R62 appeared dehydrated on presentation to the ED was that he was a mouth breather. During interview with ED1 on 02/01/2025 at 6:28 PM, she stated she expected staff to provide care according to the resident's plan of care. She stated further that it was her expectation the nurses would administer and apply all treatments as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure pain management was provided as ordered for one (Resident (R) 119) of five sampled residents reviewed for pain. The facility failed to ensure pain medication was reordered timely and available to the resident per the physician's orders and comprehensive care plan. The findings include: Review of the facility's policy, Medication Administration, dated 01/02/2024, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice. Further review revealed staff were expected to keep the medication cart stocked with adequate supplies. The policy stated the expectation that medication was administered within 60 minutes prior to or after its scheduled time unless otherwise ordered by the physician. Additional review revealed medications that were readily available for administration will be obtained from the Emergency Kit, drop shipped from the pharmacy or obtained from an alternative pharmacy. Per the policy, the physician will be notified timely of medication omissions. Review of the facility's policy titled, Pain Management, dated 12/02/2024, revealed the facility must ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Further review revealed in order to help a resident attain or maintain the highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will do so consistent with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences. The policy stated that assessment of pain by the interdisciplinary team may necessitate gathering information such as the resident's current conditions, characteristics of the pain, activities that exacerbate the pain, impact of pain on quality of life, current prescribed pain medications, including dosage and frequency. Additional review revealed the interventions for pain management would be incorporated into the comprehensive care plan, including to consider administering medication around the clock instead of on demand (PRN) or combining longer acting medications with PRN medications for breakthrough pain. Further review revealed opioids would be prescribed and dosed in accordance with current professional standards of practice and manufacturer's guidelines to optimize their effectiveness and minimize their adverse consequences. Per the policy, facility staff will notify the practitioner, if the resident's pain was not controlled. Review of R119's closed record revealed the facility admitted the resident on 02/09/24 from an acute care facility with a principal diagnosis of right acetabulum fracture with delayed healing, as well as atherosclerotic heart disease of native coronary artery, type 2 diabetes mellitus, and generalized osteoarthritis. Further review of R119's admission Record revealed R119 was discharged home on [DATE] and the resident was unavailable for interview. Review of R119's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2024, revealed the resident was taking, and had a documented indication, for opioid medication. Review of the admission MDS revealed he was receiving a scheduled pain medication regimen, had received as needed pain medications, and that the Pain Assessment Interview should be conducted. Review of the ensuing Pain Assessment Interview revealed R119 had experienced frequent pain in the past five days, to include occasional inability to sleep and frequent inability to participate in therapy due to pain. Review of R119's Comprehensive Care Plan, dated 02/12/2024, revealed a focus that he was at risk for pain related to the right acetabulum fracture, arthritis, and back pain. Interventions including for staff to administer pain medications as ordered, assist with distracting attention off of his pain with music, television, audio books, counting, drawing or coloring, and notify the physician of unrelieved or worsening pain. Review of R119's physician orders revealed an admission order for oxycodone, 10 mg tablet every four hours as needed (PRN), dated 02/09/2024. This was followed by an order on 02/15/2024 to change the oxycodone 10 mg tablet orders to every four hours (routine, not PRN). Further review revealed that this order was discontinued on 04/16/2024. A new order for Oxycodone 10 mg every four hours was initiated on 04/16/2024 at 1:00 PM. Additional review revealed no orders for retrieval of oxycodone, if needed, from the Emergency Kit. a. Review of R119's Medication Administration Record (MAR) for 04/2024 revealed the Oxycodone order dated 02/15/2024 was documented as having been administered on 04/16/2024 at 3:00 AM and 7:00 AM. The 11:00 AM dose was marked as Other - see progress notes. Further review of the 04/2024 MAR revealed the new order of Oxycodone, as of 04/16/2024, was marked at 1:00 PM and 5:00 PM as Other - see progress notes. Review of the associated note for the missed 11:00 AM dose documented by State Registered Nursing Assistant/Qualified Medication Aide (SRNA/QMA) 8 revealed they were waiting on script [prescription]. Review of the associated note for the new order of oxycodone revealed that the 04/16/2024 doses scheduled for 1:00 PM and 5:00 PM were not given as the medication was documented as on order. Continued review of the MAR revealed the ordered pain medication was not given until 9:00 PM on 04/16/2024. Review of R119's Controlled Drug Administration Record (CDAR) for the 30 tablets of Oxycodone, 10 mg, received 04/09/2024, revealed the last of the 30 tablets was signed out on 04/16/2024 at 3:00 AM. Review of the CDAR for the 30 tablets of Oxycodone, 10 mg, which was received after the new order on 04/16/2024, confirmed the first tablet was signed out on that date at 9:00 PM . Review of R119's medical record progress notes revealed no evidence that non-pharmacological pain relief interventions were applied/attempted during the time that the resident was without pain medication, Further review of the record revealed the only pain assessment for 04/16/2024 was completed prior to the resident missing any scheduled doses of medication Review of R119's Pain Level Summary, completed on 04/16/2024, at 6:40 AM, revealed that the resident was experiencing pain at a score of 7/10 on the scale. Further review of R119's progress notes revealed no evidence indicating the provider was notified that the medication was unavailable or requested an authorization for medication retrieval from the Emergency Kit. b. Review of R119's MAR for 05/2024 revealed the Oxycodone 10 mg tablets scheduled for 1:00 AM and 5:00 AM on 05/02/2024 were not administered and were marked as Other - see progress notes. Review of the associated notes revealed both were documented as Waiting on delivery. Review of the Weights and Vitals section of R119's medical record revealed only one pain assessment was completed on 05/02/2024. During this assessment, at 10:01 AM, R119 reported pain at 5/10. During telephone interview with SRNA8 on 01/31/2025 at 8:55 PM, she stated she tries to order when residents' medications get down to 15 pills. For pain medication, she stated she must relay the need to the nurse because only they could get on the pharmacy online system (Mediprocity), to communicate with them and put in narcotic orders. She stated if she found a resident was out of a narcotic, she would relay that to the nurse who should contact the provider for a one-time dose to retrieve from the Emergency Kit in the Pyxis (a machine storage system for medications). During interview with SRNA22 on 01/31/2025 at 8:19 AM, she stated it was best to prevent running out of medication by ordering by the time a resident's stock was down to about 10 pills. SRNA 22 stated that if she did give the last pill of a resident's prescription, the process should be to alert the nurse to reorder and if the resident needed the next dose before it could be delivered, the nurse should request to obtain a one- time dose from the Emergency Kit in the Pyxis. During interview with SRNA7 on 01/31/2025 at 8:24 AM, she stated to prevent running out of residents' medications, staff should report to the nurse when they were down to about 10 pills, so it could be reordered. SRNA7 stated this gives time for the provider to sign and get the medication delivered before the remaining pills were used. In further interview, she stated if a medication ran out, there was a process for the nurse to contact the provider and get an order to retrieve the medication from the Emergency Kit. She stated it was important that residents received their medication timely. Interview with Licensed Practical Nurse (LPN) 3, on 01/30/2025 at 4:54 PM, revealed that when the Qualified Medication Aides (QMA)s were down to eight pills on a medication card, they were to notify the nurse, and she reordered it. She stated they if they run out, they have pain medications in the Pyxis and that they could call the physician for a one- time order. LPN3 also stated that they could reorder medications online. She stated they received two deliveries every day from the Pharmacy, and there was no reason for anyone to run out of medications. During interview with the Director of Nursing Services (DNS) on 01/31/2025 at 8:05 AM, she stated the staff should be aware of declining stock and order it in time to be delivered before it was needed. She stated the QMAs were expected to alert the nurse to reorder the medications and nurses could message the pharmacy through the online system to check the status of the medications. In further interview, the DNS stated if a resident's medication supply was empty, the nurse could contact the provider for a one time order to retrieve the medication from the Emergency Kit.

Based on interview, record review, and facility policy review, the facility failed to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive for eight of 13 sampled residents reviewed for advanced directives. (Resident (R) 93, R124, R17, R102, R5, R76. R12, and R36). The findings include: Review of the facility's undated policy, titled, Advance Directives, revealed that prior to or upon admission, the Social Services Director (SSD) or Designee will provide written information to the resident concerning his/her right to make decisions about medical care including the right to accept or refuse medical treatment, and the right to formulate advance directives. Further review revealed the SSD or Designee will inquire about the existence of any advance directives and, should the resident indicate that they issued advance directives about their care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive should be included in the resident's medical record. Review of a Skilled Nursing Facility admission Agreement revealed that, under the section titled, Treatment Decision Making and Surrogate Decision Makers/Right to Make Treatment Decisions and Make Advance Directives, the resident had the right to make informed treatment decisions for him/herself including the right to refuse treatment and to exercise those rights through a surrogate decision maker (Guardian, Patient Advocate, or other legally appropriate representative) when the resident was not competent to do so him/herself, in accordance with applicable law. Additional review revealed a competent resident also had the right to make an advance directive to appoint a surrogate decision maker and to provide information about what kind of treatment was desired in the future in the event the resident became unable to make his/her own treatment decisions. Final review revealed information about how to make an advance directive and the facility's policies regarding implementation of the residents right to make an advance directive was attached and incorporated into the agreement as Exhibit N. Review of a sample resident admission packet revealed that under Section 10, titled Exhibits, it stated, By signing this Agreement, the Resident acknowledges that he/she has received a copy of all of the following Exhibits to the Agreement, each of which is incorporated into and made part of this Agreement. Exhibit N of the agreement outlined information about Advance Directives and included documents to be completed which were labeled as N-11, N-12, and N-13. Review of Exhibit N revealed that this section of forms included spaces with the instructions to check box and initial line if you desire the option below for various living will directives, including marking whether they desired life-saving treatment. 1. Review of R93's Face Sheet revealed the facility admitted the resident on 12/24/2024 with diagnoses including infection and inflammatory reaction due to indwelling urethral catheter, type 2 diabetes, and muscle weakness. Review of R93's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/31/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. In an interview with R93 on 01/28/2025 at 4:15 PM, he stated he did not have an advance directive in place and was not asked by facility staff at admission if he wished to formulate an advance directive. Review of R93's, Skilled Nursing Facility admission Agreement, dated 12/24/2024, revealed an incomplete Living Will Packet in the section titled, Exhibit N - Information About Advance Directives. The only information filled in on the form was the resident's name and birthdate. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner he understood. 2. Review of R124's record revealed the facility admitted the resident on 01/16/2025 with diagnoses including rehab following myocardial infarction (MI) with life vest, sepsis related to septic knees, and intravenous (IV) antibiotic therapy. Review of R124's admission MDS, with an ARD of 01/16/2025, revealed the resident had a BIMS score of 15/15, indicating the resident was cognitively intact. In an interview with R124 on 01/28/2025 at 10:16 AM, she stated she had an existing advance directive; however, facility staff had not requested a copy, and she was not asked about advance directives on admission. Although R124, who was cognitively intact, stated she had an existing advance directive completed prior to admission, review of R124's Resident Documents revealed no evidence the resident had an existing advance directive in her electronic medical record (EMR). Review of R124's Skilled Nursing Facility admission Agreement, dated 01/16/2025, revealed an incomplete Living Will Packet in the section titled, Exhibit N - Information About Advance Directives. The only information filled in on the form was the resident's name and birthdate. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner she understood, or that the facility requested a copy of the advance directive she had previously formulated. 3. Review of R17's Face Sheet revealed the facility admitted the resident on 09/14/2024 with diagnoses including acute and chronic respiratory failure with hypoxia, alcoholic cirrhosis of the liver with ascites, and congestive heart failure (CHF). Review of R17's quarterly MDS, with an ARD of 12/19/2024, revealed the resident had a BIMS score of 15/15, indicating the resident was cognitively intact. Review of R17's admission Agreement, dated 09/14/2024, revealed an incomplete Living Will Packet in the section titled, Exhibit N - Information About Advance Directives. The only information filled in on the form was the resident's name and birthdate. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner he understood. 4. Review of R102's Face Sheet revealed the facility admitted the resident on 10/15/2024 with diagnoses including dementia, major depressive disorder, and muscle weakness. Per the Face Sheet, the resident's daughter was her Responsible Party (RP). Review of R102's quarterly MDS, with an ARD of 01/15/2025, revealed the resident had a BIMS score of 3/15, indicating the resident was severely cognitively impaired. Review of R102's Skilled Nursing Facility admission Agreement, dated 10/15/2024 revealed an incomplete Living Will Packet in the section titled, Exhibit N - Information About Advance Directives. The only information filled in on the form was the resident's name and birthdate. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident and/or their RP in a manner they understood. 5. Review of R5's Face Sheet revealed the facility admitted the resident on 07/13/2023 with diagnoses including end stage renal disease (ESRD), type 2 diabetes, and CHF. Review of R5's quarterly MDS, with an ARD of 12/25/2024, revealed the resident had a BIMS score of 15/15, indicating the resident was cognitively intact. Review of R5's, Skilled Nursing Facility admission Agreement, dated 07/13/2023, revealed an incomplete Living Will Packet in the section titled, Exhibit N - Information About Advance Directives. The only information filled in on the form was the resident's name and birthdate. Further review revealed no documented evidence the facility explained the opportunity to formulate or decline an advance directive to R5 in a manner she understood. 6. The facility admitted R76 on 07/18/2022 with diagnoses of quadriplegia, heart failure diabetes mellitus, and malnutrition. Review of R76's Skilled Nursing Facility admission Agreement revealed R76 had signed and printed her name under the statement that read, By signing below, the parties have executed this Agreement, intending to be bound by its terms. The resident party(ies) certify by their signatures that they have read and understand this Agreement, and that they received a copy of this Agreement, and the other documents referred to or attached to this Agreement, including but not limited to all Exhibits. However, the form was undated and there was no indication when it was completed. Although R76 signed that they received a copy of all exhibits, review of the documents revealed that all required exhibits were not completed. Review of Page 10 of R76's Exhibit N of the Skilled Nursing Facility admission Agreement, titled, Information about Advance Directives revealed that the sections which should have been filled out and signed by R76 were blank. 7. The facility admitted R12 on 04/30/2024 with diagnoses of Parkinson's disease, schizophrenia, seizures, depression, and diabetes mellitus. Review of R12's Skilled Nursing Facility admission Agreement revealed R12 had signed and printed her name, indicating that she had received a copy of all documents referred to or attached to this Agreement, including but not limited to all Exhibits. However, review of R12's Skilled Nursing Facility admission Agreement revealed Exhibit N, titled Information about Advance Directives, was not completed. Review of R12's Skilled Nursing Facility admission Agreement under the section titled, Kentucky Living Will Directive and Healthcare Surrogate Designation exhibits N-11, N-12 and N-13 revealed R12's name and date of birth had been filled in at the top but the check boxes for the sections labeled, Health Care Surrogate Designation and Living Will Directive were blank and the document was unsigned. No declination to formulate an Advance Directive was documented. 8. Review of R36's admission Record found in the resident's EMR revealed the facility admitted the resident on 12/31/2020 with diagnoses to included Alzheimer's disease, dementia, and chronic obstructive pulmonary disease. Per the Face Sheet, the resident had an RP. Review of R36 's Quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/30/2024 revealed the resident was assessed by the facility as having long and short-term memory problems. Review of R36's Resident Documents, revealed there was no Skilled Nursing Facility admission Agreement, found in the resident's medical record. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident and/or RP in a manner which she understood. Further record review revealed R36 had Authorization to Treat and Code Status, documents, dated 11/05/2015 and 11/20/2021, which indicated that she had a Do Not Resuscitate (DNR) code status. However, review of 36's, Resident Documents, revealed no evidence the resident had an existing Advance Directive/Living documented in her EHR. During an interview with the Social Services Director (SSD) on 01/31/2025 at 10:58 AM, she stated she acted as the Admission's Coordinator, and reviewed all admission documentation with the residents and/or their representatives. She stated this process included discussions about Advance Directives. Additionally, she stated that as part of the admission packet, all residents and/or their representatives were given the opportunity to complete an Advanced Directive/Living Will. The SSD stated all information regarding advance directives was documented in each resident's chart. Furthermore, she stated if a resident has an advance directive prior to admission, a copy was obtained and uploaded to the resident's EHR. When asked about the failure to complete the forms/have evidence that the information was actually provided to each resident, the SSD stated it was acceptable to include the blank forms in the record because she had discussed the information verbally with the residents. Interview with the Director of Nursing Services (DNS) on 02/01/2025 at 7:15 PM, revealed the SSD was to discuss advance directives with residents and/or their representatives at admission. She further stated it was important the entire advance directive process was explained to residents in a manner they easily understood. Further interview with the DNS revealed she was unaware that there was no evidence that the process had actually been completed as required, with each resident afforded the opportunity to formulate, decline, or provide a copy of an advance directive which had previously been formulated. During an interview with the Executive Director (ED1) on 01/28/2025 at 9:00 AM, she stated that residents or their legal representatives sign paperwork in the admission packet, acknowledging receipt of all its components. At this time, the survey team requested evidence that the information in Section N regarding advance directives was actually provided to the residents and all required forms were completed. The ED stated all the residents had signed the Acknowledgement of Receipt of documents, and That was enough. ED1 stated that the signed page was all the facility obtained and they could not provide any other evidence to show that the above-listed residents received the information about Advance Directives and were given the opportunity to formulate or decline formulation of an advance directive. Additional interview with ED1, on 02/01/2025 at 6:28 PM, revealed the Admissions Coordinator reviews admission documentation, including Advanced Directives and Living Wills, at the time of admission. In addition, she stated the facility provides opportunities for residents to discuss and review advance directives on a quarterly basis, and as needed. ED1 stated it was her expectation that all residents have the chance to engage in discussions about their advance directives and it was important to ensure their wishes were honored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to notify the resident and/or the resident's representative(s) in writing of the specific reasons for transfer to another facility for five (Residents (R) 6, R61, R62, R12, and R84) of seven residents reviewed for hospitalization. The findings include: Review of the facility's policy Transfer and Discharge, dated 12/12/2023, revealed the facility was to provide residents and their representatives with a written notice for the specific reason for the transfer, including for emergency transfers to an acute care hospital. 1. Review of R6's admission Record revealed the facility admitted the resident on 03/22/2019 with diagnoses including early onset Alzheimer's disease, Crohn's disease (a disease of the intestines), and ulcerative colitis (a disease of the intestines). Review of R6's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. Review of the Progress Note, dated 08/18/2024, revealed R6 had bloody stools and was sent to the hospital for evaluation. Review of the facility's document, Notice of Transfer or discharge: Notice of Bed Hold Days, dated 08/18/2024, revealed the facility documented R6 was transferred for eval. Further review revealed the document failed to include the specific reason which necessitated the transfer. In an interview on 01/26/2025 at 2:59 PM, R6 stated she recalled needing to go to the hospital in the last few months but did not recall the facility giving her paperwork related to her transfer to the hospital. 2. Review of R61's admission Record revealed the facility admitted the resident on 12/15/2022 with diagnoses including schizoaffective disorder, morbid obesity, and unspecified disorders of the skin. Review of the Progress Note, dated 11/03/2024 revealed R61 was coughing up blood on that date and was sent to the hospital for evaluation. Review of the facility's document Notice of Transfer or discharge: Notice of Bed Hold Days, dated 11/03/2024 revealed the facility documented R61 was transferred for eval. Further review revealed the notice failed to include the specific reason condition which necessitated the transfer. 3. Review of R62's admission Record revealed the facility admitted the resident on 04/14/2022 with diagnoses including Dravet syndrome (severe epilepsy) seizure disorder, and obstructive uropathy. Review of R62's Quarterly MDS, with an ARD of 12/26/2024, revealed the resident had severe cognitive impairment and a legal guardian who participated in the resident's overall assessments and goal setting and all decision making. Review of a Progress Note, dated 10/12/2024, revealed R62 had excessive vomiting and bowel obstruction and was sent to the local hospital for evaluation. Review of the Notice of Transfer or discharge: Notice of Bed Hold Days, dated 10/09/2024, revealed the facility documented R62 was transferred for eval. Further review did not provide additional details about the specific reason that led to the transfer. 4. Record review revealed the facility admitted R12 on 04/18/2024 with diagnoses of Parkinson's Disease, schizophrenia, seizures, depression, and diabetes mellitus. Review of R12's MDS Assessment records from 06/12/2024-12/23/2024 revealed R12 was transferred to the hospital on [DATE] and 08/22/2024. Review of R12's Progress Note dated 08/08/2024 at 6:00 PM revealed R12 was admitted to the hospital with diagnosis of hepatic encephalopathy. Review of R12's Progress Note dated 08/22/2024 at 4:24 PM revealed R12's blood ammonia level was elevated; the Nurse Practitioner was notified, and orders were to send the resident to the hospital. Review of R12's EMR revealed no evidence that notice of the resident's transfer, which included the specific reason for the transfer, was provided to the resident for either of the two hospitalizations. 5. Review of R84's admission Record, revealed the facility admitted the resident on 01/11/2024 with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and gastrointestinal hemorrhage. Review of R84's, Progress Note, dated 01/24/2025 revealed the resident reported to staff she had breathing difficulties and continuous oxygen at 4 Liters (L). Further review of the progress note revealed the resident had an elevated pulse rate of 158 beats per minute (BPM). The Nurse Practitioner (NP) was present, and instructed staff to call 911, and R84 was transferred to a hospital via Emergency Medical Services (EMS). Review of the facility's document Notice of Transfer or discharge: Notice of Bed Hold Days, dated 01/24/2025, revealed the facility documented R84 was transferred for eval. Further review revealed the transfer notice failed to detail the specific reason which necessitated the transfer. During an interview with the Medical Records Nurse (MRN) on 01/29/2025 at 1:37 PM, she stated that the resident/representative gets a copy of the Bed Hold notice referenced above. The MRN provided no further evidence that the resident/representative was provided the specific reason, in writing, for the transfer, as opposed to the generic term eval which was used on the above-referenced forms. During an interview with the Executive Director (ED1) on 01/30/2025 at 9:32 AM, she stated that the resident and family were informed verbally of the specific reason that a transfer was necessary. However, she confirmed that the written notice that the resident/representative received did not include the specific reason for the transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and review of the manufacturer's instructions, the facility failed to store medications at the correct temperature. Insulin was stored below the recommended temperature range of 36 degrees Fahrenheit (F) and 46 degrees F in two of four medication refrigerators. The findings include: Review of the manufacturer's instructions, revised 02/2023, for NovoLog, (insulin aspart)100 units per milliliter (u/ml), revealed unused NovoLog Pens were to be stored in the refrigerator at 36 degrees F - 46 degrees F. Further review revealed instructions to not freeze NovoLog nor use NovoLog if it had been frozen. Review of the manufacturer's instructions for Fiasp, (insulin aspart) 100 u/ml, revealed it should not be frozen, nor used if having been frozen. Further review revealed instruction to store unused insulin in a refrigerator between 36 degrees F and 46 degrees F. Review of the manufacturer's instructions for Tresiba (insulin degludec injection) 100 u/ml FlexTouch pen, copyrighted and revised 07/2022, revealed guidance to store unused pens in the refrigerator at 36 degrees F to 46 degrees F and to not freeze the pens nor use them if having been frozen. Review of the package insert for Lantus (insulin glargine) 100 u/ml, dated 2023, revealed unused Lantus should be stored in a refrigerator between 36 degrees F and 46 degrees F. Further review revealed instruction not to freeze Lantus and to discard if frozen. Review of Basaglar, (insulin glargine) 100 u/ml, instructions for use, revised 08/2022, revealed instruction to not freeze Basaglar and to not use it if it had been frozen. Further review revealed instruction to store the pens in the refrigerator between 2 degrees Celsius (C) and 8 degrees C (35.6 F and 46.4 F.) Review of the manufacturer's instructions for Admelog insulin, dated 11/2019, revealed instruction to keep new pens in the refrigerator between 36 degrees F and 46 degrees F. Further review revealed Admelog should not be frozen or used if it had been frozen. 1. Observation in the Front Hall Medication Room on 01/29/2025 at 3:10 PM revealed Refrigerator 1's thermometer registered 26 degrees F. Further observation revealed thick frost in the small freezer section in the top of the refrigerator. Observation of the temperature logbooks revealed instructions that the accepted range was 36 degrees F - 46 degrees F. The inventory in the refrigerator included the following insulin pens: Lantus 100 u/m - three pens Insulin Glargine 300 u/ml - two pens Insulin Deglu[DATE] u/ml - two pens Basaglar 100 u/ml - three pens Novolog 100 u/ml - five pens. 2. Observation in the Back Medication Room on 01/29/2025 at 3:40 PM revealed Refrigerator 3's thermometer registered 30 degrees F. The inventory in Refrigerator 3 included: Admelog insulin 100 u/ml- four pens Fiasp insulin 100 u/ml - one vial Fiasp insulin 100/u/ml three pens Tresiba insulin 100 u/ml - seven pens Basaglar insulin 100 u/ml - three pens Lantus insulin 100 u/ml - eight pens. During an interview with the Assistant Director of Nursing (ADON) on 01/29/2025 at 3:10 PM, she stated the outcome of medications stored at 26 degrees F was that they would freeze and thus be ineffective. Additional interview with the ADON, on 01/29/2025 at 5:05 PM, revealed the Maintenance Director needed to adjust or repair the two refrigerators and defrost Refrigerator 1. The ADON added that the medications in both refrigerators needed to be returned back to the pharmacy. Interview with the Executive Director (ED1) on 02/01/2025 at 6:28 PM revealed the nurses were responsible for monitoring the medication refrigerator temperatures. She indicated the temperatures were to be monitored on both shifts. In further interview, she stated if staff observed temperatures out of range, the nurses were responsible to take action to correct the temperature and to contact the pharmacy about whether medications should be discarded and reordered. A Medication Storage policy was requested in writing on 01/29/2025 at 6:04 PM and by email on 02/11/2025 at 10:59 AM. However, none was received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of manufacturer's directions for use (DFU), and review of the facility's policies, the facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices to help prevent the development and transmission of communicable diseases and infections. Additionally, the facility failed to ensure that food items used during medication administration were properly dated when opened and kept on ice during use, for 5 of 5 medication carts observed, 3 medication carts on the Back Hall and 2 medication carts on the Front Hall. 1. Observation of room [ROOM NUMBER], a droplet precaution room, on 03/31/2025 revealed a CDC Droplet Precaution sign on the door. However, the facility did not ensure that a personal protective equipment (PPE) cart was available outside the room for staff to use to provide PPE before entering. 2. Observation of room [ROOM NUMBER], a droplet precaution room, on 04/01/2025 revealed staff failed to ensure the door to the room was closed according to CDC guidelines related to transmission-based precautions (TBP). 3. The facility failed to ensure staff cleaned and sanitized shared equipment according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's DFU. a. Observation of the Front Hall on 04/01/2025 revealed Licensed Practical Nurse (LPN) 9 failed to properly clean and sanitize a glucometer (a blood sugar monitoring device) after use according to the EPA registered disinfectant manufacturer's DFU. Additionally, LPN9 failed to perform hand hygiene after removing her gloves. b. Observation of the Back Hall on 04/01/2025 revealed LPN11 failed to properly clean and sanitize bandage scissors at the point of care and walked through the hall and entered the nurses' station holding the contaminated bandage scissors with bare hands. Additionally, LPN11 failed to properly clean and sanitize the bandage scissors according to the EPA registered disinfectant manufacturer's DFU. 4. Observation of the Back Hall on 04/01/2025 revealed LPN8 failed to properly bag and transport contaminated cups away from her person when she disposed of them. 5. Observations made on 03/31/2025 and 04/01/2025 of the Front and Back Halls, revealed the facility did not ensure that food items used during medication administration were properly dated when opened and kept on ice during use of medication carts. Multiple observations revealed opened pudding and applesauce containers that were neither dated nor stored on ice during or after medication administration. The findings include: Review of the CDC's Guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately after glove removal. Additionally, the guidelines stated facilities should ensure proper selection and use of PPE based on the nature of the resident interaction and potential for exposure to infectious materials. Review of the CDC's Guidelines, provided by the facility, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/2021, revealed reusable medical equipment should be cleaned and disinfected according to manufacturer's instructions or the facility's policies before and after use. Further review of the guidelines revealed staff should be trained in the correct steps for cleaning and disinfection of shared equipment. Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], dated 01/02/2024, revealed the facility maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. Per the policy, all staff was responsible for adhering to IPCP policies, including the use of PPE and hand hygiene according to established procedures. Continued review revealed all reusable resident care equipment would be cleaned and disinfected in accordance with current facility procedures. Review of the facility's policy titled, Standard Precautions, revised 03/05/2025, revealed the charge nurse was responsible to check PPE supply carts twice per shift and replenish as needed. Review of the facility's policy titled, Glucometer Disinfection, undated, revealed the facility would ensure glucometers would be cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use, using an EPA registered disinfectant. According to the policy, nursing staff would remove and discard their gloves and perform hand hygiene before leaving the room. Nursing staff would then reapply gloves and take two disinfectant wipes from the container. Per the policy, the first wipe was used to clean and remove any heavily soiled blood or other contaminants from the surface of the glucometer. The policy stated, after cleaning, the second wipe was used to thoroughly disinfect the glucometer, following the manufacturer's instructions. Review of the cleaning and disinfecting DFU for the Evencare ProView Meter, undated, revealed the meter should be clean and disinfected between each resident use. Per the directions, perform hand hygiene and put on gloves; clean the glucose meter, including the front, back, and sides; use a second wipe and follow the disinfectant's instructions for the dwell time (time a surface must remain visibly wet after the application of a disinfectant) listed on the disinfecting wipes DFU. Review of the cleaning and disinfecting DFU for the Super Sani-Cloth Germicidal Wipes container, undated, revealed for cleaning, to use one or more wipes as necessary to thoroughly clean the surface. Then, the DFU stated to use a second wipe to thoroughly wet all surfaces to be treated. According to the DFU, all surfaces must remain visibly wet for a two-minute dwell time to assure complete disinfection of all pathogens and let air dry. 1. Observation, upon initial entrance to the facility, of the Front Hall on 03/31/2025 at 1:35 PM, revealed room [ROOM NUMBER] was designated as a TBP room. The entrance door to the room had a CDC Droplet Precaution sign on it. However, observation revealed there was no PPE cart available outside the room for staff to put on before entering. Further observation revealed there was no PPE cart near room [ROOM NUMBER] or anywhere in the hallway. During an interview with Qualified Medication Aide (QMA) 7 on 03/31/2025 at 1:40 PM, she stated PPE carts should be located outside any TBP room or nearby, allowing staff easy access to the necessary PPE to care for residents. She stated she was unaware the room lacked a PPE cart. She further stated having PPE readily available was important not only for the protection of staff, but also to help prevent the spread of infection. During an interview with LPN1 on 03/31/2025 at 1:50 PM, she stated PPE supply carts should be positioned outside any TBP room or in close proximity, ensuring staff had easy access to the necessary equipment to care for residents. She stated she was not aware room [ROOM NUMBER] did not have a PPE cart. LPN1 stated the Infection Preventionist/Staff Development Coordinator (IP/SDC) ensured carts were available and stocked. LPN1 stated having PPE available was important to protect staff and prevent the spread of infection within the facility. During an interview with the IP/SDC on 04/01/2025 at 10:50 AM, she stated the residents in room [ROOM NUMBER] were COVID-19 positive. She stated she did not know why there was not a PPE cart outside the room and, There is one there now. She stated everyone was responsible for ensuring there were PPE supply carts available and stocked. 2. Observation of the Front Hall on 04/01/2025 at 8:54 AM revealed room [ROOM NUMBER] was designated as a TBP room. However, the entrance door to the room was open, and a CDC Droplet Precaution sign was displayed on the door which indicated the door should remain closed. During an interview with LPN1 on 04/01/2025 at 8:55 AM, she stated room [ROOM NUMBER] had been designated as a droplet precaution room because the two residents in the room were diagnosed with COVID-19. LPN1 stated she was unsure why the door had been left open. She stated, according to CDC guidelines, the door must remain shut to prevent the spread of infection. During continued interview with the IP/SDC on 04/01/2025 at 10:50 AM, she stated the door should remain closed at all times according to signage on the door and CDC guidelines because infection could be transmitted through respiratory droplets produced by a patient [resident] who was coughing or sneezing. During an interview with the Assistant Director of Nursing Services (ADNS) on 04/02/2025 at 4:10 PM, the ADNS stated that doors to droplet precaution rooms should remain closed to prevent droplets produced from coughing or sneezing from spreading into the hall. During an interview with the Director of Nursing Services (DNS) on 04/02/2025 at 6:40 PM, she stated doors to droplet precaution rooms should remain closed to prevent infection spreading. During an interview with Executive Director 2 on 04/01/2025 at 8:58 AM, he stated the door should remain closed in accordance with CDC guidelines. During additional interview with Executive Director 2 on 04/01/2025 at 4:37 PM, he stated, upon inspection, room [ROOM NUMBER]'s door latch was not functioning properly, preventing the door from closing securely. He stated he had requested for maintenance to repair the door, and it was now functioning properly. 3.a. Observation of the Front Hall on 04/01/2025 at 4:10 PM revealed LPN9 exited room [ROOM NUMBER] holding a glucometer with gloved hands. She disposed of the lancet, placed the glucometer on top of the medication cart, and removed her gloves. She did not perform hand hygiene before opening the container of Super Sani-Cloth Germicidal Wipes. She then wiped down the glucometer with one germicidal wipe for 21 seconds and placed it on a barrier sheet. She did not keep the glucometer wet for the required two-minute dwell (time that a device is placed in a specific area). Additionally, LPN9 did not sanitize the top of the medication cart. During an interview with LPN9 on 04/01/2025 at 4:14 PM, she stated she performed hand hygiene after removing her gloves and put on gloves to clean the glucometer. She stated she cleaned the glucometer with a disinfection wipe and placed it on the barrier sheet to dry. She stated each medication cart had a second glucometer to alternate while one was drying. She stated the dwell was the time the glucometer must dry between uses. During additional interview with the IP/SDC on 04/02/2025 at 12:00 PM, she could not explain the steps for cleaning and disinfecting the glucometer. She stated items should be cleaned for one minute and left to air dry. She stated once cleaned and disinfected, the glucometer could be placed on the medication cart because the cart is clean. The IP/SDC did not mention the use of barriers to prevent cross-contamination of disinfected shared equipment. She stated nursing staff was educated to use the two glucometers on the medication carts: one to use and one to dry. She stated everyone should perform hand hygiene before and after resident care to prevent the spread of infection. During continued interview with the ADNS on 04/02/2025 at 4:10 PM, she stated nurses had been educated on how to clean shared glucometers. She stated each treatment cart was equipped with two glucometers to use alternately. She stated nurses should use two wipes to clean and disinfect the glucometer and then wrap it to keep it wet for the allotted dwell time. She stated dwell times varied depending on the product used. She stated the glucometer should be allowed to air dry. The ADNS stated staff should not place glucometers on a bare surface, but a barrier should be used when the glucometer was set down. 3.b. Observation of the Back Hall on 04/01/2025 at 6:50 PM revealed LPN11 walked down the entire hall and approached the nurses' station while holding contaminated bandage scissors wrapped loosely in a glove. She requested disinfecting wipes from another staff member. LPN11 used her contaminated hand to take the wipes, removed the lid, and reached inside the container for a wipe without first performing hand hygiene. LPN11 cleaned the bandage scissors for 33 seconds using one Super Sani-Cloth Germicidal Wipe and then closed the blades while still wet. She did not allow the scissors to remain wet for the required two-minute dwell time, nor did she ensure that all surfaces were air-dried. During an interview with LPN11 on 04/01/2025 at 6:53 PM, she stated she used scissors to cut a resident's cushion. She stated she discovered there were no wipes available in the Front Hall, which prompted her to walk from the Front Hall to the Back Hall in search of disinfecting wipes. LPN11 stated she should have placed the bandage scissors in a container for transport, rather than carrying them with a contaminated glove. She stated she should have gathered her supplies in advance to bring to the point of care. Additionally, LPN11 stated she should have performed hand hygiene and put on gloves to prevent contamination before opening the container of wipes and cleaning the bandage scissors. LPN11 stated she had received IPCP training on multiple occasions since her hire. During continued interview with the ADNS on 04/02/2025 at 4:10 PM, she stated it was her expectation that nursing staff cleaned and disinfected shared equipment according to CDC guidelines and that all nurses followed the facility's policy related to cleaning and disinfecting shared equipment. She stated it was important to prevent the spread of infection. During continued interview with the DNS on 04/02/2025 at 6:40 PM, she stated it was her expectation that nursing staff used the designated disinfectant on any shared items before and after use. She stated, This means that when a nurse picks up a piece of equipment, it should be clean and ready for them to use. She stated any equipment used on one resident should be thoroughly cleaned before it was used on another resident. 4. Observation of the Back Hall on 04/01/2025 at 6:25 PM revealed LPN8 took two large stacks of small plastic drink cups off of the medication cart and transported the cups away, holding them against her scrub top. During an interview with LPN8 on 04/01/2025 at 6:27 PM, she stated she had observed a resident approach the medication cart, touch multiple cups, and take some. She stated she was removing the cups because they were contaminated. She further stated to prevent cross-contamination, she should have used a trash bag to dispose of the cups and not transported them against her person. LPN8 stated she had received multiple training modules related to IPCP during her employment at the facility. During continued interview with the IP/SDC on 04/02/2025 at 12:00 PM, she stated while transporting any items, especially items for residents' use or contaminated items, staff should ensure the items were held away from their person to prevent cross-contamination. 5.a. Observation of the Back Hall on 03/31/2025 at 1:35 PM, revealed three of three medication carts observed each had one opened applesauce container that was not dated and was not being stored on ice to keep it chilled. 5.b. Observation of the Front Hall on 03/31/2025 at 1:45 PM revealed two of two medication carts observed each had opened, undated pudding that was not stored on ice to keep it chilled. During additional interview with QMA7 on 03/31/2025 at 1:48 PM, she stated she was in the middle of medication administration and had just opened the pudding but had not yet dated the container. She stated typically, at the end of each medication administration, there was usually no pudding or applesauce left, and any remaining portions were discarded. She also stated she was getting ice to keep the pudding and applesauce cold when she was approached by the State Survey Agency (SSA) Surveyor for an interview. QMA7 stated food used for medication administration should be dated when opened and placed on ice for the remainder of medication administration. She stated unused food should be discarded at the end of administration. She stated she received IPCP education. QMA7 stated properly storing residents' food was important to control infection and prevent foodborne illnesses. During continued interview with the IP/SDC on 04/02/2025 at 12:00 PM, the IP/SDC stated food used for medication administration should be dated when opened and placed on ice for the remainder of the administration. She stated unused food should be discarded. She stated staff members were educated on how to prevent foodborne illnesses. During continued interview with the ADNS on 04/02/2025 at 4:10 PM, she stated food used for medication administration should be dated when opened and placed on ice for the remainder of the administration. She stated nurses should discard unused food at the end of each administration and should replace them with fresh food items. She stated staff members were educated on the prevention of foodborne illness. During additional interview with the DNS on 03/31/2025 at 1:35 PM, she stated food used for medication administration should be dated when opened and placed on ice for the remainder of medication administration. She stated unused food should be discarded at the end of the administration. She stated clinical staff licensed to administer medications were educated on this. She stated it was important to prevent foodborne illness. During continued interview with the IP/SDC on 04/02/2025 at 12:00 PM, she stated it was her expectation that all staff adhered to infection control policies and procedures. She stated all facility staff had received infection control training, which she provided and reviewed many times throughout the year. She stated it was important to follow CDC guidelines to prevent the spread of infection and cross-contamination. During continued interview with the DNS on 04/02/2025 at 6:40 PM, she stated adhering to infection control guidelines was important to prevent the spread of infection and disease to both residents and staff. During additional interview with Executive Director 2 on 04/02/2025 at 4:00 PM, he stated it was his expectation that all staff followed facility polices related to infection control to help prevent the spread of infection and diseases. During an interview with the Medical Director on 04/02/2025 at 4:53 PM, he stated it was his expectation that all staff followed facility polices related to infection control to help prevent the spread of infection and diseases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility staffing documentation and review of the facility's Payroll Based Journal (PBJ) [NAME] report, the facility failed to have an effective system in place to ensure sufficient, qualified, nursing staff with the appropriate competencies and skill sets was present in sufficient numbers to provide nursing and related services to residents. The facility failed to provide nursing services to meet the assessed needs of the residents according to each resident's care plan and in a manner that promoted each resident's rights, physical, mental, and psychosocial well-being. A lack of sufficient, competent staff has the potential to affect the total census of 109 residents. The findings include: 1. Based on observation, interview, and record review, dependent residents R25, R52, R90, F79, R36, and R22 failed to receive needed assistance with Activities of Daily Living (ADL) in the areas of incontinence care and dental care. (Refer to F677 for specific findings.) 2. Based on observation, interview, and record review, R124, R80, and R36 failed to receive care as needed. Staff incorrectly applied medicated treatments, failed to properly clean a resident's prosthetic eye, and failed to change a dressing as ordered. (Refer to F684 for specific findings.) 3. Based on observation, interview, and record review, R27 and R10 developed facility-acquired pressure ulcers after staff failed to provide pressure prevention approaches including incontinence care and turning/repositioning. (Refer to F686 for specific findings.) 4. Based on observation, interview, and record review, R1 and R125, who each had a catheter, failed to receive care in a manner to prevent and/or timely treat urinary tract infections. (Refer to F690 for specific findings.) 5. Based on interview and record review, R62 was hospitalized for dehydration and hypernatremia after failing to receive all ordered nutrition and fluids through a feeding tube, (Refer to F693 for specific findings.) 6. Based on interview and record review, R119 failed to receive pain medication as ordered after nursing staff failed to order it in a timely manner. (Refer to F697 for specific findings.) Review of the facility policy titled, Staffing, effective 10/01/2024, revealed the purpose was to provide sufficient care team members with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The census, acuity and diagnoses of the resident population would be considered based on the facility assessment. Further review of the facility policy revealed the company would supply services by sufficient numbers of each of the following care team member types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: licensed nurses and other nursing personnel, including but not limited to State Registered Nurse Aides (SRNAs). Review of the facility document titled, Facility Assessment Tool (FAT) dated 11/2023-12/2024 revealed the purpose was to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The assessment was used to make decisions about direct care staff needs as well as the facility's capability to provide services to the residents in the facility and was focused on ensuring each resident was provided care that allowed the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Continued review of the document, dated 11/2023-12/2024, revealed the intent of the facility assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Additional review of the FAT, Page 3, revealed the facility average daily census was 109 and Page 18 revealed the facility had assessed the need for 12-18 nurse SRNAs per day, four to ten on the day shift and four to eight on the night shift, as well as, the need for four to seven nurses per day, two to five on the day shift and two to four on the night shift. Per the FAT, the facility estimated caring for an average of 35 residents who were dependent of staff for toileting needs with an additional 61 residents requiring assistance of one or two staff members for toileting. Additionally, the facility estimated all residents required some form of assistance with eating, eight of which were totally dependent and an additional three who required substantial/maximal assist. The general facility process section of the FAT outlined to ensure the facility had sufficient staff to meet the needs of the residents at any given time was documented as refer to the Centers for Medicare and Medicaid (CMS) Minimum Staffing Rule. Review of the facility's PBJ [NAME] report for the fourth quarter of the Fiscal Year 2024 (July 1 - September 30) revealed the facility had a One Star Staffing Rating and submitted weekend staffing data was excessively low. Initial review of the Detailed Hours Report (DHR) which documented actual hours staff were punched in for work for hours worked on weekend shifts for 09/07/2024, 09/08/2024, 09/15/2024, 09/21/2024, 10/05/2024, and 10/06/2024, 10/20/2024 revealed: 7. On 09/07/2024, five SRNAs worked from 6:00 AM-6:00 PM and an additional one SRNA worked from 8:00 AM to 2:00 PM, indicating from 6:00 AM to 8:00 AM and from 2:00 PM to 6:00 PM each SRNA was responsible for the care of 22 residents and from 8:00 AM to 2:00 PM each SRNA was responsible for the care of 18 residents. On 09/08/2024, six SRNAs worked from 6:00 AM-6:00 PM indicating each SRNA was responsible for the care of 18 residents. On 09/15/2024 four SRNAs worked from 6:00 AM-6:00 PM indicating each SRNA was responsible for the care of 27 residents. On 09/21/2024 six SRNAs worked from 6:00 AM-6:00 PM indicating each SRNA was responsible for the care of 18 residents. On 10/05/2024 six SRNAs worked from 6:00 AM-6:00 indicating each SRNA was responsible for the care of 18 residents. On 10/06/2024 five SRNAs worked from 6:00 AM-6:00 indicating each SRNA was responsible for the care of 22 residents. On 10/20/2024 four SRNAs worked from 6:00 AM-6:00 PM each SRNA was responsible for the care of 27 residents. Review of the DHR dated 10/14/2024 revealed one nurse was working from 6:00 PM to 12:00 AM and was responsible for the care of all the facility's residents. Review of the facility DHR dated 01/21/2025 revealed five SRNAs were working from 6:00 PM-6:00 AM requiring each SRNA to be responsible for the care of 22 residents. Review of the DHR dated 01/24/2025 revealed four SRNAs worked from 6:00 PM-6:00 AM and one SRNA worked from 6:00 PM to 12:00 AM, requiring each SRNA to be responsible for the care of 21 residents from 6:00 PM to 12:00 AM and 27 residents from 12:00AM to 6:00 AM. Review of the DHR dated 01/25/2025 revealed three SRNAs worked from 6:00 PM-9:00 PM, requiring each SRNA to be responsible for the care of 37 residents until an additional two SRNAs arrived at 9:00 PM, totaling five SRNAs who worked from 9:00 PM-6:00 AM requiring each SRNA to be responsible for the care of 22 residents. Review of the facility document titled Daily Staffing (DS) sheet dated 01/26/2025 revealed the facility scheduled a total of four SRNAs from 6:00 PM-6:00 AM, requiring each SRNA to be responsible for the care of 27 residents. Review of the DS dated 01/28/2025 revealed six SRNAs worked from 6:00 PM-6:00 AM, requiring each SRNA to be responsible for the care of 18 residents. Review of the DS dated 01/29/2025 revealed three SRNAs worked from 1:00 AM-6:00 AM, requiring each SRNA to be responsible for the care of 36 residents. Review of the DS dated 02/01/2025 revealed six SRNAs worked from 6:00 AM-6:00 PM, requiring each SRNA to be responsible for the care of 18 residents. Review of the facility document titled, Engagement Survey Results, dated 11/2024 revealed documented comments from staff citied the chronic frustrations with the need for more SRNAs 17 times. One comment stated, We need more SRNAs, the workload is horrible and to get everyone changed you sometimes have to miss showers. Review of the facility document Detailed Hours, dated 07/23/2024 revealed a total of seven SRNAs working from 6:00 AM until 2:00 PM and six SRNAs working from 2:00PM until 6:00 PM. Further review revealed a total of five SRNAs working 6:00 PM until 6:00 AM. Review of the staffing sheet for 07/23/2024 revealed a facility census of 115. 8. a. Review of a Report of Concern, dated 07/02/2024, Family Member (F) 52 reported a concern of R52's call light not being answered timely. The Executive Director (ED) marked the grievance as confirmed and wrote that nurses were educated about call light wait times. In an interview on 01/27/2025 at 9:47 AM, F52 stated she reported to the facility that there had been multiple times the family had waited with R52 for over 20 minutes after pressing the call light. She further stated when they had been waiting, they would go down to the nurse's desk to find nurses sitting there. Per interview, F52 stated the ED took notes of the concerns and said she would talk to staff. F52 continued to state administration told her they would put it in R52's Care Plan that she needed to be toileted more frequently than every two hours. F52 added that R52 had a doctor's appointment on 07/24/2024 and was supposed to receive a shower on the evening of 07/23/2024 and wear the clean clothes F52 put out on R52's wheelchair. Per interview, when F52 met R52 at the doctor's office, R52 was still wearing the clothes she was wearing during the day on 07/23/2024, not the clean ones. R52's hair was dirty and unbrushed. She stated she filed a grievance with the ED, who told her the aide had not given the shower but had charted that she had by mistake. In further interview, F52 stated the ED told her if she did not like the care provided to R52, she could take R52 home. Review of the facility time punch document, Detailed Hours, dated 11/02/2024 revealed a total of six SRNAs working from 6:00 AM until 6:00 PM. Further review revealed a total of four SRNAs working from 6:00 PM until 6:00 AM. Review of the facility staffing sheet for 11/02/2024 revealed the census was 115. b. Review of a Report of Concern, dated 11/02/2024, revealed F52 filed a grievance when she found R52 sitting in briefs and clothes soiled with urine and noted urine dripping into the floor beneath R52's wheelchair. Further review revealed the ED marked the grievance as confirmed and noted the care team member was terminated on 11/04/2024. In an interview on 01/27/2025 at 9:47 AM, F52 stated on 11/02/2024, she came in to find R52's briefs, clothing, and wheelchair saturated with urine and urine puddled in the floor beneath R52's wheelchair. F52 asked an aide, whose name she could not recall, to clean R52 up. F52 stated the staff member told her she could not help until she had picked up dinner trays. In an interview on 02/01/2025 at 6:28 PM, the Executive Director (ED) stated she recalled F1's grievance related to R52 being left wet on 11/02/2024. She further stated that in investigating the grievance, she confirmed R52 had been wet with urine and the SRNA who responded was rude to F52. c. Review of the facility time punch document, Detailed Hours, dated 11/22/2024 revealed a total of five SRNAs working 6:00 PM until 6:00 AM. Review of the facility staffing sheet dated 11/22/2024 revealed the facility census was 109. In an interview on 01/27/2025 at 9:47 AM, F52 stated that on 11/22/2024, she waited one hour and three minutes for staff to answer R52's call light when the resident needed assistance with toileting/incontinence care. Per interview, F52 timed the wait on her phone and took a video. d. Review of the facility time punch document Detailed Hours, dated 12/04/2024 revealed six SRNAs working from 6:00 AM until 6:00 PM, with two additional SRNAs working 10:00 AM until 4:00 PM, and one SRNA working 6:00 AM until 4:00PM. Further review revealed four SRNAs working 6:00 PM until 6:00 AM. Review of the facility staffing sheet dated 12/04/2024 revealed the facility census was 103. In an interview on 01/27/2025 at 9:47 AM, F52 stated that on the evening of 12/04/2024, she waited a prolonged period of time for staff to answer R52's call light when the resident needed assistance with toileting and incontinence care. e. Review of the facility time punch document, Detailed Hours, dated 01/14/2025, revealed six nurse aides working 6:00 AM until 6:00 PM, one SRNA working 12:30 PM until 5:00 PM, one SRNA working 10:00 AM until 6:00 PM, and the wound care SRNA working 9:00 AM until 5:00 PM. Review of the facility staffing sheet dated 01/14/2025 revealed the census was 108. In an interview on 01/27/2025 at 9:47 AM, F1 stated she came in the afternoon of 01/14/2025 to find R52 in a soaked brief and clothes wet with urine. f. Review of the facility time punch document Detailed Hours, dated 01/15/2025, there were six SRNA working 6:00 AM until 6:00 PM, with two additional SRNAs working partial shifts. Further review revealed five SRNAs working from 6:00 PM until 1:00 AM, and 4 SRNAs working from 11:00 PM until 7:00 AM. Review of the facility staffing sheet for 01/15/2025 revealed the facility census was 109. In an interview on 01/27/2025 at 9:47 AM, F52 stated she came in the afternoon of 01/15/2025 to find R52 in a soaked brief and clothes wet with urine. 9. a. Observation on 01/29/2025 at 4:42 PM revealed three call lights, both visual and audible, were alerting on the back hall. A male resident was overheard stating, Can someone help me, I am a mess. Licensed Practical Nurse (LPN) 2 stated, You will need to wait, buddy. b. Observation, on 01/29/2025 at 4:45 PM, during dining service, revealed the call light for room [ROOM NUMBER], both visual and audible, was alerting on the front hall. LPN6 was observed sitting at the nurse's station with the call light board behind him alarming and illuminated and he did not get up to assist with answering the call light. c. Observation on 01/29/2025 at 4:46 PM during dining service, revealed a call light for room [ROOM NUMBER], both visual and audible, was alerting on the front hall. The Activities Director (AD) walked past the room and did not address the call light. d. Observation on 01/31/2025 at 10:53 AM revealed two call lights illuminated and audible on the South Hall. LPN1 and LPN2 were observed sitting at the nurse's station with the call light board behind nurses' station illuminated and audible. Neither LPN1 nor LPN2 got up to answer the call lights. e. Observation on 01/31/2025 at 4:45 PM of one SRNA in the dining room sorting meal tickets while six meal trays were waiting in the pass through ready to be given to the residents and four call lights on the North Hall were illuminated and audible. f. Observation on 01/31/2025 at 7:50 AM revealed the call light for room [ROOM NUMBER] was lit above the resident's door. Further observation revealed the call light board at the nurse's station displayed a light indicating room [ROOM NUMBER]'s call light was on, as well as making an intermittent beep to alert staff to the call light. Continued observation revealed LPN1 and LPN2 sitting at the nurse's desk, in view of the control board, where the beeping could be heard, Neither LPN looked over at the control board to see which light was on, nor did they get up to look in the hallway. Per observation, the call light for room [ROOM NUMBER] sounded for four minutes without any response from the LPNs. In an interview on 01/31/2025 at 8:00 AM, LPN1 and LPN2 stated it was everyone's responsibility to answer call lights. When asked about the call light that had sounded for several minutes prior to the interview, the LPNs asked the survey team if the sound went off at the nurse's station. When the survey team confirmed that the sound went off, the LPNs failed to provide any response to why they had not acknowledged the call lights. g. Observation on 02/01/2025 at 10:08 AM revealed the call light for room [ROOM NUMBER] was on. No SRNAs were seen in the hallway. Qualified Medication Aide (QMA)8 was present, preparing medicine. The Maintenance Director walked past room [ROOM NUMBER] without turning his head. Observations at 10:12 and 10:13 AM revealed the Social Services Director (SSD) also walked by room [ROOM NUMBER] while the call light was on, without turning her head to look in the resident's room. Observation at 10:17 AM revealed the call light was still going off (nine minutes after first observed) when ED2 entered the room, asked the resident what he needed and stated he would go get the nurse. The call light remained lit until 10:19 AM when LPN4 entered, asked the resident if he wanted a breathing treatment, and began to administer it, then walked away while it was going in. 10. a. During an interview on 01/26/2025 at 4:40 PM with R90, she stated she had been sitting in a wet bed for a couple hours, had put her call light on twice and was told by the SRNAs they had a new admission and were busy. Observation during this interview revealed the resident's brief appeared heavy with urine. Review of the DHR, dated 01/26/2025, revealed six SRNAs worked from 6:00 AM-6:00 PM and one SRNA worked from 8:00 AM to 5:00 PM. During the time that R90 was left sitting in the wet bed, each SRNA was responsible for the care of 18 residents from 8:00 AM to 5:00 PM and 22 residents from 6:00AM to 8:00 AM and from 5:00 PM to 6:00 PM. b. During an interview on 01/26/2025 at 1:58PM with R362, she stated on 01/24/2025 at 6:00 PM during shift change, she requested help having her brief changed. She stated it took staff until after 10:00 PM for them to come and change her brief. R362 stated having to lay in her waste made her feel humiliated/nasty. She stated it took staff so long to come in and change her that some of her body fluid had leaked on her right leg splint where she had broken her leg back in December. R362 also indicated on her cell phone where she had tried to call the facility for help, and no one would answer the phone. c. During an interview on 01/26/2025 at 2:03 PM, R79 stated she also had to wait at least four (4) hours on 01/24/2025 for staff to come in and change her. R79 stated she felt nasty having to lay in bed waiting for help to change her. She stated she had a stroke and needed assistance in cleaning herself. She stated one staff member came in her room and turned off the call light and disappeared without providing assistance. During an interview on 01/28/2025 at 9:06 AM with SRNA4, she stated when there were four SRNA's on the back (North) hall, they had between 12-15 residents apiece. When there were only three SRNAs, they had approximately 20 residents apiece. She stated the back hall had many residents who were overweight and were a higher level of care and she needed SRNA3, who was in training, to help out. During an interview on 01/29/2025 at 10:27 AM with SRNA7, she stated staffing had been an issue at the facility for a while. SRNA7 stated that although she could not remember the exact date, there was one night there were three SRNAs for the entire building. SRNA7 further stated it was hard to get staff to come to work, as well as, retain new staff due to the heavy workload. During an interview on 01/30/2025 at 9:41 AM with SRNA3, she stated she had been at the facility about a month, worked day shift and was typically assigned 16-18 residents. However, one Saturday, the facility was short staffed, and she had 22 residents to care for which she felt was not safe. She stated she often felt like she was drowning and even though residents with behaviors required more care, 22 residents felt like a lot to care for anywhere. SRNA3 stated she tried to answer all the lights and had been told it was the SRNAs job to answer them. SRNA3 stated the Certified Medication Technicians (CMTs) would help when they could, but the nurses did not get up to answer call lights. She further stated residents have complained to her about long waits for their call light to be answered and there had been mealtimes when there was only one SRNA in the dining room when there should be two. During mealtimes, there were four - five residents that needed total assist with eating, and she has had to sit all those residents at the same table and feed two residents at a time. After the meal and upon her return to her assigned hall, SRNA3 stated she would often see several call lights on and no staff visible. SRNA3 stated on this day she had 14 residents and felt like she was rushing around. Further, on 01/30/2025 at 9:41 AM, SRNA3 stated she was supposed to complete check and change rounds every two hours; however, it was easy to fall behind when caring for a resident that urinated more frequently or in larger amounts. SRNA3 stated on her first round before breakfast, she had walked into a resident's room after a night shift SRNA had told her the resident had been changed. However, she found the resident's bed was soaked and it looked like he had been a mess for hours which she could tell because the longer they sit, the darker the yellow ring (urine-soakage) was. SRNA3 stated it was hard to complete every two-hour rounds on every resident and complete four showers. She stated sometimes she did not take a lunch or would have to leave a resident soiled longer while she finished another resident's shower. Ideally, SRNA3 stated she would like to be able to get to every resident before they soiled themselves so she could assist them to the bathroom if possible. She stated she had to prioritize care based on which residents were the heaviest care need and there were some residents that did not get the attention they deserved, and she felt bad about that. SRNA3 stated sometimes residents ask her to sit and talk with them, adding, she does not have time to do it. During an interview on 01/30/2025 at 9:41 AM with SRNA12, she stated she had been at the facility since January 2024. SRNA13, who was present, stated she had been at the facility since July 2024 and neither SRNA had been issued a name tag. Both SRNAs agreed that in an average day, they cared for 15-20 residents and were responsible for meals, baths/showers and changing briefs/clothes/beds as needed, assisting with transportation to activities/smoke breaks, and individual resident care requests. SRNA12 and SRNA13 stated they would lose their bonus if they did not take a lunch, so they would punch out for lunch but then worked through to keep their bonus. SRNA12 and SRNA13 stated many SRNAs have left because of the workload and the nurses did not help out. They further stated they worked short last week, there were only three SRNAs on each hall (18 residents per SRNA) and sometimes they were only staffed for two SRNAs on each hall (27 residents per SRNA). Furnter, SRNA12 and SRNA13 stated, on 01/30/2025 at 9:41 AM, there was usually one SRNA in the dining room who was responsible for sorting the meal tickets, passing the trays, and feeding the assisted diners and there had been times they would have to sit all the assisted diners at the same table and feed one while the others watched and had to wait, which was painful for staff to watch. SRNA12 and SRNA13 stated the facility was short staffed five to seven days a week and especially on the weekend. They stated with three SRNAs on each hall, they would have to split showers and get done as much as they could. They added there was never any time to sit with residents and just talk with them, even with four SRNAs on each hall. SRNA13 stated that most of the nurses were not supportive of the SRNAs and their work but would add tasks like applying a medicated cream or shampoo. They stated Nurses did not come into the room to pause a tube feeding so the SRNA could check and change a resident, they would tell the SRNA to pause the feed and restart it when care was completed. During an interview on 01/30/2025 at 11:47 AM with SRNA11, she stated it was hard to get all her responsibilities of oral care, hair combing, toileting, and feeding done and a lot of times they were short staffed. She stated she usually had to also complete three showers in a day and with four SRNAs on each hall, it was still a struggle. SRNA11 stated on this day she had 14 residents and felt like maybe she could complete a check and change every two hours on most of them. She stated her charting recorded the task was done for the resident but not how many times in the shift it was done. SRNA11 stated when they had enough staff, they could complete more showers, do nail care, and help out with work for the next shift. When they worked short, SRNA11 stated sometimes residents did not get their shower and she hoped to be able to pick up that shower the next day. SRNA11 stated that when she alerted management she was unable to complete her work, she was told, We are short and can only do what we can. In continued interview, on 01/30/2025 at 11:47 AM, SRNA11 stated the nurses would get up from the nurses' station to pass a medication or to do wound care but did not do general rounds on the residents. She stated the nurses have asked the SRNAs to put on a medicated cream or shampoo and asked her to come back and tell them what the skin looked like. SRNA11 stated the SRNAs would help each other but some were too busy with their own work and the nurses did not help. She remembered one time she entered a droplet precaution room without full personal protective equipment (PPE), only a mask, because she was so far behind, she did not take the time to put on the additional PPE. She further stated it was hard to find anyone to help due to the short staffing. She stated call lights seemed to come on one right after the other and she tried to glance in on the residents that cannot use the call light. Additionally, SRNA11 stated she had no time to just visit with the residents and felt like since staff were all the family the residents had, not being able to spend more time with them could make the residents emotionally depressed. During an interview on 01/30/2025 at 2:32 PM with SRNA2, she stated she had worked at the facility for three years. She stated staff had been hired and it seemed like she had trained many, but no one would stay. SRNA2 stated she had gotten used to working short and sometimes resident showers did not get done, but she tried to at least get them dressed and wiped off. She stated everyone deserved their shower and she tried to make it up the next day. SRNA2 stated the residents did complain about their call lights not being answered and stated residents would say, I've been waiting so long, but the SRNA came in and shut the light off and left, or said, The aide said they were going to get you and then didn't come back. During an interview on 01/30/2025 at 3:25 PM with SRNA10, he stated he had been an SRNA for thirteen years and started at the facility in 10/2024. He stated he did not know who the Director of Nursing Services (DNS) was until the state survey team entered the building, as he had never seen her. He added he did not know who the Assistant Director of Nursing Services (ADNS) was until two months after he started. SRNA10 stated typical staffing on the weekends was two SRNAs on each hall (27 residents to each SRNA) and sometimes there was a float SRNA available. He stated there were a lot of call offs on the weekends and there had been times the SRNAs were responsible for 30-35 residents each, which he felt was unsafe. SRNA10 stated management did not pitch in if short on the weekends, and he had not really seen management at all until State Surveyors showed up, then Everyone came out of the woods or something to help. He stated he believed it was everyone's responsibility to answer a call light, but the nurses did not answer a call light or change a resident. In fact, they would walk farther to try and find an SRNA instead of answering a light or changing a resident themselves. SRNA 10 stated when he was responsible for 30-35 residents, he could not get them changed every two hours, they would have to wait, and some would end up sitting for three to three and a half hours. State Registered Nurse Aide (SRNA)10 stated, on 01/30/2025 at 3:25 PM, that residents complained and told him it was ridiculous they had been laying in their urine and feces and they were upset. He stated some would end up with skin breakdown and it hurt them. Additionally, SRNA 10 stated he rarely saw nurses just round on and talk to the residents and he rarely saw management walking in the halls, they mostly stayed in their offices and the ADON only came out of her office when there was something wrong. He stated he charted at the end of the shift but knew a lot of SRNAs did all their charting in the morning which he felt was wrong because you should not chart what you had not done. He stated it got so crazy it felt like there was not enough time to get everything done and if charting was not done, staff would lose their bonus for the week. SRNA10 stated it was hard enough to care for 15 residents, let alone 35 residents and he went home feeling bad because he felt like he had given poor care and the residents had not been cared for how they should be. Finally, SRNA 10 stated he has had to use at mechanical lift alone and risk resident injury due to not enough staff to help. In an interview on 02/01/2025 at 11:07 AM, SRNA5 stated at the time of interview, she was finishing the first round of incontinence care for the residents in her assignment. Per interview, she stated she was responsible for 25 residents. In continued interview, SRNA5 stated management did not help with incontinence care, and she had rarely seen a member of management on the floor during a weekend. SRNA5 stated when she was responsible for that many residents, she did not have time to perform oral care or showers, and those tasks would only be completed if there was a float aide working. In an additional interview on 02/01/2025 at 8:04 PM, SRNA5 stated that when the facility was short staffed, the SRNAs did not typically get the support they needed to care for the residents according to their care plans. During an interview on 01/29/2025 at 7:31 AM with the Nurse Practitioner (NP) he stated he had worked at the facility for one year. The NP stated the SRNAs were great, but based on resident condition, he felt they needed more education on the importance of hygiene, position changes, and that relationship to skin breakdown. The NP also stated staffing was an uphill battle across the board and although it was improving, there was still a high turnover. During an interview on 01/29/2025 at 4:22 PM with the Scheduler (SCH) she stated she had been at the facility for thirteen years and had been the scheduler since 2020. SCH stated staffing was census based and the facility was considered full at 100 residents. SCH stated her staffing goal for each of the two halls was one to two licensed nurses on each hall, one Certified Medication Technician (CMT) on each hall and four nurse SRNAs on each hall for the day shift. On night shift, her goal was to have one licensed nurse on each hall, one CMT on each hall, and four SRNAs on each hall. SCH stated she was available 24 hours a day, seven days a week to work the schedule to find coverage for call offs. She stated there was never a time where no one was available to help, and all the staff pitched in, and all staff were responsible for answering call lights. She also stated the company had their own staff float pool as a resource and the facility did not use agency staff. SCH stated during the time of the low staffing indication on the PBJ [NAME] report, nothing unusual was going on but it was warm outside and that may have accounted for increas[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for one (1) of twenty-four (24) sample residents, (Resident #20), that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Resident #20 was prescribed the medication (Depakote) for behaviors but there was no documented evidence the facility developed and implemented a care plan specific to his/her behaviors. The findings include: Review of the Care Plan Policy, not dated, revealed the facility's Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team. Record review revealed the facility re-admitted Resident #20 on 03/24/19 with multiple diagnoses which included Alzheimer's Disease, urinary tract infection, Type 2 Diabetes, Anemia, Pneumonia, Hypothyroidism, Neonatal cerebral depression, acute respiratory failure, acidosis, acute kidney failure, and major depressive disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], Section E, Behavioral Symptoms, revealed the facility assessed Resident #20 to display episodes of physical and verbal behavioral symptoms directed toward others such as kicking, pushing, grabbing, scratching, screaming, cursing behaviors of this type occurred at least one (1) to three (3) days. Further review of the MDS revealed the Brief Interview of Mental Status (BIMS) revealed a score of three (3), which indicated the resident was severely cognitively impaired and not interviewable. Review of the Quarterly MDS, Section E, Behavioral Symptoms dated 09/18/2019 revealed the facility assessed Resident #20 as no longer displaying physical or verbal behavioral symptoms directed toward others such as hitting, kicking, pushing, scratching, or grabbing, threatening, screaming or cursing. Record review revealed Resident #20 was ordered and received the medication Depakote Capsule Delayed-Release Sprinkles, five hundred (500) milligrams (mg) three times a day related to Alzheimer's disease, unspecified. Depakote is classified as an anti-seizure medication and thus is typically prescribed to control seizures. Record review revealed Resident #20 did not have a history or a diagnosis of seizures. Medications prescribed off-label-meaning not approved by the Food and Drug Administration (FDA) for its use-should specify the medical symptom/behavior for the medication. Depakote prescribed in Alzheimer patients, should indicate behaviors associated with the disease as an indication for the order, rather than the disease itself. Review of Resident #20 Comprehensive Care Plan, initiated on 08/23/18, and revised on 09/27/19 revealed the resident was at risk for side effects from antidepressant medication use and was at risk for abnormal bleeding related to aspirin use. Approaches/interventions included a pharmacy consultant's review of the resident's medication monthly. Further review revealed there was no problem, goals or approaches care planned to address behaviors. These behaviors were not care planned with interventions on the comprehensive care plan. Phone interview with the Clinical Consultant Pharmacy Director on 10/29/19 at 1:46 PM revealed consultant clinical pharmacists have access to residents' records via PointClickCare (PCC) which allows them to review all elements of the resident's chart, looking at heights, weights, diagnoses, medication list, dosages, renal functions, and psych medications. The clinical pharmacists look for drug/drug interactions, age-specific appropriate medications, antibiotic stewardship, etc. and make recommendations based on all assessments. Per the interview, the clinical pharmacist normally did not make recommendations on how or why a prescriber uses certain medications unless the ordered drug was egregious or contraindicated. Interview with the facility's Advanced Practice Registered Nurse (APRN) on 10/24/19 at 11:15 AM and again at 2:21 PM revealed Resident #20 displayed physical and verbal behaviors such as severe agitation, restlessness and inability to focus. She acknowledged the medication order for Depakote should have specified the medicine was ordered for Alzheimer's with behaviors. The APRN recalled when Resident #20 was first admitted to the facility on [DATE], the resident was receiving Depakote to manage challenging behaviors related to her Alzheimer's disease. Documented in the Departmental notes on 09/28/18, the APRN wrote the following, Over the past week, resident has been increasingly restless and staff has been unable to redirect. She has been anxious and talking about her grandmother that she is worried about. She has been so anxious and restless that she is unable to participate in activities or follow any commands. I reviewed her medications and will increase Depakote to three times a day (TID). Hopefully, this will help with anxiety/agitation and the resident will be able to engage in activities/conversation. I feel that if the patient has less anxiety/agitation and restlessness, she may be able to actively participate in activities or at least engage in conversation and this may improve her quality of life. Additionally, the APRN stated residents get very anxious due to their disease and medications such as Depakote helps with their mood. It benefits the resident because the staff can take care of them, their basic needs are met, it calms them down, lets them focus and they have a better quality of life. She understood the importance of monitoring these drugs to prevent oversedation and/or polypharmacy prescribing. The indications for ordering the medication should be documented along with the benefit to the resident. Likewise, documented behaviors and the use of Depakote should be care planned so that non-pharmacological approaches and interventions are attempted. Interview with the Director of Nursing (DON) on 10/24/19 at 4:55 PM revealed residents were care planned based on their identified needs. She expects the care plan to begin upon admission and completed within the first twenty-one (21) days. The care plan should be individualized and focused on meeting the resident's goals. She expects a care plan developed for residents having behaviors and changes made to the care plan as necessary, including changes in behavior. Interview with the facility Administrator on 10/24/19 at 5:10 PM revealed she concurs with everything the Director of Nursing (DON) said. She expects a care plan developed for residents having behaviors and changes made to the care plan as necessary.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Medication Regimen Review (MRR) was completed for one (1) of twenty-four (24) sampled residents, (Resident #20). Record review revealed no documented evidence the MRR was completed for Resident #20 for the month of September 2019. The findings include: Review of Pharmacy Services-Role of the Consultant Pharmacist policy, last revised April 2019 revealed the facility shall have the services of a consultant pharmacist. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director. Review of the facility policy Medication Regimen Reviews, last revised May 2019 revealed the Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. Medication regimen reviews are done upon admission (or as close to the admission as possible) and at least monthly thereafter, or more frequently if indicated. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with the medication. Record review revealed the facility re-admitted Resident #20 on 03/24/19 with multiple diagnoses to include, Alzheimer's Disease, urinary tract infection, Type 2 Diabetes, Anemia, Pneumonia, Hypothyroidism, Neonatal cerebral depression, acute respiratory failure, acidosis, acute kidney failure, and major depressive disorder. Review of Resident #20's Pharmacy Consultation Report by the contracted pharmacy, revealed pharmacy reviews and recommendations for December 2018, January 2019, April 2019 and August 2019. There was no documented evidence of a pharmacy consultation report or MRR for September 2019. Phone interview with the Pharmacist who works for the pharmacy who supplies the facility its medications, on 10/24/19 at 4:24 PM revealed the pharmacy puts all orders into a resident profile, which the pharmacy uses as a source of truth for all the medications residents were receiving. The pharmacist can view the medical records electronically, which allows them to follow up with the nurse or the prescriber as needed. An internal track record makes recommendations based on the complete medication profile. These recommendations are faxed to the facility. Monthly Medication Regimen Reviews (MRR's) are done by the clinical pharmacy consultants. Phone interview with the Clinical Consultant Pharmacy Director on 10/29/19 at 1:46 PM revealed the consultant clinical pharmacists have access to residents' records via PointClickCare (PCC) which allows them to review all elements of the resident's chart, looking at heights, weights, diagnoses, medication list, dosages, renal functions, and psychiatric medications. The clinical pharmacists look for drug/drug interactions, age-specific appropriate medications, antibiotic stewardship, etc. and make recommendations based on all assessments. This review is done monthly as required by the Centers for Medicare and Medicaid (CMS). Per the interview, the facility contracted with this consulting company beginning October 1, 2019. Therefor, she could not speak for the September 2019 missing medication regimen review. Interview with the Director of Nursing (DON) on 10/24/19 at 4:55 PM revealed the consulting pharmacist performs Medication Regimen Reviews (MRR) monthly on all residents. Medical Records, the DON and the Administrator reviews and monitors to make sure the attending physician signs, agrees or disagrees with the recommendations. Per the interview, if the pharmacist fails to do a monthly MRR, or if one is done and not monitored, a medication recommendation appropriate for the resident's well-being could be missed, resulting in a negative outcome. Additionally, the DON stated she could not say why there was no evidence of the September 2019 MRR in the medical record for Resident #20. She expects that clinical pharmacist performs Medication Record Reviews monthly, and the facility reviews and monitors the recommendations. Interview with the facility Administrator on 10/24/19 at 5:10 PM revealed the consulting pharmacist was responsible for performing the MRR monthly on all residents. Medical Records and the DON and/or Administrator reviews and monitors the MRR's to make sure the physician approves and signs the recommendations. The issue for not checking the MRR could produce a medication negative outcome for the resident based on the recommendation from the pharmacist and approval by the physician. Additionally, she expects that clinical pharmacists perform the MRR monthly and designated facility staff reviews and monitors the recommendations.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the Front Hall Medication Storage Room and the Back Hall Medication Storage room. Observations on 10/23/19 revealed one (1) expired vial of PPD (purified protein derivative, diluted Aplisol 5TU/0.1ml) in the Back Hall Medication Storage Room Refrigerator. Observations on 10/23/19 revealed one (1) opened and undated vial of PPD (purified protein derivative, diluted aplisol 5TU/0.1ml), one (1) vial of Influenza vaccine (Afluria Quadrivalent 5 ml (milliliter) multi-dose vial, and six (6) influenza single dose vials with a manufacturer's expiration date of 03/16/19, in the Front Hall Medication Storage Room Refrigerator. The findings include: Review of the facility Policy, titled Storage of Medications, date revised April, 2019, revealed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Further review of the policy revealed the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Per policy, discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the facility policy Labeling of Medication Containers, date revised April, 2019, revealed all medications maintained in the facility are properly labeled in accordance with state and federal guidelines and regulations. Further review revealed labels for stock medications include all necessary information, such as the expiration date when applicable. Review of the documentation provided by the facility for Aplisol (Tuberculin Purified Protein Derivative, Diluted (Stabilized Solution) dated prescribing information as of November, 2013, revealed vials in use more than thirty (30) days should be discarded. Review of the CDC (Centers for Disease Control) document, titled Questions about Multi-dose vials, dated last reviewed: June 20, 2019, revealed Medication vials should always be discarded whenever sterility is compromised or cannot be confirmed. In addition, the United States Pharmacopeia (USP) General Chapter 797 [16], recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Observations on 10/23/19 at 3:17 PM, of the Back Hall Medication Storage Room, with Licensed Practical Nurse (LPN) #5, revealed one (1) multi-dose vial of PPD (purified protein derivative, diluted Aplisol 5TU/0.1ml), dated opened 08/23/19 at 8:00 AM. Interview with LPN #5 revealed she was not sure for how long the medication was good, after opening. Continued interview with LPN #5 revealed she viewed the box which contained the PPD and read from the box, once entered vial should be discarded after 30 days. Per interview, LPN #5 stated the PPD should have been discarded last month on 09/23/19. Further interview with LPN #5 revealed this vial of PPD was the only one in the medication refrigerator and if the PPD was used after opened for the thirty (30) days, it definitely could give a false reading for the TB skin testing. Observations of the Front Hall Medication Room on 10/23/19 at 3:42 PM, with LPN #4 revealed one (1) multi-dose vial of PPD (purified protein derivative, diluted Aplisol 5TU/0.1ml), which was opened, and without the date the PPD was opened. Interview with LPN #4 revealed she did not know if the multi-dose vial of PPD had been used, as it was opened and undated, and stated it was the only vial of PPD in the Medication Storage Refrigerator and should have been dated when opened. LPN #4 stated she wouldn't use the undated vial of PPD and would discard it. LPN #4 reviewed the PPD packaging box and stated the manufacturer instructions document once entered discard vial after thirty (30) days. Continued observation revealed one (1) multi-dose vial of Influenza Vaccine (Afluria Quadrivalent 5ml bottle multi-dose vial with manufacturer expiration 5/28/20 and lot #P100110973), which was opened and without date, and they have just been administering the influenza vaccine today. LPN #4 stated the Influenza vaccine was supposed to be dated when opened and was normally good for thirty (30) days after opened. Continued observation revealed six (6) influenza single dose vials, lot # U1981AB, with manufacturer expiration date of 03/16/19, and LPN #4 said they should not be in the Front Hall Medication Storage Room Refrigerator and should be discarded and not used, due to they were expired. Interview with Registered Nurse (RN) #1 on 10/23/19 at 4:05 PM revealed multi-dose vials of PPD and Influenza vaccine should be dated when opened. Further interview revealed she would have to read the package insert to determine how long the medications were good after opened. She stated Influenza vaccine was good for twenty-eight (28) days after opened and entered per the package insert. Further interview revealed using expired PPD and Influenza vaccine could cause the medications to be ineffective, or cause an adverse reaction. Interview with the facility Nurse Practitioner (NP) on 10/24/19 at 11:36 AM revealed using expired PPD for testing may not elicit a response, and could be weakened or possibly due to the preservatives, could cause a skin reaction. Continued interview with the NP revealed using expired Influenza vaccine, if expired, could cause a weakened immunological response, and it may not be effective, or could possibly cause a local reaction due to preservatives. Interview with the RN Clinical Nurse Educator/Infection Control Nurse on 10/24/19 at 3:26 PM revealed PPD and Influenza vaccines should be dated when opened and the reason for dating the bottles when opened, was so you would know when they expire. Continued interview revealed if any multi-dose vial was not dated when opened, it should be discarded, because you don't know if it is good or expired. Continued interview revealed Influenza vaccine was good until the manufacturer expiration date or for twenty-eight (28) days after it was opened and PPD was good for thirty (30) days after opened. Per interview, if PPD or Influenza vaccines were used past the expiration date, you wouldn't get an accurate reading or immune response. Interview with the facility Pharmacist on 10/24/19 at 4:00 PM revealed Influenza vaccine was to be stored refrigerated and was good for twenty-eight (28) days after opened. Continued interview revealed if expired, was controversial, and Influenza Vaccine has preservatives, but under reasonable conditions the biggest risk could be pyrogen growth. The Pharmacist further stated a multi-dose vial of PPD, after opened, was good for twenty-eight (28) days, or per manufacturer specific instructions. Per interview, expired PPD could have decreased effectiveness, risk of infection from pyrogen growth in the vial, and could impact efficacy. Per interview, rules should be followed with discarding expired PPD and Influenza vaccine. Interview, on 10/24/19 at 4:32 PM and 4:55 PM, with the Director of Nursing (DON) revealed nursing staff on the floor were responsible for monitoring the medication rooms and ensuring medications were not expired. Per interview, the facility did not have a policy regarding the use of multi-dose vials of medication. Continued interview revealed the facility's process for using multi-dose vials, including PPD and Influenza vaccine, was nursing staff was to date the vial when opened and PPD and Influenza vaccines were good for thirty days after opened. The DON indicated the nursing staff did have a reference chart from pharmacy, and this was how nursing staff was made aware of how long the medications were good after opened; however, the nurses interviewed did not mention the reference chart and it was not provided for review. Further interview revealed if PPD or Influenza vaccine was opened and not dated, there was no way to know if the medications were still good or if they were expired. Per interview, expired PPD and Influenza vaccine can lose strength, and it was her expectation that staff follow manufacturers recommendations. Interview with the Administrator, on 10/24/19 at 4:38 PM, revealed nursing staff was to date multi-dose vials of PPD and Influenza vaccine when opened and that nursing staff was assigned to check Medication Rooms for expired medications, and follow facility policy and procedure. Further interview revealed it was her expectation that staff follow manufacturers recommendations with regards to multi-dose vials of PPD and Influenza vaccine. Per interview, expired medications might lose strength.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's Job Description for the Activities Director, it was determined the facility failed to provide an ongoing program of Activities designed to meet, in accordance with the Comprehensive Assessment, the interests and the physical, mental, and psychosocial well-being of each resident for two (2) of three (3) sampled residents (Resident #64 and #108). Review of the Activity Participation Roster for Resident #64, dated 08/01/18 through 09/05/18, revealed the resident actively or passively participated in exercise, Television /movies, and/or socialization almost daily. However, observation and staff interview revealed the resident did not have a television to watch; and did not participate in an exercise program as the resident had a decline in condition and was in Hospice services. The facility failed to initiate individual meaningful activities to meet this resident's one (1) on one (1) activity needs. In addition, review of the Activity Participation Roster for Resident #108, dated 08/01/18 through 09/05/18, revealed the resident actively participated in exercise, music, socializing, visits and television/movies. However, observation and staff interview revealed the resident no longer attended group activities, did not participate in an exercise program, and hardly ever came out of his/her room. There was no documented evidence the facility initiated a program for individualized meaningful one (1) on one (1) activities for this resident. The findings include: A facility policy related to Activities was requested; however, interview on 09/06/18 at 08:36 AM, with the Administrator, revealed the facility did not have a policy related to Activities. Review of the Activities Coordinator Position Description, dated July 2006, revealed the Activities Coordinator was responsible for coordinating, directing, and planning the activity program to meet the specific needs of each and all residents, and ensuring residents' lifestyle is maintained to the extent possible by providing activities and contacts with the community as desired. The Activities Coordinator's Key Responsibilities include designing a therapeutic activity program to meet the individual psychosocial needs of residents; leading group activities; providing one (1) on one (1) activities to those who cannot be in a group setting; supervising activity assistants and volunteers; and documenting on assessment progress notes, and care plans. Review of the Merriam -Webster definition of exercise revealed exercise was bodily exertion for the sake of, developing, and maintaining physical fitness. 1. Review of Resident #64's medical record revealed the facility admitted the resident on 05/23/18 with diagnoses to include Anemia, Disorder of Thyroid, Osteoporosis, and Dementia with Behavioral Disturbance. Review of Resident #64's Activities Evaluation, dated 05/23/18, revealed the resident had current interests in television/movies, religious services, cooking, visits from children, arts and crafts, and pets. Review of Resident #64's Activities Comprehensive Care Plan, undated, revealed the resident was unable to participate in the usual daily routine, and was receiving Hospice services. The goal stated, visit with resident in room and talk with family. The interventions included having Activity staff ask about preferences, assist with activities the resident selected, and remind the resident when activities were scheduled. However, the Care Plan did not specify if the resident was to receive one (1) on one (1) Activities; the specific Activities to be provided; the type of activities the resident or family had selected; or how often the resident would be provided these activities. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 07/19/18, revealed the facility assessed the resident as unable to complete the interview for the Brief Interview for Mental Status (BIMS) and as receiving Hospice care. Review of the Interview for Activities Preferences, Section F-0500, of the MDS Assessment, revealed this section was not completed due to the resident was not understood and the family/significant other was unavailable. Review of the Activities One to One (1:1) List, undated, revealed Resident #64 was on the list for the intervention to have his/her hair brushed and lotion applied. Review of Resident #64's Activity Participation Roster, dated 08/01/18 through 09/05/18, revealed the resident actively and passively participated in exercise, TV/movies, and/or socialization almost daily. One (1) pet visit was documented on 08/19/18. Further review revealed the activity to have his/her hair brushed and lotion applied was not listed as occurring on the Roster. Observation of Resident #64, on 09/04/18 at 1:35 PM, 4:29 PM, and 5:52 PM, revealed the resident was laying on his/her right side in bed with eyes closed. The resident's lower extremities were contracted towards the abdomen. Resident #64 did not have a television in his/her view to watch. Further observation revealed three (3) residents in the same room had televisions: one (1) television was behind Resident #64; one (1) television was on the far side of the room; and one (1) television was on the bedside table and turned to face another resident in the bed perpendicular to Resident #64. Interview with State Registered Nursing Assistant (SRNA) #1, on 09/06/18 at 10:52 AM, revealed Resident #64 used to get up, but hardly ever got out of bed now. Per interview, the resident did not socialize much, even with the family when they visited. SRNA #1 stated the resident had no TV to watch. Further interview revealed the resident had no formal or structured exercise program. Interview with (SRNA) #2, on 09/06/18 at 11:02 AM, revealed Resident #64 was completely dependent for all care. She stated the resident did not receive any exercise and had random and seldom movements in bed which the facility considered an Activity for the resident. SRNA #2 revealed Resident #64 did not have a television and did not watch television or movies. Per interview, the resident did not socialize. Interview with SRNA #3, on 09/06/18 at 11:18 AM, revealed she occasionally assisted Resident #64 with care. She stated she did not perform any range of motion (ROM) with the resident; however, she turned the resident every two (2) hours and documented the turns in Nursing Assistant Kiosk notes. SRNA #3 stated she did not record random movements in bed as exercise. She further revealed Resident #64 did not watch television and probably could not see any of his/her roommates' televisions. Interview with SRNA #4, on 09/06/18 at 11:24 AM, revealed she never attempted to exercise Resident #64 due to the resident's condition (severe osteoporosis). She further stated she did not consider random movements in bed to be exercise. Interview with Licensed Practical Nurse (LPN) #2, on 09/06/18 at 1:07 PM, revealed Resident #64 did not socialize, even though the family generally fed the resident two (2) or three (3) meals each day. LPN #2 further stated she had not observed exercise being provided to the resident and the resident did not watch television. Interview on 09/06/18 at 9:13 AM, with the Activity Assistant, revealed he was also a SRNA. Per interview, Resident #64 received one on one (1:1) activities from the Activities staff to include exercise. The Activity Assistant revealed he had performed exercises with Resident #64 by opening and closing his/her hands and repositioning the resident in the bed and that was considered to be an activity. He further stated the resident had a pet visit on 08/14/18; however, the resident did not seem to react to the dog. Continued interview revealed the resident had not participated in any group activities for several months. Per interview, the resident used to watch television in the dining several months ago; however, the resident was hardly ever out of bed now, and just passively watched whatever programs were on other residents' televisions in the room. The Activities Assistant then clarified Resident #64 probably could not see the other residents' televisions from the position of the bed and had no television of his/her own to watch, but could listen to the other residents' televisions. Interview with the Activity Director, on 09/06/18 at 9:20 AM, revealed residents requiring individual activities were delineated on a one on one (1:1) activity list, and one on one (1:1) visits occurred twice a week for each resident on the list. Per interview, Resident #64 was to receive one on one (1:1) Activities by the Activities staff twice a week for exercise, which included observing the resident's random movements in bed. Per interview, this was exercise for purposes of activities, but there was no formal or structured exercise program for this resident and she did not know if activities staff actually performed ROM. Further, the Activity Director, admitted Resident #64 might not be able to watch television or movies as the resident did not have a television; however, she stated the resident could listen to programs on his/her roommates' televisions. She further revealed she would consider passive listening to someone else's television an activity. Continued interview revealed the resident's family visited often and this was considered socialization, as per the Activity Participation Roster. 2. Review of Resident #108's medical record revealed the facility admitted the resident on 12/05/14 with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), End Stage Renal Disease, Bipolar Disorder, Diabetes Mellitus Type 1, and Chronic Ischemic Heart Disease. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of five (5) out of fifteen (15) indicating the resident had severe cognitive impairment. Review of Resident #108's Activities Evaluation, dated 12/05/14, revealed the resident's current interest included animals, arts/crafts, cards, children visiting, exercise, visits, music, group discussion, travel, and Television/Movies. Review of Resident #108's Activities Care Plan, with problem onset date of 12/29/14, revealed the problem of little involvement in activities due to personal choice. The goal stated the resident would participate in two (2) activities per week by 11/16/18. Interventions included offering the schedule of activities for resident to choose; engaging the resident in group activities; and providing verbal reminders prior to commencement of an activity. However, there was no documented evidence of interventions for individualized meaningful one (1) on one (1) activities for this resident who no longer would come out for group activities. Review of the One to One (1:1) List, undated, revealed Resident #108 was not included on the 1:1 list. Review of the Activity Participation Roster for Resident #108, dated 08/01/18 through 09/05/18, revealed the resident actively participated in exercise, Television/movies, music and/or socialization almost daily unless the resident was out of the facility for dialysis. Observation of Resident #108, on 09/05/18 at 10:11 AM, revealed the resident was in bed with no activities provided other than the resident's television. Observation of Resident #108, on 09/06/18 at 8:31 AM, revealed the resident was awake and in bed. Interview with Resident #108, on 09/06/18 at 8:31 AM, revealed the resident was able to articulate his/her preferences for watching television and reading magazines if available. The resident stated no magazines were currently available to read. Per interview, the resident preferred activities in his/her room. Interview with SRNA #2, on 09/06/18 at 11:02 AM, revealed Resident #108 did not usually come out of the room. She stated she was unaware of any activities for this resident other than therapy visits on occasion. Interview on 09/06/18 at 11:18 AM, with SRNA #3, revealed Resident #108 rarely came out of his/her room. SRNA #3 stated she did not perform exercises with the resident and considered movement in bed as an activity of daily living, not exercise. Interview with LPN #1 on 09/06/18 at 12:47 PM, revealed Resident #108 did not receive restorative services and there was no exercise program for the resident. Interview on 09/06/18 at 1:07 PM, with LPN #2, revealed Resident #108 watched television in bed or looked at magazines. She stated the resident did not usually leave the room, but did permit nail care on occasion. Further interview on 09/06/18 at 9:13 AM, with the Activity Assistant, revealed Resident #108 was not on the one (1) on one (1) Activity List. He stated the resident rarely attended group activities and therefore did not get to socialize that much. The Activities Assistant stated any movement exerted by a resident was considered exercise including mobilizing a wheelchair, and this resident could move about in the wheelchair. Per interview, when Resident #108 moved in bed or attempted to mobilize in a wheelchair, it was considered exercise and therefore this activity was documented on the Activity Participation Roster. The Activity Assistant revealed the resident could watch television in his/her room which was an activity as well. Per interview, magazines were donated to the facility for residents; however, he did not record when Resident #108 received magazines. Interview on 09/06/18 at 9:20 AM, with the Activity Director, revealed Resident #108 received exercise when he/she mobilized self in the wheelchair. Further interview revealed Resident #108 received activities through mobilizing in the wheelchair, watching television, and socializing with staff as they assisted him/her with care. Continued interview, revealed the resident was not scheduled for one (1) on one (1) activities, even though the resident rarely came to group activities. Interview with the Director of Nursing, on 09/06/18 at 1:48 PM, revealed Resident #64 did not socialize with other residents. She stated she was not aware of any Range of Motion (ROM) being provided to the resident. She further stated the resident had osteoporosis and any exercises would be limited due to the severity of that condition. She also revealed Resident #64 did not watch television. Further interview with the DON, revealed on rare occasions Resident #108 would mobilize in a wheelchair outside the room, but no longer socialized much outside of his/her room. The DON revealed mobility of the wheelchair was an activity of daily living, rather than exercise. She stated SRNAs would encourage residents to reposition themselves; however, this would not be considered exercise, but rather an activity of daily living. Interview with the Administrator, on 09/06/18 at 2:17 PM, revealed it was her expectation for residents who did not attend group activities such as Resident #65 and Resident #108 to receive individual one (1) on one (1) activities centered on the resident's interests as per the Comprehensive Assessment. She revealed activities should be individualized and meaningful to the resident for optimal resident benefit.