Based on observation, record review, and interview, the facility failed to ensure staff followed infection control prevention standards by failing to wear a gown for 1 (#33) of 2 (#33, #11) residents observed for Enhanced Barrier Precaution (EBP) isolation during wound care. Findings: Review of the Enhanced Barrier Precaution (EBP) policy and procedure dated August 2022 revealed in part: Policy Statement: EBP are utilized to prevent the spread of multi-drug resistant organisms. Policy Interpretation and Implementation 1. EBP are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBP employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: h. Wound care 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. On 12/11/2024 at 11:12 a.m., an observation of wound care revealed S9Wound Care Nurse did not donn a gown prior to performing wound care. After wound care was completed, an interview with S9Wound Care Nurse confirmed she did not wear a gown during the wound care and should have. S9Wound Care Nurse stated she forgot to put the gown on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 1 (#276) of 1 (#276) resident reviewed for restraints. Findings: Review of the facility Use of Restraints policy revised December 2007 revealed the following, in part: Policy Statement: Restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls. Policy Interpretation and Implementation: 7. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions. 10. Restraints shall only be used upon the written order of a physician. The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. 13. The following safety guidelines shall be implemented and documented while a resident is in restraints: b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of an emergency. c. A resident placed in a restraint will be observed at least every 30 minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident' medical record. d. The opportunity for motion and exercise is provided for a period of not less than 10 minutes during each 2 hours in which restraints are employed. e. Restrained residents must be repositioned at least every 2 hours on all shifts. 18. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptoms. 19. Care plans shall also include the measures taken to systematically reduce or eliminate the need for the restraint. Review of resident #276's medical record revealed she was admitted to the facility on [DATE] with diagnoses of epilepsy, mild vascular dementia with mood disturbance, tracheostomy after aortic aneurysm repair, type 2 diabetes, chronic kidney disease, and obesity. Review of resident #276's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 99, which indicated the interview was not successful. Further review revealed she required total assistance for most activities of daily living. Review of resident #276's medical record revealed her care plan was revised on 12/03/2024 with a lap tray applied to her high-back wheelchair. Further review revealed there were no specific interventions regarding the lap tray, such as monitoring and releasing the lap tray. Further review of the medical record regarding resident #276's lap tray revealed there was no documented evidence of the following: physician order, pre-restraint assessment, and release and monitoring of the lap tray every 2 hours per the facility restraint policy. On 12/09/2024 at 10:45 a.m., an observation revealed resident #276 was observed in the secured unit in a specialized wheelchair with a lap tray that was tilted down. The resident was constantly moving her hands and was able to pick the lap tray up and move it around. Further observation revealed the lap tray was not positioned properly, it was loose and did not fit securely to the resident's wheelchair. The Velcro straps had been tied to the handles of the wheelchair. On 12/09/2024 at 1:47 p.m., an observation revealed resident #276 was observed in the secured in a specialized wheelchair with a lap tray and the Velcro straps were fastened to the armrests of the wheelchair. The lap tray was tilted down and did not fit securely to the wheelchair due to her constantly moving her arms and the lap tray. S6Certified Nursing Assistant (CNA) and S12CNA were sitting near the resident but did not attempt to adjust the lap tray or report this finding to S4Licensed Practical Nurse (LPN). On 12/10/2024 at 8:36 a.m., an observation revealed resident #276 was in secured unit in the day room in a specialized wheelchair with a lap tray that was not applied correctly. The Velcro straps were tied in a knot to the wheelchair handles. Further observation revealed the lap tray was loose and the resident was able to lift the lap tray with her hands. On 12/10/2024 at 11:50 a.m., an observation revealed resident #276 was in her room in the secured unit in a specialized wheelchair with the lap tray tilted down. The lap tray continued to be loose and the Velcro straps were fastened to the armrests on her wheelchair. Resident #276 was fidgeting and was able to move the lap tray up and down. S4LPN was present at this time and she revealed she tightens the strap but the resident was still able to loosen the Velcro straps. S4LPN confirmed the lap tray was not working out for the resident. On 12/10/2024 at 1:20 p.m., the surveyor and S2Director of Nursing observed resident #276's wheelchair and lap tray. S2DON confirmed the lap tray should be secured to the wheelchair armrests with the Velcro straps and should not be tied to the wheelchair handles. On 12/11/2024 at 03:08 p.m., an interview with S3RN/MDS Nurse Coordinator confirmed the following: there was no physician order for the lap tray when it was initially applied to the resident's wheelchair; no pre-restraint assessment completed prior to the lap tray being placed on her wheelchair; no specific interventions in the care plan regarding the lap tray; and no documented evidence nurses were monitoring and releasing the resident's lap tray every 2 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #53 Record review revealed resident #53 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, sepsis, lack of coordination, muscle wasting, osteoarthritis, and hypothyroidism. Record review revealed a physician order on admission for resident #53 to receive Ceftriaxone (Rocephin - antibiotic) 2 grams intravenously (IV) once daily with a stop date of 11/01/2024. Review of the medication administration record revealed resident #53 received Ceftriaxone as ordered and the medication was discontinued on 11/01/2024 with no record of Ceftriaxone administered IV from 11/02/2024-11/15/2024. Review of the nurse`s notes revealed documentation on 11/04/2024, 11/05/2024, 11/06/2024, 11/08/2024, 11/10/2024, 11/12/2024 and 11/15/2025 by S4Licensed Practical Nurse (LPN) that resident #53 continued to receive Rocephin IV related to sepsis. Further review revealed S5LPN also documented on 11/05/2024 that resident #53 continued to receive Rocephin IV related to sepsis. On 12/10/2024 at 10:30a.m., an interview with S2DON confirmed staff should not have recorded in the nurse`s notes that Ceftriaxone was still in use after it was discontinued on 11/01/2024. S2DON confirmed the nurses' notes appeared to have been copied and pasted by S4LPN and S5LPN from previous notes when resident #53 was receiving IV Ceftriaxone. Resident #33 Review of the record for resident #33 revealed diagnoses in part of : unspecified sequelae of other non-traumatic intracranial hemorrhage, anxiety disorder, typhoid arthritis, history of other venous thrombosis and embolism, malignant neoplasm of parotid gland, flaccid hemiplegia affecting the left non-dominant side, atrial fibrillation, aphasia following other non-traumatic intracranial hemorrhage, dysphagia following other non-traumatic intracranial hemorrhage, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #33 had a Brief Interview for Mental Status (BIMS) of 99 indicating they were unable to complete the assessment. Review of the functional abilities revealed resident #33 was dependent on staff for eating, oral hygiene, toileting, shower/bathing, dressing, hygiene and turning and mobility. Review of the pressure sore risk assessment dated [DATE] revealed resident #33 was scored as high risk for pressure ulcer development. Review of the current plan of care for pressure ulcers revealed staff were to perform weekly skin audits by licensed personnel. Review of the weekly skin/wound observations revealed on 09/04/2024, S2Director of Nurses (DON) performed a head to toe assessment that revealed skin breakdown on the right big toe and left lower medial leg. Further review revealed there were no other issues noted at this time. Review of the weekly skin/wound observation assessments dated 10/10/2024, 10/16/2024, 10/23/2024, 11/20/2024 and 12/04/2024 by S11Licensed Practical nurse (LPN) revealed she documented the resident's skin as intact and there was no mention of the resident's current pressure ulcer area. Further review of the record for resident #33 revealed he had a pressure ulcer which started on 09/04/2024 and there was current treatment being provided to the same pressure ulcer area. On 12/11/2024 at 1:34p.m., an interview with S2DON confirmed the skin/wound observations dated 10/10/2024, 10/16/2024, 10/23/2024, 11/20/2024 and 12/04/2024 by S11LPN were not accurate and did not show resident #33 already had a pressure ulcer that was being treated. Resident #9 Review of the record for resident #9 revealed an admit date of 10/28/2024 with diagnoses in part of displaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, and hypertension. On 12/09/2024 at 12:27 p.m., an observation and interview with resident #9 revealed her dentures were extremely loose and moved in her mouth while talking. Resident #9 stated her dentures were very loose and it made it difficult to chew her food and her gums were sore. She said she can really only chew soft foods. On 12/10/2024 at 8:20 a.m. observation again of resident #9 revealed her dentures continued to be loose and move in her mouth when spoken too. An observation of the breakfast tray revealed resident #9 only ate about 25% of her breakfast. On 12/11/2024 review of the admit nursing evaluation dated 10/28/2024 revealed under dental: Dentures: upper full- fit good, lower full- fit good. Review of the admission note dated 10/28/2024 by S7LPN revealed she documented resident #9 had upper and lower full dentures with good fit. Review of the oral cavity observation dated 10/28/2024 by S7LPN revealed the following: Dental -None of the above were present If resident had dentures/other appliance, describe fit - Good Review of the admission MDS assessment dated [DATE] revealed resident #9 had a BIMS of 13 indicating she was cognitively intact. Further review of the MDS under the section Oral Dental Status: B. No natural teeth or tooth fragment(s) (edentulous). The MDS did not identify: Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). Review of the 5 day MDS assessment dated [DATE] under the oral and dental- did not identify the resident's dentures were loose fitting. Review of the initial nutritional assessment dated [DATE] by S10Registered Dietician (RD) revealed Dental - nothing was noted about the resident's loose dentures. On 12/11/2024 at 10:14 a.m., an interview with S7LPN revealed resident #9 may have only told her she had dentures and may not have had them in when she did her assessment. S7LPN confirmed the dietary assessment did not even address the resident wearing dentures. On 12/11/2024 at 10:20 a.m., an interview with S8Social Services Director confirmed she was not aware resident #9 had issues with her dentures. On 12/11/2024 at 10:28 a.m., an interview with resident #9 again revealed she wears her dentures all the time and had them in when she was admitted . She again confirmed her dentures were too loose, she had ulcers in her mouth, and she had to eat soft foods. On 12/11/2024 at 1:37 p.m., an interview with S2DON revealed she went and spoke with the dietary manager and found out that resident #9 did mention her dentures were not fitting correctly and her gums were sore. S2DON said there was a slip of paper on the dietary manager's desk regarding the mouth issues and it has been entered into the computer. Based on observations, interviews, and record reviews, the facility failed to ensure the assessments accurately reflected the residents' status by failing: 1) to ensure assessments were completed in a timely manner for 1 (#35) of 5 (#13, #16, #35, #48, #276) reviewed for unnecessary medications, 2) to accurately assess the resident's skin during weekly skin/body assessments for 1 (#33) of 3 (#33, #11, #40) residents reviewed for pressure ulcers, 3) to accurately assess a resident's dental status for 1 (#9) of 1 (#9) resident reviewed for dental issues, and 4) to ensure accurate daily nursing assessments were completed for 1 (#53) of 2 (#53, #303) residents reviewed for urinary catheter or urinary tract infections (UTI). Findings: Resident #35 On 12/09/2024 at 8:58 a.m., an observation revealed resident #35 had an albuterol inhaler on her bedside table. The resident reported she kept the inhaler at her bedside. Review of resident #35's medical record revealed she had diagnoses which included chronic obstructive pulmonary disease and anxiety. Review of the Self Administration of Medications assessment dated [DATE] revealed resident #35 had been approved to self administer medications. On 12/10/2024 at 10:50 a.m., interview with S3Registered Nurse (RN)/Minimum Data Set (MDS) Coordinator confirmed an assessment had not been completed since 07/14/2023 to determine if the resident was capable of self administering the medications.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to monitor for bleeding risks for 1 (#16) of 5 (#13, #16, #35, #48, #276) residents reviewed for unnecessary medications. Findings: Review of the medical record for resident #16 revealed she had diagnoses which included atrial fibrillation and bradycardia. Review of resident #16's physician orders revealed she received the anticoagulant medication, Xarelto, 15 milligrams daily. Further review of resident #16's medical record revealed no documented evidence the facility was monitoring the resident for bleeding risks. On 12/11/2024 at 10:05 a.m., an interview with S3Registered Nurse/Minimum Data Set Coordinator confirmed nurses had not been monitoring resident #16 for bleeding risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that the resident's environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent avoidable accident hazards for 1 of (#46) of 4 (#40, #46, #50, and #68) residents sampled for falls. Findings: Review of the record for resident #46 revealed an admission date of 02/04/2019 with diagnoses including personal history of (healed) other pathological fracture, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, chronic atrial fibrillation, dizziness and giddiness. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99 indicating resident unable to complete interview and had moderate impairment of cognitive skills for daily decision making. Further review of the MDS revealed resident required extensive assist with bed mobility and personal hygiene. Review of the Resident Summary for resident #46 revealed resident was total dependence on staff for bed mobility, toileting and transfers. Review of the Incident Report for resident #46 dated 04/27/2023 at 10:45 a.m. revealed resident was being transferred by S6Certified Nurse Aid (CNA) Supervisor and S7CNA Assistant Supervisor without a lift on transfer. Further review of inicdent report revealed resident #46 was eased to the floor and sustained a laceration to the back of her head. Review of resident #46's current care plan revealed beginning 02/15/2019 resident required 2 person total assistance with transfers and a mechanical lift was to be used with all transfers and 2 person assistance. An interview on 10/24/2023 at 3:25 p.m. with S1Administrator confirmed that on 04/27/2023 an incident occurred involving resident #46, while transferring resident S6CNA Supervisor and S7CNA Assistant Supervisor had to ease resident to the floor during transfer sustaining a laceration to the back of her head. S1Administrator also confirmed S6CNA Supervisor and S7CNA Assistant Supervisor did not use a lift during transfer and Resident #46`s plan of care required 2 person assist with the use of a mechanical lift for all transfers. An interview on 10/24/2023 at 3:45 p.m. with S2Director of Nursing (DON) confirmed resident #46 required 2 person assist with use of a mechanical lift for all transfers. S2DON further confirmed that S6CNA Supervisor and S7CNA Assistant Supervisor transferred resident #46 without a lift on 04/27/2023 when the incident occurred. An interview on 10/25/2023 at 11:31 a.m. with S7CNA Assistant Supervisor confirmed that on 04/27/2022 she was transferring resident #46 with S6CNA Supervisor and resident started slipping and they eased her to the floor causing laceration to the back of resident's head. S7CNA Assistant Supervisor confirmed she did not use lift for transfer as directed by the plan of care . An interview on 10/24/2023 at 3:25 p.m. with S1Administrator confirmed that on 04/27/2023 an incident occurred involving resident #46, while transferring resident S6CNA Supervisor and S7CNA Assistant Supervisor had to ease resident to the floor during transfer sustaining a laceration to the back of her head. S1Administrator also confirmed S6CNA Supervisor and S7CNA Assistant Supervisor did not use a lift during transfer and Resident #46`s plan of care required 2 person assist with the use of a mechanical lift for all transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (#10, #282) of 4 (#10, #61, #282, and #283) residents reviewed for urinary tract infections. The facility failed to ensure resident #10 and #282 received antibiotics to treat a urinary tract infection as ordered by the physician. Findings: Resident#282 An interview on 10/23/2023 at 11:55 a.m. with Resident #282's daughter revealed her mother had a urinary tract infection. Record review revealed Resident #282 was admitted to the facility on [DATE] with diagnoses that included the following: Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, rheumatoid arthritis, age related cognitive decline, constipation, depression, ocular hypertension, lack of coordination, depression, other spondylosis cervical region, muscle wasting and atrophy left and right upper arms, and unspecified severe protein-calorie malnutrition. Review of Resident #282's lab revealed a U/A (Urinalysis) dated 10/17/2023 showing abnormalities of white blood cells (wbc) 2-4 and bacteria 2+. There was a hand written note on the urinalysis that Resident #282's physician was notified and no new orders at this time. Review of the final urine culture report dated 10/20/2023 revealed a pathogen (Citrobacter Koseri) that was susceptible to Ciprofloxacin. There was a hand written order on the urine culture report dated 10/20/2023 for Cipro 500 milligrams (mg) by mouth (PO) twice (BID) a day x 5 days by Resident #282's physician. Further review of the urine culture report revealed the antibiotic ordered was noted and signed by S3Licensed Practical Nurse (LPN) on 10/20/2023. Review of the October 2023 physician orders revealed an order for U/A with culture and sensitivity if indicated dated 10/16/2023. Further review of the physician orders revealed no order for Cipro 500 mg po BID x 5 days in Resident #282's hard chart or electronic health record. Review of the October 2023 Electronic Medication Administration Record (EMAR) revealed no documentation of Cipro 500 mg po BID x 5 days being entered or administered to Resident #282. Review of the nurse's notes revealed no documentation of Resident #282 being administered an antibiotic to treat a urinary tract infection. An interview on 10/24/2023 at11:00 a.m. with S4Licensed Practical Nurse (LPN) revealed she was assigned to provide care for Resident #282. Surveyor asked S4LPN if Resident #282 was receiving antibiotics for a urinary tract infection. S4LPN reviewed Resident #282's electronic medical record and reported Resident #282 did not have a urinary tract infection and was not receiving any antibiotics for a urinary tract infection. An interview on 10/24/2023 at 11:16 a.m. with S2Director of Nursing (DON) confirmed there was no documentation of an physician order for Cipro 500 mg po BID for 5 day in Resident #282's hard chart or electronic record. S2DON also confirmed there was no documentation of Resident #282 receiving Cipro 500 mg po BID x 5 days. S2DON further confirmed that the antibiotic order should have been written by S3LPN and the antibiotic should have been started on the evening of 10/20/2023. An interview on 10/24/2023 at 11:30 a.m. with S3LPN revealed she provided care for Resident #282 during the day shift on 10/20/2023. S3LPN confirmed she received Resident #282's urine culture result via fax that had an order for Cipro 500 mg tablet by mouth BID x 5 days written by the physician. S3LPN revealed she noted the order on the urine culture report and ordered the antibiotic from the pharmacy. S3LPN confirmed she did not write an order for Cipro 500 mg po BID x 5 days in Resident # 282's electronic record or hard chart. S3LPN confirmed she did not administer the first dose of Cipro 500 mg to Resident #282 on 10/20/2023 as ordered by the physician. Resident #10 Review of the medical record revealed resident #10 was admitted on [DATE] with diagnoses including of urinary tract infection, anorexia, chronic obstructive pulmonary disease, dementia, dehydration, hypertension, osteoarthritis, hematuria, peripheral vascular disease depression, and cardiomegaly. Review of the current care plan revealed potential reaction related to intravenous (IV) therapy. Resident #10 received Meropenem (antibiotic) IV via central line related to Extended-Spectrum Beta-Lactamase (ESLB) in the urine. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive skills for daily decision making. Resident #10 required extensive assistance with two persons for bed mobility, transfers, dressing, eating, toileting and personal hygiene. Review of the physician orders dated 10/17/2023 revealed an order for Meropenum (antibiotic) 500 milligrams (mg) IV two times a day for 10 days for diagnoses of urinary tract infection (UTI). Further review of the physician orders dated 10/17/2023 revealed an order to flush the Triple Lumen catheter with 2.5 cubic centimeters (cc) of Normal Saline followed by 2.5 cc Heparin after administration of Meropenum for the next 10 days. Review of the October 2023 Medication Administration Record (MAR) dated 10/20/2023 revealed at 8:00 p.m. the Meropenem 500 mg IV was not administered and the Triple Lumen catheter was not flushed and the heparin was not instilled in the catheter as ordered by the physician. Review of the nurses notes dated 10/20/2023 at 10:55 p.m. revealed the flush to the right triple lumen with 2.5 cc scheduled for 10/20/2023 at 10:00 p.m. was not administered due to no Registered Nurse (RN) on duty. Review of the nurses notes dated 10/20/2023 at 7:28 p.m. revealed Meropenem 500 mg IV solution scheduled for 8:00 p.m. was not administered due to there was no Registered Nurse to give the IV medication. Interview on 10/24/2023 at1:30 p.m. with S2Director of Nursing (DON) revealed there was no documented evidence of the antibiotic medication administered on 10/20/2023 at 8:00 p.m. and the Triple Lumen catheter was not flushed and the heparin instilled on 10/20/2023 at 10:00 p.m. as ordered by the physician. On 10/25/2023 at 2:30 p.m. S1Administrator was informed of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the pharmacy consultant failed to identify and report irregularities to the physician and director of nursing for 1 (#51) of 5 (#14, #40, #49, #51, #75) residents reviewed for unnecessary medications. The pharmacist consultant failed to identify the facility had not obtained an annual lipid level for Resident #51. Findings: Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included the following: essential hypertension, anxiety disorder, pain unspecified joint, insomnia, bipolar disease, hyperlipidemia, and unspecified dementia with behavioral disturbance. Review of the October 2023 physician orders revealed an active order for Crestor 5 milligrams (mg) tablet give one tablet by mouth every day and lipid panel every 12 months in April. Review of the September and October 2023 Electronic Medication Administration Record revealed documentation Resident #51 received Crestor 5mg tablet by mouth daily as ordered. Further review of Resident #51's medical record revealed the last lipid profile was collected on 04/12/2022. There was no documentation of a lipid panel being collected annually in April 2023 as ordered. Review Resident #51's monthly medication regimen reviews dated 04/11/2023, 05/05/2023, and 06/15/2023 revealed the pharmacy consultant failed to notice the lipid panel had not been collected for Resident #51 yearly in April as ordered. There were no recommendation by the pharmacy consultant that the Lipid panel had not been collected. On 10/24/2023 at 3:24 p.m. an interview with S2 Director of Nursing (DON) confirmed a yearly lipid panel had not been collected on Resident #51. On 10/24/2023 at 3:55 p.m. interview with S2DON confirmed the consultant pharmacist should have noticed that the yearly lipid panel had not been collected as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure each resident's medication regimen was free from unnecessary medications by failing to obtain an annual lipid panel for 1 (#51) of 5 (#14, #40, #49, #51, #75) residents whose medication regimens were reviewed. Findings: Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included the following: essential hypertension, anxiety disorder, pain unspecified joint, insomnia, bipolar disease, hyperlipidemia, and unspecified dementia with behavioral disturbance. Review of the October 2023 physician orders revealed an active order for Crestor 5 milligrams tablet give one tablet by mouth every day and lipid panel every 12 months in April. Review of the September and October 2023 Electronic Medication Administration Record revealed documentation Resident #51 received Crestor 5mg tablet by mouth daily as ordered. Further review of Resident #51's medical record revealed the last lipid profile was collected on 04/12/2022. There was no documentation of a lipid panel being collected annually in April as ordered. On 10/24/2023 at 3:24 p.m., an interview with S2 Director of Nursing (DON) revealed a yearly lipid panel had not been collected on Resident #51. S2DON confirmed the lipid panel should have been collected annually as ordered.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. 1) The facility failed to ensure all glucose testing items were disinfected prior to storing inside of the medication cart; 2) The facility failed to ensure employee personal items were not stored in the designated clean laundry room; and, 3) The facility failed to ensure the laundry department was free of dust and lint build-up. Findings: On 10/23/2023 at 12:15 p.m., an observation revealed S5LPN (Licensed Practical Nurse) gathering the supplies for glucose testing for resident #42. S5LPN gathered the supplies and entered resident #42's room. She placed the glucometer storage case storing the glucometer, individual lancets, and a bottle containing glucose test strips on the top of resident #42's personal refrigerator. The supplies were in direct contact with the refrigerator's surface. After completing the glucose testing, S5LPN retrieved the glucometer storage case, the unused lancet, and bottle of test strips and placed them inside of the medication cart. Further observation revealed that S5LPN did not disinfect the supplies prior to placing them inside of the medication cart. An interview with S5LPN confirmed she did not disinfect the dirty and contaminated supplies after she had retrieved them from the surface of resident #42's refrigerator prior to placing them inside of the medication cart for further storage and use. On 10/23/2023 at 3:15 p.m., an observation of the laundry department revealed S8Laundry and S9Laundry was working in the in the designated clean laundry room. Observation of the clean laundry room revealed a table with multiple items including, but not limited to clothes, towels, a set of car keys, a surgical face mask, and two cell phone chargers. An interview with S8Laundry revealed the table used for folding clean resident clothing, linens, towels, and other clean items. S8Laundry confirmed the surgical face mask belonged to her and that she had worn the mask inside of the facility prior to removing it and placed the mask on the table with the clean clothing, towel, and other clean items for resident use. S9LPN was present and confirmed the set of car keys belonged her (S9LPN). Further observation of the laundry department revealed a second laundry room that housed two large and one small washing machines, and other various items. Observation further revealed a large cart containing a pile of laundered items. S8Laundry reported the items inside the cart had been washed, clean, and available for resident use. There was a small sized air conditioner that was powered on and running. Observation revealed the air conditioner's vents, slats, and the surround areas had a dust and lint build-up throughout, and was blowing air in the direction of the cart. Further observation of the laundry room revealed a large build-up of dust and lint behind the two large washing machines including a dust build-up on the tops of the machines, and a build-up of a think, sticky, rust colored grime on the area located on the top surface, underneath the lid of the small washing machine. On 10/23/2023 at 3:30 p.m., S1Administrator was notified of the findings during the tour of the laundry department. After an observation of the laundry department with S1Administrator was completed, S1Administrator confirmed the department needed to be cleaned to help prevent cross contamination. S1Administrator was also informed of S5LPN not cleaning the glucometer and supplies before she placed them back in the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect the residents' right to be free from physical abuse by a staff member for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility Abuse Reporting Policy and Procedure revealed in part: Definitions of physical abuse- such as hitting, slapping, pinching, and kicking. Abuse Prohibition Program All employees will receive at orientation and in-services on prevention, identification, investigation and reporting abuse, neglect, and mistreatment, misappropriation of property and protection of residents. All employees will receive dementia training within 90 days of employment and annually. Reporting/Response Any employee who becomes aware of an allegation of abuse, neglect, misappropriation of property and injuries of unknown source shall report the incident to the Administrator immediately; but not later than 2 hours if the allegation involves abuse or results in serious bodily injury or no later than 24 hours if allegation does not involve abuse or does not result in serious bodily injury. If the Administrator is not in the facility or not reachable by phone and an allegation of abuse occurs, the DON (Director of Nursing), Nursing Supervisor or Nurse on call will be informed immediately. Should there be an allegation of abuse levied against employee/employees, it will result in that person's immediate suspension pending the results of our investigation. The facility will report to the state board of nursing, nurse aide registry or other licensing authority any substantiated allegation. Interviews with any and all persons having knowledge of the event will be held. Written statements will be taken. Any necessary outside agencies will be utilized and/or informed. The SIMS (Statewide Incident Management System) provided on the LDH website; will be used for reporting purposes. An internal investigation will be conducted, and all interviews will be attached to the form until the investigation is completed and then will be filed in the administrative office. Follow-up with appropriate agencies will be done in accordance to all state and local laws. The following list of incidents that must be reported immediately, within 1 hours to the Administrator. 1. Any incident or unusual occurrence that results in the death of a resident. 2. Any suspected occurrences of abuse and/or neglect to residents (including injuries of unknown sources and regardless of treatment outside the facility), whether or not it occurred on facility premises. The results of the investigation will be reported by the Administrator and/or designees to the other state officials in accordance with state law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate action will be taken. All facility personnel, including but not limited to, licensed nurses, nursing assistants, physicians, social workers, housekeepers, dietary, laundry and other personnel will upon hiring be given a copy of the abuse/neglect law and reporting policies. Each employee must sign an acknowledgment stating that the policies and procedures have been received and read. The statement shall be filed in the employee's personnel file. All staff personnel shall receive annual in-service training in identifying and reporting suspected abuse/neglect. Review of the record for Resident #1 revealed an admit date of 9/9/22 with diagnoses of cerebrovascular disease, hemiplegia following cerebral infarct affecting left non-dominant side, alcohol abuse, dysphagia, homelessness, restlessness and agitation. Review of the quarterly (MDS) Minimum Data Set, dated [DATE] revealed a BIMS 99 (not complete due to either resident chose not to participate or 4 or more items were coded 0 because the individual chose not to answer or gave a nonsensical response. Review of the functional status revealed Resident #1 is extensive assist to total assist with 1 person. Review of the plan of care revealed resident #1 had socially inappropriate/disruptive behavior: will smear feces on the walls in room, have it all over bed, on his hands/under his nails. Physically aggressive behavior will strike out at staff during ADL (activity of daily living) care, curse at staff at times during ADL care. Observation of Resident #1 revealed he was contracted in the lower leg and was confused at times but able to answer questions. Interview with Resident #1 multiple times revealed he said no one had ever slapped him or popped him on the arm and if they had he would hit them back. On 2/23/23 at 9:45 a.m. interview with S8, RN, MDS revealed on 2/15/23 it was reported to her by S7 LPN (Licensed Practical Nurse) that S3 CNA (Certified Nurses Aide) reported S2 CNA popped resident #1 on the arm on 2/13/23. S3 CNA spoke with S1 Administrator around 4 p.m. that she saw S2 CNA pop Resident #1 on the arm while feeding him on 2/13/23. S2 CNA was not working on 2/15/23 and last worked on 2/13/23. S8 RN, MDS said on 2/16/23 she and S1 Administrator spoke to S2 CNA and explained what had been reported and told her that she was suspended pending the investigation. S2 CNA said she never did it and she would never hit a resident. The Administrator and S8 RN, MDS interviewed S4 CNA the other 2-10 p.m. CNA on the 500 hall and at first she said she didn't think anyone would do that and they asked if S2 CNA ever got frustrated with residents and she said that S2 CNA would get frustrated with Resident #1 and she did witness her pop him on the arm on 2/11/23. S8 RN, MDS further said the Administrator immediately began the investigation and immediately started re-in servicing all staff on the abuse/neglect reporting policy and procedures along with the definition of what each type of abuse or neglect could be. On 3/22/23 at 3:45 p.m. interview with S4 CNA confirmed the written statement in the SIMS investigation was hers and that it read I have witnessed S2 CNA hit resident #1 Further interview with S4 CNA regarding the employee counseling/disciplinary action form dated 2/16/23 regarding failing to report physical abuse of a resident timely was reviewed by her and she understood that she must report anything like this when it happens and that it would not happen again or she would be terminated. Further interview with S4 CNA regarding the incident with S2 CNA and resident #1 revealed on 2/11/23, S2 CNA was trying to change resident #1 and she was kind of rough with him so he hit her on the right arm and S2 CNA slapped or popped the resident back and said don't hit me anymore. S4 CNA said she told S2 CNA not to change resident #1 and she would do it because he seemed to always get upset with her. S4 CNA said resident #1 has been resistive to care since she has been taking care of him. S4 CNA said she didn't say anything at that time about S2 CNA slapping/popping resident #1 and she knew better and knows that it is part of the policy to report immediately. S4 CNA further said that S3 CNA told her S2 CNA slapped/popped resident #1 and they both went and told S7 LPN. She said that S7 LPN immediately notified the Administrator and on 2/15/23 she and S3 CNA were called into the conference room to speak with the Administrator. S4 CNA also said that she has never seen any bruises or marks on resident #1 even prior to this incident. S4 CNA also said that when S2 CNA came to work on 2/16/23 she went straight to the Administrator's office and never came out to the floor and has not been in the facility since that day. On 2/27/23 at 2:15 p.m., interview with S3 CNA revealed she was counseled and received 1:1 abuse/neglect reporting training. She knew she was supposed to report immediately but she had gone into resident #1 room to pick up resident #2 supper tray and was joking with resident #2. She said S2 CNA was trying to get resident #1 to eat. He was hitting and screaming the he didn't want it and for her to stop but she just kept trying to feed him and the next thing she knew she saw S2 CNA pop resident #1 on the arm. S3 CNA said it caught her off guard because she wasn't really paying attention to them and was talking with resident #2. S3 CNA said resident #1 had no marks on his arm and when she has changed him she has not seen any suspicious marks on his back, legs, buttocks etc. S3 CNA also said she has never seen S2 CNA get verbally or physically upset with any other resident. S3 CNA further agreed the employee counseling/disciplinary action form dated 2/15/23 regarding failing to report physical abuse of a resident timely was reviewed by her and she understood that she must report anything like this when it happens and that it would not happen again or she would be terminated. On 2/27/23 at 3:00 p.m. phone interview with S7 LPN revealed S3 CNA came to her and said she had witnessed S2 CNA pop resident #1 on the arm and she immediately went and notified the Administrator. S7 LPN said she went and performed a skin assessment on Resident #1 and did not see any bruising or marks on him. S7 LPN also said the Administrator immediately began in-services for all staff on abuse and neglect and reporting immediately on 2/15/23. On 2/27/23 at 3:30 p.m. interview with S1 Administrator revealed when the allegation was reported to her she immediately started her investigation and started with abuse/neglect re-training all staff. She said she trained the staff that were on duty at the time and came back to train the night shift and then again re-trained the day staff the next day. All staff receive abuse/neglect training upon hire and yearly after that. She said she will even do more in-servicing if it is needed throughout the year. All staff are screened upon hire with background, adverse action site check monthly. S2 CNA was immediately suspended pending investigation and was ultimately terminated even though the allegation could not be proven. She further said it has been brought to QA (Quality Assurance). S1 Administrator further agreed S3 CNA and S4 CNA failed to follow the abuse reporting policy by not immediately reporting when S2 CNA slapped/popped resident #1 during care. Review of the personnel records for S2 CNA, S3 CNA and S4 CNA revealed all background checks were negative, adverse action checks were negative and all had abuse, neglect training upon hire. Interviews with S3 CNA, S4 CNA, S5 CNA, S12 CNA, S6 LPN, S7 LPN, S8 RN, MDS, S9 SSD, S10 Restorative Aid, S11 Secure Unit Activity Director all revealed they were in-serviced on 2/15/23 or 2/16/23 regarding abuse, neglect and reporting immediately. Review of the facility's plan revealed that they had implemented reporting, training, monitioring, and quality control measures regarding abuse and neglect after this incident. These correction actions were in place by 2/17/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator of the facility and to other officials (including to the State Survey Agency for 1 (#1) of 5(#1, #2, #3, #4, #5) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility Abuse Reporting Policy and Procedure revealed in part: Definitions of physical abuse- such as hitting, slapping, pinching, and kicking. Abuse Prohibition Program All employees will receive at orientation and in-services on prevention, identification, investigation and reporting abuse, neglect, and mistreatment, misappropriation of property and protection of residents. All employees will receive dementia training within 90 days of employment and annually. Reporting/Response Any employee who becomes aware of an allegation of abuse, neglect, misappropriation of property and injuries of unknown source shall report the incident to the Administrator immediately; but not later than 2 hours if the allegation involves abuse or results in serious bodily injury or no later than 24 hours if allegation does not involve abuse or does not result in serious bodily injury. If the Administrator is not in the facility or not reachable by phone and an allegation of abuse occurs, the DON, Nursing Supervisor or Nurse on call will be informed immediately. Should there be an allegation of abuse levied against employee/employees, it will result in that person's immediate suspension pending the results of our investigation. The facility will report to the state board of nursing, nurse aide registry or other licensing authority any substantiated allegation. Interviews with any and all persons having knowledge of the event will be held. Written statements will be taken. Any necessary outside agencies will be utilized and/or informed. The SIMS (Statewide Incident Management System) provided on the LDH website; will be used for reporting purposes. An internal investigation will be conducted, and all interviews will be attached to the form until the investigation is completed and then will be filed in the administrative office. Follow-up with appropriate agencies will be done in accordance to all state and local laws. The following list of incidents that must be reported immediately, within 1 hours to the Administrator. 1. Any incident or unusual occurrence that results in the death of a resident. 2. Any suspected occurrences of abuse and/or neglect to residents (including injuries of unknown sources and regardless of treatment outside the facility), whether or not it occurred on facility premises. The results of the investigation will be reported by the Administrator and/or designees to the other state officials in accordance with state law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate action will be taken. All facility personnel, including but not limited to, licensed nurses, nursing assistants, physicians, social workers, housekeepers, dietary, laundry and other personnel will upon hiring be given a copy of the abuse/neglect law and reporting policies. Each employee must sign an acknowledgment stating that the policies and procedures have been received and read. The statement shall be filed in the employee's personnel file. All staff personnel shall receive annual in-service training in identifying and reporting suspected abuse/neglect. Review of the record for Resident #1 revealed an admit date of 9/9/22 with diagnoses of cerebrovascular disease, hemiplegia following cerebral infarct affecting left non-dominant side, alcohol abuse, dysphagia, homelessness, restlessness and agitation. Review of the quarterly (MDS) Minimum Data Set, dated [DATE] revealed a BIMS 99 (not complete due to either resident chose not to participate or 4 or more items were coded 0 because the individual chose not to answer or gave a nonsensical response. Review of the functional status revealed Resident #1 is extensive assist to total assist with 1 person. Review of the plan of care revealed resident #1 had socially inappropriate/disruptive behavior: will smear feces on the walls in room, have it all over bed, on his hands/under his nails. Physically aggressive behavior will strike out at staff during ADL (activity of daily living) care, curse at staff at times during ADL care. Observation of Resident #1 revealed he was contracted in the lower leg and was confused at times but able to answer questions. Interview with Resident #1 multiple times revealed he said no one had ever slapped him or popped him on the arm and if they had he would hit them back. On 2/23/23 at 9:45 a.m. interview with S8, RN, MDS revealed on 2/15/23 it was reported to her by S7 LPN (Licensed Practical Nurse) that S3 CNA (Certified Nurses Aide) reported S2 CNA popped resident #1 on the arm on 2/13/23. S3 CNA spoke with S1 Administrator around 4 p.m. that she saw S2 CNA pop Resident #1 on the arm while feeding him on 2/13/23. S2 CNA was not working on 2/15/23 and last worked on 2/13/23. S8 RN, MDS said on 2/16/23 she and S1 Administrator spoke to S2 CNA and explained what had been reported and told her that she was suspended pending the investigation. S2 CNA said she never did it and she would never hit a resident. The Administrator and S8 RN, MDS interviewed S4 CNA the other 2-10 p.m. CNA on the 500 hall and at first she said she didn't think anyone would do that and they asked if S2 CNA ever got frustrated with residents and she said that S2 CNA would get frustrated with Resident #1 and she did witness her pop him on the arm on 2/11/23. S8 RN, MDS further said the Administrator immediately began the investigation and immediately started re-in servicing all staff on the abuse/neglect reporting policy and procedures along with the definition of what each type of abuse or neglect could be. On 2/22/23 at 3:45 p.m. interview with S4 CNA confirmed the written statement in the SIMS investigation was hers that it read I have witnessed S2 CNA hit resident #1 Further interview with S4 CNA regarding the employee counseling/disciplinary action form dated 2/16/23 regarding failing to report physical abuse of a resident timely was reviewed by her and she understood that she must report anything like this when it happens and that it would not happen again or she would be terminated. Further interview with S4 CNA regarding the incident with S2 CNA and resident #1 revealed on 2/11/23, S2 CNA was trying to change resident #1 and she was kind of rough with him so he hit her on the right arm and S2 CNA slapped or popped the resident back and said don't hit me anymore. S4 CNA said she told S2 CNA not to change resident #1 and she would do it because he seemed to always get upset with her. S4 CNA said resident #1 has been resistive to care since she has been taking care of him. S4 CNA said she didn't say anything at that time about S2 CNA slapping/popping resident #1 and she knew better and knows that it is part of the policy to report immediately. S4 CNA further said that S3 CNA told her S2 CNA slapped/popped resident #1 and they both went and told S7 LPN. She said that S7 LPN immediately notified the Administrator and on 2/15/23 she and S3 CNA were called into the conference room to speak with the Administrator. S4 CNA also said that she has never seen any bruises or marks on resident #1 even prior to this incident. S4 CNA also said that when S2 CNA came to work on 2/16/23 she went straight to the Administrator's office and never came out to the floor and has not been in the facility since that day. On 2/27/23 at 2:15 p.m., interview with S3 CNA revealed she was counseled and received 1:1 abuse/neglect reporting training. She knew she was supposed to report immediately but she had gone into resident #1 room to pick up resident #2 supper tray and was joking with resident #2. She said S2 CNA was trying to get resident #1 to eat. He was hitting and screaming the he didn't want it and for her to stop but she just kept trying to feed him and the next thing she knew she saw S2 CNA pop resident #1 on the arm. S3 CNA said it caught her off guard because she wasn't really paying attention to them and was talking with resident #2. S3 CNA said resident #1 had no marks on his arm and when she has changed him she has not seen any suspicious marks on his back, legs, buttocks etc. S3 CNA also said she has never seen S2 CNA get verbally or physically upset with any other resident. S3 CNA further agreed the employee counseling/disciplinary action form dated 2/15/23 regarding failing to report physical abuse of a resident timely was reviewed by her and she understood that she must report anything like this when it happens and that it would not happen again or she would be terminated. On 2/27/23 at 3:00 p.m. phone interview with S7 LPN revealed S3 CNA came to her and said she had witnessed S2 CNA pop resident #1 on the arm and she immediately went and notified the Administrator. S7 LPN said she went and performed a skin assessment on Resident #1 and did not see any bruising or marks on him. S7 LPN also said the Administrator immediately began in-services on abuse and neglect and reporting immediately on 2/15/23. On 2/27/23 at 3:30 p.m. interview with S1 Administrator revealed when the allegation was reported to her she immediately started her investigation and started with abuse/neglect re-training staff. She said she trained the staff that were on duty at the time and came back to train the night shift and then again re-trained the day staff the next day. All staff receive abuse/neglect training upon hire and yearly after that. She said she will even do more in-servicing if it is needed throughout the year. All staff are screened upon hire with background, adverse action site check monthly. S2 CNA was immediately suspended pending investigation and was ultimately terminated even though the allegation could not be proven. She further said it has been brought to QA (Quality Assurance). S1 Administrator further agreed S3 CNA and S4 CNA failed to follow the abuse reporting policy by not immediately reporting when S2 CNA slapped/popped resident #1 during care. Interviews with S3 CNA, S4 CNA, S5 CNA, S12 CNA, S6 LPN, S7 LPN, S8 RN, MDS, S9 SSD, S10 Restorative Aid, S11 Secure Unit Activity Director all revealed they were in-serviced on 2/15/23 or 2/16/23 regarding abuse, neglect and reporting immediately. Review of the facility's plan revealed that they had implemented reporting, training, monitioring, and quality control measures regarding abuse and neglect after this incident. These correction actions were in place by 2/17/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure that a resident receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#14) of 1 (#14) resident reviewed for eye concerns by not assessing or providing treatment for an eye condition. Findings: Review of the medical record revealed resident #14 was a [AGE] year old with diagnoses including Alzheimer's disease, unspecified dementia with behavioral disturbance, and history of conjunctivitis. Review of the 06/28/2022 yearly Minimum Data Set revealed she had a BIMS (Brief Interview for Mental Status) of 7 which indicated severe cognitive impairment and she was rarely/never understood. Further review revealed she required extensive to total assistance with all activities of daily living. On 09/19/2022 at 10:16 AM, resident #14 was in her bed in her room, and her eyes were red and matted. On 09/20/2022 at 11:10 AM, resident #14 was sitting in her wheelchair in the secured unit day room. Her eyes were pink with matted areas in her eyelashes. Review of resident #14's September Nurses' Notes revealed there was no documentation the resident's eyes were red or matted. Review of resident #14's September Physician's Orders revealed there was no documentation of an order for routine or as needed eye drops. On 09/20/22 at 3:40PM an interview with S5CNA (Certified Nursing Assistant) revealed resident #14 has had problems with her eyes being red and draining for a long time. S5CNA revealed when she wiped the resident's eyes, it comes right back. She was unsure if the nurse was putting eye drops in resident #14's eyes. On 09/21/22 at 8:51AM, an interview with S4LPN (Licensed Practical Nurse) revealed that resident #14 has had issues with her eyes in past with redness and drainage. S4LPN confirmed she noticed yesterday (09/20/22) that resident #14's eyes were more red than normal and the CNA had to wipe the resident's eyes because they were matted. S4LPN revealed resident #14 does not have a current order for routine or as needed eye drops. S4LPN confirmed she has not reported resident #14's eye issue to her physician. On 09/21/22 at 11:03AM, resident #14 was in her bed. Her eyes were pink bilaterally and her right eye was slightly edematous. Resident #14 had crusty drainage in the corners of her eyes. When the surveyor questioned resident #14 if her eyes hurt, she stated a little bit. On 09/21/22 at 11:05AM, an interview with S6CNA revealed she has worked the day shift this week on Monday, Tuesday, and Wednesday and has worked with resident #14 all three days. S6CNA revealed she noticed the resident's eyes have been red this week and were draining. S6CNA reported she had to wipe the resident's eyes at least 2 times a shift. S6CNA confirmed resident #14 has had an ongoing issue with her eyes for a while but it has been worse than normal this week. On 09/21/2022 at 11:15AM, the surveyor brought resident #14's eye condition to the attention of S2DON (Director of Nursing). At 11:45AM, S2DON provided a copy of a new order for resident #14 that was dated 09/21/2022 for Vigamox (antibiotic eye drops) 0.5% eye drops.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement a comprehensive person-centered care plan for 1 (#48) of 3 (#48, #67, and #76) residents reviewed for blood glucose monitoring. The facility failed to have documented evidence of accu checks obtained as ordered. Findings: Review of the medical record for sampled resident #48 revealed an admit date of 07/02/2012 with diagnoses of alcoholic liver disease, arthropathy, glaucoma, diabetes mellitus type 2, reflux, hyperlipidemia, muscle spasm, pain, spondylosis, hypertension, osteoarthritis, and depression. Review of the Facility's Obtaining a Finger stick Glucose Level policy revealed - Documentation The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 16. How resident tolerated the procedure. 17. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages), etc. 18. The signature and title of the person recording the data. Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident had moderate impaired cognition for daily decision making. Resident #48 required limited assistance with one person assist for bed mobility, hygiene, dressing and bathing, extensive assistance with one person assist with transfers, and independent with setup help only for eating. Review of the careplan revealed Diabetes mellitus type 2 and the approaches were to maintain blood sugar level within acceptable limits, observe for signs of hypoglycemia and hyperglycemia and to obtain blood sugars as ordered. Review of the physician orders revealed an order dated 10/27/2021 to obtain accu checks two times a day at 7:00AM and 4:00PM. If the blood sugar is above 180 give Novolin R 10 units subcutaneous (SQ), then recheck in 2 hours, if blood sugar remains above 180 see prn (as needed) Novolin R orders. Further review of the physician orders revealed an order dated 12/17/19 for Novolin R 100 units/milliliter vial administer 10 units subcutaneous every 2 hours prn for blood sugar greater than 180. Repeat dose every 2 hours until blood sugar less than 200. Review of the September 2022 Medication Administration Record (MAR) revealed 30 times during the month of September 2022 the resident's blood sugar level was greater than 180 and there was no documented evidence of the accu check rechecked as ordered. Review of the September 2022 nurses notes revealed no documented evidence of accu checks obtained 2 hours after the staff received a blood sugar level of 180 or greater. On 09/21/2022 at 9:00AM an interview with S2DON (Director of Nursing) revealed there was no documented evidence in the medical record that the accu checks were rechecked when the blood sugar levels were greater than 180. On 9/21/2022 at 9:30AM an interview with S3LPN (Licensed Practical Nurse) revealed the nurses do not document in the medical record of the recheck accu check when the resident's blood sugar levels were greater than 180. On 9/21/22 at 11:00AM S1Administrator was notified of no documented evidence that the blood sugar was rechecked as stated in the orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the pharmacist failed to report irregularities to the attending physician and the facility's medical director and director of nursing for 1 (67) of 5 (14, 25, 42, 56, 67) residents reviewed for unnecessary medications. Findings 09/19/22 11:54 AM an interview with Resident # 67 was conducted in her room. Resident # 67 confirmed she took vitamin B-12 injections. Record review revealed Resident # 67 was admitted to the facility on [DATE] with diagnosis that included thyrotoxicosis, type one diabetes, vitamin B-12 deficiency anemia, and long term drug therapy. Review of the most recent quarterly MDS (Minimum data set) dated 05/17/2022 revealed a BIMS (brief interview of mental status) score of 12 which indicated moderate cognitive impairment. Review of active physician orders revealed an order written on 04/15/2021 for Cyanocobalamin (vitamin B-12) 1000 mcg (micrograms)/ml (milliliter) to be given via injection each month on the 8th. No order was recorded for vitamin B-12 levels to be drawn at any time from 04/15/2021 - 09/20/2022. Review of the pharmacist communication sheet to the physician dated 07/14/2021 revealed a suggestion to check vitamin B - 12 level. A nurse practitioner agreed with the recommendation and signed the communication sheet. The Nurse practitioner wrote on the communication sheet for the vitamin B-12 level to be drawn every six months. Review of lab results from 07/14/2021-09/20/2022 revealed no record of a vitamin B-12 level for Resident #67. Review of the monthly medication regimen review from January 2022 - August 2022 revealed no record that the vitamin B-12 levels were collected and monitored for Resident #67. On 09/20/22 at 02:10 PM an interview with S2 DON confirmed the B-12 level had not been collected since the recommendation on 07/14/2021. S2 DON confirmed Resident # 67 had been receiving Cyanocobalamin monthly as ordered and the B-12 level should have been collected and monitored every six months as the pharmacist and practitioner had agreed on 07/14/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's drug regimen was free from unnecessary drugs by failing to monitor vitamin B-12 levels for 1 (67) of 5 (14, 25, 42, 56, 67) residents reviewed for unnecessary medications. Findings 09/19/22 11:54 AM an interview with Resident # 67 was conducted in her room. Resident # 67 confirmed she took B-12 injections. Record review revealed Resident # 67 was admitted to the facility on [DATE] with diagnosis that included thyrotoxicosis, type one diabetes, vitamin B-12 deficiency anemia, and long term drug therapy. Review of the most recent quarterly MDS (Minimum data set) dated 05/17/2022 revealed a BIMS (brief interview of mental status) score of 12 which indicated moderate cognitive impairment. Review of active physician orders revealed an order written on 04/15/2021 for Cyanocobalamin 1000mcg (micrograms)/ml (milliliter) to be given via injection each month on the 8th. Review of the Physician orders revealed there was no order for the B-12 levels to be drawn at any time from 04/15/2021 - 09/20/2022. Review of the Pharmacist communication sheet to the physician dated 07/14/2021 revealed a suggestion to check Vitamin B - 12 level. A nurse practitioner agreed with the recommendation and signed the communication sheet. The Nurse practitioner wrote on the communication sheet for the vitamin B-12 level to be collected every six months. Review of laboratory results from 07/14/2021 - 09/20/2022 revealed no record of vitamin B-12 levels collected. On 09/20/22 at 02:10 PM an interview with S2 DON confirmed the B-12 level had not been collected since the recommendation on 07/14/2021. S2 DON confirmed Resident # 67 had been receiving Cyanocobalamin monthly as ordered and the vitamin B-12 level should have been collected and monitored every six months as the pharmacist and nurse practitioner had agreed on 07/14/2021.