**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assess a resident for the risk of elopement and failed to ensure an assessment accurately reflected the resident's status for 1 (#1) of 3 (#1, #2, #3) residents reviewed for elopement, impaired cognition and/or a diagnosis which may increase the risk of elopement by failing to: 1. Ensure a nursing assessment and elopement risk assessment were completed for Resident #1 at the time of readmission on [DATE]. 2. Ensure Resident #1's behavioral section on Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/31/2025 was completed accurately. Findings: Review of the facility's undated Elopement/Missing Resident policy revealed in part: Purpose: - Ensure a safe and secure environment for all residents. - In the event a resident is missing from the facility, the resident is located in a timely manner. - Ensure staff awareness of the importance of the resident safety and security. Procedure: 3. All residents will be assessed for risk of elopement, following admission, quarterly, with significant change in condition Minimum Data Set (MDS) assessments and when behaviors indicate. Review of the facility's undated admission of Resident policy revealed in part: Purpose: - Process MDS Entry Tracking form in order to notify Centers for Medicare and Medicaid Services (CMS) Procedure: 7. When the resident has settled in a bit (no more than 2 hours after admission at most), the licensed nurse will begin the assessment of the resident's status upon admission, completing the Nursing Assessment/Data Collection or other nursing assessment form. Review of Resident #1's medical record revealed in part, Resident #1 was originally admitted to the facility on [DATE] and transferred/discharged to a local hospital on [DATE]. Further review of Resident #1's medical record revealed Resident #1 was readmitted to the facility on [DATE] with diagnoses including, but not limited to: dementia, unsteadiness on feet, and generalized muscle weakness. Review of Resident #1's admission MDS with ARD of 03/31/2025 revealed in part, Resident #1 had a Brief Interview Mental Status (BIMS) score of 7 indicating severe cognitive impairment and wandering behavior did not occur during 7 day look back period. Review of Resident #1's medical record failed to reveal a nursing assessment and risk for elopement assessment was completed at the time of Resident #1's 03/30/2025 readmission. Review of Resident #1's progress notes revealed in part: 03/30/2025 at 9:23 p.m. by S6Licensed Practical Nurse (LPN): Resident #1 wandered to nurse's station and attempted to exit out front door. Explained that door was kept locked for everyone's safety . 06/10/2025 at 10:35 a.m. by S7LPN: On the hall passing medication, Resident #1 was observed walking up and down Hall A when Resident #1 was asked if he wanted to take his medication, resident said no and continued walking . Later the social worker came and informed nurse (S7LPN) Resident #1 was found outside facility. I (S7LPN) immediately went to locate Resident #1 and found Resident #1 in the parking lot walking towards the entrance with several other staff members . During an interview on 06/17/2025 at 10:00 a.m., S3Director of Nursing (DON) reported if a resident is gone from the facility over 48 hours, an admission MDS and a risk for elopement assessment should be completed. S3DON reported a risk for elopement assessment is built into the admission assessment. S3DON further reported a risk for elopement assessment is performed at time of admission, with quarterly and significant change MDS, and if a resident is actively trying to get out of the facility. During an interview on 06/17/2025 at 12:57 p.m., S3DON confirmed a risk for elopement assessment was not conducted at Resident #1's readmission on [DATE] and should have been. S3DON reported S6LPN was the charge nurse on 03/30/2025 who was responsible for performing Resident #1's admission assessment. During an interview on 06/17/2025 at 1:25 p.m., S13Social Services (SS) reported she was the staff member who completed Section E, behaviors of the MDS. S13SS reported she did not read Resident #1's progress notes prior to completing Section E. S13SS reported she relied on other staff members' verbal reports to gather information for the behaviors section of Resident #1's MDS. S13SS reviewed Resident #1's nurse's progress note dated 03/30/2025 at 9:23 p.m. written by S6LPN and confirmed if she had read the progress note prior to completing Resident #1's behavior section on admission MDS with ARD of 03/31/2025, the behavioral section would have been completed differently. S13SS reported she would have answered the question regarding wandering to reflect Resident #1 displayed wandering behavior and exit seeking behavior. During an interview on 06/17/2025 at 1:35 p.m. S3DON confirmed S13SS should have read Resident #1's progress notes prior to completing section E, behaviors on Resident #1's MDS with ARD of 03/31/2025. During an interview on 06/18/2025 at 3:15 p.m., S6LPN confirmed an admission assessment which includes a risk for elopement assessment was not completed at time of Resident #1's readmission to the facility on [DATE]. S6LPN further reported she did not know a risk for elopement assessment needed to be completed at the time of Resident #1's readmission on [DATE].

Based on observation and interviews the facility failed to ensure a resident received the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1( #3) resident out of 3 (#1,#2, #3) sampled residents. The facility failed to ensure a resident request for toileting assistance was answered in a timely manner. Findings: Review of Resident #3's medical record revealed an admit date of 03/14/2025 and a readmission date of 05/09/2025 with diagnoses of but not limited to unspecified fracture of left femur, hyperlipidemia, essential hypertension, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, irritable bowel syndrome, parkinsonism, major depressive disorder, esophageal obstruction, gastronomy and dysphagia. Review of Resident #3's MDS (Minimum Data Set) revealed Resident #3 was assessed to require assistance with using the toilet. Review of Resident #3's Care Plan revealed a problem of: ADL (activities of daily living) self-care performance deficit related right sided hemiplegia and required total assistance by staff with toileting. Observation on 05/12/2025 at 1:45 p.m. revealed Resident #3 in the restroom calling out for help, while hovering over the toilet attempting to sit down without assistance. Observation also revealed the emergency call light was activated and lit up outside of Resident #3's room door with an audible beeping at the nurse's station. Further observation failed to reveal staff on the hallway and no staff at the nurse's station monitoring the call system. Observation revealed staff failed to respond to Resident #3's emergency call light and request for assistance for 15 minutes. During an interview 05/12/2025 at 2:00 p.m. S3 LPN confirmed the assigned certified nursing assistants were not on the hall when Resident #3's emergency call light was activated. During an interview on 05/12/2025 at 2:01p.m. S1 DON confirmed Resident #3's request for assistance should have been answered in a timely manner. S1 DON further confirmed there should have been a staff member at the nurse's station answering resident request for assistance with call light system.

Based on record review and interview the facility failed to implement the plan of care to meet the needs of 1 (#1) out of a total of 3, (#1, #2, #3) sampled residents by failing to complete an x-ray as ordered by the physician. Findings: Review of Resident #1's medical record revealed an admit date of 04/16/2025 with diagnoses of but not limited to acute respiratory failure with hypercapnia, pneumonia, type 2 diabetes mellitus without complications, spinal stenosis cervical region, cognitive communication deficit, spinal stenosis lumbar region without neurogenic claudication, essential (primary) hypertension and dysphagia. Review of Resident #1's physician's orders revealed an order for a STAT (immediately or right now) Chest x-ray on 04/18/2025. Review of Resident #1's medical record revealed a chest x-ray report with a completion date of 04/19/2025. Review of Resident #1's progress notes revealed an entry on 04/19/2025 at 4:05 p.m. stating, Resident #1's chest x-ray was completed at 1:15 p.m. and results were sent to the provider. During an interview on 05/13/2025 at 8:30 a.m. S2LPN (licensed practical nurse) confirmed Resident #1's chest x-ray should have been done on 04/18/2025 instead of 04/19/2025 because it was ordered STAT which meant it should have been done on the same day it was ordered by Resident #1's physician. S2LPN further confirmed failing to notify Resident #1's physician that Resident #1's STAT chest x-ray was not completed until the next day. During an interview on 5/13/2025 at 9:00 a.m. S1DON (Director of Nurses) confirmed Resident #1's chest x-ray should have been completed on the same day it was ordered and Resident #1's physician should have been notified of its completion on the next day.

Based on observation and interview, the facility failed to ensure the nurse staffing data was posted on a daily basis at the beginning of each shift. Findings: Observation on 04/16/2025 at 8:30 a.m. revealed staffing posted was dated 04/12/2025. During an interview on 04/16/2025 at 9:05 a.m. with S2 Interim DON (Director of Nursing)/Director of Clinical Operations acknowledged the staffing posted was dated 04/12/2025 and should have been posted daily.

Based on record reviews and interviews, the faciity failed to implement the care plan for 2 (#2, #3) of 3 (#1, #2, #3) sampled residents reviewed. The facility failed to administer antibiotic for Resident #2 and provide wound care for Resident #3 as ordered. Findings: Resident #2 Review of Resident #2's medical records revealed an admit date of 03/26/2025 with the following diagnoses, including in part: dependence on renal dialysis, type 2 diabetes mellitus without complications and myalgic encephalomyelitis/chronic fatigue syndrome. Review of Resident #2's Physician's orders revealed an order dated 03/27/2025 for Levofloxacin oral tablet 250 mg (milligram) give 1 tablet by mouth one time a day for UTI (urinary tract infection) for 10 Days. Review of Resident #2's March and April 2025 Medication Administration Records (MAR) failed to reveal Levofloxacin tablet 250 mg give 1 tablet by mouth one time a day for 10 days was administered on 03/28/2025, 03/31/2025, 04/02/2025 and 04/04/2025. During an interview on 04/16/2025 at 1:30 p.m. S2 LPN (Licensed Practical Nurse) acknowledged Resident #2 did not receive Levofloxacin tablet 250 mg give 1 tablet by mouth one time a day for 10 Days on 03/28/2025, 03/31/2025, 04/02/2025 and 04/042025 as ordered. During an interview on 04/16/2025 at 2:30 p.m. S1 Interim DON (Director of Nursing) acknowledged Resident #2 did not receive Levofloxacin ablet 250 mg give 1 tablet by mouth one time a day for 10 days on 03/28/2025, 03/31/2025, 04/02/2025 and 04/04/2025 and should have. Resident #3 Review of Resident #3's medical records revealed an admit date of 03/12/2025 with the following diagnoses, including in part: pressure ulcer of sacral region, muscle wasting and atrophy/multiple sites, other spondylosis with myelopathy lumbar region, dependence on wheelchair and chronic pain syndrome. Review of Resident #3's Physician's orders revealed an order dated 04/01/2025 to clean left hip with wound cleanser and pat dry, apply calcium alginate to wound bed and cover with a dry dressing every other day and as needed. Further review revealed orders dated 03/15/2025 for 1) sacrum - cleanse with wound cleanser, pat dry, apply skin prep to peri area; apply medihoney to slough and then calcium alginate then cover with dry dressing daily until resolved and prn (as needed); 2) left hip - cleanse with wound cleanser, pat dry, apply skin prep to peri area, apply betadine to eschar and cover with a dry dressing daily until resolved. (discontinued on 03/30/2025). Review of Resident #3's March and April 2025 MAR/TARs (Treatment Administration Record) failed to reveal left hip and sacrum wound care was completed on 03/18/2025, 03/24/2025, 03/28/2025, 04/01/2025, 04/07/2025, and 04/09/2025. During an interview on 04/16/2025 at 2:30 p.m. S1 Interim DON acknowledged Resident #3 did not receive wound care to left hip and sacrum on 03/18/2025, 03/24/2025, 03/28/2025, 04/01/2025, 04/07/2025, and 04/09/2025 and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to immediately notify the resident's representative after an incident with an injury for 1 (#2) of 3 (#1, #2, #3) sampled residents reviewed. Findings: Review of the facility's Condition Change of the Resident policy (no revision date) revealed: Procedure: After all resident falls, possible injuries or changes in physical or mental function: 6. Notify Resident's Responsible Party. Review of Resident #2's medical record revealed an admit date of 02/26/2025 with diagnoses which included, in part: Type 2 diabetes mellitus, unspecified dementia, muscle weakness, difficulty walking, cognitive communication deficit and chronic kidney disease. Review of Resident #2's admission MDS (Minimum Data Sets) assessment dated [DATE] revealed Resident #2 had a BIMS (Brief Interview for Mental Status) score of 11 indicating moderately impaired cognition. Review of the facility's incident log revealed Resident #2 had an incident which involved an injury on 03/16/2025. Review of Resident #2's medical record revealed a progress note dated 03/16/2025 at 11:40 p.m. which documented Resident #2 was transported via stretcher per EMS (Emergency Medical Services) to a local hospital. Further review revealed the facility was not able to contact the family of the incident due to no family contact listed on Resident #2's face sheet. Review of Resident #2's medical record failed to reveal Resident #2's family was notified immediately after an incident on 03/16/2025. Review of Resident #2's medical record revealed a progress note dated 03/17/2025 at 3:18 a.m. which documented Resident #2 returned to the facility from the hospital. Review of Resident #2's medical record revealed a progress note dated 03/17/2025 at 7:55 a.m. which documented Resident #2's family/RP (Responsible Party) was contacted. Further review revealed the RP asked, Why wasn't I notified last night? RP was informed at this time of no contact listed on the face sheet in the computer or chart. During an interview on 04/01/2025 at 4:15 p.m. S1 Administrator confirmed Resident #2's family was not notified of the incident on 03/16/2025 until his return from the hospital on [DATE]. S1 Administrator further confirmed contact information was not located on Resident #2's profile page at the time of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure a baseline care plan was developed for 1 (#2) of 3 (#1, #2, #3) sampled residents. The facility failed to ensure a baseline care plan was developed for Resident #2. Findings: Review of Resident #2's medical record revealed an admit date of 02/26/2025 with diagnoses which included, in part: Type 2 diabetes mellitus, unspecified dementia, muscle weakness, difficulty walking, cognitive communication deficit and chronic kidney disease. Review of Resident #2's admission MDS (Minimum Data Sets) assessment dated [DATE] revealed Resident #2 had a BIMS (Brief Interview for Mental Status) score of 11 indicating moderately impaired cognition. Review of Resident #2's medical record failed to reveal a baseline care plan had been completed. During an interview on 04/01/2025 at 1:30 p.m. S3 LPN (Licensed Practical Nurse) confirmed Resident #2 did not have a baseline care plan and should have. During an interview on 04/01/2025 at 2:15 p.m. S1 Administrator acknowledged a baseline care plan was not done for Resident #2 and should have been.

Based on record review and interview, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day 7 days per week. This deficient practice had the potential to affect all 24 residents residing in the facility. Findings: Review of the Nursing/Ancillary Personnel Staffing Pattern Reporting Form for the week days of 03/09/2025 to 03/22/2025 completed by S4 Human Resource Director revealed there were no staffing hours for an RN on 03/21/2025. Review of the facility's Employee Hours Per Day record, provided by S4 Human Resource Director, dated 03/21/2025 revealed no RN hours were clocked on 03/21/2025. During an interview on 04/01/2025 at 2:15 p.m. S1 Administrator reviewed the Personnel Staffing Pattern report from 03/02/2025 to 03/22/2025 and confirmed the facility did not have RN coverage on 03/21/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure medications were available for administration for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. The facility failed to ensure a controlled drug was available and administered to Resident #1. Findings: Policy: Pharmacy Services: (no revision date) Purpose: Ensure accurate and safe provision or obtaining of pharmaceutical services, including the provision lot routine and emergency medications and biologicals as well as the services of a licensed pharmacist to meet the needs of the resident. Procedure: The facility must: 2. Provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. 3. Employ or obtain the services of a licensed pharmacist who b. Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. c. Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Review of Resident #1's medical record revealed an initial admit date of 12/23/2024 with the following diagnoses, in part: Type 2 diabetes mellitus, acute osteomyelitis, difficulty walking, prosthetic heart valve and generalized anxiety disorder. Review of Resident #1's admission MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. Review of Resident #1's physician order dated 03/05/2025 revealed an order for Temazepam (a controlled drug) 7.5 mg (milligrams), give 1 capsule by mouth at bedtime for anxiety. Review of Resident #1's 2025 March and April MAR (Medication Administration Record) revealed Tamazepam 7.5mg was not administered on 03/30/2025, 03/31/2025 and 04/01/2025 due to (9) other - See Notes: Not available. During an interview on 03/31/2025 at 4:00 p.m. Resident #1 reported the nurse told her she did not receive her Temazepam the night of 03/30/2025 because the pharmacy had not filled her medication and she did not have any Temazepam left. During an interview on 04/02/2025 at 10:50 a.m. S3 LPN (Licensed Practical Nurse) reported prescriptions should be ordered before the resident runs out of their medication. An observation on 04/02/2025 at 11:41 a.m. with S5 RN (Registered Nurse) revealed Temazepam was not available for Resident #1 on the medication cart and should have been. During an interview on 04/02/2025 at 11:41 a.m. S5 RN reported medications should be refilled 7 days before they run out. S5 RN confirmed Resident #1 was not administered Temazepam 7.5 mg at bedtime on 03/30/2025, 03/31/2025, and 04/01/2025 and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure a baseline care plan was completed within 48 hours of admission for 2 (#75, #76) of 20 sampled residents. Findings: #75 Review of Resident #75's medical records revealed an admit date of 10/09/2024 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus due to underlying condition with diabetic polyneuropathy, and hyperlipidemia. Review of Resident #75's admission MDS (Minimum Data Set) with an assessment reference date 10/09/2024 in progress (not completed). Review of resident #75's medical record failed to reveal a Baseline Care Plan was completed. During an interview on 10/17/2024 at 1:50 p.m. S4 DOCO (Director of Clinical Operations) reported it is the nurse's responsibility to complete the Baseline Care Plan for the resident on admit. S4 DOCO reported if the Baseline Care Plan is not in the paper chart, it has not been completed and it should have been. #76 Review of Resident #76's medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses that included, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic atrial fibrillation unspecified, essential (primary) hypertension, heart failure unspecified, chronic kidney disease unspecified, prediabetes, chronic pain and insomnia. Review of Resident #76's Admission, 5-day MDS with assessment reference date of 10/09/2024 revealed Resident #76 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated cognitively intact. Review of Resident #76's medical record failed to reveal a Baseline Care Plan had been completed. During an interview on 10/17/2024 at 12:00 p.m. S4 DOCO reviewed #76's medical record and reported a baseline care plan had not been conducted for Resident #76 and it was the nurse's responsibility to complete the baseline care plan. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to ensure oxygen therapy was provided according to the facility's Policy and Procedure for Oxygen therapy for 3 (#12, #15, and #175) of 3 residents reviewed for respiratory care. The facility failed to ensure: Resident #12 had a physician order for oxygen therapy when Resident #12 had been receiving oxygen for several days. Resident #15's CPAP (continuous positive airway pressure) mask and tubing was stored properly when not in use. Resident #175 had a physician order for CPAP and was care planned for the use of CPAP. Resident #175's CPAP mask and tubing was stored properly when not in use. Findings: Review of the facility's Oxygen Therapy Policy and Procedure presented by S4 Director of Clinical Operation (DOCO) (07/2024) revealed, in part: Subject: Oxygen Therapy Policy: Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Responsibility: All licensed Nursing Personnel/Respiratory Therapist Procedure: 1. Oxygen therapy is to be provide under the direction of a written physician's order. A Physician's Order for O2 therapy is to contain liter flow per minute via mask or cannula/timeframe. On an emergency basis, O2 may be used at 2 Liters/minute until the physician is notified. 4. Adjust delivery rate as ordered. 8. Change tubing weekly. 9. Date tube when changed (weekly). Reference: [NAME]'s Nursing Procedures. 5th ed. Philadelphia. Wolters Kluwer/[NAME] & [NAME], 2009, 569-74. Print. Resident #12 Review of resident #12's medical records revealed admission date of 08/29/2024 with medical diagnoses that include but not limited to chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypoxia, generalized anxiety disorder, type 2 diabetes mellitus without complication, difficulty walking and muscle weakness. Review of resident #12's October 2024 physician orders failed to reveal an order to provide oxygen therapy including liter flow per minute. Review of resident #12's admission MDS (minimum data sets) with ARD (assessment reference date) 09/04/2024. Section I - Active Diagnoses of debility, cardiorespiratory conditions, COPD (chronic obstructive pulmonary disease) with acute exacerbation. Section O - Special Treatments, Procedures, and Programs, oxygen therapy. Review of resident #12's care plan revealed admitted with diagnosis of COPD. Some of the interventions are inhalers, nebulizer treatment as ordered; document minutes used, check lung sounds pre and post treatment, monitor pulse and respirations pre and post treatment, observe for sputum. Head of bed elevated to at least 30 degrees. Observation on 10/15/2024 at 4:15 p.m. revealed resident #12 was sitting in a wheel chair at the bedside. Resident #12 had oxygen in progress at 2 liters by a nasal cannula. Observation on 10/16/2024 at 4:50 p.m. with S2 DON (Director of Nursing) confirmed resident #12's oxygen in progress. S2 DON reported they did not know how many liters of oxygen resident #12 should be receiving because she could not find a physician order for the oxygen. Resident #15 Review of resident #15's medical record revealed an admit date of 07/20/2024 with medical diagnoses that include but not limited to non-rheumatic aortic (valve) stenosis, unspecified systolic (congestive) heart, acute on chronic diastolic (congestive) heart failure, acute respiratory failure with hypoxia, and chronic obstructive respiratory failure. Review of resident #15's October 2024 Physician Orders revealed: 09/27/2024: Device and settings: IPAP (inspiratory positive airway pressure) 10/ EPAP (expiratory positive airway pressure) 5/ FiO2% (fraction of inhaled oxygen) 30 09/27/2024: Fill water chamber with distilled water every at bedtime 09/27/2024: Clean tubing weekly; every night shift every 7 days Review of resident #15's admission MDS with an ARD 9/27/2024 revealed a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating cognitively intact. Review of resident #15's care plan revealed resident had altered respiratory status related to diagnoses of chronic obstructive pulmonary disease, heart failure, respiratory failure, obstructive sleep apnea with interventions to administer medication, inhalers, and nebulizer treatments as ordered. Monitor for effectiveness and side effects. CPAP at bedtime using prescribed settings with full face mask. Observation on 10/14/2024 at 12:04 p.m. revealed resident #15's CPAP (continuous positive airway pressure) was not in use. Further observation revealed resident #15's CPAP tubing was hanging over the head of the bed and mask was not stored in a plastic bag. Observation on 10/15/2024 at 4:30 p.m. with S6 LPN (Licensed Practical Nurse) revealed resident #15's CPAP mask and tubing was on top of CPAP machine on bedside table and not stored in a plastic bag. During an interview on 10/15/2024 at 4:30 p.m. S6 LPN reported when CPAP mask is not in use the mask should be stored in a plastic bag. S6 LPN confirmed resident #15's CPAP mask and tubing was stored on on top of CPAP machine and resident #15's CPAP mask should be stored in a plastic bag when not in use. Resident #175 Review of resident #175's medical record revealed an admit date of 09/27/2024 with medical diagnoses that include but not limited to orthostatic hypotension and chronic atrial fibrillation. Review of resident # 175's October 2024 physician orders failed to reveal any order for CPAP. Review of resident #175's admission MDS with an ARD 10/01/2024 revealed resident #175's speech was clear, hearing and vision was adequate. Resident #175 had the ability to understand others and make self understood. Review of resident #175's care plan failed to reveal focus or interventions related to use of CPAP machine. Observation on 10/14/2024 at 1:09 p.m. revealed resident # 175's CPAP mask and tubing was on the floor. During an interview on 10/15/2024 at 4:30 p.m. S6 LPN reported when CPAP was not in use the mask should be stored in a plastic bag. S6 LPN confirmed resident #175's CPAP mask and tubing was on the floor and not stored properly in a plastic bag when not in use. During an interview on 10/16/2024 at 10:35 a.m. resident #175 reported he used the CPAP machine at night. During an interview on 10/16/2024 at 2:20 p.m. S4 DOCO reported the facility did not have a policy for storing of CPAP mask and tubing when not in use. S4 DOCO reported CPAP mask and tubing should be stored in a plastic bag when not in use. During an interview on 10/17/2024 at 8:40 a.m. S4 DOCO confirmed resident #175 did not have a physician order or care plan for use of CPAP.

Based on record reviews and an interview, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 (#18) of 1 resident reviewed for dialysis by failing to obtain weekly weights according to the plan of care and communicate and collaborate with the dialysis facility by completing the hemodialysis communication record form. Findings: Review of Dialysis Communication Record (dated 07/2024) policy revealed, in part: Policy: A Dialysis Communication Record Form is completed each time a resident receives outpatient dialysis. This ensures communication between the two facilities. Procedure: 1. The top section of the Dialysis Communication Record Form is completed by the nurse responsible for sending the resident to the dialysis unit/facility. 2. The middle section of the form is completed by personnel responsible for the resident at the dialysis facility and returned to the nursing home with the resident. 3. The bottom of the form is completed by personnel responsible for the resident upon return to the facility. 4. Once the form is completed in its entirety, the form should be filed under the miscellaneous section of the electronic medical record. Review of Resident # 18's face sheet revealed an admit date of 09/20/2024. Review of Resident # 18's Medical Diagnoses revealed the following diagnoses but not limited to hyperkalemia, hypocalcemia, anemia in chronic kidney disease hypomagnesemia, and chronic kidney disease, stage 5. Review of Resident #18's October 2024 Physician Orders revealed: 09/20/2024: Hemodialysis: Tuesday, Thursday, and Saturday at 11:30 am 09/20/2024: Hemodialysis- Assess site right chest wall port for bruising/bleeding/symptoms of infection 09/20/2024: Renal diet: Regular texture, Regular/Thin Liquids consistency Review of Resident #18's 5 day Medicare MDS (Minimum Data Sets) dated 10/08/2024 revealed a BIMS (Brief Interview of Mental Status) of 15 out of 15 indicating cognitively intact. Review of Resident #18's Care Plan revealed: The resident has potential nutritional deficits and is receiving a renal diet with interventions to weigh weekly for 4 weeks, then monthly and/or as needed. Date Initiated: 09/27/2024 The resident needs hemodialysis; has diagnoses of ESRD (end stage renal disease) with interventions to check dressing at left chest wall access site every shift; change only per dialysis and physician orders. Resident receives dialysis on Tuesday, Thursday, and Saturday with intervention for vital signs per facility protocol/dialysis orders. Review of Resident # 18's Hemodialysis Communication Record form with S2 DON (Director of Nursing) revealed dialysis communication forms were not completed in its entirety: 09/21/2024: form not completed by facility upon return from dialysis 10/05/2024: dialysis center failed to complete portion of hemodialysis communication record form 10/10/2024: dialysis center failed to complete portion of hemodialysis communication record form and facility failed to perform assessments and complete vital signs when resident returned to the facility. 10/12/2024: dialysis center failed to complete portion of hemodialysis communication record form and facility failed to perform assessments and complete vital signs when resident returned to the facility. 10/15/2024: dialysis center failed to complete portion of hemodialysis communication record form Further review of Resident #18's Hemodialysis Communication Record form failed to reveal hemodialysis communication record form for 10/01/2024 and 10/08/2024. During an interview on 10/16/2024 at 3:30 p.m. S2 DON reviewed Resident #18's paper record and EHR (Electronic Health Record) and confirmed Resident #18's weights were not obtain according to the plan of care. S2 DON confirmed Resident #18's dialysis communication record forms was not completed in its entirety on 09/21/2024, 10/05/2024, 10/10/2024, 10/12/2024, and 10/15/2024, and there was no hemodialysis communication record forms for 10/01/2024 and 10/08/2024.

Based on record reviews and interview, the facility failed to ensure the use of services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week during FY (Fiscal Year) Quarter 3 2024 (April 1- June 30). Findings: Review of the PBJ (Payroll Based Journal) Staffing Report for FY Quarter 3 2024 (April 1- June 30) revealed the facility triggered for: Failed to have Licensed Nursing Coverage 24 Hours/Day on 05/04/24, 05/05/2024, 05/18/2024, 05/26/2024, 06/02/2024, 06/16/2024, 06/22/2024, 06/23/2024, 06/29/2024, and 06/30/2024. During review of the Facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 10/17/2024 provided for the triggered dates on the PBJ Staffing Report FY Quarter 3 2024 (April 1- June 30) failed to reveal RN services were used on 05/05/2024 and 05/18/2024. During an interview on 10/17/2024 at 2:00 p.m. S1 Administrator reviewed the Facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 10/17/2024 for the triggered dates on the FY Quarter 3 2024 (April 1- June 30) PBJ Staffing Report and acknowledged RN services were not used on 05/05/2024 and 05/18/2024.

Based on record reviews and interview the facility failed to ensure annual performance evaluations were conducted on 2 CNAs [Certified Nursing Assistants (S13 CNA, S14 CNA)] out of 5 CNA personnel records reviewed. Findings: Review of S13 CNA's personnel record revealed S13 CNA was hired on 01/05/2018. Further review of S13 CNA's personnel record failed to reveal documentation of an annual performance evaluation since 01/12/2023. Review of S14 CNA's personnel record revealed S14 CNA was hired on 07/23/2023. Further review of S14 CNA's personnel record failed to reveal documentation of an annual performance evaluation since hire. During an interview on 10/17/2024 at 12:36 p.m. S15 Human Resources reviewed S13 CNA and S14 CNA's records and confirmed there was no documentation of annual performance evaluations.

Based on record review and interviews the facility failed to accurately submit mandatory direct care staffing information to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 3 2024 (April 1- June 30). Findings: Review of the PBJ (Payroll Based Journal) Staffing Report for FY Quarter 3 2024 (April 1- June30) revealed the facility triggered for Failed to have Licensed Nursing Coverage 24 Hours/Day on 05/04/24, 05/05/2024, 05/18/2024, 05/26/2024, 06/02/2024, 06/16/2024, 06/22/2024, 06/23/2024, 06/29/2024, and 06/30/2024. Review of the Facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 10/17/2024 for the triggered dates on the FY Quarter 3 2024 (April 1- June 30) PBJ Staffing Report revealed licensed nursing coverage. During an interview on 10/17/2024 at 2:00 p.m. S1 Administrator reported the facility's corporate office submits the PBJ to CMS from the facility's time clock management system. S1 Administrator indicated agency staffing hours were likely left off of the submission to CMS.

Based on record review and interview, the facility failed to conduct Quality Assessment and Assurance (QAA) meeting at least quarterly with required staff present since last annual survey dated 10/04/2023. Findings: Review of QAA binder with S1 Administrator failed to reveal a QAA meeting for the 1st quarter and the Director of Nursing (DON) was not present for the QAA meeting in the 2nd quarter. During an interview on 10/17/2024 at 4:45 p.m. S1 Administrator confirmed the facility did not meet during the 1st quarter and confirmed the DON was not present for the 2nd quarter meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure immunizations were administered to residents who consented to receive the influenza, pneumococcal and/or COVID-19 immunizations during the admission process for 2 (#11, #77) of 2 (#11, #77) residents reviewed for immunizations. Findings: Review of the facility's Influenza, Pneumococcal and COVID-19 Vaccination policy dated 07/2024 revealed in part, the following: Responsibility: The Director of Nursing in conjunction with the Infection Preventionist or RN (Registered Nurse) designee. Procedure: 1. On admission, residents will be offered the influenza, pneumococcal, and COVID-19 vaccines. 3. For those residents accepting, record all influenza, pneumococcal, and COVID-19 vaccines administered on the resident immunization record. 5. Obtain a physician's order for all residents to receive the Influenza, Pneumococcal, and COVID-19 vaccines. Review of Resident #11's Immunization Informed Consent signed on admission on [DATE] revealed Resident #11 consented to receive pneumonia vaccine and COVID-19 vaccine. Review of resident #11's October 2024 Physician Orders failed to reveal any previous or current orders for the pneumonia vaccine or the COVID-19 vaccine to be administered to resident #11. Review of resident #11's medical records failed to reveal any documentations the pneumonia vaccine or the COVID-19 vaccine were ever administered. Review of Resident #77's Immunization Informed Consent signed on admission on [DATE] revealed Resident #77 consented to receive the pneumonia vaccine. Review of resident #77 October 2024 Physician Orders failed to reveal an order to administer the pneumonia vaccine. Review of resident #77's medical records failed to reveal any documentations the pneumonia vaccine was ever administered. During an interview on 10/15/2024 at 11:30 a.m. S3 Infection Preventionist reported during the admissions process all residents are offered the Influenza Vaccine, Pneumonia Vaccine, COVID-19 Vaccine by the admission team and the consents are signed at that time. S3 Infection Preventionist reported the admission team are to scan the admission packet. S3 Infection Preventionist reported the admission packet was not scanned and she never received the consents for the vaccines. During an interview on 10/16/2024 at 1:00 p.m. S4 Director of Clinical Operation reported the residents did not get the immunizations due to the admission packet not being scanned and given to S3 Infection Preventionist nurse. S4 Director of Clinical Operation reported the Immunization Informed Consent forms should have been given to S3 Infection Preventionist nurse to administer the vaccines and they were never scanned or given to her.

Based on record reviews and interview the facility failed to ensure CNAs (Certified Nursing Assistants) received the required training for 1 CNA (S12) out of 5 CNA personnel records reviewed. Findings: Review of S12 CNA's personnel record revealed S12 CNA was hired on 05/17/2024. Further review of S12 CNA's personnel record failed to reveal S12 received required dementia training. During an interview on 10/17/2024 at 12:36 p.m. S15 Human Resources reviewed S12 CNA's personnel record and confirmed there was no documentation of dementia training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails and received a written order from the physician for bed rails prior to installation for 7 (#4, #20, #125, #22, #75, #9, #126) of 7 (#4, #20, #125, #22, #75, #9, #126) residents reviewed for accident hazards. Findings: Review of the Facility's Restraint Evaluation & Restraint Reduction Policy dated 07/2024 revealed in part: -Definition: Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Responsibility: All members of the interdisciplinary team (as appropriate to individual resident needs) and monitored by the Director of Nursing. -Procedure: 1. The following devices are considered physical restraints and require evaluation (Category I is considered most restrictive with Category IV being the least restrictive): -Category I: wrist, Pelvic, Full Body -Category II: Chest/vest, Waist, Poncho, Hand Mitt, Roll Belt -Category III: Seat belts, Wheelchair lab [NAME], Geri-chair with or without tray, Wheelchair with lap tray, Roll bar, Lap buddy -Category IV: Wedge Cushion, Recliner/Beanbag --side rails that restrict freedom of movement and cannot be easily removed are considered a restraint. 2. All residents using a restraint are to be evaluated utilizing the Physical Restraint Evaluation assessment and/or the Side Rail Evaluation assessment for side rails. Restraint use is to be re-evaluated approximately every quarter. The evaluation is to be conducted by a licensed nurse and reviewed by a physical therapist and or occupational therapist and/or physician and/or rehab certified RN (Registered Nurse), as appropriate. 4. A specific physician's order is to be entered in the resident's Medical Record which details the medical reason, type of restraint and when to be used. 8. Care Plan updates are to occur approximately every quarter and/or as a goal or approach direction changes. Findings: Resident #4 Review of Resident #4's medical record revealed Resident #4 was admitted on [DATE] with diagnoses which included lymphedema, generalized muscle weakness, and difficulty in walking. Review of Resident #4's most recent MDS (Minimum Data Set) asssessment dated 10/08/2024 revealed Resident #4 had a BIMS (Brief Interview for Mental Status) of 11 indicating moderately impaired cognition. Further review of Resident #4's most recent MDS revealed Resident #4 was dependent on staff for activities of daily living. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #4 revealed Resident #4 was in bed with quarter side rails in use. Review of Resident #4's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #4's care plan revealed Resident #4 had an ADL (Activity of daily living) self-care deficit. Review of Resident #4's medical record failed to reveal documentation Resident #4 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #20 Review of Resident #20's medical record revealed Resident #20 was admitted on [DATE] with diagnoses which included cellulitis of right lower limb, congestive heart failure, cardiomyopathy, hypertension, and difficulty in walking. Review of Resident #20's most recent MDS dated [DATE] revealed Resident #20 had a BIMS of 9 indicating moderately impaired cognition. Further review of Resident #20's most recent MDS revealed Resident #20 was dependent on staff for activities of daily living. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #20 revealed Resident #20 was in bed with quarter side rails in use. During an interview on 10/14/2024 at 9:00 a.m. Resident #20's son reported the quarter side rails were used to assist Resident #20 with positioning. Review of Resident #20's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #20's medical record failed to reveal documentation Resident #20 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #125 Review of Resident #125's medical record revealed Resident #125 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, bilateral primary osteoarthritis of knee, lack of coordination, difficulty in walking, and generalized muscle weakness. Review of Resident #125's most recent MDS assessment dated [DATE] revealed Resident #125 had a BIMS of 4 indicating severely impaired cognition. Further review of Resident #125's most recent MDS assessment revealed Resident #125 was dependent on staff for activities of daily living. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #125 revealed Resident #125 was in bed with quarter side rails to the head of the bed bilaterally. Review of Resident #125's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #125's care plan revealed Resident #125 had an ADL self-care performance deficit. Review of Resident #125's medical record failed to reveal documentation Resident #125 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #22 Review of Resident #22's medical record revealed Resident #22 was admitted on [DATE] with diagnoses which included encounter for surgical aftercare following surgery on the digestive system, scoliosis, low back pain, restless leg syndrome, generalized muscle weakness, difficulty in walking, and lack of coordination. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #22 revealed Resident #20 was in bed with quarter side rails in use. Review of Resident #22's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #22's medical record failed to reveal documentation Resident #22 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #75 Review of Resident #75's medical record revealed Resident #75 was admitted on [DATE] with diagnoses including the following, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes, hypertension, difficulty walking and heart failure. Review of Resident #75's admission MDS assessment dated [DATE] revealed in progress (not completed). During an observation on 10/14/2024 at 08:30 a.m. revealed Resident #75's bed was observed to have bilateral assistive devices (bed rails) attached to the bed. During an interview on 10/16/2024 at 11:30 a.m. Resident #75 reported the bed rails help her turn and position while in bed. Review of resident #75's current Physician Orders fail to reveal documentation of an order for the use of side rails. Review of resident #75's medical record failed to reveal documentation Resident #75 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #9 Review of Resident #9's medical record revealed Resident #9 was admitted on [DATE] with a re-admission date of 10/02/2024. Resident #9's diagnoses included Parkinson's disease without dyskinesia, congestive heart failure, chronic kidney disease, unspecified atrial fibrillation, lack of coordination, generalized muscle weakness, and difficulty walking. Review of Resident #9's most recent MDS assessment dated [DATE] revealed Resident #9 had a BIMS score of 15 indicating intact cognition. Further review of Resident #9's most recent MDS revealed Resident #9 was dependent on staff for activities of daily living. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #9 revealed Resident #9 was in bed with grab bars to the head of the bed bilaterally. Review of Resident #9's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #9's care plan revealed Resident #9 had an ADL self-care performance deficit. Review of Resident #9's medical record failed to reveal documentation Resident #9 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. Resident #126 Review of Resident #126's medical record revealed Resident #126 was admitted on [DATE] with diagnoses which included in part metabolic encephalopathy and type 2 diabetes mellitus with diabetic amyothrophy and diabetic neuropathy, generalized muscle weakness, lack of coordination, and difficulty walking. Review of Resident #126's most recent MDS assessment dated [DATE] revealed assessment in progress. Further review of Resident #126's record revealed Resident #126's admission functional abilities and goals assessment indicated Resident #126 had independent cognition and was dependent on staff for activities of daily living. During the survey dates of 10/14/2024 - 10/17/2024 observations of Resident #126 revealed Resident #126 was in bed with quarter rails to the head of the bed bilaterally. Review of Resident #126's current Physician Orders failed to reveal documentation of an order for use of bed rails. Review of Resident #126's medical record failed to reveal documentation Resident #126 was assessed for the risk of entrapment from bed rails prior to instillation and use of bed rails. During an interview on 10/17/2024 at 10:09 a.m. S2 DON (Director of Nursing) reviewed Resident #4, #20, #125, #22, #75, #9, #126's records and confirmed there was no documentation of an order for use of bed rails. S2 DON further confirmed there was no documentation of an assessment for risk of entrapment from bed rails for #4, #20, #125, #22, #75, #9, and #126 prior to instillation and use of bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident's drug regimen was free of unnecessary medications for 4 (#9, #11, #76, #175) of 5 (#9, #11, #76, #127 and #175) residents reviewed for unnecessary medications. The facility failed to ensure adequate monitoring of: Resident #9 for edema related to the use of diuretic Bumex. Resident #11 for edema related to the use of the diuretic Furosemide (Lasix). Resident #11 for bleeding related to the use of an anticoagulant Apixaban (Eliquis). Resident #76 for edema related to the use of the diuretic Furosemide. Resident #175 for bleeding related to the use of the anticoagulant Dabigatran Etexillate Mesylate. Findings: #9 Review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included, in part, Parkinson's disease, systolic (congestive) heart failure, essential (primary) hypertension, and chronic kidney disease. Review of Resident #9's 5-day MDS (minimum data set) with ARD (assessment reference date) of 10/08/2024 revealed Resident #9 had a BIMS (Brief Interview Mental Status) score of 15, which indicated Resident #9 was cognitively intact. Review of Resident #9's physician orders revealed the following orders: 10/09/2024 Bumex Oral Tablet 2 mg (milligram) - give 1 tablet by mouth two times a day for edema. 10/02/2024 (discontinued on 10/11/2024) Bumex Oral Tablet 1 mg - Give 1 tablet by mouth two times a day for edema. 09/19/2024 (discontinued on 10/02/2024) Bumex oral tablet 2 mg - give 1 tablet by mouth two times a day for CHF (congestive heart failure). Review of Resident #9's October 2024 MAR (medication administration record) failed to reveal monitoring for edema had been conducted for Resident #9 who was receiving Bumex. Review of Resident #9's Care Plan revealed Resident #9 was on diuretic therapy (Bumex) with interventions that included, in part, administer Bumex as ordered by physician; monitor for side effects and effectiveness every shift; monitor edema 0, +1, +2, +3, +4; notify MD (medical doctor) if +3 or greater X 3 consecutive days; and monitor/document/report PRN (as needed) adverse reactions to diuretic therapy. During an interview on 10/16/2024 at 1:40 p.m. S7 LPN (Licensed Practical Nurse) reviewed Resident #9's MAR and reported monitoring for edema had not been conducted for Resident #9. #11 Review of Resident #11's medical records revealed an admit date of 8/21/2024 with diagnoses that included, in part, cerebral infarction dues to unspecified occlusion or stenosis of left middle cerebral artery, generalized muscle weakness, dysphagia, difficulty walking, and cognitive communication deficit. Review of Resident #11's October 2024 Physician orders revealed the following orders: 09/30/2024 Apixaban (Eliquis) oral tablet 5 mg. Give one by mouth one time a day for blood thinner. 09/30/2024 Furosemide (Lasix) oral tablet 20 mg. Give 1 tablet by mouth one time a day for edema. Review of Resident #11 - 5 Day MDS with ARD 10/07/2024 revealed section N, high-risk drug classes anticoagulant and diuretic. Review of Resident #11's Care Plan revealed the following problems with some of the interventions: 1. The resident is on anticoagulant therapy Apixaban (Eliquis) status post CVA (cerebral vascular accident). Some of the interventions are to administer anticoagulant Apixaban (Eliquis) as ordered by physician. Monitor for side effects and effectiveness every shift. Observe, document and report any adverse reactions of anticoagulant therapy. 2. The resident is on diuretic therapy Furosemide (Lasix). Some interventions are administer diuretic medications as ordered by physician. Monitor for side effects (edema, light-headiness, ringing in the ears, and increase thirst and effectiveness every shift. Observe, document, and report any adverse reactions to diuretic therapy. During an interview on 10/16/2024 at 1:00 p.m. S5 LPN reviewed Resident #11's medical records including the October 2024 Physician orders and MAR and reported there was no monitoring being done for bleeding related to the use of anticoagulant Apixaban (Eliquis) and no monitoring for edema related to the use of Furosemide (Lasix). #76 Review of Resident #76's medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses that included, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, essential (primary) hypertension, heart failure unspecified, and chronic kidney disease. Review of Resident #76's 10/09/2024 admission 5-day MDS revealed Resident #76 had a BIMS score of 15, which indicated Resident #76 was cognitively intact. Review of Resident #76's physician orders revealed a 10/02/2024 order for Furosemide tablet 20mg - give 20mg by mouth one time a day for edema. Review of Resident #76's October 2024 MAR failed to reveal monitoring for edema had been conducted for Resident #76 who was receiving Furosemide. During an interview on 10/16/2024 at 1:25 p.m. S6 LPN reviewed Resident #76's MAR and reported monitoring for edema had not been conducted for Resident #76. #175 Review of Resident #175's medical record revealed Resident #175 was admitted to the facility on [DATE] with diagnoses that included, in part, type 2 diabetes mellitus, chronic atrial fibrillation, and essential hypertension. Review of Resident #175's medical record revealed Resident #175 had a BIMS score of 14, which indicated Resident #175 was cognitively intact. Review of Resident #175's physician orders revealed the following orders: 10/10/2024 Dabigatran Etexillate Mesylate Oral Capsule 150mg - Give 1 capsule by mouth two times a day for blood thinner. 09/27/2024 (discontinued on 10/02/2024) Dabigatran Etexillate Mesylate Oral Capsule 150mg - Give 1 capsule by mouth two times a day for atrial fibrillation. Review of Resident #175's October 2024 MAR failed to reveal monitoring for bleeding had been conducted for Resident #175 who was receiving Dabigatran Etexillate Mesylate. Review of Resident #175's Care Plan revealed Resident #175 was care planned for anticoagulant therapy with interventions that included, in part, administer anticoagulant medications as order by physician , monitor for side effects and effectiveness every shift, and observe/document/report any adverse reactions of anticoagulant therapy. During an interview on 10/16/2024 at 1:35 p.m. S5 LPN reviewed Resident #175's MAR and reported monitoring for bleeding had not been conducted for Resident #175.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident's drug regimen was free of unnecessary medications for 2 (#9, #175) out of 5 (#9, #11, #76, #127, #175) residents reviewed for unnecessary medications. The facility failed to ensure monitoring of side effects and behaviors had been conducted for Resident #9 and Resident #175 who were each receiving a psychotropic. Findings: #9 Review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] and had diagnoses that included, in part, Parkinson's disease, systolic (congestive) heart failure, essential (primary) hypertension, chronic kidney disease, and generalized anxiety disorder. Review of Resident #9's 5-day MDS (minimum data set) with ARD (assessment reference date) of 10/08/2024 revealed Resident #9 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated Resident #9 was cognitively intact. Review of Resident #9's physician orders revealed the following orders: 10/04/2024 Buspirone HCl (hydrochloride) oral tablet 7.5mg (milligram) - Give 1 tablet by mouth two times a day for anxiety. Review of Resident #9's October 2024 MAR (medication administration record) failed to reveal monitoring for side effects and behaviors had been conducted for Resident #9 who was receiving Buspirone. Review of Resident #9's care plan revealed the following care plan, in part: Resident uses anti-anxiety medications with interventions that included, in part, administer anti-anxiety medications as ordered by physician; monitor for side effects and effectiveness every shift; and observe, document, and report any adverse reactions to anti-anxiety therapy. During an interview on 10/16/2024 at 1:40 p.m. S7 LPN (Licensed Practical Nurse) reviewed Resident #9's MAR and reported monitoring for side effects and behaviors had not been conducted for Resident #9 who was receiving Buspirone. #175 Review of Resident #175's medical record revealed Resident #175 was admitted to the facility on [DATE] with diagnoses that included, in part, bipolar II disorder, major depressive disorder recurrent unspecified, type 2 diabetes mellitus, chronic atrial fibrillation, and essential hypertension. Review of Resident #175's medical record revealed Resident #175 had a BIMS score of 14, which indicated Resident #175 was cognitively intact. Review of Resident #175's physician orders revealed a 10/10/2024 order for Cymbalta Oral Capsule Delayed Release Particles 30mg (Duloxetine HCl) - Give 1 capsule by mouth two times a day for depression. Review of Resident #175's October 2024 MAR failed to reveal monitoring for side effects and behaviors had been conducted for Resident #175 who was receiving Cymbalta. Review of Resident #175's care plan revealed: Resident uses antidepressant medication with interventions that included, in part, administer antidepressant medications as ordered by physician and monitor, document, and report any adverse reactions to antidepressant therapy. During an interview on 10/16/2024 at 1:35 p.m. S5 LPN reviewed Resident #175's MAR and reported monitoring for side effects and behaviors had not been conducted for Resident #175 who was receiving Cymbalta.

Based on record reviews and interviews the facility failed to comply with Federal, State, and Local Laws, and Professional Standards by: 1. Failing to ensure CNA (Certified Nursing Assistant) staff had undergone and passed criminal background checks prior to working in the facility for 2 CNAs (S12, S14) of 5 CNA personnel records reviewed. 2. Failing to ensure the nurse aide registry/adverse action list was searched monthly for 3 CNAs (S12, S13, S14) of 5 CNA personnel records reviewed. Findings: Review of S12 CNA's personnel record revealed S12 CNA was hired on 05/17/2024 with a criminal background check performed on 09/06/2024. Further review of S12 CNA's personnel record failed to reveal monthly nurse aid registry/adverse action list searches. Review of S13 CNA's personnel record revealed S13 CNA was hired on 01/05/2018. Further review of S13 CNA's personnel record failed to reveal monthly nurse aid registry/adverse action list searches. Review of S14 CNA's personnel record revealed S14 CNA was hired on 07/23/2023 with a criminal background check performed on 09/06/2024. Further review of S14 CNA's personnel record failed to reveal monthly nurse aid registry/adverse action list searches. During an interview on 10/17/2024 at 12:36 p.m. S15 Human Resources reviewed S12 CNA, S13 CNA, and S14 CNA's records and confirmed there was no documentation of criminal background checks prior to hire for S12 CNA and S14 CNA. S15 Human Resources further confirmed there was no documentation of monthly nurse aid registry/adverse action list searches for S12 CNA, S13 CNA, and S14 CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure an effective system was in place for advanced directives. The facility failed to ensure: 1. Resident's medical records accurately reflected the residents' wishes for emergency basic life support for 8 (#1, #15, #9, #76, #77, #126, #127, #175 ) residents; 2. Failed to document residents and/or resident's representative were given information on Advanced Directives on admission for 12 (#9, #76, #77, #126, #127, #175, #4, #11, #12, #20, #75, #125) residents, of 19 (#9, #77, #11, #75, #12, #76, #125, #126, #1, #127, #4, #20, #15, #175, #2, #8, #22, #24, and #18) residents reviewed for Advanced Directives. Total facility census was 23. Findings: Review of the Facility's Advance Directive Policy dated 07/2024 revealed in part: It is the policy of the Facility to respect the resident's right of self-directed care including the right to issue Advance Directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on behalf of the resident when the resident lacks the capacity to do so. 2. Upon admission the Facility will provide each resident medically deemed competent or resident's representative, who does not have an existing Advanced Directive, with written information and instruction regarding the right to make Advance Directives prior to the initiation of care or at any requested time. c. The resident's instructions, the resident's receipt of written information, and the existence or non-existence of the resident's Advance Directive must be documented in the resident's record. Review of the Facility's Do Not Resuscitate (DNR) Policy dated 07/2024 revealed in part: It is the policy of the Facility to respect the resident's right of self-directed care . This also includes the ability to initiate a DNR directive. -Responsibility: All Facility Employees, Monitored by Social Services Director and Executive Director -DNR Orders: 1. Residents with Capacity: To enter a DNR order for an adult resident who has decision-making capacity: a. Discuss the order with resident and inform resident about his/her condition, risks and benefits or CPR (Cardiopulmonary Resuscitation), and consequences of DNR order. b. Seek the resident's oral or written consent: -Oral consent must be witnessed by two (2) adults, one of whom is a physician affiliated with the Facility. -Written consent must be signed by two (2) adult witnesses. c. Record decision in electronic medical record d. Enter DNR order in medical record 2. Residents Who Lack Capacity: To enter a DNR order for an adult resident without capacity who has appointed a health care agent by written Power of Attorney for Health care: b. Seek health care agent's oral or written consent: -Oral consent must be witnessed by two (2) adults, one of whom is a physician affiliated with the Facility. -Written consent must be signed by two (2) adult witnesses. c. Record decision in medical record. 4. Residents Who Lack Capacity (Surrogate Decision) To enter a DNR order for an adult who lacks capacity and has not appointed a health care agent: d. Inform surrogate about resident's condition, risks, and benefits of CPR and consequences of DNR order. e. Seek surrogate decision maker's oral or written consent: -Oral consent must be witnessed by two (2) adults, one of whom is a physician affiliated with the Facility. -Written consent must be signed by the surrogate before one (1) adult witness. f. Inform resident, if resident is capable of understanding information g. Enter DNR order in medical record. During an interview on [DATE] at 3:00 p.m., S9 Admissions and S8 Admissions reported the Admissions staff complete the admissions packet. S9 Admissions and S8 Admissions reported the completed admission packet should be given to the floor nurses. If a resident chooses DNR status, the order form should be taken out of the admission packet and placed at the nurses' station to be signed by the physician. After the DNR order is signed then the order should then go to medical record to be scanned in the residents' EHR (Electronic Health Record). 1. Resident #1 Review of Resident #1's medical record revealed Resident #1 was admitted [DATE] with diagnoses which included osteomyelitis unspecified, disorders of plasma-protein metabolism, and paraplegia. Review of Resident #1's [DATE] physician orders failed to reveal an order for code status. Review of Resident #1 care plan revealed a focus dated [DATE] and revised on [DATE] with a code status of full code. Further review revealed Resident #1's care plan interventions included: resident will have advanced directive followed, discuss directives with resident and/or resident RP (responsible party), and initiate CPR (cardiopulmonary resuscitation) if needed. During an interview on [DATE] at 3:30 p.m., S4 DOCO (Director of Clinical Operations) reviewed Resident #1's record and acknowledged there was not an order for Resident #1's code status. Resident #15 Review of Resident #15 medical record revealed Resident #15 was admitted on [DATE] with diagnoses which included non-rheumatic aortic (valve) stenosis, unspecified systolic (congestive) heart, acute on chronic diastolic (congestive) heart failure, acute respiratory failure with hypoxia, chronic obstructive respiratory failure. Review of Resident # 15's [DATE] physician orders dated [DATE] revealed code status: Full code. Review of Resident #15's baseline care plan dated [DATE] revealed code status: Full code. Review of Resident #15's DNR Order form was signed by Resident #15's responsible party on [DATE] and attending physician on [DATE]. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #15's medical record and acknowledged Resident # 15's code status did not match throughout Resident #15's medical record. S4 DOCO reported Resident #15's physician orders should have been changed to a DNR after the DNR order was signed by the physician. 1. and 2. Resident #9 Review of Resident #9's medical record revealed Resident #9 was admitted on [DATE] with a re-admission date of [DATE]. Resident #9's diagnoses included Parkinson's disease without dyskinesia, congestive heart failure, chronic kidney disease, and unspecified atrial fibrillation. Review of Resident #9's [DATE] physician orders revealed, in part, an order dated [DATE] for Do Not Resuscitate that was not signed by a physician. Review of Resident #9's care plan revealed a focus initiated [DATE] and revised [DATE] with a code status of DNR. Further review revealed Resident #9's care plan interventions included: resident will have advanced directive followed; discuss advance directives with resident and/or resident's Responsible Party (RP) on admit, quarterly or as needed; DNR status posted in medical record; and physician order for DNR. Further review of Resident #9's admission packet information failed to reveal Resident #9 and/or the resident representative received written information regarding advance directives. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #9's record and acknowledged Resident #9 had a care plan for DNR and an unsigned physician's DNR order. S4 DOCO further reviewed Resident #9 record and acknowledged there was no documentation Resident #9 and/or the resident representative received written information regarding advance directives. Resident #76 Review of Resident #76's medical record revealed Resident #76 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic atrial fibrillation unspecified, essential (primary) hypertension, heart failure unspecified, chronic kidney disease unspecified, prediabetes, chronic pain and insomnia. Review of Resident #76's [DATE] physician orders failed to reveal a code status. Review of Resident #76's current care plan revealed he was a full code. Review of Resident #76's advance directive acknowledgement form failed to reveal documentation Resident #76 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #76's record and acknowledged the physician orders did not reveal a code status and there was no documentation Resident #76 and/or the resident representative received written information regarding advance directives. Resident #77 Review of Resident #77's medical record revealed Resident #77 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #77's [DATE] physician orders revealed an order dated [DATE] for a Full Code. Further review revealed Resident #77 signed a DNR [DATE] and his physician signed the DNR [DATE]. The DNR Physician Order form was found in another resident's electronic record on [DATE]. Review of Resident #77's care plan revealed he was a full code. Review of Resident #77's advance directive acknowledgement form failed to reveal documentation Resident #77 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #77's record and acknowledged Resident #77's [DATE] Physician Orders was full code, DNR order was not scanned in the electronic system after it was signed by the physician and the code status was not updated. S4 DOCO reported there was no documentation Resident #77 and/or the resident representative received written information regarding advance directives. Resident #126 Review of Resident #126's medical record revealed Resident #126 was admitted [DATE] with diagnoses which included in part metabolic encephalopathy and type 2 diabetes mellitus with diabetic amyothrophy and diabetic neuropathy. Review of Resident #126's [DATE] Physician Orders failed to reveal an order for code status. Review of Resident #126's admission packet information revealed a State of Louisiana Declaration dated [DATE] with Resident #126's name at the top of the page and signed by Resident #126 at the bottom of the page with no indications of Resident #126's wishes. Further review of Resident #126 admission packet failed to reveal Resident #126 and/or the resident representative received written information regarding advance directives. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #126's record and acknowledged there was not an order for Resident #126's code status and there was no documentation Resident #126 and/or the resident representative received written information regarding advance directives. Resident #127 Review of Resident #127's record revealed Resident #127 was admitted on [DATE] with diagnoses including encephalopathy and Alzheimer's disease. Review of Resident #127's [DATE] physician orders failed to reveal documentation of an order for code status. Review of Resident #127's admission packet information revealed an undated State of Louisiana Declaration page with no indications of wishes signed per Resident #127's RP and a DNR Do Not Resuscitate order page with the date [DATE] with no name or signature. Further review of Resident #127's admission packet failed to reveal Resident #127 and/or the resident representative received written information regarding advanced directives. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #127's record and acknowledged there was not an order for Resident #127's code status and there was no documentation Resident #127 and/or the resident representative received written information regarding advanced directives. Resident #175 Review of Resident #175's medical record revealed Resident #175 initial admit date was [DATE] and a re-entry admit on [DATE] with diagnoses which included orthostatic hypotension and chronic atrial fibrillation. Review of Resident #175's [DATE] physician orders failed to reveal a code status. Review of Resident # 175's medical record failed to reveal advance directive acknowledgment form. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #175's medical record and acknowledged Resident #175 did not have physician order for a code status and there was no documentation Resident #175 and/or the resident representative received written information regarding advanced directives. 2. Resident #4 Review of Resident #4's medical record revealed Resident #4 was admitted on [DATE] with diagnoses which included unspecified systolic (congestive) heart failure, chronic kidney disease, stage 3, acute respiratory failure with hypoxia, and acute respiratory failure with hypercapnia. Review of Resident #4's advance directive acknowledgement form failed to reveal documentation Resident #4 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #4's record and acknowledged there was no documentation Resident #4 and/or the resident representative received written information regarding advance directives. Resident #11 Review of Resident #11's medical records revealed Resident #11 was admitted on [DATE] with diagnoses that include cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, polyneuropathy, muscle weakness, acute kidney failure and cognitive communication deficit. Review of Resident #11's advance directive acknowledgement form failed to reveal documentation Resident #11 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident # 11's record and acknowledged there was no documentation Resident #11 and/or the resident representative received written information regarding advance directives. Resident #12 Review of Resident #12's medical record revealed Resident #12 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypoxia, generalized anxiety disorder, type 2 diabetes mellitus without complication, difficulty walking and muscle weakness. Review of Resident #12's advance directive acknowledgement form failed to reveal documentation Resident #12 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #12's record and acknowledged there was no documentation Resident #12 and/or the resident representative received written information regarding advance directives. Resident #20 Review of Resident # 20's medical record revealed Resident #20 was admitted on [DATE] with diagnoses which included chronic diastolic (congestive) heart failure, failure of cardiac pacemaker, cardiomyopathy, unspecified essential (primary) hypertension, chronic kidney disease, stage 4 severe pneumonia. Review of Resident #20's advance directive acknowledgement form failed to reveal documentation Resident #20 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #20's record and acknowledged there was no documentation Resident #20 and/or the resident representative received written information regarding advance directives. Resident #75 Review of Resident #75's medical record revealed Resident #75 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus due to underlying condition with diabetic polyneuropathy, hyperlipidemia. Review of Resident #75's advance directive acknowledgement form failed to reveal documentation Resident #75 and/or the resident representative received written information regarding advance directives from the facility. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #75's record and acknowledged there was no documentation Resident # 75 and/or the resident representative received written information regarding advance directives. Resident #125 Review of Resident #125's medical record revealed Resident #125 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #125's advance directive acknowledgement form failed to reveal documentation Resident #125 and/or the resident representative received written information regarding advance directives. During an interview on [DATE] at 3:30 p.m., S4 DOCO reviewed Resident #125's record and acknowledged there was no documentation Resident #125 and/or the resident representative received written information regarding advance directives. During an interview on [DATE] at 4:38 p.m., S7 LPN (Licensed practical Nurse) reported all residents were a full code until the doctor signed the DNR. S7 LPN reported the DNR order and advance directives should be scanned into EHR. S7 LPN reported she would look in the resident's orders and under miscellaneous tab for the advance directives. During an interview on [DATE] at 4:43 p.m., S6 LPN reported the resident's code status is located on the dashboard information in the resident's EHR. S6 LPN reported if it was not on the dashboard the other places to locate code status would be in the orders and in the admission information. S6 LPN reported the information should be easily accessible because in an emergency there would not be time to do a search for status. During an interview on [DATE] 8:05 a.m., S7 LPN and S6 LPN reported the advance directive form that should be on admission should be kept in the resident chart and in the electronic chart. S7 LPN reported residents are a full code until the DNR order is signed by the physician. After the DNR order is signed by the physician; the floor nurse or the admission coordinator inputs the DNR order in the computer and places the form on the paper chart or scan the DNR order in the electronic health record under the miscellaneous tab. During a telephone interview on [DATE] at 11:37 a.m., S11 Medical Director reported he signed DNR orders when he made weekly onsite visits. S11 Medical Director reported the nurse practitioner will notify him when a DNR order needs to be signed during his weekly visits. S11 Medical Director reported during his weekly onsite visits the floor nurse just hands him the DNR orders that need to be signed. S11 Medical Director reported the facility also has the option to fax over DNR orders that need to be signed. S11 Medical Director reported he recently checked the residents' EHR and found there were discrepancies with code status. S11 Medical Director then confirmed residents' code status should match what the family wants. During an interview on [DATE] at 10:20 a.m., S16 NP (Nurse Practitioner) reported she did not sign DNR orders only S11 Medical Director signed them. S16 NP reported she has a binder that she checks when she comes into the facility that the DNR orders that need to be signed would be placed in. S16 NP reported she comes to the facility 3 to 4 times a week and S11 Medical Director comes every Thursday. S16 NP reported she would notify S11 Medial Director if there was a DNR order in the binder that required a signature. When asked if there had been any DNR orders for signature in her binder in the last couple weeks S16 NP reported there were 2 that she could recall. S16 NP reported she had not had any in September that she could recall. During an interview on [DATE] at 3:30 p.m., S4 DOCO acknowledged admission packets were not entered into residents' EHR in a timely manner leading to resident's wishes for emergency basic life support not accurately being documented in their record and accessible to all staff. S4 DOCO also reviewed a sampling of resident records and confirmed the advance directives information in the residents' records was inaccurate and incomplete.

Based on interviews, the facility failed to notify resident representative of changes in condition for 1 (#2) out of 3 (#1, #2, #3) sampled residents reviewed. The facility failed to notify Resident #2's resident representative of a fall requiring treatment at a hospital. Findings: Review of Resident #2's Medical Record revealed an admit date of 02/08/2024 with the following diagnoses, in part: acute cerebrovascular insufficiency, muscle weakness (generalized), other lack of coordination, cognitive communication deficit and other abnormal glucose. Review of Resident #2's Baseline Care Plan revealed: Falls - resident has had an actual fall - 03/02/2024 resident states he got up on his own and fell - laceration to back of head - sent to emergency room (ER), area closed with Dermabond. Review of Facility's Incident Log revealed an incident for Resident #2 dated 03/02/2024 - resident room - fall - laceration - 911 EMS (emergency medical services) dispatched .has quarter sized laceration to back of head . During an interview on 03/12/2024 at 9:45 a.m. Resident #2's wife reported she was never notified of resident falling and going to emergency room for a laceration on the back of his head. She further reported she had noticed something on the back of his head and wondered where it came from. During an interview on 03/12/2024 at 10:25 a.m. S1 Administrator acknowledged Resident #2's wife visits every day and should have been notified of fall on 03/02/2024 which required resident to be taken to the hospital for treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a care plan for 1 (#1) out of 3 (#1, #2, #3) sampled residents reviewed. Findings: Review of Resident #1's Medical Record revealed an admit date [DATE] with the following diagnoses, in part: end stage renal disease, major depressive disorder, chronic systolic (congestive) and diastolic (congestive) heart failure, muscle weakness (generalized), other lack of coordination, difficulty in walking/not elsewhere classified, polyneuropathy/unspecified, long term use of anticoagulants, diabetes mellitus and dependence on renal dialysis. Review of Resident #1's Care Plan with revision date of 02/29/2024 failed to reveal problems and approaches for: risk for falls, congestive heart failure, anticoagulant therapy, major depressive disorder, impaired mobility, self-care deficit, and diabetes mellitus. Review of Resident #1's Physician's Orders revealed the following orders dated 02/28/2024: Eliquis oral tablet 2.5mg (milligrams) give 1 tablet by mouth two times a day for preventative, Furosemide oral tablet 20mg give 1 tablet by mouth every 12 hours for edema, Amiodarone HCL (hydrochloride) oral tablet 200mg give 1 tablet by mouth two times a day for heart, Midodrine HCL oral tablet 10mg give 1 tablet by mouth three times a day for low b/p (blood pressure), Sitagliptin oral tablet 25mg give 1 tablet by mouth one time a day for dm (diabetes mellitus) and Escitalopram Oxalate oral tablet 20mg give 1 tablet by mouth one time a day for depression. During an interview on 03/12/2024 at 9:10 a.m. S2 MDS (Minimum Data Set) acknowledged the care plan she provided for Resident #1 was incomplete and did not include all of his problems.

Based on record review, observations and interviews, the facility failed to ensure 2 (#2, #3) out of 3 (#1, #2, #3) sampled resident's received treatment and care in accordance with professional standards of practice and the comprehensive care plan. The facility failed to: 1. Identify Resident #2 and Resident #3 as high risk falls, and 2. Ensure Resident #3 was wearing proper foot wear to prevent falls. Findings: Review of Facility's Falling Star Program (revision date 07/27/2018) revealed: Policy: To decrease the number of resident falls in the facility, the Falling Star program is designed to facilitate recognition of residents who are at high risk for falls. Procedure: .Residents identified for the program will have a star placed outside their room by their nameplate and on the outside of their chart near the name label. A star will be attached to the resident's w/c (wheelchair), gerichair, and all mobility aids (walkers, canes, etc.). A star will be placed above the resident's bed. Resident #2 Review of Resident #2's Medical Records revealed an admit date of 02/08/2024 with the following diagnoses, in part: acute cerebrovascular insufficiency, muscle weakness (generalized), other lack of coordination, cognitive communication deficit and other abnormal glucose. Review of Resident #2's Baseline Care Plan revealed: Falls - resident has had an actual fall - 03/02/2024 resident states he got up on his own and fell - laceration to back of head - sent to emergency room (ER), area closed with Dermabond. Review of Facility's Incident Log revealed an incident for Resident #2 dated 03/02/2024 - resident room - fall - laceration - 911 EMS (emergency medical services) dispatched .has quarter sized laceration to back of head .02/09/2024 - resident sitting up in w/c in day area. Attempted to get out of wheelchair and fell over. Resident unable to give description. Skin tear to left finger. Confused, impaired memory, recent illness and weakness/fainted. admitted within the last 72hours. Observation on 03/11/2024 at 11:25 a.m. revealed Resident #2 sitting up in wheelchair. Further observation failed to reveal a star on the door, above the bed, or on the wheelchair. Observation on 03/11/2024 at 4:35 p.m. revealed Resident #2 sitting in wheelchair in common area in front of nursing station. Able to propel himself. No star observed on door, above the bed, or on the wheelchair. Observation on 03/12/2024 at 10:05 a.m. failed to reveal a star on Resident #2's door, above the bed, or on the wheelchair indicating resident was a fall risk. During an interview on 03/12/2024 at 10:15 a.m. S4 LPN (Licensed Practical Nurse) acknowledged Resident #2 did not have a star on his door, above his bed or on his wheelchair and should because he is a very high fall risk. Resident #3 Review of Resident #3's Medical Records revealed an admit date of 03/01/2024 with the following diagnoses, in part: muscle weakness (generalized), other lack of coordination, esophageal cancer, pancreatic cancer, hypertension, CVA (cerebral vascular accident), severe ataxia and type 2 diabetes mellitus. Review of Resident #3's Baseline Care Plan dated 03/01/2024 revealed: Falls/safety - remain free of injury, evaluate cognitive status and gait steadiness, proper foot wear and ambulation device and maintain safe environment. Review of Facility's Incident Log revealed the following incident for Resident #3 dated 03/10/2024 - resident bathroom - fall - skin tear/right ear. Review of Resident #3's Daily Skilled Nurse's Notes revealed the following entry dated 03/10/2024 at 8:30 p.m. - upon rounds resident noted making attempts to get out of bed w/o (without) assistance. Observation on 03/11/2024 at 11:15 a.m. revealed Resident #3 sitting up in wheelchair wearing regular socks - no non-skid socks. Observation on 03/11/2024 at 4:10 p.m. revealed Resident #3 sitting up in wheelchair in room. Resident wearing regular socks on feet. Observation on 03/12/2024 at 9:55 a.m. revealed Resident #3 in therapy and wearing regular socks. Observation on 03/12/2024 at 11:15 a.m. revealed Resident #3 being walked by therapy using his walker and a gait belt. Resident #1 was wearing only regular socks. During an interview on 03/12/2024 at 11:50 a.m. S3 RN (Registered Nurse) while reviewing Resident #3's care plan, acknowledged Resident #3 was supposed to have non-skid socks on and does not.

Based on record review and interview, the facility failed to obtain orders on admission for Oxygen, Foley catheter and Trilogy Machine use, care and treatment for 1 (#24) of 2 (#24, #25) closed records reviewed. Findings: Review of resident #24's closed record revealed an admit date of 08/04/2023 with discharge/transfer on 08/12/2023 and diagnoses that include in part acute and chronic respiratory failure with hypercapnia, chronic atrial fibrillation, urinary tract infection, dependence on supplemental oxygen, essential hypertension, and asthma. Review of resident #24's progress notes from 08/04/2023 to 08/12/2023 revealed in part resident #24 was admitted to the facility with Oxygen in use at 2 liters per minute via nasal cannula, Foley catherer in place and a Trilogy machine for use at bedtime. Review of resident #24's physician orders failed to reveal orders for Oxygen, Foley catheter and Trilogy machine use, care and treatment. Review of resident #24's current care plan failed to reveal interventions related to Oxygen, Foley catheter and Trilogy machine use, care and treatment. During an interview on 10/04/2023 at 4:00 p.m. S2 Director of Nursing reviewed resident #24's electronic record and confirmed resident #24 did not have physician orders for Oxygen, Foley catheter and Trilogy Machine use, care, and treatment and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure appropriate care and services had been provided for 1 (#177) of 1 (#177) resident reviewed for Dialysis. The facility failed to ensure Resident #177's dialysis shunt was accurately assessed and monitored. Findings: Review of the EHR (Electronic Health Record) revealed the following, in part, Resident #177 was admitted to the facility on [DATE] with a primary diagnosis of sepsis. Review of Resident #177's Progress Note dated 10/02/2023 revealed Resident #177 had a dialysis shunt site to the left upper arm. Review of Resident #177's September and October 2023 eMAR (Electronic Medication and Administration Record) failed to reveal documentation the dialysis shunt site had been assessed and monitored. Review of the Dialysis Communication Records for Resident #177 failed to reveal an assessment of Resident #177's dialysis shunt site upon returning to the facility on [DATE] and 10/02/2023. During an interview on 10/02/2023 at 4:00 p.m. Resident #177 reported going to a dialysis center on Monday, Wednesday, and Friday and verified the facility sends to dialysis and receives from dialysis a Dialysis Communication Record to be completed after Resident #177's return to the facility. During an interview on 10/03/2023 at 4:00 p.m. S2 DON (Director of Nursing) verified Resident #177's Dialysis Communication Records for 09/29/2023 and 10/02/2023 failed to reveal an assessment had been completed and monitoring had been done for Resident #177's dialysis shunt site and should have been. During an interview on 10/04/2023 at 11:55 a.m. S9 MDS (Minimum Data Set) Nurse confirmed Resident #177 was not care planned for dialysis including assessment and monitoring of the dialysis shunt site. During an interview on 10/04/2023 at 12:00 p.m. S2 DON acknowledged Resident #177 was not care planned to assess and monitor the dialysis shunt site.

Based on record reviews and interview the facility failed to ensure State Registry verifications were completed prior to hire for 1 [S6 CNA (Certified Nursing Assistant)] of 5 CNA personnel files reviewed. Findings: Review of S6 CNA's personnel file revealed a hire date of 01/16/2023 and first day of work 01/16/2023. Further review of S6 CNA's personnel file revealed the Criminal Background and Sex Offender Registry checks were completed on 01/23/2023. During an interview on 10/04/2023 at 3:00 p.m. S3 Human Resources confirmed the State Registry verifications had not been completed prior to hire for S6 CNA and should have been.

Based on record reviews and interview, the facility failed to complete an annual performance review of every nurse aide at least once every 12 months for 4 [S4 CNA (Certified Nursing Assistant) S5 CNA, S7 CNA, and S8 CNA)] of 5 CNA personnel files reviewed. Findings: Review of the personnel records revealed the following: 1. S4 CNA-date of hire was on 03/19/2015. Further review failed to reveal the annual performance review had been completed in March 2023. 3. S5 CNA-date of hire 05/10/2022. Further review failed to reveal the annual performance review had been completed in May 2023. 2. S7 CNA-date of hire 05/26/2021. Further review failed to reveal the annual performance review had been completed in May 2023. 4. S8 CNA-date of hire 05/07/2020. Further review failed to reveal the annual performance review had been completed in May 2023. During an interview on 10/04/2023 at 3:00 p.m. S3 Human Resources confirmed the annual performance evaluations had not been completed every 12 months for S4 CNA, S5 CNA, S7 CNA, and S8 CNA and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents received necessary treatment and services consistent with professional standards of practice and to promote healing for 2 (#3, #5) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility failed to ensure: 1. Resident #3 had weekly pressure wound assessments conducted; 2. Resident #5 had evidence wound care was conducted as ordered by physician. Findings: 1. Resident #3 Review of Policies and Procedures, Subject: Pressure Injury Record with revision date of 4/01/2017 revealed: POLICY: To document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is resolved. One site will be recorded per page. PROCEDURE: 1. Residents will have a Pressure Injury Record completed for each skin impairment that is related to pressure. 2. [NAME] the pressure area on the body description identifying the site. 3. Enter the date 4. Enter the stage of the pressure injury 5. Enter the size of the pressure injury-length x width x depth in centimeters 6. Enter the tissue type and color 7. Enter the wound edges and drainage 8. Enter the peri-wound information 9. Licensed nurse to sign the appropriate area Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] and had diagnoses that included, in part, difficulty in walking; Muscle weakness (generalized); Body Mass Index [BMI] 50.0-59.8 adult (morbid obesity); other ascites; Type 2 Diabetes Mellitus without complications; Chronic Kidney Disease; and unspecified Cirrhosis of Liver. Review of 02/23/2023 admission MDS (Minimum Data Set) revealed Resident #3 had a BIMS (Brief Interview Mental Status) score of 15, which indicated Resident #3 was cognitively intact. Further review of the 02/23/2023 MDS revealed Resident #3 was at risk for Pressure Ulcer/Injury and had two Stage 2 pressure ulcers that were present upon admission. Review of Resident #3's March 2023 physician orders revealed the following orders: -An order dated 02/27/2023 for Wound care to sacrum: clean area with wound cleanser and pat dry. Apply a foam dressing to area for protector measures every other day or as needed. -An order dated 02/17/2023 for Wound care to buttocks (between cheeks) - clean area with wound cleanser. Pat dry. Apply hydrocolloid dressing. Change dressing every 3 days or as needed-one time a day every 3 days. Review of Resident #3's Weekly Wound Assessment reports indicated wounds were measured in centimeters and presented in legnth x width x depth. Resident #3's Weekly Wound Assessments revealed only the following wound assessments: -Report dated 02/17/2023 - Right thigh (front), Stage 2 measured 4 x 0.5 x 1) and Coccyx, Stage 2 measured 1 x 0.4 x 0.01. -Report dated 03/02/2023 - Left thigh (rear), Stage 2 measured 2 x 1 x 0.01 -Report dated 03/09/2023 - Right buttock (area is between right and left buttock) Stage 2 measured 1 x 0.5 x 0.01. During an interview on 03/14/2023 at 1:05 p.m. S2 Treatment Nurse reported Resident #3 had 2 pressure wounds she had been conducting wound care on, one of Resident #3's sacrum and one on Resident #3's buttocks (between the cheeks). During an interview on 03/15/2023 at 01:15 p.m. S1 DON (Director of Nursing) reported she was responsible for conducting the weekly pressure wound assessments. S1 DON further reported upon review of Resident #3's weekly pressure wound assessments, the pressure wound assessments had not been conducted weekly for each pressure wound and should have been. 2. Resident #5 Review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] and had diagnoses that included, in part, fracture of unspecified part of neck of right femur; COPD (chronic obstructive pulmonary disease); muscle wasting and atrophy not elsewhere classified multiple sites; muscle weakness; essential hypertension, and Type 2 Diabetes Mellitus. Review of Resident #5's current physician orders revealed: -An order dated 03/14/2023 to Cleanse wound Stage 2, #1 on buttocks with wound cleanser. Pat dry, apply to wound bed, cover with hydrocolloid dressing, change every 3 days and as needed. -An order dated 03/14/2023 to Cleanse wound Stage 2, #2 on buttocks with wound cleanser, pat dry, apply to wound bed, cover with hydrocolloid dressing, change every 3 days and as needed. -An order dated 03/14/2023 to Cleanse wound Stage 2, #3 on buttocks with wound cleanser, pat dry, apply to wound bed, cover with hydrocolloid dressing, change every 3 days and as needed. Review of Resident #5's March 2023 TAR (treatment administration record) revealed no entries to indicate that Resident #5 had received any wound care. Review of Resident #5's admission Wound Assessments dated 03/02/2023 revealed Resident #5 had 3 Stage 2 pressure wounds: Right buttock #1, Right buttock #2, and Right buttock #3 that were present upon admission. Review of Resident #5's Baseline Care Plan dated 03/02/2023 revealed Resident #5 had potential for altered skin integrity with interventions that included turn every 2 hours and as needed, immediately report any skin redness to nurse, report any skin breakdown to charge nurse and provide incontinent care as needed. The baseline care plan did not indicate that Resident #5 had any pressure wounds. During an interview on 03/14/2023 at 12:45 p.m. S2 Treatment Nurse reported Resident #5 had three pressure ulcers to her right buttock that were each being treated with wound cleanser, pat dry and apply hydrocolloid dressing every 3 days. S2 Treatment Nurse further reported the orders for the wound care had not been entered into the electronic health record yet. During an interview on 3/15/2023 at 1:50 p.m. S2 Treatment Nurse reported she was unable to produce any evidence Resident #5's wound care had been completed. During an interview on 3/15/2023 at 1:55 p.m. Resident #5 reported she had received wound care but that it had not been done every 3 days and she could not remember how many times it had been done since she was admitted on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the plan of care had been revised for 1 (#4) of 17 total sampled residents reviewed for care plans. The facility failed to ensure the comprehensive plan had been revised to include advance directives and Code Status for 1 (#4) resident. Findings Review of resident #4's medical record revealed an admit date of [DATE] with diagnoses that include in part atherosclerotic heart disease, presence of cardiac pacemaker, and Atrioventricular block complete. Review of resident #4's current physician orders revealed: [DATE] DNR (Do Not Resuscitate) [DATE] Resident admit to hospice care Review of resident #4's Hospice record revealed Hospice agreement signed by RP (Legal representative)-Son of resident #4 on [DATE]. Further review revealed Louisiana Physician Orders for Scope of Treatment (LaPost) designating resident as DNR. Comfort focused treatment, signed [DATE] by resident #4's RP. Review of facility medical record revealed a hand written order for DNR status with no date. LaPost and Advanced Directives signed/dated [DATE] indicating resident #4 as DNR. Review of Quarterly MDS (Minimum Data Set) dated [DATE] revealed in Part: Cognitive: Brief interview for mental status=13-cognitively intact Special Services: Hospice Care Participation in Assessment: resident participated in care plan. No active discharge plan, no plan to return to the community. Review of comprehensive care plan revealed the following problems and interventions: -Resident #4 has no advanced directives r/t (related to) code status: revision on [DATE]: LaPost document in medical records, Provide CPR (cardiopulmonary resuscitation), Review Code status quarterly or as needed. - Resident #4 admitted to Hospice r/t diagnosis of Coronary Artery Disease: revision [DATE]: Review resident's advanced directive and ensure it is followed. - Resident #4 wishes to return home with home health: revision [DATE]: evaluate and discuss with the resident/resident's representative/caregivers the prognosis for independent or assisted living. During an interview on [DATE] at 2:25 pm S3 MDS Coordinator reported resident #4's comprehensive care plan should have been updated to DNR status, and resident #4 was not planning on being discharged home due to her Hospice status.

Based on observation and interview the facility failed to ensure the staffing data was posted daily at the beginning of each shift. The facility census was 28 according to the Residents Census and Conditions Report provided by the facility on 10/3/2022, Findings: Observation on 10/3/22 at 9:45 am revealed staffing posted on a bulletin board in the facility common area dated 9/29/22. During an interview on 10/3/22 at 9:45 am S1 Administrator reported the Director of Nursing (DON) posts the daily staffing during the week and the weekend RN (Registered Nurse) should post it on the weekends and it wasn't done. During an interview on 10/5/22 at 9:10 am S2 DON reported the company does not have a specific policy related to posting staffing but it was usually done by the charge nurse and it wasn't done everyday like it should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure items in the medication Storage room resident medication refrigerator were properly stored as evidenced by having open, unlabeled or dated food times belonging to facility staff in the resident medication refrigerator. The total census was 28 according to the Resident Census and Conditions of Residents form provided by the facility on 10/3/2022. Findings: Policy review revealed 3.6: Facility should ensure that food is not to be stored in the refrigerator, freezer or general storage areas where medications and biologicals are stored. 8. Facility should ensure that resident medication and biological storage areas are locked and do not contain non-medication/biological items. Observation on 10/3/22 at 10:00 am with S2 DON (Director of Nursing) of the medication refrigerator with a label on front of the door with instructions for residents only, label and date items, remove after 7 days. Observation inside the resident medication refrigerator revealed opened bottles of lemonade, Body [NAME] juice, coffee mate creamer, salad dressing, and a container of pudding. None of the opened bottles or containers had a name or date. During an interview on 10/3/22 at 10:00 am S2 DON reported the only thing that might be a residents would be the pudding but without a name she could not be sure. The S2 DON further reported, all the other opened items belonged to staff and should not have been in the resident medication refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the provider failed to ensure a baseline care plan was completed for one (#172) of 17 sampled residents. Findings: Record review of Resident # 172's electronic health record revealed the resident was admitted to the facility on [DATE]. Record review of Resident # 172's care plans failed to show that a baseline care plan was completed for the resident. During an interview on 10/5/2022 at 11:40 AM, S3MDS Coordinator indicated a baseline care plan for Resident # 172 was not completed and one should have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 (#3, #17) of 17 total sampled residents. Findings: Resident #3 Record review of Resident # 3's comprehensive care plans failed to reveal a completed comprehensive care plan for Resident #3. During an interview on 10/5/22 at 12:49 PM, S3MDS Coordinator verified Resident #3 did not have a comprehensive care plan completed and one should have been completed. Resident #17 Review of resident #17's medical record revealed an admit date of 8/19/2022 with diagnoses that include in part sepsis, chronic kidney disease, cerebral infarction, chronic pulmonary embolism, anxiety disorder, Alzheimer's disease, type 1 diabetes mellitus, bilateral above the knee amputee, urinary tract infections, and polyneuropathy. Review of resident #17's medical record failed to reveal a comprehensive care plan was developed and implemented for catheter care, Alzheimer's disease, anxiety, use of antianxiety medications, monitoring for behaviors and side effects, use of anticoagulants and monitoring, assistance for ADL care for dependent resident, therapy and use of hand roll for contracture, and diabetes mellitus. During an interview on 10/3/22 at 8:30 am S3 MDS ([NAME] Data Set) Coordinator reported being the only person doing the MDS assessments and the care plans for the facility and the care plans were behind on some of the residents. S3 MDS Coordinator verified resident #17 did not have a comprehensive care plan and should have.

Resident #77 Record review of resident #77's medical record revealed an admit date of 9/23/22 with diagnoses that include in part Type 2 Diabetes Mellitus and Atrial fibrillation. Review of Resident #4's current physician orders revealed orders for Ozempic 1ml (milliliter) dose subcutaneous solution pen-injector 5mg (milligram)/3ml (milliliter), Inject 1mg subcutaneously one time a day every Saturday for diabetes, and an order for Glipizide 5mg po (by mouth) daily for diabetes. Review of Resident #77's Hospital Discharge Summary and admission packet revealed the following; -Discharge (to home) Medication Reconciliation Form: Insulin Lispro Injection 100u (units)/ml (humalog) Range. 1 Unit to 10 unit subcutaneous 5 minutes before meal and at bedtime. Blood glucose: less than 70 -hypoglycemia protocol 70-150-no coverage 151-200-2 units 201-250-4 units 252-300 6 units 301-350- 8 units 351-400-10 units greater than 400 -10 units and notify provider Review of Resident #77's September and October MAR (Medication Administration Record) revealed Ozempic and Glipizide was documented given as ordered. Review of Resident #77's medical record failed to reveal documentation of blood glucose monitoring from 9/23/2022 (admission) -10/4/2022. Further review failed to reveal a clarification order from the physician indicating whether resident #77 should have continued to receive sliding scale insulin and blood glucose monitoring once admitted to the facility. Observation on 10/4/22 at 8:15 am during medication pass revealed, S5 LPN verified resident #77 was a diabetic and received antidiabetic medications but did not have an order for blood sugar checks. During an interview on 10/4/22 at 8:20 am resident #77 reported the nurses have only checked his blood sugar once before when he asked them to. Resident #77 confirmed he was a diabetic and received medications daily for his diabetes. During an interview on 10/4/22 at 11:00 am S2 DON reported when a nurse puts in orders for insulin the computer will automatically put in a warning to check a blood sugar but if the resident is not on insulin and the doctor doesn't order blood sugar checks, then it isn't done. S2 DON further reported, if it's not charted on the medication administration record, it wasn't done. S2 DON verified resident #77 was a diabetic and received oral and injectable medications for diabetes and the nurse should have clarified with the doctor to continue resident #77's sliding scale insulin and testing blood sugars from the hospital discharge and it wasn't done. S2 DON further reported, the nurse should have done a finger stick blood sugar before giving diabetic medications as part of professional standards and did not. Based on record review and interview, the facility failed to provide care and services that met professional standards of quality by failing to check residents blood glucose level prior to administering insulin and oral hypoglycemic medication for 2 (#72, #77) of 2 (#72, #77) diabetic residents reviewed. Findings: Resident #72 Review of resident #72's electronic health record revealed an admit date of 9/30/2022 with diagnosis of but not limited to, Infection and inflammatory reaction due to internal orthopedic prosthetic devices, implants and grafts. Further review of resident #72's Hospital Discharge Summary revealed resident #72 had a history of insulin dependent diabetes mellitus, diabetic neuropathy, hypertension and bacteremia. Review of resident #72's October 2022 Physician's orders revealed an order for Lantus Insulin Solo-Star Pen-injector 100unit/milliliter give 20 units in the evening for diabetes Review of resident #72's Baseline Plan of Care revealed: Metabolic/Diabetic: resident will have no complications related diabetes: check blood sugars as ordered and as needed, medication as ordered, monitor for signs and symptoms of hyperglycemia, diet as ordered and encourage compliance, lab tests as ordered, monitor skin, provide nail care. Review of resident #72's October 2022 Medication Administration Record revealed documentation of Lantus Insulin 20 units given subcutaneously in the evening for diabetes as ordered on 10/1/2022, 10/2/2022, 10/3/2022 and 10/4/2022. Review of resident #72's electronic health record and medication administration record failed to reveal the monitoring of resident #72's blood glucose prior to being given Lantus insulin subcutaneously on 10/1/2022 and 10/2/2022. During an interview on 10/05/22 12:56pm S2 DON (Director of Nursing) confirmed the common professional practice of nurses to check a resident's blood glucose level prior to administering insulin. S2 DON also confirmed resident #72's blood glucose level should have been check prior to being given insulin.

Based on record review and interview the facility failed to ensure wound care was provided for one (#76) out of two (#73, 76) residents reviewed for pressure ulcer/injury. Findings: Record review of Resident #76's physician orders revealed the following, in part: Clean stage IV pressure ulcer to left buttock with wound cleanser; apply alginate dressing, and cover with foam dressing every Monday, Wednesday, and Friday for wound healing and as needed. Review of Resident #76's TAR (treatment administration record) for September 2022 revealed the following, in part: Scheduled stage IV wound care to left buttock for September 23rd, 26th, 28th and 30th of 2022 was not marked as completed. During an interview on 10/5/2022 at 10:30 AM, S2DON verified Resident #76's TAR was left blank on the dates of September 23rd, 26th, 28th and 30th of 2022 for the resident's left buttock wound care and should have been marked as completed or if resident refused. When the space is left blank it would indicate the wound care was not completed. During an interview on 10/5/2022 at 11:15 AM, S1Administrator verified Resident #76's left buttock wound care was left blank on the dates of September 23rd, 26th, 28th and 30th of 2022. S1Administrator indicated blank spaces would indicate the wound care had not been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #172 Record review of Resident #172's physician orders for September and October of 2022 revealed an order for Eliquis 5mg (milligrams) by mouth two times a day related to history of pulmonary embolism. Record review of Resident #172's diagnosis revealed a diagnosis of history of pulmonary embolism. Record review of Resident #172's MAR (medication administration record) for September and October 2022 revealed the following, in part: 1. Eliquis 5mg by mouth two times a day was given as ordered from September 23-October 5 of 2022. 2. No monitoring for bleeding/bruising was noted. During an interview on 10/5/2022 at 12:05 PM, S1Administrator verified Resident #172 was receiving Eliquis 5mg by mouth two times a day and the resident was not being monitored for use of an anticoagulant. During an interview on 10/5/2022 at 12:30 PM, S4LPN indicated monitoring for bleeding/bruising for Resident #172 had not been documented since the resident started taking an anticoagulant on September 23, 2022 through October 5, 2022 and should have been. Based on record review and interview the facility failed to ensure monitoring for bleeding/bruising was completed for residents that were receiving an anticoagulant for two (#71, 172) out of six (#3, 5, 71, 72, 121, 172) residents reviewed for unnecessary medications. Findings: Resident #71 Review of resident #72's electronic medical record revealed an admit date [DATE] and a diagnosis of but not limited to syncope and collapse, type 2 diabetes, chronic kidney disease, muscle weakness, lack of coordination, essential hypertension, vitamin A deficiency, long term use of anticoagulants, major depressive disorder, and iron deficiency disorder, Review of resident #71's October 2022 Physicians Orders revealed an order for Enoxaparin Sodium (Lovenox) Injection 30 mg(milligrams)/0.3 ml (milliliters) subcutaneous one time a day (anticoagulant) 9/23/2022 Review of resident #71's October 2022 Medication Administration Record failed to reveal documentation of monitoring for bleeding. Review of resident #71's baseline care plan revealed a problem and approach of the following: Will have no complication related to anticoagulant use; monitor lab and monitor signs and symptoms of internal and external bleeding; During an interview on 10/5/2022 at 11:50 am S4LPN reported resident #71 was prescribed and was administered Lovenox (Enoxaparin), an anticoagulant. S4LPN confirmed resident #71 had not been monitored for bleeding.