Based on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#22) of 5 (#4, #17, #22, #55, and #78) residents reviewed for unnecessary medications. Findings: Review of the facility's Pharmacy Services- Role of the Consultant Pharmacist policy and procedure, revised April 2007, revealed the following in part: 4. The Consultant Pharmacist will provide specific activities related to medication regimen review including: b. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated. Review of resident #22's record revealed and admission date of 08/16/2022 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, spinal stenosis, other sequelae of cerebral infarction, adjustment disorder with depressed mood, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance and anxiety, and major depressive disorder. Review of resident #22's current Electeronic Health Records (EHR) revealed an order dated 11/12/2024 for Quetiapine Fumarate oral tablet give 50 milligrams (mg) by mouth (po) 2 times a day for mood related to adjustment disorder with depressed mood. Review of the monthly drug regimen review revealed the phamacist reviewed resident #22 on 11/22/2024, but no documented evidence that the pharmacist identified an irregularity on regarding the use of Quetiapine Fumarate without an appropriate diagnosis. An interview on 12/04/2024 at 2:00 p.m. with S2Director of Nursing (DON) confirmed the pharmacist did not notify the facility, DON, or physician regarding resident #22 not having an appropriate diagnosis for the use of Quetiapine Fumarate (antipsychotic medications).

Based on record review and interview, the facility failed to ensure resident's drug regimens were free from unnecessary psychotropic medications for 1 (#22) of 5 (#4, #17, #22, #55, and #78) residents reviewed for unnecessary medications. The facility failed to ensure a psychotropic medication was used only when there was an acceptable diagnosis documented in the medical record for resident #22. Findings: Review of resident #22's record revealed an admission date of 08/16/2022 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, other sequelae of cerebral infarction, adjustment disorder with depressed mood, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance and anxiety, and major depressive disorder. Review of resident #22's current Electeronic Health Records (EHR) revealed an order dated 11/12/2024 for Quetiapine Fumarate oral tablet give 50 milligrams (mg) by mouth (po) 2 times a day for mood related to adjustment disorder with depressed mood. An interview on 12/04/2024 at 2:00 p.m. with S2Director of Nursing (DON) confirmed resident #22 has an order for Quetiapine Fumarate with the a diagnosis of adjustment disorder with depressed mood. S2DON confirmed resident #22 does not have an appropriate diagnosis for the use of Quetiapine Fumarate (antipsychotic medication).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure an accurate assessment was completed to reflect a resident`s condition. The failed practice was evidenced by 1 (#316) of 5 (#50, #62, #80, #102, and #316) residents reviewed for pressure ulcers not having an accurate wound assessment completed by a Registered Nurse (RN) upon discovery of skin breakdown. Findings: Resident #316 On 12/02/2024 at 4:06 p.m., observation revealed resident #316 was alert and oriented while sitting in a chair at his bedside. He reported he had a wound to his sacrum area. Record review revealed resident #316 was admitted to the facility on [DATE] with diagnoses that included idiopathic pulmonary fibrosis, chronic cough, hypotension, hypokalemia and mild protein malnutrition. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated no cognitive impairment. Review of active physician orders for December 2024 revealed the following: Sacrum: Clean stage 3 wound with wound cleanser, pat dry, paint wound bed with betadine, cover with Calcium Alginate and foam dressing every other day and as needed for dislodgement until resolved. Record review of a body assessment completed on 11/19/2024 revealed no record of skin issues related to resident #316. Review of a nurse`s note dated 11/23/2024 at 10:11 a.m., revealed the following; LATE ENTRY: On 11/22/2024, it was reported to S3Licensed Practical Nurse (LPN)/ Wound Care Nurse (WCN) that resident #316 had skin breakdown noted. S3 LPN/WCN assessed resident #316 and found skin to sacrum to be moist, soft, and boggy. No broken skin was noted. New physician orders were obtained for the sacrum to be cleaned with wound cleanser, pat dry, apply foam dressing every 3 days for preventative measures. Review of the wound assessments revealed the following: On 11/27/2024 a wound assessment was completed for resident #316 and signed by S2Director of Nurses (DON). The assessment revealed the wound was first assessed by a RN on 11/27/2024. Further review of the wound assessments revealed no record of a wound assessment being completed by a registered nurse when the skin breakdown was discovered on 11/22/2024. On 12/04/2024 at 9:15 a.m. an interview with S2DON confirmed the first wound assessment was completed by a registered nurse for resident #316` s pressure ulcer to the sacrum on 11/27/2024. S2DON further confirmed an initial wound assessment was not completed by a registered nurse on 11/22/2024 when the skin breakdown was first identified. On 12/04/2024 at 10:55 a.m. an interview with S2LPN/WCN confirmed the skin breakdown to resident #316`s sacrum was identified on 11/22/2024. S2LPN/wound care nurse confirmed she assessed the wound, notified the physician, obtained and implemented physician orders, she further confirmed an initial wound care assessment was not completed and signed by a RN on 11/22/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #104 Review of resident #104's record revealed an admission date of 08/02/2024 with diagnoses including hypertension, atrial fibrillation, shortness of breath, and gastroesophageal reflux disease. Review of resident #104's December 2024 Physician's Orders revealed an order dated 08/02/2024 for continuous Oxygen at 2 liters per nasal cannula. Observations on 12/02/2024 at 2:25 p.m., 12/03/2024 at 4:15 p.m., and 12/04/2024 at 9:05 a.m. of resident #104 revealed resident had Oxygen in use, but there was no Oxygen in use sign posted on the outside of the resident's door. An interview on 12/04/2024 at 2:25 p.m. with S2DON confirmed resident #104 had Oxygen in use without an Oxygen in use sign posted on the outside of the resident's door. Resident #316 Record review revealed resident #316 was admitted to the facility on [DATE] with diagnoses that included idiopathic pulmonary fibrosis, chronic cough, hypotension, hypokalemia and mild protein malnutrition. Review of the most recent MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated no cognitive impairment. Review of the plan of care revealed resident #316 was to receive Oxygen at 2 liters per minute via nasal cannula. On 12/02/2024 at 4:06 p.m., observation revealed resident #316 was alert and oriented while sitting in a chair at his bedside. He was observed wearing a nasal cannula that was providing Oxygen at 2 liters per minute via an Oxygen concentrator located in the corner of the room. There was no signage observed at the entrance of the room that indicated oxygen was in use. Based on observations, record reviews, and interviews, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice by not having signage on the outside of the residents' room door to indicate oxygen was in use for 3 (#29, #104, #316) of 5 (#17, #29, #67, #104, #316) residents reviewed for oxygen. Findings: Review of the facility's Oxygen Administration policy and procedure, revised October 2010, revealed the following, in part: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure 2. Place an Oxygen in Use sign in a designated place outside resident room. Resident #29 Review of the medical record for sampled resident #29 revealed an admission date of 12/03/2021 with diagnoses of idiopathic peripheral autonomic neuropathy, pulmonary edema, diabetes mellitus, dysarthria, depression, dysphagia, cardiomyopathy, heart failure, and dementia. Review of the physician's orders dated 11/20/2024 revealed administer continuous oxygen at 2 liters per nasal cannula. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #29 had a Brief Interview for Mental Status (BIMS) scored of 3 which indicated the resident had severe cognitive impairment for daily decision making. Review of the current care plan for resident #29 revealed the resident had oxygen therapy related to ineffective gas exchange, respiratory illness, give medications as ordered by the physician, and observe for signs and symptoms of respiratory distress. On 12/02/2024 at 9:45 a.m., and 12/03/2024 at 12:31 p.m., observations of resident #29 revealed she was in the bed and received oxygen at 2 liters per nasal cannula. Observations of the outside of the resident's door revealed there was no sign to indicate the resident received oxygen therapy. On 12/04/2024 at 2:15 p.m. observation of the outside of resident #29's door with S2Director of Nursing (DON) revealed there was no signage to indicate the resident was on oxygen. S2DON confirmed the signage for oxygen use was not on the outside of the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #22 Review of resident #22's record revealed and admission date of 08/16/2022 with diagnoses including fibromyalgia, chronic kidney disease stage 3, type 2 diabetes mellitus with diabetic neuropathy, spinal stenosis, other sequelae of cerebral infarction, adjustment disorder with depressed mood, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance and anxiety, and major depressive disorder. Review of resident #22's December 2024 Physician's Orders revealed no orders for side rails. Review of resident #22's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Observations on 12/02/2024 at 3:30 p.m., 12/03/2024 at 4:00 p.m., and 12/04/2024 at 9:15 a.m. of resident #22 revealed resident had half side rail to one side of the bed in the up position. Review of resident #22's Side Rail Utilization Assessment revealed an effective date 10/01/2024 with the assessment and consent signed and dated on 12/04/2024. Further review of the assessment revealed no documentation that risks of entrapment were assessed prior to the implementation of the side rail. An interview on 12/04/2024 at 2:10 p.m. with S2DON confirmed the facility did not complete the Side Rail Utilization Assessment or consent prior to the implementation of the side rails. S2DON further confirmed there was no documentation of risks of entrapment assessed prior to the installation of side rails. Resident #104 Review of resident #104's record revealed an admission record of 08/02/2024 with diagnoses including hypertension, atrial fibrillation, and shortness of breath. Review of resident #104's December 2024 Physician's Orders revealed no order for use of side rails. Review of resident #104's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. Observations of resident #104 on 12/02/2024 at 2:25 p.m., 12/03/2024 at 4:15 p.m., and 12/04/2024 at 9:05 a.m. revealed resident had bilateral half side rails in place in the up position. Review of resident #104's Side Rail Utilization assessment dated [DATE] revealed no documentation of identifying risks of entrapment prior to the installation of side rails. An interview on 12/04/2024 at 2:35 p.m. with S2DON confirmed there was no documentation of assessing risks of entrapment prior to the installation of side rails on resident #104. Resident #50 Record review revealed resident #50 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysphagia, aphasia, essential hypertension, chronic pain, diabetes mellitus, generalized muscle weakness, muscle wasting and atrophy multiple sites, encounter for attention gastrostomy, acquired absence of right leg and left leg above the knee, and major depressive disorder. Review of quarterly MDS assessment dated [DATE] revealed BIMS score of 99 which indicated resident #50 was unable to complete due to severe cognitive impairment. Further review revealed resident #50 was dependent on staff assistance with all activities of daily living. On 12/02/2024 at 9:30 a.m., an observation of resident #50 revealed she was lying in bed with head of bed elevated up 30 degrees. The quarter side rails on each side of the bed were in the upright position. On 12/03/2024 at 9:50 a.m., an observation of resident #50 revealed she was lying in bed with head of bed elevated up 30 degrees. The quarter side rails on each side of the bed were in the upright position. Review of active care plans revealed resident #50 had an activities of daily living self-care performance deficit. An intervention listed included resident #50 used side rails to maximize independence with turning and repositioning. On 12/04/2024 at 2:28 p.m., S2DON provided surveyor with resident #50's side rail utilization assessment that had an effective date of 09/30/2024 included a consent for bilateral side rails. Further review of the side rail utilization assessment form revealed resident #50 was not assessed for entrapment. S2DON confirmed there was no documentation of resident #50 being assessed for entrapment prior to the use of side rails. Based on observations, record reviews and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from side rails prior to the installation of side rails for 5 (#22, #40, #50, #55, #104) of 5 (#22, #40, #50, #55, #104) residents reviewed for side rails. The facility failed to complete the Side Rail Utilization Assessment and consent for side rails prior to implementation for resident #22. Findings: Review of the facility's Proper Use of Side Rails policy and procedure, revised August 2024, revealed the following, in part: General Guidelines 3. Upon admission, readmission, with routine quarterly or significant change MDS and prn, therapy/designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When use for mobility or transfer, the assessment will include a review of the resident's: c. risk for entrapment from the use of side rails 4. Consent for use of side rail will be obtained from the resident or legal representative, after presenting potential benefits and risks 5. The resident's care plan will reflect the use of side rails and updated as necessary; 9. The resident will be checked at least every shift for safety and proper functioning of the side rail use; Resident #40 Review of the medical record for resident #40 revealed an admission date of 05/03/2021 with diagnoses including muscle wasting and atrophy, diabetes mellitus, chronic obstructive pulmonary disease, convulsions, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was a 4 which indicated severe cognitive impairment for daily decision making. Resident #40 required extensive assistance with bed mobility, toileting and transfers. Review of resident #40's December 2024 Physician's Orders revealed no order for side rails. On 12/02/2024 at 4:12 p.m. and 12/03/2024 at 2:10 p.m., observations of resident #40 revealed he was in the bed, quarter side rails were in the raised position on both sides of the bed. Review of the Side Rail Utilization assessment dated [DATE] for resident #40 revealed no documentation that risks of entrapment were assessed prior to the implementation of the side rail. On 12/04/2024 at 2:00 p.m. interview with S2Director of Nursing (DON) confirmed the side rail assessment for resident #40 did not address the assessment for risk of entrapment prior to installation. Resident #55 Review of the medical record for resident #55 revealed an admission date of 11/20/2019 with diagnoses of muscle wasting and atrophy, muscle spasm, heart failure, anxiety, and diabetes mellitus. Review of the quarterly MDS dated [DATE] revealed resident #55 had a BIMS score of 15 which indicated no cognitive impairment and she required assistance with bed mobility and transfers. Review of resident #55's December 2024 Physician's Orders revealed no order for side rails. On 12/02/2024 at 2:00 p.m., and 12/04/2024 at 7:45 a.m. observations of resident #55's bed revealed quarter side rails were in the raised position on both sides of the bed. Review of the Side Rail Utilization assessment dated [DATE] for resident #55 revealed no documentation that risks of entrapment were assessed prior to the implementation of the side rail. On 12/04/2024 at 2:00 p.m. interview with S2DON confirmed the side rail assessment for resident #55 did not address the assessment for risk of entrapment prior to installation.

Based on record review and interview, the facility failed to conduct Quality Assessment and Assurance meetings at least quarterly. Findings: Record review revealed the Quality Assessment and Assurance meetings revealed the past four meetings were held on 10/18/2023, 04/09/2024, 07/10/2024, and 10/30/2024. There was no record of a meeting between the dates of 10/18/2023 and 04/09/2024. On 12/04/2024 at 5:36 p.m., an interview with S1Administrator confirmed there was no record of a quarterly meeting in January 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure an entry in the Emergency (ER) Transfer Log was completed and the Ombudsman was notified of the transfer for 1 (#64) of 1 (#64) residents reviewed for Notice Requirements Before Transfer/Discharge. The failed practice was made evident by the facility failing to ensure emergency transfer logs were completed and the ombudsman was notified when resident #64 was transferred to the emergency room on the dates of 07/05/2023 and 11/03/2023. Findings: Review of the electronic health record revealed resident #64 was admitted to the facility on [DATE] with diagnoses that included in part, hemiplegia, spondylolysis, cervical region, aphasia following cerebral infarction and dysarthria following cerebral infarction, and transient ischaemic attack. Review of the nurse's notes dated 11/03/2023 at 5:19 p.m., revealed in part, resident #64 was sent to the emergency room for evaluation and treatment due to having trouble gathering words and making sentences. Review of the ER (Emergency) transfer logs presented by S1Administrator revealed there were no documented logs noted after the month of June 2023. On 11/29/2023 at 1:30 p.m., an interview with S1Administrator revealed that S11Social Services (Previous Employee), had been responsible for completing the emergency transfer logs prior to ending her employment with the provider in August of 2023. S1Administrator further reported that after S11Social Service's employment was terminated with the nursing facility, he, (S1Administrator) assumed the position and was currently responsible for completing the emergency transfer logs. S1Administrator confirmed there was no documented evidence of the ER transfer logs being completed and the ombudsman being notified of any transfer/discharge after the month of June 2023. Further review of the nurse's notes revealed that on the date of 07/05/2023 at 6:13 p.m., resident #64 had facial drooping and was sent to the emergency room for evaluation. On 11/29/2023 at approximately 4:45 p.m., S1Administrator was notified of the additional findings regarding resident #64 being transferred to the ER on the date of 07/05/2023. S1Adminsistrator further confirmed that he had not completed the ER transfer log to reflect resident #64's transfer to the ER and he had not notified the ombudsman of the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide assistance for residents who were unable to carry out activities of daily living (ADL) by failing to maintain good grooming and personal hygiene for 3 (#7, #29, and #39) of 4 (#7, #29, #39, and #72) residents reviewed for activities of daily living. Findings: Resident #7 Review of the medical record for resident #7 revealed the resident was admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, peripheral autonomic neuropathy, pain in right shoulder, lack of coordination, dysarthria following cerebral infarction, muscle weakness, pain, atrial fibrillation, insomnia, dyspnea, major depression disorder, seizures, aphasia following cerebral infarction, and hemiplegia following cerebral infarction affecting left dominant side. Review of the Yearly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognitive skills for daily decision making. The resident required one person limited assistance with personal hygiene. Review of the care plan revealed self-care deficit related to inability to perform own activities of daily living (ADLs) independently. Further review revealed the following approaches: assist with ADLs as needed, nail care when necessary and weekly, monitor/trim toenails and fingernails, bathing, dressing, and hygienic needs (shaving per one person assist). Observation on 11/27/2023 at 12:26 p.m. revealed the resident's facial hair was unkempt and he needed to be shaved. Further observation revealed the resident had long dirty fingernails. Interview at this time revealed that he wanted to be shaved and a Certified Nursing Assistant told him that he would shave him but hasn't yet. Further interview revealed he would like his fingernails trimmed. Observations on 11/28/2023 at 1:10 p.m. and 11/29/2023 at 11:00 a.m. revealed the resident's facial hair was unkempt and he needed to be shaved. Further observation revealed the resident had long fingernails. Observation of resident #7 with S9Licensed Practical Nurse (LPN) on 11/29/2023 at 1:10 p.m. confirmed the resident's facial hair needed to be shaved and his nails were in need of trimming. Observation of resident #7 with S2Director of Nursing (DON) on 11/29/2023 at 2:25 p.m. confirmed the resident's facial hair needed to be shaved and his nails were in need of trimming. Interview with the resident at this time revealed he would like his face shaved and nails filed. Resident #29 Review of the medical record for resident #29 revealed the resident was admitted on [DATE] with diagnoses of chronic atrial fibrillation, encephalopathy, congestive heart failure, arthritis, pain in left shoulder, rotator cuff tear left shoulder, gout, sleep disorder, hypertension, and pain in knee. Review of the admission MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required maximal assistance for personal hygiene. Review of the care plan revealed the resident was at risk for falls with an approach to assist the resident as needed with transfers and activities of daily living. Observation on 11/27/2023 at 12:30 p.m. revealed the resident's facial hair was unkempt and he needed to be shaved and his teeth needed to be brushed. Further observation revealed the resident had long fingernails. Interview at this time with the resident revealed he had not been shaved or had his teeth brushed since admit. Further observation revealed there was not a toothbrush in his room. Observation on 11/29/2023 at 11:10 a.m. revealed the resident's fingernails are long with one fingernail jagged. Interview at this time revealed he would like his fingernails and toenails trimmed. Further interview revealed he had not received oral care and he doesn't have a toothbrush. Observation of the resident on 11/29/2023 at 1:15 p.m. with S9LPN confirmed the resident's nails were in need of trimming. Interview with the resident at this time revealed he needed his fingernails and toenails trimmed and he also needed a toothbrush. Interview on 11/29/2023 at 2:30 p.m. with resident #29 and S2DON confirmed the resident needed his fingernails and toenails trimmed. Further interview at this time with the resident revealed he had not received oral care since he has been here. Observation by S2DON confirmed there was not a toothbrush in his room. Resident #39 Review of the medical record for resident #39 revealed the resident was admitted on [DATE] with diagnoses of fractured right femur, muscle wasting and atrophy, diabetes, Chronic Obstructive Pulmonary Disease, convulsions, insomnia, depression, Alzheimer's, Transient Ischemia Attack and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required maximal assistance for personal hygiene. Review of the care plan revealed the resident required staff assistance for all activities of daily living. Further review of the approaches revealed hygienic needs/grooming and shaving, the resident required 1 person assist, and weekly nail care per nursing to my fingernails and my toenails. Observations on 11/27/2023 at 9:19 a.m., 11/28/2023 at 12:30 p.m., and 11/29/2023 at 11:05 a.m. revealed the resident's facial hair was unkempt and he needed to be shaved. Further observations revealed the resident had long dirty fingernails. Observation of resident #39 with S9LPN on 11/29/2023 at 1:19 p.m. confirmed the resident's facial hair needed to be shaved and his fingernails needed to be trimmed. Observation of resident #39 with S2DON on 11/29/2023 at 2:35 p.m. confirmed the resident's facial hair needed to be shaved and his fingernails needed to be trimmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#83) of 1 residents reviewed for pressure ulcers. The facility failed to provide a pressure relieving device while in the wheelchair for resident #83. Findings: Resident #83 Review of the medical record for resident #83 revealed the resident was admitted on [DATE] with diagnoses of aphasia, muscle wasting and atrophy, obesity, and abnormality of gait and mobility. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had independent cognitive skills for daily decision making. The resident required maximal assistance with transfers and toileting hygiene. The resident was frequently incontinent of bowel and bladder. Review of the Wound assessment dated [DATE] revealed a stage II pressure ulcer on the coccyx identified on 11/17/2023 and resolved on 11/20/2023. Review of the physician orders for November 2023 revealed an order dated 10/27/2023 - may have pressure relieving cushion to wheelchair every shift as tolerated and monitor for placement. Observation of resident #83 on 11/27/2023 at 3:30 p.m., 11/28/2023 at 12:40 p.m., and 11/29/2023 at 10:55 a.m. revealed the resident was up in her wheelchair in her room. The wheelchair did not have a pressure relieving device. An interview with S9Licensed Practical Nurse (LPN) on 11/29/2023 at 1:22 p.m. confirmed the resident should have a pressure relieving device in her wheelchair and the resident did not have one at this time. An interview with S2Director of Nursing (DON) on 11/29/2023 at 2:32 p.m. confirmed resident #83 should have a pressure relieving device in her wheelchair.

Based on record review and interview, the facility failed to ensure a performance review was completed at least once every 12 months for 3 (S4 Certified Nursing Assistant (CNA), S6CNA, S8CNA ) of 5 (S4CNA, S5CNA S6CNA, S7CNA, and S8CNA) personnel records reviewed. Findings: Review of S4CNA, S6CNA, and S8CNA personnel records revealed there was no documentation that an annual performance review was completed in the past 12 months. On 11/29/2023 at 3:24 p.m., an interview with S1Administrator revealed he could not provide annual performance reviews for S4CNA, S6CNA, and S8CNA. S1Administrator confirmed S4CNA, S6CNA, and S8CNA should have annual performance reviews completed in the past 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for a resident's need by not having a controlled medication available and administered in accordance with physician orders for 1 (#8) of 5 (#7, #8, #34, #72, and #86) residents reviewed for unnecessary medications. Findings: On 11/27/2023 at 4:17 p.m., an interview with Resident #8 was conducted in her room. She reported she did not receive her Lyrica (controlled medication) on the morning of 11/27/2023 or on 11/26/2023 as scheduled. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included left hip fracture, diabetes, adjustment disorder with depressed mood, and presence of artificial hip and artificial knee. Review of most recent Minimum Data Set, dated [DATE] revealed Resident #8 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated she had no cognitive impairment. Review of active physician orders for the month of November 2023 included an order for Lyrica 150 milligrams (mg) by mouth to be administered three times daily. Review of November 2023 Medication Administration Record (MAR) revealed Lyrica 150 mg was not given on 11/25/2023 at 8:00 p.m., 11/26/2023 at 8:00 a.m., 2:00 p.m. and 8:00 p.m., and 11/27/2023 at 8:00 a.m. and 2:00 p.m. Review of the current facility`s policy and procedure related to ordering controlled medications revealed re-orders for controlled substances should be made allowing for appropriate time for the pharmacy to obtain the prescription and to assure an adequate supply is on hand. On 11/27/2023 at 9:30 a.m., an interview with S10Licensed Practical Nurse (LPN) revealed Resident #8 did not receive her Lyrica as ordered on 11/25/2023, 11/26/2023 and 11/27/2023 because it was not available. On 11/28/2023 at 2:26 p.m., an interview with S2 Director of Nurses (DON) confirmed Resident # 8 should not have missed doses of Lyrica due to the medication not being available. S2DON revealed the nursing staff should have ordered the Lyrica for Resident #8 ahead of the scheduled times in accordance with their policy on re-ordering controlled medications to ensure Resident #8 did not miss a dose of the scheduled medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure routine medications were administered to each resident for 3 (#18, #34, and #69) of 4 (#18, #34, #69, and #101) residents reviewed for pharmceutical services. The facility failed to have documented evidence as to the reason why the residents were not administered their medications in accordance with the physician's orders. Findings: Resident #18 Review of the medical record revealed resident #18 was admitted to the facility on [DATE]. Her diagnoses included in part, dry eye syndrome of unspecified lacrimal gland, constipation, chronic obstructive pulmonary disease, asthma, exocrine pancreatic insufficiency, restless leg syndrome, psoriatic arthopathy, rheumatoid arthritis, and fibromyalgia. Review of the Minimum Data Set, dated [DATE] revealed resident #18 had a brief interview for mental status score of 15. A score of 13-15 indicated that resident #1 was cognitively intact with daily decision making. On 11/27/2023 at 10:45 a.m., during an interview with resident #18, she revealed that she was supposed to have gotten Systane Complete (Over-the-counter medication used to treat dry eyes), because she had extremely dry eyes. Further interview revealed it had been approximately two weeks since the medication had been ordered and she had not received the medication to date. Review of the November 2023 physician orders revealed resident #18 was ordered the following medications: 11/08/2023: Systane Complete; give one drop four times a day (7:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m.). Review of the November 2023 MAR revealed no documented evidence of the medication being administered on 11/17/2023 at 9:00 p.m. and on 11/28/2023 at 4:00 p.m. 11/08/2023: Flonase Allergy RLF (Relief) 50 micrograms spray; give two puffs in each nostril daily (8:00 a.m.,). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on 11/25/2023 at 8:00 a.m. 10/24/2023: Creon 3,000 unit-9,500 unit capsule; give one capsule by mouth three times daily (8:00 a.m., 2:00 p.m., and 8:00 p.m.). Review of the November 2023 MAR revealed there was no documented evidence on the MAR of the medication being administered on 11/04/2023 at 8:00 a.m., 2:00 p.m. and 8:00 p.m., on 11/22/2023, 11/23/2023, and 11/24/2023 at 2:00 p.m. 10/24/2023: Ropinirole HCL (Hydrocloride) 0.25 mg tablet; take one tablet by mouth at bedtime (8:00 a.m. and 8:00 p.m.). Further review revealed there was no documented evidence on the MAR of the medication being administered on 11/22/2023, 11/23/2023, and 11/24/2023 at the schedule 2:00 p.m. 10/26/2023: Hydrocortisone 1% topical cram apply topically to area on back three times daily (8:00 a.m., 2:00 p.m., and 8:00 p.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the date of 11/22/2023, 11/23/2023, and 11/24/2023 at 2:00 p.m. Review of the November 2023 nurse's notes revealed no documented evidence of the reason why resident #18 was not administered the medications as ordered by the physician. Resident #34: Review of the EHR (Electronic Health Record) revealed resident #34 was admitted to the facility on [DATE] with diagnoses including in part, Parkinsonism, primary osteoarthritis, muscle wasting and atrophy, Type 2 diabetes mellitus with diabetic nephropathy, allergy, constipation, and anxiety disorder. Review of the quarterly Minimum Data Set, dated [DATE] revealed resident #34 had a brief interview for mental status score of 10. A score of 8-10 indicated resident #34 was moderately cognitively impaired with daily decision making. Review of the November 2023 physician orders revealed resident #34 was ordered the following medications: 03/15/2023: Nystatin 100,000 unit/gram powder; apply powder to affected area three times daily until healed, may keep at beside or use (8:00 a.m., 12:00 p.m., and 4:00 p.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the dates of 11/02/2023, 11/08/2023, 11/21/2023, and 11/22/2023 at 12:00 p.m. 04/24/2023: Gabapentin 600 mg tablet; take one by mouth three times daily (8:00 a.m., 2:00 p.m., and 8:00 p.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the dates of 11/02/2023, 11/08/2023, 11/10/2023, 11/21/2023, and 11/22/2023 at 2:00 p.m. 11/10/2023; Prednisone 10 mg tablet; take one tablet mouth once daily for 5 days (9:00 a.m.). Review of the November 2023 MAR revealed there was documented evidence of the medication being administered on the dates of 11/21/2023 and 11/22/2023 at 9:00 a.m. 03/11/2022: Clotrimazole-betamethasone cream; apply to affected area bid (8:00 a.m. and 8:00 p.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the date of 11/18/2023 at 8:00 a.m. 01/20/2023: Docusate Sodium 100 mg capsule take one capsule by mouth once daily (8:00 a.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the dates of 11/04/2023, 11/11/2024, and 11/18/2023 at 8AM. 03/10/2023: Zyzal 5 mg tablet give on tablet by mouth every morning (8:00 a.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the date of 11/18/2023 at 8:00 a.m. 07/25/2023: Spiriva Respimat 1.25 mg micrograms; inhale two puffs daily (8:00 a.m.). Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the date of 11/18/2023 at 8:00 a.m.) 11/07/2023: Isosorbide Mononit Extended Release 60 mg; take one by mouth every morning. Review of the November 2023 MAR revealed no documented evidence of the medication being administered on the date of 11/08/2023 at 8:00 a.m. 02/02/2023: Hydralazine 50 milligram tablet take on tablet by mouth three times daily (8:00 a.m., 1:00 p.m., and 8:00 p.m.). Review of the November 2023 MAR revealed no documented evidence of the medication being administered on the dates of 11/02/2023, 11/08/2023, 11/21/2023, and 11/22/2023 at 1:00 p.m. 10/06/2023: Pataday twice daily 0.1% daily drops apply one drop in each three times a day for 7 days (6:00 a.m., 2:00 p.m., and 10:00 p.m.). Review of the November 2023 MAR revealed no documented evidence of the medication being administered on the dates of 11/02/2023, 11/08/2023, 11/10/2023, 11/21/2023, and 11/22/2023 at 2:00 p.m., 11/09/2023 and 11/16/2023 at 6:00 a.m., 11/12/2023, 11/17/2023, and 11/25/2023 at 10:00 p.m. Review of the nurse's noted dated November 2023 revealed no documented evidence of the reason why resident #34 did not receive her medications as ordered by the physician. Resident #69: Review of the medical record revealed resident #69 was admitted to the facility on the date of 06/16/2023. Resident #69's diagnoses included in part, pain, unspecified dementia, unspecified severity and without behaviors, Addisonian crisis, pain, muscle wasting and atrophy, multiple sites, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set, dated [DATE] revealed resident #69 had a brief interview for mental status score of 15. A score of 13-25 indicated that resident #69 was cognitively intact with daily decision making. Review of the November 2023 physician orders revealed the following: 10/20/2023: Neurontin 100 mg capsule; take one capsule by mouth three times daily (6:00 a.m., 2:00 p.m., and 10:00 p.m.) until end of November then will evaluate effectiveness. Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the dates of 11/06/2023, 11/21/2023 and 11/22/2023 at 2:00 pm, 11/08/2023, 11/16/2023, and 11/25/2023 at 6:00 a.m., and 11/25/2023 at 10:00 p.m. 06/22/2023: Klonopin 0.5 mg tablet take one by mouth once daily at 2:00 p.m. Review of the November 2023 MAR revealed there was no documented evidence of the medication being administered on the dates 11/22/2023 and 11/24/2023 at 2:00 p.m. Review of the nurse's noted dated November 2023 revealed no documented evidence of the reason why resident #69 did not receive her medications as ordered by the physician. On 11/19/2023 at 4:15 p.m., S3Corporate Nurse was notified of the findings. S2Director of Nursing was present. After a review of the medical records for residents #18, #34, and #69, S2Corporate confirmed there was no documented evidence as to the reason why the residents did not receive their medications in accordance with the physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of policy and procedure, and interview, the facility failed to ensure that residents environment remains free of accident hazards as is possible by 1) staff leaving unidentified medications at bedside for 1(#6) of 6 (#1,#2,#2,#4,#5,#6) sampled residents and 2) leaving medication cart, unlocked and unattended with unidentified medications and cigarette lighters on top of cart and accessible to residents. Findings: 1. Review of the Facility's Policy for Administering Oral Medications revealed in part: Steps in the Procedure 21. Remain with the resident until all medications have been taken. Review of the medical record for resident #6 revealed an admission date of 08/16/2022 with diagnoses including fibromyalgia, muscle wasting, diabetes mellitus, vascular dementia, hypertension, hypothyroidism, depression, hyperlipidemia, and neuralgia. Review of the annual Minimum Data Set, dated [DATE] revealed the resident was independent with cognition for daily decision making and required assistance with activities of daily living. On 08/09/2023 at 8:30 a.m., observation of resident #6 revealed she was sitting on the side of the bed and two unidentified pills were observed in a medication cup on the bedside table. Further observation revealed the pills were unattended and accessible to the resident. On 08/09/2023 at 8:30 a.m. S4 Licensed Practical Nurse (LPN) was notified and she went into resident #6's room to retrieve the two unidentified pills. She confirmed the pills should not have been left at the bedside unattended. On 08/09/2023 at 9:00 a.m. S2 Director of Nursing (DON) was informed of the two unidentified pills left at the bedside. S2 DON revealed the pills should not have been left at the bedside unattended. 2. On 08/09/2023 at 8:33 a.m., observation of the 400 Hall medication cart revealed two medication cups of unidentified pills, totaling four pills on top of unlocked cart. Further observation revealed 2 cigarette lighters sitting on top of the medication cart. Observation revealed the unlocked cart, pills, and cigarette lighters were unattended and accessible to residents. On 08/09/2023 at 8:37 a.m., interview with S3 LPN confirmed that she was out of view of the medication cart and that the pills and cigarette lighters should not be accessible to residents when out of view of cart. Further interview with S3 LPN confirmed that the medication cart must be locked when out of view. On 08/09/2023 at 9:05 a.m. S2 DON was informed of the unlocked medication cart and the unidentified pills and cigarette lighters on top of the cart. S2 DON revealed that cart is to be locked and that pills are not to be accessible.

Based on record review and interview, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (#1, #3) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This was evidenced by 1) a licensed practical nurse administering a thyroid medication at the wrong time and with other medications to Resident #3 and, 2) a licensed practical nurse administering a medication to treat low blood pressure to Resident #1 within 3 hours of previous administration of the same medication. Findings: 1. Review of Resident #3's medical record revealed an admit date of 06/09/2022 with diagnoses that included in part .Hypothyroidism, Muscle Wasting and Atrophy. Review of Resident #3's August 2023 physician's orders revealed an order dated 06/09/2022 for Synthroid (medication used to treat low thyroid) 175 micrograms (mcg), take one tablet by mouth every day at 8:00 a.m. Observation of medication administration for Resident #1 on 08/07/2023 at 11:58 a.m. revealed S4 LPN (licensed practical nurse) administered Synthroid 175 mcg, 1 tablet, in addition with 10 other oral medications. Review of Resident #3's August 2023 Medication Administration Record (MAR) revealed S4 LPN documented that the Synthroid 175 mcg, 1 tablet, was administered on 08/07/2023 at 8:00 a.m. Interview on 08/07/2023 at 12:25 p.m. with S6 Nurse Practitioner revealed she was unaware that the Synthroid medication was being administered with other medications. She further stated that the Synthroid was ordered to be administered separately from other medications. 2. Review of Resident #1's medical record revealed an admit date of 04/27/2023 with diagnoses that included in part .Orthostatic Hypotension, Secondary Hypertension, Adjustment Disorder with Depressed Mood and History of Falls. Review of Resident #1's August 2023 physician's orders revealed an order dated 07/19/2023 for Midodrine HCL (medication used to treat low blood pressure) 10 mg tablet, take one tablet by mouth three times a day. (DO NOT HOLD) Review of Resident #1's August 2023 Medication Administration Record (MAR) revealed Resident #1 is to receive Midodrine, 10mg by mouth three times per day at 6:00 a.m., 12:00 p.m., and 8:00 p.m. Review of the MAR for Resident #1 revealed on 08/09/2023 the 6:00 a.m. dose of Midodrine was recorded as administered by S6 LPN at 5:04 a.m. Review of the MAR for Resident #1 revealed on 08/09/2023 the 12:00 p.m. dose of Midodrine was recorded as administered by S3 LPN at 8:00 a.m. Interview on 08/09/2023 at 8:37 a.m., S3 LPN confirmed that she administered Midodrine 10mg at 8:00 a.m. and that the medication was not to be administered until 12:00 p.m. Interview on 08/09/2023 at 9:05 a.m. with S2 DON confirmed that resident's #1 Midodrine should not have been administered at 8:00 a.m.

Based on observations and interviews, the facility failed to ensure staff practices were consistent with current infection control guidelines to prevent infection and cross contamination. The facility failed to ensure staff practiced proper hand hygiene after performing incontinence care for 1 (#98) of 1 (#98) residents observed for incontinence care. Findings: During an observation on 10/04/2022 at 10:00 AM, S10CNA (Certified Nurse Assistant) provided incontinence care for resident #98. After completing incontinence care, S10CNA failed to remove gloves and sanitize hands before proceeding to assist resident #98 out of bed to wheel chair. S10CNA continued to wear the contaminated gloves and assisted resident #98 with putting on shoes, opened resident #98's drawer and personal bag, moved items around in resident #98's drawer and personal bag and located resident #98's hairbrush and a hair tie. S10CNA then brushed resident #98's hair and tied it back without removing the contaminated gloves. During an interview on 10/04/2022 at 10:15 AM, S10CNA confirmed after completing incontinence care, she failed to remove her gloves and sanitize hands before proceeding to assist resident #98 with further tasks of daily living and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The failed practice was evident for 1 (#79) of 1 (#79) resident investigated specifically for edema. Findings: On 10/03/22 at 01:04 PM Resident # 79 observed sitting in a chair at her bedside with 2 plus edema to both feet. Resident # 79 reported she had edema from time to time to lower extremities due to poor circulation. On 10/04/22 at 10:00 AM, Resident # 79 was observed sitting on her bed with 2 plus edema noted to both feet. Record review revealed Resident # 79 was admitted to the facility on [DATE] with diagnosis that included anxiety disorder, localized edema, varicose veins of lower extremities and peripheral neuropathy. Review of Resident #79's most recent MDS (minimum data set) dated 09/05/2022 revealed Resident # 79 had a BIMS (brief interview of mental status) score of 14 which indicated she was cognitively intact. Review of Resident #79's active physician orders included an order dated 08/31/2022 for Torsemide (diuretic) 20 milligrams once daily. Review of Resident #79's September 2022 and October 2022 MARs (medication administration record) revealed Torsemide 20 milligrams had been given once daily as ordered since admission. There was no record of edema being monitored. During an interview on 10/05/2022 at 11:45 AM, S3Corporate RN (Registered Nurse) confirmed Resident # 79 had no record of edema monitoring and Resident # 79 should have been monitored for edema while receiving a diuretic.

Based on record review, observation, and interviews, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#58) of 5 (#58, 65, 86, 111, 119) sampled residents reveiwed for pressure ulcers. Findings: Review of the medical record for resident #58 revealed diagnoses including but not limited to Stage 3 pressure ulcer (PU) of left heel, congestive heart failure, type 2 diabetes with diabetic neuropathy, peripheral vascular disease, and morbid obesity. Review of resident #58's 08/18/2022 Minimum Data Set revealed a BIMS (Brief Interview for Mental Status) score of 12, which indicated moderate cognitive impairment. Further review revealed he required extensive one person assistance for most activities of daily living and was assessed to be at a high risk for pressure ulcers. On 10/03/2022 at 12:45PM, an observation revealed resident #58 had a kerlix dressing and specialized shoe on his left foot. Interview with resident #58 at this time revealed he developed a blister on his left heel at another facility and his doctor recently changed his wound care to twice a day. Resident #58 stated his left foot dressing ha not been changed at all this past weekend (10/01/2022-10/02/2022). On 10/05/2022 at 10:15AM, an interview with S9LPN (Licensed Practical Nurse)/Wound Care Nurse revealed she did not work this past weekend but she changed resident #58's dressing on Friday (09/30/2022). When the surveyor informed her that the resident reported his dressing was not changed this weekend, she confirmed she was aware of this on 10/03/2022. S9LPN/Wound Care Nurse stated when she was providing wound care for resident #58 on 10/03/2022, he had the same dressing on his left heel dated 09/30/2022. She realized the dressing had not been changed over the weekend which resulted in 4 missed dressing changes. S9LPN/Wound Care Nurse confirmed she did not report this to S2DON (Director of Nursing) and knew she should have. Review of resident #58's October 2022 Physician's Orders revealed the following treatment order for his left heel PU: clean Stage 3 wound with wound cleanser, pat dry, apply Acetic Acid (topical agent for wounds), cover with gauze, ABD (abdominal pads) pad, wrap with Kerlix (dressing) and tape twice daily until resolved. Review of resident #58's October 2022 Medical Administration Record (MAR) revealed documentation the above wound care treatment was provided for his stage 3 left heel PU on 10/01/2022 and 10/02/2022 at 4:00PM. Also review of resident #58's October 2022 Treatment Administration Record (TAR) revealed documentation the above wound care treatment was provided for his stage 3 left heel PU on 10/01/2022 and 10/02/2022 at 12:30PM. On 10/05/2022 at 2:50PM, interviews with S2DON and S3Corporate DON confirmed S9LPN/Wound Care Nurse should have reported that wound care was not provided for resident #58 for 10/01/2022 and 10/02/2022. S2DON and S3Corporate DON reviewed the above MAR & TAR and confirmed the nurse's should not have documented that wound care was provided for resident #58 on 10/01/2022 and 10/02/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#14) of 2 (#14, #21) residents investigated for position and mobility. Findings: On 10/03/2022 at 03:31 PM Resident #14 was observed in her bed with a contracture to her right hand without a splint or hand roll in place. On 10/04/2022 at 02:00 PM Resident # 14 was observed in bed with a contracture to her right hand without a splint or hand roll in place. On 10/04/2022 at 02:28 PM an observation of Resident # 14 was made with S4 LPN in Resident # 14`s room. S4 LPN confirmed Resident # 14 had a contracture to her right hand and did not have a splint or hand roll in her hand. S4 LPN further confirmed there was not a splint available in the room. Record review revealed Resident # 14 was admitted to the facility on [DATE] with diagnosis that included flaccid hemiplegia affecting right dominant side, contracture to right hand and lack of coordination. Review of Resident #14's most recent MDS (minimum data set) dated 09/29/2022 revealed a BIMS (brief interview of mental status) score of 3 which indicated severe cognitive impairment. Review of Resident #14's active physician orders revealed an order for Resident # 14 to have a right wrist splint for contracture management and to monitor skin every shift. Review of Resident #14's September 2022 and October 2022 medication administration records revealed documentation for every shift skin checks and management of right wrist splint for contracture management with the last documentation being from S4LPN at 8:00 AM on 10/4/2022 as being completed. During an interview on 10/05/2022 at 11:28 AM S2DON (director of nurses) confirmed Resident # 14 shouild have had a splint on her right hand as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to ensure that a resident's environment remains as free of accident hazard as is possible; and that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (#9) of 1 (#9) sampled residents reviewed for restraints. Findings: Review of the medical record for resident #9 revealed she was [AGE] years old with diagnoses including but not limited to muscle weakness and wasting, other abnormalities of gait and mobility, unspecified psychosis, and unspecified dementia with behavioral disturbance. Review of resident #9's Quarterly Minimum Data Set, dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 00, which indicated the resident was unable to complete the interview. Further review revealed she required extensive, 1 person assistance for most ADLs (Activities of Daily Living). On 10/04/2022 at 1:32PM, an observation revealed resident #9 was in the hallway near her room. The resident was in her wheelchair with a clear lap tray. Further observation revealed the resident's lap tray was not applied correctly. The Velcro straps were not in the designated slots on the lap tray and were tied in a slip type knot to the wheelchair armrests. The front of resident #9's lap tray was leaning slightly downward and it was not fitting securely to the wheelchair. An interview with S6CNA at this time revealed since the Velcro on the resident's lap tray was not working, she had been tying the Velcro instead of fastening the Velcro. S6CNA stated she had been doing this about a week and she had reported this to the resident's nurse. S7CNA and S8CNA also reported that resident #9's Velcro straps on her lap tray were tied in a slip type knot to the wheelchair armrests for approximately a week. On 10/04/2022 at 2:05PM, an interview with S5LPN, resident #9's nurse, revealed she was not aware that resident #9's CNAs tied the Velcro straps to the resident's wheelchair. She further revealed S6CNA just reported the above situation with the resident's lap tray to her today (10/04/2022). On 10/04/2022 at 2:30PM, the surveyor accompanied S2DON and S3Corporate RN to observe resident # 9's lap tray. An observation revealed the Velcro straps on the resident's lap tray were in the slotted areas of the lap tray and tied in a slip type knot to the armrest of her wheelchair. S2DON and S3CorporateRN confirmed that resident #9's lap tray was not applied correctly and should not have been tied to the armrest of resident #9's wheelchair.

Based on record review, observation, and interviews, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure a nurse administered medications in a safe manner for 1 (#37) of 34 initial pool residents. Findings: Review of resident #37's medical record revealed diagnoses including but not limited to neuralgia and neuritis, hypertension, Alzheimer's disease, type 2 diabetes mellitus, heartburn, and adjustment disorder with depressed mood. Review of resident #37's 07/21/2022 Quarterly Minimum Data Set revealed she had a BIMS (Brief Interview for Mental Status) of 15, which indicated no cognitive impairment. Further review revealed she required limited to extensive assistance for most activities of daily living. On 10/03/2022 at 9:45AM, an observation of resident #37 revealed she was in bed in her room. Further observation revealed there were 6 pills noted in a medication cup on her bedside table. There was 1 yellow capsule, 1 large white pill, 1 small tan pill, 1 small pink pill, 1 small white pill, and 1 blue oblong pill. An interview with resident #37 at this time revealed her nurse left the morning medications with her so she could take them with her breakfast. Resident #37 also stated that she did not eat her breakfast so she was saving the pills to take with her lunch. On 10/03/2022 at 10:50AM, the surveyor accompanied S4LPN to resident #37's room. The above 6 pills remained on resident #37's bedside table. S4LPN confirmed the medications were resident #37's 8:00AM medications and she left them for the resident to take after she ate her breakfast. S4LPN agreed she should not have left them unattended at the resident's bedside. Review of resident #37's October 2022 MAR (Medical Administration Record) revealed there was no documented evidence on 10/03/2022 the following 8:00AM medications for resident #37 were administered: Gabapentin (anticonvulsant) 300mg (milligrams) 1 po (by mouth) 3 times daily, Lisinopril (antihypertensive) 20mg 1 po twice daily, Aricept (for Alzheimer's disease) 5mg 1 po daily, Metformin HCL (antidiabetic) 500mg 1 po twice daily, Omeprazole DR (antacid) 40mg 1 po every day, Zoloft (antidepressant) 50mg 1 po every day, and Eliquis (anticoagulant) 2.5mg 1 po bid. On 10/03/2022 at 2:00PM, S1Administrator was informed that S4LPN left resident # 37's morning medications unattended at her bedside. On 10/05/2022 2:50PM, an interview with S2DON and S3Corporate Nurse confirmed S4LPN should not have left resident # 37's morning medications at her bedside. They also confirmed that S4LPN's actions resulted in missed morning medications for resident #37.