Based on observation, interview, and record review, the facility failed to ensure the MDS assessments accurately reflected the resident's status for 1 (Resident #1) of 3 sampled residents. Findings: Review of Resident #1's medical record revealed an admission date of 03/07/2025, with diagnoses including, in part . Cerebrovascular Accident and Dysphagia. Review of Resident #1's admission MDS with ARD of 03/14/2025 revealed, in part . a BIMS score of 3, indicating severe cognitive impairment. Review of Resident #1's Discharge Return Anticipated MDS with an ARD 04/03/2025 revealed, in part .Resident #1 did not have a mechanically altered diet. Review of Resident #1's Medicare 5-Day End of Part A Stay MDS with an ARD of 04/08/2025 revealed, in part .Resident #1 did not have coughing or choking during meals or when swallowing medications. Review of Resident #1's physician's orders revealed, in part . 1. a mechanical soft diet was ordered on 04/02/2025, 2. a pureed diet with nectar consistency for aspiration pneumonia was ordered on 04/07/2025, and 3. a chest x-ray (CXR) was ordered after Resident #1 choked while eating lunch on 04/02/2025 Review of Resident #1's current comprehensive care plan revealed, in part . 1. Pureed diet with nectar consistency, created on 05/12/2025 with an initiation date of 04/07/2025, and 2. Diagnosis of Aspiration Pneumonia, created on 05/12/2025 with an initiation date of 04/07/2025. Review of a facility report titled, Incidents by Incident Type, revealed Resident #1 had a Choking Incident on 04/02/2025. Resident #1's Choking Incident Report dated 04/02/2025 revealed, in part .resident choked while eating lunch and the Heimlich Maneuver was performed. The provider was notified and orders were to obtain a CXR and downgrade the Resident #1's diet to mechanical soft. Interview with S4MDS on 05/28/2025 at 3:25 p.m. confirmed Resident #1's Discharge Return Anticipated MDS with an ARD of 04/03/2025 did not indicate a mechanically altered diet, but should have. S4MDS confirmed Resident #1's Medicare 5-Day End of Part A Stay MDS with an ARD of 04/08/2025 did not indicate coughing or choking during meals, but should have.

Based on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for 1 (Resident #1) of 3 sampled residents. Findings: Review of the facility's policy entitled, Care Plan Process with a revision date of 12/2024, revealed, in part .the baseline care plan shall be developed within 48 hours of a resident's admission. Review of Resident #1's medical record revealed an admission date of 03/07/2025 with diagnoses including, in part . Cerebrovascular Accident and Dysphagia. Review of Resident #1's Baseline Care Plan revealed an effective date of 03/10/2025 at 3:06 p.m. Interview with S2DON on 05/28/2025 at 9:36 a.m. revealed Resident #1 was admitted to the facility on Friday, 03/07/2025 and the Baseline Care Plan was developed on Monday, 03/10/2025. S2DON confirmed Resident #1's Baseline Care Plan was not developed within 48 hours of admission to the facility, but should have been.

F657: CARE PLAN TIMING AND REVISION Based on observation, interview, and record review, the facility failed to ensure a resident's comprehensive care plan was revised after a quarterly assessment for 1 (Resident #3) of 3 sampled residents. Findings: Review of the facility's policy entitled, Care Plan Process with a revision date of 12/2024 revealed, in part .A well developed and executed assessment and care plan re-evaluates the resident's status at prescribed intervals using the RAI and then modifies the individualized care plan as appropriate and necessary. Review of Resident #3's medical record revealed an admission date of 10/17/2019, with diagnoses including, in part . Huntington's Disease, Altered Mental Status, Cognitive Communication Deficit, and Repeated Falls. Review of Resident #3's Quarterly MDS with an ARD of 03/25/2025 revealed, in part .a BIMS score of 15, which indicated intact cognition. Resident #3 had no fractures. Review of Resident #3's current comprehensive care plan revealed, in part .Acute Non-displaced Fracture at the tip of the nasal bones, initiated on 02/09/2025 and revised on 02/24/2025. Interview with S4 MDS on 05/28/2025 at 3:25 p.m. revealed Resident #3 was care planned for an active diagnosis of an Acute Non-displaced Fracture at the tip of the nasal bones. Interview with S5 MDS on 05/28/2025 at 3:38 p.m. revealed Resident #3's comprehensive care plan was not revised after the Quarterly MDS with an ARD of 03/25/2025. S5 MDS confirmed Resident #3's care plan should have been revised following the Quarterly MDS with an ARD of 03/25/2025 to reflect a history of a nasal fracture, but was not.

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of quality for 1 (Resident #3) of 3 sampled residents. The facility failed to ensure a swallowing assessment was completed for a resident who exhibited difficulty swallowing and coughing during meals. Findings: Review of the facility's policy entitled Therapy Screenings, revised 10/2019, revealed, in part .residents are to be screened when there is a referral from another discipline, or a change in function. High-risk residents (those who have had previous treatment or have a medical condition which may contribute to decreased function or impairment) are to be re-screened. A nurse who notes a functional decline in the long-term resident should complete a Nursing Therapy Progress Note. The therapy department should coordinate the therapy screening procedure to ensure completion within 48 hours. Review of Resident #3's medical record revealed an admission date of 10/17/2019, with diagnoses including, in part . Huntington's Disease, Altered Mental Status, and Cognitive Communication Deficit. Review of Resident #3's Quarterly MDS with an ARD of 03/25/2025 revealed, in part .a BIMS score of 15, indicating intact cognition. Review of Resident #3's orders revealed, in part .ST three times per week for 90 days for skilled services, ordered on 04/07/2025 Review of Resident #3's current comprehensive care plan revealed, in part .Resident #3 was at risk for impaired communication related to diagnosis of aphasia, revised on 03/24/2025. Interventions included ST consult as needed, initiated on 03/14/2025. Review of Resident #3's progress notes revealed, in part . On 04/16/2025 Resident #3 was coughing during breakfast. The Nurse Practitioner was notified and a CXR was ordered. On 05/27/2025 Resident #3 started coughing during lunch. Resident stated it went down the wrong way. Review of Resident #3's ST Notes revealed, in part .05/26/2025, 04/17/2025, and 04/16/2025 notes per S6SLP revealed no documentation regarding swallowing evaluation, difficulty swallowing, coughing, or choking. Observation in the facility's dining room on 05/27/2025 at 11:52 a.m. revealed Resident #3 was intermittently coughing while eating lunch. A nearby resident stated She's having trouble with her food and indicated to Resident #3. Resident #3's face was reddened and she was coughing. Review of Resident #3's meal ticket revealed she was served a regular diet. Resident #3 nods affirmatively when asked if she is having difficulty swallowing her food. Multiple residents were turned in their chairs, observing Resident #3 and expressing concern. A resident provided Resident #3 with a napkin. This surveyor notified S2DON Resident #3 was having difficulty swallowing and was coughing while eating her food. S2DON stated she has Huntington's. S2DON and S3LPN stood by the chair of Resident #3. S2DON told nearby residents She's coughing. She's okay. At 11:57 a.m. Resident #3 resumed consuming her regular diet. Occasional coughing noted. Observation of the facility's dining room on 05/28/2025 at 11:40 a.m. revealed Resident #3 had been served a mechanical soft diet. Interview of S9LPN on 05/28/2025 at 11:48 a.m. revealed Resident #3 had difficulty swallowing last week. Stated swallowing difficulty was due to a diagnosis of Huntington's Disease.S9LPN stated ST had recommended a mechanical soft diet this am. Interview with S6SLP and S7RehabD on 05/29/2025 at 10:15 a.m. revealed S6SLP was notified last week by nursing staff that Resident #3 was having some problems swallowing. S6SLP stated she did not evaluate Resident #3's ability to swallow because she had already had her 3 visits for the week. S7RehabD stated a resident could have an extra visit if nursing staff reported the resident was having difficulty swallowing. S7RehabD stated a resident with difficulty swallowing should have an evaluation of their swallowing by ST. S7RehabD confirmed Resident #3 did not have an extra visit or evaluation of her swallowing when nursing staff reported she was having difficulty swallowing. S6SLP stated Yesterday I passed her in the hall and noticed she was having trouble swallowing her pills, so we downgraded her diet to mechanical soft. S6SLP stated a swallowing evaluation had not been provided for Resident #3. Review of Resident #3's Multidisciplinary Screening Form dated 05/23/2025 reveals, in part .resident coughs, difficulty swallowing, and drools. ST to continue monitoring current diet, aspiration risk, and potential diet change during ST sessions. Interview with S6SLP on 05/29/2025 at 11:10 a.m. revealed Resident #3 did not receive ST services or ST evaluation on 05/23/2025. S6SLP confirmed the Multidisciplinary Screening Form was completed on 05/23/2025 with information reported by nursing staff. S6SLP confirmed Resident #3 was not seen by ST until 05/28/2025.

Based on interview and record review the facility failed to provide services that met professional standards for 2 (Resident #7 and Resident #19) of 33 residents reviewed by failing to administer medications properly. Findings: Review of the facility policy titled Administration of Medications with a revision date of 01/2024 revealed the following in part: Topical Medications - Purpose: Application of medication to the skin; Supplies: Topical Medication; As Indicated: Measuring Device; and Procedure: 2. Verify the physician order, comparing the medication label to the order verify the following: b. Right Dosage; 11. Apply the topical medication according to the directions. Resident #7 Review of Resident #7's Face Sheet revealed an initial admit date of 06/24/2024 and a readmit date of 10/18/2024. Resident #7 had the following diagnoses including: Pneumonia, unspecified organism; MRSA, unspecified site and UTI. Review of Resident #7's 10/2024 Physician Orders revealed the following: 10/18/2024 - Zyvox Oral Tablet 600 mg po BID for UTI until 10/28/2024. Review of Resident #7's 10/2024 e-MAR revealed the following including: 10/18/2024 - Zyvox Oral Tablet 600 mg give 1 tablet po BID for UTI until 10/28/2024. Resident #7 did not receive a dose of Zyvox on the evening of 10/21/2024. Interview on 10/30/2024 at 2:30 p.m. with S3ADON/IP confirmed Resident #7 was not given the evening dose of Zyvox and should have been. Resident #19 Review of Resident #19's EHR revealed an admit date on 09/23/2022 with the following diagnoses including: Osteoarthritis; Low Back Pain; Other lack of Coordination; and Pain. Review of Resident #19's 10/2024 Physician Orders revealed the following: 08/01/2024 - Voltaren Arthritis Pain External Gel 1% apply to bilateral extremities topically BID related to Pain, Unspecified. Review of Resident #19's 10/2024 EMAR revealed there was no specific dosage for Voltaren noted on the EMAR. Review of the Voltaren Packaging Insert revealed the following in part . You should always use the dosing card to measure out the correct dose. Interview on 10/30/2024 at 11:09 a.m. with S16 LPN confirmed there was no dosage for Voltaren Gel on Resident #19's MD orders or EMAR. S16 LPN stated she did not measure the gel when applying. S16 LPN stated it was always done that way as long as she had given Resident #19's medications. Interview on 10/30/2024 at 2:00 p.m. with S7 Corporate RN confirmed that there should be a dosage specified on the order and EMAR for Voltaren.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to provide a necessary communication aid for 1 (#80) of 1 Resident reviewed for communication. The total sample size was 33. Findings: Review of the facility's policy on 10/29/2024 at 10:27 a.m. titled Communication-Interpreter/Translation Services dated 06/2018 read in part . Purpose: To ensure effective communication with potential and current residents. Auxiliary aids will be provided as necessary to communicate with residents that have impaired sensory, manual, or sensory skills. The following is a list of auxiliary aids which may be available within the nursing home: Flash cards, Communication boards/books. Review of Resident #80's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . Dysphagia, Primary Generalized Osteoarthritis, Gastrostomy Status, and Hypertensive Heart Disease with Heart Failure. Review of Resident #80's Significant Change MDS with an ARD date of 10/13/2024 revealed Resident #80 had BIMS of 15 (Cognitively Intact). Resident #80 was dependent on staff for eating, oral hygiene, toileting, dressing, and transferring. Resident #80 required Substantial/ Maximal assistance from staff for personal hygiene. Review of Resident #80's Comprehensive Person Centered Care Plan revealed Resident had a communication deficit with unclear speech noted. Goal: Resident will be able to make needs known. Interview and observation on 10/28/2024 at 10:05 a.m. with Resident #80 revealed he had difficulty speaking and communicating his needs. Observation of Resident #80's room at that time revealed there was no communication aid/board to assist in communication with resident. Resident #80 shook his head no when surveyor asked if he could write down what he was trying to communicate. Resident #80 shook his head no when surveyor asked if he had a communication board to point to his needs. Resident #80 shook head yes when surveyor asked if he had trouble communicating his needs to staff. Observation on 10/28/2024 at 5:00 p.m. of Resident #80's room revealed there was no communication aid to assist in communication with resident. Interview on 10/29/2024 at 9:29 a.m. with S6 LPN revealed Resident #80 had difficulty speaking. S6 LPN stated she had trouble understanding Resident #80's needs most of the time. S6 LPN confirmed Resident #80 did not have a communication board, or any type of communication aid in his room to assist with communication. S6 LPN revealed Resident #80 would benefit from a communication board to assist in communication, because he was unable to write down his wants or needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #80 Review of Resident #80's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . Dysphagia, Primary Generalized Osteoarthritis, Gastrostomy Status, and Hypertensive Heart Disease with Heart Failure. Review of Resident #80's Significant Change MDS with an ARD date of 10/13/2024 revealed Resident #80 had BIMS of 15 (Cognitively Intact). Resident #80 was dependent on staff for eating, oral hygiene, toileting, dressing, and transferring. Resident #80 required Substantial/ Maximal assistance from staff for personal hygiene. Review of Resident #80's Comprehensive Person Centered Care Plan revealed Resident had an ADL self-care deficit related to muscle weakness, limited range of motion, and intervertebral disorder with radiculopathy. Review of Resident #80's active 10/2024 physician orders revealed: Fingernail/Toenail care monthly, clean and trim as needed every day shift. Interview and observation on 10/28/2024 at 10:05 a.m. with Resident #80 revealed thick 1/2 inch nails in length, with the right thumb nail approximately 1 inch in length. Resident #80 stated he would like his nails trimmed. Interview and observation on 10/28/2024 at 4:33 p.m. with Resident #80 revealed his nails were thick and approximately 1/2 inch in length, with the right thumb nail approximately 1 inch in length. Resident #80 stated he would like his nails trimmed. Interview on 10/28/2024 at 4:50 p.m. with S5 LPN confirmed Resident #80's nails needed to be cleaned and trimmed. S5 LPN stated S4 Treatment Nurse was responsible for trimming nails at least monthly, and she was unsure why Resident #80's nails had not been trimmed. Interview on 10/28/2024 at 5:00 p.m. with S4 Treatment Nurse revealed she was responsible for trimming resident's nails. Observation of Resident #80's finger nails with S4 Treatment Nurse confirmed Resident #80's nails needed to be trimmed, and had not been. Based on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 3 (#16, #24, and #80) of 4 (#16, #24, #32, and #80) Residents reviewed for ADL's. The total sample size was 33. Findings: Review of the facility's policy on 10/29/2024 at 10:27 a.m. titled Resident Quality of Care dated 08/2024 read in part . The policy of the facility is to establish a minimum acceptable level of daily care which shall include and involve the maximum utilization of the resident's capabilities; while providing the necessary assistance to accomplish the following: Partial bath- by resident, if able, assisted by staff, or performed completely by staff daily or as often as indicated by the physical condition of the resident. This shall include: Washing face, hands, axilla, and perineal/rectal area. Oral hygiene, dental care. Hair care including shampoo as needed. Nail care. Skin Care. Resident #16 Record review revealed Resident #16 was admitted to the facility on [DATE] with the following diagnosis that included: Muscle Weakness, Anorexia, Gastrostomy, and Type 2 Diabetes Mellitus. Review of Resident #16's Quarterly MDS with ARD of 09/24/2024 revealed a BIMS of 99 indicating severe cognitive impairment. Resident #16 was dependent on staff for personal hygiene and bathing. Review of Resident #16's care plan with a target date of 12/24/2024 revealed resident needed assistance with ALDs due to hemiplegia. Observations on 10/28/2024 at 1:08 p.m. and 10/29/2024 at 9:41 a.m. revealed Resident #16 was lying in bed, noticeable facial hair. Interview on 10/29/2024 at 9:50 a.m., with S10 LPN, revealed the CNAs are responsible for removing hair from the chin during ADL care. S10 LPN revealed Resident #16's bath days were Monday, Wednesday, and Friday. S10 LPN revealed Resident #16's facial hair should have been removed on Monday (10/28/2024). S10 LPN revealed there were no reports of Resident #16 refusing to have hair removed from her face. Interview on 10/29/2024 at 10:00 a.m., with S11 CNA, revealed Resident #16 received a bed bath on Monday (10/28/2024). S11 CNA confirmed Resident #16's facial hair was not removed on her bath day, because she forgot. Interview on 10/29/2024 at 10:05 a.m. with S3 ADON/IP confirmed Resident #16 had facial hair. S3 ADON/IP revealed Resident #16's facial hair should have been removed on her bath day and/or as needed. Resident #24 Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses that included: Cerebrovascular Disease, Shortness of Breath, Repeated Falls, Overactive Bladder, Anxiety Disorder, and Muscle Weakness. Review of Resident #24's Quarterly MDS with ARD of 10/17/2024 revealed Resident #24 had a BIMS of 3 indicating severe cognitive impairment. Resident #24 was dependent on staff for personal hygiene and bathing. Review of Resident #24's care plan with a target date of 01/17/2025 revealed Resident #24 needed assistance with ALDs due to muscle weakness. Review of Resident #24's Physician Orders revealed: 10/14/20024 fingernail/toenail care monthly, clean and trim as needed. Observation on 10/28/2024 12:53 p.m. revealed Resident #24 was eating lunch. Resident #24's fingernails were long with a thick brown substance under the nailbed. Observation on 10/29/2024 at 8:16 a.m. revealed Resident #24 was eating breakfast. Resident #24's fingernails were long with a thick brown substance under the nailbed. Interview on 10/29/2024 at 8:40 a.m. with Resident #24 revealed he wanted he wanted his fingernails cleaned and cut. Interview on 10/29/2024 at 8:44 a.m. with S12 CNA revealed Resident #24's fingernails were long and dirty. S12 CNA revealed Resident #24's fingernails should have been clean during ADL care. Interview on 10/29/2024 at 8:50 a.m. with S10 LPN confirmed Resident #24 fingernails were long and dirty. S10 LPN revealed the CNAs were responsible for cleaning and cutting fingernails. S10 LPN revealed there were no reports of Resident #24 refusing to have his fingernails cut. Observation on 10/30/2024 at 8:40 a.m. with S2 DON of Resident #24's finger nails revealed the fingernails were long, and had a thick brown substance under his nails. S2 DON confirmed Resident #24's fingernails needed to be cleaned and trimmed.

Based on record review and interview the facility failed to accurately submit mandatory direct care staffing information, based on payroll, 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 Excessively Low Weekend Staffing. Review of the Facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 10/30/2024 for the triggered dates on the FY Quarter 3 2024 (April 1- June 30) PBJ Staffing Report revealed the facility provided more hours than required of nursing coverage. Interview on 10/30/2024 at 10:50 a.m. with S1 Administrator revealed that an employee of the facility failed to enter staffing information for agency staff working in the facility. S1 Administrator stated the staff member no longer worked in the facility and he now performs the task.

Based on observation, record review, and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the recipe in regards to ingredients of the meal for 6 of 6 (#7, #30, #36, #40, #87, and #99) sampled residents who received a puree diet. Findings: Review of the facility's policy dated 05/2018 titled: Preparation and Service of Pureed Diets read in part . After preparation of all food items the cook, will use the specified serving, portion out the needed amount of food to puree from the stock of regular or therapeutic food items. Review of the recipe for 10 servings of pureed rotisserie chicken revealed the following: -10 4 oz. rotisserie chicken -3 tablespoon and 1/2 teaspoon of food thickener bulk -1 1/2 cup and 1 tablespoon of chicken stock Review of the recipe for 10 servings of pureed broccoli cauliflower blend revealed the following: -10 1/2 cup of broccoli cauliflower blend -3 tablespoon and 1teaspoon food thickener bulk Interview on 10/29/2024 at 9:00 a.m. with S8 Dietary Manager confirmed the facility had 6 residents who received a pureed diet. Observation on 10/29/2024 at 9:05 a.m. revealed S9 Dietary [NAME] prepared pureed rotisserie chicken without measuring the chicken according to the recipe. S9 Dietary [NAME] revealed she never measured food items. S9 Dietary [NAME] added an unmeasured amount of water and unmeasured amount of food thickener to the rotisserie chicken. S9 Dietary [NAME] then prepared pureed broccoli cauliflower blend. S9 Dietary [NAME] did not measure the broccoli cauliflower before adding to the blender. Interview on 10/29/2024 at 9:30 a.m., with S8 Dietary Manager revealed water was used when preparing pureed foods. S8 Dietary Manager confirmed S9 Dietary [NAME] did not follow the recipe for preparing pureed rotisserie chicken or pureed broccoli cauliflower, but should have. Interview on 10/30/2024 at 10:00 a.m. with S2 DON confirmed S9 Dietary [NAME] should have followed the recipe to prepare pureed rotisserie chicken and pureed broccoli cauliflower blend.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #5 and Resident #7) of 33 residents reviewed for infection control. The facility failed to follow proper infection control practices during wound care for Resident #5 and failed to properly isolate Resident #7, as ordered. Findings: Resident #5 Observation on 10/28/2024 at 1:07 p.m. revealed Resident #5 lying in bed. She had a wound vac in progress and stated she had a wound to her bottom. Resident #5 was on Enhanced Barrier Precautions due to wound, catheter, and tube feeding. Observation on 10/28/2024 at 4:13 p.m. revealed S4 Treatment Nurse arrived at Resident #5's room. S4 Treatment Nurse entered room wearing gloves only and no gown. S4 Treatment Nurse exited after a few moments and stated she would have to change Resident #5's wound vac and was going to gather her supplies. Observation on 10/28/2024 at 4:28 p.m. revealed in progress wound care to Resident #5. A paper drape was noted to Resident #5's bedside table with supplies placed onto drape. S4 Treatment Nurse, S13 RN and a CNA (who assisted with Resident #5's positioning) all put on gowns and gloves. At 4:28 p.m., Resident #5 was assisted to a right side-lying position by the CNA. S13 RN removed soiled under pad from beneath Resident #5 and placed the soiled linen on the foot of the bed. S4 Treatment Nurse removed dressing and wound vac apparatus while wearing gloves and gown. At 4:31 p.m., S4 Treatment Nurse removed soiled gloves and then removed a new pair of gloves from the box on Resident #5's bed side table. S4 Treatment Nurse asked for hand sanitizer from the treatment cart in hall outside Resident #5's room. Hand sanitizer was obtained and S4 Treatment Nurse applied hand sanitizer and placed the bottle on the bed side table. As S4 Treatment Nurse was putting on gloves, one of the gloves came in contact with her gown. At 4:36 p.m., S4 Treatment Nurse applied skin prep to skin around Resident #5's wound. At 4:37 p.m., S13 RN wearing gloves while lifting and observing supplies placed onto drape sheet, changed gloves without application of hand sanitizer. At 4:38 p.m., S13 RN exited room and quickly returned, wiping a pair of scissors with ungloved hands and a sanitary wipe. S4 Treatment Nurse and S13 RN then used the scissors to cut a dressing for application to skin around wound. Scissors were place directly onto bedside table, not on wound care field. Dressing was applied. At 4:42 p.m. S13 RN, wearing gloves, picked up scissors from uncovered surface of bedside table and used scissors to cut sponge-like product, which was then inserted into wound. Scissors were placed onto drape. At 4:44 p.m., S4 Treatment Nurse applied wound cover/clear dressing. S4 Treatment Nurse picked up scissors from the drape sheet and used them to cut a small opening in clear dressing overlying sponge-like wound packing. Scissors placed onto uncovered bedside table. Additional sponge-like product applied and covered with clear dressing. At 4:37 p.m., S4 Treatment Nurse picked up scissors from uncovered surface of bedside table and used to cut small opening in clear dressing. Tube inserted into opening and wound vac connected. Review of Resident #5's EHR revealed an admit date of 10/10/2024 with the following diagnoses including: Pressure Ulcer of Sacral Region, Stage 2 and Pressure Ulcer of Sacral Region, Stage 3. Review of Resident #5's 10/2024 Nurse Notes revealed the resident went to the Wound Care Center on a weekly basis for wound care/monitoring. Resident #5 had a wound vac in place to sacral area. Interview on 10/30/2024 at 2:18 p.m. with S4 Treatment Nurse and S13 RN revealed they were in agreement with findings in regard to inappropriate infection control methods used during wound care when reviewing wound care notes from 10/28/2024. Resident #7 Review of a Facility Policy dated 08/21 titled Isolation-Guidelines revealed the following including: Isolation procedures are designed to protect other residents, personnel, and visitors from the spread of a confirmed or suspected infection or contagious disease. Residents should be isolated or isolation procedures instituted whenever there is a risk of spreading infection. The methods used for controlling the infection's spread are determined by the characteristics of the pathogen. The mode used for infection control is determined by the usual route of excretion of the pathogen and its site or entry into the body. The health care team and visitors should be instructed on the importance and necessity of maintaining isolation techniques before entering the resident's room. Observation on 10/28/2024 at 11:00 a.m. revealed there was a sign on Resident #7s door that stated she was on Enhanced Barrier Precautions (EBP) and Isolation for Contact and Droplet Precautions. Start date of EBP was 10/21/2024. End date was 10/28/2024. There was signage that indicated that Resident #7 had a roommate. There was EBP supplies which included gloves, shoe covers and regular mask (not N95) hanging on Resident #7's room door. There were gowns noted in the inside of the resident's room. Review of Resident #7's Face Sheet revealed an initial admit date of 06/24/2024 and a readmit date of 10/18/2024. Resident #7 had the following diagnoses including: Pneumonia, unspecified organism; and UTI. Review of Resident #7's 10/28/2024 MD Orders revealed the following including: 10/11/2024 at 11:07 a.m. - Strict Isolation for droplet/contact precautions above standard precautions with private room, N95 mask, disposable dishes, related to MRSA, to prevent further spread of disease. Resident to remain in private room. All services provided in room to resident every shift for MRSA until 10/18/2024. 10/21/2024 - Contact/Droplet Isolation precautions above standard precautions with N95 mask, disposable dishes (if applicable), related to MRSA, to prevent further spread of disease. Resident to remain in room. All services provided in room to resident every shift for MRSA until 10/28/2024 23:59. Review of Resident #7's 10/2024 EMAR revealed documentation that the resident was not on isolation from 10/21/2024 - 10/23/2024. Review of Resident #7's 10/2024 Nursing Notes revealed the following including: 10/11/2024 at 11:44 a.m. - Doxycycline Hyclate Oral Capsule 100 mg 1 cap po BID related to MRSA, unspecified site until 10/18/2024. 10/11/2024 at 5:30 p.m. - Resident up to wheelchair eating supper in dining room on memory care unit. Continues antibiotic related to Pneumonia. 10/11/2024 at 5:39 p.m. - Doxycycline Hyclate Oral Tablet 100 mg give 1 tablet po related to MRSA, unspecified site for 7 days. 10/12/2024 at 1:30 p.m. - Antibiotic remains in progress due to Pneumonia 10/12/2024 at 11:00 p.m. - Continue Antibiotic for Pneumonia 10/13/2024 at 12:40 p.m. - Antibiotic remains in progress due to Pneumonia 10/13/2024 at 11:34 p.m. - Continue Antibiotic for Pneumonia 10/18/2024 at 1:00 a.m. - Readmit to facility, dx: UTI, Hypotension, Hypothermia 10/18/2024 at 5:00 a.m. - Zyvox 600 mg initial dose started tonight 10/18/2024 at 1:40 p.m. - Resident readmitted to facility, admit diagnosis, UTI, Hypotension. 10/20/2024 at 11:43 a.m. - Resident remains on Antibiotic for UTI 10/20/2024 at 7:01 p.m. - Antibiotic therapy in progress d/t UTI 10/20/2024 at 10:50 p.m. - Resident on Antibiotic for UTI 10/21/2024 at 3:01 p.m. - At 11:45 a.m. Resident awake, alert and stable up to wheelchair in memory care unit dining area eating lunch. Tolerated meds well along with antibiotic therapy of Zyvox 600 mg BID related to dx: UTI. 10/21/2024 at 5:25 p.m. - Resident up to wheelchair in dining room inside memory care unit. 10/22/2024 at 10:38 a.m. - At 8:30 a.m. Resident awake, alert and stable up to wheelchair in memory care unit dining area eating breakfast. Tolerated meds well along with antibiotic therapy of Zyvox 600 mg BID related to dx: UTI 10/22/2024 at 12:13 p.m. - Resident gaining former roommate back. Resident and Resident's RP made aware (Communication Note) 10/23/2024 at 2:41 p.m. - At 8:30 a.m. Resident awake, alert and stable up to wheelchair in memory care unit dining area eating breakfast. Tolerated meds well along with antibiotic therapy of Zyvox 600 mg BID related to dx: UTI 10/23/2024 at 7:58 p.m. - Antibiotic therapy in progress due to UTI 10/24/2024 - 2:06 a.m. - Antibiotic therapy remains in progress for UTI/MRSA. Remains in contact isolation 10/24/2024 at 6:51 p.m. - Antibiotic therapy in progress due to UTI 10/25/2024 at 2:58 a.m. - Antibiotic therapy remains in progress for UTI/MRSA. Remains in contact isolation 10/25/2024 at 4:58 p.m. - At 8:00 a.m. Resident awake, alert, and stable up to wheelchair in memory care unit dining area eating breakfast. Tolerated meds well along with Antibiotic therapy of Zyvox 600 mg BID related to dx: UTI 10/25/2024 at 6:00 p.m. - Continues Antibiotics related to UTI. Contact Precautions remains in place 10/26/2024 at 4:02 p.m. - Antibiotic in progress for UTI 10/26/2024 at 11:00 p.m. - Antibiotic for UTI 10/27/2024 at 8:15 a.m. - Antibiotic remains in progress related to UTI 10/27/2024 at 4:41 p.m. - Antibiotic in progress for UTI 10/27/2024 at 11:00 p.m. - Resident on Antibiotic for UTI 10/28/2024 at 10:44 a.m. - At 8:00 a.m. Resident awake, alert and stable up to wheelchair in memory care unit dining area eating breakfast. Tolerated meds well along with final dose of Zyvox 600 mg BID related to dx: UTI Review of the facility 10/28/2024 census revealed that Resident #7 had a roommate. Interview on 10/28/2024 at 10:45 a.m. with S14 CNA revealed Resident #7 was on isolation and that all staff /visitors were to wear full PPE including gown, gloves, mask, and shoe covers when entering Resident #7's room. C14 CNA stated she wore a regular mask, not a N95 mask when entering Resident #7's room. Interview on 10/28/2024 at 11:00 a.m. with S15 LPN revealed that Resident #7 was on contact/droplet isolation. S15 LPN stated that staff was to wear gowns, gloves, masks, and foot covers when entering room. She stated that Resident #7 had a roommate and that the roommate did not wear PPE when in the room with Resident #7. S15 LPN stated Resident #7's roommate was allowed to come in and out of Resident #7's room without practicing infection control measures; and mix with other residents in the memory care unit. S15 LPN stated that she was unsure of why the roommate did not have to follow isolation procedures and staff did, but stated that the S2 DON instructed her that it was okay for Resident #7 to have a roommate while on isolation. S15 LPN stated that she did not wear an N95 mask when providing care to the resident, but wore a regular mask Interview on 10/28/2024 at 2:00 p.m. with S2 DON revealed that according to the facility policy, if Resident #7 was able to perform self-care she could not have a roommate. She stated that since all care was provided by staff that the policy allowed Resident #7 to have a roommate. Interview on 10/30/2024 at 2:30 p.m. with S3 ADON/IP and S13 RN confirmed the above MD orders for isolation were not followed as ordered and should have been.

Resident #2 Review of Resident #2's medical records revealed an admit date d of 10/05/2023 with diagnoses that included: Displace Fracture of base of neck of left femur (02/16/2024), Generalized Muscle Weakness, lack of coordination, Unsteadiness on feet, Cognitive communication deficit, Unspecified Dementia, Chronic Atrial Fibrillation, Pain in left hip, and Bipolar Disorder. Review of Resident #2's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/22/2024, revealed a BIMS score of 3, indicating severely impaired cognition. Resident #2 required 1 person physical assistance with transfers. Review of Resident #2s Comprehensive Plan of Care with a review dated of 07/05/2024, read in part . At risk for falls due to a history of falls and unsteadiness on feet. Interventions: Ensure resident has, and wears proper footwear and clothing. Observation on 04/11/2024 at 11:44 a.m., revealed Resident #2 was observed with socks without grips or shoes. During an interview on 04/11/2024 at 11:40 a.m., S3 LPN confirmed Resident #2 was not wearing proper footwear, and was wearing socks without grips instead. Based on interview, observation and record review, the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #1 and Resident #2) of 4 sampled residents. The facility had a total census of 114. The facility failed to ensure a person-centered plan of care was: 1. Implemented for 1 resident (Resident #1) reviewed for transfers. The facility failed to ensure Resident #1 who required substantial/ maximal assistance was transferred by 2 person assistance according to his CPOC. 2. Implemented for 1 resident (Resident #2) reviewed for high risk of falls. The facility failed to ensure Resident #2 had proper footwear according to her CPOC. Findings: Review of the facility's policy and procedure on Lifting stated in part . Procedures: Blue - No Mechanical lift required - Hold hand or assist x 1. Yellow - Stand-n-Lift 1 or more person transfer. Red - Total Lift - 1 or more person transfer. This information will be posted in a designated area and on Resident's ADL documentation, indicating the color, red, green, blue or yellow with the transfer instructions. The appropriate color dot will be placed at the head of bed. Resident #1 Review of Resident #1's Medical Record revealed an admission date of 07/15/2022 with diagnoses that included Hemiplegia following Cerebral Infarction affecting right dominant side, Parkinson's Disease, Morbid Severe Obesity, Primary Generalized Osteoarthritis, Generalized Muscle Weakness, Lack of Coordination, unspecified Fracture of shaft of right fibula, initial for closure fracture (03/19/2024), Unsteadiness on Feet, Repeated Falls, Age-related Osteoporosis, other Muscle Spasm and Abnormalities of Gait and Mobility. Review of Resident #1's Quarterly MDS with an ARD of 03/05/2024 revealed a BIMS score of 03, indicative of severely impaired cognition. Functional limitation in ROM with bilateral impairment to upper and lower extremities. Resident #1 required substantial/ maximal assist for in part . bed to chair transfers. Review of Resident #1's Care Plan with a Target date of 06/05/2024 revealed history of falls with potential for further falls due to Parkinson's. Goal of staff will decrease risk of falls by providing safe environment. Approaches included in part . ADLs: Transfers - Resident #1 needs total assist x 2 assist with chair/ bed to chair transfers due to Osteoarthritis, Muscle Weakness and Parkinson's. 10/16/2023 Transfers status changed to blue x 2. Review of Resident #1's imaging report dated 03/19/2024 revealed in part . Procedure: Right ankle, 2 views. Findings: Examination: Radiographs of ankle. Indication: pain. Findings: The ankle demonstrates decreased bony ossification. Acute fracture of the distal fibula. No evidence of osteomyelitis. Impression: Acute Fracture of distal fibula, Osteopenia. Review of Physician's Visit Notes dated 03/22/2024 revealed subjective: Right distal fibula Fracture, No complaints. 1. Right distal fibula Fracture Plan: NWB (non-weight bearing), Ortho F/U, Conservative treatment. 2. HTN 3. Depression 4. Anxiety. Observation on 04/11/2024 at 8:40 a.m. revealed Resident #1 in room awake sitting up in his Geri chair with lower extremities elevated and an air boot noted to his right lower extremity. Resident #1 stated the aides had just got him out of bed. Resident #1's wife at bedside revealed resident visited with the doctor yesterday and came back with a boot. Resident #1 stated, I hurted my foot but don't know how I hurted it. Telephone interview on 04/11/2024 at 9:27 a.m. with S5 CNA revealed she was trained on the coding of resident's transfer procedures during her orientation and admitted that she did not look for the blue x2 assist dot code on signage posted on the wall over Resident #1's head of bed in his room. S5 CNA revealed she instead had asked Resident #1 how he is transferred when he said he can stand up. S5 CNA verified that she should have asked for assistance to transfer him but did not. S5 CNA confirmed that she assisted Resident #1 to standing position and then transferred him from the bed to his Geri chair by herself. Interview on 04/11/2024 at 10:35 a.m. with S2 DON revealed she had spoken with Resident #1 on the morning of 03/19/2024 when S6 CNA reported his right ankle swollen with discoloration. S2 DON stated she asked resident what happened and stated he had Hurted his foot but didn't know how he hurted it. S2 DON revealed that she initiated an investigation before the findings of x-ray and called S5 CNA to come in for conference due to noting that she had cared for resident last on the 10-6 shift. S2 DON revealed S5 CNA admitted to transferring Resident #1 by herself without assistance and should have asked for assistance and did not. S2 DON revealed S5 CNA was trained on proper transfers of Resident #1 and did not follow policy on the morning of 03/19/2024 and should have. S2 DON revealed that she suspended S5 CNA pending investigation because she had violated policy. S2 DON confirmed that S5 CNA transferred Resident #1 from his bed to his Geri chair by herself against policy and should not have. Interview on 04/11/2024 at 1:50 p.m. with S2 DON revealed that Resident #1 required 2 person assist and had a #2 blue dot on the signage posted over the head of his bed. S2 DON confirmed Resident #1 required to be transferred by 2 person assistance and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #97) of 1 residents sampled for dignity, by failing to ensure she was free of facial hair. Findings: Review of Resident #97's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part . Schizophrenia, Anxiety, Epilepsy, Malnutrition, and Anorexia. Review of Resident #97's Quarterly MDS with an ARD of 08/29/2023 revealed she had a BIMS score of 99 (unable to assess cognitive impairment). The MDS revealed Resident #97 required extensive 1 person physical assist for dressing, toileting, and personal hygiene. Review of Resident #97's care plan revealed she required extensive assistance with ADL's, and interventions included to assist Resident#97 with ADL's. Observation on 10/09/2023 at 12:45 p.m. revealed Resident #97 was noted to be unshaven with thick facial hair on her upper lip and long facial hair on her chin that was approximately 1 inch in length. Observation on 10/10/2023 at 8:56 a.m. revealed Resident #97 was noted to be unshaven with thick facial hair on her upper lip and long facial hair on her chin that was approximately 1 inch in length. Interview at the time of the observation on 10/10/2023 at 08:56 a.m. with S8 CNA revealed the CNA's are responsible for removing facial hair on bath days. S8 CNA stated Resident #97's scheduled bath days were Monday, Wednesday, and Friday. S8 CNA stated the CNA should have removed Resident #97's facial hair yesterday (Monday) when she received her bath. S8 CNA stated Resident #97 was always cooperative with staff when they assisted Resident #97 with personal hygiene. Interview on 10/10/2023 at 9:04 a.m. with S7 LPN revealed it was the CNA's responsibility to shave residents, and that was typically done on their shower days. S7 LPN confirmed Resident #97 should be free of facial hair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement an effective discharge planning process for 1 (#108) of 1 residents reviewed for choices. The facility failed to update the resident's discharge care plan to reflect the resident's legal inability to make choices related to discharge and failed to update the discharge care plan to accurately reflect the discharge wishes of the resident's POA. Findings: Review of Resident #108's clinical record revealed an admit date of 06/20/2023. Resident #108's diagnosis included COPD, Chronic Atrial Fibrillation, Secondary Parkinsonism, Hyperlipidemia, and Dementia. Interview on 10/09/2023 at 2:40 p.m. with Resident #108 revealed he had asked the people up front about being discharged home. Resident #108 stated he had improved and could now ambulate without assistance and could do many things for himself that he could not do before. Resident #108 stated he was a veteran, owned his own home, and his daughter functioned as his POA. Review of Resident #108's plan of care with target date of 09/27/2023 revealed in part Discharge planning. Resident plans to discharge home Resident will be able to demonstrate tasks for homecare by discharge. Multidisciplinary to do list with discharge conference involving resident family to discharge from facility. Community referral made. Review of physicians order dated 06/21/2023 revealed Full Code. Interdiction Papers. Review of Resident #108's social assessment dated [DATE] and documented by S3 Social Services revealed in part .Resident and RR plan for resident to remain long term in the facility. Interview on 10/10/2023 at 9:51 a.m. with S3 Social Services revealed Resident #108 was interdicted and the RP/POA wanted Resident #108 to stay in the facility. S3 Social Services stated she has discussed this with Resident #108 in the past. S3 Social Services revealed she had not documented the wishes of Resident #108's RP/POA regarding Resident #108 remaining in the facility long term and should have. Interview on 10/10/2023 at 1:00 p.m. with S2 DON revealed Resident #108's discharge care plan did not reflect that Resident #108 was interdicted and should have. S2 DON also confirmed Resident #108's discharge care plan did not accurately reflect the discharge plans for Resident #108, whose POA wished for the resident to remain in the facility, and should have.

Based on interview and record review the facility failed to ensure each Resident's drug regimen was free from unnecessary drugs. The facility failed to provide documentation of a clinical rationale to continue use of psychotropic medications for 2 (#43 and #58) of 6 (#14, #43, #58, #69, #82, and #94) sampled resident's reviewed for psychotropic medication usage. Findings: #43 Review of Resident #43's medical record revealed an admission date of 11/29/2019 with diagnoses that included in part . Cognitive Communication Deficit, Generalized Anxiety Disorder, Major Depressive Disorder, Bipolar disorder, and Vascular Dementia. Review of Resident #43's Quarterly MDS with an ARD of 09/21/2023 revealed Resident #43 had a BIMS of 9 (Moderate Cognitive Impairment). Resident #43 received Antianxiety and Antidepressant medications 7 out of 7 days. Review of Resident #43's Care Plan revealed Resident #43 had potential for altered mood state related to diagnosis of Anxiety. Interventions included to administer medications as ordered and evaluate on a routine basis for gradual dose reduction. Review of Resident #43's 10/2023 Physicians Orders revealed in part . Alprazolam 0.25mg 1 tablet by mouth three times a day for Generalized Anxiety Disorder. Zoloft 25mg 1 tablet by mouth daily for Major Depressive Disorder. Review of Resident #43's Pharmaceutical Consultant Report dated 01/06/2023 revealed the consultant pharmacist requested the physician to evaluate the use of the following psychotropic medications and to consider a dose reduction; Alprazolam 0.25mg three times daily, and Zoloft 100mg daily. The report stated if a dose reduction is not desired, CMS regulations require a clinical rationale as to why a dose reduction is contraindicated. Please provide the clinical rationale as indicated below. Review of the Pharmaceutical Consultant Report revealed there was no documentation of clinical rationale for continuance of Alprazolam 0.25mg. Review of Resident #43's Pharmaceutical Consultant Report dated 07/27/2023 revealed the consultant pharmacist requested the physician to evaluate the use of the following psychotropic medications and to consider a dose reduction; Alprazolam 0.25mg three times daily, and Zoloft 50mg daily. The report stated if a dose reduction is not desired, CMS regulations require a clinical rationale as to why a dose reduction is contraindicated. Please provide the clinical rationale as indicated below. Review of the Pharmaceutical Consultant Report revealed there was no documentation of clinical rationale for continuance of Alprazolam 0.25mg. Interview on 10/10/2023 at 4:18 p.m. with S6 Corporate QI Nurse revealed the process for reviewing the Pharmaceutical Consultant Reports was the facility faxed the physician a brief summary of medications needing to be addressed according to the Pharmaceutical Consultant Report, and the physician gave orders if changes were needed, or provided a rational for continuing the medication. S2 Corporate QI Nurse stated the physician would sign the Pharmaceutical Consultant Report when they came to facility. S6 Corporate QI Nurse confirmed the physician should have provided a documented rationale for continuing Resident #43's Alprazolam 0.25mg on 01/06/2023 and 07/27/2023 Pharmaceutical Consultant Report's. #58 Review of Resident #58's medical record revealed an admission date of 06/13/2022 with diagnoses that included in part . Anxiety disorder, Arthritis, and Hypertension. Review of Resident #58's Quarterly MDS with an ARD of 08/17/2023 revealed Resident #58 had a BIMS of 11 (Moderate Cognitive Impairment). Resident #58 received antianxiety medication 7 out of 7 days. Review of Resident #58's Care Plan revealed Resident #58 had potential for altered mood state related to diagnosis of Anxiety. Interventions included to administer medications as ordered and evaluate on a routine basis for gradual dose reduction. Review of Resident #58's 10/2023 Physicians Orders revealed in part . Buspirone HCL 10mg by mouth twice daily for Anxiety Disorder. Review of Resident #58's Pharmaceutical Consultant Report dated 07/27/2023 revealed the consultant pharmacist requested the physician to evaluate the use of the following psychotropic medication and to consider a dose reduction; Buspirone 10mg twice daily. The report stated if a dose reduction is not desired, CMS regulations require a clinical rationale as to why a dose reduction is contraindicated. Please provide the clinical rationale as indicated below. Review of the Pharmaceutical Consultant Report revealed there was no documentation of clinical rationale for continuance of Buspirone medication. Interview on 10/11/2023 at 12:45 p.m. with S2 DON confirmed the physician should have provided a documented rationale for continuing Resident #58's Buspirone 10mg on the 07/27/2023 Pharmaceutical Consultant Report.

Based on observation, record review, and interview the facility failed to ensure a resident received services in accordance with professional standards. The facility failed to ensure physician's orders were followed for the management of hypoglycemia for 1 (#1) of 1 residents sampled for hospitalization and failed to administer medications as ordered for 1 (#5) of 1 residents sampled for dialysis. Findings: #1 Review of Resident #1's clinical record revealed an admit date of 12/14/2010. Resident #1 had diagnosis that included Parkinsons, Type II Diabetes Mellitus, Hyperlipidemia, Hypothyroidism, Dementia and Bipolar Disorder. Review of Resident #1's yearly MDS assessment with ARD of 08/22/2023 revealed Resident #1 had a BIMS score of 8, indicating moderate cognitive impairment. Review of Resident #'1's comprehensive care plan revealed in part Diabetes Mellitus. History of elevated blood sugar secondary to effects of diabetes and is noncompliant with diet. History of diabetic ketoacidosis. Insulin dependent. Potential for low blood sugar. Approaches include: Accuchecks as ordered. Monitor for signs and symptoms of hypo/hyperglycemia, changes in LOC, confusion, weakness, diaphoresis, N/V, nurse will contact MD. Review of Resident #1's nurses' notes dated 10/07/2023 at 6:18 a.m. and documented by S4 LPN revealed Resident #1 was in a wheelchair in the facility dining room with stable vital signs and skin was warm and dry to touch. Review of Resident #1's nurses' notes dated 10/07/2023 at 12:01 p.m. revealed Resident #1 was observed slouching in bed S5 LPN. Resident #1 was noted to be hypoglycemic and S5 LPN began measures to increase Resident #1's blood sugar. Upon rechecking, Resident #1's sugar had dropped again. Resident #1 was transferred to a local hospital for treatment and evaluation. PCP and RP made aware. Review of Resident #1's October 2023 MAR revealed Resident #1 had a CBG of 184 at 6:00 a.m. on 10/07/2023 and was administered 50 units of Novolin 70/30 subcutaneously as ordered by S4 LPN. Review of Resident #1's October 2023 MAR also revealed that on 10/07/2023 at 7:06 a.m. Resident #1 received 1 ampule of Glucagon IM for a CBG of 43. Review of facility physician's standing orders revealed in part For glucose less than 60: If patient can tolerate oral fluids, give ½ cup orange juice and/or per peg and recheck CBG q15 minutes until blood glucose level is above 70mg/dl. Telephone interview on 10/11/2023 at 3:25 p.m. with S4 LPN revealed that on the morning of 10/07/2023 a CNA came and got her from the nurses station because Resident #1 was slumped over, shaking and sweaty in the facility dining. S4 LPN stated she checked Resident #1's blood sugar and it was in the 40's. S4 LPN stated she gave the resident an amp of Glucagon and then reported off to her relief nurse, S5 LPN. Interview on 10/11/2023 at 12:58 p.m. with S5 LPN revealed on 10/07/2023 S4 LPN gave Glucagon to Resident #1 for a 43 glucose before finishing her shift. S5 LPN stated she rechecked Resident #1's blood sugar during her morning rounds between 8:00 a.m. and 8:30 a.m. and Resident #1's glucose was 71. S5 LPN stated she checked Resident #1's glucose again about 30 minutes later and it was down to the 56. S5 LPN stated Resident#1 was alert and she gave orange juice at that time and called the doctor. S5 LPN stated she received the order to send Resident #1 to the hospital for evaluation. S5 LPN stated she checked Resident #1's glucose a third time about 30 minutes after the second CBG check and it was down to 36. S5 LPN stated at the time of the 36 CBG reading the ambulance had arrived and took over Resident #1's care. S5 LPN confirmed she did not document any of the followup CBG checks in Resident #1's record nor did she do q15 minute CBG checks on Resident #1 in accordance with Resident #1's Physician's Standing Orders and should have. Interview on 10/11/2023 at 2:14 p.m. with S2 DON revealed q15minute CBG's should have been initiated for Resident #1 after his 43 CBG check and then restarted after his 56 CBG check and were not.#5 Review of Resident #5's EHR revealed an admit date of 01/29/2023 with diagnoses including End Stage Renal Disease; Dependence on Renal Dialysis; Mild Protein-Caloric Malnutrition; and other Mechanical Complication of Surgically created Arteriovenous Fistula. Review of Resident #5's Care Plan with target date of 11/30/2023 read in part . End Stage Renal Disease - dialysis on Tuesday, Thursday, and Saturday. Review of Resident #5's Quarterly MDS with an ARD of 08/30/2023 revealed a BIMS of 3 (severe cognitive impairment) and Resident #5 was on dialysis. Review of Resident #5's 10/2023 Physician Orders revealed the following in part: 01/30/2023 - Resident to receive Dialysis on Tuesday, Thursdays, and Saturday at dialysis center 01/30/2023 - Vitamin C 500 mg po daily 01/30/2023 - Aspirin 81 mg po daily 01/30/2023 - Isosorbide Mononit ER 30 mg po daily 01/30/2023 - Sodium Bicarb 650 mg 2 tablets po daily 01/30/2023 - Metoprolol Tartrate 25 mg ½ tab po daily 02/24/2023 - Hydralazine 50 mg 1 po TID 02/24/2023 - Amlodipine Besylate 5 mg po at 4:00 p.m. 06/13/2023 - Renvela 800 mg po TID with meals Review of Resident #5's 09/2023 - 10/2023 eMAR revealed Resident #5 was not administered the following medications as follows: Renvela 800 mg po TID with meals - 11:00 a.m. - September 5th, 7th, 9th, 12th, 14th, 16th, 19th, 21st, 23rd, 26th, 28th, 29th (not a dialysis day) and 30th; and October 3rd, 5th, 7th and 10th. Renvela 800 mg po TID with meals - 4:00 p.m. - October 7th Amlodipine Besylate 5 mg q day at 4:00 p.m. - September 7th Hydralazine 50 mg po TID - 2:00 p.m. - September 9th and October 7th Sodium Bicarb 650 mg 2 tablets po daily - September 9th Metoprolol Tartrate 25 mg ½ tab po daily - September 9th Vitamin C 500 mg po daily - 8:00 a.m. - September 9th ASA 81 mg po daily - 8:00 a.m. - September 9th Isosorbide Mononit ER 30 mg po daily - September 9th Interview on 10/11/2023 at 12:05 p.m. with S2 DON confirmed the above medication dosages were missed and should not have been. S2 DON stated she did not know why Resident #5 had not received her prescribed medications on the days she received dialysis. Interview on 10/11/2023 at 3:14 p.m. with S6 Corporate revealed upon review of the facility's Standing Orders there was no standing order to hold medication on the days residents received dialysis. S6 Corporate stated there was no facility policy or order for Resident #5's medications to be held.

Based on observation and interview, the facility failed to ensure medications and biologicals were stored and labeled properly in accordance with currently accepted professional principles. The facility failed to: 1. Ensure blood glucose controls were properly labeled after opening on 2 of 4 medications carts. 2. Properly store vaccines in refrigerator for 1 of 1 medication storage rooms. Findings: 1. Observation on 10/11/2023 at 11:00 am of Medication Cart A with S9 LPN revealed the blood glucose control bottles were opened, but not individually dated with an open date. S9 LPN confirmed the blood glucose control bottles should be labeled with an open date. Observation on 10/11/2023 at 11:33 a.m. of Medication Cart with S2 DON revealed the blood glucose control bottles were opened, but not individually dated with an open date. S2 DON confirmed the blood glucose control bottles should be dated with an open date. Interview on 10/11/2023 at 12:05 p.m. with S2 DON revealed facility policy does not address how long blood glucose controls are good for once opened, so she would refer to the manufacture insert for guidance. Review of facility's package insert titled Assure Dose Control Solution read in part .Use the control solution within 90days of first opening. It is reccomended that you write the date of opening on the control solution bottle label as a reminder to dispose of the opened solution after 90 days. 2. Review of the facility's policy titled Influenza Vaccination Program for Employees and Residents read in part . Vaccine Storage and handling is critical to ensure vaccine antigens remain viable and can elicit an immune response in recipients. These are storage instructions. Place the vaccine in the center of the refrigerator, away from the freezer compartment, the back wall, and the bottom of the refrigerator where the temperature is usually colder. Observation on 10/11/2023 at 11:05 a.m. of the facility's medication storage room with S5 LPN revealed (10) single dose syringes of Prevnar-20 vaccines stored in the left bottom drawer of refrigerator, and (7) Boxes containing 10 single dose syringes of Flu- AD-Quadrivalent vaccines stored in the right bottom drawer of refrigerator. S5 LPN stated she did not know if the vaccines should be stored at the bottom of refrigerator. Interview on 10/11/2023 at 3:00 p.m. with S6 Corporate QI Nurse revealed she was not aware the vaccines were to be stored in a certain area of the refrigerator. S6 Corporate QI Nurse stated she thought as long as the vaccines were not stored in the door of refrigerator that would be okay.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents' assistive devices were maintained in good working condition for 1(#62) of 35 sampled Residents. Findings: Observation on 10/17/2022 at 10:35 a.m. revealed Resident #62 resting quietly in bed with a wheelchair positioned next to the front wall under the television. The wheelchair was noted to have missing cushion under right arm rest, with bilateral multiple tears on both arm rests, and a blue seat cushion with a large amount of dried brownish substance on the middle lower edge. Interview with Resident #62 at the time of the observation revealed he uses the wheelchair to move around the Facility. Resident #62 further stated the wheelchair armrests has been torn for a while (unable to recall how long) and was not sure when and if the seat cushion was removed and clean. Observation on 10/17/2022 at 11:40 a.m. revealed Resident #62 up in dining room in his wheelchair. The wheelchair remained with bilateral tear to the arm rests, and blue seat cushion with a large amount of dried brownish substance on it. Observation on 10/18/2022 at 10:45 a.m. revealed Resident #62 sitting in his room in his wheelchair. The wheelchair remained with bilateral tear to the arm rests, and blue seat cushion with a large amount of dried brownish substance on it. Observation on 10/18/2022 at 10:57 a.m. accompanied by S1 DON revealed Resident #62 smoking on the patio sitting in his wheelchair. S1 DON confirmed at the time of the observation that Resident #62's wheelchair was in need of cleaning, repairs and/or replacement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to encode and transmit a Discharge MDS (Minimum Data Set) Assessment within the required time frame for 1 Resident (#1) of 1 sampled Resident with an MDS record over 120 days old. The total sample size was 35. Findings: Review of the clinical record for Resident #1 revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Anemia, Anorexia, COVID-19, Hypothyroidism, Hyperlipidemia, Schizophrenia, Essential Primary Hypertension, Cognitive Communication Deficit and Dementia. Review of Resident #1's Discharge MDS with an ARD (Assessment Reference Date) of 08/24/2022 was encoded and transmitted on 10/18/2022. Interview on 10/18/2022 at 12:13 p.m. with S8 RN MDS revealed she was the Nurse Case Manager was responsible for submitting MDS resident assessments. S8 RN MDS stated she got distracted and forgot to encode and submit Resident #1's Discharge MDS Assessment. Interview on 10/18/2022 at 2:25 p.m. with S8 RN MDS confirmed Resident #1's Discharge MDS Assessment with an ARD of 08/24/2022 was not submitted until today (10/18/2022) after she was confronted by S9 RN Corporate Nurse earlier. S8 RN MDS further confirmed Resident #1's Discharge MDS Assessment was not encoded and transmitted within the required time frame, but it should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #65 Review of Resident #65's medical record revealed an admission date of 05/23/2022 with diagnoses that included Type 2 DM, Essential Primary Hypertension, Chronic Respiratory Failure with Hypoxia, Idiopathic Pulmonary Fibrosis, COVID-19, Cough and COPD. Review of Resident #65's Physician's orders for 10/2022 revealed: Oxygen at 2 lpm (liters per minute) per nasal cannula every night at bedtime. Notify MD if Oxygen saturation <95%. Oxygen at 2 lpm per nasal cannula as needed for shortness of breath. Notify MD if oxygen saturation <95%. Ipratropium Bromide/Albuterol Sulfate 0.5-3(2.5) mg/3ml one vial in nebulizer every 6 hours as needed for shortness of breath. Dx: Chronic Respiratory Failure with Hypoxia. Review of Resident #65's Quarterly MDS with ARD of 08/23/2022 revealed a BIMS score of 10 which indicated Resident had moderate cognitive impairment. Further review of the MDS revealed Resident required oxygen therapy. Review of Resident #65's Care Plan with target date of 11/23/2022 revealed a potential for shortness of breath with diagnosis of Chronic Respiratory Failure/ Pulmonary Fibrosis with order for oxygen at 2 liters per minute via nasal cannula at bedtime/ prn shortness of breath. Interventions included to change neb mask and tubing weekly, observe for shortness of breath as needed and administer oxygen as ordered. Observation on 10/18/2022 at 11:18 a.m. of Resident #65 revealed the Resident awake, sitting up in her recliner with oxygen in progress at 2l/min via nasal cannula per oxygen concentrator. Interview with Resident #65 at this time revealed she got a breathing treatment last night and she used oxygen every night and as needed during the day. Observation at this time of portable nebulizer machine on the nightstand with aerosol facemask and tubing that was not dated and not contained. Further observation revealed Resident #65's portable oxygen tank with undated tubing connected hanging uncovered on the back of the Resident's wheelchair. Interview on 10/18/2022 at 3:15 p.m. with S5 LPN confirmed Resident #65's facemask and tubing which was connected to the portable nebulizer machine not contained in a plastic bag and should have been. S5 LPN stated she was not aware of this because the night shift nurse changed out the oxygen tubing. S5 LPN further confirmed that the oxygen tubing connected to the portable oxygen tank was left open to air and should have been contained and was not. Based on observations, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (#74, and #65) of 2 residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly changed, labeled, and stored. The total survey sample size was 35. Findings: Review of the Facility's Policy and Procedure titled Infection Control Oxygen Equipment Cleaning read in part: Use disposable tubing, masks, and cannula for patients receiving oxygen therapy. This equipment is to be discarded as this procedure dictates. 5. Pre-filled humidifiers are to be dated and replaced when the water level is insufficient .but not less than once per month. 6. Refillable humidifiers should be washed every 72 hours with distilled or sterile water and dated. 7. Tubing should be replaced every 7 days. 8. Masks should be replaced every 7 days. 9. Cannula should be replaced every 7 days. 10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the Resident's name and date. Review of the Facility's Policy and Procedure titled Nebulizer read in part: Cleaning Nebulizers 4. Air dry parts on clean paper towels. Store in clean plastic bag. #74 Review of Resident #74's EHR revealed she was admitted to the facility on [DATE] with Admitting Diagnoses of Epilepsy Unspecified Intractable without Status Epilepsy Epilepticus, GERD, Type 2 Diabetes Mellitus with Hyperglycemia, Depressed, Cor Pulmonale, and Anorexia. Review of Resident #74's October 2022 Physician Orders revealed: O2 @ 3L/min per nasal cannula continuously * Notify MD if O2 Sat. Below 95%.* Ipratropium- Albuterol 0.5 -3(2.5) mg/3 ML inhale 3 ml per neb. 3 times a day. Review of Resident #74's Care Plan revealed COPD/Potential for SOB/Respiratory complications with a target date of 12/02/2022 with approaches that included change neb mask and tubing once weekly, change oxygen tubing once weekly. Observation on 10/17/2022 at 2:40 p.m. revealed Resident #74 resting quietly in bed receiving supplemental oxygen in progress at 3 LPM (Liters per minute) via nasal cannula. There was no date noted on the nasal cannula and humidifier bottle. Further observation revealed an aerosol mask attached to tubing and a nebulizer machine open to air and undated on the resident's nightstand. There was an empty plastic zip-lock bag on the night stand dated 10/08/2022. Interview with Resident #74 on 10/17/2022 at 2:42 p.m. revealed she uses the oxygen continuously and uses the nebulizer facemask 3 times per day. Observation on 10/18/2022 at 12:30 p.m. accompanied by S2 DON revealed Resident #74's nasal cannula, and humidifier bottle remained in use and undated. Further observation revealed an aerosol mask attached to tubing and nebulizer machine remained open to air and undated on the resident's night stand. An interview conducted on 10/18/2022 at 12:32 p.m. with S2 DON confirmed the nasal cannula, humidifier bottle, and the aerosol mask were undated and unused equipment should be stored in a ziploc bag and Resident #74's were not. S2 DON further confirmed that the cannula, and aerosol mask should have been changed out weekly. S2 DON stated she was unable to determine when the cannula, humidifier bottle, and aerosol mask had been changed because they were not dated and should have been.

Based on observation, interview, and record review the facility failed to ensure the medications were stored and labeled properly in accordance with professional principles. The facility failed to ensure expired medications were not available for use/administration to residents, and there were no loose pills on 2 of 2 medication carts observed. The facility failed to ensure multi-dose vials were properly labeled after opening for 1 of 1 medication storage room. Findings: Review of the facility's policy titled Medication Labeling revealed in part Medications in multiple dose vials (e.g., Insulin) or containers (e.g., bulk liquids) must have a label indicating the date the vial or container was first opened or used. Medication storage shall meet all applicable federal, state and local guidelines. Observation on 10/19/2022 at 12:00 p.m. of the Hall A medication cart accompanied by S7 LPN revealed it contained the following items: (24) ampules of Refresh Plus lubricant eye drops with an expiration date of 05/2022, (3) Biscodyl 10mg suppositories with an expiration date of 08/2022, (6) Hemorrhoidal suppositories with an expiration date of 05/2022, (1) 2 ounce tube of Hemorrhoidal cream with an expiration date of 03/2022 and 1 loose pill. Interview with S7 LPN at the time of observation confirmed findings. Observation on 10/19/2022 at 12:30 p.m. of the Hall B medication cart accompanied by S5 LPN revealed it contained the following items: (2) opened 15 ml bottles of sterile eye drops that expired on 09/2022 and 21 and 1/2 loose tablets between the first and second drawers. Interview with S5 LPN at the time of observation confirmed the findings. S5 LPN stated it was the responsibility of all nurses working the medication cart to check dates on medications and discard loose pills. Observation on 10/19/2022 at 1:45 p.m. of the facility medication storage room refrigerator revealed it contained (1) opened, undated 5 ml multi-dose vial of Tuberculin purified protein. Further observation of the medication storage room revealed (1) opened, undated 10 ml multi-dose vial of Lidocaine HCL 100mg/ml. Interview on 10/19/2022 at 1:51p.m. with S4 LPN confirmed the above findings. S4 LPN stated that when a nurse opens a new vial of medication it is their responsibility to date the vial. Interview on 10/19/2022 at 3:00 p.m. with S2 RN DON revealed all nurses were responsible for ensuring there are no expired medications or loose pills on facility medication carts.