**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/16/24 at 10:00 a.m., a surveyor met with Resident #356 in their room. Resident #356 was admitted on [DATE] with a new Right Below the Knee amputation. Resident #356 stated that she/he fell out of bed the other day reaching for the call bell and hurt their left knee. Stated that the bed was too small and it was difficult to move around in the bed. The resident is 6 feet 2 inches. The surveyor observed that Resident #356's upper torso fills the width of the bed and with the head of the bed elevated their leg cannot be straightened. Resident #356 stated she/he had spoken with staff about the size of the bed. Record review of Resident #356's electronic medical record (EMR) revealed a fall out of bed on 12/11/24 due to reaching for the call bell. No mention was made regarding the size of the bed. An x-ray was obtained for left knee pain following the fall. On 12/17/24 at 12:40 p.m. a surveyor met with Resident #356 in their room and was told that they almost fell out of bed again this morning but managed to catch themselves on the overbed table. On 12/17/24 at 1:13 p.m a surveyor met with RN#1 regarding the size of Resident #356's bed. RN#1 stated they were unaware of any issues with the bed. On 12/17/24 at 1:30 p.m., a surveyor met with the Director of Nursing and was told that they were unaware the bed for Resident #356 was an issue. Stated that anyone can request a larger bed for a resident. Confirmed that a bed assessment was completed upon admission with no issues noted. Based on interviews, observations and record reviews, the facility failed to meet the reasonable needs of residents in the areas of beverage choices and bed size for 2 out of 16 residents screened for accomodation of needs (Resident #42 and Resident #356) Findings: 1. On 12/17/24 at 1:30 p.m., during a resident council meeting, Resident #42 complained that she cannot get Ginger Ale to drink unless the nurse calls the Kitchen and says that the resident is sick. On 12/18/24 at 11:50 a.m., a surveyor asked the staff on [NAME] Unit if they had ever been told that the residents could not have Ginger Ale unless the resident was ill? Medication Technician (MT) #1 and Certified Nursing Assistant (CNA) #1 stated that they have both been told that. When we call to the Kitchen and ask, we have been told that residents cannot get Ginger Ale unless they are sick. On 12/18/24 11:45 a.m., a surveyor asked the Food Service Director if the residents can get Ginger Ale. He stated that if their diet allows them, they can have Ginger Ale. On 11/18/24 at 12:45 p.m., In an interview with Food Service Director and Director of Operations of Health Care Services the finding of lack of Ginger Ale being provided to the residents was confirmed with them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 of 2 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Residents #91). Finding: Resident #91 was admitted to the facility on [DATE] with diagnosis of Major Depressive Disorder and Suicidal Ideations. Resident #91's clinical record contained a PASRR Level I determination letter dated 8/27/24 that stated further PASRR evaluation was not required due to a Time Limited Waiver of 30 days. Resident #91 had a suspected or confirmed PASRR Condition: Mental Health Disability. Resident #91 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after the Residents stay changed from short-term to long-term. On 12/17/24 at 2:15 p.m., in an interview, the Licensed Social Worker confirmed that Resident #91 has been at the facility for longer than 30 days and the facility did not submit a new PASRR Level I to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, interviews, and record review the facility failed to complete an personal property list, identify, and assist resident to get new eye glasses when they were lost for 1 of 41 resident reviewed during survey. Findings: Review of the facility policy titled Personal Property: Patient's revised on 8/15/23 states that personnel will identify and record the patient/patient's belongings upon admission to a center Any loss or breakage of a patient's personal item will be documented on the property loss form be the person receiving the report, and then referred to the Administrator . Administrator or designee will investigate the lost item. On 12/16/24 at 11:06 a.m., during an interview with Resident #63, stated his/her glasses have been missing for several months. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating he/she s cognitively intact. Reviwe of quarterly Minimum Data Set (MDS) dated [DATE], Section B1200 was checked yes, that Resident #63 wears glasses. Review of nursing documentation on 4/7/23 shows Resident #63 wears glasses. Review of care plan meeting notes, dated 6/18/24, shows that Resident #63 enjoys watching T.V. On 12/17/24 at 2:00 p.m., during an interview Resident 63 states that she is unable to see the T.V. without his/her glasses. On 12/17/24 at 2:10 p.m., during an interview with CNA #2, who stated that she saw Resident #63 wearing glasses a few months ago. On 12/17/24 at 2:20 p.m., during an interview with the Registered Nurse Manager of the second floor, stated that when residents are admitted to the facility an inventory sheet has to be completed. She also discusses that if a resident advises staff of a missing item an incident report is to be filled out. On 12/17/24 at 2:13 p.m., during an interview with the Director of Nursing, it was confirmed that no inventory sheet , incident report was filled out for Resident #63. In addition, the facility did not assist Resident #63 with obtaining new glassess after they were lost.

Based on Interviews and record reviews, the facility failed to prevent a decrease in the Range of Motion (ROM) and/or mobility for 2 of 11 residents screened for maintenance of physical abilities following discharge from physical/occupational therapies. (Resident #45 and Resident #500) Findings: 1. On 12/18/24 at 10:13 a.m. a surveyor reviewed a binder provided by therapy services with Restorative Nursing Program Goals Sheets for residents discharged from Physical and/or Occupational therapy. This binder contains the after therapy plans recommended to maintain the physical abilities the resident achieved during therapy. A surveyor located a plan for Resident #500 in this binder, dated 7/9/24, that stated: Ambulate with walker, gait belt and wheelchair follow 1-2 times a day as patient allows. Have patient do lower extremity home exercise program once a day as patient allows (program in patient room). Record review of Resident #500's care plan failed to find the above program as an intervention. Facility was unable to provide any documentation that the above program was followed or the reason for not following. Record review of Electronic Medical Record (EMR) indicated that Resident #500 experienced falls on 8/28/24 and 9/2/24 and was once again referred to Physical therapy on 9/3/24. 2. On 12/18/24 at 10:30 a.m., a surveyor interviewed Resident #45 and learned she/he does not get to walk every day or perform exercises since ending therapy last summer. I'm noticing that I'm more weaker. Resident #45 Restorative plan dated 6/5/24 states Ambulate with CNAs or Restorative CNA daily with walker and gait belt. Encourage patient to perform lower extremity home exercise program Record review of Resident #45 care plan failed to show the restorative plan as an intervention. Facility was unable to provide documentation that the above program was followed or the reason for not following. On 12/18/24 at 10:39 a.m., a surveyor interviewed Certified Nursing Assistant (CNA) #4 and learned that while she/he was trained to be a restorative aide (RA) in addition to a CNA, it was rare she/he was able to perform the RA role. I usually have a CNA assignment and can't do the restorative plans. Confirmed that therapy went over the restorative plans with him/her as shown by his/her signature on the plans. On 12/18/24 at 11:48 a.m., a surveyor interviewed CNA#3 and learned she/he does not have time to assist residents with exercise programs or range of motion beyond getting dressed and undressed. She/he was unaware of any exercise programs for residents. Residents are lucky to get a walk to the bathroom in the morning. CNA#3 was working with Resident #45 today and was unaware of an exercise or ambulation plan. On 12/18/24 at 12:35 p.m., a surveyor interviewed a Unit Manager and learned the recommendations are not added to the care plan because there is no restorative nursing program due to lack of staffing. Confirmed that ambulation and range of motion were important nursing tasks to prevent falls, contractures, loss of range of motion, pressure ulcers, circulation and breathing difficulties. A surveyor reviewed the Facility Assessment for the facility and found under A.1. Function - Care Requirements Facility provides Mobility/fall prevention: Transfers, ambulation, restorative nursing, contracture prevention/care; supporting resident independence in doing as much of these activities by himself/herself. On 12/18/24 at 2:24 p.m. a surveyor reviewed the above with the Administrator.

Based on facility policy, observations, and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 2 residents reviewed for respiratory care (Resident 98 and 405). Findings: Review of facility procedure titled Oxygen: Nasal Cannula last revised on 8/7/23 states Date and store cannula in a treatment bag when not in use. On 12/16/24 at 1:09 p.m. and on 12/17/24 at 7:48 a.m., observation of Resident 98's nebulizer tubing stored on bedside table. On 12/16/24 at 2:36 p.m. and on 12/17/24 at 7:44 a.m., observation of Resisent 405's oxygen tubing stored under the oxygen concentrator handle. 12/17/24 3:42 p.m., during an interview with the Director of Nursing, the above information was confirmed.

Based on review of the Quality Assessment and Assurance (QAA) attendance sheets and interview, the facility failed to ensure that an Infection Preventionist attended 2 of 4 quarterly QAA meetings. Finding: A review of the quarterly QAA meeting attendance sheets indicated that an Infection Preventionist did not attend the 7/25/24 and 10/31/24 quarterly QAA meetings. On 12/18/24 at approximately 9:00 a.m., in an interview with the surveyor, the Administrator stated, she does not know why the Infection Preventionist (I/P) was not at the July meeting, but she left the facility in mid-October, so she was not at the October meeting. Since that time there has not been anyone in that role. A new I/P has been hired. She was just here on Monday to finalize her position. The above was confirmed with the Marketing Clinical Advisor on 12/18/24 at 2:00p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #405 was admitted to the facility on [DATE]. Review of Resident #405 clinical record lacked evidence of an advance directive being offered or completed. 3. Resident #306 was admitted to the facility on [DATE]. Review of Resident #306's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. On 12/17/24 at 3:25p.m. The social worker stated that this resident did not have advance directive paperwork given to her because she was out on leave, and it was not done. Based on record reviews and interview, the facility failed to ensure that the resident and/or resident representative written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate and advanced directive, was completed for 4 of 10 residents reviewed for advanced directives. (Residents #70, #90, #306, and #405) Findings: 1. Resident #70 was admitted to the facility on [DATE]. Review of Resident #70's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Resident #90 was admitted to the facility on [DATE]. Review of Resident #90 's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. On 12/17/24 at 3:25 p.m., in an interview, the Licensed Social Worker confirmed the Resident's clinical records did not include evidence that the residents and/or representatives were asked or offered and refused assistance filling out an advanced directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 7 of 7 units ([NAME], [NAME], [NAME], [NAME], [NAME], [NAME] and [NAME]) and the Activity Room for 1 of 1 facility tour. Findings: On 12/19/24 from 8:05 a.m. to 8:40 a.m., 2 surveyors conducted an Environmental Tour with the Maintenance Director, the Director of Nursing and the Administrator in which the following findings were observed: [NAME] Unit(100s) - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. The room heating unit had a cracked/broken top plastic grill with rough edges. The bathrooms walls were marred/marked with black marks. - Resident room [ROOM NUMBER] - The bathroom floor was heavily soiled with dirt. - Resident room [ROOM NUMBER] - The caulking around the base of the toilet was dirty. The privacy curtain was missing hooks and hanging down and in disrepair. - Resident room [ROOM NUMBER] - The ceiling is dirty and has holes in it where a curtain track used to be. [NAME] Unit (200s) - The linen closet had linen and trash/debris on the floor. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. - Resident room [ROOM NUMBER] - The walker had white nursing tape on the cross brace holding an arm rest attachment secure. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. [NAME] Unit(300s) - Resident room [ROOM NUMBER] - The closet had a ceiling tile missing. - Resident room [ROOM NUMBER] - There was a bed pan and a urinal stored behind the toilet with the bed pan tucked in between toilet and wall. There were fruit flies observed in the room. Activity Room- The activity room doors had chipped/missing paint and black marks on them. [NAME] Unit(500s) - The linen closet had linen and trash/debris on the floor. - Resident room [ROOM NUMBER] - There was a dried brown substance next to the head of the bed #1. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. - Resident room [ROOM NUMBER] - There was a large amount of a dried pink substances on the floor to the left of bed #1. - Resident room [ROOM NUMBER] - The bathroom had a broken ceiling tile sitting on the back of the toilet. The caulking around the base of the toilet was dirty. The bathroom floor tiles, around the toilet, have a light brownish substance coming up between the seams and the floor is dirty. The sink is dirty. The room walls had chipped/missing paint exposing sheetrock. - Resident room [ROOM NUMBER] - The wall thermostat was missing the cover exposing the wires. The sit-to-stand patient lift, in the hallway, had food and debris in the foot base area and dried liquid residue on the back of the kneepads. [NAME] Unit(600s) - The linen closet had linen and trash/debris on the floor. - The dining room window is fogged and hard to see out. - The table fan on the windowsill was dusty/dirty. [NAME] Unit (700s) - The linen closet had linen and trash/debris on the floor. - Resident room [ROOM NUMBER] - The room had a very strong odor of urine that extended down the hall past two other rooms even with the room door closed. - Resident room [ROOM NUMBER] - The ceiling, directly next to the room air vent, was soiled with dust/dirt. [NAME](800s) - Two ceiling tiles around the dining room ceiling air conditioning unit were dusty/dirty. - The storage room had linen and trash/debris on the floor. - The shower room walls had caulking, in the grout areas between the tiles, around the base of the room that had a black substance on it. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. The bathroom ceiling light had debris in it. On 12/19/24 at 8:40 a.m., in an interview, the Maintenance Director, the Director of Nursing and the Administrator confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 3 of 3 observations for 2 of 4 days of survey (12/16/24 and 12/18/24). Findings: The Safety Data Sheet for Clorox Healthcare Bleach Germicidal Wipes noted the following: 4. First Aid Measures Eye contact: Rinse thoroughly with water as necessary. If symptoms persist, call a physician. Skin contact: Wash with soap and water. If skin irritation persist, call a physician. Inhalation: Remove to fresh air. If breathing is difficult, trained personnel should give oxygen. If symptoms persist, call a physician. Ingestion: Drink one to two glasses of water. Get medical attention if symptoms occur. The Safety Data Sheet for Pure Bright Germicidal Ultra Bleach noted the following: 4. First Aid Measures Eye contact: Immediately flush with plenty of water. After initial flushing, remove any contact lenses and continue flushing for at least 15 minutes. Skin contact: Wash skin with soap and water. If symptoms persist, call a physician. Inhalation: Remove to fresh air. Ingestion: Do not induce vomiting. Clean mouth with water and drink afterwards plenty of water. If symptoms persist, call a physician. 1. On 12/16/24 at 10:25 a.m., a surveyor observed an unsecured 1 pound 10 ounce container of Bleach Germicidal Wipes stored on top of a soiled utility cart in the unlocked shower room. On 12/16/24 at 10:30 a.m., in an interview, [NAME], LPN #1 confirmed the finding and stated that there were confused and compromised residents that can move around the unit and access this room even in their wheelchairs. On 12/16/24 at 11:18 a.m., a surveyor discussed the finding with the Director of Nursing. 2. On 12/16/24 at11:59 a.m., a surveyor observed in the [NAME] unit the shower room, three(3) unsecured 1 pound 10 ounce containers of Bleach Germicidal Wipes in the unlocked shower room. On 12/16/24 at 12:02 p.m., in an interview, the Director of Nursing confirmed the chemicals were being stored in the unsecured and unlocked [NAME] shower room. She removed the chemicals and confirmed that there were confused and compromised residents that can move around the unit and access this room even in their wheelchairs. 3. On 12/18/24 at 10:50 a.m., a surveyor observed in the [NAME] unit shower room a 12 ounce spray bottle marked Bleach and Water. The bottle had no labeling and the ratio of bleach to water was unknown. On 12/18/24 at 11:00 a.m., in an interview, the Administrator confirmed that the bleach/water spray bottle was not labeled appropriately and it should have been secured and stored behind a locked door. She additionally confirmed that the unit had residents that can get around and that are confused, have dementia and are compromised.

Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings: Review of Payroll Based Journal staffing report revealed the facility triggered for Excessively Low Weekend Staffing during the fourth quarter 4 (July 1, 2024 through September 30, 2024). On 12/19/24 at approx. 11:00 a.m., review of weekend staffing from July 1, 2024 through September 30, 2024, both the Director of Nursing and the Scheduler/Payroll/Human Resource personal confirmed the facility did not have enough staff to meet resident needs on the weekends.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that 8 out of 25 licensed staff had current certification in Healthcare Basic Life Support (BLS) as required by facility. Licensed Practical Nurse (LPN) #2, Registered Nurse (RN) #2, RN#3, RN#4, RN#5, RN#6, RN #7 and RN#8. Findings: A surveyor reviewed the Job Descriptions for Registered Nurses and Licensed Practical Nurses at the facility and found under Specific Educational/Vocational Requirements: Maintains current BLS/CPR certification A surveyor reviewed the documentation provided by the facility for the 25 licensed staff currently employed and found 8 staff without documentation of a current BLS/CPR certification. LPN #2, RN #2, RN#3, RN#4, RN#5, RN #6, RN#7 and RN #8. On [DATE] at 1:13 p.m. a surveyor met with the Director of Nursing and discussed the above findings.

Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the floor, the walk-in freezer, a sink, a food mixer, ceiling tiles, a food disposal unit, a blender and a convection oven; failed to ensure food in the dry storage room was closed and secured shut; and failed to ensure that the kitchen ice machine was plumbed in accordance with code requirements to prevent food contamination for 1 of 1 kitchen tour for 1 of 1 day of survey (12/16/24). Findings: This direct connection of waste water and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one inch (2.54 cm) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils. On 12/16/24 from 9:10 a.m. to 9:45 a.m., 2 Surveyors did an Initial Kitchen Tour with the Food Service Director, the Director of Operations, and the District Manager in which the following findings were observed: - There was food, paper/ plastic trash on the entire floor and under the equipment and shelving. - The dish room spray sink was leaking liquid into a bucket sitting under the corner of the sink. - The food mixer had chipped/missing paint on the mix arm and base. - There were 5 ceiling tiles, above a food preparation area, that had dried liquid spatter on them. - There was a broken ceiling tile next to the ceiling air conditioner near the walk-in freezer. - The food disposal unit outside surface was covered with dried food particles and dried liquid residue. - The blender had dried food particles and dried liquid residue on the outside surface of the unit. - The convection oven had dried food particles and dried liquid residue on the outside surface of the unit. - The dry storage room had a 50 pound bag of previously open sugar, which was not secured shut and was sitting in an opened bin. - The walk-in freezer had a large box of sandwich buns that had a large ice build-up on the opened box. - The ice machine was not plumbed in accordance with code requirements to prevent food contamination. On 12/16/24 at 9:45 a.m., in an interview with 2 surveyors, the Food Service Director, the Director of Operations, the District Manager confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 6 units ([NAME], [NAME] and [NAME]) for 1 of 1 days of survey.(8/20/24) Findings: 1. On 8/20/24 from 8:55 a.m., to 9:25 a.m., during tour of the Gilber Unit by a surveyor, the following findings were observed: > Resident room [ROOM NUMBER] - The wall heater unit has chipped/missing paint and had rust on it creating an uncleanable surface. The walls around the room and in the bathroom were marred/marked. > Resident room [ROOM NUMBER] - The bathroom walls were marred/marked. > Resident room [ROOM NUMBER] - The room wall heating unit has chipped/missing paint and had rust on it creating an uncleanable surface. Additionally the walls were marred/marked around the entire room. > Resident room [ROOM NUMBER] - The privacy curtain, between the two resident beds, had large dirty and stained areas in multiple places. The walls around the entire room were marred/marked. On 8/20/24 at 9:30 a.m., in an interview, the Director of Nursing confirmed the above findings. 2. On 8/20/24 from 9:35 a.m., to 10:15 a.m., during tour of the [NAME] Unit and [NAME] Unit by a surveyor, the following findings were observed: [NAME] Unit: > Resident room [ROOM NUMBER] - The entrance door frame and door had chipped missing paint. > Resident room [ROOM NUMBER] - The entrance door frame and bathroom door frame had chipped missing paint. > Resident room [ROOM NUMBER] - The entrance door frame and bathroom door frame had chipped missing paint. > Resident room [ROOM NUMBER] - The entrance door frame and door had chipped missing paint. > Resident room [ROOM NUMBER] - The bathroom door frame had chipped/missing paint. > The dining room heater had chipped/missing paint creating an uncleanable surface. [NAME] Unit: > Resident room [ROOM NUMBER] - The bathroom door frame had chipped/missing paint. The floor was dirty around the base of the toilet. > Resident room [ROOM NUMBER] - The bathroom door frame had chipped/missing paint. > Resident room [ROOM NUMBER] - The bathroom door frame had chipped/missing paint. > Resident room [ROOM NUMBER] - The entrance door frame and bathroom door frame had chipped missing paint. > Resident room [ROOM NUMBER] - The base board heater had chipped/missing paint creating an uncleanable surface. On 8/20/24 at 10:15 a.m. the surveyor discussed the findings with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that the resident's environment was free of accident hazards relating to a base board heater, a wooden resident room door and a resident toilet for 1 of 1 day of survey. (8/20/24) Findings: 1. On 8/20/24 at 8:55 a.m., a surveyor observed the following on the [NAME] Unit: > Resident room [ROOM NUMBER] - The bath room toilet was loose and not secured to the floor. Additionally, the bathroom door had chipped/gouged and splintered wood which was sharp. 2. On 8/20/24 from 9:35 a.m. and 10:15 a.m., a surveyor observed the following on the [NAME] Unit: > Resident room [ROOM NUMBER] - The base board heater was broken apart creating sharp metal. > Resident room [ROOM NUMBER] - The entrance door had chipped/gouged and splintered wood which was sharp. On 8/20/24 at 10:15 a.m., in an interview, the surveyor discussed the findings with the Director of Nursing.

Based on observation, record review and interview, the facility failed to ensure that Oxygen was administered according to physicians orders for 1 out of 3 sampled residents. (#69) Finding: On 9/20/23 at 9:00 a.m., a surveyor observed Resident 69's Flowmeter on the oxygen concentrator was set at 5 liters per minute (LPM) delivering a continuous flow of oxygen at 5 LPM. A review of Resident 69's physician's order dated 6/14/23 instructed staff to administer supplemental oxygen via nasal cannula at 2 liters, as needed, for Shortness of Breath. On 9/20/23 at 9:44 a.m., a surveyor confirmed this finding with the Nurse Manager of the Short Stay unit that Resident 69's order for supplemental oxygen was not being administered according to physicians orders.

Based on observation and interview, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 2 of 3 dumpsters for 1 of 3 days of survey. (9/18/23) Findings: On 9/18/23 at 9:20 a.m., a surveyor and the Food Service Director observed 2 of 3 dumpsters, one with the left side door open exposing trash and one with both the left side door and right side open exposing trash. Additionally, there was paper trash and used disposable gloves on the ground around the dumpsters. On 9/18/23 at 9:20 a.m., in an interview, the Food Service Director confirmed the finding. On 9/18/23 at 10:00 a.m., in an interview, the surveyor discussed the finding with the Administrator and the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 7 of 7 Units ([NAME], [NAME], [NAME], [NAME], [NAME], [NAME], and [NAME]), the laundry room, the first floor common area, and the second floor common area for 3 of 3 environmental tours (9/18/23. 9/19/23 and 9/21/23) Findings: 1. On 9/18/23 at 10:15 a.m., a surveyor observed dried liquid and food residue on the floor under and in front of the unit refrigerator. On 9/18/23 at 10:19 a.m., Certified Nursing Assistant[CNA #1} confirmed the findings. 2. On 9/19/23 between 9:27 a.m. and 10:06 a.m. on the [NAME] Unit, a surveyor observed the following: > Resident #68's wheelchair was heavily soiled with dirt/debris > Resident #60's Broda chair was soiled with dirt/debris > Resident #14's wheelchair was heavily soiled with dirt debris. On 9/19/23 at 2:29 p.m., a surveyor confirmed the above findings with the Administrator, who stated that she would have the chairs cleaned immediately. 3. On 9/21/23 from 9:30 a.m. to 10:15 a.m., an environmental tour was completed with the Administrator, the Maintenance Director, the Account Manager for HealthCare Services Group, the District Manager for HealthCare Services Group and the Director of Nursing in which the following findings were observed: First Floor Common Area > The hallway wall by the business office has a large, ripped section of wall paper. Laundry: > The center metal strip on entrance door was coming off the door. There is one missing ceiling tile above stored linens. There are numerous missing floor tiles behind the dyers. There are four missing floor tiles around the left washing machine. There is one cracked/broken floor tile in front of the left washing machine. [NAME] Unit: > The flooring transition strip at the unit entrance doors was broken and missing sections in two places. > The EZ sit-to-stand lift had dirt and food debris in the foot base area. > Resident room [ROOM NUMBER]- There was a hole in the wall as you walk in the room to the right by the entrance door. The wall under the calendar and behind the bed was scraped/gouged exposing sheetrock. > The shower room toilet tank cover was chipped/broken. > The resident refrigerator surface was scraped/marred and rusty. > The ceiling air handling unit was dirty/dusty. [NAME] Unit: >There was one broken/missing floor tile in the hallway by the [NAME] Unit entrance. > The ceiling vent next to the air intake was dirty with debris and hair. > The kitchenette cabinet was missing the bottom two drawers. > The ceiling air handling unit was dirty/dusty. > The refrigerator was missing the door handle and the freezer door handle. The Resident refrigerator surface was scraped/marred and rusty. > There were ten ceiling tiles that were dirty, broken, and/ or stained with dried foods and liquid residue. > The bathroom floor between Resident room [ROOM NUMBER] and #204 was dirty around the base of the toilet. [NAME] Unit: > The EZ sit-to-stand patient lift had dirt and food debris in the foot base area. > Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and in disrepair. Second floor Common Area: > The wheelchair scale had torn/ripped/missing non-slip surface and the paint on the base was chipped/gouged creating an uncleanable surface. [NAME] Unit: > Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and in disrepair. > Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and in disrepair. [NAME] Unit: > Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and in disrepair. The television had tape holding it together. > Resident room [ROOM NUMBER]-2 - The privacy curtain was missing hooks and in disrepair. > The ceiling air handling unit was dirty/dusty and had chipped/missing paint creating an uncleanable surface. > The hallway and dining area walls were marked/marred and dirty, and the doors and doors frames had chipped/missing paint creating uncleanable surfaces. [NAME] Unit: > Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and in disrepair. > Resident room [ROOM NUMBER]-1 - There was soiled bed pan on the bathroom floor. There was a ceiling tile not in place above toilet. The privacy curtain was missing hooks and in disrepair. > The ceiling air handling unit was dirty/dusty. > The hallway and dining area walls were marked/marred and dirty, and the doors and doors frames had chipped/missing paint creating uncleanable surfaces. [NAME] Unit: > Resident room [ROOM NUMBER]-2 - The resident wheelchair had a broken left side armrest. On 9/21/23 at 10:15 a.m., in an interview, the Administrator, the Maintenance Director, the Account Manager for HealthCare Services Group, the District Manager for HealthCare Services Group and the Director of Nursing confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that the resident's environment was free of accident hazards relating to a patient lifts for 2 of 2 facility tours, for 1 of 3 days of survey. (9/18/23) Findings: 1. On 9/18/23 at 10:05 a.m., a surveyor observed an EZ sit-to-stand patient lift on the [NAME] Unit that was missing the left side lift/swing arm safety clip which is used to secure the lift sling/pads on the lift/swing arm when in use. 2. On 9/18/23 at 10:22 a.m., a surveyor observed an EZ sit-to-stand patient lift on the [NAME] Unit that was missing both the left side lift/swing arm safety clip and the right side lift/swing arm safety clip which is used to secure the lift sling/pads on the lift/swing arm when in use. On 9/18/23 at 11:22 a.m., in an interview, the Director of Nursing confirmed that the two sit-to-stand patient lifts were missing safety hooks on the lift/swing arm and the lifts were accident hazards.

Based on observations, interview, and the facility's Food and Nutrition Services Policies and Procedures, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling lights, ceiling vents, the hood exhaust system, the food mixer, the cook stove and the grease trap cover. Further, the facility failed to ensure all staff were wearing facial hair protectors. Additionally, the facility failed to ensure foods were labeled in the walk-in freezer for 2 of 2 tours on 1 of 4 days of survey. (9/18/23) Findings: Review of the facility's Food and Nutrition Services Policies and Procedures, Food Receiving and Storage Policy (last reviewed 5/1/23) noted: FNS407 Food Handling Policy: Foods are stored, prepared, and served in a safe and sanitary manner. 22.1 Unused portions that have been properly handled, refrigerated, covered, labeled, and dated with used by dates or frozen and reheated and served 26. The following is a guide to use when establishing a use by date for food items. The manufacturers expiration date, when available, is the use by date for unopened items. The manufacturer's instructions for use by date of opened items overrides these guidelines. Guidelines assume that food is properly stored, covered, and handled. Guidelines apply, regardless of the storage location. On 9/18/23 from 9:10 a.m. to 9:50 a.m., a surveyor conducted an initial kitchen tour with the Food Service Director in which the following findings were observed: 1. > The dish room had a ceiling light with a broken/cracked lens cover and two ceiling lights with rust on the metal end caps. > The hood exhaust system filters were dusty/dirty. > The food mixer had dried food and liquid residue on the mixer arm and base. There was also chipped/missing paint on mixer arm and base creating uncleanable surfaces. > There were two ceiling air conditioning units above food preparation and service areas that were dusty/dirty. > The cook stove surface and burner areas were heavily soiled with dried foods and dried liquid residue. > The grease trap cover, under the three bay pot sink, had large amounts of rust on it creating an uncleanable surface. > The ceiling light, above the reach-in freezer, had dried liquid residue spatter on it. > The walk-in freezer had large amounts of ice build-up on an opened box of beef liver. Additionally, there was one bag of hash browns and two bags of french fries not labeled and dated. > There was one male kitchen worker with a mustache and facial hair that was not wearing facial hair protection. On 9/18/23 at 9:50 a.m., in an interview, the Food Service Director confirmed the findings. On 9/18/23 at 10:00 a.m., in an interview, a surveyor discussed the findings with the Administrator and the Director of Nursing. 2. On 9/18/23 at 10:11 a.m., the surveyor observed two unmarked white cups with lids in the resident refrigerator which were not dated and labeled with resident names. On 9/18/23 at 10:19 a.m., in an interview, Certified Nursing Assistant[CNA #1} confirmed the findings.

Based on interviews, the facility's bathing schedule and facility's bathing documentation, the facility failed to ensure that resident's preferences were being followed in the area of bathing for 2 of 4 residents reviewed. (Resident #6 and #7) Findings: 1. On 12/14/22 at 8:40 a.m., during an interview, Resident #6 stated that he/she stated, I am supposed to have my shower on Fridays in the afternoon. I am to get a shower once a week. I want my shower on Fridays every week and I am not getting them regularly. Review of the facility's shower schedule noted that Resident #6 is scheduled for a shower on Friday in the afternoon(PM). Review of the facility's bathing documentation from 9/1/22 to 12/14/22 noted Resident #6 did not refuse a shower and was not given a shower on 9/9/22, 9/23/22, 9/30/22, 10/14/22, 10/21/22, 10/28/22, 11/4/22, 11/11/22, 11/18/22, 11/25/22 and 12/9/22. 2. On 12/14/22 at 9:35 a.m., review of the facility's shower schedule noted that Resident #7 is scheduled for a shower on Friday in the morning(AM). Review of the facility's bathing documentation from 9/1/22 to 12/14/22 noted Resident #7 did not refuse a shower and was not given a shower on 9/2/22, 9/16/22, 10/7/22, 11/4/22, 11/18/22, 11/25/22 and 12/2/22. On 12/14/22 at 3:00 p.m., in an interview, the Director of Nursing (DON) confirmed that both residents did not receive their showers as scheduled and preferred.

Based on observation, record review and interviews, the facility failed to ensure that a resident's representative was notified of a significant change in the resident's medical condition and failed to follow it's own policy and procedure for Change in Condition: Notification of, for 1 of 1 resident reviewed for Transmission Based Precautions (#32). Findings: The facilities Change in Condition: Notification of, Policy and Procedure: revised on 6/1/21. Indicates the following: The center must immediately inform the resident/patient, consult with the patient's physician, and notify, consistent with his/her authority, the patient's health care decision maker when there is: A significant change in the patient's physical, mental or psychosocial status (that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) and They need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). On 11/1/21 at 11:57 a.m., observation of Transmission Based Precautions posted on Resident #32's door indicating Contact precautions, with a Personal Protective Equipment cart next to the room. On 11/1/21 at approx. 11:59 a.m., during an interview with the Certified Nurses Aid, she confirmed Resident #32 was on Contact precautions for Clostridium Difficile (C-Diff). During review of Resident #32's medical record the following physician orders were noted: Order dated 10/23/21 for Collect stool sample to test for C-diff one time only for loose stools. Order dated 10/24/21 for Infection Precautions - contact every shift for c.diff infection. Order dated 10/25/21 for Vancomycin HCl Suspension, give 125 milligrams (mg) by mouth four times a day for c.diff infection for 10 Days. On 11/1/21 at 12:46 p.m., during an interview with Resident #32's representative, he/she confirmed he/she was not made aware of Resident #32's current infection of C-Diff stating, last thing I heard health wise, was the UTI and One Aide told me resident had diarrhea but I never knew he/she had that. On 11/1/21 at 3:28 p.m., in an interview with the Director of Nursing and the Clinical Quality Specialists, a surveyor discussed the above findings. In an additional interview with the Director of Nursing on 11/2/21 at 10:55 a.m., she stated Resident #32's representative was called and notified of the resident's current diagnosis of C-Diff. Review of a nursing note dated 11/1/21 at 3:48 p.m., confirmed the resident respresentative was notified of residents current C-Diff diagnosis and treatment.

Based on record reviews and interviews, the facility failed to notify the resident and/or the resident representative in writing of the transfer/discharge to the hospital for 1 of 4 sampled residents (#70) Finding: 1. Documentation in Resident's #70's clinical record indicated he/she was transferred to the hospital on 9/29/21 and subsequently admitted . The medical record lacked evidence that Resident #70 or his/her representative was provided a written transfer/discharge notice. On 11/2/21 at 12:02 p.m., in an interview with a Director of Nursing, a surveyor confirmed the above findings.

Based on record review and interviews, the facility failed to ensure that staff followed physician orders for PICC Line Care for 1 of 1 resdiens reviewed with a PICC Line. (Resident #85) Finding: Resident #85's clinical record contained physician's treatment orders, dated 10/21/2021, that instructed staff to Change Catheter Site Transparent Dressing. Indicate external catheter length and upper arm circumference (10cm above antecubital). Notify practitioner if the external length has changed since last measurement every day shift every Thursday weekly, and Change Needleless Connector every day shift every Thursday weekly. A review of October 2021's Treatment Administration Record (TAR) did not reflect documentation that the treatment orders were performed on October 21st and October 28th. On 11/2/21 at 1:00 p.m., during an interview with the Director of Nursing, it was confirmed that the treatment orders were not performed on these days as ordered.

Based on record review and interviews, the facility failed to ensure pressure ulcer wound care was completed as per the physician orders for 1 of 3 Residents reviewed for pressure ulcers. (#39) Finding: Review of Resident #39's medical record indicated he/she had an unstageable pressure ulcer located on the coccyx. A Physician's order dated 8/20/21, instructed nursing to provide care for the unstageable pressure ulcer stating, cleanse with Vashe wash, pat dry, skin prep to surrounding tissue, pack wound bed with Maxsorb AG cover with optilock dressing secure with pink tape change twice daily and prn every day shift for Unstageable Ulcer Monitor for maceration, notify provider if worsening. Review of Resident #39's Treatment Administration Records (TAR) dating from 8/20/21 through 11/2/21 documented the dressing being changed once daily, lacking evidence of the dressing being changed twice daily as ordered. On 11/3/21 at 11:39 a.m., the surveyor confirmed the above finding with the Director of Nursing

Based on record review and interviews, the facility failed to respond to a pharmacist's reported irregularity related to the use of a psychotropic medication for 1 of 5 residents reviewed for unnecessary medications. (#32) Finding: On 11/2/21, during a review of Resident #32's Monthly Medication Regimen Reviews (MRR), the Pharmacy Consultant report dated 7/13/21 commented that the resident receives Terazosin Hydrochloride as needed (PRN) for urinary retention. Please consider discontinuing. Treatment for BPH is dosed routinely. Terazosin is also a high risk medication and with the recommendation of Please discontinue PRN Terazosin. Further review of the consultation report lacked evidence of a Physician response to the recommendation. Review of the resident's physician orders indicated the medication was not addressed and/or discontinued until 9/23/21, 72 days after the recommendation. On 11/2/21 at approximately 2:54 p.m., in an interview with the Director of Nursing, Nurse Practitioner and Clinical Quality Specialist, a surveyor confirmed the above finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide adequate maintenance services to maintain an orderly and homelike interior on 4 of 7 units ([NAME], [NAME], [NAME] and [NAME] Units) and a hallway for 1 of 1 tours. Findings: On 11/4/21 from 8:45 a.m. to 9:20 a.m., an Environment Tour was conducted with the Maintenance Director, the Administrator, and the Director of Nursing in which the following findings were observed: - The hallway floor outside of the laundry room was worn through and missing the surface creating an uncleanable surface. [NAME] House - The shower room floor was dirty around the base of the toilet. The sit-to-stand lift foot base had dirt/debris in it. The ceiling exhaust fan was dirty/dusty. - The soiled room had three(3) ceiling tiles that had brown stains on them. - Resident room [ROOM NUMBER] - The floor was dirty around the base of the toilet. The toilet was not secure to the floor. The cove base behind toilet was soiled and had soiled caulking around it. [NAME] House - The shower room ceiling light lens was dirty/dusty. The ceiling tile, around the light, had the paper surface ripped. - The linen closet had linen and trash debris on the floor. - Resident room [ROOM NUMBER] - The floor was dirty around the base of the toilet. - Resident room [ROOM NUMBER] - The room heating unit was missing a part of the top grill. The floor was dirty around the base of the toilet - Resident room [ROOM NUMBER] - The base of tube feeding pole was dirty and rusty. [NAME] House - Resident room [ROOM NUMBER] - The wheelchair had electrical tape on right arm rest creating an uncleanable surface. [NAME] House - Resident room [ROOM NUMBER] - The room entrance door was dirty and soiled. - Resident room [ROOM NUMBER] = The wall under the right side window was scuffed and had chipped/missing paint creating an uncleanable surface. - Resident room [ROOM NUMBER] = The door frame had chipped/missing paint creating an uncleanable surface. The left wall, when entering the room, was scuffed and marred. The floor near the right side armoire, had two(2) areas of dried liquid residue on it. - Resident room [ROOM NUMBER] - The bed b wheelchair had a ripped and torn seat and right armrest. The bed A bed had a peeling surface on the footboard top creating an uncleanable surface. - The dining room wall and cove base area near the hanging phone was soiled with dried liquids and food debris. - The dining room wall to the right of the microwave had ripped/torn wall paper creating an uncleanable surface. On 11/4/21 at 9:20 a.m., during an interview, the Maintenance Director, Administrator and the Director of Nursing confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to issue a bed hold notice to a resident, known family member or legal representative for 2 of 4 sampled residents who had been transferred to the hospital. (#38 and #70) Findings: 1. Resident #38's clinical record revealed that the resident was transferred to the hospital on 6/15/21, 6/23/21 and 7/29/21. The clinical record included incomplete bed-hold notices for all 3 transfers, which did not include the daily bed hold cost and/or left blank. On 11/04/21 at 10:50 a.m., during an interview with the Director of Nursing (DON) the above findings were confirmed. 2. Resident #70's clinical record revealed that the resident was transferred to the hospital on 9/29/21 and admitted . The clinical record lacked evidence that the facility issued a written bed hold notice to the resident and/or resident representative. The resident was again transferred to the hospital on [DATE] and admitted . The clinical record included an incomplete bed-hold notice, dated 10/15/21 which did not include the daily bed hold cost. On 11/2/21 at 12:02 p.m., in an interview with the DON, a surveyor confirmed the above findings.

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling vents, ceiling tiles, a floor fan, a reach-in refrigerator, cooking spray and a standing floor mixer. Additionally, the facility failed to label and date foods in the reach-in refrigerator. This was for 1 of 1 kitchen tours on 1 of 4 days of survey (11/1/21). Findings: 1. On 11/1/21 from 9:10 a.m. to 9:40 a.m., a surveyor conducted a tour of the kitchen with the Food Service Director in which the following were observed: - The ceiling vent, by the walk-in refrigerator, was dusty/dirty. - The ceiling vent, by the reach-in refrigerator, was dusty/dirty. - The ceiling tiles, above the triple bay pot sink, were dirty and splattered with dried liquid residue. - The dish room ceiling was splattered with dried liquid residue. - The standing floor fan, by the dish room, was dusty/dirty. - The reach-in refrigerator had a two handled sippy cup of fluid that was unlabeled and undated. - There was a 17 ounce can of [NAME] cooking spray, which was labeled flammable, sitting on the propane cooking stove. - The large floor mixer had dried food debris on the housing and cage guard. On 11/1/21 at 9:40 a.m., during an interview, the Food Service Director confirmed the findings.

Based on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate documentation for 3 of 36 sampled residents (#41, #75 and #82). Findings: 1. A review of Resident #41's Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed the following: - Order for Cyclobenzaprine Hydrochloride (HCl) Tablet 10 milligrams (mg): Give 1 tablet by mouth three times a day for muscle spasm relief with start date of 1/5/21. A review of the October 2021 MAR revealed no documentation that the medication was administered at 1:00 p.m. on 10/4/21. - Order for Bilevel Positive Airway Pressure (BIPAP): replace mask cushion every month and prn as needed with start date of 2/19/21. A review of the October 2021 TAR revealed no documentation that the mask cushion was replaced on 10/23/21. - Order for BiPAP: Clean reservoir, corrugated tubing and mask/nasal pillow with soap and water daily. Air dry. Store mask/nasal pillow in a plastic bag when not in use after drying. every day shift for sleep apnea with a start date of 2/20/21. A review of the October 2021 TAR revealed no documentation that the cleanings were completed on 10/5/21, 10/6/21, 10/11/21, 10/12/21, 10/14/21 and 10/29/21. - Order to Cleanse wound with Saline: Pat dry. Apply skin prep on surrounding intact skin. Apply wound bed with Anacept gel to wound base; apply a strip of silver alginate. Cover with Abdominal Pad(ABD) dressing, use minimal tape (paper tape preferred) r/t surrounding erythema, every day shift for wound care to left groin and every 24 hours as needed for left groin wound care as needed with a start date of 10/1/21. A review of the October 2021 TAR revealed no documentation that the cleanings were completed on 10/1/21, 10/6/21, 10/9/21, 10/13/21, 10/14/21, 10/15/21, 10/20/21, 10/23/21, 10/26/21, 10/28/21, 10/29/21 and 10/31/21. - Order for Wound care to rash Bi-lateral (BL) groin: Cleanse area with mild soap and water, pat dry. Apply Miconazole 2% powder topically every day and evening shift for Until resolved with a Start Date of 9/30/21. A review of the October 2021 TAR revealed no documentation that wound care was completed on the day shift on 10/1/21, 10/6/21, 10/13/21, 10/14/21, 10/15/21, 10/20/21, 10/26/21, 10/28/21, 10/29/21 and 10/31/21. - Order for Monitor leg wounds from minor bumps and scrapes: Resident #41 doesn't have a lot of feeling in his legs and he often bumps them. Notify an Nurse Practitioner (NP) if needed. every shift with a start date of 3/22/21: A review of the October 2021 TAR revealed no documentation that wound monitoring was completed on the 10:00 p.m. to 6:00 a.m. shift on 10/3/2021, 10/25/21 and 10/28/21. - Order for Resident #41 has a diagnosis of Chronic Obstructive Pulmonary Disease(COPD). Does the resident have shortness of breath when lying flat? Yes/No (Y/N) every shift for COPD with a start date of 6/1/21. A review of the October 2021 TAR lacked documentation of monitoring breathing was completed on the 10:00 p.m. to 6:00 a.m. shift on 10/3/21, 10/25/21 and 10/28/21. 2. A review of Resident #75's MAR/TAR revealed the following: - Order for Acetaminophen Tablet 500 mg: Give 1000 mg enterally every 12 hours for pain supervised self administration with a start date of 3/10/21. A review of the October 2021 MAR revealed no documentation that the medication was administered at 9:00 a.m. on 10/12/21 and 10/15/21. - Order for Ascorbic Acid Tablet: Give 500 mg enterally one time a day for supplement with a start date of 4/8/2020. A review of the October 2021 MAR lacked documentation that the medication was administered on 10/12/21 and 10/15/21. - Order for Folic Acid Tablet 1 MG: Give 1 tablet enterally one time a day for supplement with a start date of 4/8/2020: A review of the October 2021 MAR lacked documentation that the medication was administered on 10/12/21 and 10/15/21. - Order for Hydroxyzine HCl Tablet 25 mg: (Hydroxyzine HCl) Give 25 mg enterally three times a day for pruritis with a start date of 7/23/21. A review of the October 2021 MAR lacked documentation that the medication was administered from 7:00 a.m. to 10:00 a.m. on 10/12/21 and 10/15/21. - Order for MiraLax Powder (Polyethylene Glycol 3350): Give 17 gram enterally one time a day for constipation with a start date of 4/08/2020: A review of the October 2021 MAR lacked documentation that the medication was administered on 10/12/21 and 10/15/21. - Order for Omeprazole Powder: Give 20 mg via Percutaneous Endoscopic Gastrostomy (PEG-Tube) one time a day for GI distress with a start date of 4/10/2020. A review of the October 2021 MAR lacked documentation that the medication was administered on 10/12/21 and 10/15/21. - Order for Sertraline HCl Concentrate 20 mg/Milliliter (ml): Give 6 ml via PEG-Tube one time a day for depression total dose 120mg with a start date of 5/1/21. A review of the October 2021 MAR lacked documentation that the medication was administered on 10/12/21 and 10/15/21. - Order for Simethicone Tablet 80 mg: Give 1 tablet enterally three times a day for Gastrointestinal (GI) distress with a start date of 9/9/21: A review of the October 2021 MAR lacked documentation that the medication was administered at 9:00 a.m. on 10/12/21 and 10/15/21. - Order for Colostomy Care every shift with a start date of 4/8/2020. A review of the October 2021 TAR lacked documentation that care was completed on the 10:00 p.m. to 6:00 a.m. shift on 10/28/21. - Order for Enteral Feed Order every shift Jevity 1.5 CAL: Administer continuous via Pump 80 ml per hour. 42 ml water flush every 1 hour via pump for a total of 1008 ml of water/24hrs and 1920 ml of 1.5 formula /24hrs with a start date of 2/24/21. A review of the October 2021 TAR lacked documentation that the Enteral feeding was administered on the 10:00 p.m. to 6:00 a.m. shift on 10/28/21. - Order for Enteral Feed: Elevate head of bed 30-45 degrees during feeding & for 30-45 minutes after every shift with a start date of 4/7/2020 . A review of the October 2021 TAR lacked documentation that the head of bed elevation was completed on the 10:00 p.m. to 6:00 a.m. shift on 10/28/21. - Order for Enteral Feed: Check for residual and record every shift prior to feeding or If 500 ml or over, hold feeding for one hour and recheck. If residual is 250 ml or over (upon recheck) hold feeding, notify physician and document amount in ml. with a start date of 4/07/2020. A review of the October 2021 TAR lacked documentation that the enteral residual was checked on the 10:00 p.m. to 6:00 a.m. shift on 10/28/21. - Order for Enteral Feed: Cleanse site daily with soap and water, one time a day for site cleanse with a start date of 6/15/2020. A review of the October 2021 TAR revealed no documentation that the enteral feeding cleanse was completed on 10/5/21. - Order for Enteral Feed: Flush tube with 15 ml of water before each medication pass every shift. Flush tube with at least 15 mls of water between each medication with a start date of 4/7/2020. A review of the October 2021 TAR revealed no documentation that the enteral feed tube flush was completed on the 10:00 p.m. to 6:00 a.m. shift on 10/28/21. - Order for Flush tube with at least 15 mls of water after final medication every shift with a start date of 4/07/2020. A review of the October 2021 TAR revealed no documentation that the enteral feed tube flush was completed on the 10:00 p.m. to 6:00 a.m. shift on 10/28/21. - Order for Is resident free from side effects of psychotherapeutic medications?(if no, document side effects in Progress Notes (PN) every shift with a start date of 4/8/2020: A review of the October 2021 TAR revealed no documentation that the check was completed on the 10:00 p.m. to 6:00 a.m. shift on 10/28/21. - Order for Nurse to document resident participation in tube feeding: Independent? Resident performs entire task of feeding. Nurse does not participate. Supervision? Nurse only coaches resident. No touching. Limited ? Nurse only guides resident's hands. No physical lifting. Extensive ? Involves lifting. Nurse pours fluid and/or feed into tube. Resident may participate some by holding the Tube. Dependent ? Nurse performs entire task of feeding. Resident does not physically participate. every shift with a start date of 7/1/21. A review of the October 2021 TAR revealed no documentation of participation was completed on the 10:00 p.m. to 6:00 a.m. shift on 10/28/21. - Order for Placement and Tube Length in Centimeters (cm) every shift. Check tube for proper placement prior to each feeding, flush, or medication administration by measuring the length of the tube with a start date of 4/7/2020. A review of the October 2021 TAR revealed no documentation was completed on the 10:00 p.m. to 6:00 a.m. shift on 10/28/21. 3. A review of Resident #82's clinical medication administration record/treatment administration record (MAR/TAR) revealed the following: - Order for Check dressing placement on right calf every shift until resolved with a start date of 10/04/2021 1400 -D/C Date- 10/15/2021 0827. A review of the October 2021 TAR revealed no documentation checking the dressing placement was completed on the 6:00 a.m. to 2:00 p.m. shift on 10/5/21. - Order for wound care to open area on right mid-calf: Cleanse area with wound cleanser, pat dry. Apply skin prep to surrounding tissue, allow to dry. Cover with Optifoam gentle dressing. every day shift Until resolved with a start date of 10/4/2021 0600 -D/C Date- 10/15/2021 0828. A review of the October 2021 TAR revealed no documentation that wound care was completed on the 6:00 a.m. to 2:00 p.m. shift on 10/5/21. - Order for Vital Signs Short Term/Skilled Patient every (q) shift x72 hours then daily every day shift with a start date of 9/06/2021 0600 -D/C Date-10/19/2021 0243. A review of the October 2021 TAR revealed no documentation that daily vital signs were completed on 10/5/21, 10/9/21, 10/10/21, 10/11/21, 10/12/21, 10/13/21, 10/14/21, 10/15/21, 10/16/21, 10/17/21 and 10/18/21. - Order for weigh one time only for two days with a start date of 10/04/2021 0930. A review of the October 2021 TAR revealed no documentation of weight being monitored on 10/5/21. On 11/2/21 at 1:35 p.m., during an interview, the Director of Nursing confirmed that the MAR/TAR's did not contain complete and accurate documentation.