Based on observation and interview with facility staff, it was determined that the facility failed to protect the dignity of a resident with urine bag. The deficient practice was found evident for 1 resident (Resident #11) out of 1 resident observed with urine bag during the facility's Medicare/Medicaid recertification survey. The findings include: An indwelling urinary catheter, often called a Foley catheter, is a flexible tube inserted into the bladder to drain urine when a person is unable to urinate on their own. It is typically held in place by a small balloon inflated with sterile water inside the bladder. A urine bag, also known as a drainage bag, is a medical device used to collect urine when a person cannot urinate on their own or needs a way to collect urine for medical testing. It's typically connected to a urinary catheter, which is a tube inserted into the bladder. Urine drains from the bladder through the catheter and into the bag. On 06/23/25 at 08:23 AM, during the initial tour of the facility, the surveyor observed that Resident #11 had a urinary bag which was visible as soon as the surveyor entered into the resident's room. On 06/23/25 at 08:25 AM, Geriatric Nursing Assistant (GNA #10) entered into Resident #10's room to ask him/her if he/she was ready to get out of bed. When she was asked if the urine bag was supposed to be exposed, she stated that a bag cover was not used because Resident #11 was in bed and that she would put the urine bag in a dignity bag when the resident was out of bed and in his/her wheelchair. On 06/23/25 at 09:33 AM, while the surveyor was still on the unit, Resident #11 was observed in the hallway with the dignity bag totally ripped on the left side exposing the urine bag. The surveyor requested Licensed Practical Nurse(LPN #9) for a dual observation of the ripped dignity bag and she confirmed it. When LPN #9 was asked for the process of protecting the dignity of a patient with a Foley catheter who had a urine bag, she stated that the urine bag should have a dignity bag at all times which should not be visible to people. When asked if the urine bag should have a dignity bag while Resident #11 was in bed, she stated that the urine bag should have a dignity bad at all times which should not make the the urine bag visible to any one. LPN #10 took Resident #11 back to his/her room and informed the surveyor that she would get a new dignity bag to replace the ripped one. On 06/23/25 at 09:41 AM, The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the concerns and the DON stated that the resident should have had a dignity bag in place, irrespective of being in bed or not and that visitors should not be able to see the urine bag. She added that she would reeducate GNA #10. On 06/23/2025, the surveyor informed the Inter-Disciplinary Team(IDT) of the concern at the exit conference.

Based on review of medical records and staff interview, it was determined that facility staff failed to notify a resident's physician when a resident displayed changes in their baseline condition. This was evident for 1 (Resident #4) of 4 residents reviewed for accidents during the annual survey. The findings include: On 3/29/23 at 9:32 AM a medical record review was conducted for Resident #4. A 3/13/23 at 1:12 AM nursing note documented, Resident has been showing some confusion on whether [h/she] went to restroom or not. Resident was noted leaning forward while on toilet and leaning towards the right while in the wheelchair. A 3/13/23 at 4:18 AM nursing note documented, Resident was sitting on side of bed attempting to go to restroom. Staff assisted with transfer to wheelchair. Resident began leaning to right side and unable to get up to get on commode. Writer noticed confusion again and resident was noncompliant with answers. DON (Director of Nursing) updated at 4:18 AM and stated resident has a history of being weak and then stronger and may need to rest in bed. A 3/13/23 at 11:08 AM nursing note documented, resident continues with MS (mental status) change and right-side weakness. Unable to put hearing aids in [him/herself] this AM, appeared bewildered, usually requests to do it [him/herself], very quick and automatic. Noted leaning to the right when seated in wc (wheelchair), RUE (right upper extremities) hanging over the armrest. Resident transferred to recliner upon return from PT, fidgeting and restless despite stating [she/he] was going to rest. Assistance of 2 required with transfer, poor wt. bearing, needed 2 attempts to stand/pivot and much cueing with hand placement. Further review of the medical record failed to produce documentation that Resident #4's physician was notified of the mental status change and right-side weakness. On 3/28/23 at 2:56 PM during an interview Staff #9 expressed that Resident #4 seemed aware of the day and routine events, realized when it was time for breakfast and medication. Staff #9 stated that usually Resident #4 could put his/her hearing aids in but that morning the resident was confused, thought the hearing aids were dropped even though they were in the resident's hands. Staff #9 stated that Resident #4 was more confused. Staff #9 stated that Resident #4's posture was usually normal but, on that morning, the right arm and body were leaning over the armrest. Staff #9 stated, I had been given something from the night shift report. Staff #9 stated she spoke to the DON and that is how she proceeded when she noticed something different. Staff #9 stated, I was concerned, definitely, it was new to me. On 3/28/23 at 3:27 PM Staff #13 stated that Resident #4 was leaning to the side and could not get out of bed. I thought something was up. I did neurochecks and vital signs. Staff #13 stated she called the DON, and the DON told her the resident had a history of doing that. Staff #14 stated, I had never seen [him/her] do that before. That is why I called [DON name]. When asked if she would normally notify the physician she said, normally, but they don't do that here. We call [DON] first and then she will either call the doctor or tell us to call. On 3/29/23 at 8:58 AM during an interview with Resident #4's physician, the surveyor read the nursing note of 3/13/23 to the physician. The physician stated that he would have expected to be notified of the change so that he could have called Resident #4's son to discuss comfort care or do a CT scan. The physician stated he was not sure if Resident #4 had TIAs (transient ischemic attacks). On 3/29/23 at 9:10 AM further medical record review failed to produce documentation in the physician's history and physical and monthly progress notes that the resident had TIAs. The diagnosis section of the electronic medical record did not list TIAs as a diagnosis. On 3/29/23 at 11:18 AM the DON told the surveyor that the nurses should have known about the TIAs because they talk about it all the time and there were no adverse effects. The surveyor informed the DON that the physician expressed he should have been notified and her reply was, Oh, I'll have to talk to him about that. On 3/29/23 at 2:34 PM the Nursing Home Administrator was made aware of the findings.

Based on resident and staff interview and policy review, it was determined that facility staff failed to report missing jewelry to the Administrator when first notified by the resident. This was evident for 1 (Residents #9) of 6 residents reviewed for missing personal items during the annual survey. The findings include: On 3/23/23 at 9:04 AM an interview was conducted with Resident #9. Resident #9 was asked if h/she had any missing personal property. Resident #9 stated that about 2 months ago, he/she was missing an 18-carat gold chain and a gold bracelet. Resident #9 stated it was reported to Staff #18 and Staff #18 stated she would look into it. On 3/28/23 at 9:31 AM the Nursing Home Administrator (NHA) was asked what the process was for missing resident items. The NHA stated, we go to see the resident and we interview and ask how, when, why and basic questions and anything they can tell us. We want to see them sooner than later. After we interview the person, we will talk to staff that might have worked that particular day in the unit or the staff that would have an impact on that item being missing. We have a grievance counselor, Staff #28 that would document those types of issues. On 3/28/23 at 10:27 AM Staff #28 was interviewed and stated there was nothing on the grievance log about the missing jewelry. On 3/28/23 at 11:34 AM the NHA stated, we found the gold bracelet in sister's office. It was in a wooden box for jewelry. They (staff) did not know anything about a gold chain and were trying to contact the POA (Power of Attorney). They stated the resident was also repeatedly asking where [his/her] jewelry was. On 3/29/23 at 10:23 AM Staff #18 was interviewed about the missing gold chain and stated, my mistake is I didn't report to my supervisor. Lately [he/she] kept complaining about missing it, kept repeating after we kept looking for it. I did mention to some of the sisters that it was missing. The bracelet is in [his/her] box with a watch. The gold necklace with crucifix could not be found. Staff #18 was asked if she knew the process of what to do when a resident's item was missing. Staff #18 stated, the process is to report immediately to the supervisor but that is my failure. I am still learning to report to the NHA. I have been here a year. On 3/29/23 at 10:52 AM a review of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy documented on page 7, abuse policy requirements. It is the policy of this home that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. On page 11 of the policy, Section G, Reporting and Response documented, it is the policy of this home that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The Home will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation or resident property, are reported immediately, but not later than two (2) hours after the allegation is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (Resident #16) of 3 residents reviewed for hospitalization during the annual survey. The findings include: On 3/23/23 at 10:52 AM a review of Resident #16's medical record was conducted. A 10/29/22 nursing note documented, called to room @ 0945 with report of resident on floor in bathroom. Unable to move RLE (right lower extremity), c/o (complained of) severe pain. [name] and [name] notified, 911 called to transport to ED (emergency department). There was no documentation in Resident #16's medical record as to what was done for the resident prior to transfer and if the resident understood where h/she was being transported to and why h/she was being transported. On 3/28/23 at 11:33 AM Staff #3 was interviewed and stated, the nurses usually document in a progress note. Staff #3 was shown that there was no documentation found in nursing notes as to what was done for the resident and that the resident understood. The concern was discussed with the Director of Nursing and the Nursing Home Administrator on 3/29/23 at 2:34 PM.

Based on review of resident medical records and interview with facility staff, it was determined that a resident's attending physician failed to supervise and respond to abnormal laboratory test results. This was evident for 1 (Resident #2) of 6 residents reviewed for unnecessary medication. The findings include: Potassium is an electrolyte that is essential in maintaining fluid balance and in the proper functioning of muscle contractures and nerve impulses. Having too much potassium is dangerous and can lead to life-threatening heart problems, muscle weakness, and paralysis. Normal potassium levels are 3.5 to 5.2 miliequivalents per liter (mEq/L). Potassium is measured by taking a blood sample. Resident #2's medical record was reviewed on 3/24/23 at 2:02 PM. The review revealed that Resident #2 had multiple abnormal potassium levels in February and March 2023. Lab results revealed that the resident had a potassium level of 5.5 mEq/L on 2/7, 5.3 on 2/9, and 5.4 on 3/7. Lab results for potassium were not available in the medical record for any other day in February and March 2023. Review of Resident #2's orders revealed that the resident was prescribed a potassium-lowering medication on 2/12/23 in response to the potassium levels of 5.5 and 5.3 mEq/L. The medication was to be taken for 3 days (until 2/15). No repeat potassium lab test was ordered after the completion of the potassium-lowering medication. No potassium-lowering medication was ordered for Resident #2 following the potassium level of 5.4 on 3/7/23. Review of Resident #2's physician notes revealed a note dated 2/15/23 and written by the Attending Physician #14 that stated, noted that potassium was elevated on two tests, in the chief complaint section. The plan of treatment section stated, HIGH POTASSIUM - repeat level stable. Resident #2's Attending Physician #14 was interviewed on 3/29/23 at 8:59 AM. During the interview, the Attending Physician stated, We normally do a follow up value for potassium after administering a potassium-lowering medication. We obtain it about a week later, usually on a Tuesday or a Thursday as those are our lab days. This includes [Resident #2's medication]. I'll order 2 or 3 doses and then repeat the lab. The Attending Physician was asked why Resident #2's elevated potassium on 3/7/23 was treated differently (i.e., no medication was ordered) than the elevations in February 2023. The Attending Physician stated he would investigate and return to the survey team. No additional information was provided by the physician or the facility regarding the 3/7/23 elevated potassium by the end of the survey.

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to monitor the heart rate prior to administering a blood pressure medication per physician's orders. This was evident for 1 (Resident #9) of 6 residents reviewed for unnecessary drugs during the annual survey. The findings include: On 3/30/23 at 12:34 PM a review of Resident #9's medical record was conducted and revealed a physician's order for Metoprolol Succinate ER Tablet, Extended Release 50 mg. to be given every day. The order stated to hold the medication for a SBP (systolic blood pressure) less than 100 or HR (heart rate) below 60. The top number of the blood pressure refers to the amount of pressure in the arteries during the contraction of the heart muscle. This is called systolic pressure. Review of Resident #9's March 2023 Medication Administration Record (MAR) documented that the SBP was being monitored but not the heart rate. Further review of the December 2022, January 2023, and February 2023 MARS also failed to reveal documentation that the heart rate was being monitored prior to administering the medication. Nursing notes dated 2/21/23, 2/23/23, and 1/24/23 documented that the medication was held due to the heart rate being below 60. However, there was no other monitoring of the heart rate documented for the other days. Review of the vital sign section of the medical record documented the heart rate was taken, however it was not taken every day and there was no correlation of when the heart rate was taken to when the medication was administered. On 3/30/23 at 1:48 PM an interview was conducted with Staff #3 and Staff #31. Both stated that the heart rate should have been documented next to the medication on the MAR.

3) On 3/27/23 at 2:00 PM, Resident #2's medical record was reviewed. Review of the resident's MAR for the month of February 2023 showed that on 2/11/23, Resident #2 was ordered a medication to lower potassium with instructions to give 1 packet by mouth one time a day for 3 Days (2/12, 2/13, and 2/14). The MAR documented that the resident received the medication on 2/13 and 2/14, but that the resident did not receive the medication on 2/12. Further review of the resident's progress notes revealed a nurse's note dated 2/12/23 at 9:26 AM that stated that the medication was unavailable. A note was also found dated 2/13/23 at 12:30 AM that stated the resident received the first dose of the medication. No note could be found indicating that the resident's physician was notified of the missed dose. There was also no evidence that the medication's schedule was extended to ensure 3 doses were administered. On 3/29/23 at 11:00 AM, an interview was conducted with the Administrator and Licensed Practical Nurse (LPN) #3. During the interview, LPN #3 was shown Resident #2's February MAR indicating that only 2 doses were administered. LPN #3 stated that she would investigate the situation and inform the survey team of what she found. She stated that medication requiring delivery from the pharmacy sometimes does not come the next day when an order was placed late the previous day. In those circumstances, LPN #3 stated that the medication should be scheduled to begin later or the schedule should be extended when the first dose was unavailable. On 3/29/23 at 12:20 PM, LPN #3 returned to the survey team and confirmed that the dose was missed. Based on medical record review and staff interview, it was determined that facility staff failed to ensure residents were free from significant medication errors as evidenced by failing to follow a physician's order related to holding blood pressure medications and administering insulin if outside of physician ordered parameters. This was evident for 3 (Resident #4, #10, #2) of 6 residents reviewed for unnecessary medications during the annual survey. The findings include: Blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through the arteries. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps the blood out into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). A fingerstick (FS) is when the fingertip is pricked with a small needle called a lancet to produce a blood drop. The blood drop is then placed against the test strip in the glucose meter, and the meter shows the blood sugar level within seconds. The reading in the glucose meter will then be compared against physician's orders to determine if insulin coverage is needed. 1) On 3/23/23 at 1:40 PM a medical record review was conducted for Resident #4. Resident #4 was admitted in December 2022 with diagnoses that included atherosclerotic heart disease of native coronary artery, severe chronic kidney disease, stage 4, acute on chronic systolic (congestive) heart failure, sick sinus syndrome, bradycardia, atrial fibrillation, nonrheumatic aortic (valve stenosis), hypertension and repeated falls. Review of physician's orders revealed an order for Amiodarone 200 mg. every day, hold for heart rate less than 55. Amiodarone is used to treat and prevent certain types of serious, life-threatening ventricular arrhythmias (a certain type of abnormal heart rhythm) when other medications did not help or could not be tolerated. Amiodarone is in a class of medications called antiarrhythmics. The physician also ordered the medication Metoprolol Tartrate, 25 mg., give 0.5 tablet twice per day and hold for SBP less than 100, heart rate less than 55. This medication is a beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure. The physician also ordered the medication Losartan 100 mg., hold for SBP less than 120. Losartan can treat high blood pressure. It can reduce the risk of stroke in patients with high blood pressure and an enlarged heart. It can also treat kidney disease in patients with diabetes. It was also noted that Resident #4 was taking the medication Isosorbide Dinitrate Tablet 20 mg. 3 times per day for hypertension and Spironolactone 25 mg. every day for congestive heart failure. Review of the January 2023 Medication Administration Record (MAR) documented that the Losartan 100 mg. was given when the SBP was below 120. On 1/8/23 the blood pressure (b/p) was 117/42, on 1/21/23 the b/p was 115/64 and on 1/22/23 the b/p was 105/64. Licensed Practice Nurse #9 was the nurse that gave the medications outside of physician ordered parameters. Review of the February 2023 MAR documented that on 2/8/23 Resident #4's heart rate was 50. Amiodarone 200 mg. was given, and Metoprolol 12.5 mg. was given even though the physician ordered it to be held for a heart rate below 55. LPN #9 was the nurse that gave the medications outside of physician ordered parameters. Review of the March 2023 MAR documented that on 3/4/23 the heart rate was 50 and the Amiodarone 200 mg. and metoprolol 12.5 mg. were given and on 3/5/23 the heart rate was 54 and both medications were given by LPN #9. Again, the medications were given outside of the physician ordered parameters. On 3/28/23 at 12:21 PM the MARs were reviewed with Staff #31. Staff #31 confirmed that the medications should have been held. 2) On 3/24/23 at 11:53 AM a medical record review was conducted for Resident #10 and revealed a physician's order for NovoLog Flex Pen Solution Pen injector 100 UNIT/ML (Insulin Aspart), Inject 5 unit subcutaneously before meals related to type 2 Diabetes Mellitus. The order stated to, Administer for FS 130 or greater. Review of Resident #10's January 2023 MAR documented on 1/29/23 at 1730 the FS was 130 and Staff #33 did not give the insulin and on 1/25/23 at 7:30 AM the FS was 144 and LPN #9 did not give the insulin coverage. Review of Resident #10's February 2023 MAR documented on 2/28/23 at 1730 the FS was 130 and was not given by LPN #32. Review of Resident #10's March 2023 MAR documented on 3/8/23 and 3/13/23 at 1730 (5:30 PM) the FS was 130 and the medication was not given. The nurse that failed to administer the insulin was LPN #32. Review of LPN #32's employee performance appraisal dated 2/2023 documented, work quality was rated I (improvement needed) due to, incomplete and poorly written documentation; medication errors and missed assessments continue. The quantity of work was rated I, medication errors caused by not respecting the 5 rights of medication administration. The performance improvement plan was signed on 3/6/23. On 3/28/23 at 12:14 PM the medication issues were reviewed with Staff #31, (Assistant Director of Nursing). Staff #31 was asked if there had been any medication administration issues with LPN #32. Staff #31 stated that they have had issues with LPN #32 and that she would take care of the issue right away. On 3/29/23 at 2:34 PM the Nursing Home Administrator and Director of Nursing were made aware.

Based on observation, interview and medical record review, it was determined that the facility failed to ensure that humidified bottles for oxygen delivery were discarded in a timeframe for good infection control practice. This was evident for 1 (Resident #14) of 1 resident reviewed for respiratory care. The findings include: Oxygen therapy is a medical treatment in which oxygen is added to the air that a resident breathes. The simplest and most common form of oxygen delivery is through a nasal cannula which delivers oxygen directly into a resident's nostrils through a flexible tube. Medical oxygen lacks water content and is often humidified to increase comfort and decrease the drying effect of the oxygen. Nasal cannula systems are often humidified by attaching a sterile humidifier bottle to the delivery system. The oxygen bubbles through the sterile water prior to reaching the resident. If the water is not sterile, the oxygen could deliver pathogens directly to the resident's airway, increasing the risk of infection. Resident #14's room was observed on 03/27/23 at 02:12 PM. During the observation, a humidifier bottle attached to the resident's oxygen supply was noted to be dated 2/14/23. The bottle still had distilled water in it. Resident #14 was present in the room and was interviewed at that time. Resident #14 stated that he/she only uses oxygen infrequently as needed. The resident was noted to not being wearing the oxygen at that time. On 03/27/23 at 2:35pm, Licensed Practical Nurse (LPN) #9 was interviewed and stated that oxygen tubing should be changed weekly. When asked if the humidifier bottles are also changed, LPN #9 stated they monitor it and change it when it got low. When told that Resident #14 had a humidifier bottle dated 2/14/23, LPN #9 stated that one month was too long, especially with it not bubbling since [Resident #14] doesn't use it all the time. LPN #9 stated that she would change the humidifier bottle now. On 03/27/23 at 2:50 pm Resident #14's medical record was reviewed. The review revealed that resident had an active order to receive oxygen as needed. On 03/29/23 at 12:00 pm, the facility policy entitled Oxygenator was reviewed and it revealed that step number 4 of the procedure instructed staff to change humidifier bottles weekly. Resident #14 was not noted to be using oxygen at any point during the survey over approximately 10 observations.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that resident's mattresses were sized to securely fit the bed frames. This was evident for 1 (Resident #5) of 17 resident beds observed during the survey. The findings include: Resident #5's room was observed on 3/22/23 at 10:20 AM. During the observation, a gap of approximately 6 inches was seen between the mattress and the end of the bed. The Maintenance Director was interviewed on 3/28/23 at 10:19 AM in Resident #5's room. During the interview, the Maintenance Director inspected Resident #5's bed and confirmed that the mattress was not the standard size and did not fit the bed correctly. The Maintenance Director stated that he would find a more appropriate mattress and switch it out. On 3/28/23 at 10:56 AM, the Maintenance Director stated to the surveyor that a larger mattress had been located and placed on the bed. Resident #5's bed was observed on 3/28/23 at 2:56 PM. The mattress fit much better between the head and the foot of the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to: 1) orient, prepare, and document a resident's preparation for a transfer to the hospital and 2) document that information was provided to the acute care facility when a resident was transferred there emergently. This was identified for 3 (Resident #9, #16, #4) of 3 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 3/23/23 at 9:17 AM an interview was conducted with Resident #9. Resident #9 was asked if h/she had been sent to the hospital recently. Resident #9 stated, yes, to rule out a vein blockage. On 3/24/23 at 8:27 AM a review of Resident #9's medical record was conducted and revealed a 10/10/22 nursing note that documented the resident was, alert and verbal but not at baseline and remained in bed this shift d/t 'feeling lousy.' The physician was notified and ordered for 911 to be called to send the resident to the hospital. There was no documentation in Resident #9's medical record that the receiving facility was given information about the resident prior to the transfer and what documentation was sent with the resident. 2) On 3/23/23 at 10:52 AM a review of Resident #16's medical record was conducted. A 10/29/22 nursing note documented, called to room @ 0945 with report of resident on floor in bathroom. Unable to move RLE (right lower extremity), c/o (complained of) severe pain. [name] and [name] notified, 911 called to transport to ED (emergency department). There was no documentation in Resident #16's medical record that the receiving facility was given information about the resident prior to the transfer and what documentation was sent with the resident. 3a) On 3/29/23 at 9:32 AM a review of Resident #4's medical record was conducted and revealed a 1/11/23 nursing note that documented Resident #4 had chest pain and difficulty breathing. The physician was notified and ordered to transfer the resident to the hospital for evaluation. There was no documentation in Resident #4's medical record that the receiving facility was given information about the resident prior to the transfer and what documentation was sent with the resident. 3b) Continued review of Resident #4's medical record revealed a 1/28/23 nursing note that documented Resident #4 complained of shortness of breath with chest tightness, pain, and episodes of emesis (vomiting). The physician was notified and gave orders to transfer to the emergency room for evaluation and treatment. There was no documentation in Resident #4's medical record that the receiving facility was given information about the resident prior to the transfer and what documentation was sent with the resident. 3c) Further review of Resident #4's medical record revealed a 3/14/23 nursing note that documented Resident #4 was on the floor complaining of pain to the right hip. The physician was called and ordered to transfer the resident to the emergency department. There was no documentation in Resident #4's medical record that the receiving facility was given information about the resident prior to the transfer and what documentation was sent with the resident. On 3/28/23 at 11:33 AM Staff #3 was interviewed and stated, the nurses call the Director of Nursing (DON), notify the physician, update the POA (Power of Attorney), call EMS, and print out all medical information that goes with resident. Staff #3 stated, the nurses usually document in a progress note that report was given. Staff #3 was shown that there was no documentation found in nursing notes that the receiving facility was notified and what information was sent with the resident. The concerns were discussed with the DON and the Nursing Home Administrator on 3/29/23 at 2:34 PM.

4) Resident #2's medical record was reviewed on 3/29/23 at 10:57 AM. The review revealed an MDS quarterly assessment with an ARD of 1/24/23. In the assessment, Item N0300 documented that Resident #2 had received injections for 7 out of 7 days of the look-back period. Item N0350B documented that the resident had received insulin for 7 out of 7 days of the look-back period. Resident #2's MAR for January 2023, was reviewed on 3/29/23 at 11:10 AM. The review revealed that resident received insulin on only 3 days (1/19, 1/20, and 1/22) from 1/18/23 to 1/24/23, the look-back period of the quarterly MDS assessment. Based on observation, interview and medical record review, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#3, #6, #9, #2) of 14 records reviewed during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 3/22/23 at 1:21 PM an interview was conducted with Resident #3 who stated h/she had a fall in the bathroom. On 3/30/23 at 9:19 AM a review of Resident #3's medical record revealed the resident had a history of falls. Continued review of Resident #3's medical record revealed a nursing note dated 3/16/22 that stated the resident had an assisted fall/lowered to the floor during a stroll out at the front porch and no injury was noted. Review of the MDS with an Assessment Reference Date (ARD) of 6/12/22, section J1900, failed to capture the fall of 3/16/22. A 12/29/22 at 16:03 (4:03 PM) a nursing note documented the resident was found seated on the floor in the bathroom. Resident #3 sustained an abrasion on the right cheek that was cleansed, and steri-strips were applied. A 2/8/23 at 20:57 (8:57 PM) a nursing note documented the geriatric nursing assistant (GNA) was in another room and heard the resident fall. Resident #3 sustained a laceration to the right temple. Review of the MDS with an assessment reference date (ARD) of 2/8/23, Section J1900, documented that Resident #3 had (1) fall with injury. This was incorrect as there were (2) falls with injury. 2) On 3/23/23 at 2:07 PM a record review was conducted for Resident #6. A 1/2/23 skin/wound note documented that the physician was seen for follow-up of scar tissue to sacrum. Recommendations were, scar tissue, sacrum, continue skin prep every day. Review of the MDS with an ARD of 1/5/23, Section M0100A, documented no pressure ulcer. Question M0210 unhealed pressure ulcers documented yes. and Section M0300B1 documented 1 stage 2 pressure ulcer. This was an error. 3a) On 3/23/23 at 9:22 AM an interview was conducted with Resident #9. Resident #9 stated h/she had limited range of motion (ROM) to the bilateral lower extremities and some issues with the upper extremities. On 3/29/23 at 12:15 PM observation was made of Resident #9 in the dining room and Staff #30 was seen cutting up Resident #9's food. On 2/29/23 at 2:16 PM an interview was conducted with Staff #30. Staff #30 stated they cut up Resident #9's food due to his/her due to his/her disability and will move the food closer to the resident. On 3/30/23 at 11:41 AM an interview was conducted with Staff #6 (PT manager) who stated that Resident #9 had limited mobility in the bilateral shoulders from his/her disease process, was receiving occupational therapy and the highest Resident #9 could lift the shoulders was 90 degrees. Review of the MDS with an ARD of 8/28/22, Section G0400, Functional limitation in range of motion, documented Resident #9 had an impairment in both the upper and lower extremities, however the MDS with an ARD of 12/12/22 and 2/8/23 failed to capture the impairment in the upper extremities. 3b) Review of the MDS with an ARD of 5/28/22 Section H0100C, ostomy, was coded yes. An ostomy is an artificial opening in an organ of the body, created during an operation where bodily waste is rerouted from its usual path because of malfunctioning parts of the urinary or digestive system. Review of Resident #9's medical record failed to produce documentation that the resident had surgery related to an ostomy. The MDS was coded in error. On 3/30/23 at 1:36 PM the areas in the MDS were discussed with Staff #31. Staff #31 confirmed the errors and stated she would do corrections.

Based on observation, medical record review, and staff interview it was determined that facility staff failed to develop and initiate comprehensive, resident centered care plans for residents residing in the facility. This was evident for 6 (Resident #3, #4, #5, #6, #9, #10) of 14 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 3/22/23 at 1:18 PM the surveyor entered Resident #3's room and attempted to interview Resident #3. Resident #3 sat in the chair and stared at the surveyor. The surveyor attempted to ask the resident questions and the resident responded like he/she could not hear the surveyor. Upon looking around the resident's room a small white dry erase board was found on the dresser by the television. The surveyor wrote down questions and Resident #3 answered the questions. On 3/30/23 at 9:19 AM a medical record review revealed a 9/21/22 physician's annual note which documented, patient has HOH (hard of hearing) and questions have to be written up. On 3/30/23 at 10:49 AM an interview with geriatric nursing assistant (GNA) #17 was conducted. GNA #17 stated that they write down what they want to say because Resident #3 was severely hearing impaired. Review of the MDS with an assessment reference date (ARD) of 2/8/23, Section B, coded highly impaired for hearing. Review of Resident #3's care plans failed to produce a care plan for hearing impairment/communication. 2) On 3/24/23 at 8:08 AM a medical record review was conducted for Resident #4. Review of physician's orders documented Resident #4 received Buspirone 3 times a day for anxiety. Review of progress notes for behavior documented on 3/24/23 at 3:10 AM that Resident #4 had 3 episodes during the night shift of yelling out and thinking it was time to get up. On 2/18/23 at 2:23 AM it was documented the resident was constantly calling out, nurse, nurse. The resident would yell out if any noise or someone talking was heard. Interventions were put into place and were ineffective. On 2/17/23 at 11:15 PM it was documented that there were at least 7 times of restlessness and confusion. On 2/16/23 at 7:42 AM it was documented that the nurse tried to administer morning medications and the resident stated, don't touch me. Review of the care plan section of the medical record failed to produce a care plan for anxiety. 3a) Observation was made on 3/22/23 at 10:24 AM of Resident #5 sitting in a high back wheelchair. Resident #5's hands appeared to be contracted along with the right arm. On 3/23/23 at 3:07 PM a medical record review was conducted and revealed a care plan, PROM (passive range of motion) diminished ability to actively perform ROM (Range of Motion) r/t contractures with a goal, resident will cooperate with staff during exercises. There was only 1 intervention on the care plan, support joints and limbs as you move through the range for each limb. Do not cause discomfort. The care plan was not comprehensive, and resident centered. 3b) Further review of Resident #5's care plans revealed a care plan for Vitamin B12 deficiency anemia that was initiated on 12/6/21 with a goal, will not have symptoms that could be related to diagnosis of B12 anemia, will have not have symptoms that could be r/t diagnosis of B12 anemia, will not experience local side effect from Vitamin B 12 monthly injection, and will not experience excessive Vitamin B 12 level. The only intervention on the care plan was, Vitamin B 12 injection q month. The care plan was not comprehensive, and resident centered. 4) On 3/23/23 at 2:07 PM a record review was conducted for Resident #6. A 12/5/22 skin/wound note documented that the physician saw the resident due to voiced complaints of pain in the area of the buttocks. The recommendations were skin prep applications scheduled for 10 AM as the area was a scar that initially measured 1.5 cm by 1.0 cm. Resident #6 was seen weekly by the skin/wound physician and recommendations were to continue skin prep every day. Review of Resident #6's care plans failed to produce a care plan for the skin or a skin prevention care plan for a resident that was seen weekly by a skin/wound physician with areas of concern in the area of the sacrum/buttocks. 5a) On 3/23/23 at 9:22 AM an interview was conducted with Resident #9 who stated that h/she had limited range of motion to his/her lower extremities and some problems with the upper extremities. On 3/30/23 at 12:34 PM a review of Resident #9's medical record revealed the care plan, ROM: Diminished ability to actively perform ROM r/t decreased mobility and weakness with the goal, resident will cooperate with staff during exercises. There was only 1 intervention on the care plan, Support joints and limbs as you move through the range for each limb. Do not cause discomfort. The care plan was not comprehensive and specific to Resident #9. 5b) Continued review of Resident #9's medical record revealed a physician's order, Pressure Ulcer - Unstageable cleanse with NSS (normal saline solution), pat dry, apply Santyl, apply Calcium-Alginate, cover with dry dressing -Start Date12/14/2022 -D/C Date 02/20/2023. Review of the MDS with an Assessment Reference Date (ARD) of 12/12/22 and 2/8/23 documented in Section M0100, Skin, that Resident #9 had an unhealed pressure ulcer, and it was present upon readmission to the facility in December 2022. Review of care plans revealed a, potential impairment to skin integrity care plan but there was no specific care plan for the left heel. 5c) Further review of Resident #9's medical record revealed a physician's order for Metoprolol Succinate ER Tablet, Extended Release 50 mg. to be given every day. The order stated to hold the medication for a SBP (systolic blood pressure) less than 100 or HR (heart rate) below 60. The top number of the blood pressure refers to the amount of pressure in the arteries during the contraction of the heart muscle. This is called systolic pressure. Review of Resident #9's March 2023 Medication Administration Record (MAR) documented that the SBP was being monitored but not the heart rate. Further review of the December 2022, January 2023, and February 2023 MARS also failed to reveal documentation that the heart rate was being monitored prior to administering the medication. Review of the care plan, on daily medications for essential (primary) hypertension had the intervention, administer hypertension medications daily per physician's orders. The care plan was not implemented as the physician ordered parameters for the heart rate and the heart rate was not documented as monitored prior to medication administration. 5d) On 3/23/23 at 9:22 AM during an interview with Resident #9, it was learned that Resident #9 used a condom catheter during the night. A condom catheter is a urine collection device that fits like a condom over the penis, but also has a tube that goes to a collection bag strapped to the leg. The purpose of the catheter was due to urinary incontinence at night. Review of the MDS with an ARD of 2/8/23 coded an external catheter in Section H, urinary status. Review of the care plan section of the medical record failed to produce a care plan for the catheter. 6) On 3/24/23 at 11:53 AM a review of Resident #10's medical record was conducted and revealed an order for NovoLog Flex Pen Solution Pen injector 100 UNIT/ML (Insulin Aspart), Inject 5 unit subcutaneously before meals related to Type 2 Diabetes Mellitus. The order stated to administer for a fingerstick (FS) reading of 130 or greater. Review of Resident #10's January 2023 MAR documented on 1/29/23 at 1730 the FS was 130 and on 1/25/23 at 7:30 AM the FS was 144. The insulin was not administered. Review of Resident #10's February 2023 MAR documented on 2/28/23 at 1730 the FS was 130 and the insulin was not administered. Review of Resident #10's March 2023 MAR documented on 3/8/23 and 3/13/23 at 1730 (5:30 PM) that the FS was 130. The insulin was not administered. Review of the care plan, has Diabetes Mellitus had the intervention, diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. (Humulin NPH, Levemir, and Novolog). The nurses failed to follow the care plan by failing to follow physician's orders for administering insulin when the fingerstick reading was 130 or above. On 3/28/23 at 12:21 PM reviewed the care plan concerns with Staff #3 and Staff #31. Both stated understanding and that the care plans needed work.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) The Maryland Orders for Life-Sustaining Treatment (MOLST) form is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. It was designed to ensure that healthcare providers throughout Maryland have a uniform system of communicating a resident's end-of-life wishes in the event of cardiac or respiratory arrest. Cardiopulmonary Resuscitation (CPR) is the act of attempting to revive someone one their heart or breathing have stopped. Resident #1's medical record was reviewed on [DATE] at 8:32 AM. The review revealed that the resident had an order for comfort care. The review also revealed that the resident's MOLST, dated March, 2020, specified No CPR, option B (palliative care). Review of Resident #1's care plan revealed a care plan topic for Discharge Planning. The care plan was most recently revised on [DATE] as evidenced by the goals being updated. However, the interventions included Resident has a CPR/Full Code Order. 4) Resident #2's medical record was reviewed on [DATE] at 12:36 PM. During the review, it was noted that the resident was prescribed an anticoagulant (blood thinner) medication called Eliquis. The order date for the Eliquis was [DATE]. The resident was not prescribed any other anticoagulant medication. Review of Resident #2's care plan revealed a care plan topic stating, Resident is on warfarin [another anticoagulant] per physician's orders for acute embolism and thrombosis of bilateral lower extremities. The care plan was most recently revised on [DATE] as evidenced by the goals being updated. There was no evidence in the medical record that the resident should have been taking warfarin at that time. 5) Resident #12's medical record was reviewed on [DATE] at 11:32 AM. The review revealed that the resident was prescribed Eliquis, an anticoagulant (blood thinner) medication. The order date for the Eliquis was [DATE]. There was also an order for aspirin, which also affects the body's ability to form blood clots. Review of Resident #12's care plan revealed a care plan topic for receiving aspirin. The topic included interventions relevant to monitoring for bleeding tendency and other side effects from anticoagulant medication. However, the care plan did not address the resident's order for Eliquis, which has a greater potential for side effects than aspirin. Based on interview and medical record review, it was determined the facility staff failed to evaluate and revise resident care plans to reflect accurate and current interventions. This was evident for 5 (Resident #3, #5, #1, #2, #12) of 14 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On [DATE] at 1:18 PM an interview was conducted with Resident #3. Resident #3 was asked if h/she had any recent falls. Resident #3 stated h/she slipped in the bathroom and fell and hit his/her head and was sore. On [DATE] at 9:19 AM Resident #3's medical record was reviewed and revealed the resident has had several falls. Review of the care plan, is a high risk for falls r/t gait/balance problems, vision/hearing. problems, failed to produce evaluations of the care plan due to the number of falls. It was documented that the resident had a fall on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] night shift, [DATE] evening shift and [DATE]. Interventions on the care plan included, anticipate and meet needs, call light within reach and encourage to use for assistance and prompt response to request for assistance, offered and assisted with mobility in a wheelchair for all outside activities which require long distance ambulation sessions, educated resident/family/caregivers about safety reminders, encourage to utilize the wheelchair when outside of the home with an escort, ensure wearing appropriate footwear, follow facility fall protocol, keep furniture in locked position and maintain a clear pathway, keep needed items within reach, and ensure rolling walker in in place as needed. Further review of interventions on the care plan revealed only 1 updated intervention after the fall on [DATE] which was a bed alarm at all times while in bed to alert staff of movement. There was no evaluation of the care plan and no further updates of interventions to prevent the falls. On [DATE] at 11:04 AM interview Licensed Practice Nurse (LPN) #29 revealed the resident had bradycardia (low heart rate) and was getting a pacemaker on [DATE]. LPN #29 stated that hopefully getting the pacemaker would prevent the resident's dizziness and falls. 2a) On [DATE] at 3:07 PM Resident #5's medical record was reviewed. Resident #5's care plan, will have no complications related to diabetes through the review date documented the intervention, Diabetes medication as ordered by doctor (ACTOS). Review of Resident #5's medications for diabetes did not include the medication Actos. The care plan was not updated to reflect the change. Further review of the care plan documented, Educate regarding medications and importance of compliance. Have [name of resident] verbally state an understanding. This was not resident centered as the MDS with an assessment reference date of [DATE], Section C, Cognition, documented Resident #5 was severely impaired. Additionally, the care plan intervention, FS (fingerstick) every Tuesday as ordered by MD was not on the physician's order page. Review of the vital sign section of the medical record documented the last time the FS was performed was [DATE]. 2b) Continued review of Resident #5's medical record revealed the physician decreased the antipsychotic medication Seroquel from 25 mg. in the AM and 50 mg. in the PM to just 25 mg. in the PM on [DATE]. Review of the psychotropic medication care plan had the intervention, Seroquel 25 mg. q 8 AM, 50 g q HS (bedtime) that was revised on [DATE]. The care plan was not updated after the MDS was completed on [DATE] and a care plan conference was held on [DATE]. On [DATE] at 12:21 PM reviewed the care plan concerns with Staff #3 and Staff #31. Both stated that they did not write out care plan evaluations. Both also acknowledged the care plan concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that residents had only one Maryland Order for Life-Sustaining Treatment (MOLST) form in their paper medical record. This was evident for 4 (Residents #14, #1, #16, and #4) of all 17 residents present in the facility at the time of the survey. The findings include: The Maryland Orders for Life-Sustaining Treatment (MOLST) form is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. It was designed to ensure that healthcare providers throughout Maryland have a uniform system of communicating a resident's end-of-life wishes in the event of cardiac or respiratory arrest. Cardiopulmonary Resuscitation (CPR) is the act of attempting to revive someone one their heart or breathing have stopped. On [DATE] at 9:24 AM, a review was done of the paper medical records for all 17 residents in the facility. The review revealed that all residents had a Maryland Order for Life-Sustaining Treatment (MOLST) form located early on in their paper medical record. However, four residents had more than one MOLST form in their record: - Resident #14 was noted to have a MOLST form dated [DATE] that had No CPR Option A-2 selected and another MOLST form dated [DATE] that had No CPR Option B: Palliative selected. Neither form was voided. - Resident #1 was noted to have a MOLST form dated [DATE] and another form dated [DATE]. The forms had been filled out identically. Neither form was voided. - Resident #16 was noted to have a MOLST form dated [DATE] that had No CPR Option A-2 selected and another MOLST form dated [DATE] that had Attempt CPR selected. The documents were in a plastic sleeve together; the newer one was the first one visible while the older one was behind it and could only be accessed by removing the first. Neither form was voided. - Resident #4 was noted to have a MOLST form dated [DATE] and another MOLST form dated [DATE]. The forms had been filled out identically. Neither form was voided. Licensed Practical Nurse (LPN) #29 was interviewed on [DATE] at 9:42 AM. When asked what document she would utilize to determine a resident's code status, LPN #29 stated that she would refer to the MOLST in the paper record. LPN #29 indicated that the residents' code status was also available electronically. LPN #29 was handed Resident #16's paper chart and was asked how she would determine the code status for the resident. Prior to looking in the chart, she stated that she knew that Resident #16's code status to be No CPR. She then referenced the chart, located the MOLST dated [DATE], and indicated that this is the MOLST that she would use to determine the resident's code status. She then opened up Resident #16's electronic medical record and showed that the resident had a current code status of No CPR ordered for her that displayed on the resident's banner at the top of the screen. LPN #29 stated that previous MOLSTs should be voided. The Administrator was interviewed on [DATE] at 10:30 AM. During the interview, the Administrator was notified that 4 residents' paper medical records had multiple MOLST forms in them. The Administrator indicated that this was incorrect practice and that the expectation was for old MOLST forms to be voided. On [DATE] at 1:00 PM, the Administrator and LPN #3 provided the requested photocopies of all MOLST forms to the survey team and stated that they had ensured that all 4 charts had been corrected and now contained only one MOLST form.

Based on medical record review and staff interview it was determined the facility failed to 1) keep the pharmacy reviews with recommendations that identified irregularities in the resident's medical record and 2) report that a physician ordered parameter was not being monitored. This was evident for 4 (#4, #5, #10, #9) of 6 residents reviewed for unnecessary medications. The findings include: 1) On 3/23/23 at 1:40 PM a medical record review was conducted for Resident #4 and revealed progress notes that documented monthly pharmacy reviews were done on 1/18/23 with no recommendations and on 2/16/23 with no recommendations. The 3/9/23 pharmacy review documented, see report. There was no report found in the medical record for the 3/9/23 pharmacy review, therefore there was no documentation if the physician agreed or disagreed with the recommendation. 2) On 3/23/23 at 3:07 PM a medical record review was conducted for Resident #5 and revealed progress notes that documented pharmacy reviews were done on 1/18/23, 9/19/22, 6/7/22, and 5/10/22 that noted, see report. Further review of the medical record failed to produce the reports, therefore there was no documentation if the physician agreed or disagreed with the recommendation. 3) On 3/24/23 at 11:53 AM a medical record review was conducted for Resident #10 and revealed progress notes that documented pharmacy reviews were done on 2/16/23, 1/18/23, 11/14/22, and 1/11/22 that noted, see report. Further review of the medical record failed to produce the reports, therefore there was no documentation if the physician agreed or disagreed with the recommendation. On 3/24/23 at 2:14 PM an interview was conducted with Staff #3 and the Nursing Home Administrator (NHA) regarding the monthly pharmacy reviews (MRR). Staff #3 stated that the MRR's were printed for the Director of Nursing, saved for the physician to review, and if nursing could address the concern they would do it. If not, once the physician reviewed and completed, they send the reviews to her and she keeps the reviews in a binder in the office. On 3/29/23 at 2:34 PM the Nursing Home Administrator and Director of Nursing were informed of the findings. 4) On 3/30/23 at 12:34 PM a review of Resident #9's medical record was conducted and revealed a physician's order for Metoprolol Succinate ER Tablet, Extended Release 50 mg. to be given every day. The order stated to hold the medication for a SBP (systolic blood pressure) less than 100 or HR (heart rate) below 60. Review of Resident #9's March 2023 Medication Administration Record (MAR) documented that the SBP was being monitored but not the heart rate. Further review of the December 2022, January 2023, and February 2023 MARS also failed to reveal documentation that the heart rate was being monitored prior to administering the medication. Further review of the medical record revealed monthly drug regimen reviews were done on 12/13/22, 1/18/23, 2/16/23, and 3/9/23 and documented no irregularities. The monthly reviews did not capture that the heart rate was not being monitored prior to medication administration. On 3/30/23 at 1:48 PM the above concerns were discussed with the Assistant Director of Nursing and Staff #3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility staff failed to: 1) discard expired food items, 2) label food items when opened, and 3) discard damaged food items. This was evident during an inspection of the kitchen, dry storage room, and kitchenette on the unit during the annual survey. The findings include: On 3/22/23 at 9:03 AM a tour of the kitchen was conducted with the Director of Food Service, Staff #20. Observation was made in the refrigerator of the following items: (1) opened gallon of Classic Gourmet tarter sauce with a best by date of 1/31/23 (1) opened gallon of [NAME] Brand Buttermilk Ranch dressing with a best by day of 1/18/23 (2) opened 32 oz. Tulkoff Brand horseradish with best by date of 5/18/22 and 5/15/22 respectively (1) opened gallon of Kens [NAME] Slaw Dressing with no date opened (1) opened gallon of Kens Thousand island dressing with a manufactured date of 3/8/22, with no date opened. Staff #20 stated those items should have been discarded. Observation was made in the dry storage room adjacent to the kitchen of the following: (2) 6 lb. 8 oz. cans of sliced apples that had dents in the cans (40) packages of 24 oz. bags of mixed dry fruit punch and dry orange crystal drink mix that were hard. Staff #20 stated they had a new employee working in the kitchen that should have not put the dented cans in the rack. Staff #20 also stated the packages that were hard should have been thrown out. On 3/23/23 at 10:00 AM observation was made in the unit of the kitchenette refrigerator. There was (1) fruit cocktail with a best by date of 10/28/22 and (1) opened half gallon of reduced fat milk with a date of 3/17/23. Staff #20 was with the surveyor at the time of observation. The concerns were discussed with the Director of Nursing and the Nursing Home Administrator on 3/29/23 at 2:34 PM.

5) Resident #2's medical record was reviewed on 3/22/23 at 12:58 PM. During the review, no evidence could be found in the medical record that Resident #2 had developed an advanced directive. The Director of Nursing (DON) was interviewed on 3/23/23 at 8:58 AM. During the interview, the DON stated that most of residents' advanced directives were in the paper medical record or uploaded to the miscellaneous section of the electronic medical record. However, she stated that some advanced directives were not in the medical record and were kept in a locked office. The Administrator and Licensed Practical Nurse (LPN) #3 were interviewed on 3/24/23 at 8:03 AM. During the interview, the Administrator stated that the Medical Records Coordinator was in the process of uploading some advanced directives into the electronic medical record. LPN #3 provided the surveyor with a copy of Resident #2's advanced directive. LPN #3 stated that the advanced directive was in an office and was not elsewhere in the medical record. The Medical Records Coordinator was interviewed on 3/24/23 at 11:25 AM. During the interview, the Coordinator stated that she was in the process of uploading documents and that the social work department usually provides advanced directives to her to upload. She stated that she hadn't been given a copy of Resident #2's advanced directive to upload yet, and that the advanced directive was probably in the social worker's office. 6) The electronic medical records for Resident #12 and #2 were reviewed on 3/24/23. The review revealed documentation that monthly medication regimen reviews (MRRs) were being completed by a consultant pharmacist. When no variance was identified by the pharmacist, that was documented clearly in the medical record. But when the pharmacist did identify a variance, the progress note stated to refer to a report. No reports could be found in the electronic medical record for Resident #2's variances identified on 8/9/22, 6/7/22, and 4/11/22, nor for Resident #12's variances identified on 9/19/22, 8/9/22, and 7/11/22. Both residents' paper medical records were also reviewed on 3/24/23. No documentation regarding these variances was found there either. The Administrator and Licensed Practical Nurse (LPN) #3 were interviewed on 3/24/23 at 2:14 PM. During the interview, LPN #3 stated that MRR reports were printed by the Director of Nursing (DON) for the physician to review. Once completed and addressed, the report returns to the DON's office and is kept in a binder there. The binder is not an accessible part of residents' medical records. Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 6 (#4, #5, #10, #13, #2, #12) of 14 residents reviewed during the annual survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 3/23/23 at 1:40 PM a medical record review was conducted for Resident #4 and revealed the 3/9/23 pharmacy review documented, see report. There was no report found in the medical record for the 3/9/23 pharmacy review. 2) On 3/23/23 at 3:07 PM a medical record review was conducted for Resident #5 and revealed progress notes that documented pharmacy reviews were done on 1/18/23, 9/19/22, 6/7/22, and 5/10/22 that noted, see report. Further review of the medical record failed to produce the reports. 3) On 3/24/23 at 11:53 AM a medical record review was conducted for Resident #10 and revealed progress notes that documented pharmacy reviews were done on 2/16/23, 1/18/23, 11/14/22, and 1/11/22 that noted, see report. Further review of the medical record failed to produce the reports. On 3/24/23 at 2:14 PM an interview was conducted with Staff #3 and the Nursing Home Administrator (NHA) regarding the monthly pharmacy reviews (MRR). Staff #3 stated that the MRR's were printed for the Director of Nursing, saved for the physician to review, and if nursing could address the concern, they would do it. If not, once the physician reviewed and completed, they send the reviews to her, and she keeps the reviews in a binder in the office and not in the resident's medical record. 4) On 3/30/23 a review of Resident #13's medical record was conducted. Review of the current physician's orders documented, vital signs and weights monthly. Review of the weight section of the medical record revealed the last weight documented was on 6/15/22. On 6/8/22 Resident #13 was placed on comfort care. Review of the care plan, at nutritional risk documented the intervention, Comfort care now D/C weights on 9/19/22. On 3/30/23 at 1:48 PM Staff #3 and Staff #31 confirmed that the order for weights should have been discontinued as the resident was on comfort care.

Based on staff interview it was determined the facility failed to have a full time certified dietary manager to oversee the operations in the dietary department. This was evident during a tour of the kitchen during the annual survey and had the potential to affect all residents. The findings include: On 3/22/23 at 9:03 AM a tour of the kitchen was conducted with the Director of Food Service, Staff #20. Staff #20 was asked if she was a certified dietary manager (CDM). Staff #20 stated, I have a pre CDM, but I still have to take the test. On 3/29/23 at 1:30 PM an interview was conducted with the Registered Dietician (RD). The RD stated she was only at the facility one day a week on Mondays. When asked if she supervised the kitchen operations she stated, I don't supervise in the kitchen. On 3/29/23 at 2:34 PM the Nursing Home Administrator was informed of the concern and failed to produce documentation that Staff #20 was a CDM.

Based on documentation review and interview, it was determined the facility failed to have a quality assurance policy that had written procedures for quality assurance activities. This was evident during the annual survey and had the potential to affect all residents. The findings include: On 3/30/23 at 1:52 PM an interview with was conducted with Licensed Practical Nurse (LPN) #3 who oversaw quality assurance activities and Staff #31. LPN #3 described the items that were reported on in quality assurance meetings. The quality assurance and performance improvement program policy was reviewed with LPN #3 and Staff #31. The policy was six pages and documented the purpose, organization, authority, responsibilities, methodology, problem assessment, confidentiality, and evaluation. The policy was an outline of what the facility planned to do and did not have a breakdown of the procedures to do the activities. The policy was missing the following: - procedures for data collection from staff, residents, and RP's (resident representatives) - procedures in the Problem Assessment section - procedures for tracking performance or quality indicators - procedures for determining underlying causes of identified problems - what performance improvement plans were scheduled, or at least how many they plan to do in a year - procedures for abuse and neglect as it relates to quality assurance -procedures for monitoring accidents, medication errors, pressure ulcers, nutrition, unexpected death -timeframes for referral to the quality assurance committee -a description of the thresholds and performance parameters that represent acceptable care for the measured criteria -the methodology for evaluating and analyzing data to determine trends and patterns. -procedures for how the quality assurance activities will be documented -a description of the plan for follow-up to determine effectiveness of the recommendations LPN #3 stated, we have concern boxes, and we talk to staff on a consistent basis about issues. LPN #3 stated, education was an issue and we reinstated all the education back together. The concern was discussed with LPN #3 how the plan was not detailed with procedures. When asked how the facility involved the residents, staff, and families, LPN #3 stated, we use verbal, and we use to do a satisfaction survey prior to 2020. LPN#3 agreed that the procedures were not detailed and that the plan needed work.

Based on medical record review and staff interview it was determined the facility staff failed to ensure that the information used to complete the Minimum Data Set (MDS) comprehensive assessments was accurate for: 1) the use of restraints for Resident #7; and 2) skin conditions for Resident #27. This was evident for 2 of 3 residents reviewed for MDS accuracy during this complaint revisit survey. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. MDS or Minimum Data Set coordinators are nurses that are tasked to ensure that patient servicing is well documented especially during the assessment phase in facilities that are accredited or offer Medicaid or Medicare services. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1)The facility failed to enter accurate information in the MDS assessment regarding restraints for Resident #7. Medical record review, on 1/3/19, revealed a care plan, with an initiation date of 7/13/18, that addressed the risk for elopement. Interventions included the placement of a Wander Alert device to the right wrist security bracelet. Elopement is defined as a resident that is not pre-authorized to leave the agency or activity site but does so intentionally and the resident's location is unknown. The Wander Alert management system is utilized to protect residents, at risk of wandering and elopement. If a resident wearing a Wander Alert bracelet signaling device passes through a monitored area, an alarm sounds to alert staff of a possible departure. The Wander Alert alarm will continue to sound until staff respond to the door to reset the alarm. A physician's order for a roam alert bracelet to be worn at all times was entered in the medical record on 7/17/18 for Resident #7. Review of the quarterly MDS assessment, dated 10/10/18, Section P-Restraints revealed that facility staff failed to code the resident for the use of the Wander Alert bracelet. In interview with the surveyor, on 1/3/19 at 2:17 PM, the MDS Coordinator acknowledged this oversight and submitted a modification of the assessment on 1/4/19. 2) The facility failed to enter accurate information in the MDS assessment regarding skin conditions for Resident #27. Medical record review on 1/3/19 revealed a Skin Assessment, dated 12/1/18, that noted an open area on the right abdominal fold due to moisture measuring 0.1 centimeters x 2 centimeters. Review of the December 2018 Medication Administration Record revealed a treatment order to apply rolled gauze to bilateral abdominal folds to prevent moisture associated skin damage. Another order, dated 12/1/18, directed staff to apply Calcium Alginate (wound treatment) to the right abdominal fold topically every evening and night for moisture associated skin damage. Moisture Associated Skin damage is a general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus (www.woundsource.com/patientcondition/moisture-associated-skin-damage-masd). Review of the quarterly MDS Assessment, dated 12/1/18, section M1040-Moisture Associated Skin Damage, revealed that the facility failed to code the resident as having skin damage. In interview with the surveyor, on 1/3/19 at 2:17 PM, the MDS Coordinator confirmed the inaccuracy and submitted a modification to the MDS assessment on 1/3/19.

Based on medical record review and staff interview it was determined the facility staff failed to provide evidence of ongoing monitoring and documentation of target symptoms for the administration of psychotropic medications to determine the efficacy and necessity of these medications for Residents #7 and #5. This was evident for 2 of 3 residents reviewed for unnecessary medications during this survey. MDS or Minimum Data Set Coordinators are nurses that are tasked to ensure that patient servicing is well documented especially during the assessment phase in facilities that are accredited or offer Medicaid or Medicare services. The findings include: 1)The facility failed to demonstrate consistent monitoring and documentation of target symptoms for Celexa and Trazadone, the use of non-pharmacological interventions, and provide a rationale for the simultaneous use of two antidepressants to determine the necessity and efficacy of the medications for Resident #7. Medical record review revealed that Resident #7 was a long-term care resident with diagnoses that included but were not limited to Dementia, Depression and Unspecified Behavioral Disturbances. Medical record review revealed physician's orders for Celexa for depression, entered on 7/12/18 and Trazadone for behavioral problems, entered on 8/21/18. An order was entered in the medical record on 7/17/18 to document episodes of wandering and exit seeking every shift if the behavior occurs along with interventions and outcome in the resident's record. Physician's orders, dated 7/19/18, instructed staff to document episodes of anxiety/agitation every shift if an episode occurs and episodes of insomnia every night shift along with interventions and outcomes in the medical record. Review of the Medication Administration Records revealed that staff indicated that the resident demonstrated anxiety/agitation on November 3, 4, 7, 12, 16, 17, 18, 21, and 26, 2018, December 1, 2, 7, 10, 11, 14,15,16,19, 20, 21, 25, 27, 28, 29, and 30, 2018, and January 2, 2019. Review of the medical record failed to reveal corresponding progress notes that documented specific behaviors, interventions to address the behaviors and outcomes. 2)The facility failed to demonstrate consistent monitoring and documentation of target symptoms for psychotropic medications and a rationale for the simultaneous use of two antidepressants and two antianxiety medications for Resident #5. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, anti-psychotics, anti-depressants, anti-anxiety and hypnotics. Medical record review, on 1/4/18, revealed that Resident #5 was a long-term care resident with diagnoses that included but were not limited to Anxiety Disorder, Depression and Unspecified Psychotic Disorder. A Care plan initiated on 6/8/15 addressed the use of multiple psychotropic drugs used to manage bipolar disorder, anxiety, insomnia and depression. The last noted revision was 6/26/18. The plan did not list target symptoms for monitoring. Another care plan initiated on 6/8/15 addressed antidepressants to manage depression and insomnia. These care plans did not include non-pharmacologic interventions to assist in managing the resident's symptoms. Review of the medical record on 1/4/18 revealed orders for Ativan (antianxiety), initiated on 9/4/18 for anxiety/insomnia, Celexa (antidepressant), initiated on 9/4/18 for depression, Clonazepam (antianxiety) initiated on 9/3/18 for anxiety/insomnia, Seroquel (antipsychotic) initiated on 9/3/18 for Bipolar Disorder, and Trazadone (antidepressant) initiated on 9/3/18 for depression. A Physician's order dated 9/3/18 instructed staff to document episodes of increased anxiety every shift related to anxiety disorder. Another physician's order dated 9/3/18 instructed staff to document episodes of insomnia every night shift and if symptoms were present document interventions and outcome in the medical record. Review of the November 2018 Medication Administration Record (MAR) revealed that staff indicated that the resident experienced 18 episodes of anxiety on the day shift, 11 episodes on the evening shift and 25 episodes on the night shift. Facility staff indicated in the December 2018 MAR that the resident experienced 14 episodes of anxiety on the day shift, 11 episodes on the evening shift and 23 episodes on the night shift. For January 2019 staff documented 1 episode of anxiety on the day shift and 3 on the night shift. Review of the November 2018 MAR revealed the staff indicated that the resident experienced insomnia 25 of 30 nights. Review of December 2018 MAR revealed staff indicated that the resident experienced insomnia 23 of 31 nights. Review of the January 2019 MAR revealed the behavior occurred 3 of 3 nights. Review of the medical record failed to reveal corresponding notes with specific behaviors and interventions to include non-pharmacological measures to address the behaviors and outcomes to assist in determining the necessity and efficacy of the psychotropic medications prescribed for Resident #5. The findings for Residents # 7 and #5 were discussed and confirmed with the MDS Coordinator on 1/4/19 at approximately 10:23 AM. On 1/4/19 at approximately 12:30 PM the Director of Nursing stated to the surveyor that facility staff completed an audit on all behavior monitoring orders and discovered the electronic documentation system required an adjustment to prompt staff to enter the required information.