Based on observation and staff interview, it was determined that the facility staff failed to treat a resident in a dignified manner by leaving two urinals that contained urine hanging on the bedrail. This was evident for 1 (Resident #17) of 83 residents reviewed during the annual survey. The findings include: During an observation of Resident #17 on 7/11/2023 at 9:54 AM, the surveyor observed the resident sitting in their wheelchair by the left side of the bed and watching TV. Surveyor observed two urinals hanging on the resident's right upper bed rail (one was completely full of yellow colored urine and the other urinal was 1/4 full). When asked if the resident had used the urinals prior to breakfast, s/he said yes. Resident #17 stated that s/he had used the urinals a couple of hours ago. Observed on the floor by the foot of the resident's bed was dirty linen and a hamper full of dirty laundry with fruit flies/gnats on them. Resident stated, they don't do nothing for me. On 7/11/2023 at 10:20 AM, Resident #17's nurse, Licensed Practical Nurse (LPN #6) and the 2nd floor Unit Manager (UM #4) were notified of surveyor's observation. They both went into the resident's room and validated surveyor's findings. UM #4 immediately emptied the urinals while LPN #6 took the dirty linen and laundry out of the resident's room. The above concerns were reviewed with the Director of Nursing (DON) on 7/26/2023 at 11:15 AM.

Based on observation and interview, it was determined the facility failed to accommodate the needs of a resident by failing to ensure the call bell was in reach when needed. This was evident for 1 (#39) of 83 residents reviewed during the survey. The findings include: A call bell is a bedside button or cord attached to the wall in the resident's room, which allows the resident to alert a nurse or other healthcare staff member remotely of their need for help. The use of a nurse call bell system is designed to contribute to ensuring resident safety and allows residents in healthcare setting to alert staff remotely of their need for help. Immobile residents can use the nurse call bell to communicate with staff for any type of assistance. On 7/10/2023 at 10:11 AM, Resident #39 was observed lying in bed watching TV. When asked to use her/his call bell, Resident #39 looked around but could not find the device. The call bell was observed behind the resident's head of bed and out of reach. Resident # 39 attempted to get it twice and was unable to reach it both times. S/he gave up trying to reach the call bell and stated that it was placed away from their reach because the staff did not want her/him using the call bell. Surveyor gave the resident the call bell and asked her/him to push it. Resident #39 pushed the call button, but it did not light up outside of the room door and did not ring at the nurses' station. On 7/10/2023 at 10:20 AM, in an interview with Licensed Practical Nurse, LPN # 5, she verified the surveyor's observation and confirmed that the call bell was not working. LPN #5 stated that the call bell should be where the resident could reach it and added that she (LPN #5) was going to put in a work order for maintenance to fix it. On 7/10/2023 at 2:40 PM, in a follow up interview with LPN #5, she stated that the call bell was fixed, and surveyors visually confirmed that they were working properly. On 7/26/2023 at 11:15 AM, in an interview with the Director of Nursing (DON), surveyor reviewed concerns related to the residents' call bell. Cross Reference: F919.

Based on interviews and medical record review it was determined that the facility failed to have a process in place to ensure residents receive written notice of room changes. This was evident for 3 (Residents #250, #144, and #251) out of 3 residents who had expressed their concern regarding room changes during the recertification survey. The findings include: 1.)During an interview with Resident #144 on 7/10/23 at 9:58 AM, they expressed their concern that they had been moved to their room all of a sudden, and with no reason for it 2.) On 7/10/23 at 9:58 AM, during the interview with Resident #144, Resident #251, (the roommate of Resident #144) verbalized not having received any advance notice of him/her receiving a roommate . 3.) During an interview with Resident #250 on 7/12/23 at 2:28 PM, they reported that they were moved to another room with no advance notice. When the resident asked facility staff for a reason why, he/she reported that staff tiptoed around the reason why. On 7/24/23 at 8:43 AM, review of the medical records revealed that no documentation could be found of the residents having been notified in writing of the room changes. During an interview on 7/24/23 at 9:51 AM, the Registered Nurse Unit Manager (Staff # 23) reported to the surveyor that there is no paper notification of room changes, it is on PCC (Point Click Care- computer system used by the facility) and documented in a nurse note when the resident is notified through social work. They further stated: There are no paper forms. On 7/24/23 at 9:54 AM, the Social Worker (SW) #33 stated during an interview that it is the responsibility of the social worker to notify residents of room changes and they were not aware of any paper forms used to notify residents of room changes. The surveyor shared their concern with the SW #33 who acknowledged the concern.

Based on medical record review, staff interview, and review of administrative records, it was determined that the facility failed to provide written notification to residents when the facility determined that a resident no longer qualified for Medicare part A skilled services. This is identified for 2 (Residents #126, and #134) of 2 residents reviewed that remained in the facility after termination of Medicare part A services. The findings include. Notification to residents regarding the end of their Medicare coverage is required to be minimally 48 hours prior to the scheduled effective date that coverage will end, therefore, affording them an opportunity to appeal the decision or to prepare for discharge. In addition, CMS is very specific in the form that is required to be used for the notification of the non-coverage of Medicare services. The SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to file appeal of the decision and right to an expedited review of Medicare non-coverage of services. At the initiation of the survey on 7/10/23, the facility was requested to provide a list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months prior to the survey. Three residents were selected, one resident was discharged from the facility and two residents remained in the facility after termination of Medicare part A. Three SNF Beneficiary Protection Notification Review forms with the names of the selected residents, were provided to the Director of Social Services (staff #2). The review forms were returned on 7/28/23 at 2:30 PM and reviewed on 7/31/23. The SNF Beneficiary Protection Notification review form for resident #126 was reviewed and indicated that the resident was not provided a SNF ABN form, with indication that the resident was discharged from the facility. Resident #126 was selected due to indication that the resident remained in the facility after the last day of Medicare skilled services dated 4/4/23. Review of resident #126's medical record on 7/31/23 revealed that the resident remained in the facility after Medicare Part A services were terminated. The resident should have been issued/provided a SNF ABN. Review of the SNF Beneficiary Protection Notification review for resident #134 revealed that the resident was not provided a SNF ABN form with the handwritten documentation that the resident did not request additional Medicare service. The documentation provided by the social services director revealed the resident was not provided a NOMNC (CMS 101123) with documentation that the resident refused to sign and the form was mail to a sibling of the resident on 6/15/23. Review of resident #134's medical record on 7/3/23 at 10:13 AM revealed a physician certification dated 5/3/23 that the resident was able to make his/her own decisions without any documentation of the resident appointing a responsible party. Resident #134 was interviewed on 7/31/23 at 10:25 AM. Upon discussion of Medicare and Medicaid service the resident was shown a copy of the NOMNC form indicating the resident refused to sign. The resident stated that he/she did not refuse anything as he/she was not presented with the form. The social services director was interviewed at 10:45 AM on 7/31/23. During the discussion, she was informed of information found in resident #134's medical record indicating that the resident was competent to make own decisions and that the resident indicated, that he/she did not refuse to sign the form as the resident not being provided with the NOMNIC form. The SNF Beneficiary Protection Notification review for resident #126 was reviewed as she had indicated that the resident was not provided a SNF ABN form as per her documentation the resident was discharged . She was informed of the understanding that residents remaining in the facility after Medicare part A service are terminated should be provided with both the NOMNIC and the SNF ABN form. The social services director acknowledged not completely understanding the regulations related to providing the CMS NOMNIC and the SNF ABN forms. She indicated that resident #126 was not provided a SNF ABN form. Further review of resident #134's medical record did not reveal any social services progress notes or documentation of the resident refusing to sign documents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interviews, review of the medical record, and observation, it was determined the facility failed to properly recognize and address a resident grievance. This was evident for 1 (Resident #253) out of 1 resident who was reviewed for grievances. The findings include: During the surveyor's initial tour on 7/10/23 at 9:48 AM, Resident #253, admitted to the facility on [DATE], reported the following concerns about the therapy department: a concern that therapy staff did not always treat them with respect and dignity; a concern with their rehabilitation plan of care; and a concern that they were not able to walk in therapy because therapy required them to have an AFO (device utilized in therapy to maintain a natural foot position) which was located at his/her personal home. Resident #253 was asked by the surveyor if they had attended an interdisciplinary care plan meeting, and they stated they had not. On 7/10/23, no documentation of a care planning meeting could be found on the medical record. On 7/11/23 at 12:02 PM, Resident #253 reported that a female Occupational Therapist was swinging the cane at me (approximately) last Thursday (7/6/23) and the facility reported to my family that I was threatening the staff. Resident #253 reported having voiced their concern regarding the quality of therapy care to facility staff and was expecting the Rehab Director to come speak with them. Resident #253 stated the Rehabilitation Director never did. Additionally, they reported that after the surveyor had spoken with them on 7/10/23 they were now invited to attend an interdisciplinary care plan meeting scheduled for 7/12/23. On 7/14/23 at approximately 2:21 PM, the surveyor asked the Administrator and Director of Nursing (DON) if a facility reported incident had been submitted regarding Resident #253 from Thursday, 7/6/23. The Administrator and DON reported being unaware of any incident occurring on that date and began investigating the information relayed by the surveyor. This resulted in a facility reported incident being submitted on 7/14/23 at approximately 3:47 PM. In the facility reported incident, the facility stated, Other staff that were interviewed stated he/she never mentioned any rehab staff hitting him/her, but he/she did complain about rehab services. The surveyor noted the allegation made by the resident was that the OT was swinging a cane at them, they did not state they were hit by a staff member. Further review of the medical record on 7/17/23 at 9:16 AM revealed a social services note dated 6/26/23 at 3:08 PM that stated the resident had 30 Medicare days left and the discharge plan for the resident was to return home. On 7/17/23 at 1:16 PM the Assistant Director of Nursing (ADON), a Licensed Practical Nurse, was interviewed and reported that on 7/14/23 the facility had decided to implement male only therapy staff to work with the resident. The surveyor inquired to the ADON whether the resident had requested male-only therapy staff, to which they replied no. Additionally, they reported All he/she was explaining was that he/she did not like the therapists, all of them. He/She was having behaviors. They (the therapists) were not doing what they were supposed to be doing. At 1:38 PM, the ADON reported that it was not really a concern, they would not consider it a grievance with rehab, it was important enough for administration to know, but not important enough to document.

Based on a review of a complaint intake, 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 #160) of 6 residents reviewed for hospitalization during the annual survey. The findings include: On 7/25/23 complaint intake, MD00140476 was reviewed related to resident #160. Based on a review of the complaint the resident had a fall, and busted his/her head and was transported to the emergency room. A review of resident #160's closed medical record on 7/25/23 did not reveal any evaluations or progress notes indicating the resident had a fall and was transferred to the hospital. Review of the closed paper medical record on 7/25/23 revealed Hospital discharge instructions with the resident's name time stamped/prepared on 4/17/19 at 4:13 AM. The local hospital's discharge instructions indicated resident #160 had a fall from standing and a laceration to scalp. On 7/26/23 the assistant director of nursing (ADON) was shown the hospital discharge instructions and informed of the lack of documentation related to the resident's transfer and return to the facility on 4/17/2019. At 1:10 PM on 7/26/23 the ADON returned and confirmed the lack of documentation in the medical record indicating that the resident was transferred to the hospital and the lack of documentation of the resident's return to the facility. The ADON provided an internal document that was not part of the medical record indicating on 4/17/2019 the resident was observed on the floor with the resident's head towards the foot of the bed, laceration to the posterior head with blood, and transferred to the emergency room for evaluation. A follow-up conversation was held with the ADON on 8/3/23 at 2:40 PM to review additional regulatory non-compliance related to the lack of any documentation in resident #160's medical record of the 4/17/2019 transfer to the hospital.

Based on a review of a complaint intake, medical record review, and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (#160) of 6 residents reviewed for hospitalization during the annual survey. Findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. On 7/25/23 complaint intake, MD00140476 was reviewed related to resident #160. Based on a review of the complaint the resident had a fall, and busted his/her head and was transported to the emergency room. A review of resident #160's closed medical record on 7/25/23 did not reveal any evaluations or progress notes indicating the resident had a fall and was transferred to the hospital. Review of the closed paper medical record on 7/25/23 revealed Hospital discharge instructions with the resident's name time stamped/prepared on 4/17/19 at 4:13 AM. The local hospital's discharge instructions indicated resident #160 had a fall from standing and a laceration to scalp. On 7/26/23 the assistant director of nursing (ADON) was shown the hospital discharge instructions and informed of the lack of documentation related to the resident's transfer and return to the facility on 4/17/2019. At 1:10 PM on 7/26/23 the ADON returned and confirmed the lack of documentation in the medical record indicating that the resident was transferred to the hospital and the lack of documentation of the resident's return to the facility. The ADON provided an internal document that was not part of the medical record indicating on 4/17/2019 the resident was observed on the floor with the resident's head towards the foot of the bed, laceration to the posterior head with blood, and transferred to the emergency room for evaluation. A follow-up conversation was held with the ADON on 8/3/23 at 2:40 PM to review additional regulatory non-compliance related to the lack of any documentation in resident #160's medical record of the 4/17/2019 transfer to the hospital. There was not any documentation that resident #160 or a family representative was provided written notification of the facility's bed-hold policy related to the facility initiated transfer to the hospital.

2) On 7/31/23 at 10:47 AM a review of Resident #50's Medication Administration Record (MAR) and Minimum Data Set (MDS) records was performed. The MDS Assessment Reference Date (ARD) was 6/4/23 and indicated that no PRN (as needed) pain medications were given to the resident in the 5-day look back period. However, a review of the resident's MAR for May 2023 and June 2023 indicated that PRN pain medications were documented as given for each day of the look back period. On 7/31/23 at 11:18 AM an interview with the MDS Director, Staff #42, was conducted. The above was reviewed with the MDS Director who confirmed that the resident's MDS was incorrectly coded, and she would make the correction. On 8/02/23 at 1:39 PM an interview with the Director of Nursing (DON) was conducted. The MDS inaccuracy for Resident #50 was reviewed. No additional information related to the MDS inaccuracy was provided to the surveyor during or after the interview. Based on observation record review and staff interview, it was determined that the facility failed to adequately assess and complete the Minimum Data Set (MDS) for a resident with impaired speech. This was evident for 1 (Resident #13) of 7 residents assessed for communication and sensory and 1 (Resident #50) of 6 residents reviewed for abuse during an annual survey. The Findings include: 1) 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. On 7/10/23 at 10:24 AM, observation of Resident #13 revealed that resident had trouble with expression. Resident was asked to state name and birthday. Resident #13 Stated her name and birthday but was very hard to understand. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/23 on 7/20/23 at 12:54 PM revealed that speech clarity was documented as clear. However, a review of the prior annual MDS assessment with ARD of 2/18/23 documented Speech Clarity as unclear''. Further review of the resident's medical diagnosis documented that resident was Aphasic which is a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension. Review of Resident #13's plan of care with a focus on communication on 7/21/23 at 10:40 AM documented that resident had a communication problem related to neurological symptoms and stroke. On 7/24/23 at 9:11 AM Staff #43 a Geriatric Nursing Assistant (GNA) assigned to Resident #13 was asked about the resident's clarity of speech. The Staff #43 stated that resident had speech problem and was difficult to understood sometimes. The surveyor and Staff #43 went into the residents' room to evaluate speech clarity. Staff #43 confirmed that Resident #13's speech was not clear. The MDS Coordinator Staff #44 who completed the MDS quarterly assessment stated in an interview on 7/24/23 at 11:05 AM that she works remotely from home and gets information to complete the MDS from the resident's chart such as the admission notes, nurses' notes and speech therapist notes. Staff #44 indicated that she did not perform a physical assessment when she completed the MDS. On 7/25/23 at 1:09 PM the unit manager Staff #4 was made aware of the concerns related to inaccuracy of assessment. She confirmed that resident #13's speech was not clear and that the MDS assessment was inaccurate.

Based on medical record review, resident, and staff interview, it was determined that the facility staff failed to revise and update a comprehensive care plan for a resident with a suprapubic catheter. This was evident for 1 (#18) of 83 residents reviewed during the 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. A suprapubic catheter is a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the belly, a few inches below the navel (belly button). Medical record review was conducted for Resident #18 on 7/31/2023 at 12:11 PM. Resident #18 was originally admitted to the facility in January 2019 with diagnoses that included but not limited to paraplegia, retention of urine, neuromuscular dysfunction of bladder, and chronic kidney disease. Review of order summary report on 7/31/2023 at 12:33 PM revealed the following active orders: - Irrigate suprapubic catheter with 60cc of Sterile water BID every day and evening shift for Supra pubic patency. order date 3/17/2021. - Change Suprapubic catheter Bag and leg strap Weekly and PRN as necessary every night shift every Thu for Change urine bag. Order date 7/30/2020. On 7/31/2023 at 1:30 PM, review of Resident #18's care plan identified that the care plan interventions were not resident centered. The care plan was not revised to reflect the orders to change the suprapubic catheter bag and leg strap weekly and PRN and irrigate the suprapubic catheter with 60 cc of sterile water BID. On 8/1/2023 at 8:45 AM, an interview was completed with Resident # 18's nurse, Licensed Practical Nurse (LPN # 18). LPN #18 stated that the resident's supra pubic catheter bag was changed at least once a week and as needed. She stated that irrigation was done two times a day (every day and evening shift) with 60 cc of sterile water. On 8/1/2023 at 1:13 PM, In an interview with the 2nd floor Unit Manager (UM #4), she stated that care plan revisions were done by the MDS coordinator, Unit Managers, and Supervisors (after hours: evening, night, weekends) when there was a change in resident condition. UM #4 stated that the expectation was for care plans to be updated/revised quarterly and when there was a significant change in condition. Surveyor reviewed Resident #18's care plan with UM #4, and she acknowledged that the care plan was not revised to reflect the active orders noted above. However, UM #4 added that the resident's care plan was currently under review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) During an interview on 7/11/23 at 12:02 PM, Resident #253 stated that, despite having notified the dietician that they could not swallow rice, they still continued to receive it on their meal tray. On 8/1/23 at 10:18 AM, the surveyor observed and verified on the kitchen ' s computer system that the resident should not receive rice. On 8/1/23 at 10:34 AM, Registered Dietician (RD) #12 provided the surveyor with an email dated 6/29/23 at 4:59 PM, reporting the request for no rice to the Certified Dietary Manager, (CDM) #13. No documentation from the resident ' s medical record could be provided that explained the rationale for that request. On 8/1/23 at 10:48 AM, the surveyor requested for Staff #12 to bring any documentation regarding the reason for the resident ' s request for no rice. On 8/1/23 at 11:38 AM, RD #12 provided another email dated 6/29/23 at 1:35 PM sent to the Director of Rehabilitation (DR) #27 which stated the following information regarding Resident #253: .asked me to take rice off his/her menu b/c (because) it gets caught in his/her throat. Not sure if he/she needs SLP (Speech Language Pathologist) attention. On 6/29/23 at 1:36 PM, RD Staff #12 did not document anything regarding the resident experiencing swallowing difficulty on their nutrition evaluation of the resident. During an interview on 8/1/23 at 1:40 PM, RD #27 reported that a staff member who was supposed to be covering for the regular employee over that weekend did not communicate that they had not seen the resident and unfortunately I wasn ' t able to follow up. During an interview on 8/1/23 at 12:05 PM, Speech Language Pathologist #9, indicated that, after surveyor intervention, Resident #253 was evaluated for swallowing difficulty. 3) Subcutaneous injection is given in the fatty tissue, just under the skin. On 08/02/23 at 11:27 AM, the surveyor reviewed a complaint of MD00182706. The complainant reported that the facility provided a Lovenox (one of the anticoagulants administered via subcutaneous) shot for Resident #148 on one side, which resulted in a huge bruise. The surveyor reviewed the medical records of Resident #148 on 08/02/23 at 11:45 AM. The review revealed that the resident was admitted in July 2022 with diagnoses that included an encounter for surgical aftercare following surgery on the respiratory system, ileostomy, and chronic vascular disorder. Also, the resident had been prescribed Lovenox injection subcutaneously twice daily from 07/16/22 till the discharge date . A review of the Medication Administration Record (MAR) of July 2022 and August 2022 revealed that Resident #148 received injections twice a day while his/her staying. However, there was no documentation of the injection site. On 08/03/23 at 09:00 AM, a review of the facility policy titled Administration of Injections stated the repeated subcutaneous injections rotated site and documented the procedure on the MAR, including the location of the injection site. During an interview with the Director of Nursing (DON) on 08/03/23 at 09:39 AM, she said, Subcutaneous injection site should be documented. The surveyor shared concerns regarding Resident #148's injection site. The DON confirmed that the facility did not have an injection site documenting system yet. 4) The surveyor reviewed a complaint, MD00175033, on 07/31/23 at 8:33 AM. The complainant reported concerns about Resident #163's dehydration, so they stated, We requested IV (intravenous) therapy for him/her. Further review of Resident 163's medical record revealed that the resident was admitted to this facility on 01/03/22 with the diagnosis of dementia, depressive disorder, cerebral infarction, and metabolic encephalopathy. Before this admission, the resident had been admitted to ER due to 3-4 days of vomiting and nonblood diarrhea and was diagnosed septic with severe lactic acidosis and hypotension. A review of Resident #163's progress notes on 07/31/23 at 9:30 AM revealed that the resident had tested positive for COVID-19 on 01/11/23, and the provider ordered IV fluid for nutrition/hydration. A progress note dated 2/05/23 showed that the resident observed low blood pressure; his/her provider encouraged fluid and ordered two liters of 5% Dextrose with normal saline (D5NS). On 02/18/23, Resident #163's blood pressure dropped again to the 90s (systolic blood pressure: Blood pressure is measured using two numbers: The first number, called systolic blood pressure, measures the pressure in your arteries when your heart beats); the physician ordered IV fluid. On 03/09/23, Resident #163's provider ordered one liter of D5NS infusing due to the resident's poor intake. However, there were no orders for the monitoring/assessment/interventions regarding Resident #163's repeated dehydration. During an interview with the Director of Nursing (DON) on 7/31/23 at 1:09 PM, the DON said, The lab monitors the resident's hydration level. The surveyor reviewed the lab results tab on the PCC (Electronic medical record cloud) with her. No lab results were found for Resident #163. The DON confirmed no monitoring records for Resident #163's dehydration issue. Based on a complaint, medical record review, and interview it was determined that the facility failed to ensure 1) staff followed physician orders as evidenced by failure to monitor a resident's blood sugars, 2) failed to ensure right orders for treatment were put in and documented on, 3) failed to document and rotate the site of subcutaneous injection, 4) failed to manage a resident with dehydration, and 5) failed to respond to a resident's concern with swallowing difficulties. This was evident for 5 Residents (#91, #76, #148, #163, and #253) of 83 residents reviewed during the survey. The findings include: The hemoglobin A1C (HbA1c or HgA1c) test is a simple blood test that measures your average blood sugar levels over the past 3 months. It's one of the commonly used tests to diagnose prediabetes and diabetes and is also the main test to help you and your health care team manage your diabetes. It is an important blood test that gives a good indication of how well your diabetes is being controlled (normal level below 5.7%, prediabetes 5.7% to 6.4 %, and diabetes 6.5% or above). Hemoglobin is part of your red blood cells that carries oxygen from your lungs to the rest of your body. 1) Medical record review on 7/17/2023 at 12:56 PM revealed Resident #91 was admitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus, multiple sclerosis, chronic obstructive pulmonary disease, morbid obesity due to excess calorie. Review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2023 on 7/18/2023 at 9:45 AM, revealed Resident #91's blood sugar was not being monitored. Review of the vital sign record on 7/18/2023 at 10:01 AM, revealed the last documented blood sugar result for Resident #91 was 150 mg/dl (fingerstick) and last HbA1c was 5.9% done on 3/1/2023. In an interview with the 2nd floor Unit Manager (UM #4) on 7/18/2023 at 11:18 AM, she confirmed that Resident #91's blood sugar was last monitored in March 2023. UM #4 stated that Resident #91 was seen by the Endocrinologist and their blood sugar monitoring and diabetic medications may have been discontinued per recommendations of the Endocrinologist. On 7/18/2023 at 1:55 PM, in a follow up interview with UM #4, surveyor reviewed the endocrinology consult notes dated 10/19/2022: Under Plan: Assessment: This is a complicated high-risk patient with type 2 diabetes and multiple comorbidities. Will watch closely to prevent hypoglycemia. Goal fasting BGs are 110-140 mg/dl. Goal post prandial BGs are 140-180 mg/dl. Noted occasional low blood glucose levels (90s). Given patient's age and comorbidities, preventing hypoglycemia is a priority. Under recommendations: 1) May D/C Glipizide/Metformin (2.5/250) OD. 2) Continue all other current regimens, dietary management, activities, and BG (blood glucose) monitoring. UM #4 acknowledged that based on the above recommendations, they should have continued to monitor the resident's blood sugar levels. She added that she was going to contact the physician and have the blood sugar monitoring re-ordered. On 7/17/2023 at 1:04 PM, review of order summary report revealed order on 3/1/2023 to discontinue all diabetic medications. However, there was no order to discontinue blood sugar monitoring. On 7/26/2023 at 11:10 AM, in an interview with the Director of Nursing (DON), she was notified of surveyor's concerns regarding the lack of blood sugar monitoring for Resident #91. DON stated she will follow up. On 7/26/2023 at 11:58 AM, in an interview with the resident's attending physician, MD #26, he confirmed that he had ordered for the resident's blood sugar medications to be discontinued after the resident's HBA1C came back at 5.9 % on 3/1/2023. However, he affirmed that he did not discontinue the blood sugar monitoring. He added that usually he has standing orders for HBA1C to be monitored every 3 -6 months if the residents' blood sugars were stable. MD #26 was informed that the resident's HBA1C was last monitored on 3/1/2023 and there was no order for monitoring thereafter. However, MD #26 stated that Resident #91's HBA1C was recently checked (on 7/19/2023, result = 10.8 %) and the resident put back on sliding scale insulin, he was informed that this was done after surveyor intervention. 2) On 8/3/2023 at 8:45 AM, Resident # 76 was observed in their room. Resident #76's nails looked clean and trimmed, however, the right-hand 2nd and 4th fingernails were discolored (yellowish white) and thickened under the tip. No resting hand splint on neither right nor left hand noted. On 8/3/2023 at 8:50 AM, the 2nd floor Unit Manager (UM #4), was brought into the resident's room and observation made of the resident's hands/fingernails. UM #4 confirmed that the resident has fungal infection on the right-hand 2nd and 4th fingernails. UM #4 added that the resident was on oral antifungal meds at one point, but they were now using an antifungal cream to treat the fungal infection. A review of Resident #76's medical records on 8/3/2023 at 9:15 AM revealed the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, contracture of muscle right lower leg, vascular dementia. Review of the order summary report on 8/3/2023 at 9:40 AM revealed the following active orders: a) Lamisil AT cream 1% (Terbinafine HCL) Apply to 4th finger on right hand topically two times a day for Fungi infection. Order date 4/23/2022 and start date 4/23/2022. b) Order for resting splint on left hand wearing schedule: Pt to wear splint during the day; splint to be off at nights. Hygiene: wash weekly or as needed every morning and at bedtime for contracture prevention/management order date 7/27/2022 and start date 7/27/2022. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2023 was completed on 8/3/2023 at 9:55 AM. Staff documentation revealed Resident #76 was getting antifungal cream (Lamisil) application to right hand 4th finger twice a day, and resting hand splint to the left arm (on during the day and off at night). However, there was no medication/ treatment for the 2nd fingernail on the right hand that was also infected and no documentation of a right-hand splint. On 8/3/2023 at 10:40 AM, review of progress notes revealed Nurse Practitioner notes dated 11/8/2022 indicating: Resident is seen today f/u 4th finger and 2nd finger on right hand Fungi infection. Resident is currently on LamISIL AT Cream 1 % (Terbinafine HCl); New order: Terbinafine HCl Oral Tablet 250 MG (Terbinafine HCl) Give 1 tablet by mouth one time a day for Onychomycosis Right Fingernails / Fungi Infection for 6 Weeks . On 8/3/2023 at 11:30 AM, an interview was completed with Resident #76's nurse, Licensed Practical Nurse, LPN #6. LPN #6 stated that the resident's 4th fingernail on the right hand has a fungal infection and they (nursing staff) have been applying a cream on it twice a day. When asked about the 2nd fingernail on the right hand, LPN #6 looked through the resident's MAR and TAR and stated that there was no medication/treatment order for the 2nd fingernail. Regarding the use of resting hand splint, LPN #6 confirmed that the order for splint application on the left hand was the wrong order and that staff have been documenting on the wrong order. She stated that the resident has right sided weakness and wore a right-hand resting splint during the day to minimize contracture. She added that there was nothing wrong with the resident's left hand/arm. The problem is with the right hand/arm, reason for resting hand splint. On 8/3/2023 at 11:35 AM, a follow up observation was made of Resident # 76 accompanied by the resident's nurse, LPN #6. Resident # 76 was observed wearing a right resting hand splint. LPN #6 examined the resident's right-hand fingernails and confirmed that both the 2nd and 4th fingernails had fungal infection. Resident #76 affirmed that staff have been putting the resting hand splint on the right hand during the day and removing it at night. Resident #76 was able to lift her/his left arm up, no contracture noted. When asked to lift the right arm, Resident #76 was unable to do so and stated that s/he could not lift her/his right arm. On 8/3/2023 at 2:20 PM, in a follow up interview with the 2nd floor Unit Manager (UM #4), concerns regarding lack of treatment for Resident #76's right 2nd fingernail fungal infection was reviewed. UM #4 stated that staff were applying the medication (Lamisil) on both the 2nd and 4th fingernails but failed to update the order to reflect both fingers. Regarding the order for left hand splint application, UM #4 stated that the order was wrong. She added that the resident's left arm/hand was the active arm and did not require the use of a splint. UM #4 stated that staff have been putting the splint on the resident's right hand and not the left. She stated that staff failed to pay attention and were just signing the wrong order. She added that they failed to pick this up during the 24-hour chart check. However, UM #4 stated that she was going to review the resident's chart and update the orders. On 8/4/2023 at 8:05 AM, an interview was completed with Occupational Therapist (OT #21), who has worked in the facility since 2015. OT #21 stated that she worked with Resident #76 and the splint application was for the right hand. She stated that Resident #76 has limited range of motion on the right arm and the resting hand splint helps to keep the hand in anatomical position (alignment) and prevents contracture. When shown the order for left hand splint application, OT #21 stated that it was definitely a typo. She added that she knew Resident #76, and the splint was being used on the resident's right hand. On 8/4/2023 at 9:15 AM, review of care plan revealed the care plan had the wrong hand (left hand) for the splint application: Care plan interventions for Resident needs assistance with ADLs r/t right dominant hemiparesis, CVA, dementia, schizophrenia, RLE contracture- under Splint: resting splint on left hand wearing schedule: Pt to wear splint during the day; splint to be off at nights. Hygiene: Wash weekly or as needed. Date initiated 03/02/2022 with Revision on 09/09/2022. On 8/4/2023 at 12:05 PM, concerns related to staff failure to monitor a resident's blood sugars, and failure to ensure right orders for treatment were put in and documented on were shared with the Director of Nursing (DON).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation it was determined that the facility failed to properly identify, document, and monitor a resident's pressure ulcer. This was evident for 1 (Resident #71) of 6 residents reviewed for positioning and mobility. The findings include: A pressure ulcer is skin breakdown caused by pressure, usually over a bony prominence, but can also be caused by pressure from a medical device. Pressure ulcers are categorized using numbers for stages, a stage 1 being the most superficial type, and stage 4 being the deepest. A contracture is a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and ultimately causes rigidity, joint deformities, and a total loss of movement around the joint. Splints are used to prevent further tightening of contractures but may increase the risk of developing skin breakdown. On 7/10/23 at 1:10 PM a record review revealed that Resident #71, who was admitted to the facility on [DATE], had a history of stroke and left-sided paralysis. The resident's left hand was contracted (clenched) due to this paralysis. A record review of skin assessments on 7/18/23 at 10:16 AM revealed that although a new wound on the resident's left middle finger, was identified on 6/25/23, and documented on a Change in condition form dated 6/25/23, the wound was categorized as a blister, not a pressure ulcer. This was inconsistent with care plan documentation entered as a comment in the section titled Resident at risk for skin breakdown related to decreased mobility ., written on the same day, 6/25/23, that stated The resident has a left middle finger ruptured blister r/t [related to] splint application . which indicated that the wound was pressure related. Additionally, follow up skin assessments dated 7/2/23, 7/9/23, and 7/16/23 lacked any details of the resident's wound/blister, and incorrectly documented that the resident's skin was intact. While observing the resident on 7/18/23 at 12:02 PM, Licensed Practical Nurse (LPN), Staff #46, was at the bedside and was interviewed. The LPN explained that the hand splint was not in use because the resident developed a pressure ulcer a couple of weeks after the splint was initiated. The LPN showed the surveyor the resident's finger wound which was scabbed and measured approximately 5 mm in diameter. A review of Resident # 71's physician orders on 7/18/23 at 12:23 PM revealed an order for Occupational Therapy (OT), dated 6/23/23, written as OT Clarification; RNP [Registered Nurse Practitioner] order; Resting hand splint to be worn on L [left] hand 8 hrs on, during the day, assessing for redness, skin tears, and maintaining palmar hygiene and nail hygiene. On 7/19/23 at 10:13 AM in an interview with Staff #23, RN Unit Manager, the Unit Manager explained that the wound team saw some resident wounds but not all, it depended on if the wound was superficial, but that all pressure wounds - even stage 1 ulcers, would be followed by the wound team. On 7/28/23 at 2:00 PM the Assistant Director of Nursing (ADON) was asked to provide the wound team documentation for 6/25/23 to 7/28/23 for Resident #71. He explained that there was no wound team documentation for Resident #71 because the resident was not seen by the wound doctor or the wound team because the resident had a small blister and the standard practice of the facility was to monitor superficial wounds, which he described as a wound expected to heal within one week. He further explained that if the wound did not heal, or if it worsened, the wound team would follow up on it, but because the resident's wound was a small blister it did not need to be seen by the wound team. The ADON confirmed that the wound physician did not evaluate Resident #71's wound. In another interview with the ADON on 8/02/23 at 8:35 AM the ADON confirmed that the resident's blister was most likely a pressure ulcer related to the wound since the resident had used a hand splint. When asked if the wound team should have seen the resident, he responded that if the wound was a pressure related injury, such as when a device was being used, then the wound team should follow it. On 8/2/23 at 1:39 PM the Director of Nursing was made aware of the above concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of medical records and interviews, it was determined that the facility failed to ensure resident's Ileostomy care. This was evident for 1 (Resident #148) of 2 residents reviewed for ostomy care during the annual survey. The findings include: An ostomy is a surgery that makes a temporary or permanent opening in the skin called a stoma. A stoma is a pathway from an internal organ to the outside of your abdomen. An ileostomy is a stoma constructed by bringing the end or loop of the small intestine out onto the surface of the skin or the surgical procedure which creates this opening. Intestinal waste passes out of the Ileostomy and is collected in an external ostomy system which is placed next to the opening. On 08/02/23 at 11:27 AM, the surveyor reviewed a complaint of MD00182706. The complainant reported that the facility's nursing staff did not use the correct supplies for ileostomy bags and skin prep pads for Resident #148's care. Also, the complainant insisted that these incorrect supplies resulted in the resident's hospitalization. Further review of Resident #148's medical record revealed that Resident #148 was admitted to the facility on [DATE] for recovery from major abdominal surgery and had small bowel resection with Ileostomy. Resident #148 had an order of cleaning around the Ileostomy three times a week or as needed from 07/26/22 to the discharge date . However, there is no monitoring and/or assessment order for the Ileostomy from his/her admission and no clean order until 07/26/22 (10 days later than admission). Also, the surveyor reviewed a progress note regarding Ileostomy care. No documentation was found to support Resident #148 received Ileostomy care until the order was placed. On 08/02/23 at 01:30 PM, the surveyor reviewed the year of 2022's competency records of three nursing staff (Licensed Practical Nurse #47, #48, and #49) who had cared for Resident #148. None of them had an Ileostomy care competency record. During an interview with the Director of Nursing (DON) on 08/03/23 at 09:39 AM, the DON confirmed that Ileostomy care training competency was added this year (2023). She said, I'm not sure about the last year's training record. On 08/04/23 at 09:30 AM, the DON informed the surveyor's concerns regarding Ileostomy care. No additional documentation was provided to the surveyor team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 7/11/23 at 8:54AM Resident # 144 reported to the surveyor their concern that residents' weights were wrong. On 7/18/23 at 1:49 PM, medical records for Resident #144 were reviewed revealing they had an order in place for daily weights to be performed as part of their care monitoring for heart failure. Upon review of the MAR, weights failed to be documented on the following dates: 6/21/23, 6/23/23, 6/26/23, 6/27/23, and 7/6/23. No documentation of refusals regarding daily weights could be found in the medical record. Further review of the medical record on 7/19/23 at 9:18 AM revealed weights that were present on the medical record were being documented in two different locations on the computer system: 1.) within the tab labeled weights/vitals, and 2.) on the medication administration record (MAR). The weights found to be documented on the MAR were not on the weights/vitals tab. On 7/19/23 at 9:26AM, the surveyor observed two duplicate active orders for documentation of obtaining weights on the June 2023 treatment administration record (TAR) with documentation in two separate places on the TAR, both ordered at the time of admission. During an interview with the Licensed Practical Nurse (Staff #48) on 7/20/23 at 10:30AM, they stated: When the daily order was received, the admission order should have been placed on hold or discontinued. When the surveyor inquired to the Assistant Director of Nursing as to why documentation of weights were in different places in the medical record on 7/20/23 at 10:39AM, they replied: This was overlooked. Review of the June MAR on 7/20/23 at 10:23AM, revealed the resident weighed 149.8lbs on 6/16/23, and 200lbs on 6/17/23 indicating a 50.2lb weight increase in one day. Further review revealed on 6/21/23 the resident weighed 149.8lbs, no weight was documented on 6/21/23, and then the resident was recorded on 6/22/23 as weighing 140.2lbs, indicating a 9.6lb loss in one day, and no weight was recorded for 6/23/23 and 6/27/23. On 7/10/23 Resident #144 weighed 146 lbs. On 7/11/23, their weight was 150.4 lbs. The 4.4lb increase was documented by the Licensed Practical Nurse, (#48) as being reported to their supervisor at 8:00am, and the physician at 8:10am as a change of condition of the resident. The response was medical orders for both a stat (urgent) chest x-ray and a laboratory test. Staff #26 documented the resident ' s discharge summary on 7/11/23 at 7:44 PM and did not mention the abrupt weight change of the resident, the subsequent stat chest x-ray that had been documented by #48 was refused by the resident, or laboratory test that had been ordered but results not yet received. On 7/12/23 at 11:59 AM, the resident was documented as discharged to home. 3) Upon the surveyors initial tour on 7/10/23 at 10:19AM, Resident # 251 reported their concern that they were losing weight. Upon review of the medical record, the resident had been admitted to the facility on [DATE]. An active medical order beginning on 7/1/23 directed the following: Weight on admission/readmission and for first 2 days, then Q week x 4 weeks, until determined to be stable by DNS/Dietician one time a day for 2 days AND one time a day every 7 days for 4 weeks. Upon further review of the weights/vitals tab in the medical record on 8/2/23 at 1:41PM, it was revealed the resident had only one weight performed on admission, no weight on the second day, and then not again until several weeks later on 7/21/23. The resident 's weight was documented as 143.1lbs on 7/1/23,140.2lbs on 7/21/23, and 139.5lbs on 7/26/23. During an interview on 7/21/23 at 11:47AM, the Registered Dietician (Staff #12), reported they confirmed having completed a nutritional risk assessment in which the resident had scored as a severe malnutrition risk. They further confirmed that the risk assessment score is not always accurate, but in his/her case, it was. They further reported that they check on resident weights monthly and the only place they look for weights is on the weights/vitals tab. If the weights are not entered there, they do not flow onto a report that is used to flag resident weight issues. Several staff interviews were conducted revealing conflicting information regarding the process utilized and who was responsible for ensuring weights are in the computer system and accessible for the interdisciplinary team. Based on medical record review and staff interview, it was determined that the facility failed to have a system to monitor and respond to changes in residents' weights and notify the physician when residents' weight loss was identified. This was evident for 3 (Resident #158, #144, and #251) of 6 residents reviewed for nutrition during this survey. The findings include: 1) A review of complaints, MD00166589 and MD 00156901, was conducted on 07/19/23 at 11:20 AM. The complainants reported that Resident #158 had concerns about his/her care, including losing weights. Further review of Resident #158's medical record revealed he/she had admitted to the facility in June 2020 with diagnosed chronic obstructive pulmonary disease, heart failure, morbid (severe) obesity, paraplegia, and colostomy. Also, the resident repeated discharge to the hospital and re-admission to the facility several times: discharge (d/c) on 6/26/20 due to profuse sweating, readmit on 6/28/20, d/c on 7/14/20 due to gastrostomy tube malfunction, readmit on 7/24/20, d/c on 09/09/20 due to peg tube removed, readmit 09/21/20, d/c 11/13/20 due to urosepsis, readmit 11/21/20, d/c 5/28/21 due to abnormal pain and vomiting, readmit 5/31/21, and discharged on 11/17/21. On 07/20/23 at 08:40 AM, the surveyor reviewed Resident #158's body weight records on the PCC (electronic medical record). The body weights were documented as: - The initial body weight was documented as 250 lb. (pounds) via mechanical lift on 06/13/20. - Body weight documented 251 lb. (mechanical lift) on 08/22/20 - 140.4 lb. (hoyer lift-a specific style of patient lifts, are medical devices that are used to transfer patients with limited mobility from one location to another) on 05/31/21 - 142.8 lb. (Hoyer lift) on 06/08/21 Further review of Resident #158's progress note revealed that on 06/01/21 Staff #15 (Dietitian) documented, visited resident this morning, Resident refuses TF (tube feeding). He/she refuses most food from Dietary, preferring to purchase outside food and snacks .suggest 250 ml H2O (water) every 2 hours continuously, 3000 ml HSO daily. No other changes to suggest. MD aware. Follow However, no physician's note/order/documentation was found regarding Resident #158's body weight of 05/31/21. A review of Resident #158's care plan on 07/20/23 at 10:00 AM revealed that the facility staff initiated a care plan regarding his/her resistive to care (refused treatment, wound care, suprapubic catheter, medication, weights, and MD appointment) on 08/24/20. During an interview with Staff # 15 on 07/21/23 at 08:21 AM, Staff #15 stated if a resident refused a body weight check, she would assess the resident and educate the importance of weight check, encourage or offer different methods of weight check, and observe their intakes. The surveyor shared concerns regarding Resident #158's weight with Staff #15: no body weight recorded during repeated discharge and readmit, and significant weight loss (110 pounds) within 11.5 months. Staff #15 stated she would find more details. On 07/24/23 at 2:00 PM, the surveyor interviewed the Assistant Director of Nursing (ADON). The ADON said, Resident #158 was a very difficult resident. He/she refused almost every care, including weight check. We had a care plan about his/her refusal. The surveyor requested any documentation regarding weight check refusal for each re-admission and notification to the physician about Resident #158's significant weight loss (lost 110 pounds: documented on 5/31/21). The ADON stated that since Resident #158 did not satisfied with his/her original assigned physician (MD #59), the facility reassigned the resident's new physician (MD #24). The ADON stated, On MD#24's note dated 6/02/21 documented Resident #158 had Anorexia (an eating disorder characterized by abnormally low body weight) under Diagnosis and Assessment. This was the proof that MD was aware of the resident's condition. The surveyor reviewed MD #24's note dated 06/02/21 on 07/24/23 at 2:10 PM. MD #24 documented Anorexia with an ICD code and added a statement. However, no documentation acknowledged Resident #158's significant weight loss. During a phone interview with MD #24 on 07/26/23 at 12:10 PM, he stated that as a provider, he expected nurses or dietitians to notify a resident's significant weight loss. He said, I would document if I notified a resident's weight loss. Also, MD #24 said, Even though a resident refused a weight check, I expected to see documentation about his/her weight on each admission. On 08/04/23 at 09:30 AM, the surveyor shared the above concerns with the Director of Nursing (DON): Resident #158's absence of body weights on each re-admission and significant weight loss. The DON nodded and said, I understood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 7/27/23 at 11:36 AM, a review of the physician ' s order for oxygen for Resident #50, revealed an active order, dated 5/24/22 for: Oxygen inhalation (via nasal cannula @ 2lpm) as needed for Shortness of Breath, SPO2 <94%. This order means to give oxygen at 2 liters per minute in the nose if the resident ' s oxygen saturation goes below 94% or if the resident feels short of breath. On 7/28/23 at 9:15 AM, an observation and interview with Resident #50 was conducted. The resident was in bed, alert, and responsive. Oxygen tubing was around the resident's neck but not in his/her nose. When asked how often the resident used the oxygen, the resident took the tubing off from around his/her neck and explained that he/she only used the oxygen at night. On 7/28/23 at 11:05 AM, an interview with the 1st floor Registered Nurse (RN) Unit Manager #23 was conducted regarding Resident #50 ' s oxygen use and orders. She explained that the resident used the oxygen when the resident was short of breath, which usually happened when the resident was propelling his/herself in the wheelchair. When asked where the resident ' s oxygen use would be documented, RN #23 said that it would be documented either in the progress notes or on the Medication Administration Record (MAR). On 7/31/23 at 10:11 AM, a record review of Resident #50 ' s MAR indicated that, although there was a section for documenting the use of oxygen, there were no entries to document that the resident had used oxygen in June or July, 2023, despite both observations and reports that the resident had used the oxygen. 2) On 7/11/23 at 10:15 AM observation of resident #93 revealed that resident was on oxygen via Nasal Canula (NC), an oxygen tubing with prongs. Observation of the NC revealed that it was connected to an oxygen concentrator, a machine that concentrates oxygen from the air. The concentrator was at the bedside, set at 3.5 Liters (L). Further observation revealed that the oxygen tubing was not dated to indicate when it was last changed. On 07/26/23 at 10:02 AM a second observation was made of resident #93 in bed. The NC was lying beside the resident on the bed, It was not on the resident's nose. Observation of the oxygen concentrator revealed that it was set at 3.5 L. The o2 tubing was not labeled with a date. Review of the physician's order on 7/26/23 at 2:20 PM revealed an order written on 6/17/23 for oxygen therapy at 2L via NC every shift related to mild intermittent asthma and to change tubing every week, every night shift, every Sun. On 7/27/23 at 10:15 AM Residents #93's nurse a License Practial Nurse (LPN) Staff #6 was called to the room and was shown the resident with the NC off her nose. STaff #6 proceeded to place the oxygen back on the resident's nose. Staff #6 was asked how much o2 the resident was supposed to be on and she indicated that resident was ordered to be on 2L. She was asked to verify the o2 setting and confirmed a set rate of 3.5L. Staff #6 then proceeded to adjust the setting back to 2L. She was asked what day the o2 tubing was last changed. She confirmed that there was no date on the o2 tubing so could not tell when it was last changed. 07/27/23 10:59 AM the Unit manager Staff #4 was made aware of the above concerns. Based on medical records review and interview with staff, it was determined the facility failed to: 1) provide a BiPAP Machine mask to a resident requiring it, 2) properly label and date an oxygen tubing when changed and follow the physician's order for the administration of oxygen, and 3) properly document the administration of oxygen. This was evidence 3 (Resident #168, #93, and #50) of 5 residents reviewed for Respiratory care. The findings include: 1) BiPAP (Bilevel positive airway pressure) is a machine. It's a form of noninvasive ventilation that providers might use someone can breathe on their own but aren't getting enough oxygen or can't get rid of carbon dioxide. Choosing a suitable size mask for a resident is a critical step to use of a BiPAP machine. On 08/01/23 at 12:46 PM, the surveyor reviewed a complaint, MD00189465. The complainant reported Resident #168 did not receive respiratory care with BiPAP because the facility failed to offer an accurate size of mask for BiPAP. Further review of Resident #168's medical record revealed that the resident was admitted in December 2022 for chronic hypoxemic respiratory failure recovery. The Discharge summary dated [DATE] from an acute care facility ordered applying BiPAP at night via nasal cannula. During an interview with Staff #4 (unit manager) on 08/02/23 at 08:30 AM, she said, If a resident needs BiPAP, the facility staff would order it prior his/her admission. The hospital (or where the resident comes from) should communicate with the facility regarding settings and suitable mask sizes. It delivered within a day. Also, Staff #4 explained that the facility had a respiratory therapist who came almost daily for residents' care. On 08/02/23 at 09:52 AM, an interview was conducted with Staff #55 (admission coordinator). Staff #55 explained that the facility received a call/email/or any notice regarding a newly admitted resident. Then she collected all required documentation regarding residents' care, including needed equipment, and communicated with the facility's clinical staff. Staff #55 confirmed that the outside care center that sent residents conveyed all data like BiPAP settings and mask size. However, Staff #55 confirmed she did not document these communications between who sent residents and the facility's response. The surveyor interviewed Staff #54 (Respiratory Therapist) on 08/02/23 at 01:21 PM. He confirmed that residents' respiratory equipment would be ready before residents' admission with accurate setting and size based on prior orders. Staff #54 also explained if the mask was not fit for residents, any facility staff could re-order them, and they would be delivered shortly. Staff #54 said, I hadn't worked when Resident #148 was admitted , but I expected any nurses who cared for him/her documented their respiratory equipment use. Review of Resident #168 ' s Treatment Administration Record (TAR) on 08/02/23 at 1:45 PM revealed that BiPAP use were documented from 01/01/23 to 01/10/23: -order of remove BiPAP in the morning documented each day done. - order of BiPAP on at bedtime documented done on 01/01/23, 01/05/23,01/06/23, 01/07/23, and 01/08/23. From 01/02/23 to 01/04/23 coded as 9=other/see nurse notes. 01/09/23 coded as 5- hold/ see nurse notes. Further review of Resident #168's progress note revealed as below: -On 01/02/23 at 11:35 PM, Staff #56 (Registered Nurse) documented, resident refused BiPAP stating it's uncomfortable the face mask is small. We are going to call for a new mask, we will continue to monitor. -On 01/09/23 at 08:38 PM, Staff #57 (Licensed Practical Nurse) documented as the hose unfit able ( the Director of Nursing interpreted this as the mask was not fit on 08/02/23 at 01:57 PM). -no nursing note found for 01/03/23 and 01/04/23 regarding BiPAP order. During an interview with the Director of Nursing (DON) on 08/02/23 at 01:57 PM, the surveyor reviewed Resident #168's TAR and progress note regarding BiPAP use. She confirmed that code 9 on TAR meant something documented. If there was no progress note, it meant not documented. Also, the surveyor shared concerns that there was no documentation to support that Resident #168 had an accurate BiPAP mask. The DON said, I understood.

Based on interview, observation, and medical record review, it was determined the facility failed to administer pain medication in a timely manner and according to physicians ' orders. This was evident in 1 (Resident #46) out of 2 residents who were reviewed for pain during the recertification survey. The findings include: On 7/11/23 at 9:50 AM, Resident #46 was observed by surveyors to be sitting in their wheelchair at the entrance to their room, looking out into the hallway, at which time surveyors conducted an interview. Resident #46 reported to surveyors during the interview that they requested Tylenol for knee pain that they rated as a 5 (moderate pain on a scale of 0 to 10) and were told by the nurse that it would be brought at 9 AM with other morning medications. The resident discussed needing the pain medication to relieve the pain she/he was having and so that she/he could more fully participate in therapy. On 7/11/23 at 9:52 AM, Licensed Practical Nurse (LPN) #52, entered the room with surveyors present to administer the pain medication. Therapy staff then arrived immediately thereafter to work with the resident and the interview with surveyors ended. On 7/11/23 at 10:00 AM, Tylenol was documented on the medication administration record (MAR) as being given for pain rated as a five. Upon record review on 8/2/23 at 9:30 AM, physician orders were reviewed revealing the following order in place for Tylenol: Give 2 tablets by mouth every 4 hours as needed for mild pain (1-3). Tylenol administration documented on the MAR revealed it had been given on 7/3/23 for a pain score of 4 and a second time that day for a pain score of 0, 7/11/23 for a pain score of 5, 7/23/23 for a pain score of 4, and on 7/24/23 for a pain score of 0. Ongoing record review on 8/2/23 revealed that the July MAR included the following order: Assess and document pain level every shift record using 0-10 scale, 10 being severe. Upon further review of the MAR, the pain level of zero (meaning the resident has no pain) was selected for every day and every shift from 7/1/23 through the morning of 7/24/23, despite the resident having been transferred to the hospital for intense abdominal pain documented in a change of condition evaluation on 7/24/23. On 8/3/23 at 9:40 AM, an interview was conducted with LPN #52 who reported to the surveyor that if a resident gives a higher pain rating than the scale listed on the medication order for Tylenol, they should not give the medication and call the doctor, then move to another pain medication for moderate or severe pain. They further offered the following statement to the surveyor: You have to realize around here, a lot of these (reports of pain) are behaviors for attention. On 8/3/23 at 10:40 AM section E of the minimum data set (tool used to assess the resident's condition) was reviewed revealing Resident #46 was not documented as having any behavioral concerns.

Based on observation, interview, and record review, it was determined the facility failed to ensure that residents did not receive medications without adequate indications for their use. This finding was evident for 2 of 6 residents reviewed for unnecessary meds. (#72 and #50). 1. Albuterol is an inhaled, quick acting medication used to relieve shortness of breath caused by bronchospasm and is often ordered on a short term or as needed basis. Bronchospasm is anb abnormal contraction of the smooth muscles of the lungs, resulting in an acute narrowing and obstruction of the respiratory airway. A cough with generalized wheezing usually indicates this condition. Bronchospasm is a chief characteristic of asthma and bronchitis. Resident #72 was admitted to the facility in August 2018. The admission History and Physical done by the resident's attending physician, Staff #22, was dated 8/23/18 and indicated that the resident had no concerns with his/her respiratory system, no history of respiratory problems, and no active respiratory diagnosis. On 7/10/23 at 11:12 AM, an initial observation and interview of Resident #72 was conducted. The resident was sitting in his/her bed, was alert and responsive, and appeared calm and comfortable. No signs of cough or respiratory distress were observed. The resident denied any distress. On 7/20/23 at 9:04 AM, a review of Resident #72's medical records revealed that, in December 2021, the resident had a cough and congestion in his/her lungs. The nurse notified the physician and an order was given to administer Albuterol for cough for two days. After two days another order was written to continue the Albuterol every day and to give it 3 x day (not on an as-needed basis). It appeared that the resident required the medication for an acute condition, but the medication continued from December 2021 until the time of the survey without a supporting respiratory diagnosis. There was no documentation in the physician's notes that explained the reason for continuing the medication. There were no respiratory diagnoses listed in the resident's medical record. On 8/04/23 at 10:32 AM, Resident #72 and #39;s attending physician (Staff #22) was asked what indication supported the ordered Albuterol. Staff #22 explained that initially he ordered the Albuterol medication because the resident had an episode of allergic bronchospasms. Staff #22 confirmed that the resident did not have any chronic respiratory diagnoses. He further explained that the resident had been very stable since being on the Albuterol and that it made sense to re-evaluate the resident's need to continue the medication. Record review revealed that the Albuterol was ordered for cough; and there was no documentation of bronchospasm in the physician note. 2. On 7/27/23 at 11:46 AM a review of Resident #50's Medication Administration Record (MAR) revealed that there were the following 3 pain medications prescribed to be given as-neededt; (PRN) and other orders related to pain management: - Tylenol (non-narcotic) 325 mg (milligram) (Acetaminophen), give 2 tablet by mouth every 4 hours as needed for Mild Pain, order date 3/12/23. - Tylenol with Codeine #3 (narcotic) oral tablet 300-30mg (Acetaminophen with Codeine). Give 1 tablet by mouth every 4 hours as needed for moderate pain 1-5. Order date 3/12/23. - Oxycodone (narcotic) oral tablet, 5 mg, give 1 tablet by mouth every 4 hours as needed for pain related to chronic pain syndrome, order date 6/13/23. On 7/14/23, the resident received each one of these medications within a 3-hour time span. The resident received Oxycodone 5 mg at 1:21 PM for a pain level of 5, he/she received plain Tylenol at 4:29 PM for a documented pain level of 2 , and at 4:32 PM the resident received Tylenol with Codeine #3 for a pain level of 2. There was no indication in any of the orders if they may be given together or overlapping. In addition, although non-pharmacologic interventions were ordered to be tried prior to giving any pain meds (per the MAR), there were no entries on the MAR for either the use or refusal of those non-pharmacological interventions. In an interview on 7/31/23 at 9:10 AM with Staff #46, a Licensed Practical Nurse (LPN), the LPN was asked how she decides which pain med to give. She said she uses the 0-10 pain scale, but she gives Resident #50 what the resident asks for because he/she knew what he/she wanted. When asked about non-pharmacological interventions, she stated the resident only wants the pain medications and so no non-pharmacological interventions were offered. On 7/31/23 at 9:15 AM, Resident #50's physician (Staff #24), the resident's Unit Manager (Staff #23), and the Assistant Director of Nursing (ADON) were interviewed and asked what pain scale the facility used to determine which pain medication to administer. The Unit Manager said a scale of mild, moderate, or severe, and the physician said it was up to the nurse and the facility policy about which numbers related to mild, moderate, and severe. The Unit Manager verbalized that nurses would use the severity levels of mild 1-4, moderate 4-6, and severe 7-10, per facility policy. When the Assistant Director of Nursing (ADON) was asked about the facility's standard pain assessment scale, he responded that the facility had no standard pain scale. On 8/01/23 at 10:39 AM a review of the facility Pain Management policy revealed that although the policy stated, The facility will use a pain assessment tool , the policy lacked any such tool or scale to assess pain. In an interview with the Director of Nursing (DON) on 8/02/23 at 1:39 PM, the above findings were reviewed, and no further clarification or information was provided.

x Based on interview and review of the facility records, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident by 1) the duration of antibiotic use was not completed due to changing to a different salt form*, 2) a resident's antibiotic was prescribed without indication, and 3) the facility antibiotic stewardship program failed to document essential elements for antibiotic use. This was found to be true on 2 (Resident #69 and #399) out of 5 residents reviewed for antibiotic use and antibiotic stewardship program review during the annual survey. The findings include: *Salt form: Over 50% of all drug molecules used in medicine exist as salts, most frequently as the hydrochloride, sodium, or sulfate salts. Drugs are often formed as a weak acid or base, but this drug form is not always optimal for dissolution or absorption into your body.) Doxycycline hyclate vs Monohydrate: The antibiotic component (doxycyline) is the same in both medications, but the salt forms (hyclate and monohydrate) are different. These salt forms might affect how quickly the medication dissolves in your body, but they both appear to work as well as each other to fight infections. 1)On 07/17/23 at 09:20 AM, a review of Resident #69's medical record, including the Medication Administration Record (MAR) review for June 2023, revealed that the resident had an order of Doxycycline Hyclate give 100mg by mouth every 12 hours for abscess for ten days. : Started on 06/01/23 (initial dose administered on 06/01/23 at 6 PM) and discontinued on 06/03/23 (total 3 doses given from 06/01/23 to 06/02/23). And another order of Doxycycline Monohydrate 100mg give one tablet by mouth every 12 hours for abscess for nine days. Placed on 06/03/23 at 02:06 AM. The MAR documented doxycycline Monohydrate was administrated from 06/04/23 to 06/12/23 (total 18 doses given). Per MAR documentation, no antibiotic was administrated on 6/03/23. (10 days of doxycycline order was not completed) Further review of Resident #69's medical records, there was no documentation about Doxycycline salt form changes and/or duration of antibiotic use. **Prescribed antibiotic should always finish a course. If it is finished or missed several doses, the infection may return** During an interview with the Director of Nursing (DON) on 07/19/23 at 09:20 AM, the surveyor shared concerns regarding Resident #69's antibiotic use. The DON stated, Doxycycline Hyclate and Monohydrate were the same medication but in different forms. We changed them because of medication delivery issues. The plan was to use ten days. He/she took just one more dose. The surveyor reviewed Resident #69's MAR with the DON. It documented the resident took Doxycyline Hyclate three doses from 06/01/23, no medication administered on 06/03/23, and Doxycyline Monohydrate was given nine days from 06/04/23 to 06/12/23. The DON said, I see your concern. 2) A review of Resident #399's medical record on 07/18/23 at 01:10 PM revealed that Resident #399 had an order of Ciprofloxacin 500mg give one tablet orally every 12 hours for five day: started on 07/16/23. During an interview with an Infection Control Preventionist (ICP) on 07/18/23 at 01:40 PM, the surveyor asked about Resident #399's antibiotic indication. The ICP stated since the resident's WBC (white blood cell) elevated, he/she was on antibiotics. However, a further review of Resident #399's progress note dated 07/16/23 written by the ICP revealed that the resident had been on doxycycline twice daily regarding wound infection. And Ciprofloxacin was added for Urinary Tract Infection. On 07/19/23 at 09:20 AM, an interview was conducted with the Director of Nursing (DON). The surveyor shared concern regarding Resident #399' antibiotic order. The DON stated that the provider used ICD code for indication. She said, I will let them know. 3) The surveyor reviewed the facility's antibiotic stewardship binder from January 2023 to July 2023 on 07/18/23 at 01:00 PM. The review revealed that the infection control log sheet contained columns of resident name, admit date , onset date, site, infection diagnosis, culture, x-ray date, organism, antibiotic, isolated (Yes/ no), HAI, re-culture date, and date resolved. However, not all information for residents who were on antibiotics was documented on the sheet. During an interview with ICP on 07/18/23 at 01:40 PM, she said, Since the column was so narrow, I wrote details of residents' condition on the back page of the sheet. Further review of the Antibiotic stewardship binder revealed that : -report period 02/21/23: a resident admit date documented as 2/19, no detail documented -report period 04/01/23-04/31/23: a resident name listed on the front page, without infection diagnosis, site, and onset date -report period May 2023: a resident name listed without diagnosis, site, and date. On 08/04/23 at 09:30 AM, the surveyor shared concerns about the antibiotic stewardship program with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview it was determined the facility staff failed to keep the building clean, neat, attractive and in good repair. This was evident on both floors of the facility. The findings include. An environmental tour was conducted with the maintenance director (staff #16) on 7/21/23 at 9 AM. The maintenance director was informed of the accumulated environmental concerns by multiple members of the survey team during the initial days of the survey beginning on 7/10/23. The following observations were confirmed by the Maintenance director. In room [ROOM NUMBER] bathroom, revealed vinyl cove/base molding separating from wall along the left wall, a browned stained ceiling tile near the ventilation fan and a rust stained metal suspended ceiling strip above the sink. In room [ROOM NUMBER] bathroom, revealed a hole in the bottom of the wall to the right of the sink area measured approximately 10 inches long, 3 to 4 inches deep extending down under the cove molding area and appeared larger than what was visible. The wall was spongy and moved to slight pressure. Near the baseboard/cove molding to the left of the toilet was damage to the wall approximately 4 inches long where the vinyl cove molding was separated from the wall. Behind the head of bed C was exposed plaster above the cove molding approximately 3 x 5 inches. In room [ROOM NUMBER] bathroom noted wall damage at the area above the cove molding and the cove molding was separating from the wall. The bathroom sink was loose from the wall and slightly separated from the wall with damage to the wall at the sink area. On the wall directly across from the B bed, there were multiple scraps in the drywall halfway up the wall exposing the base layer of the Throughout the tour the maintenance director confirmed the observed damage and incomplete repairs and indicated that when the bathroom floors were replaced there was damage to the walls that was not repaired at the time and the vinyl cove molding should have been taller. Additionally, he called his assistant a couple of times to report what needed to be fixed. In room [ROOM NUMBER], behind the head of the bed A, noted peeling paint approximately 2 by 4 feet long area on the wall. In room [ROOM NUMBER], behind the head of the bed C, observed damage/peeling paint in an area approximately 1 foot x 1 foot. A second environmental rounds was initiated with the maintenance director on 7/27/23 at 12:30 PM. The maintenance director confirmed the following observations: In room [ROOM NUMBER] bathroom, the base/cove vinyl cove molding was separating below the sink and along the wall left of the sink. The wall behind the toilet shown to have a foot long brown stain. In room [ROOM NUMBER] bathroom, the paint was noted to be peeling off the wall underneath the toilet paper dispenser and above the base/cove molding approximately 2.5 feet long. Multiple damage areas on the walls above the cove molding shown to have top layer of wall board torn with spots missing. In room [ROOM NUMBER] bathroom, along the left wall to the sink areas of peeling paint above the base/cove molding approximately 3 feet long with separation between the base molding and the walls. On the right bathroom wall noted 6-inch dark oval discoloration in the middle of the wall. In room [ROOM NUMBER] bathroom, a length of the base/cove molding approximately 8 inches long was unattached to the wall exposing rough unpainted section of the wall where the molding was previously attached. The wall behind the head of bed C appeared to have streaks of peeling paint approximately 5 x 12 inches long as if the wall was scrapped by a rake. In the hallway outside of the 2nd floor dining room was a 1-foot semicircle stain in a ceiling tile. Throughout the tour the maintenance director confirmed the observed damage and incomplete repairs and indicated that when the bathroom floors were replaced there was damage to the walls that was not repaired at the time and the vinyl cove molding should have been taller. Additionally, he called his assistant a couple of times to report what needed to be fixed.

4) On 8/1/23 at 10:00 AM, a review of the facility ' s documentation of their investigation into an alleged employee-to-resident abuse of Resident #71 revealed that the documents lacked details of the date, time, place of the incident, the date and time of the interviews, the name of the alleged perpetrator, and the name of the person conducting the investigation interviews. A form titled January 6, 2023, which was a written statement signed by the resident's, Social Worker (SW), lacked the time it was written, the date and time of the incident, and the name of the alleged perpetrator or victim. Another form was found entitled, Resident Interview that had two questions on it: 1. Did any staff shout at you during care on 1/6/23?, and 2. Did any staff slap you during care on 1/6/23? A sentence below the questions read The resident is unable to answer due to his/her cognitive deficits. The resident ' s name was handwritten on the top of the page. There was no notation of the date or time of the incident, date or time of the interview, or the author of the document. There were also 4 other forms titled Re: Investigation which listed 4 questions which appeared to be questions targeted for residents. There was also a set of 3 forms titled Re: Investigation which listed 6 questions and appeared to be targeted to staff. Each of these forms had handwritten one-word answers and illegible marks at the bottom of each form which appeared to be signatures. None of the forms had any name or identifier, any dates or times of when they were created, any date or time of the incident, or the name and title of the author/interviewer. On 08/04/23 at 08:30 AM, during an interview with Geriatric Nursing Assistant (GNA) #30 who was the alleged perpetrator, the GNA was asked if she made a written statement regarding the incident and she responded that she gave a verbal statement to the Director of Nursing (DON), who wrote it down, but the GNA did not write her own statement. On 08/04/23 at 11:55 AM, the folder of the facility ' s investigation documentation was reviewed with the Director of Nursing (DON). The DON was shown the contents of the folder which lacked sufficient details. The DON asked if she could add the missing elements to the form and confirmed that the facility ' s investigation documentation was not thorough. Based on interviews and record review it was determined the facility failed to perform a thorough investigation of an allegation of abuse. This was evident for 4 (Resident #253, #1, #175, and #71) out of 6 residents reviewed for abuse. The findings include: 1) Resident #253 relayed to the surveyor on 7/11/23 at 12:02 PM an allegation of abuse in which they had reported that an Occupational Therapist was swinging the cane at me (approximately) last Thursday (7/6/23) and the facility reported to my family that I was threatening the staff. On 7/17/23 at 12:01 PM, PTA (Staff #28), stated in an interview with surveyors regarding the alleged incident on 7/7/23: We had to pull him/her back in the chair. We snugged him/her back in the chair by the gait belt. He/she wants to walk. On 7/21/23 at 12:00 PM, the facility ' s incident self report form was reviewed by surveyors. The report indicated that, on 7/14/23 at approximately 3:47 PM, the facility began investigating an allegation that Resident #253 had been abused during a therapy session on or around 7/6/23. The facility documented that Resident #253 reported the following information during a follow up visit on 7/14/23 done by the Assistant Director of Nursing, Administrator, and Social Worker: The resident did report to them that while working with the therapist on Thursday (7/6), the therapist pulled the resident ' s cane from him/her and tried to poke and hit him/her. The report further documented: When asked if he/she was actually hit with the cane, he/she said no, she tried to. The surveyor noted that Resident #253 had not made an allegation of being hit by a staff member. Further review of the facility reported incident provided the following information: The investigation revealed this incident was reported by the therapist to the RD (Director of Rehab) that the resident had swung at her with his/her cane, the cane was taken away and he/she attempted to hit her with his/her walker after refusing to sit in his/her chair to prevent a fall. In a statement from the investigation file with an email date of 7/14/23, Physical Therapy Assistant (PTA, Staff #28), wrote the following information: Pt (patient) got angry and replied No, I ' m not sitting down. PTA (Physical Therapy Assistant) had to pull pt (patient) back in chair to prevent pt (patient) from falling.The complete investigation file was reviewed and failed to address that Resident #253 had the right to say no to sitting back down. Review of the facility reported incident investigation revealed the following statement: Other staff interviewed stated he/she never mentioned any rehab staff hitting him/her, but he/she did complain about rehab services. No further information regarding the resident ' s complaints about rehab services was included in the facility ' s investigation file. Further review of the investigation file revealed that there was one question asked to twenty-two staff members documented on 7/17/23: Have you witnessed or experienced any abuse of resident or staff from (Staff #21), OT? The following items were not documented in the facility ' s complete investigation file: 1.) interview times, 2.) additional information that had been asked or reported, 3.) 19 out of 22 staff interviewed had no position title listed, 4.) there was no documentation of who had performed the interviews of staff and residents, 5.) there were no interview dates, times, notes, or questions asked by the facility to the three staff members who provided statements, 6.) there was no written statement obtained from the resident. Reference to F585 2) A facility-reported incident, MD 00156247, was reviewed on 07/21/23 at 01:52 PM. The report review revealed that Resident #1's family member informed the Director of Nursing that an assigned nurse hit the resident's arm on 07/16/2020. The facility's investigation packet contained four staff interviews: the interview sheet had a written question, Have you witnessed or have knowledge of any staff members physically harming any residents specifically [XX: Resident #1's name]?. Four staff members checked yes or no on these sheets with signatures; however, no name, title, or details were documented. Also, the facility's investigation packet had nine residents' interview sheets (the headline of the page titled resident's interview) with a written question, Have you witnessed or have knowledge of any staff members physically harming any residents specifically [XX: Resident #1's name]. Four resident interview sheets had handwritten names with their credentials (RN-registered nurse, or their shift (ex. 3-11 PM), two of them had written names and room numbers, and three had only written names. There were no records for Resident #1's statement and alleged perpetrator staff status/evaluations. During an interview with the Director of Nursing (DON) on 07/21/23 at 2:15 PM, the surveyor reviewed the facility's investigation packet with the DON. The DON agreed the investigation was not thoroughly conducted. 3)The surveyor reviewed a facility-reported incident MD00188119 on 07/24/23 at 08:11 AM. The review revealed that Resident #175's family member reported that a GNA (Geriatric Nurse Aide) threw and swung his/her leg while they cared for the resident. Further review of the facility's investigated packet, the alleged perpetrator GNA had an interview via telephone on 01/23/23. The written statement showed, on 1/23/23 this writer called alleged perpetrator about working with resident in xxx[Resident #175 ' s room number] However, there was no additional information about who conducted this phone interview. Also, the investigated packet had three interviewed papers named Re: Investigation including six written questions: did you work on [specific unit] on 1/22/23 on 3-11 PM shift? Were you assigned to room [resident #175's room number]? At any time did you enter room [the resident's room]? If yes, what care did you provide to the resident(s)? Did you hear or witness any physical or verbal inappropriate behavior? And have you heard any concerns related to any GNA's or other coworkers? All three sheets did not include the name, date, and signatures who filled out these forms. Additionally, there were four sheets named Re: investigation, including four written questions: do you have any concerns? Is the staff providing care for you? Have you heard or witnessed physically or verbal inappropriate behavior from staff? And do you feel safe in the facility? These four sheets contained signatures; however, not able to identify who and when signed these. During an interview with the Director of Nursing (DON) on 08/04/23 at 09:30 AM, the surveyor shared the above concerns with the DON.

Based on a review of a complaint intake, medical record review, and staff interview it was determined that the facility failed to document the reason leading up to a transfer of a resident to the hospital in the medical record including a reason for the transfer. This was evident for 1 (Resident #160) of 6 residents reviewed for hospitalization. The findings include: On 7/25/23 complaint intake, MD00140476 was reviewed related to resident #160. Based on a review of the complaint the resident had a fall, and busted his/her head and was transported to the emergency room. A review of resident #160's closed medical record on 7/25/23 did not reveal any evaluations or progress notes indicating the resident had a fall and was transferred to the hospital. Review of the closed paper medical record on 7/25/23 revealed Hospital discharge instructions with the resident's name time stamped/prepared on 4/17/19 at 4:13 AM. The local hospital's discharge instructions indicated resident #160 had a fall from standing and a laceration to scalp. On 7/26/23 the assistant director of nursing (ADON) was shown the hospital discharge instructions and informed of the lack of documentation related to the resident's transfer and return to the facility on 4/17/2019. At 1:10 PM on 7/26/23 the ADON returned and confirmed the lack of documentation in the medical record indicating that the resident was transferred to the hospital and the lack of documentation of the resident's return to the facility. The ADON provided an internal document that was not part of the medical record indicating on 4/17/2019 the resident was observed on the floor with the resident's head towards the foot of the bed, laceration to the posterior head with blood, and transferred to the emergency room for evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the medical chart on 7/18/23 at 1:56 PM revealed a physician's order written on 5/9/23 to transferred resident to the hospital for medical treatment. Further review of the AUTM Change in condition/Concurrent review'' document dated 5/9/23 revealed that the transfer/discharge section was checked off to indicate that a notification for transfer was given to the resident's representative when resident was sent out to the hospital. On 7/19/23 at 9:48 AM Resident was asked in an interview if s/he was given a written notice prior to hospital transfer/discharge on [DATE]. Resident stated that s/he did not and that it may have been given to his/her daughter who was the resident's representative. The resident's daughter on 7/19/23 at 2:43 PM was asked in an interview if she received a written notice of transfer when resident was sent out to the hospital on 5/9/23. Resident's daughter indicated that she did not. On 7/20/23 at 9:07 AM the unit manager Staff #4 was asked if a written notice before Transfer/Discharge was given to the resident, or their representatives and she responded that the resident or family members were notified verbally by phone and that written notices are not sent. The Director of Nursing (DON) was made aware on 7/20/23 at 9:34 AM that the document was checked off as given to the resident's representative when resident was sent out to the hospital on 5/9/23. She was asked to provide a copy. On 7/20/23 at 10:15 AM the DON confirmed that the facility did not have a written notice of Transfer/Discharge document that they mail out to resident's or their representatives on transfer to hospital/ discharge. Based on medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (Residents #105, 119, 106, and 160) of 6 residents reviewed for Notice requirements before transfer/discharge. The findings include: 1) Review of the medical record for Resident #105 on 7/28/2023 at 10:07 AM revealed that Resident #105 was transferred to an acute care facility on the following dates: 2/8/2022 for left hip acute fracture, on 10/29/2022 for change in mental status, on 4/12/2023 for unwitnessed fall, and on 7/13/2023 for change in mental status and hypotension (low blood pressure). However, there was no documentation and/or evidence in the record indicating that the facility staff notified the resident/resident's representative (RP) in writing of the reason for the transfer/discharge to the acute care facility on the above dates/times the resident was transferred out. 2) Review of medical record for Resident #119 on 7/31/23 at 10:20 AM revealed that Resident #119 was transferred to an acute care facility on 10/18/2022 for altered mental status, hypotension, dehydration, and positive for COVID, and on 5/13/2023 for change in mental status, incoherent with slurred speech and SOB (shortness of breath). On 7/31/2023 at 10:34 AM, review of the facility's Bed Hold policy revealed the resident was given a written notification of the policy on 10/18/2022 and 5/13/2023 respectively (the two times he was sent to the hospital). However, there was no written documentation that the resident and/or resident representative was notified in writing of the reason for the transfer/discharge to the hospital. On 7/31/2023 at 11:00 AM, in an interview with the 2nd floor Unit Manager (UM #4), she stated that residents, their representatives (RP)/family members were notified verbally when a resident was transferred to the hospital by the transferring nurse. She confirmed that the notification was done verbally and not in writing. However, UM #4 added that they (facility staff) have started as recently as last week to send written notifications in addition to the bed hold policy to residents and their RP/family when a resident was transferred to the hospital. 4) On 7/25/23 complaint intake, MD00140476 was reviewed related to resident #160. Based on a review of the complaint the resident had a fall, and busted his/her head and was transported to the emergency room. A review of resident #160's closed medical record on 7/25/23 did not reveal any evaluations or progress notes indicating the resident had a fall and was transferred to the hospital. Review of the closed paper medical record on 7/25/23 revealed Hospital discharge instructions with the resident's name time stamped/prepared on 4/17/19 at 4:13 AM. The local hospital's discharge instructions indicated resident #160 had a fall from standing and a laceration to scalp. On 7/26/23 the assistant director of nursing (ADON) was shown the hospital discharge instructions and informed of the lack of documentation related to the resident's transfer and return to the facility on 4/17/2019. At 1:10 PM on 7/26/23 the ADON returned and confirmed the lack of documentation in the medical record indicating that the resident was transferred to the hospital and the lack of documentation of the resident's return to the facility. The ADON provided an internal document that was not part of the medical record indicating on 4/17/2019 the resident was observed on the floor with the resident's head towards the foot of the bed, laceration to the posterior head with blood, and transferred to the emergency room for evaluation. A follow-up conversation was held with the ADON on 8/3/23 at 2:40 PM to review additional regulatory non-compliance related to the lack of any documentation in resident #160's medical record of the 4/17/2019 transfer to the hospital. There was not any documentation of resident #160 or a family representative was provided written notification of the facility initiated transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that the facility failed to failed to develop and implement comprehensive, Resident-centered care plans for residents residing in the facility. This was evident for 5 (Resident #71, #252, #177, #93, and #399) of 33 resident care plans reviewed during the survey. The findings include: 1) A review of Resident #71's physicians orders on 7/18/23 at 1:51 PM revealed an order dated 6/23/23 for OT (Occupational Therapy) Clarification; RNP (Registered Nurse Practitioner) order; Resting hand splint to be worn on L [left] hand 8hrs [hours] on, during the day, assessing for redness, skin tears, and maintaining palmar hygiene and nail hygiene. This order was discontinued on 7/18/23. On 7/19/23 at 9:14 AM, the resident's care plan was reviewed and revealed that there was no focused care plan problem listed for the hand splint ordered on 6/23/23. In an interview with the Rehabilitation Director (Staff #27), on 7/24/23 at 12:56 PM, Staff #27 stated that when OT transitioned the resident's hand splint care to nursing, the Minimum Data Set (MDS) Nurse or the Unit Nurse Manager would update the care plan. On 8/04/23 at 9:26 AM, in an interview with the Director of Nursing (DON), the DON showed the surveyor a copy of Resident #71's care plan that included an intervention for a hand splint, but the Date Initiated was 4/12/19. When further questioned, the DON was not sure if the copy of the care plan was current. On 8/04/23 at 9:44 AM, the MDS Director was interviewed and the copy of the resident's care plan was reviewed. The MDS Director clarified that the 4/12/19 date was incorrect and was associated with a different problem, that the hand splint care plan was initiated on 7/18/23. When asked where the splint intervention on the plan of care for the transition from OT to Nursing on 6/23/23, the MDS Director stated that it was not entered on the care plan at that time, that it was missed. The new hand splint problem dated 7/18/23 was for a new order for the hand splint dated 7/18/23. The MDS Nurse said she informed the DON regarding the missing information. 4) On 7/11/23 at 10:15 AM observation of resident #93 revealed that resident was on oxygen via Nasal Canula (NC), an oxygen tubing with nose prongs. The NC was connected to a humidifier on the oxygen concentrator, a machine that concentrates oxygen from the air, at the bedside. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/8/23 on 7/26/23 at 2:20 PM documented that resident was on oxygen therapy. Further review of the physician's order revealed an order written on 7/22/23 for oxygen therapy at 2 liters via NC every shift related to mild intermittent asthma. On 7/27/23 at 11:12 AM Review of the most recent care plan with a completion date of 7/21/23 revealed that there was no care plan developed for the use of oxygen therapy. On 7/27/23 at 11:27 AM The unit manager was made aware of this concern and asked to provide a copy of the care plan. She confirmed that the care plan for oxygen therapy was not developed for resident #93. 5) On 7/10/23 at 09:00 AM observation of resident #399 in bed revealed that resident #399's bed was raised up high to the surveyor's hip level. The resident was nonverbal and could not answer the surveyor's questions. No one was in the room with the resident. On 7/11/23, and 7/12/23 at 0900, resident was observed again in bed with the bed elevated up to the surveyor's hip level. On 7/12/23 at 2:19 PM, the unit manager Staff #4 and the Respiratory Therapist Staff #54 were at the bedside. The unit manager was made aware of the concerns and indicated that Resident #399 's wife visits resident daily and would put the bed up to chat with resident. Review of the physician's order revealed an order written on 5/9/23 that reads Bed in low position while resident is in bed every shift for injury prevention. Review of the resident's care plan with target completion date of 6/15/23 has as focus. Resident is at risk for falls related to (r/t) dependent on transfers, recent surgery, Cardiovascular Accident (CVA) with hemiplegia a paralysis on one side of the body. The goal was that Resident will remain free of falls through next review and the interventions was to Keep bed in lowest position. On 7/24/23 at 09:00 AM -Resident #399's bed was observed again in the high position with resident lying on it. The unit manager staff #4 and the Assistant Director of Nursing (ADON) were brought into the room and the concern reviewed with them. 2) On 07/26/23 at 10:51 AM, the surveyor reviewed Resident #252's medical records. The review revealed that the resident was admitted to the facility in November 2022 with the diagnosis of old myocardial infarction, dementia, anemia, and spinal stenosis. Further review revealed that The facility staff monitored Resident #252's hemoglobin level from 04/04/23. On 04/07/23, the resident was transferred to an acute care facility to treat low hemoglobin (6.3 g/dl: normal range 12.1-15.1g/dl). Resident #252's discharge summary from the acute care facility dated 4/14/23 showed that the resident received the management of gastrointestinal (GI) bleeding during his/her hospitalization. However, no care plan was developed regarding Resident #252's GI bleeding after the resident's readmission on [DATE]. On 7/26/23 at 12:50 PM, the surveyor shared the above concerns with the Director of Nursing (DON). The DON confirmed the deficiency. 3) 08/03/23 at 8:30 AM, a review of Resident #177 ' s medical record revealed that he/she had an actual fall on 04/08/21 without injury: the change in condition form documented that resident found on the floor in a sitting position between his/her bed and wheelchair with lap buddy pushed to the side. Another change in condition form dated 04/20/21 documented that an unwitnessed fall occurred on 4/20/21 at 10:40 AM: Resident was observed lying on the floor in a prone position bedside his/her bed and wheelchair with lap buddy on the floor. During an interview with the Assistant Director of Nursing (ADON) on 8/04/23 at 07:35 AM, he said, Resident #177 was very confused while he/she had resided in this facility and had no awareness about fall risk. He/she always tried to stand up or move. That's why we applied lap buddy for fall precaution. On 08/04/23 at 11:03 AM, an interview was conducted with Staff (#27, Director of Rehab). Staff #27 stated that Resident #177 had the lap buddy since 2014 per his/her family's request, and the evaluation for the lap buddy used was done prior to applying. However, a review of Resident #177's care plan (in the electronic medical record: PCC) on 08/04/11:45 AM revealed no evidence that a care plan was developed regarding the use of a lap buddy. On 08/04/23 at 3:25 PM, the ADON submitted a copy of the lap buddy care plan for Resident #177 dated 3/02/17, which was in paper format, not PCC. The care plan's approaches/interventions indicated that A. evaluate and assess for the use of the least restrictive device (s), B. assess no less than q 90 days for possible restraint reduction/elimination, C. refer to PT/OT for evaluation of positioning, safety and mobility needs, D. educate Resident and family related to device, consequences/alternatives, E. apply devices per MD's order: Type- lap buddy, Reason- prevent falls, F. provide exercise daily, and G. maintain dignity. However, there was no further evaluation and/or revised documentation for the lap buddy in Resident #177's medical record (including a paper chart or PCC). During an interview with the ADON on 08/04/23 at 3:40 PM, he confirmed that the facility currently uses PCC for residents' records. Also, he explained that since Resident #177 had resided in the facility for a long time, they used paper for the care plan in 2017. The surveyor asked how current Staff could follow the Resident's lap buddy care plan. The ADON could not provide an answer. On 08/04/23 at 04:10 PM, the DON and Nursing Home Administrator were made aware of this issue.

6) In an interview with Resident #50 on 7/12/23 at 10:48 AM, the resident explained that despite asking, he/she has not been allowed to reside in a room with his/her spouse who is also a resident at the facility. On 7/28/23 at 08:06 AM a record review revealed no documentation in the Social Worker notes regarding Resident #50 ' s request to reside with his/her spouse. In an interview with Staff #33, the first floor Social Worker (SW), and Staff #2, the Director of Social Work, on 7/28/23 at 9:45 AM, Staff #2 reported that neither the resident's, nor the resident ' s spouse ' s rooms were big enough to accommodate them both based on their care needs. Staff #2 confirmed that there was no documentation in the resident record regarding this concern. 7) A record review on 7/18/23 at 10:16 AM for Resident #71 revealed a document entitled Change in condition dated 6/25/23 which described finding a new blister on the resident's left hand. Further review of skin assessment documentation revealed 3 consecutive weekly skin evaluations dated 7/2/23, 7/9/23, and 7/16/23 and all described the resident's skin as intact. On 7/18/23 at 12:02 PM, during an observation of Resident #71, and an interview with Licensed Practical Nurse (LPN) #46, the LPN showed the surveyor the resident's left hand with a scabbed blister approximately 5 mm (millimeters) in diameter. In an interview with the Unit Manager for Resident #71's unit on 7/19/23 at 10:13 AM the Unit Manager described the facility process for documenting skin assessments, and said that any new or existing skin alteration, including scratch and abrasion, should be documented weekly. On 8/02/23 at 1:39 PM in an interview with the Director of Nursing (DON), the DON confirmed that Resident #71's skin records on 7/2/23, 7/9/23, and 7/16/23 failed to capture the blister first identified on 6/25/23 and still present at the time of the survey. 8) On 7/20/23 at 11:46 AM a review of a Psychiatric Progress Note dated 7/13/23 for Resident #72 revealed that the printed document incorrectly listed the author, Nurse Practitioner (NP #29), as a Physician. The printed electronic document did not contain an e-signature, and the text of the document did not include the author ' s name or credentials. In an interview with the Director of Nursing (DON) on 8/01/23 at 9:10 AM, the DON said that she indicated that she did not have information about the NP notes that were documented. On 8/01/23 at 11:03 AM an interview with the Nursing Home Administrator (NHA) was conducted. The NHA explained that there were issues with Staff #29's User Role when he was first set up at another facility. When asked what his correct role was, the NHA confirmed that Staff #29 is an NP and not a Medical Doctor. The NHA also confirmed that the medical record documentation incorrectly indicated that Staff #29 was a physician. 4) On 7/18/23 at 8:22 AM the Assistant Director of Nursing (ADON) brought Staff #29, Psychiatric Certified Registered Nurse Practitioner to the surveyor. The ADON introduced Staff #29 as the Psychiatrist. Staff #29 was asked by the surveyor if they were the Psychiatrist, and they responded yes. The surveyor had previously reviewed medical records which referred to Staff #29 as a Nurse Practitioner. During medical record review for Resident #253 on 8/1/23 at 9:46 AM, psychiatric notes were reviewed which documented Staff #29's position as physician. It was also noted by surveyors that Staff # 29's notes were electronically signed as a Physician instead of a Certified Registered Nurse Practitioner. In a note with an effective date of 6/29/23, Staff #29 had electronically signed the evaluation of Resident #253 as a Physician. A note for a visit performed on 7/18/23 by Staff #29 was not created and available on the medical record until 7/21/23. The note for a visit performed on 7/14/23 by Staff #29 was not created and available on the medical record until 7/18/23. During an interview with the Director of Nursing on 8/1/23 at 9:00 AM, they reported there was no set facility process in place for oversight of psychiatric records to ensure they are documented, timely, and accurate. During an interview with the facility Administrator on 8/1/23 at 11:03 AM, they stated the facility was not aware of Staff #29 documenting and signing as a physician, and their user role in the computer system had now been corrected. At this time, they acknowledged the surveyor's concerns. 5) On 8/2/23 at 11:21 AM, the surveyor reviewed the prescription dated 7/21/23 for Resident #31 to receive Trulicity injectable medication located in the medical record which states the following information: Inject 0.5 mililiters (0.75 miligrams total) under the skin once a week. Further review of the medical record revealed an order beginning 7/21/23 that directed a different amount of Trulicity: Inject 0.75 mililiters subcutaneously (under the skin) one time a day every Fri for Diabetes Mellitus. On 8/2/23 at 2:30 PM, the surveyor asked to see the Trulicity for Resident #31 which revealed each pen contained 0.5ml/0.75mg and the prescription labeling of the pens matched the labeling of the box they were stored in. The facility administrator and Director of Nursing were subsequently notified by the surveyor of the concern and acknowledged the surveyor ' s concern. 3) On 7/11/23 at 2:34 PM Resident #43 was observed in room with limited range of motion to the left upper extremities and a Left-hand contracture. Resident was observed without a splint to the left hand. Resident's daughter was at the bedside and on interview stated that the resident had an order for a left-hand splint to be worn every 4-6 hours daily. The daughter further stated that staff stopped applying the splint because it hurts resident's hands. Review of the quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/6/23 on 7/26/23 at 9:43 AM documented an impairment to the upper extremities on one side. Review of the physician's order written on 5/12/22 had Order for left hand roll splint on left hand. Wearing Schedule: 4-6 Hours daily one time a day for Contracture prevention/management. On 07/26/23 at 10:09 AM a review of Resident #43's care plan with an ARD of 5/12/22 revealed a care plan for pain related to Cardiovascular Accident (CVA) with hemiparesis (a weakness or paralysis on one side). Some of the interventions were splint: left hand roll splint on left hand. Wearing Schedule: 4-6 Hours daily. On 7/26/23 at 11:00 AM a second observation was made of the resident, there was no splint to the Left arm. On 7/26/23 at 11:05 AM review of the residents July 2023 Treatment Administration Record (TAR) revealed that nursing staff were signing off that resident wore the splint. Resident #43 was observed again on 7/27/23 at 9:20 AM, 10:15AM and at 12:30PM. Observation revealed that resident was not wearing a splint to the Left hand. Review of the TAR on 7/27/23 at 12:35 PM revealed that this intervention was signed off by nursing to indicate that the splint was placed On 7/27/23 at 12: 40 PM The residents nurse a License Practical Nurse (LPN) Staff #6 was called to Resident #43's room and asked to show the surveyor where the splint was. Staff #6 looked through the resident's bedside table draws and found the splint, tried to put it on the resident's wrist but could not. Staff #6 could not tell the surveyor when last the splint was placed. The Geriatric Nursing Assistant (GNA) Staff #45 came over and told Staff #6 and the surveyor that the resident stopped wearing the splint a while back because resident complained that it hurts when staff attempted to place it. On 7/27/23 at 2:00 PM the unit manager Staff #4 was made aware of the concern that staff were signing off to indicate that the splint was placed when it was not. 2) On 08/02/23 at 11:27 AM, the surveyor reviewed a complaint, MD00182706. The complainant reported that the facility provided paperwork for Resident #148, including incorrect date of birth (DOB) and age. Also, the complainant added there was wrong code status documented on the papers. On 08/02/23 at 11:45 AM, Resident #148's medical records, including electronic (PCC: electronic medical record cloud) and paper charts, were reviewed. On admission record and PCC recorded Resident #148's date of birth as [xx/xx/xx: specific date in the middle 1950s]. Also, Resident #148's code was updated as DNR (Do Not Resuscitation) on 07/16/22 from the full code. A review of the order for the resident revealed that he/she had active order for DNR. However, there were multiple patient orders (documentation for internal communication between facility staff to providers) documented as below: a. Resident #148's lab result from [XX: name of laboratory] dated 07/18/22 at 01:25 PM documented DOB as 11/19/1950 (not Resident #148's DOB per PCC). b. The patient's order form dated 07/18/22 at 02:14 PM for Resident #148's diet order from dietitian to physician contained the resident's DOB as 11/19/1950. c. The patient's order form dated 07/18/22 at 07:35 PM regarding Resident #148's lab result from the facility staff to the physician documented the resident's DOB as 11/19/1950, which was not his/her DOB on PCC. d. Resident #148's lab result from the XX [name of laboratory] dated 07/19/22 at 03:05 PM documented Resident #148's DOB as 11/19/1950. e. Resident #148's lab result from the XX [name of laboratory] dated 07/22/22 at 01:39 PM contained the resident's DOB as 11/19/1950. f. The patient's order form dated 07/31/22 at 10:01 PM for Resident #148's x-ray result from the facility nursing staff to the physician documented the resident code as full code. On 08/02/23 at 02:10 PM, the surveyor verified that no other resident had the same name as Resident #148 in the facility's system. During an interview with the Director of Nursing (DON) on 08/03/23 at 09:39 AM, the DON confirmed that patient orders were a part of residents' medical records. The surveyor reviewed the patient's order sheets, and lab result reports with Resident #148's incorrect information. The DON said, I will talk to the laboratory too. On 08/04/23 at 04:10 PM, the DON and Nursing Home Administrator were made aware of this issue. Based on medical record review, interviews, and observations it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 8 (Resident #69, #148, #43, #253, #31, #50, #71, #72) of 83 residents reviewed during the survey. The findings include: 1) On 7/24/2023 at 1:11 PM, Review of order summary report for Resident #69 revealed two separate medication orders for Bactroban: - Bactroban External Ointment 2 % (Mupirocin) Apply to face topically one time a day for wound care. Order date 6/26/2023 and discontinued on 7/19/2023. - Left Cheek/Face Wound- Apply Bactroban and leave open to air twice a day. every day and evening shift order date 6/6/2023 and discontinued on 7/19/2023. On 7/24/2023 at 2:15 PM, Review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June and July 2023 was completed. Staff documentation revealed duplicate medication (Bactroban) application to the resident's face from 6/27/2023 through 7/19/2023: MAR application noted one time a day for wound care and TAR, twice a day every day and evening shift. On 7/26/2023 at 10:40 AM, Review of Resident #69's paper chart revealed dermatology follow up notes dated 7/18/2023 that indicated the Resident's left cheek wound was biopsied with new order for treatment with bacitracin twice a day (reason why the Bactroban was discontinued on 7/19/2023). On 7/26/2023 at 10:45 AM, Surveyor reviewed Resident #69's MAR and TAR for June 2023 and July 2023 with the resident's nurse, Licensed Practical Nurse (LPN #18) and the Assistant Director of Nursing (ADON). They both stated that the check mark on the MAR and TAR meant the medication was administered to the resident. LPN #18 confirmed that the order for Bactroban was a duplicate order. She stated that the medication came from the pharmacy and for pharmacy to send a refill she had to put in another order (reason for the Bactroban order of 6/26/2023 on the MAR). She acknowledged that her signature on both the MAR and TAR meant she was applying the same medication two different times on day shift. However, LPN #18 stated that she only did the treatment once during the dayshift and confirmed that her documentation on the MAR for Bactroban application was not accurate. The ADON stated that the order put in to get pharmacy to refill the Bactroban should have been discontinued once the medication was delivered. The ADON added that the order on 6/26/2023 was put in wrong and staff was just documenting on the MAR and TAR without paying attention to the duplicate order. On 7/26/2023 at 11:15 AM, Resident #69's MAR and TAR for June 2023 and July 2023 were reviewed with the Director of Nursing (DON) who confirmed the order for Bactroban was duplicated and staff documentation inaccurate. On 7/26/2023 at 11:31 AM, in a follow up interview with Resident #69, s/he stated that staff had been applying the Bactroban to his/her left cheek wound two times a day. On 7/27/2023 at 10:15 AM, in an interview with the 2nd floor Unit Manager (UM #4), a discussion was held regarding the lack of accurate documentation related to the order for Bactroban. UM #4 confirmed that the check mark on the MAR for Bactroban meant the medication was applied. She added that because the medication was already in the treatment section (TAR), the nurse should have called the pharmacy for a refill instead of writing it as a new order. UM #4 further stated that the nurses were not applying the medication three (3) times as reflected in their documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Observation of the facility's call bell system revealed a light located in the hallway above each bedroom door frame to alert staff when any of the residents in that room activated a call button. Call bell panels were located in residents' rooms on the wall above the head of each resident bed. A call bell cord was plugged into each panel. A small light was located on each wall panel and a cord with an activation device/button at the end was plugged into each panel. A reset button was also located on each panel for staff to deactivate the call bell when responding to the resident who activated it. During an interview and observation on 7/12/23 at 11:55 AM the resident in the C bed of room [ROOM NUMBER] was observed lying in bed. The resident indicated that staff did not always respond when he/she pushed his/her call bell. When the resident pressed his/her call button at the surveyor's request, the call light located in the hallway above the resident's door, the light on the bed C wall panel as well as the light on the panel for bed B lit up. When the surveyor attempted to reset the call bell by pressing the button on the panel for bed C, neither wall panel nor hallway lights turned off. However, when the reset button on the panel for bed B was pressed the hallway light as well as the indicator lights for both bed B and C reset/turned off. On 7/12/23 at 12:10 PM, another test of the call device was performed. The surveyor activated the call bell for the resident who resided in the C bed of room [ROOM NUMBER]. Again, the light on the wall panel for both the C bed and the B bed lighted. The Director of Nursing (DON) entered the room and asked the resident in bed B if he/she needed anything and then the DON cancelled/reset the B bed call device at the wall behind the B bed. The DON did not ask the resident in the C bed if he/she needed assistance. In an interview on 7/18/23 at 11:03 AM Staff #16 the Maintenance Director was made aware of the above concerns. He indicated that when a call light is activated in a room on the B wing, all the wall panel lights will light up in the room. When asked how staff would know which resident called for assistance, he indicated that he could see how that could be a problem and that he was not sure why but, that was how the system worked. Based on observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order. This was evident for 2 (Unit 2C and Unit 1B) of 4 nursing units observed during the annual survey. The findings include: 1) A call bell is a bedside button or cord attached to the wall in the resident's room, which allows the resident to alert a nurse or other healthcare staff member remotely of their need for help. The use of a nurse call bell system is designed to contribute to ensuring resident safety and allows residents in healthcare setting to alert staff remotely of their need for help. Immobile residents can use the nurse call bell to communicate with staff for any type of assistance. During an initial observation of the 2C unit on 7/10/2023 at 10:00AM, the surveyor observed the following: On 7/10/2023 at 10:11 AM, Resident #39 was observed lying in bed watching TV. When asked to use her/his call bell, Resident #39 looked around but could not find the device. The call bell was observed behind the resident's head of bed and out of reach. Resident # 39 attempted to get it twice and was unable to reach it both times. S/he gave up trying to reach the call bell and stated that it was placed away from their reach because the staff did not want her/him using the call bell. Surveyor gave the resident the call bell and asked her/him to push it. Resident #39 pushed the call button, but it did not light up outside of the room door and did not ring at the nurses' station. On 7/10/2023 at 10:20 AM, in an interview with Licensed Practical Nurse, LPN # 5, she verified the surveyor's observation and confirmed that the call bell was not working. LPN #5 stated that the call bell should be where the resident could reach it and added that she (LPN #5) was going to put in a work order for maintenance to fix it. An observation of Resident # 26 on 7/10/2023 at 10:35 AM, revealed a call bell that was not working. Resident #26, when asked, pushed the call button at 10:41 AM but it did not ring at the front desk and the call light was not activated outside the resident's door. On 7/10/2023 at 10:44 AM, Licensed Practical Nurse, LPN #5, was brought into Resident #26's room and she confirmed the call bell was not working. LPN #5 stated that she was going to put in a work order / contact maintenance to fix it. In a follow up interview with LPN #5 on 7/10/2023 at 2:40 PM, she stated that both call bells were fixed, and surveyors visually confirmed that they were working properly. On 7/26/2023 at 11:15 AM, in an interview with the Director of Nursing (DON), surveyor reviewed concerns related to the residents' call bell.

2) The Facility Reported Incident #MD00187603 was reviewed on 8/1/23 at 8:45 AM. The report revealed an allegation was made that Staff #30, a Geriatric Nursing Assistant (GNA) was abusive toward Resident #71. The final report indicated that after an investigation the facility was not able to conclude that abuse occurred. On 8/3/23 at 11:24 AM an interview with the Assistant Director of Nursing (ADON) was conducted to ask if any training was provided to Staff #30 at the time that Staff #30 was hired and at the time of the alleged incident of abuse. He stated that he was not sure. The surveyor requested copies of abuse training at hire, and any specific training provided to Staff #30 related to the incident on 1/6/23. No further documentation was provided. A review of Staff #30's employee file on 8/3/23 at 10:58 AM failed to reveal documentation that the facility provided Staff #30 with abuse prevention training at the time of hire. On 8/3/23 at 12:18 PM the ADON confirmed to the surveyor that Staff #30 did not receive abuse training at the time of hire, and no training at the time of the incident. Based on interviews and documentation review, it was determined the facility failed to ensure a training program was set up and in place for their staff to be educated on Abuse, neglect, and exploitation, and resident abuse prevention. This was evident for 5 (Staff #14, #35, #36, #37, #38) out of 5 staff training records and 1 (Staff #30) of 1 nurse aide reviewed for nurse aide abuse training. The findings include: 1) On 07/20/23 at 12:59 PM, an interview was conducted with Assistant Director of Nursing (ADON), an educator. The ADON stated that all nursing staff must complete the annual mandatory competency packet, which was filed on the competency binder. A review of annual competency packet binder on 07/20/23 at 01:30 PM revealed that the form contained several categories of nursing skills quizzes, including resident Abuse, neglect prevention & bill of rights: the section had ten printed statements and staff supposed to answer true or false. Also, each staff's competency packet was stapled with post-tests of other training ( hand hygiene, dementia care, infection control, HIPPA, and so on). However, no post-tests of Abuse, neglect, and exploitation training were in the packet. During an interview with the ADON on 07/20/23 at 02:40 PM, the surveyor asked about the abuse training. He stated since the competency record covered T/F questions about the Abuse, it was a part of abuse training. Also, the ADON said, the facility provided abuse training. I would find more documentation. 07/21/23 at 08:45 AM, the ADON submitted a document titled Abuse and a copy of abuse training attending sheet: staff development sign-in sheet date as ongoing and presented by nursing without attaching details of education contents. The ADON stated the facility used the document titled Abuse for staff education. A review of the documentation revealed it had the same contents as interpretative guidelines of federal regulation about Abuse and resident rights; however, which did not contain a procedure for reporting incidents and/or evaluation, assessing the potential risk to residents. Also, the surveyor asked about the sign-in sheet dated as ongoing. The ADON explained that since the facility offered abuse training to all staff every month, it was documented as ongoing. The surveyor questioned how the facility staff tracked their Abuse training. The ADON said, I will try to figure it out when they receive the training. Per the surveyor's requestion, the Director of Nursing (DON) provided copies of abuse training records dated 01/31/21, 02/16/22, and 06/15/23. The surveyor verified training records for randomly selected five staff (#14, #35, #36, #37, #38) who worked in the facility since 2019. The 01/31/21 staff development sign-in sheet and the 06/15/23 town hall sign-in sheet documented Staff #37's signature. However, no signature was found for staff #14, #35, #36, and #38 on three years of abuse training records. During an interview with the DON and the ADON on 07/25/23 at 09:40 AM, the surveyor shared concerns that the facility did not track/document staff's abuse training. The DON insisted that they could prove staff's abuse training with competency fair sign-in sheet. On 07/25/23 at 10:21 AM, the DON brought a presentation board and copies of competency fair sign-in sheets 02/18/22 and 03/03/23. The DON said, During the competency fair, we used this presentation board for abuse training sessions. The social worker presented it, and the staff who attended that session signed off on the Abuse Competency packet. This is our training method. The signatures of Staff #14, #35, #36, #37, and #38 were listed on both sign-in sheets (single pages). However, the sign-in sheet had no information on who provided education and what contents were used. The surveyor shared the above concerns with the DON on 08/04/23 at 10:10 AM. No further documentation was submitted to the surveyor team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of Room # 250 and during an interview with Resident # 31, the facility failed to the patch the wall in the back of bed C in room [ROOM NUMBER]. This was observed for 1 out of 37 rooms. The findings include: On 1/22/19 at 2:01 PM this surveyor interviewed Resident # 31. During an observation of the room, a patch of drywall was missing from the back of bed C. On 1/23/19 the area was shown to the Director of Support Services. Staff # 4 stated that he will patch the dry wall, right away. The Directof of Nursing (DON) and the Administrator were informed.

Based on medical record review and staff interviews it was determined the facility staff failed to conduct a comprehensive assessment when a significant weight gain occurred in Resident #104's condition. This was evident for 1 of 3 residents reviewed for change in condition during the survey process. The findings include: Medical record review revealed that Resident #104 was admitted to the facility with a medical diagnosis that included but not limited to Arthritis due to Bacteria of knee and shoulder for rehabilitation and antibiotic therapy. Review of the skilled nursing assessment revealed that staff documented weights for Resident #104 on 1/20/19 of 177.5 lbs. On 1/21/19 skilled nursing assessment staff documented a weight of 194.0 lbs. for Resident #104 which is a change in weight of 16.5 lbs. in 24 hours. On 1/25/19 at 2:30 P.M. the surveyor conducted a staff interview with the Director of Nursing (DON) who verified that the fluctuation of weight involving Resident #104 was not addressed according to the care and treatment policy. The Administrator, Director of Nursing with Corporate staff were informed of the care concerns prior to and during the survey exit.

Based on medical record review and staff interviews is was determined that the facility failed to revise and update the care plan that addressed a resident's after change in condition. This was evident 1 out of 37 resident's involving Resident #104 during the survey process. The finding includes: The 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. Medical record review revealed that Resident #104 was admitted to the facility with diagnoses which included but not limited to Arthritis due to Bacteria of knee and shoulder for rehabilitation, antibiotic therapy and other chronic health conditions that require ongoing treatment. Continued record review revealed that on 1/21/19 staff documented on the skilled nursing assessment that Resident # 104 weighed 194 lbs. On 1/20/19 staff documented on the skilled nursing assessment that Resident #104's weight was 177.5 lbs., a change in condition. Medical record review revealed a dietary and weight care plan with initiation dates of 12/24/18 and 12/26/18 which included goals and approach interventions for fluid imbalance with risk for weight fluctuation. Further review of the medical record revealed that the facility failed to update and revise the care plan that addressed the residents weight gain which occurred on 12/21/18. During an interview on 1/25/18 at 2:30 P.M. with the Director of Nursing, the surveyor was informed that the weight care plan was not updated. All findings were discussed with the Administrator and Director of Nursing prior to and during the survey exit.

Based on observation and staff interviews the facility staff failed to label a vaccine vial with the date when opened. This was evident for 1 out of 2 medication rooms observed during the survey process. The findings include: On 01/28/19 around 01:29 PM, 2 medication rooms were surveyed. The 2A/2B medication room had a vial of Tuberculin Vaccine that was opened but not dated. Tuberculin should be discarded if it has been opened for more than 30 days or the expiration date has passed. Without a date of when opened there is no way to determine how old the vaccine would be.