Based on complaint, medical record review, and interview, it was determined the facility failed to ensure a custom-made wheelchair was available for a resident during transport to an appointment. This was evident for 1 (Resident #4) of 28 residents reviewed for complaints during a complaint survey. The findings include: On 5/12/25 a review of complaint MD00215793 was conducted, and it was alleged that Resident #4 obtained a broken ankle at the facility. Review of an investigation done by the facility revealed staff written statements that Resident #4 did not have a fall. Staff statements documented that Resident #4 was transferred with 2 people from the bed to the wheelchair in a Hoyer lift per the care plan. A written statement from Geriatric Nursing Assistant (GNA) #37 documented the resident was sliding from the wheelchair. GNA #37 and 4 other staff members helped pull the resident up and reposition the resident. Despite being repositioned, Resident #4 continued to slide from the wheelchair. At that time Resident #4 was transferred to a different wheelchair by staff. The resident denied any pain or discomfort. On 5/13/25 at 8:32 AM GNA #37 was interviewed about the incident and stated that Resident #4 was sliding out of the wheelchair. GNA #37 stated the resident normally was either in bed or went to dialysis in a geriatric (geri) chair and that the resident did not normally sit in a wheelchair except for when he/she went out to appointments. GNA #37 stated the resident never fell to the floor and never touched the ground as there were 5 total people helping the resident when he/she was observed sliding out of the wheelchair. GNA #37 stated they quickly lifted the resident up and repositioned in the wheelchair. GNA #37 stated that the resident started sliding again so they got another wheelchair and placed the resident in that wheelchair. The other wheelchair had a high back. GNA #37 stated because the resident only had 1 leg, they put a pillow under the foot rest, and it made the resident sit back in a more comfortable position. GNA #37 stated Resident #4 never complained of pain or injury. On 5/13/25 at 8:59 AM LPN #39 was interviewed and stated she was the nurse supervisor for 2 West. LPN #39 stated the resident was going out to a vascular appointment and that the VA (Veteran's Administration) scheduled the transportation which was a wheelchair transport. She reiterated that the resident did not fall or hit the floor. LPN #39 stated someone ran quickly to get a high back wheelchair. On 5/14/25 at 1:27 PM an interview was conducted with Resident #4's daughter who stated that the resident was using other people's wheelchairs. She stated that the VA had given Resident #4 a wheelchair, however the facility lost it, so the VA had a wheelchair specially made to fit the resident's needs. The daughter stated that she complained to several staff members including the previous Director of Nursing (DON), Nursing Home Administrator (NHA), the nurse manager on the unit and the nurses on the floor. When he/she went on appointments he/she was in someone else's wheelchair and the doctor asked the daughter about it and she had to tell him the facility misplaced the wheelchair. The daughter stated Resident #4 needed a wheelchair to fit him/her due to the leg amputation. The daughter stated the VA fitted the resident again for a wheelchair and the facility lost it again. On 5/15/25 at 9:07 AM the NHA was interviewed and stated she had been looking for the wheelchair but had not found any specialty wheelchairs, only power wheelchairs. The NHA stated in October 2024 during a Utilization Review meeting one of the VA reps stated the daughter asked for a chair and they knew that they had already issued a wheelchair, and they wanted the Director of Rehab to see if she could locate it or look for it. She said it has been her understanding that there have been several chairs missing. The NHA stated, no one knows where the chair is. On 5/15/25 at 9:37 AM an interview was conducted with a representative from the VA who stated they did supply Resident #4 with a wheelchair on 1/8/24. She stated the resident had a second wheelchair ordered, a custom wheelchair ordered by the VA and it was delivered directly to the facility from the vendor on 3/6/24. On 5/15/25 at 12:10 PM an interview was conducted with the NHA, and she was informed that the vendor delivered the wheelchair to the facility last year. The NHA was informed there was no follow-up with rehab knowing the chair had been ordered, where it was, and there was no follow-up with nursing staff who knew that the resident had a custom-made wheelchair with a seat belt and nobody followed up. The NHA stated she agreed with the findings that the facility failed to meet the resident's needs.

2. On 5/13/25 at 10:50 AM a review of Resident #22's medical record was conducted and revealed a 12/15/23 note that Resident #22 was admitted for comprehensive rehabilitation and had admitting diagnoses that included cerebral infarction without residual deficits, hypertension, type 2 diabetes mellitus with hyperglycemia and a sacral wound. Review of the weight section of Resident #22's medical record documented on 12/14/23 the weight was 128.0 lbs. and on 12/15/23 the weight was 128.0 lbs. The next weight was taken on 1/5/24 and was 102.2 lbs. which was a 25.8 lb. or 20 percent weight loss in 3 weeks. Continued review of the medical record failed to produce documentation that the physician, dietician, and family were notified of the weight loss when it was found on 1/5/24. The previous dietician did not assess Resident #22 until 1/16/24, which was 11 days after the documented weight loss. There was no documentation that Resident #22 was evaluated in weekly risk meetings until 1/18/24 which was 13 days after the documented weight loss. Review of the Change in a Resident's Condition or Status Policy that was given to the surveyor on 5/13/25 at 1:34 PM documented a policy statement that stated, our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition. Number 1 stated, the nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition; e) need to alter the resident's medical treatment significantly. Number 2 documented, A significant change of condition is a major decline or improvement in the resident's status that: a) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, c) requires interdisciplinary review and/or revision to the care plan; and d) ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. On 5/14/25 at 10:05 AM an interview was conducted with Physician #29 who stated that she would expect to be notified of that amount of weight loss right away to determine if it was excessive fluid loss or wanted weight loss. On 5/15/25 at 10:44 AM an interview was conducted with the Director of Nursing (DON). The DON stated she was not here at the time, and they have since put weight loss and notification in place along with doing a change in condition. Based on medical record review and interview, the facility staff failed to notify a resident's physician timely for a change in condition (Resident #10) and failed to timely notify a resident's physician, responsible party, and dietician of a significant weight loss (Resident #22). This was evident for 2 of 28 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to notify Resident #10's physician for a low blood pressure timely. Review of Resident #10's medical record on 5/7/25 revealed the Resident was admitted to the facility in October 2024 with a diagnosis to include heart failure. Heart failure occurs when the heart can't pump enough blood to meet the body's needs. Further review of Resident #10's medical record revealed a nurse's note on 10/27/24 at 11:40 PM stated outgoing nurse reported that resident's blood pressure just suddenly dropped to 70/54, writer went to resident room blood pressure assess 81/54. Another nurse's note on 10/28/24 at 1:14 AM stated, writer assessed patient and no distress noted, paged provider about patient's low blood pressure no response. Resident's family member insisted not to send resident out to the hospital. Another nurse's note on 10/28/24 at 4:47 AM, writer continue to monitor resident's blood pressure as it continues to drop to 76/49, page on call provider no response, family at bedside. Writer discussed with family to send patient out to the hospital for further evaluation, family refused. Family agreed for Emergency Medical Services to come and assess patient in house. Writer called 911, they arrived and assess patient, family asked what they wanted to do. Family told them not to transfer to hospital. Management and provider notified. During interview with the Director of Nursing (DON) on 5/15/25 at 9:00 AM, the DON stated the expectation when the facility staff are unable to reach a resident's primary physician in a timely manner is to contact the Medical Director. Interview with the DON on 5/15/25 at 12:25 PM confirmed the facility staff failed to notify Resident #10's physician timely on 10/27/24 and 10/28/24 when the Resident had low blood pressure.

Based on reviews of facility reported incidents and interview, it was determined the facility failed to report allegations of abuse to the regulatory agency, the Office of Health Care Quality (OHCQ) within 2 hours of the allegation. This was evident for 3 (Residents #6, #1, #18) of 13 residents reviewed for facility reported incidents during a complaint survey. The findings include: 1) On 5/8/25 at 12:13 PM a review of facility reported incident MD00212791 was conducted and revealed Resident #6 was noted with a laceration to the right thumb area on 12/17/24 at 5:40 PM. Resident #6 was non-verbal and cognitively impaired and could not verbalize how the injury happened. Review of the facility's investigation revealed the injury happened on 12/16/24. Licensed Practical Nurse (LPN) #19 confirmed that he worked on 12/16/24 and stated that the physical therapist had reported to him that the resident was bleeding from the right thumb. LPN #19 stated he did not document the incident or notify the supervisor. Facility administration did not become aware of the incident until the next day. Review of the email confirmation revealed the initial self-report was sent to OHCQ on 12/17/24 at 7:38 PM which was not within 2 hours of an injury of unknown origin. On 5/15/25 at 7:50 AM the report was discussed with the DON who confirmed the findings. 2) On 5/12/25 at 9:43 AM a review of facility reported incident MD00217118 was conducted and revealed Resident #1 had an x-ray done on 4/24/25 with a result of a dislocation to the left shoulder. Resident #1 had a diagnosis of tracheostomy, G-tube status, Diabetes, hemiplegia and hemiparesis, and was dependent on a ventilator for breathing. Resident #1 was sent out to the hospital for evaluation and treatment. Review of the facility's investigation revealed the dislocation was found on 4/24/25 and then confirmed on 4/25/25 at 13:02 PM. Review of the initial report email confirmation to OHCQ for an injury of unknown origin revealed the report was not sent until 4/26/25 at 10:06 AM. It was not reported within 2 hours of the findings. On 5/15/25 at 7:50 AM an interview was conducted with the DON who confirmed the findings. The DON was not employed at the facility at the time. 3) On 5/13/25 at 1:21 PM a review of facility reported incident MD00206042 was conducted and revealed Resident #18's spouse reported to the nurse that a geriatric nursing assistant (GNA) physically assaulted Resident #18 on 5/24/24 at 4:15 PM. Review of the facility's investigation revealed Resident #18 alleged that on 5/24/24 GNA #16 pulled the resident's beard to get the resident to open the mouth and punched the resident on the right side of the face to get the resident to open the mouth. The DON was not notified until the morning of 5/25/24. A written statement from GNA #16 stated that the GNA came back from lunch break on 5/24/24 and the family was accusing him of slapping the resident which was false. GNA #16 stated the nurse called him to the room because the resident had fallen. A written statement from the nurse who worked that evening documented she took care of the resident after the allegation, however a written statement from the evening supervisor documented that he was never made aware of any physical abuse or concerns during his shift. Review of the initial email confirmation revealed the initial report was sent to OHCQ on 5/25/24 at 10:30 AM which was not within 2 hours of an abuse allegation. On 5/15/25 at 7:50 AM an interview was conducted with the DON who confirmed the findings of late reporting. The DON was not employed at the facility during that time.

Based on medical record review and interview, the facility staff failed to have quarterly care plan meetings for a resident (Resident #12). This was evident for 1 of 7 residents reviewed during a complaint survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. Review of Resident #12's medical record on 5/6/25 revealed the Resident was admitted to the facility in November 2020 with a diagnosis to include dementia. Dementia is a general term for a decline in mental ability that is severe enough to interfere with daily life. Interview with the Resident #12's representative (RP) on 5/14/25 at 1:14 PM the RP complained about the facility's lack of communication. Further review of Resident #12's medical record revealed the facility staff completed a quarterly MDS assessment 12/27/23, 3/8/24, 6/28/24 and an annual MDS assessment on 9/12/24. Review of Resident's medical record revealed the only documented care plan meeting was on 4/22/24 and a note saying a Social Services Assessment saying a care plan meeting was scheduled for 9/20/24. There is no evidence in the medical record a quarterly care plan meeting was held in January and July 2024. Further review of Resident #12's medical record revealed no documentation of a summary or what was discussed at the April and September 2024 care plan meetings. Interview with the Director of Nursing on 5/16/25 at 10:30 AM confirmed the facility staff failed to have a quarterly care plan meeting for Resident #12 in January and July 2024 and failed to include in the Resident's medical record the details of the care plan meeting in April and September 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident medical record, the facility failed to provide care (toileting/ turning/ positioning) on day shift for Resident # 37 who is extensive assistance with 2 person assistance. This is evident for 1 out of 1 person reviewed during the complaint survey. Findings include: MDS is a A Minimum Data Set (MDS) is a standardized, core set of data elements used for clinical assessment in various settings, including nursing homes and skilled nursing facilities. It provides a common language and format for collecting and analyzing data, ensuring consistency and comparability across different facilities and locations. The MDS helps identify resident care problems, informs individualized care plans, and is used for reimbursement and quality monitoring purposes. Resident was admitted to the facility on [DATE] and discharged on 9/17/22 due to a lack of care. On 5/6/25 at 9:28 AM, an investigation was conducted for Resident # 37. The Resident came to this facility for rehab after surgery for periprosthetic hip fracture. Complainant complained of no staffing, resident not being changed or turned and repositioned. Call bells were also not answered. Upon review of GNA ( geriatric nursing assistant) documentation, it was determined that the GNA assigned to resident did not perform turning and reposition for 9/15/22, 9/16/22, and 9/17/22 and bowl and bladder care for 9/15/22, 9/16/22, and 9/17/22 day shift. According to MDS dated [DATE] resident # 37 needs extensive assistance with 2 person assist for transfers, bed mobility, dressing, toileting and general hygiene Administrator was made aware of deficient practice on 5/12/25 at 1:41 PM and stated OK.

Based on review of complaints, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health (Resident #10 and #13). This was evident for 2 of 28 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to address the recommendations of a consultant for Resident #10. Review of Resident #10's medical record on 5/7/25 revealed the Resident was admitted to the facility in October 2024 with a diagnosis to include anemia and thyrotoxicosis. Anemia is a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues and Thyrotoxicosis is a treatable condition that happens when you have too much thyroid hormone in your body. Further review of Resident #10's medical record revealed the Resident was seen by a Consultant on 12/18/24 for anemia, volume status and secondary hyperparathyroidism. Review of the Consultant's 12/18/24 note revealed the Consultant documented, The patient was seen this morning, he/she was resting in bed. His/her family member reports his/her appetite has been poor, he/she will only eat a few spoonfuls of soup a time. The Consultant note states, Consider starting appetite stimulant. Albumin is 1.9, recommend starting prosource protein supplement. Further review of Resident #10's medical record revealed the Resident was discharged from the facility on 12/30/24 and the facility staff failed to start the Resident on an appetite stimulant or prosource protein supplement prior to discharge. Interview with the Director of Nursing on 5/15/25 at 12:25 PM confirmed the facility staff failed to address the Consultant's recommendations for Resident #10 on 12/18/24. 2. The facility staff failed to properly perform neuro checks after an unwitnessed fall for Resident #13. A neuro check after a fall refers to a neurological assessment performed by a healthcare professional to evaluate potential brain injuries by checking a person's level of consciousness, orientation, pupil response, muscle strength, sensation, and coordination. Review of Resident #13's medical record on 5/6/25 revealed a nurse's change in condition note on 7/13/24 at 9:30 AM stated, Resident laying on the floor on his/her right side bedside his/her bed, assessed resident denies any pain or discomfort, denies hitting his/her head, no apparent injury noted, can move all extremities with no pain, neuro check initiated. Review of the facility's Neurological Assessment-Indications for policy provided by the Director of Nursing (DON) on 5/14/25 stated following an unwitnessed fall neurological assessment should be completed at least every 15 minutes times 1 hour, every 30 minutes times 2 hours, every 1 hour times 2 hours and then every shift until 72 hours have passed or as otherwise ordered by the physician. Further review of the Resident's medical record revealed the Neurological Check List completed by facility staff on 7/13/24 and 7/14/24. The facility staff documented the 1st neuro check on 7/13/24 at 9:30 AM at the time of the fall. The facility staff failed to assess and document neuro checks on 7/13/24 at 9:45 AM, 10:00 AM and 10:15 AM. The neuro check documented on 7/13/24 at 10:30 AM did not include vital signs at 10:30 AM but from the 1st neuro check. The facility staff failed to assess and document neuro checks on 7/13/24 at 11:00 AM, 11:30 AM and 12:00 PM. The neuro check documented for 7/13/24 at 12:30 PM included vital signs from later that day at 5:37 PM. The neuro check documented on 7/13/24 at 2:30 PM included vitals signs from the 1st neuro check. The neuro check for evening shift was documented for 7/13/24 at 8:35 PM but included vital signs from 5:37 PM. The neuro check for night shift was documented for 7/14/24 at 1:27 AM but included vital signs from later that shift at 7:30 AM, also stated the resident was observed sleeping in bed, the extremities assessment was documented as N/A (not applicable) and stated the resident was in bed resting, not much of any activity was going on. Interview with the DON on 5/14/25 at 11:50 AM confirmed the facility staff completed neuro checks for Resident #13 at incorrect time intervals per facility protocol and inaccurately on 7/13/24 and 7/14/24.

Based on medical record review, documentation review, and interview, it was determined the facility staff failed to recognize a resident's weight loss and notify the physician and dietician promptly in order for interventions to be placed timely. This was evident for 1 (Resident #22) of 28 complaints reviewed during a complaint survey. The findings include: On 5/13/25 at 10:50 AM a review of complaint MD00202446 alleged the facility staff were not feeding Resident #22. A review of Resident #22's medical record was conducted and revealed a 12/15/23 note that Resident #22 was admitted for comprehensive rehabilitation and had admitting diagnoses that included cerebral infarction without residual deficits, hypertension, type 2 diabetes mellitus with hyperglycemia and a sacral wound. Resident #22 was prescribed a regular diet with moist ground meat, finely chopped vegetables texture, thin consistency. A physician's physical and history note dated 12/15/23 documented the resident was admitted to the hospital with weakness and decreased intake and weight loss. Review of a 12/15/23 Nutritional Risk Assessment documented Resident #22's ideal body weight was 154 pounds (lbs.), and the most recent weight was 128 lbs. as of 12/14/23. The previous dietician, Staff #36, documented a recommendation for weekly weights times 4 weeks and the RD (registered dietician) would monitor and adjust diet as indicated. The staff was to monitor weights as the resident was at risk for malnutrition. The assessment was dated 12/15/23, however was not signed by the dietician until 1/16/24. Review of the weight section of Resident #22's medical record documented on 12/14/23 the weight was 128.0 lbs. and on 12/15/23 the weight was 128.0 lbs. The next weight was taken on 1/5/24 and was 102.2 lbs. which was a 25.8 lb. or 20 percent weight loss in 3 weeks. Further review revealed weekly weights were not taken after admission and there was no weight recheck until 1/16/24 when the resident's weight was 101.0 lbs. Continued review of the medical record failed to produce documentation that the physician, dietician and family were notified of the weight loss. Review of the medical record revealed the previous dietician did not assess Resident #22 until 1/16/24 which was 11 days after the documented weight loss. There was no documentation that Resident #22 was evaluated in weekly risk meetings until 1/18/24 which was 13 days after the documented weight loss. Review of the Weight Assessment and Intervention Policy that was received from the Director of Nursing on 5/13/25 at 1:34 PM revealed number 3, under weight assessment, any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Number 5 documented, the threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. On 5/14/25 at 10:05 AM an interview was conducted with Physician #29 who stated that she would expect to be notified of that amount of weight loss right away to determine if it was excessive fluid loss or wanted weight loss. On 5/15/25 at 10:44 AM an interview was conducted with the Director of Nursing (DON). The DON stated she was not here at the time, and they have since put weight loss and notification in place along with doing a change in condition.

Based on review of a complaint, interview, and observation of resident wheelchairs, it was determined the facility failed to provide maintenance services necessary to keep all wheelchairs in a sanitary, comfortable, and well-maintained condition. This was evident on 2 of 3 nursing units observed during the complaint survey. The findings include: 1) On 5/6/25 at 2:00 PM a review of complaint MD00216562 alleged that Resident #3 went out to an appointment. The resident attended the appointment in a wheelchair. The complaint alleged that the family and resident were embarrassed about the condition of the wheelchair and the padding. The complaint alleged, the doctor/nurse was also taken aback by the stench that we have complained about for months. Upon unzipping the pillow, we were all appalled, disgusted, and I, embarrassed, by the urine and fecal matter present in the gel pad and the inside of the pillow cover. The complaint stated, the presence of urine and fecal matter in and of itself can cause other issues to include wounds in the area subjected to such filth. The complaint stated that the physician/nurse showed the family how to clean the gel pad. The smell and the appearance of the pillow confirms improper or no cleaning at all. On 5/13/25 at 1:25 PM an interview was conducted with Staff #35 from housekeeping. Staff #35 stated that she had been employed at the facility for the past 4 months and was in charge of housekeeping. Staff #35 confirmed the condition of Resident #3's wheelchair cushion and stated, prior to this incident there was not a schedule for cleaning or maintenance of the wheelchairs or cushions. Anything attached to the wheelchair is cleaned by us. Staff #35 stated, the chair was pretty gross when we initially cleaned it. It looked like it was never cleaned. Staff #35 stated she just developed a cleaning schedule and started cleaning wheelchairs. On 5/16/25 at 9:10 AM the Nursing Home Administrator (NHA) confirmed that she was made aware about the condition of the wheelchair cushion from Resident #3's family member. 2) On 5/14/25 at 12:50 PM observation was made of several wheelchairs that were in disrepair. Resident #7's wheelchair was sitting in his/her room. The vinyl on the right armrest was cracked and ripped which left the edges of the vinyl sharp. Resident #41 was sitting in a wheelchair and there was no armrest on the right side of the wheelchair. A resident was sitting in a wheelchair in the memory care unit. The vinyl on the left armrest was cracked and torn in the front and along the left side of the armrest. Resident #42 was sitting in a wheelchair. The vinyl on the left armrest was torn in the front and along the side and the vinyl on the right armrest was cracked throughout. Resident #43's wheelchair right armrest was missing 6 inches of vinyl and yellow foam was exposed. Resident #44 and Resident #45's wheelchair was missing an armrest on the right side of the wheelchair. There was only the frame of the wheelchair for them to put their right arm on. Resident #46's wheelchair was missing an armrest on the left side. On 5/16/25 at 9:10 AM the Nursing Home Administrator (NHA) was informed of the condition of the wheelchairs. The NHA confirmed the issue with Resident #3's wheelchair and confirmed that Staff #35 was putting a process in place for the maintenance of the wheelchairs.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (Resident #22, #24, #18, #3) of 46 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1a) On 5/13/25 at 10:50 AM a review of Resident #22's medical record was conducted. Review of the weight section of Resident #22's medical record documented on 12/14/23 the resident's weight was 128.0 lbs. The next weight was taken on 1/5/24 and was 102.2 lbs. which was a 25.8 lb. or 20 percent weight loss in 3 weeks. Review of the MDS Assessment with an assessment reference date (ARD) of 1/8/24, Section K, swallowing/nutritional status; K0200B weight was documented as 128 lbs. which was incorrect as it should have been documented as 102 lbs. K0300 weight loss was documented as 0. no or unknown which was incorrect and should have been documented as 2, yes, not on prescribed weight-loss regimen. Further review of the medical record revealed a note that documented Resident #22 had a fall on 12/27/23. Review of Section J, Falls, failed to capture the fall on 12/27/23. 1b) Review of Resident #22's February 2024 Medication Administration Record (MAR) documented that the resident received Metformin 500 mg. twice per day (hypoglycemic) from 2/21/24 to 2/27/24 and had received (2) insulin injections (hypoglycemic) on 2/22/24 and 2/23/24 at 16:30 requiring 2 units of insulin. Review of the MDS with an ARD of 2/27/24, Section N, Medications, failed to capture the hypoglycemics. 1c) Review of the MDS with an ARD of 12/15/23, Section N, Medications, documented that Resident #22 received an opioid medication. Review of the December 2023 MAR failed to produce documentation that the resident received an opioid. On 5/14/25 at 10:54 AM an interview was conducted with the MDS coordinators. The MDS's were reviewed with them and they confirmed errors. 2) On 5/13/25 at 1:12 PM a review of Resident #24's medical record was conducted. Review of a 10/17/23 at 23:10 document stated the resident was admitted to the facility with bilateral wounds to both heels. A 10/19/23 at 6:50 AM nurse's note documented, ABT (antibiotic) Doxycycline in progress for bilateral feet wound infection. Review of the October 2023 Treatment Administration Record (TAR) for Resident #24 documented treatments to the left and right heel wounds. The left and right heel were to be cleansed with NSS (normal saline solution), apply medihoney and wrap with Kerlex and an ace bandage daily. Review of the MDS assessment with an ARD (assessment reference date) of 10/24/23, Section M Skin Conditions, M0100 coded no pressure ulcer. M0150 coded no for at risk of pressure ulcer, M0210 unhealed pressure ulcer coded no, M1030 Venous and Arterial Ulcers coded no, M1040A code no to infection of the foot, M1200E code no to pressure ulcer/injury care, and M1200I coded no to application of dressings to feet. The facility failed to capture the bilateral heel wounds. Review of the 11/27/23 MDS discharge return anticipated assessment, Section M0100 coded no pressure ulcer. M0150 coded no for at risk of pressure ulcer, and M0210 unhealed pressure ulcer coded no. Review of weekly skin notes in November 2023 documented venous insufficiency (statis) ulcer for the bilateral heels. There was a 11/6/23 wound note that documented a Stage 2 pressure ulcer to the sacrum and a stage 3 pressure ulcer to the right buttock. Review of the November 2023 TAR documented treatments to both the heels, sacrum, and right buttocks. The facility failed to capture the pressure ulcers and the venous ulcers. Further review of the 11/27/23 MDS assessment, Section N coded that no medications were administered during the 7 day look-back period. Review of the November 2023 MAR documented the resident received Insulin (hypo-glycemic), Lasix (diuretic), Lyrica (opioid), Venlafaxine (anti-depressant), doxycycline (antibiotic), and Lovenox (anti-coagulant). On 5/14/25 at 10:30 AM the surveyor reviewed the MDS assessments from 10/24/23 and 11/27/23 with the MDS coordinator and the Regional MDS Coordinator. Both confirmed the errors. 3a) On 5/13/25 at 1:21 PM a review of Resident #18's medical record was conducted. Review of nursing notes revealed a note dated 5/24/24 at 19:31 that documented, Falls, lowered to floor. Review of Resident #18's MDS with an Assessment Reference Date (ARD) of 6/19/24, Section J1900, Falls since previous assessment was coded, no. The facility failed to capture the fall. Further review of the medical record revealed a skin and wound note dated 6/18/24 which documented; left heel wound, pressure, unstageable, stable eschar. Review of Section M, Skin Conditions for the MDS with an ARD of 6/19/24 documented there were no unhealed pressure ulcers and no unstageable pressure ulcers. The facility failed to capture the left heel pressure ulcer. Review of Section N, medications, was coded zero for the use of antibiotics. Review of the June 2024 medication administration record (MAR) documented on 6/13/24 the use of Firvanq for c-diff. 3b) Review of Resident #18's August 2024 MAR documented the resident received Eliquis, an anticoagulant used to prevent blood clots twice per day. Review of the MDS with an ARD of 8/1/24, Section N, failed to capture use of Eliquis. Review of a skin and wound note date 7/29/24 documented; left heel wound, pressure, unstageable, wound debridement, removal of necrotic tissue. Review of Section M, Skin Conditions for the MDS with an ARD of 8/1/24 failed to capture the unstageable heel ulcer. On 5/15/25 at 11:20 AM the MDS assessments were reviewed with the MDS coordinator who confirmed the findings. 4) On 5/14/25 at 2:00 PM a review of Resident #3's medical record was conducted. Review of the MDS assessment with an assessment reference date (ARD) of 2/6/25 captured that the resident had a pressure ulcer, Section M. Review of the medical record revealed weekly skin sheets that documented the left heel wound that Resident #3 had was healed as of 1/20/25. The staff should not have coded pressure ulcer. Review of Resident #3's February 2025 Medication Administration Record (MAR) revealed Resident #3 was administered Aspirin (antiplatelet), Jardiance and insulin (hypoglycemic), and Seroquel (antipsychotic), Review of Section N, Medications, failed to capture the use of the anti-platelet, hypoglycemic, and antipsychotic medications. On 5/15/25 at 11:25 AM an interview was conducted with the MDS coordinators who confirmed the errors.

Based on review of the medical record and interview with staff, it was determined that facility staff failed to notify the physician and the resident's responsible party after a vulnerable resident left the facility unaccompanied, placing themselves at increased risk for serious injury or harm. This was evident for 1 (#1) of 3 residents reviewed for Resident Safety. The findings include: Review of Resident #1's medical record, on 11/29/22 at 10:51 AM, revealed the resident was admitted to the facility's locked unit on 9/2/22 with diagnoses which included, but were not limited to: muscle weakness, difficulty in walking, need for assistance with personal care, atherosclerotic heart disease, dementia with behavioral disturbance and other symptoms and signs involving cognitive functions and awareness. A guardian of person and property was appointed by the court on 7/28/22 to act on Resident #1's behalf, due to him/her lacking mental capacity as a result of a disability defined as dementia. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Review of complaint #MD00186060 on 11/29/22 at 10:51 AM revealed that, on the morning of 11/26/22, Resident #1 walked out of and away from the facility, unaccompanied, was picked up by police on a busy 6 lane road and taken to a crisis center. The crisis center notified the facility staff, who picked the resident up and returned him/her to the facility. Resident #1's record failed to reveal that the resident's physician and his/her guardian were notified of the elopement event which posed a significant risk to Resident #1's safety and wellbeing, by the facility staff. The Director of Nursing was made aware of these concerns during an interview on 11/30/22 at 11:47 AM. An interview was conducted on 12/7/22 at 1:25 PM with Staff #5 a Registered Nurse. She confirmed that she was the Manager on Duty on 11/26/22, that she received the phone call from the crisis center regarding Resident #1, that she and Staff #3 determined Resident #1 was missing from the facility, went to the crisis center and returned the resident to the facility. She confirmed that she did not report the elopement event to anyone. Cross reference F - 689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility staff failed to have a process in place to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair. This was evident in 1 of 3 nursing units observed during a revisit survey. The findings include: On 2/22/23 at 8:25 AM during a tour of the dementia unit, observation was made of room [ROOM NUMBER]A. The call bell unit on the wall behind the bed was hanging off the wall. Observation was made in room [ROOM NUMBER] of the vanity in the bathroom. The left door to the vanity was hanging off the hinge. The lid to the toilet tank was not on the back of the toilet. The tank lid was propped up next to the toilet on the floor. There was dust hanging off the bathroom ceiling vent grate. Observation was made of the dining room floor in the dementia unit. The entire floor was covered in crumbs. On 2/22/23 at 3:20 PM Staff #4, the Maintenance Director, was interviewed and stated that he is made aware of repairs through work orders. Staff #4 stated, we either look in TELS (computerized system for repairs) or if a nurse finds something wrong, she should put it in TELS. We make rounds daily and anything we see we take care of it. Staff #4 also stated there was no set schedule for looking at rooms. Normally in the morning I check water temps in rooms. We have issues a lot of times with staff not putting in the work orders in TELS. GNAs (geriatric nursing assistants) and nurses are told all the time about putting work orders in TELS. The surveyor informed Staff #4 of the maintenance concerns. On 2/22/23 at 5:00 PM, Staff #4 informed the surveyor that he saw the concerns and would take care of them. The Nursing Home Administrator was made aware of the concerns on 2/22/23 at 5:05 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with facility staff, it was determined that the facility staff failed to ensure that assessments accurately reflected the resident's status. This was evident for 1 (#1) of 3 residents reviewed for Resident safety. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. The findings include: Review of Resident #1's medical record on 11/29/22 at 10:51 AM revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to: need for assistance with personal care, dementia in other diseases classified elsewhere with behavioral disturbance and other symptoms and signs involving cognitive functions and awareness. Further review of the record on 11/29/22 at 1:20 PM revealed an admission progress note on 9/2/22 at 19:31 which indicated that the resident refused initial vital signs, weight, head to toe skin assessment and PPD (Tuberculin skin test) testing. A note on 9/3/22 at 14:08 documented that Resident #1 refused his/her morning medications on 2 occasions and refused his/her therapy session. A Skin/Wound progress note on 9/6/22 at 13:19 noted skin assessment attempted second time, resident refuse to be assessed despite encouragement. A routine nurses note at 13:27 on 9/6/22 reflected the refusal of the skin assessment and also noted refusal of the PPD step 2 administration. A note on 9/7/22 12:31 again noted continued refusal of the skin assessment and another note written about 1 minute later on 9/7/22 at 12:32 noted that Resident #1 remained non-compliant with ADL's (Activities of Daily Living) assistance, initial nursing assessment, and PPD Step 2 administration. A nursing progress note on 9/8/22 at 13:34 noted that the resident was post admission day 6/7, remined non-compliant with ADL assistance, eating in the dining area and skin assessment. A note at 7:04 on 9/9/22 noted that Resident #1 refused routine labs that morning. Additional progress notes at 18:26 and 22:59 on 9/9/22 indicated that Resident #1 was non-compliant with admission and routine skin check, bathing, showers or eating in the dining room, taking aspirin, ADL's and refused PPD. A health status note, dated 9/16/22 at 14:07, noted that Resident has been refusing lab draws and Atorvastatin (a blood pressure medication). That the physician was made aware, the medication was discontinued due to resident refusal, and the lab test were to be done in 3 months. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The record review also revealed that a plan of care was initiated on 9/16/22 with the Focus: Non-compliance with prescribed treatment plan related to: refusal to follow treatment plan/refuses lab draws and medication, refuses assistance with ADL's and vitals to be done. However, Resident #1's 5 day admission MDS assessment with an assessment reference date (ARD) of 9/9/22, and Quarterly MDS assessment with an ARD of 9/17/22, revealed that Section E Behavior; E0800. Rejection of Care asked: Did the resident reject evaluation or care that is necessary to achieve the resident's goals for health and well-being? Both assessments were coded: 0. Behavior not exhibited. In an interview on 12/6/22 at 12:45 PM the Administrator was made aware of the findings that Resident #1's MDS assessments failed to capture the resident's refusals. An interview was conducted on 12/7/22 at 12:17 PM with Staff #9, a MDS Coordinator, and Staff #10 corporate MDS Nurse. They indicated that Refusal of Care was changed for the MDS Assessments dated 9/9/22 and 9/17/22, after the surveyor's discussion with the Administrator on 12/6/22, and both assessments were resubmitted. They also indicated that the Social Work department was responsible for completing Section E of the MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview with staff, it was determined the facility staff failed to develop and implement a comprehensive person-centered care plan to assist the resident to attain their highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (#1) of 3 residents reviewed for Resident Safety. The findings include: Complaint #MD00186060 involving Resident #1 was also reviewed on 11/29/22 at 10:51 AM and revealed that Resident #1 was found by police walking with a walker on [NAME] Avenue wearing hospital socks. The resident was taken to a crisis center, the facility was notified who were unaware that the resident was missing, and said they would pick him/her up. Review of the resident's medical record on 11/29/22 at 10:51 AM revealed that Resident #1 was admitted to the locked unit of the facility on 9/2/22 from an acute care hospital with diagnoses which included, but were not limited to: Chronic Obstructive Pulmonary Disease (COPD), dementia with behavioral disturbance, other symptoms and signs involving cognitive functions and awareness, Cognitive communication deficit, muscle weakness, difficulty in walking, need for assistance with personal care and atherosclerotic heart disease. A guardian of person and property was appointed by the court on 7/28/22 to act on Resident #1's behalf due to him/her lacking the mental capacity as a result of a disability defined as dementia. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. An Emergency Department Clinician note, dated 8/25/22, revealed that prior to hospitalization Resident #1 resided at another rehab facility and attempted elopement twice. On the second occasion, he/she became aggressive, attempted to bite people, and was brought to the hospital on an Emergency Petition. The report included: EMS (Emergency Medical Services) and police are concerned that the facility is not able to care for him/her. A facility Psychiatric Progress note, with an assessment date of 11/25/22, indicated: On evaluation, the patient is confused, very guarded and not a good historian in providing details of his/her medical problems or admission here. He/She continues to have paranoia, non-compliant to his/her medications (per staff) and stays in his/her room. However, comes out only for dinner or lunch. Mental Status Examination: included Attention & Concentration: Alert/Brief/Impaired/Poor Concentration/ Easily Distracted. Psychomotor Behavior: Suspicious/Guarded. Affect: Irritable/Withdrawn/Suspicious. General fund of knowledge: Poor/ Unaware of current events/Unaware of Past History/ Partial awareness. Problem Solving: Poor. Judgement/Insight: Poor. Thought Process: Blocked/Confused/Confab/Perseverative. Abnormal or Psychotic Thoughts: Persecutory. Orientation: Oriented to Person, Place, Date, and Time. Short-term memory test used, and Long-term memory test used both indicated: Patient is uncooperative with MSE but expected to be impaired. Remote Memory: Fair. Poor recall. The diagnosis indicated Unspecified dementia, unspecified severity, with agitation. A Plan of Care with the Focus: I am an elopement risk/wanderer was initiated on 9/22/22 for Resident #1. The resident's goals were: I will not leave facility unattended through the next review date; and My safety will be maintained through the next review date. Both goals had a target date of 12/9/22. The interventions that the facility implemented to assist the resident in achieving his/her goal were: Monitor for fatigue and weight loss and Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The plan was not clear how monitoring for fatigue and weight loss would assist the resident in reaching his/her stated goals. It was not apparent that staff considered the resident's prior history of becoming aggressive toward others during an elopement attempt from another facility or how walking outside was a safe intervention. The plan did not reflect that the resident was evaluated for his/her signs or symptoms of risk behaviors nor when and how staff should implement effective individualized interventions. The plan did not indicate the objectives that would be measured to evaluate the effectiveness or need to revise the plan. Staff #3, a charge nurse, was interviewed on 11/30/22 at 11:18 AM. When asked if the resident was on elopement precautions at the time, Staff #3 indicated that he thought the resident had always been on elopement precautions. When asked what precautions were put into place after the elopement he stated, I don't think he/she was. In an interview on 11/30/22 at 11:47 AM, the Director of Nursing was made aware of these concerns. Cross reference F 689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview with staff, it was determined the facility staff failed to update and revise a comprehensive person-centered plan of care after a resident walked away from the facility unaccompanied. This was evident for 1 (#1) of 3 residents reviewed for Resident Safety. The findings include: Complaint #MD00186060 involving Resident #1 was also reviewed on 11/29/22 at 10:51 AM and revealed that Resident #1 was found by police walking with a walker on [NAME] Avenue wearing hospital socks. The resident was taken to a crisis center, the facility was notified, were unaware that the resident was missing, and said they would pick him/her up. Review of the resident's medical record, on 11/29/22 at 10:51 AM, revealed that Resident #1 was admitted to the locked unit of the facility on 9/2/22 from an acute care hospital with diagnoses which included, but were not limited to: Chronic Obstructive Pulmonary Disease (COPD), dementia with behavioral disturbance, other symptoms and signs involving cognitive functions and awareness, Cognitive communication deficit, muscle weakness, difficulty in walking, need for assistance with personal care and atherosclerotic heart disease. A guardian of person and property was appointed by the court on 7/28/22 to act on Resident #1's behalf due to him/her lacking the mental capacity as a result od a disability defined as dementia. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A Plan of Care with the Focus: I am an elopement risk/wanderer was initiated on 9/22/22 for Resident #1. The resident's goals were: I will not leave facility unattended through the next review date; and My safety will be maintained through the next review date. Both goals had a target date of 12/9/22. The interventions that the facility implemented to assist the resident in achieving his/her goal were: Monitor for fatigue and weight loss and Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The record failed to reveal that the plan of care was updated to reflect that the resident left the facility unaccompanied on 11/26/22 or that the current goals and interventions were reviewed, evaluated, and revised after the incident. Staff #3 a charge nurse was interviewed on 11/30/22 at 11:18 AM. He was asked what happened when Resident #1 came back to the facility. He indicated it was lunchtime and the resident was hungry. He was asked if anything was put into place after the resident's elopement. He indicated we just checked on him/her every hour. When asked if that was still going on now, he stated I don't think it is. When asked if the resident was on elopement precautions at the time, Staff #3 indicated that he thought the resident had always been on elopement precautions. When asked what precautions were put into place after the elopement he stated, I don't think he/she was. In an interview on 11/30/22 at 11:47 AM the Director of Nursing was made aware of these concerns. Cross reference F 689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and documentation review, it was determined that facility staff failed to 1) keep treatment carts locked when unattended and 2) date medication/biologicals when opened and discard medications/biologicals when expired. This was evident on 1 of 2 nursing units observed during random observations made during the revisit survey. The findings include: On [DATE] at 8:36 AM, observation was made of an unlocked and unattended treatment cart sitting across from the nurse's station and sitting/dining area on the second floor. There were residents in the area sitting in the dining area. The surveyors were able to open all the treatment cart drawers. The surveyors observed ointments, betadine, alcohol, peroxide, various dressings, and hemoccult solution with cards in the drawers. Observation was made in the bottom drawer of the treatment cart of a 0.25% 500 ml. bottle of Acetic Acid irrigation solution, Lot J2L925 that was not dated when opened for Resident #12. There was a pink label on the bottle that stated, discard 24 hours after opening. The date and time opened was blank. (was prescribed for wounds). The bottle was in the bottom drawer in the back surround by flat dressings in foil. The pink label was clearly stuck to the bottle. Also observed was Resident #13's Acetic Acid 3% 250 ml. bottle with an expired date of [DATE]. On [DATE] at 8:41 AM, the Director of Nursing (DON) was in the hallway and the surveyor showed the DON the unlocked and unattended treatment cart along with the undated and expired items. The DON stated that the pink label did not belong on the Acetic Acid bottle. The DON acknowledged that the Acetic Acid bottle was not dated when opened and she acknowledged that Resident #13's Acetic Acid had expired. According to the manufacturer's website, https://www.baxterpi.com/pi-pdf/Acetic_Acid_PI.pdf, 0.25% Acetic Acid Irrigation, USP, is a sterile solution. The contents of an opened container should be used promptly to minimize the possibility of bacterial growth or pyrogen formation. Discard the unused portion of irrigation solution since no antimicrobial agent has been added. Review of the Storage of Medications policy that was given to the surveyor by the DON on [DATE] at 4:09 PM revealed #1, drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. Number 6 stated, compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Discussed with the Nursing Home Administrator and DON on [DATE] at 5:05 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with staff, it was determined the facility staff failed to maintain complete and accurately documented medical records by 1) failure to document information related to a resident's elopement in the medical record. This was evident for 1 (#1) of 3 residents reviewed for Resident Safety; and 2) failure to document care, treatments, and medication administration in the residents' medical record per nursing standards. This was evident for 2 (Residents #3, #6) of 6 residents reviewed during a complaint survey. The findings include: Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Review of Resident #1's medical record on 11/29/22 at 10:51 AM revealed the resident was admitted to the facility's locked unit on 9/2/22 with diagnoses which included, but were not limited to: muscle weakness, difficulty in walking, need for assistance with personal care, atherosclerotic heart disease, dementia with behavioral disturbance and other symptoms and signs involving cognitive functions and awareness. A guardian of person and property was appointed by the court system on 7/28/22 to act on Resident #1's behalf due to him/her lacking mental capacity related to a disability defined as dementia. Review of complaint #MD00186060 on 11/29/22 at 10:51 AM revealed that, on the morning of 11/26/22 Resident #1 walked out of and away from the facility, was picked up by police and taken to a crisis center. The crisis center notified the facility staff who picked the resident up and returned him/her to the facility. Resident #1's record failed to reveal documentation reflecting the elopement including but not limited to the circumstances surrounding the resident's elopement and return, notification of the physician, the resident representative and facility administration, an assessment of the residents physical, emotional and mental condition upon his/her return, a reassessment of the resident's elopement risk, and any actions taken to prevent further elopement attempts such as behavior monitoring, and the resident's response. In an interview on 11/30/22 at 11:18 AM Staff #3 a Licensed Practical Nurse confirmed he was the charge nurse on the locked unit on day shift 11/26/22. He indicated that around 10:30 AM on 11/26/22, the Manager on Duty informed him that Resident #1 was missing, that the police had called and that she asked if he could return the resident to the facility. When asked what happened when the resident returned, he indicated that the resident was hungry, and that it was lunch time. Approximately 11:20 - 11:40 AM. He stated, we did vital signs, checked skin, head to toe assessment, no bruising or anything, all he/she wanted was something to eat. He was asked where these assessments were documented. He then stated, Other thing was that they called the DON (Director of Nursing) and she said she was going to do the documentation. When asked if the DON was in the facility he stated no, they called her, or the manager was going to do the documentation. Staff #3's progress note, dated 11/26/22 12:24 PM, was reviewed with him at that time. It indicated that a head to toe skin assessment was performed and that no skin issues were noted. He was asked why his note did not reflect any information to indicate that the resident had eloped. Staff #3 then stated, The manager told me that they would take care of the documentation regarding elopement. The Director of Nursing was made aware of these findings during an interview on 11/30/22 at 11:47 AM. An interview was conducted, on 12/7/22 at 1:25 PM, with Staff #5 a Registered Nurse. She confirmed that she was the Manager on Duty on 11/26/22, that she received the phone call from the crisis center regarding Resident #1, that she and Staff #3 went to the crisis center and returned Resident #1 to the facility. When asked what occurred once the resident returned to the facility, she indicated that Resident #1 was taken to his/her room, gave him/her lunch and told him/her to let someone know next time he/she wants to go somewhere. When asked if anybody assessed Resident #1, she indicated that the nurse was supposed to do that. When asked what she did afterward she stated I really didn't do anything after that. I assumed it was a behavior. She indicated that she did not know that it was an elopement. Cross reference F-689. 2) A review of complaints MD00185568 on 12/01/22 revealed an allegation that Resident #3 was not provided with quality care. a) Resident #3 was admitted to the facility on [DATE] with diagnoses that included, but were limited to: end stage renal disease on hemodialysis, diabetes, respiratory failure, tracheostomy, feeding tube, and a stroke. Resident #3 was totally dependent upon the nursing staff for all aspects of his/her care. A review of Resident #3's closed medical record on 12/01/22 revealed that Resident #3 was sent to the hospital and admitted on [DATE]. A review of Resident #3's November medication administration record failed to reveal that the nursing staff were documenting 1) checking Resident #3's feeding tube for placement and residual tube feeding during the night shifts on 11/01, 11/02, 11/08, 11/09, 11/10, and day shift on 11/04, 2) Perform and document finger stick glucose results on 11/03 at 12 midnight and 6 am, 11/04 at 12 noon, 11/05 at 6 am, 11/09 at 12 midnight and 6 am, 11/10 at 12 midnight and 6 am, 11/10 at 12 midnight and 6 am, 3) document administering a sliding scale insulin administration on 11/03 at 12 midnight and 6 am, 11/05 at 6 am, 11/09 at 6 am, 11/10 at 12 midnight and 11/11/22 at 12 midnight and 6 am. b) Resident #6 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to cancer of the mouth, feeding tube, osteoarthritis, anemia, muscle wasting, and a stroke. Resident #6 was dependent upon the nursing staff for several aspects of his/her care. A review of Resident #6's medical record on 12/02/22 at 10 am revealed the nursing staff failed to document the following treatments and administration in Resident #6's November 2022 medication administration record on 1) checking Resident #6's feeding tube for placement and residual tube feeding during the night shifts on 11/26 night shift and 11/27 evening shift, 2) document administering water flushes on 11/27/22 at 12 midnight, 4 am, 4 am and 8 PM. In an interview on 12/02/22 at 2:22 PM, the DON stated that she/he was unable to determine the reason why the nursing staff failed to document performing treatments and administrations to Residents #3 and #6. These findings were shared with the facility Administrator and a Director of Nurses at the exit conference on 12/02/22 at 2:45 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to maintain infection control practices on 2 out of 2 resident living floors and 1 out of 1 administrative floor reviewed for infection control practices. The findings include: On [DATE] at 8:45 AM, a tour of the facility was conducted. Observation was made of 40 out of 40 Medline Spectrum Sanitizer Gel hand cleaning stations affixed to the walls. The sanitizer stations were found to have expired hand sanitizing gel in them with the expiration date of 12/2022, lot #0506805. On [DATE] at 8:25 AM, observation was made in room [ROOM NUMBER] of a large pile of clear to creamy white examination gloves on the counter next to the hand washing sink. The gloves were out of the box that they came stored in. The hand washing sink was located just inside the resident room to the left. Surveyors were unable to determine if the gloves were clean or dirty. On [DATE] at 3:06 PM, an interview was conducted with the Infection Control Nurse (Staff #6). Staff #6 was asked if it would be acceptable for staff members to utilize expired hand sanitizer to which she replied no. Staff #6 was informed that during a tour of the building, 40 out of 40 wall mounted hand sanitizing gel stations were expired. Staff #6 indicated that she was not aware that they were expired. Two surveyors walked with Staff #6 to unit 2W to visualize one of the hand sanitizing stations. Staff #6 confirmed that the hand sanitizing gel in the hand sanitizing station expired in [DATE]. At 3:23 PM, Staff #6 said that the facility would replace all of the wall hand sanitizing gel stations with little bottles of hand sanitizer, with pumps, until replacements for the wall hand sanitizing stations could be obtained. Discussed with the Nursing Home Administrator and the Director of Nursing on [DATE] at 5:05 PM.

Based on review of the medical record and interview with staff, it was determined the facility failed attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to ensure that policies and procedures were developed to guide staff in delivery of resident care related to elopement. This was evident during review of 1 (#1) of 3 residents reviewed for Resident Safety and has the potential to affect all residents in the facility. The findings include: Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Complaint #MD00186060 was reviewed on 11/29/22 at 10:51 AM. The complaint indicated that Resident #1 was found by the police on 11/26/22, wandering with hospital socks on. He/She was taken to a crisis center, the facility was contacted and picked the resident up. Review of Resident #1's medical record at that same time failed to reveal documentation related to the resident leaving the facility unaccompanied. During an interview on 11/30/22 at 11:47 AM, the Director of Nursing was asked to provide the surveyor with a copy of all facility policy and procedures related to elopement including elopement risk.The surveyor was provided with a 1 page Policy titled Wander Management and Elopement Prevention. The Policy Statement was: The facility will maintain the safety of residents who wander and/or are at risk for elopement. The Policy Interpretation and Implementation contained 9 points. 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). a. The list of identified residents will be placed in location(s) easily accessible to staff, including at the receptionist's desk, and will include the resident's name, photo, and face sheet. 2. The staff will implement a wander management system device, if recommended, as a part of the plan of care. 3. Resident care plans will include resident specific interventions to ensure safe wandering and prevent elopement. 4.- 9. Pertained to a wander management system device. There was no policy nor procedure to provide staff guidance for elopement risk assessments, monitoring of resident behavior, interventions related to elopement & elopement risk, staff actions in the event of a missing resident, including notification, reporting, documentation, and investigation, follow up once resident was located. During an interview on 12/1/22 at 9:04 AM with the DON (Director of Nursing) and Staff #4 Corporate Regional Director of Operations. Staff #4 indicated that the facility was in the process of having a company come to check the door alarms and access codes and that the wander guard (wander management system) was initiated for the residents on the locked unit. When asked if the wander guard system was already in place, He indicated that it was a new system, and the facility just got the bands in. He confirmed that the policy that was provided to the surveyor on 11/20/22 by the DON was the only policy and procedure that the facility had related to elopement. In an interview on 12/1/22 at 9:27 AM, Staff #12 the Maintenance Director, was asked about the wander guard system. He indicated that he was new, did not see any wander guard bracelets on the residents and did not know about a wander guard system being used in the facility. He was asked if there was a system in use, would he be responsible for checking it for proper functioning, he indicated yes but he had not been doing it at this facility. In an interview on 12/7/22 at 1:25 PM, Staff #5 (a Registered Nurse who was the Manager on Duty on 12/26/22 7 AM-3 PM) indicated that she received a call from a crisis center that Resident #1 was there. She indicated that she went to the locked unit where Staff #3 the Charge Nurse indicated they thought Resident #1 was around. They were unable to locate the resident on the unit and went to pick him/her up at the crisis center. Upon return, the resident was given lunch and told him/her to let someone know next time he/she wants to go somewhere. When asked if anyone assessed the resident, she indicated that Staff #3 was supposed to assess him/her. When asked what was done after the resident returned, she indicated she really didn't do anything after that, and that she considered it a behavior. When asked if the facility had a protocol for elopements, she indicated that at that time she did not know it was an elopement. When asked what else it could have been, she indicated, that she considered it a behavior. When asked if she reported the elopement to anyone she stated, no. Cross reference F-689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A hard chart medical record review for Resident #113 was conducted on [DATE] at 12:22 PM, and revealed a Maryland Orders for Life-Sustaining Treatment (MOLST) form completed by the attending physician #55. Attending physician #55 had marked that she had entered these orders based on a discussion and informed consent of the patient's healthcare agent as named in the patient's advanced directives. Further review of the hard chart had not revealed a copy of the resident's advanced directive. In addition, there had been a form titled, Physician's Certification of Incapacity to Make an Informed Decision. Section I that had been completed by the attending physician and signed and dated. However, the Section II (for the second physician) was blank. A medical record review in Point Click Care (PCC), the facility's electronic medical record system, on [DATE] at 8:13 AM revealed no Advanced Directive for Resident #113 nor had a second certification of incapacity been uploaded into the resident's medical record. On [DATE] at 12:05 PM, surveyor requested copies of the MOLST, Advanced Directives, and Certificates of Incapacity from the Unit Manager (UM) #37. At that time, she was made aware that this surveyor was unable to find a second certificate of incapacity and advanced directive for Resident #113. The Director of Nursing (DON) was made aware on [DATE] at 10:32 AM, that the surveyor was unable to locate the second cert of incapacity and the Advanced Directive for Resident #113 that had been referred to on the MOLST dated [DATE]. The DON reported that she would look for this information and if found she would provide copies. However, by the end of the survey the DON had not provided copies of the documents. The concerns were discussed with the DON on [DATE] at 9:58 AM. Based on medical record review and interview, it was determined that the facility failed to ensure that orders for life-sustaining treatment were made in accordance with residents' advance directives, . This was found to be evident for 2 (Resident #26, Resident # 113) out of 6 residents reviewed for advance directives. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options. According to Maryland's Health Care Decision Act, unless otherwise provided in the document, an advance directive shall become effective when the patient's attending physician and a second physician certify in writing that the patient is incapable of making an informed decision. 1) On [DATE], review of Resident #26's medical record revealed the resident was initially admitted to the facility in [DATE]. Review of the MOLST revealed that it was completed by the attending physician (#55) on [DATE], with the patient's health care agent as named in the patient's advance directive. Further review of the medical record, including both the electronic health record and the paper chart, failed to reveal a copy of the resident's advance directives as referenced on the MOLST. On [DATE] at 10:39 AM, surveyor reviewed the concern with the unit nurse manager (#4) that the MOLST referenced the resident's advance directives, but further review failed to reveal documentation of Advance Directives for this resident. Review of the medical record on [DATE] revealed a social service note, dated [DATE], that indicated a social service worker requested the family bring in the Advance Directive documentation. Further reiew of the medical record failed to reveal documentation to indicate the facility had attempted to obtain the Advance Directives prior to [DATE]. On [DATE] at 8:05 AM, surveyor requested a copy of the resident's MOLST from the Administrator and reviewed the concern that the note indicated it was discussed with the Health Care Agent as named in the advanced directives, but there were no Advanced Directives on the chart. [DATE] 08:56 AM, the Social Service Director (#9) director reported that she did not have the advance directives for the resident. On [DATE] at 2:16 PM, an intervierw was conducted with the PCP #55 and the Administrator. When asked about completing a MOLST for a resident who does not have capacity, the primary care phyisician (PCP#55) reported: I do it with the family or their surrogate or guardian, who ever is listed; in the computer, sometimes it says first person of contact and they are asked if they are the guardian; or the surrogate; or if they have the POA [Power of Attorney]; and if they have any documentation they need to bring it in. When asked about when she would document that the orders were based on a discussion with the health care agent as named in the advance directive, the PCP reported that would be their POA and they would have to of course bring in the paperwork, and that usually goes to social work. The PCP went on to report that, for this resident, the person she spoke with told her s/he was the POA and was supposed to bring in the paperwork. On [DATE] at 10:23 AM, surveyor reviewed with the Director of Nursing (DON) the concern regarding the facility's failure to address the issue of the missing advance directives with the family prior to [DATE]. The DON reported that the Social Worker is responsible for following up with two doctors to complete the certifications of incapacity, and they proceed after the certifications are obtained. On [DATE] at 12:50 PM, the DON presented Power of Attorney documentation, dated [DATE], that covered medical decisions. Further review of the electronic health record revealed this document was uploaded to the medical record on [DATE], this observation was confirmed by the DON. Cross reference to F 842

Based on record review and staff interview, it was determined that the facility failed to implement a grievance policy as evidenced by staff failing to report resident concerns to a supervisor. This was evident for 1 (#59) of 9 residents reviewed for abuse. The findings include: A medical record review for Resident #59 was conducted on 8/2/22 at 10:24 AM and revealed a History and Physical progress note from Attending Physician #61 that documented Resident #59 was in the facility for ongoing medical management. Resident #59 was on hemodialysis due to Chronic Renal disease, and had the following diagnoses: high blood pressure, pain in left shoulder, blindness, and muscle weakness. Further review revealed a Minimum Data Set, (MDS) with an assessment reference date of 5/26/22, that documented in section C that Resident #59 scored 15:15 on the Brief Interview for Mental Status which indicated Resident #59 had no cognitive impairment. In section G it was documented that Resident #59 relied on staff for most daily functions, such as eating, toileting, bathing, personal hygiene, and getting dressed. An interview with the Ombudsman on 8/2/22 at 10:50 PM, revealed Resident #59's family member had called her the week of 7/17/22 to report concerns with the care Resident #59 had been receiving. The concerns received were that staff were rough with the resident, had not been feeding the resident, and was not careful to leave the call bell where the resident was able to reach it. The Ombudsman reported that she had visited Resident #59 and that the resident had been tearful and crying. Resident #59 reported to the Ombudsman that staff had been rough during care and caused the resident pain in the left shoulder and that the staff were not respectful of the fact that the resident was blind. The Ombudsman reported that she had told Licensed Practical Nurse (LPN) #38 about the concerns voiced by Resident #59 and the family member at the time of the visit with Resident #59. LPN #38 was interviewed on 8/2/22 at 11:27 AM regarding Resident #59 and she reported that the Ombudsman had reported some concerns to her about a week or two ago. LPN #38 reported that she was told the family and Resident #59 had complained that when staff had dressed him/her that the pain in the left should was worse, and staff should exercise more patience when providing care. LPN #38 reported that she went to Certified Nursing Assistant (CNA) #59 regarding the concern. When asked if she talked to Resident #59 about the concerns, she stated she had not. LPN #38 stated that she should have reported the concerns to her supervisor. Surveyor had attempted, but was unable to interview Resident #59, because he/she went to the hospital and wasthe surveyor was unable to contact the family member. On 8/8/22 at 12:40 PM, surveyor reviewed the concerns with the Administrator and she confirmed that staff should have reported those concerns to their immediate supervisor who would then contact either the Director of Nursing or the Administrator.

Based on observation, record review, and interview, it was determined that the facility failed to implement their abuse policy by failing to recognize, report, and investigate a resident's missing wheelchair as misappropriation of resident property. This was evident for 1 (#94) of 2 residents reviewed for personal property. The findings include: On 8/10/22 at 10:30 AM, a medical record review for Resident #94 revealed a Minimum Data Set, (MDS) with an assessment reference date of 6/19/22, which documented in section C that Resident #94 scored a 12:15 on the Brief Interview for Mental Status, which indicated no cognitive impairment. Documentation in section G revealed that Resident #94 relied on staff for transferring him/her from bed to chair and relied on wheelchair for locomotion on the unit. During an interview on 7/26/22 at 11:23 AM, Resident #94 reported that he/she had brought a wheelchair from home when admitted to the facility. Resident #94 reported that an unidentified staff member had taken the wheelchair from Resident #94's room and told the resident she was borrowing it for another resident. Reportedly, Resident #94 had not seen his/her wheelchair since. Resident #94 stated he/she had told the Administrator and had called the police to report it missing. Resident #94 stated that the Administrator told him/her that she would replace the wheelchair and she replaced it with that one (pointing to an obsess wheelchair sitting next to the resident's bed). Resident #94 stated she had told staff (including the Administrator) that the wheelchair was too large, and that it had been too hard to propel himself/herself around. On 8/15/22 at 5:39 PM, Resident #94 forwarded an email that had been sent to the Administrator on 4/21/2022 from a friend of Resident #94. It stated that the friend was inquiring about Resident #94's missing wheelchair. The friend stated that the wheelchair had been brought to the facility a year ago and was marked with Resident #94's name and room number. The friend stated that Resident #94 had reported that the wheelchair had been used for another resident. An interview on 8/10/22 at 10:15 AM with the Administrator confirmed Resident #94 had brought a wheelchair to the facility from home. The Administrator had spoken to Resident #94 regarding the missing wheelchair but was unable to recall a date or time as she had failed to document the concern. The Administrator denied being told that the wheelchair had been used for another resident and stated Resident #94 had told her he/she was not sure what had happened to the wheelchair. The Administrator reported that, after looking for the wheelchair they were unable to locate it, and that she told the Resident #94 that it was probably thrown away by staff during construction. The Administrator informed the resident that she would replace the wheelchair. The Administrator reported she was aware that Resident #94 was unhappy with the wheelchair they bought to replace his/hers. The Administrator reported that Therapy had evaluated the resident for the wheelchair size prior to purchasing the wheelchair. Administrator stated that she could provide a copy of the receipt to show the facility had replaced Resident #94's wheelchair. However, the Administrator had failed to recognize this as misappropriation of resident property and failed to report it to the State Agency as required. On 8/15/22 at 11:00 AM, a review of the information provided by the Administrator regarding the replacement of the lost wheelchair revealed an email that was forwarded to her from the corporate office that stated the following wheelchairs had been shipped. There were two wheelchairs listed on the shipping information, however, there were no resident names on the order. The Administrator had circled one to indicate that it had been for Resident #94. The size and serial number were provided on the email. A visit to Resident #94's room on 8/15/22 at 11:45 AM revealed that the wheelchair that was in his/her room was larger and had a different serial number than what was noted on the email. On 8/15/22 at 12:00 PM, during a subsequent interview with the Administrator, she reported she had been aware that the wheelchair listed in the email from corporate had not been the wheelchair that was currently in Resident #94's room and that they had been looking for the one that had been purchased but had not been able to locate it. However, the Administrator failed to recognize the incident as misappropriation of resident property and had not reported the second missing wheelchair for Resident #94. Cross Reference: F610

Based on record review and staff interview, it was determined that the facility failed to protect their residents from a staff member who had been accused of abuse of a resident as evidenced by the staff member continuing to work with vulnerable residents after an allegation of abuse had been received. This was evident for 1 (#59) of 9 residents reviewed for abuse. The findings include: A review of an email sent to surveyor on 8/2/22 at 9:54 AM, revealed a police report that was filed on 7/29/22, for an allegation of abuse regarding Resident #59. An interview with the Administrator on 8/2/22 at 11:54 AM, revealed that she had a visit from 2 detectives regarding the abuse report, however, she was not given the alleged perpetrator's name. The Administrator reported that she had initiated an investigation. Administrator was informed of the complaint #MD00180931 which had named a perpetrator of Certified Nursing Assistant (CNA) #59. She stated she would investigate it and provide the results of the investigation to the survey team. A review of the facility's investigation file on 8/8/22 at 11:35 AM revealed the facility had conducted the investigation for the allegation of abuse from 8/2/22 until 8/5/22. However, review of the schedules revealed that CNA #59 worked dayshift, with is 7:00 AM - 3:00 PM on 8/2/22, 8/3/22, and 8/4/22. The facility's Abuse Investigation and Reporting Policy was reviewed on 8/8/22 at 11:44 AM. In the policy, regarding the role of the Administrator (#4), it was documented that the Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. An interview with the Administrator on 8/8/22 at 12:40 PM revealed that she had not suspended CNA #59 as stated in the facility policy because when the word rough was used, she did not feel CNA #59 should have been suspended.

4) Resident # 133 was admitted to the facility in March 2022. Record review revealed an order, dated 5/14/22, for Transfer patient to the ER for Altered Mental Status/weakness and possible CT on the head. On 8/11/22, review of the medical record revealed an Intent to Transfer Resident with less than 30 days ' notice, dated 5/15/22, which revealed documentation that a written bed hold policy had not been provided. On 8/15/22, further review of the electronic and paper medical record revealed the resident was responsible for him/herself and no documentation was found that s/he received a bed hold policy at the time of the transfer to the hospital. On 08/18/22 at 8:55 AM, the Director of Nursing stated that they make copies of everything they send to the hospital with a resident when they are transferred to the hospital. In addition, she stated there would be documentation in the electronic medical record of what was sent to the hospital with the resident. The surveyor requested a copy of the documentation that a written bed hold policy was given to the resident. As of the time of survey exit, on 8/23/22, no documentation was provided to the survey team to indicate the bed hold policy was provided to Resident #133 when sent to the hospital in May. Based on medical record review and interview, it was determined that the facility failed to have an effective system in place to ensure that residents and the resident's responsible representative were notified in writing of the bed hold policy at the time of transfer to a hospital. This was found to be evident for 4 (Resident #26, #196, #192, #133 ) out of 12 reviewed for hospitalizations during the investigative portion of the survey. The findings include: A Bed-hold policy is the facility's policy regarding holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1) Review of Resident #26's medical record revealed that the resident had severly impaired cognitive skills, and had two certification of incapacity to make informed decisions. The resident had a health care power of attorney (responsible respresentative). The resident was admitted to the facility in January 2022 and had a discharge to the hospital in June 2022 with a re-admission in July. Further review of the medical record revealed that a Notice of Intent to Transfer/Discharge Resident form was completed on 6/26/22. The last item on this form was Bed hold Policy provided to the resident or responsible party with this notice? Staff marked Not Applicable. Further review of the medical record failed to reveal documentation to indicate the responsible representative was provided a written copy of the bed hold policy when the resident was transferred to the hospital in June. On 8/2/22 at 12:32 PM, the Unit Nurse Manager (#4) confirmed that this information was not provided to the resident or sent to the responsible respresentative by nursing. She indicated she would ask the social worker if the information was sent to the responsible representative. On 8/03/22 at 8:53 AM, the Social Service Director (#9) denied being involved in providing the bed hold notice when a resident is sent to hospital. On 8/12/22 at 10:11 AM, surveyor reviewed with Director of Nursing the concern that no documentation was found to indicate that a copy of the bed hold policy was provided to the responsible representative at time of transfer. As of time of survey exit on 8/23/22, no additional documentation was provided regarding this concern. 2) On 8/11/22, a review of Resident #196's medical record revealed that the resident was admitted to the facility in December 2021 and was transferred to the hospital on 1/1/22. Further review of the medical record failed to reveal documentation to indicate that the bed hold policy was provided, or discussed, with either the resident or a responsible representative at the time of the 1/1/22 transfer. On 8/22/22 at 3:34 PM, surveyor reviewed the concern with the DON that no documentation was found to indicate the bed hold policy was provided to the resident when sent to the hospital on 1/1/22. As of time of survey exit on 8/23/22, no additional documentation was provided regarding this concern. 3) Review of Resident #192's medical record revealed the resident was admitted to the facility in January 2021 and was discharged to the hospital in February 2021. Further review of the medical record failed to reveal documentation to indicate the resident was provided the bed hold policy at the time of the discharge. On 8/17/22 at 3:30 PM, surveyor reviewed the concern with the DON regarding the failure to provide the bed hold policy to Resident #192. As of time of exit, no additional documentation was provided regarding this concern. Resident # 133 was admitted to the facility in March 2022. Record review revealed an order dated 5/14/22, for Transfer patient to the ER for Altered Mental Status/weakness and possible CT on the head. On 8/11/22, review of the medical record revealed Intent to Transfer Resident with less than 30 days' notice, dated 5/15/22, which revealed documentation that a written bed hold policy had not been provided. On 8/15/22, further review of the electronic and paper medical record revealed the resident was responsible for him/herself and no documentation was found that she/he received a bed hold policy at the time of the transfer to the hospital. On 08/18/22 at 8:55 AM, the Director of Nursing stated that they make copies of everything they send to the hospital with a resident when they are transferred to the hospital. In addition, she stated there would be documentation in the electronic medical record of what was sent to the hospital with the resident. The surveyor requested a copy of the documentation that a written bed hold policy was given to the resident. As of the time of survey exit, on 8/23/22, no documentation was provided to the survey team to indicate the bed hold policy was provided to the resident when sent to the hospital in May.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#131, #31) of 6 residents reviewed for positioning and mobility. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 7/25/22 at 12:10 PM, Resident #131 was observed wearing a right hand splint (brace), sitting at a table in the dining area. At the time, the resident was observed picking up food with his/her left hand, feeding self with staff supervision. On 7/27/22 at 9:32 AM, Resident #131 was observed wearing a right hand splint while walking independently in the hall, and, on 8/1/22 at 1:28 PM, Resident #131 was observed wearing a right hand brace and walking independently in the corridor of the nursing unit. On 8/1/22 at 9:00 AM, a review of Resident #131's medical record revealed the Resident #131 had resided in the facility since June 2021 and had diagnoses not limited to, Alzheimer's dementia. The medical record documented that Resident #131 was cognitively impaired, dependent on staff for assistance with all ADLs (activities of daily living) and wore a right hand brace (splint) every day. Physician orders included a 6/24/22 order, OT (occupational therapy) clarification: resting hand splint on right upper extremity, on AM/off PM; continue to check for skin irritations as needed, in the morning and remove per schedule, and a 6/24/22 order Remove brace on the right hand and perform skin checks every 2 hours every day and evening shift Review of Resident #131's quarterly MDS with an ARD (assessment reference date) of 7/1/22 identified MDS inaccuracies: - Section G. 0110 Activities of Daily Living (ADL) Assistance, documented Resident #131 required extensive assistance with 2 person physical assist for eating. The MDS did not accurately document the ADL support provided to the resident for eating. - Section G0400. Functional Limitation in Range of Motion, code for limitation that interfered with daily functions or placed resident at risk of injury documented that Resident #131 had no impairment in either the upper or lower extremities. The MDS failed to accurately capture the functional limitation in range of motion of the resident's right upper extremity. - Section G0600. Mobility Devices documented that Resident #131 used a wheelchair for mobility. The MDS failed to capture that Resident #131 had not required a mobility device. - Section H0500, Bowel Toileting Program documented the resident was on a bowel toileting program. Concurrent review of the medical record documented the resident was cognitively impaired, frequently incontinent of bowel and no documentation was found to support the resident was on a bowel toileting program. - Section O0250. Influenza vaccine documented Resident #131 did not receive an influenza vaccine during this year's influenza vaccination season because the resident was not in the facility during the year's influenza vaccination season. Concurrent review of the resident's EMR (electronic medical record) revealed the resident received an influenza vaccine on 10/1/21. On 8/2/22 at 11:09 AM, Staff #26, RN, MDS Coordinator was made aware of the concerns with the accuracy of the MDS. 2. On 7/26/22 at 10:37 AM, Resident #31 was observed wearing a right shoulder/arm sling and a right hand splint while sitting in a wheelchair in the dining area, on 7/27/22 at 11:34 AM Resident #31 was observed a right shoulder/arm sling and a right hand splint while sitting in a wheelchair in the dining area, and on 8/3/22 at 12:30 PM, an observation was made of Resident #31 was observed wearing a right shoulder/arm sling and a right hand splint while sitting in a wheelchair in the resident's room. 08/18/22 08:21 AM, a review of Resident #31's medical record revealed the resident resided in the facility since May 2020 and documented the resident had diagnoses that include hemiplegia (paralysis on 1 side of the body) and hemiparesis (weakness) following a cerebral infarction (stroke) affecting right dominant side, a right hand contracture (decrease in passive range of motion (ROM) at a joint), and the resident was dependent on staff support for all activities of daily living. Review of Resident #31's physician orders revealed a 7/5/18 order for the resident to wear right shoulder/arm sling, on in the morning and off at bedtime, and a 7/5/18 order for Resident #31 to wear a right hand splint, on in the morning and off at bedtime. Review of Resident #31's care plans, revealed a care plan, the resident has limited physical mobility r/t stroke with right sided weakness, weakness, confusion, right hand contracture; at risk for further contractures with interventions that included, 1. Resident to wear splint to right hand as ordered and 2. Locomotion: the resident requires extensive assistance by 1 staff for locomotion using wheelchair A review of Resident #31's quarterly MDS with an ARD of 7/31/22 revealed: - Section G. Functional status, Section G0400. Functional Limitation in Range of Motion, code for limitation that interfered with daily functions or placed resident at risk of injury documented Resident #31 had no impairment in either the upper or lower extremities. The MDS failed to accurately capture Resident #31's functional limitation in ROM - Section G0600 Mobility Devices documented Resident #31 did not use a mobility device. The MDS failed document that Resident #31 used a wheelchair for mobility. On 8/18/22 at 11:00, Staff #26 was made aware of above concern and confirmed the MDS inaccuracies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On [DATE] at 11:02 AM, a review of Resident #23's medical record revealed a MOLST form (signed and dated [DATE]) that documented Resident #23 elected No CPR, Option B, Palliative and supportive Care. A Maryland MOLST (Maryland Orders for Life Sustaining Treatment) is a portable and enduring medical order form covering options for CPR (cardiopulmonary resuscitation) and other life-sustaining treatments based on a patient's wishes about medical treatment. 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. Review of Resident #23's care plans revealed a care plan, initiated on [DATE], I have an Advanced Care Directive, which included the resident's HCA (healthcare agents) with the goal I will express my need to change my Advance Directives if I wish to and the interventions 1. I am a Full Code (if heartbeat or breathing stops all medical efforts would be provided to keep the person alive) and 2. I have a designated health care proxy which included resident's HCA. Continue review of Resident #23's medical record revealed the facility failed to update the care plan when there was a change in Resident #23's wishes for CPR and life sustaining measures changed as evidenced in his/her MOLST election for No CPR, Option B, Palliative and supportive Care on [DATE]. There was no evidence in the medical record that the care plan had been evaluated following the resident's significant change assessment with an assessment reference date (ARD) of [DATE] and quarterly assessment with an ARD of [DATE]. On [DATE] at 11:37 AM, the Director of Nurses was made aware of the above concerns. Based on review of the medical record and interview with staff, it was determined that the facility staff failed to review and revise the residents care plans after each comprehensive and quarterly assessment, failed to ensure that the residents and/or residents' representative were included in the development of the care plan and failed to update the resident's care plan when there was a change in their wishes for CPR and life sustaining measures. This was evident for 2 (#105, #23) of 4 residents reviewed for Care Plan. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Resident #105's representative was interviewed on [DATE] at 12:17 PM. When asked if they attended the resident's care plan meetings, the representative indicated that, when the resident was first admitted , they were called by the Social Worker and a voice mail message was left regarding a meeting. However, when they tried to return the call, the Social Worker did not have voicemail, they left messages with the receptionist for the Social Worker to return their calls, but she never did. The representative indicated that they have not been invited to any care plan meetings since that time. Resident #105's medical record was reviewed on [DATE] at 10:04 AM. The resident's MDS assessment history reflected that a quarterly MDS was completed on [DATE]. A care plan meeting review note was dated [DATE], 16 days after completion of the MDS assessment. It included that the meeting was attended by Nursing, Social Services, Activities and Family, however, it did not reflect the date and time of the meeting nor the names of the attendees including the family member. No documentation was found in the Resident #105's medical record to indicate that the residents care plan was revised after the Quarterly MDS assessments, dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. No documentation was found to reflect that a comprehensive plan of care was developed within 7 days after the comprehensive annual assessment dated [DATE]. A progress note, dated [DATE], was written by Staff #57 (a former Social Worker) and indicated that a care plan meeting was held on [DATE] and attended by Nursing, Social Service, Therapy, and family, but the note did not identify the names of the attendees. There was no indication that the family member who attended the meeting was the resident's representative. This meeting was more than 7 days beyond the completion of the most recent quarterly MDS assessment. No documentation was found to indicate that the facility invited and coordinated the care plan meeting with Resident #105 and their representative, nor documentation of the name of the attendees including the staff, the resident and resident's family/representative. An interview on [DATE] at 10:30 AM, the Administrator was made aware of these findings. She was asked to provide any documentation reflecting that care plan meetings were held to review and revise Resident #105's plan of care after the quarterly and annual MDS assessments and that the resident's representative was invited to the meetings. She indicated there were no other notes. She added that she became aware in March or April that the care plan meetings/revisions were not in compliance. A new system was put into place, the Social Worker was counseled, things did not improve, and the Social Worker was terminated. The new - current Social Worker was hired in [DATE]. She was made aware that there was no evidence that Resident #105's care plan was reviewed/revised after the MDS assessment dated [DATE]. An interview was conducted with Staff #20, a MDS coordinator on [DATE] at 10:18 AM. She was asked to describe the care plan process. She indicated that she will usually email the interdisciplinary team with the admission date for new admissions. A huddle meeting will be held within 3 days of admission prior to completion of the MDS to discuss the residents primary care, conditions, review if anything is different from the hospital. When asked how she communicated that the MDS was completed, she indicated during the morning meeting, sometimes she sent an email, and that there is a calendar for annual and quarterlies that is updated monthly. When asked who is notified that the MDS is completed and that the Care Plan needs to be reviewed, she indicated the unit managers and Social Services are informed during the morning meetings. When asked if she was involved with the care plan meetings Staff #20 indicated that she is only involved when there is a request or demand for MDS to be there. She indicated that she conducted an in-service about 4-5 months prior regarding the care plan process and timing. She indicated that the in-service was attended by the unit managers, dietician, Activity Director, Social Services, Rehab Director, the Director of Nursing, and the Administrator. She reported when asked, that Social Services is responsible for setting up the care plan meetings with the residents' family.

7) The Medication Administration Record (MAR) is used to document medications administered and, if not administered, document a rationale for the medication not being given. Resident #201 was admitted to the facility in 2019 with diagnoses that incuded, but were not limited to, bipolar disorder, schizophrenia, hypertension, and hypothyroidism. A review of Resident #201's January 2021 Medication Administration Record (MAR) on 8/19/22 at 9:54 AM revealed: -Clonidine prescribed for hypertension (high blood pressure) scheduled 3 time per day MAR was blank from 1/21-1/27 at 1PM administration time. (7 days in a row) -Gabapentin prescribed for agitation scheduled 3 time per day. MAR was blank from 1/21-1/23 & 1/25-1/27 & 1/29 at 1PM administration time. (7 days missing for this administration time) -Hydralazine prescribed for hypertension scheduled 3 times per day MAR was blank from 1/21-1/23 & 1/25-1/27 & 1/29 at 8AM administration time. (7 days in a 9 day window) MAR was blank from 1/21-1/27 at 1PM administration time (7 days in a row) -Oxcarbazepine prescribed for seizures scheduled 3 times per day. MAR was blank from 1/21-1/23 & 1/25-1/27 & 1/29 at 1PM administration time. (7 days in a 9 day window) -Seroquel prescribed for bipolar disorder scheduled 2 times per day. MAR was blank on 1/22 and 1/24 for the dose due at 9PM MAR was blank on 1/7 for the dose due at 8AM -Metoprolol Tartrate prescribed for hypertension scheduled 2 times per day. MAR was blank from 1/21-1/23 & 1/25-1/27 & 1/29 at 8AM administration time. (7 days in a 9 day window) -Cozaar prescribed for hypertension scheduled 2 time per day. MAR was blank on 1/7 for the dose due at 8AM MAR was blank on 1/22 and 1/24 dose due at 9PM -Amlodipine Besylate prescribed for hypertension scheduled 1 time per day. MAR was blank from 1/21-1/23 & 1/25-1/27 & 1/29 at 8AM administration time. (7 days in a 9 day window) -Levothyroxine Sodium prescribed for hypothyroidism (low thyroid levels) scheduled 1 time per day. MAR was blank on 1/13 for the dose due at 6:30 AM -Loratadine prescribed for allergy scheduled administration 1 time per day MAR was blank on 1/7 for the dose due at 8 AM. Further review of the medical record failed to reveal documentation to indicate the resident had refused medications when due on the above listed dates. On 8/23/22 at 10:30 AM surveyor reviewed the concern with the Director of Nursing regarding the failure to administer the resident's medication as ordered on multiple occasions. 8) On 7/29/22 at 9:22AM, a review of the medical record revealed that Resident #21 resided at the facility since 2021. A progress note written by a nurse practitioner (NP) on 7/13/22 revealed that Resident #21 was seen for dysuria (painful or difficult urination). The NP documented in the Assessment and Plans section: 1. Dysuria plan UA (Urinary Analysis) & C/S (Culture and sensitivity) ordered. Further review of the medical record revealed an order placed on 1/13/2021 for a UA & C/S. An interview with Unit Nurse Manager (#4) on 07/29/22 at 12:47 PM revealed when a lab is ordered by a provider, the facility staff then enters it into the system for labs to process the order. The Unit Nurse Manager (#4) indicated she/he was unaware than an order for a UA & C/S was placed on 1/13/21 for Resident #21. After the Unit Nurse Manager reviewed the electronic medical record of Resident #21, she/he reported the order was placed incorrectly. The Unit Nurse Manger (#4) reported the nurses were responsible for making sure the order is entered correctly. Review of the medical record for Resident #21 failed to reveal any results from the urinary lab ordered on 7/13/21. Further review of the medical record failed to reveal documentation to indicate that staff had attempted to obtain the urine sample that was required for the U/A order on 7/13/21. Further review of Resident #21's medical record on 7/29/22 at 9:09AM revealed the resident was seen by a dental provider on 6/9/22. Review of the Initial Exam Report revealed the following recommendations: Brush tongue twice a day; Monitor teeth for signs/symptoms of problems.; Recommend oral surgery for panoramic xray, surgical extractions, and nitrous sedation.; Recommend oral surgery for removal of remaining teeth #21-28 and panoramic xray. Further review of the medical record failed to reveal documentation to indicate the recommendations were reported to or reviewed by the primary care provider. During an interview on 07/29/22 at 1:34 PM, the Administrator indicated that, after a resident is seen by a consultant, the report should be given directly to the Director of Nursing (DON). It is then the DON's responsibility to relay the finding to the primary care physician. The Administrator revealed that the dental consult note for Resident #21 was uploaded directly from the dental group to resident's medical record and was not given to the nursing staff. The Administrator acknowledged the result of the consult was not communicated to the primary care physician and were not addressed. Review of the medical record on 8/1/22 at 7:42 AM revealed a progress note dated 7/29/22 6:29 PM from Unit Nurse Manager (#4) stating dental consult was reviewed with primary care physician and Resident #21. Further review of orders written on 7/29/22 revealed an order for brush tongue 2x daily consistent with recommendation given by dental consult. 6) Resident #233's medical record was reviewed on 8/22/22 at 9:10 AM. The record revealed that the resident had a 12 day stay in the facility during May 2022. The resident had many complicated diagnoses which included, but were not limited to, Atherosclerotic Heart Disease, Myocardial infarction, Hypertension, Diabetes, Adult Failure to Thrive, Stage 4 chronic kidney disease with dependence on Dialysis. Review of the MAR (Medication Administration Record) and TAR (Treatment Administration Record) revealed that Resident #233 was prescribed multiple medications and treatments, and required several assessments to manage their medical conditions. The MAR and TAR provide space for the assigned nursing staff to initial each medication or task as completed or initial and provide an appropriate code to indicate the rationale if it was withheld. Resident #233's MAR and TAR for 5/2022 revealed several blank spaces and did not reflect that the resident received the medication or care as ordered or that it was withheld. The MAR was not signed off on 5/12/22 and 5/19/22 to indicate that Resident #233 received their 0900 dose of: Allopurinol 100 mg (milligrams) (gout medication) Amiodarone 200 mg (for heart rhythm problems), Atorvastatin 40 mg (for cholesterol), Multiple Vitamins with Minerals 1 tablet (for supplement), Prosource Supplement (for wound healing), Senokot S tablet 8.6-50 mg (for bowel movement), Metoprolol Tartrate 25 mg (for blood pressure) including documentation of the blood pressure for parameters. The MAR was not signed off on 5/15/22 for Resident #233's 2100 (9 pm) dose of: Ciprofloxacin HCL 500 mg (an antibiotic), Glargine Insulin 40 Units (for diabetes), Mirtazapine 7.5 mg (for appetite), Tamsulosin HCl 0.4 mg (for benign prostatic hypertrophy), Metoprolol Tartrate 25 mg (for blood pressure) including documentation of the resident's blood pressure for parameters to hold the medication. The MAR was not signed off for: Lidocaine Patch 4% (for pain control) application at 0900 (9 am) on 5/12/22, Lidoderm Patch 5% (for pain control) application at 0900 on 5/19/22, Robaxin 500 mg (for muscle spasms) at 1700 on 5/15/22 and 0900 on 5/19/22, Sinemet 25-100 mg (for Parkinson's) at 0900 and 1300 (1 pm) on 5/12/22 and 5/19/22 and 1700 (5 pm) on 5/15/22, Tylenol Extra Strength Tablet 500 mg was not signed off at 0900 and 1300 on 5/12/22 and at 1700 on 5/15/22, Lispro Insulin Sliding scale coverage with blood sugar readings were not signed off on 5/12/22, 5/14/22 and 5/19/22 at 0800 (8 am) and 1100 (11 am), and on 5/15/22 at 1800 (6 pm) and 2100, Famotidine 20 mg every 48 hours (for heartburn/acid reducer) on 5/19/22. Nepro Supplement 1 can with meals for poor appetite was not signed off as completed at 0730 (7:30 am) and 1230 (12:30 pm) on 5/12/22, 5/14/22, 5/19/22 and at 1700 on 5/15/22. Nepro Supplement three times a day for dialysis was not signed off at 0900 and 1300 on 5/19/22. The resident's weight assessment was not documented as completed on 5/14/22 day shift COVID-19 evaluation: Vital signs were not documented and signed off on day shift 5/9/22, 5/12/22, 5/14/22, 5/19/22, and evening shift on 5/15/22. COVID-19 symptom checks were not documented and signed off on day shift 5/12/22, 5/14/22, 5/19/22, and evening shift on 5/15/22. Vital Signs checks were not signed off on day shift 5/12/22, 5/14/22, 5/19/22; evening shift 5/7/22 and 5/15/22; and night shift 5/18/22 and 5/22/22. On 5/12/22, 5/14/22, 5/19/22 and 5/20/22, the TAR was not signed off to indicate that the resident's sacral wound treatment was performed as ordered on day shift. Urinary Catheter care, checking the resident's dialysis access site and turning and positioning of the resident every 2 hours were not signed off as completed by staff on day shift 5/12/22 and 5/19/22; on evening shift on 5/7/22; and on night shift 5/18/22. Resident #233's Plan of Care was reviewed. The plan included that staff would monitor for signs and symptoms of hyper/hypoglycemia and blood sugar as ordered, turn, and reposition every 2 hours and as needed, administer treatments as ordered, nutritional supplementation as ordered to promote wound healing, administer medication as ordered, Foley (urinary) catheter care as ordered, provide, and serve supplements as ordered, weekly weights x 4, then per facility protocol. The Director of Nursing was made aware and confirmed these findings during an interview on 8/23/22 at 11:01 AM. She did not provide any additional information. Based on medical record review, review of complaints and interviews, it was determined that the facility failed to ensure that staff were able to access an interim supply of medications prior to the pharmacy's delivery of a resident's medication; failed to ensure that pain medication was administered according to the ordered parameters, failed to ensure that medication was administered as ordered; failed to ensure there were orders and a care plan to address the continued use of an indwelling urinary catheter, failed to provide care in accordance with standards of nursing practice by failing to follow physician orders, failed to reveal documentation to indicate that staff had attempted to obtain a urine sample, and failed to have an effective system in place to relay recommendations from consultations. This was found to be evident for 7 (Resident #193, #192, #197, #201, #202, #233, #21) out of 79 residents reviewed during the investigation stage of the survey. The findings include: 1) Review of Resident #193's medical record revealed that the resident was admitted to the facility for rehabilitation in April 2021 after a hospitalization for a hip replacement. The resident also had diagnoses that were not limited to, high blood pressure, osteoarthritis and anemia. Review of a physician progress note, with an effective date of 4/10/22, revealed that the resident had decreased range of motion of the left hip secondary to pain and that the resident was on oxycodone and Tylenol for pain. This note also revealed that the resident was on Coumadin for anticoagulation, as well as Norvasc and metoprolol for hypertension. Review of a progress note with an effective date of 4/10/21 at 3:42 PM, revealed the following: Resident received in the unit at 1210 .Report given to incoming nurse to follow up with doctors notification and complete admission. Further review of the progress notes revealed documentation to indicate the resident's medication orders had been entered into the electronic health record by 6:30 PM. On 8/16/22 at 8:17 AM, the Director of Nursing provided a list of house stock medications. House Stock refers to over the counter items that a facility keeps on hand to use as needed. Review of this list revealed acetaminophen tablets; Senna tablets, bisacodyl tables, and famotidine tablets. a) There was a physician order, dated 4/10/21, to give three 325 mg acetaminophen (Tylenol) tablets by mouth three times a day. Review of the medication administration record (MAR) revealed the acetaminophen was scheduled to be given at 6:00 AM, 12 noon and 8:00 PM, however the first dose was not scheduled to be given until 4/11/21. Further review of the MAR failed to reveal documentation to indicate the acetaminophen was administered when due on 4/11/21 at 12 noon. No documentation was found as to why the Tylenol order was entered to start the day after admission or why the medication was not administered when due at noon on the second day of admission. b) There was a physician order, with a start date of 4/11/21, to give two 8.6 mg Senna tablets by mouth in the morning for bowel regimen. Further review of the MAR failed to reveal documentation to indicate this medication was administered as ordered on 4/11/21. No documentation was found to indicate why the dose was not administered as ordered on 4/11/21. c) There was a physician order, with a start date of 4/10/21, to give one 5 mg bisacodyl tablet by mouth at bedtime for bowel regimen. Further review of the MAR failed to reveal documentation to indicate this medication was administered as order on 4/10 or 4/11/21. No documentation was found to indicate why the two doses were not administered when due. d) There was a physician order, ith a start date of 4/10/21, to give one 40 mg famotidine tablet by mouth at bedtime for gastroesophogeal reflux disease (GERD). Further review of the MAR failed to reveal documentation to indicate this medication was administered as order on 4/11/21, however it was documented as administered on 4/10. No documentation was found to indicate why the dose not administered when due on 4/11/21. On 8/16/22, the Director of Nursing (DON) also provided a list of medications kept available in the Pyxis machine. The Pyxis is a machine kept at the facility that stores a limited amount of a variety of prescription medications. Staff are able to access specific medications from the Pyxis so the medication can be administered prior to the pharmacy delivering the resident's specific medications. The following medications were found on the list of medications available in the Pyxis machine: amlodipine; methocarbamol, metoprolol ER, and warfarin. e) There was a physician order, with a start date of 4/10/21, to give one 10 mg amlodipine by mouth at bedtime for hypertension (high blood pressure). Amlodipine is the generic name for Norvasc. Further review of the MAR failed to reveal documentation to indicate this medication was administered as ordered on 4/10/22 or 4/11/21. No documentation was found to indicate why the two doses were not administered when due. f) There was a physician order, with a start date of 4/11/21, to give one 500 mg Methocarbamol Tablet by mouth three times a day for spasm. Further review of the MAR failed to reveal documentation to indicate this medication was administered as ordered on 4/11/21. No documentation was found to indicate why the three doses of Methocarbamol were not administered when due on 4/11/21 at 9:00 AM, 1:00 PM or 5:00 PM. g) There was a physician order, with a start date of 4/11/21, to give one one 50 mg Metoprolol Extended Release tablet by mouth one time per day for hypertension. Further review of the MAR failed to reveal documentation to indicate this medication was administered as ordered on 4/11/21. No documentation was found to indicate why the dose was not administered as ordered on 4/11/21. h) There was a physician order, with a start date of 4/10/21, to give one 5 mg warfarin tablet at bedtime. Warfarin is the generic name of Coumadin, an anticoagulant medication. Anticoagulant medication is used to help prevent the formation of blood clots that can cause heart attacks, stokes or pulmonary embolisms (blood clot in the lungs). Further review of the medical record failed to reveal documentation to indicate this medication was administered as ordered on either 4/10 or 4/11/21. No documentation was found to indicate why the dose was not administered as ordered on 4/11/21. On 8/16/22 at 3:02 PM, the surveyor reviewed the concern that several medications that were available in either the Pyxis or the house stock were not administered to the resident on the first few days of the admission. The concern regarding failure to access interim medications was also reviewed with the DON on 8/17/22. Cross reference to F 760 As of time of exit on 8/23/22 at 3:00 PM, no additional documentation was provided regarding this concern. 2) Further review of Resident #193's medical record revealed an order with a start date of 4/12/21 for 2 tablets of oxycodone 5 mg every 4 hours as needed for pain level 7-10. Oxycodone is a narcotic pain medications. Narcotic pain medications are potent and effective at managing moderate to severe pain but have significant side effects and the potential for abuse. As a result, facilities are required to track the medication carefully and be able to reconcile administered doses with evidence of that medication's dispensation. The Controlled Substance Record includes information as to when the supply of the narcotic was received, and the total number of doses received. There are spaces for nursing staff to document the date and time a dose was removed, the amount on hand, the amount given (removed) and the amount remaining. There is also an area for the nursing staff who removed the narcotic to sign their name. Review of the Medication Administration Record (MAR) revealed areas for nursing staff to document the resident's reported pain level at the time of the prn oxycodone administration. Further review of the MARs revealed that on the following occasions the resident had pain at a level between 7-10 but was administered one 5 mg oxycodone rather than the two that were ordered: On 4/21 at 1:42 AM pain was documented as a level 8; review of corresponding Controlled Substance Record confirms only one oxycodone was removed from the supply. On 4/22 at 12:44 AM, pain was documented as a level 7; review of corresponding Controlled Substance Record confirms only one oxycodone was removed from the supply. On 8/17/22 at approximately 3:40 PM surveyor reviewed with the Director of Nursing the concern regarding the failure to ensure oxycodone was administered according to the ordered parameters. As of time of exit on 8/23/22 at 3:00 PM no additional documentation was provided regarding these concerns. 3) On 8/12/22 review of Resident #197's medical record revealed the resident was originally admitted to the facility in 2020. The resident's diagnosis included but not limited to liver disease, end stage kidney disease with a dependance on renal (kidney) dialysis, diabetes and heart disease. Further review of the medical record revealed an order, in effect from 12/23/2020 thru 1/16/21, for Lactulose three times a day for encephalopathy. Encephalopathy is a term used for any diffuse disease of the brain that alters brain function or structure. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. Lactulose can be used in preventing and treating clinical encephalopathy. Its chief mechanism of action is by decreasing the intestinal production and absorption of ammonia. Review of a complaint revealed a report that the resident was not receiving the lactulose as ordered. Review of the Medication Administration Record (MAR) for December 2020 revealed documentation of 22 when due on 12/24/20 at 1:00 PM. Review of the Chart Codes on the MAR revealed a 22 that indicated the drug/treatment was not administered. No documentation was found as to why this dose was not administered or that the resident had refused the dose. Review of the MAR for January 2021 revealed the medication was not administered (as indicated by a 22) when due on 1/2 at 1:00 PM, 1/6 at 5:00 PM and 1/14 at 1:00 PM. No documentation was found as to why these doses were not administered or that the resident had refused on these three occasions. Review of the progress notes revealed that on 1/16/21 at 4:57 PM the physician was made aware of an elevated ammonia level and ordered an increase in the lactulose to 4 times a day. Further review of the medical record revealed the order for the Lactulose was changed from three times a day to four times a day on 1/16/22. The four times a day frequency remained in effect until the resident was discharged in February. Further review of the January MAR revealed staff documented 6 when the Lactulose was due on 1/16 at 5:00 PM and 9:00 PM and on 1/17 at 9:00 PM. Review of the Chart Codes on the MAR revealed a 6 indicates the resident was hospitalized at the time the medication was due to be administered. Further review of the medical record failed to reveal documentation to indicate the resident was at the hospital on either 1/16 or 1/17/21. Further review of the January MAR failed to reveal documentation to indicate the lactulose was administered when due on 1/21/21 at 9:00 AM or 12:00 Noon. The concern regarding the failure to administer the lactulose as ordered on multiple occasions was reviewed with the Director of Nursing on 8/17/22 at 3:37 PM. As of time of survey exit on 8/23/22 at 3:00 PM, no additional documentation was provided regarding this concern. 4) Review of Resident #202's medical record on 8/22/22 revealed the resident was admitted to the facility in February 2022 with diagnoses that included, but were not limited to, multiple sclerosis and osteoarthritis. a) Review of the Medication Administration Record for February 2022 revealed the following were scheduled to be administered at 9:00 AM on the morning of 2/25/22: Enoxaparin injection for the prevention of deep vein thrombosis (blood clot); Gentle Iron Capsule for supplement; Budesonide Suspension inhale orally via nebulizer for wheezing and Formoterol Fumarate Solution inhale orally via nebulizer for asthma. Further review of the MAR failed to reveal documentation to indicate that these four medications were administered to the resident when due on the morning of 2/25/22. b) Review of Chart Codes for the administration records revealed that a check is documented when the medication is admininstered. The Chart Codes revealed several numbers that can be used to document why a medication was not given, including a 6 which indicates the resident was hospitalized . Further review of the February MAR revealed the nurse did not administer the evening medications when due on the evenings of 2/26 and 2/27 as evidenced by documentation of a 6 in the box to document administration. Further review of the medical record failed to reveal other documentation to indicate the resident was in the hospital, or otherwise not available on the evenings of 2/26 and 2/27. The medications that were not administered on the evening of 2/26 and 2/27 include: Sertraline (an antidepressant medication); Formoterol Fumarate Solution inhale orally via nebulizer for asthma; Gabapentin (an anticonvulsant medication) given for neuropathy (weakness, numbness, or pain from nerve damage); Pravastatin for high cholesterol; and Risperidone (an antipsychotic medication) for psychosis with hallucinations Budesonide Suspension (a steroid medication) ordered to be inhaled orally via nebulizer for wheezing was documented as not administered on the evening of 2/26, but was documented as administered on the evening of 2/27. c) Further review of the February MAR revealed that the Risperidone was originally ordered on 2/18/22, but staff documented NA when due on 2/20, 2/22 and 2/23. Further review of the Chart Codes revealed that NA indicates: No Intervention Noted. Further review of the record revealed a note related to the dose not administered on 2/22/22, that revealed the pharmacy required a clarification order sheet for approval prior to delivery. Review of the list of medications available in the Pyxis machine revealed that Risperidone was available at the facility. On 8/22/22 at 3:58 PM, surveyor reviewed the concerns with the Director of Nursing regarding the failure to ensure that medications were administered as ordered on the morning of 2/25, staff documentation that medications were not administered on 2/26 and 2/27 due to the resident being hospitalized when there was not documentation found to indicate the resident was hospitalized on those dates, and failure to provide the Risperidone due to its unavailablilty from the pharmacy. As of time of exit on 8/23/22 at 3:00 PM, no additional documentation was provided regarding these concerns. 5) Review of Resident #192's medical record revealed that the resident was admitted to the facility in January 2021. Review of a 1/13/21 physician progress note revealed the resident had an indwelling urinary catheter (known as a foley). Review of the Minimum Data Set (MDS) assessments with reference dates of 1/13/21 and 2/18/21, Section H Bladder and Bowel, both reveal documentation that the resident had an indwelling catheter. Review of the handwritten physician orders revealed an order, dated 1/27/21, to obtain a urine specimen for a urinalysis and to change the foley. Further review of the medical record revealed an order, with an initial start date of 1/15/21 to make a follow-up appointment with urology for a follow up cystogram (an imaging test of the bladder) and foley removal. Review of the Treatment Administration Record revealed staff signed off on this order daily from 1/18/21 thru 2/5/21. The resident was seen by the urologist on 2/10/21. Review of the Report of Consultation for the 2/10/21 visit revealed the foley catheter needed to remain in place and if it stopped draining then it should be exchanged immediately. Further review of the medical record failed to reveal physician orders for the care of the indwelling urinary catheter. No documentation was found to indicate that regular care of the foley was being completed by nursing staff. On 8/17/22 at 3:30 PM, surveyor reviewed the concern with the Director of Nursing regarding the failure to have orders for the use or care of the foley catheter. On 8/19/22, review of the 1/13/21 MDS Care Area Assessment (CAA) Triggers Summary report revealed documentation that the indwelling urinary catheter was triggered and addressed in the care plan. However, review of the care plan that was established during the resident's stay failed to reveal documentation regarding the urinary foley catheter. This issue was addressed with the MDS nurse #20 on 8/19/22 at 3:09 PM. The MDS nurse #20 reported the unit managers have been told to care plan for each triggered item. As of time of exit on 8/23/22 at 3:00 PM, no additional documentation was provided regarding the failure to have orders or a care plan to address the use of an indwelling foley catheter for this resident.

Based on medical record review, interview and observation, it was determined that the facility failed to ensure tha wound treatments were completed as ordered and failed to ensure orders for treatment were included in the medical record. This was found to be evident for 1 (Resident #24) out of 5 residents reviewed for pressure ulcers. The findings include: On 8/2/22, review of Resident #24's medical record revealed the resident had wounds to the right foot with orders for daily dressing changes. On 8/04/22 at 1:20 PM, surveyor observed nurse #65 prepare for and complete Resident #24's dressing changes. While preparing for the dressing change, surveyor observed nurse #65 obtain supplies which included: one pad of calcium alginate silver; one pad calcium alginate plain and one honey coated absorbent dressing. Surveyor observed the nurse remove the old dressings and then proceeded to clean three wounds: one on the ankle, one on the lateral (outer) side of the foot and one on the medial (inner) side of the foot. The nurse proceeded to apply the silver alginate dressing to the ankle wound; the honey coated dressing to the lateral (outer) wound and the calcium alginate to the medial (inner) wound. The nurse also applied Betadine to the resident's toes, heel and area above the ankle. Betadine (povidone iodine) is an antispetic used for skin disinfection. On 8/04/22, after the observation, further review of the medical record revealed wound care orders that did not correspond to the observation. These, orders in effect since 7/31/22, were to apply med honey (honey coated dressing) and calcium alginate to the lateral (outer) wound; and to apply med honey to the medial (inner) wound. Additionally, no order was found for the use of the Betadine to the area above the resident's ankle. This concern was reviewed with the Admnistrator on 8/4/22 at 3:00 PM. On 8/4/22 at 3:40, nurse #65 reported that the nurse practitioner told them to use the Betadine on the leg above the ankle to keep it dry, but confirmed that there was no order in the record for that specific area. After reviewing the concern regarding what was ordered for the wounds and what was observed, the nurse reported she mixed up the treatments. Surveyor then reviewed that there were orders for med honey for both the lateral and medical foot wounds and was used on only one of them. On 8/11/22, further review of the medical record revealed an order, with a start date of 8/5/22, to apply Betadine to the lower leg and monitor the site daily. As of time of survey exit on 8/23/22, no additional information was provided regarding these concerns.

3) On 7/27/22 at 10:02 AM, Resident #33 was observed in sitting in a wheelchair without leg or footrests and the resident's feet did not touch the floor. Multiple surveyor observations during the survey, revealed the resident in the wheelchair without foot support, causing the resident to dangle his/her feet and the resident's feet could not touch the floor. On 8/10/22 at 2:00 PM, a review of Resident #33's medical record revealed the resident resided in the facility since 2013 and was dependent on staff for ADLs (activities of daily living). Review of Resident #287's most recent assessment with at reference date of 5/14/22 documented Resident #287 had severe cognitive impairment, was dependent on staff for activities of daily living, and required a wheelchair for mobility. On 8/11/22 at 12:55 PM, Staff #23, LPN, Unit Manager, was made aware of the multiple surveyor observation of Resident #33 sitting in a wheelchair without leg or footrests and the concern with Resident #33's inability to place feet on the floor while sitting in the wheelchair. At that time, along with Staff #23, Resident #33 was observed in the dining area, sitting in a wheelchair with no leg or footrests. The resident's feet were dangling with his/her toes pointed downward and the resident's feet did not touch the ground. At that time, Staff #23 stated he/she would expect Resident #33 to have leg and footrests on his/her wheelchair and knew of no reason why they were not on the wheelchair. Staff #23 then requested Staff #24, LPN to retrieve the wheelchair's footrests from the Resident #33's room. Staff #24 obtained the footrests and applied them to the resident's chair. Based on medical record review and interviews, it was determined that the facility failed to have an effective system in place to ensure that restorative nursing services were encorporated into residents' care plans and provided by staff as recommended upon discharge from therapy; failed to ensure for therapy evaluations were acted upon and care plans were updated to reflect current goals and interventions, and failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion by failing to ensure that a resident's feet were supported when sitting in a wheelchair. This was found to be evident for 2 (Resident # 26, #33) out of 10 residents reviewed for activities of daily living (ADL) and 1 (Resident #48) out of 6 residents reviewed for mobility/positioning. The findings include: 1) Review of Resident #26's medical record revealed that the resident had severely impaired cognitive skills, required extensive assist for bed mobility and total dependence on staff for transfers and bathing. On 7/25/22 at 2:37 PM, review of the medical record revealed an order, dated 3/1/22, for OT [occupational therapy] clarification: OT recertification: tx [treat] 3x/week for 2 weeks then plan to discharge to RNP [restorative nursing program]; and an order dated 3/2/22, for PT [physical therapy] Clarification: PT recertification: tx 3x/week for 2 weeks then plan to discharge to RNP. Further review of the medical record, including the resident's current care plan, failed to reveal documentation to indicate a restorative nursing program was established for the resident. On 8/2/22, review of the OT discharge summary, signed by OT (#16) on 3/24/22, revealed the resident received services from 1/28/22 - 3/16/22. The reason for discharge from OT was Maximum Potential Achieved, referred for RNP. The Discharge Recommendations included FMP (functional maintenace program /RNP and 24 hour care, however in the section of the discharge recommendations specific for both Restorative Program Established/Trained and Functional Maintenance Program Established/Trained, the OT documented Not Indicated at This Time. On 8/02/22 at 9:25 AM, the Acting Rehabilitation Director (#33) who confirmed that the therapy discharge instructions included recommendations for functional maintenance program (FMP)/RNP. She went on to report that the plans included ROM (range of motion) for both upper and lower extremities. In regard to implementation, the Acting Rehab Director reported that therapy would train the nursing staff and after discharge nursing would follow through. On 8/02/22 at 12:47 PM, the unit nurse manager (#4) reported that the therapist usually put the RNP into the care plan and then the interventions will go to tasks. Tasks is the section of the electronic health record that the geriatric nursing assistants have access to that includes specific instructions for each resident. After reviewing the tasks section of the electronic health record, the unit nurse manager confirmed that the range of motion instructions had not been included. On 8/3/22 at 11:19 AM, OT #16 reported that she can put in orders for FMP/RNP interventions like passive range of motion in the electronic health record system. Surveyor reviewed the concern that there was no documentation as to what the FMP/RNP recommendations were or that one was implemented. OT acknowledged issues with communication with nursing. On 8/03/22 at 3:17 PM, surveyor reviewed with Administrator the concern regarding the failure to ensure that the FMP/RNPs recommended by therapy, and included in the physician order, were implemented. The Administrator acknowledged the concern and indicated she would establish a communication form. 2) Review of Resident #48's medical record revealed the resident had resided at the facility for several years. The resident has had several re-hospitalizations since initial admission. Review of the 6/2/22 Minimum Data Set assessment revealed the resident requires extensive assistance for bed mobility, transfers, locomotion and dressing. The resident also has an impairment in range of motion on one side for both upper and lower extremities. On 7/27/22 at 10:00 AM, the resident reported that they used to go to an outside provider for therapy and that she/he has lost some of his abilities since the start of the pandemic. a) On 8/4/22, further review of the medical record revealed that, prior to a hospitalization in June of 2020, Resident #48 had a care plan addressing limited physical mobility that included a goal of The resident will increase level of mobility by ambulating 300 ft with no assistive device and modified independence by the next review date. Interventions listed as cancelled or resolved in the June 2020 version of the care plan included Restorative Program involving Active ROM (range of motion) and a Walking program. Further review of the medical record revealed a 6/15/20 care plan note stating: Mobility remains via w/c. The resident is able to propel [him/herself] slowly. [S/He] participates in RESTORATIVE PROGRAM AROM [active range of motion] to be completed to fingers, wrists, elbows, shoulders, hips, knees, ankles and toes through full available ROM with verbal instruction for10 repetitions, 2 times per day. No documentation was found to indicate when or why the Restorative Program AROM had been cancelled from the care plan. Further review of the medical record revealed documentation to indicate that Resident #48 stopped participating in the walking program in 2018. The current version of the care plan, initiated in December 2021, included the same goal of ambulating 300 ft with no assistive device . but no restorative program interventions were not found on the current care plan or interventions that would facilitate the goal of ambulating with no assistive device. On 8/10/22 at 12:24 PM, the surveyor reviewed with Administrator the concern that the care plan goal, with a target date of 8/17/22, was for Resident #48 to walk 300 ft with no assistive device but that goal did not reflect the resident's current status or interventions. The Administrator reported that she had spoken with the unit manager about the care plan. b) Further review of the medical record revealed PT and OT evaluations with plans to treat were initiated in November 2021, but resident was discharged after the initial evaluation due to hospitalization. Further review of the mobility care plan revealed an intervention of PT and OT referrals as ordered, initiated 12/21/21. Review of the physician orders revealed an order dated 3/23/22 for PT, OT, ST [speech therapy] and PMR [physical medicine and rehab] evaluation and treat. Further review of the medical record failed to reveal documentation to indicate that evaluations had been completed by PT, OT, ST or PMR while the order was in effect from 3/23/22 until the order was put on hold on 4/16/22 and discontinued on 4/18/22. These April dates correspond to another hospitalization. On 8/10/22 at 12:24 PM, surveyor reviewed with Administrator that no documentation was found to indicate that the March order for therapy evaluations was implemented. On 8/11/22 at 9:08 AM, the Director of Rehab #34 reported that if there is an order for an evaluation that it should be completed, or if there are extenuating circumstances, it should be documented in the electronic health record with a plan to complete the evaluation or request an order to discontinue. On 8/23/22 at 10:42 AM surveyor reviewed with the Director of Nursing the concern regarding failure to ensure that Resident #48's therapy evaluations were completed when ordered in March and a failure to update the care plan to reflect the resident's current status.

Review of Resident #188's medical record revealed an admission for rehabilitation following a brief hospitalization. The resident's diagnosis included but not limited to limited to abnormalities in gait and bed mobility. On 7/28/22 at 3:00 PM Resident # 188 was observed lying on the bed. The grab bar was observed on the right side of the bed. Review of Safety/Assistive Device Evaluations dated 7/14/22 and 7/31/22 revealed documentation that the resident did not use rails or grab bars for bed mobility or to get in and out of the bed independently. Further review of these evaluations revealed documentation that the resident did not request a grab bar. During an Interview with Unit Nurse Manager (#4) on 08/03/22 at 12:48 PM she stated that Resident # 188 had a grab bar. Surveyor conducted an observation of Residents #188's room at 12:56 PM with the Unit Nurse Manager and noted the resident had a grab bar on the right side of the bed. On 08/04/22 at 9:20 AM an interview was conducted with the Administrator and the Regional Director of Physical Therapy (#36). The Regional Director of Physical Therapy stated that a physical therapy evaluation is completed prior to installing the bed rails, to determine the appropriateness of the bed rails. And education and training are provided to the resident once the bed rails are installed. Surveyor requested documentation regarding the evaluation and training for the grab bar for Resident #188 from both the Administrator and the Regional Director of Physical therapy. As of the time of survey exit, on 8/23/22, no documentation was provided to the survey team to indicate an evaluation or education regarding the risks and benefits of the grab bar were completed prior to the installation of the grab bars on the resident's bed. Based on observation, record review and interviews, it was determined that the facility failed to have an effective system in place to ensure assessment of residents for the use of side rails, and that the resident and or the responsible representative were educated regarding the risks and benefits prior to the installation of side rails, and failed to ensure the mattress appropriately fit the bed in which side rails were being used. This was found to be evident for 2 (Resident #26 and # 188) out of 7 residents reviewed for accidents. Bed rails (also known as side rails) and grab bars are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes. Some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. All bed rails should be used with caution, especially with older adults and people with altered mental status, physical limitations, and certain medical conditions. The findings include: Review of Resident #26's medical record revealed the resident has severely impaired cognitive skills, required extensive assist for bed mobility and total dependence on staff for transfers and bathing. The resident also had a seizure disorder. On 7/27/22 at 11:35 AM, surveyor observed the resident in bed with quarter side rails up on either side of the bed. On 7/28/22 at 1:27 PM, review of the medical record revealed Safety/Assistive Device Evaluations which were completed by nursing staff. The section of these evaluations for Recommendation for Safety/Assistive Device Needs revealed several choices including: none, grab bars, quarter siderails, half siderails and perimeter mattress. A Safety/Assistive Device Evaluation dated 7/13/22 Safety/Assistive Device Evaluation revealed a recommendation of None. Review of the physician orders did reveal a current order, dated 7/13/22, for the quarter side rails. On 7/28/22 at 2:12 PM surveyor observed Resident #26 with nurse #14, who was assigned to care for her at that time. Nurse confirmed the observation of quarter side rails being in the up position on both sides of the bed. The nurse reported the resident had the side rails due to seizures. In addition to the side rails the nurse and surveyor observed that there was approximately 3 inches between the mattress and the side rail and this was evident on both sides of the bed. The nurse reported the resident had previously had an air mattress which was larger than the current mattress. On 7/28/22 at 2:20 PM when asked about side rails, the unit nurse manager #4 reported that they have therapy do an assessment. Surveyor then reviewed the concern that the most recent safety assessment revealed no device was indicated, and there is about a 3 inch gap on either side between the mattress and the side rail. On 7/28/22 at approximately 2:45 PM surveyor reviewed the concern with the Director of Nursing regarding potential entrapement risk based on the 3 inch gap between the mattress and the side rails. On 7/28/22 at 3:17 PM the Administrator reported she was aware of surveyor concern about the gap, and that it's already changed out. She also reported she was currently having maintance check all around the buildings. On 7/29/22 at 10:17 AM observation at this time with the DON reveals resident's mattress fits the bed, no side rails on the bed at this time, bed currently in low position with fall mat in place. Further review of the medical record revealed Safety/Assistive Device Evaluation on 1/27/22, 2/2/22, and 2/28/22 all of which indicated None under recommendation for Safety/Assistive Devices (siderails). Review of the orders revealed an order for the quarter side rails was in effect from 4/27/22 until discontinued on 7/12/22. Further review revealed a Safety/Assistive Device Evaluation dated 5/28/22 that included a recommendation for bilateral quarter rails, however, this evaluation was completed a month after the 4/27/22 order. Further review of the medical record failed to reveal documentation to indicate therapy had conducted an evaluation prior to the institution of the quarter side rails. Additionally, no documentation was found to indicate the responsible representative had been educated on the risks and benefits of the use of the side rails prior to them being instituted, and no documentation to indicate informed consent was obtained prior to the installation of the side rails. On 8/17/22 at 4:00 PM surveyor reviewed the concerns with the DON regarding the failure to assess a resident for need and safety prior to implementation of side rails; and failure to educate or inform the responsible representative regarding the risks and benefits prior to implementation of the side rails. As of time of exit on 8/23/22 at 3:00 PM no additional documentation was provided regarding these concerns.

Based on record review and staff interview, it was determined that the facility failed to ensure that Certified Nursing Assistants working during the blanket waivers issued during the COVID - 19 pandemic had been appropriately trained when the waiver ended. This was evident for 2 (Staff #59 and Staff #60) of 2 staff reviewed. The findings include: An interview with Staff #60 on 7/27/22 at 11:11 AM revealed that she was a Certified Nursing Assistant and had not been certified as a Geriatric Nursing Assistant. A review of employee record for Staff #59 on 8/8/22 at 2:45 PM, revealed a Maryland Certification as a Nursing Assistant and not a Geriatric Nursing Assistant. Staff #59 had been hired in March 2020. On 8/8/22 at 3:01 PM, an interview with the Administrator revealed that she thought the waiver for GNA certification had been extended and would bring the guidance to the survey team. A review of the state licensing board revealed that Staff #59 had been a certified as a nursing assistant in 2020, no Geriatric certification had been issued. Staff #60 had been certified as a nursing assistant since 2018. The Administrator provided a company email that stated that the Centers for Medicare and Medicaid (CMS) Waiver [Blanket Waivers] ended on 6/6/22. The TNAs [undefined abbreviation] have 120 days to become certified so October 6, 2022 is the last date TNAs will be allowed to work. Further stated that this was confirmed by the state licensing board. However, further review conducted off-site on 8/24/22, revealed a CMS memo QSO-22-15-NH & NLTC & LSC releases on 4/7/22 and stated that Emergency Declaration Blanket Waivers for Various Provider-Types Ending 60 Days from Publication of this Memorandum: which means the waiver for nurse aide training ended on 6/7/22. The following was included regarding the nurse aide training waiver: We are aware that there may be instances where the volume of aides that must complete a state approved NATCEP exceed the available capacity for enrollees in a training program or taking the exam. This may cause delays in in nurse aides becoming certified. If a facility or nurse aide has documentation that demonstrates their attempts to complete their training and testing (e.g., timely contacts to state officials, multiple attempts to enroll in a program or test), a waiver of these requirements (42 CFR §483.35(d)) is still available and the aide may continue to work in the facility while continuing to attempt to become certified as soon as possible. However, for all other situations, this waiver is terminated. When capacity issues exist, facilities should inform their state officials of the issue. State agencies should also verify the capacity issues that are reported. On 8/25/22, via a phone call the Director of Nursing was made aware of the fact that the waiver had ended on 6/9/22, and the facility needed to provide evidence that staff were in a class and/or attempting to become certified. She verbalized that the Human Resource person was not available and that she would provide information to the surveyor on Monday, 8/29/22, or Tuesday, 8/30/22 and had not provided it to this date.

Based on review of medical records and interviews, it was determined that the facility failed to ensure that narcotics removed from the resident's supply were administered to the resident as evidenced by staff documenting the removal of narcotics without documentation of the need for the narcotic or documentation that the narcotic was administered to the resident. This was found to be evident for 1 (Resident #193) out of 5 residents reviewed during the survey. The findings include: Review of Resident #193's medical record revealed the resident was admitted to the facility for rehabilitation in April 2021 after a hospitalization for a hip replacement. The resident also had diagnoses of, but not limited to, high blood pressure, and osteoarthritis. Review of a physician progress note, with an effective date of 4/10/22, revealed the resident had decreased range of motion of the left hip secondary to pain and that the resident was on oxycodone and Tylenol for pain. Oxycodone is a narcotic pain medications. Narcotic pain medications are potent and effective at managing moderate to severe pain but have significant side effects and the potential for abuse. As a result, facilities are required to track the medication carefully and be able to reconcile administered doses with evidence of that medication's dispensation. The Controlled Substance Record includes information as to when the supply of the narcotic was received, and the total number of doses received. There are spaces for nursing staff to document the date and time a dose was removed, the amount on hand, the amount given (removed) and the amount remaining. There is also an area for the nursing staff who removed the narcotic to sign their name. Review of the Medication Administration Record (MAR) revealed areas for nursing staff to document the resident's reported pain level at the time of the prn oxycodone administration. Review of the Controlled Substance Record for oxycodone 5 mg tablets revealed a 10 mg dose (two 5 mg oxycondone) were removed from the supply on 4/30/21 at 6:00 AM, 5:40 PM, and 10 PM. Review of the MAR and the progress notes failed to reveal documentation to indicate the resident requested, required or received these three doses. Review of the Controlled Substance Record for the oxycodone 5 mg tablets revealed five 10 mg doses (two 5 mg oxycodone per dose) were removed between 5/1/21 at 12 noon and 5/2/21 at 7:00 PM. Review of the MAR failed to reveal documentation to indicate the resident received these five doses of oxycodone. Review of the progress notes also failed to reveal documentation to indicate the resident received these five doses. Further review of the Controlled Substance Record revealed that a 10 mg dose (two 5 mg tablets) was removed from the supply on 5/3/21 at 3:30 AM and again on 5/3/21 at 8:00 PM. Further review of the MAR and the progress notes failed to reveal documentation to indicate the resident received either of these doses. Further review of the Controlled Substance Record revealed a 5 mg dose (one 5 mg tablets) was removed from the supply on 5/5/21 at 10:00 AM. Further review of the MAR and the progress notes failed to reveal documentation to indicate the resident received this dose. Further review of the Controlled Substance Record revealed that a 10 mg dose (two 5 mg tablets) was removed from the supply on 5/6/21 at 6:00 PM, and again on 5/6/21 at 11:30 PM. Further review of the MAR and the progress notes failed to reveal documentation to indicate the resident received either of these doses. On 8/16/22 at 3:02 PM, surveyor reviewed the concern with the Administrator of multiple occassions when the narcotics were being removed from the supply but not being documented as administered to the resident. This concern was addressed with the Director of Nursing on 8/17/22. As of time of exit on 8/23/22 at 3:00 PM, no additional documentation was provided regarding this concern.

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to timely respond and act upon a pharmacist's recommendations when notified of an irregularity,failed to ensure that the attending physician document in the medical record when an irregularity had been reviewed and what, if any action was taken, failed to ensure that the pharmacists findings were included in the resident's medical record or maintained within the facility and readily available for view, and failed to develop and maintain a policy that included the time frames for the physician to respond when notified of an irregularity in a residents monthly drug review. This was evident for 2 (#131, #23) of 6 residents reviewed for Advanced Directives. The findings include: 1) On 8/1/22 at 9:00 AM, a review of Resident #131's medical record revealed in a Consultant Pharmacist Report, dated 5/15/22, that the pharmacist requested the physician evaluate if a Trazodone (antidepressant) dosage reduction could be attempted at that time, which was followed by a handwritten response to f/u (follow-up) with psych handwritten on the form. At the bottom of the form, was a printed checked response Disagree & Reason followed by the handwritten response f/u psych and the form was signed by Staff #5, RN. Further Review of Resident #131's medical record failed to reveal documentation to indicate that the consultant pharmacist's request for the physician to evaluate the resident's trazodone dose had been reviewed by a psychiatric provider and there was no documentation from Resident #131's attending physician to indicate that the physician reviewed the consultant pharmacist's report and any action, if any, had been taken to address it. On 8/03/22 at 01:24 PM, the DON (Director of Nurses) made aware of the above concerns. 2) On 8/3/22, at approximately 2:30 PM, a review of the Consultant Pharmacist Reports list (which identified residents who had a received a monthly medication review) revealed that the pharmacist identified an irregularity with Resident #23's medications and made a recommendation on 1/12/22, 4/13/22 and 7/9/22. At that time, a concurrent review of Resident #23's medical record failed to reveal documentation of the pharmacist's recommendations in the resident's medical record and copies of consultant pharmacist's reports for Resident #131 were requested. On 8/5/22 at 11:41 AM, when asked for the status of the requested consultant pharmacists reports for Resident #23, the NHA indicated the DON was following up on the pharmacist's recommendations. On 8/8/22 at 9:35 AM, the surveyor was provided with a Consultant Pharmacist Report, dated 7/9/22, for Resident #23 that listed pharmacist identified irregularities with Resident #31's medication with the pharmacist's recommendations for the attending physician address, as follows: (1) Is prn (as needed) Lorazepam (Ativan) (anxiolytic) concentrate still needed? If so, suggest order includes a length of therapy up to x90 days (2) Suggest prn Ibuprofen & Morphine orders include the type of pain (i.e. mild/moderate/severe) (3) Please evaluate if Lorazepam dosage reduction could be attempted at this time (4) Is Mirtazapine (Remeron) (antidepressant) (for appetite) and Melatonin (for insomnia) still needed? Below the pharmacist's list of irregularities was an undated, handwritten response [Staff #58, physician] and psych NP (nurse practitioner) made aware, see notes, which was signed by Staff #5, RN. The physician's signature line on the report form was blank. A concurrent review of Resident #23's EMR (electronic medical record) revealed on 8/4/22 at 3:46 PM, Staff #5, RN, in a Health Status Note, indicated that the physician was paged to make him/her aware of concerns identified by the pharmacist in a consultant pharmacist report and the psych NP (Nurse Practitioner) was made aware of the concerns. In the EMR was a late entry psych progress note, with a service date of 7/10/22 and electronically signed on 8/5/22 that documented the Resident #23 was seen for a possible GDR(gradual dose reduction) for Ativan and Mirtazapine and a GDR was not warranted at that time. Also, on 8/5/22 at 11:35 AM, in a health status note, Staff #5 wrote that the physician, Staff #58, did not want to make any changes as Resident #23 was a hospice patient, and per psych NP assessment, GDR was not warranted at this time. Continued review of Resident #23's medical record failed to reveal evidence that the physician reviewed the pharmacist's identification of an irregularity with the resident's prn pain medication and there was no documentation in the medical record to indicate the irregularity had been acted upon. Resident #23 had a 12/14/21 physician order for Ibuprofen 400 mg (milligram) tablet by mouth every 6 hours for pain and a 1/25/22 order for Morphine Sulfate by mouth every 6 hours as needed for pain and SOB (shortness of breath). The orders for the medications, prescribed as needed for pain, failed to include parameters to indicate when to administer which medication first for pain. On 8/9/22 at 9:26 AM, the DON provided the surveyor with a Consultant Pharmacist Report for Resident #23 dated 1/12/22 and a Consultant Pharmacist Report dated 4/13/22 and indicated he/she was looking for the signed copies of the reports. The 1/12/22 pharmacist report, listed the irregularities the pharmacist identified with Resident #23's medication for the physician to review: a) Is Melatonin for insomnia still needed? b) Is Mirtazapine for appetite still needed? c) Ibuprofen suggested for dosing with food. There was no response to the pharmacist's identified irregularities written on the form, and the physician signature line was blank. Continued review of the medical record failed to reveal evidence that the irregularities with Resident #23's medication which were identified by the pharmacist on 1/12/22 were reviewed by the physician or evidence that action had been taken to address them. The 4/13/22 pharmacist report listed the identified irregularities, a) Is prn Lorazepam concentrate still needed? If so, suggest order includes a length of therapy up to x90 days and b) suggest prn Ibuprofen & Morphine orders include the type of pain (i.e mild/moderate/severe). There was no response to the pharmacist's identified irregularities written on the form, and the physician signature line was blank. Continued review of the medical record failed to reveal evidence the irregularities with Resident #23's medication which were identified by the pharmacist on 4/13/22 had been reviewed by the physician or evidence that action had been taken to address them. On 8/10/22 at 9:50 AM, during an interview, the DON stated that the facility's copies of Resident #23's consultant pharmacy reports for 1/12/22 and 4/13/22 could not be found, so he/she called the pharmacist consultant who sent them to the DON. At that time, the DON was made aware of concerns related to failing to ensure that the pharmacist reported irregularities were reported to the attending physician and acted upon timely, failing to ensure the attending physician document when the identified irregularity had been reviewed, and any action taken to address it, and failing to ensure 3) A review of the facility's policy titled Medication Regimen Review revealed that the policy failed to include measurable time frames for the physician to respond to the consulting pharmacists report of an irregularity identified in a resident's MMR (monthly medication review). Under the heading, Policy Interpretation and Implementation, were 17 numbered key elements of the policy. The key elements of the policy included the statement within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physician for each resident identified as having a non-life threatening medication irregularity, and if the If the irregularity represents a risk to a person's life, health, or safety, the consultant pharmacist contacts the physician immediately (within 1 hour) to report the information to the physician verbally and documents the notification,. The policy also included the statement If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director of (if the medical director is the physician of record) the administrator and the attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. Continued review of the facility's MMR policy failed to reveal measurable time frames for the physician to respond to the consulting pharmacists report of an irregularity identified in a resident's MMR.

Based on medical record review and interview, it was determined that the facility failed to ensure that residents were free from excessive medication as evidenced by administration of narcotic pain medication outside of the ordered parameters. This was found to be evident for 1 (Resident #193) out of 5 residents reviewed during the survey. The findings include: 1) Review of Resident #193's medical record revealed the resident was admitted to the facility for rehabilitation in April 2021 after a hospitalization for a hip replacement. The resident also had diagnoses of, but not limited to, high blood pressure, and osteoarthritis. Review of a physician progress note, with an effective date of 4/10/22, revealed the resident had decreased range of motion of the left hip secondary to pain and that the resident was on oxycodone and Tylenol for pain. Oxycodone is a narcotic pain medications. Narcotic pain medications are potent and effective at managing moderate to severe pain but have significant side effects and the potential for abuse. As a result, facilities are required to track the medication carefully and be able to reconcile administered doses with evidence of that medication's dispensation. The Controlled Substance Record includes information as to when the supply of the narcotic was received, and the total number of doses received. There are spaces for nursing staff to document the date and time a dose was removed, the amount on hand, the amount given (removed) and the amount remaining. There is also an area for the nursing staff who removed the narcotic to sign their name. Review of the Medication Administration Record (MAR) revealed areas for nursing staff to document the resident's reported pain level at the time of the prn oxycodone administration. Further review of the medical record revealed an order with a start date of 4/12/21 for 1 tablet of oxycodone 5 mg every 4 hours as needed for pain level 1-4, and a second order for 2 tablets of oxycodone 5 mg every 4 hours as needed for pain level 7-10. Further review of the medical record failed to reveal an order for as needed pain medication for a pain level of 5-6. Further review of the Medication Administration Record (MAR) revealed that on 4/13/22 the resident had pain at a level 2 and was administered two 5 mg oxycodone, rather than the one that was indicated in the order. Further review of the MARs revealed that, on the following occasions, the resident had pain at a level of 5 or 6 and oxycodone was administered despite there being no order for oxycodone for pain at this level: On 4/23 at 10:48 AM, pain was documented as a 6, staff documented administration of one 5 mg oxycodone; review of the corresponding Controlled Substance Record confirms one oxycodone was removed from the supply. On 4/28 at 4:05 AM, pain was documented as a 5, staff documented administration of one 5 mg oxycodone; review of the corresponding Controlled Substance Record confirms one oxycodone was removed from the supply. Further review of the MAR and progress notes revealed that, on 5/3/21 at 9:34 AM, the resident's pain was at a level two and that the nurse administered two 5 mg oxycodones. Review of the Controlled Substance Record revealed corresponding documentation that two 5 mg oxycodone were removed from the supply on 5/3/21. On 8/17/22 at approximately 3:40 PM, surveyor reviewed with the Director of Nursing the concern regarding the failure to have an as needed order for pain on the scale of 5-6 and failure to ensure oxycodone was administered according to the ordered parameters. As of time of exit on 8/23/22 at 3:00 PM, no additional documentation was provided regarding these concerns.

Based on record review and staff interviews, it was determined that the facility failed to assess and document the indications for administering a PRN (as needed) psychotropic medication to a resident. This was evident for 1 Resident (Resident #188) out of 5 residents reviewed regarding unnecessary medication. The findings include: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. On 8/3/2022 at 3:06 PM, review of Resident #133's medical record revealed that the resident was admitted for rehab following a hospitalization with diagnoses including, but not limited to, anxiety disorder. Further review revealed a physician order for Alprazolam tablets .5mg by mouth every 8 hours as needed for anxiety related to adjustment disorder with mixed anxiety and depressed mood. These orders were in effect from 7/19/22-7/28/2022. Alprazolam is an antianxiety medication. On 8/5/22 at 9:12 AM, review of the medication administration Record (MAR), revealed the administration of Alprazolam on 7/19/2022, 7/24/2022, 7/26/2022 and 7/28/2022. Further review of the MAR and progress notes, failed to reveal documentation to indicate the need for the Alprazolam administration on these dates. Additionally, no behavior monitoring orders, or documentation of behavior monitoring was found for this resident. During interview with Director of Nursing (DON) on 8/18/22 at 8:52 AM, she stated that she would expect the nurses to assess and document the behaviors that were exhibited by the patient that would indicate the reason for the administration of an as needed medication. She went on to report the staff would document this information in a behavioral monitoring report. Surveyor then addressed the concern regarding the administration of the psychotropic medication without documentation of the need for the medication.

Based on medication administration observation, medical record review and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 2 (#50, #286) of 6 residents observed with 34 medication administration opportunities resulting in an error rate of 5.88 % by 2 Licensed Practical Nurses. The findings include: 1) ER (extended release) initials that follow the name of the medication means the medication will be released in the blood stream over an extended period. Breaking or crushing the pill form of the medication may cause too much of the medication to be released at one time which could cause serious side effects. EC and ER medications should not be crushed. On 8/11/22 at 9:23 AM, during an observation of medication administration, LPN, Staff #39, was observed dispensing 9 pills into a medication cup for Resident #50. One of the pills was Potassium Chloride ER. Staff #39 was then observed to crush the pills and mix the crushed pills in applesauce for the resident to take by mouth. Staff #39 committed an error while administering the medication to Resident #50 as, the Potassium Chloride ER should not have been crushed. 2) On 8/12/22 at 9:35 AM, during an of medication administration, Staff #38, LPN was observed dispensing 5 pills into a medication cup for Resident #286. One of the pills given to the resident was a Calcium Carbonate Vitamin D 600-400 mg (milligrams)-unit tablet, which was a combination of Calcium 600 mg and Vitamin D 400-units. Following the medication observation, a review of Resident #286's August 2022 MAR (medication administration record) revealed a physician's order for Calcium Carbonate -Vitamin D 600-800 mg-unit which was signed off as given. In the order, the dosage of the Vitamin D (800 units) was different than the dosage of Vitamin D (400 units) that Staff #38 administered to Resident #286. Staff #38 committed a medication error when he/she failed to follow the physician's order. The Director of Nurses was made aware of the medication administration errors on 8/12/22 at 3:45 PM.

2) During an interview with Resident #94 on 7/26/22 at 11:23 AM, he/she reported that staff had not been administering his/her thyroid medication on a regular basis. Resident #94 reported that Licensed Practical Nurse (LPN) #62 was coming to the unit to administer the medication to him/her, since it was being missed by other staff. A medical record review for Resident #94 on 8/5/22 at 8:41 AM revealed a MDS with an ARD of 12/16/21 that documented in section C that Resident #94 had a BIMS of 12:15 which indicated that he/she had no cognitive impairment. A physician's progress note revealed that resident #94 had a diagnosis of hypothyroidism requiring medication management. Review of the physician order summary Resident #94 had an order for levothyroxine Sodium tablet 75 mcg, give 1 tablet by mouth one time a day for hypothyroidism. (This is a medication that needs to be administered before a person eats in the morning to ensure proper absorption and to ensure the person receives the most effectiveness of the medication). Further review revealed the Medication Administration Record (MAR) for 4/22, in which staff had not signed off that the Levothyroxine was given on 4/3/22, 4/10/22, 4/17/22, and 4/20/22. A MAR for 5/22, in which staff had not signed off the medication was given on 5/20/22. A MAR for 7/22, in which staff had not signed off the medication as being administered on 7/6/22 and 7/7/22. The MAR for 8/22 documented staff had not administered the medication on 8/7/22. The findings were reviewed with the Director of Nursing on 8/23/22 at 9:58 AM. Based on medical record review and interview, it was determined the facility failed to ensure that residents were free from significant medication errors as evidenced by the failure to administer an anticoagulant medication on two consecutive days to a resident who recently had surgery, thereby putting the resident at increased risk of developing a blood clot. This was found to be evident for 1 (Resident #193) out of 79 residents reviewed during investigative stage of the survey. Additionally, the facility failed to ensure that residents receive their medications as prescribed as evidenced by staff failing to administer a resident's medication as prescribed. This was found to be true for 1 (Resident #94) out of 79 residents reviewed. The findings include: 1) Review of Resident #193's medical record revealed the resident was admitted to the facility for rehabilitation in April 2021 after a hospitalization for a hip replacement. The resident also had diagnoses of, but not limited to, high blood pressure, osteoarthritis and anemia. Review of a physician progress note, with an effective date of 4/10/22, revealed the resident was on Coumadin for anticoagulation. Coumadin is a brand name of warfarin, an anticoagulant medication. Anticoagulant medication is used to help prevent the formation of blood clots that can cause heart attacks, stokes or pulmonary embolisms (blood clot in the lungs). Recent surgery places a resident at increased risk of the formation of blood clots. Review of a progress note, with an effective date of 4/10/21 at 3:42 PM, revealed: Resident received in the unit at 1210 .Report given to incoming nurse to follow up with doctors notification and complete admission. Further review of the progress notes revealed documentation to indicate that the resident's medication orders had been entered into the electronic health record by 6:30 PM. There was a physician order, with a start date of 4/10/21, to give one 5 mg warfarin tablet at bedtime. Further review of the medical record failed to reveal documentation to indicate this medication was administered as ordered on either 4/10 or 4/11/21. On 8/16/22 at 8:17 AM, the Director of Nursing (DON) provided a list of medications kept available in the Pyxis machine. The Pyxes is a machine kept at the facility that stores a limited amount of a variety of prescription medications. Staff are able to access specific medications from the Pyxis so the medication can be administered prior to the pharmacy delivering the resident's specific medications. Review of the list provided by the DON revealed warfarin is kept in the Pixes. Further review of the medical record failed to reveal documentation to indicate why the doses of warfarin were not administered as ordered on two consecutive days.

Based on observation and staff interview, it was determined the facility staff failed to ensure that all medications and biologicals were stored and labeled properly. This was evident for 1 (#5) of 6 residents reviewed from medication administration and 3 of 4 medication carts reviewed for medication storage during the survey. The findings include: 1) On 8/12/22 at 9:26 AM, during a medication observation, Staff #38, LPN was observed administering medication to Resident #5. Following the medication observation, a review of Resident #5's August 2022 MAR (medication administration record) revealed a physician's order for Flonase Suspension (Fluticasone Propionate) 2 sprays in both nostrils one time a day was signed off as given to Resident #5, on 8/12/22 at 9:00 AM, however, the administration of the Flonase was not observed by the surveyor. On 8/12/22 at approximately 2:30 PM, during an interview, Staff #38 stated he/she had administered the Flonase to Resident #5 prior to the med pass observation, he/she then opened the medication cart to show the surveyor the resident's Flonase, which was not found in the cart. Staff #38 stated maybe he/she had left the Flonase in Resident #5's room, went to the resident's room and returned with the bottle of Flonase which had prescribed for Resident #5. Flonase, a medication prescribed by the physician, should not be left at the resident's bedside 2) On 8/16/22 at 2:00 PM, an observation of Unit 1-West's Medication Cart A revealed On the top of the medication cart was an opened container of blood glucose monitor test strips that were not dated when opened. Inside the medication cart, there was a bottle of Valproic Acid oral solution labeled with Resident #26's name that was not labeled with the date opened. Inside the medication cart was a bottle of Levetiracetam solution, labeled with Resident #26's name that was not labeled with the date opened. The findings were confirmed with Staff #14, LPN on 8/16/22 at 2:33 PM 3) On 8/16/22 at 2:45 PM, an observation 1-East's Medication Cart A revealed: - There was an opened container of Blood glucose monitor test strips that were not dated when opened. - There was an opened bottle of Prednisolone Acetate ophthalmic Suspension, labeled with Resident #14's name, that that was not labeled with the date the bottle was opened - Inside the medication cart, there was an opened bottle of Enulose (Lactulose) Solution, labeled with Resident #5's name, that was not labeled with the date opened. - Inside the medication cart was a bottle of Levetiracetam solution, labeled with Resident #113's name, that was not labeled with the date opened. The concerns were discussed with 1-East's Unit Manager, Staff #37, RN on 8/16/22 at 3:06 PM. 4) On 8/16/22 at 4:00 PM, an observation of 2-West's Medication Cart B revealed: - There was an opened container of blood glucose monitor test strips on the medication cart that were not dated when opened. - Inside the medication cart there was a Lantus Solostar 100 unit ml insulin pen labeled with Resident #14's name. Per the manufacturer, Sanofi, Lantus should be stored in the ref refrigerator (36°F to 46°F) when unopened and unopened Lantus SoloStar pens should aways be store in the refrigerator. On 8/16/22 at 4:40 PM, Staff # 43, LPN was made aware of the above findings.

Based on observation and interview, it was determined that the facility failed to ensure that clean dishes were stored in a manner to prevent contamination. This practice has the potential to affect all residents who consume food provided by the facility kitchen. The findings include: On 7/25/22 at 8:28 AM, surveyor observed several bins containing bowls. The bins were open with no cover. Several of the bowls inside the bins were open side up with visible water pooling in the bottom of the bowl. The kitchen staff (staff # 51) identified these as clean bowls. He was alerted to the water at the bottom of the bowls. He removed the bowls that contained water. He stated that the clean dish bin should not be this close to washing area. He then closed the lid to the bin. The practice of storing dishes prior to being completely air dried is known as wet nesting. Wet nesting creates conditions in which microorganisms can grow. During an Interview with Kitchen staff #51 on 7/25/22 at 8:30 AM, he stated that the dishes are dried in the dishwasher. The dried dishes are stored in the clean area with a lid on the bin. On 8/15/22 at 11:42 PM, a revisit to the kitchen was conducted with the Food Service Director #52. Observation of the clean dish storage area revealed a rack of bowls double stacked with bowls on top of the other. Several of the bowls were visibly wet on the inside of the bowl. The Food service director identified these as clean cups. The Food service director was alerted to the wet bowls. He removed the bowls on the top layer and placed them in an empty rack. Surveyor reviewed the concern that wet dishes had also been identified during the initial kitchen tour.

Based on review of the Quality Assurance and Performance Improvement (QAPI) Program plan and interview with staff, it was determined that the facility failed to develop a facility specific QAPI plan. This deficient practice has the potential to affect all of the residents. The findings include: As part of the initial entrance conference conducted with the Administrator on 7/25/22, a copy of the facility's QAPI plan was requested. A QAPI plan is the written plan containing the process that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improve. The plan should describe how the facility will conduct its required QAPI committee functions. The QAPI plan must describe in detail the scope of the QA committee's responsibilities and activities, and the process addressing how the committee will conduct the activities necessary to identify and correct quality deficiencies. Review of the QAPI Program documentation revealed the following under Implementation: 1. The QAPI Committee oversees implementation of our QAPI Plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI Committee. 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of the process include: o Tracking and measuring performance; o Establishing goals and thresholds for performance measurement; o Identifying and prioritizing quality deficiencies; o Systematically analyzing underlying causes of systemic quality deficiencies; o Developing and implementing corrective action or performance improvement activities; and o Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. 3. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities amd make adjustments to the plan. Further review of the QAPI plan failed to reveal specifics in regard to the process of how the tracking, goal setting, prioritizing, analyzing, developing corrective action and monitoring of corrective action would occur. The plan failed to include a description of how relevant information would be referred to the QAPI committee. According to state regulations, the facility's QA committee is required to develop and implement a plan that includes procedures for concurrent review (monitoring all aspects of resident care), resident complaints, accidents and incidents, and abuse and neglect. Further review of the QAPI plan failed to reveal procedures to evaluate clinical data for residents with a change in condition or description of monitoring other aspects of the residents' care. The plan failed to address the complaint process, the process for reporting accidents and injuries or a process for evaluating abuse and neglect. On 8/23/22 at 11:21 AM, interview with the Quality Coordinator RN #1 revealed she was also the staff educator and the infection preventionist. The Quality Coordinator was unable to verbalize a specific process on how they identify what will be addressed by the QAPI committee, although she did mention at risk meetings, collecting data from all the units, coming up with plans of correction and conducting follow up. When asked for an example of an issue they had identified, developed a plan and conducted follow up on, the Quality Coordinator responded that since she started in March, there were no big big issues that she needed to follow up on. When asked, the Quality Coordinator reported that she had no training specifically related to Quality Assurance, however, she indicated that the Administrator had told her she would be going for training in a little bit. Surveyor reviewed the concern that review of the QAPI plan failed to reveal specifics regarding how data will be collected and addressed with the Quality Coordinator. This was addressed at time of exit on 8/23/22 at 3:00 PM with the Director of Nursing as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined that the facility failed to provide a safe, clean, homelike environment for their residents as evidenced by stains on the walls and ceiling tiles, bathroom vents not clean, cooling unit vents that were dusty and had debris on them, windows were cracked, and window screens had holes in them, failure to provide private closet space in each resident room, and failure to maintain a resident shower room in a safe and hygienic manner. This was found to be evident on 2 out of the 4 nursing units observed during the survey. The findings include: 1) On 7/25/22 at 10:49 AM, a tour of Resident #56's room revealed a brown substance splashed on the wall to the left of the bathroom door that was dried. 2) On 7/25/22 at 11:26 AM, a second tour of Resident #56's room revealed the cooling unit attached to the wall had food and paper in the air vents as well as a build-up of gray substance. The ceiling tiles in the right corner of the room had brown stains on them and inside the bathroom door, there were ceiling tiles that were off the braces and had a brown colored stain on them. The vent in the ceiling of the bathroom had a build-up of a black and gray substance. The door jamb of the bathroom had a black mark that extended upwards from the floor 2 ft. 3) On 07/25/22 at 11:42 AM, in room [ROOM NUMBER] a door was missing from the residents cabinet door. The cabinet was being used as a closet. 4) A tour of Resident #73's room on 7/25/22 at 1:07 PM revealed the cooling unit attached to walls were dusty. The bathroom had a pink substance that had been poured into the toilet that had not been flushed and two drop of the pink substance was on the seat and staff had not cleaned it up. 5) A tour of Resident #80's room on 7/27/22 at 10:27 AM revealed the wall that both beds faced had a bulletin board that was hanging sideways and there were scrapes on the wall. The cooling unit under the window had broken slats where the air vents were located. The window screen had been dislodged and there was a gray substance and debris on the windowsill. In addition, the floor had popcorn and crumbs under and around the resident's bed. The bathroom that was shared by potentially 4 residents had a dried brown substance on the back of toilet near the flush handle on the front of the toilet seat and down the front of the toilet. The toilet paper holder was dissembled and laying on the back of the toilet. An unidentified housekeeping staff was in the room next door and stated she was finished cleaning the bathroom and there was a blue substance in the toilet. 6) On 7/27/22 at 10:49 AM, a tour of Resident #59's room was conducted. The cooling unit was detaching from the wall, the air vents were dirty. The windowsill had a crack measuring 5 inches on the right side. The screen was bent and coming away from the window frame. The windows were dusty and had a spider web in the left corner. There was popcorn and crumbs under and around the resident's bed. Above the bed was a dried light brown substance splashed on the ceiling that was on the metal frame of the privacy curtain runner and on the privacy curtain. The privacy curtain was missing some of the metal hooks. The bathroom toilet paper holder was missing, and a roll of toilet paper was on the back of the toilet. 7) Resident #59 left the faciity on 7/29/22 and a subsequent tour was made on 08/04/22 at 11:11 AM, and the bed was made, but the light brown splatter was still on the ceiling, the privacy curtain runner, and on the privacy curtain. 8) A tour of Resident #113's room revealed a 1 inch by 1 inch hole in the upper right corner of the screen and 3 slits that measured: 3 inches, 1 inch, and 2 inches. The bathroom vent had a buildup of black and gray substance. 9) During a tour of the 2 East unit on 8/2/22 at 3:14 PM, the surveyor observed a door labeled Shower Room. The door was equipped with a coded push key entry lock. The door was ajar, and the lock was not engaged. The door was lodged in its frame and required excessive force for the surveyor to push it open. Inside the shower room, the surveyor observed a patch of spackling approximately 1 foot x 2 feet in area, located on the wall directly behind the handle of the entry door. The patch was not sanded nor painted leaving a porous surface susceptible to moisture and pathogens. 10) The first door on the right of the shower room, revealed a toilet room with a hand sink. The interior door handle was loose. The tile grout across the floor was dark gray. However, around the base of the toilet and along the base of the walls the tile grout was black. 11) A shower stall was located along the same wall just beyond the toilet room door. The handheld shower head was lying on the handrail. There did not appear to be a functioning mounting bracket for the shower head. The metal flange around the water control knob was loose.The shower head was rapidly dripping water. The shower floor and the floor approximately 1 foot beyond the threshold was covered in standing water. 12) A thick fabric shower curtain with a vinyl liner was hanging on a curtain rod, partially open, across the entrance of the shower stall. The bottoms of both curtains were resting in the standing water on the floor. 13) The wall on the right of the shower and just outside of the shower entrance had a long crack. A brown smudge, approximately 4 inches in diameter, was located near the call light activation switch. A brown smear, approximately 4-5 inches long by ½ inch wide, was located on the lower portion of the same wall. Along the corner of the wall, the underlying metal drywall bead was exposed from the floor extending approximately 2 ½ feet up the wall. Several deep gouges and holes were observed in the drywall along this corner. 14) Another shower stall was located opposite the entrance door to the shower room. A strip of wall, approximately 1.5 inches wide from floor to ceiling, was located along the edge of the shower tile on the left side just outside the shower stall. The strip was not painted and appeared to be porous unfinished plaster/spackling. 15) A door located to the left of the 2nd shower stall opened to a room approximately 7 feet x 10 feet. The room contained reusable resident care equipment including, but not limited to, numerous wheelchairs, several bed mattresses including alternating pressure air mattresses, fall mats and wheelchair leg rests and other resident care items. The equipment was piled in a disorganized manner, several feet deep, over the entire floor of the room to the doorway. The floor was not visible. The items were not stored in a clean sanitary manner protected from potential damage. 16) To the left of the storage room, a ceramic tiled wall was missing a triangular piece of tile . A long narrow shower stall to the left of the storage room contained a shower stretcher. Horizontal metal handrails were located along the walls around the entire stall. The metal flange for the second handrail located on the right side of the shower was not affixed to the wall and was located approximately 1 foot from the end of the rail. No cleaning supplies were observed within the shower room. 17) Staff #27, a maintenance assistant, arrived in the Shower Room a few moments later and began to move items in the storage room. They were asked what the room was being used for, and they indicated that it was a storage room, thatneeded to be straightened up. When asked to explain the facility's protocol for processing reusable equipment, he offered no response. On 8/2/22 at approximately 3:30 PM, an interview was conducted with Staff #23, the Unit Manager. She was asked where the supplies were kept for cleaning the showers between resident use. She indicated that housekeeping cleaned them. When asked if housekeeper cleaned the showers after each resident showered, she indicated she wasn't sure. When asked to show the surveyor where the supplies were kept for cleaning the showers between resident usage, she indicated that Clorox wipes were used. She was unable to clarify if the facility's procedure was for staff to use the sanitizing wipes to clean the showers after each resident use. The Administrator and Staff #12, the Housekeeping Manager, were present and were unable to confirm the procedure for cleaning the showers after each resident. A walking tour of the shower room was conducted at approximately 3:45 PM on 8/2/22 with Staff #12 and the Administrator. They were made aware and shown the above concerns identified by the surveyor at that time. On 8/03/22 at 10:17 AM, the Housekeeping Director was interviewed and reported that the expectation of the housekeeping was to check the privacy curtains for holes, stains and missing clips and report any issue to her or the Floor Technician. Also, if nursing staff noticed any housekeeping or maintenance issues, they may enter a work order in the Tels system (which is a computer system the facility uses to track maintenance issues/concerns). The Housekeeping Director reported that they audit the resident's room daily and will meet with the housekeeper assigned to the room if they find any problems. When asked how often the vents and windows were cleaned, s/he stated that they were done weekly. Surveyor requested the room audits for the month of 07/2022. On 8/3/22 at 10:13 AM, Staff #12 requested to speak to the surveyor regarding the shower cleaning process. S/he indicated that housekeeping was to clean the entire shower room one time/day. Nursing was to clean, using a hydrogen peroxide spray cleaner, after each shower. S/he was asked if this procedure was started yesterday after the surveyor identified concerns. S/he stated no, this morning. S/he was then asked whose responsibility it was to inform maintenance of areas requiring repair. S/he indicated that TELS system was used to send referrals to maintenance. When asked if s/he would have expected housekeeping staff to notify someone regarding the areas in need of repair in the 2 East shower room, s/he indicated Yes. When asked if s/he knew anything about the storage room within the shower room s/he stated, Unfortunately no, that is maintenance. The surveyor on 8/3/22 at 12:00 PM requested to review the room audits. The requested audits submitted to the surveyor by the Housekeeping Director revealed that Resident #56's and Resident #113's room had not been audited in 7/2022, Resident #80's room had been audited on 7/22/22. On 8/04/22 at 11:28 AM, the Housekeeping Director went with the surveyor to the room [ROOM NUMBER]. The surveyor asked if the room was ready for a new admission. The response from the housekeeping director was: s/he thought it had been completed, however, s/he was not positive. There was a resident's walker tucked in the corner of the room, beside the nightstand and a wheelchair foot rest was lying on top of the wardrobe. S/he was made aware that the light brown stain that was first noted on 7/25/22 by the surveyor was still on the ceiling, as well as on the privacy curtain runner, and on the privacy curtain. During an observation, with the Maintenance Director #41, on 8/19/22 at 10:00 AM in room [ROOM NUMBER], revealed a door was missing from the resident's cabinet. The door was seen lying on floor in the back of the room near the window. During an interview with the Maintenance Director #41 on 8/19/22 at 10:05 AM, s/he stated that s/he was not aware the door was off the cabinet. S/he stated that there was no work order submitted in TELS. TELS is a computer system that assists with tracking building maintenance. Staff can submit work orders for environmental concerns in the TELS system. On 8/22/22 at 10:48 AM, the Regional Director of Plant Operations was made aware of the concerns that were noted during the tour of the 1 East Unit. He reported that they have a routine monthly tour of the building to identify issues. When asked to provide a copy of these rounds year to date, he only provided a document that was dated 3/2/22.

4) Resident # 133 was admitted to the facility in March 2022 and transferred to the hospital on 5/14/2022. Review of records for Resident #133 on 8/10/22 at 7:57 AM revealed a physician order dated 5/14/22 for Transfer patient to the ER for Altered Mental Status/weakness and possible CT on the head. Further Review of Record on 8/11/22 revealed a Notice of Intent to Transfer/Discharge which indicated the reason for transfer as .the residents health has improved sufficiently, and the resident no longer needs the services provided by the nursing facility. In addition, the transfer date is documented as 5/15/22. On 8/18/22 at 8:55 AM, the Director of Nursing reported that the information regarding the reason for transfer found on the 5/15/22 Notice of Intent to Transfer/Discharge documentation was a mistake. Further review of the medical record failed to reveal documentation to indicate that neither the resident, nor the responsible representative, were provided written documentation that reflected the reason for the discharge as indicated in the physician order. 5) On 8/16/22 at approximately 10:15 a.m. during closed medical record review of facility reported incident intake MD00168805 involving Resident #533 for hospitalization transfer revealed that, on 6/22/22, resident #533 experienced a change in condition. Resident #533 was sent out to the hospital for further medical evaluation. 6) On 8/16/22 at approximately 12:35 p.m., during closed medical record review of complaint intake MD00181496 involving Resident #398 for hospitalization transfer revealed that, on 7/29/22, resident #398 had experienced a change in condition. Resident #398 was sent out to the hospital for further medical evaluation. On 8/15/22 at 1:30 p.m., in an interview with the nursing home administrator, she was asked if the facility provides reason for transfer in writing to residents or family members. The NHA answered: no, we don't provide a reason of transfer in writing to them yet. The Administrator, along with the Director of Nursing, were provided details related to these residents in detailed discussions prior and during survey exit on 08/23/22 at 3:00 PM. Based on medical record review and interview, it was determined that the facility failed to have an effective system in place to ensure residents and the resident's responsible representative were notified in writing of the reason for a transfer or discharge. This was found to be evident for 6 (Resident #26, #133,#196, #192,# 398, #533) out of 79 residents reviewed during the investigative portion of the survey. The findings include: 1) Review of Resident #26's medical record revealed the resident had severly impaired cognitive skills, and had two certification of incapacity to make informed decisions. The resident had a health care power of attorney (responsible respresentative). The resident was admitted to the facility in January 2022 and had a discharge to the hospital in June 2022 with a re-admission in July. Additional review of the medical record revealed that a Notice of Intent to Transfer/Discharge Resident form was completed on 6/26/22. This form includes information regarding where the resident was transferred to and why, as well as information regarding rights to appeal the decision to transfer/discharge. Further review of the medical record failed to reveal documentation to indicate that the responsible representative was provided a written copy of the Notice of Intent to Transfer/Discharge Resident form. On 8/2/22 at 12:32 PM, the Unit Nurse Manager (#4) confirmed that this information was not provided to the resident or sent to the responsible respresentative by nursing. She indicated that she would ask the social worker if the information is sent to the responsible representative by Social Work. On 8/03/22 at 8:53 AM, the Social Service Director (#9) denied being involved in providing the transfer notice when a resident is sent to hospital. On 8/12/22 at 10:11 AM, surveyor reviewed with Director of Nursing the concern that no documentation was found to indicate a notice of transfer was provided to the responsible representative. 2) On 8/11/22, review of Resident #196's medical record revealed the resident was admitted to the facility in December 2021 and was transferred to the hospital on 1/1/22. Further review of the medical record failed to reveal a Notice of Intent to Transfer/Discharge Resident form related to the 1/1/22 discharge to the hospital. On 8/22/22 at 3:34 PM, surveyor reviewed the concern with the DON that no documentation was found to indicate that the transfer notice was provided to the resident when sent to the hospital on 1/1/22. As of time of survey exit on 8/23/22, no additional documentation was provided regarding this concern. 3) Review of Resident #192's medical record revealed the resident was admitted to the facility in January 2021 and was discharged to the hospital in February 2021. Further review of the medical record failed to reveal documentation to indicate the resident was provided the transfer notice at the time of the discharge. On 8/17/22 at 3:30 PM, surveyor reviewed the concern with the DON regarding the failure to provide the bed transfer notice to Resident #192. As of time of exit no additional documentation was provided regarding this concern.

4) On 8/10/22 at 2:44 PM, a review of Resident #283's medical record revealed the resident was admitted to the facility in early July 2022. On 7/2/22, in a nurse's admission/readmission note, the nurse indicated that Resident #283 arrived at the facility with his/her family, the resident was alert and oriented X 1, able to walk, occasionally incontinent of bowel and bladder and required assistance of 1 with ADLs (activities of daily living). On 7/3/22, in a history and physical note, the physician wrote that Resident #283's had diagnoses that included hypertension, high cholesterol, diabetes and dementia, and was admitted to the facility for rehabilitation, nursing and ongoing medical services. Continued review of Resident #283's medical record failed to reveal a baseline care plan forResident #283. On 8/11/22 at 12:54 PM, during an interview, Staff #23, RN, Unit Manager, stated that the admission nurse would initiate the baseline care plan and the care plan would be in the resident's paper chart unless it was uploaded to the resident's electronic medical record. Staff #23 stated that the resident's family was supposed to sign the care plan and they would be given a copy of care plan. At that time, Staff #23 confirmed a copy of a baseline care plan was not in the resident's medical record and indicated he/she hoped the family hadn't taken the original care plan home. Review of Resident #283's care plans revealed that, within 48 hours of the resident's admission to the facility, a care plan had been developed that addressed cognitive function, potential for pain, risk for falls, ADL status and potential for skin breakdown, however, no documentation was found to indicate that a copy of care plan and a summary of the resident's medication had been given to Resident #283's and/or his/her representative. On 8/12/22 at 10:05 AM, the Director of Nurses was made aware the above findings. 2) On 8/19/22 on1:18 PM, a review of a complaint alleging quality of care concerns for Resident #289 was reviewed. Review of Resident #289's medical record revealed that, following an acute hospitalization, Resident #289 was admitted to the facility in the beginning of February 2022 with diagnoses that included Type 2 Diabetes. On 2/8/22 at 11:24 AM, in a progress note, the physician wrote that Resident #289 was seen for follow-up post admission, and when he/she was in the hospital, Resident #289 received insulin twice a day and took Glipizide (Glucotrol) and Metformin (Glucophage) for diabetes; the Metformin was discontinued, and the resident was discharged on Glipizide only The physician wrote that on that that day, Resident #289's blood sugar was 584, the resident was given Novolog insulin, and sliding scale (the insulin dose varies based on blood glucose level) insulin would be started, the resident's fasting blood glucose would be monitored, and insulin twice a day would be reordered if needed. Review of Resident #289's February 2022 MAR (medication administration record) documented that Resident #289 received Glipizide by mouth two times a day for diabetes since admission, and an order for Novolog Insulin 10 units sq (subcutaneously) (applied under the skin) one time only was documented as given on 2/8/22. The resident also had a 2/8/22 order for Insulin Lispro (Humalog) inject as per sliding scale before meals and at bedtime that documented the resident received insulin in response to his/her blood sugar every day. Review of Resident #289's baseline care plans failed to reveal evidence that a baseline care plan which addressed the resident's diabetes had been developed and implemented within 48 hours of Resident #289's admission to the facility, or while Resident # 289 was a resident of the facility. Further review of the medical record failed to reveal documentation that the facility reviewed the baseline care plan with Resident #289 and/or his/her representative, as applicable, and there was no documentation that a copy of the care plan along with a summary of his/her medications had been provided to the resident and/or representative. 3) Resident #105's medical record was reviewed on 8/9/22 at 10:35 AM. A baseline care plan was developed on 11/11/20. No documentation was found to indicate that the facility staff provided the resident and their representative with a summary of the baseline care plan. During an interview on 8/10/22 at 7:33 AM, the Administrator was made aware of the above concern. She indicated that she was aware that there was a problem with care plans and that a corrective plan was put into place. She was asked to provide any documentation related to the resident's baseline care plan. On 8/10/22 at 4:02 PM, the administrator informed the surveyor that she was unable to find any information regarding Resident # 105's baseline care plan. Based on medical record review, complaints and interview, it was determined that the facility 1) failed to have an effective system in place to ensure that copies of the baseline care plans were provided to the resident and or responsible representatives and 2) failed to provide residents/representatives with a copy of their baseline care plan that included a summary of the resident's medication, and 3) failed to develop and implement a baseline care plan that addressed a resident's diabetes . This was found to be evident for 4 (Resident #26, # 104, #192) out of 6 residents reviewed for care plans and evident for 1 (#283) of 2 residents reviewed for communication and 1(#289) of 31 residents review for general concerns during the annual and complaint survey.during the survey. The findings include: 1) Review of Resident #26's medical record revealed the resident had severly impaired cognitive skills, and had two certification of incapacity to make informed decisions. The resident had a health care power of attorney (responsible respresentative). The resident was admitted to the facility in January 2022. On 8/12/22 at 8:59 AM, further review of the medical record revealed an initial care plan established within 48 hours of admission, however, no documentation was found to indicate that the responsible representative was provided or offered a copy. On 8/12/22 at 10:03 AM, the Director of Nursing (DON) reported that, for residents who were not their own responsible party, a care plan meeting is held at the bedside with the family on the phone, if not in the building. In regard to providing the copy of the care plan, the DON reported that, if the responsible representative was not present for the meeting, a copy of the care plan is left in the patient's room for them to pick up when they come in. She went on to report that, if the responsible representative does not visit, then the care plan would be sent in the mail, but that she was not aware of any that were not able to visit. Further review of the medical record failed to reveal documentation to indicate that a care plan meeting occurred for this resident prior to July 2022. On 8/17/22 at 4:00 PM, this surveyor reviewed the concern with the Director of Nursing that the facility failed to provide the baseline care plan to the responsible representative. As of time of exit on 8/23/22 at 3:00 PM, no additional documentation was provided regarding this concern. 2) Review of Resident #192's medical record revealed the resident was admitted to the facility in January 2021. Review of a complaint revealed a report that the resident was not provided information about his/her care. Further review of the medical record failed to reveal documentation to indicate a copy of the baseline care plan was provided to the resident. On 8/17/22 at 3:30 PM, surveyor reviewed the concern with the DON regarding the failure to provide the baseline care plan to Resident #192. As of time of exit, no additional documentation was provided regarding this concern.

6) Review of Resident #21's medical record revealed the resident had been admitted to the facility in 2021. On 7/28/22 01:28 PM, a review of the current care plan in the electronic health record failed to reveal a care plan to address activities. On 8/01/22 11:08 AM, an interview was conducted with the Recreation Director (staff #6), who indicated that all residents should have an activity care plan. The Recreation Director reported he/she attended care plan meeting and addresses the activity needs for the residents. On 8/3/22, the Administrator was interviewed and validated that all residents should have activities in their care plans. The administrator was made aware that Resident #21 did not have a care plan for activities. Cross reference to F 679 4) On 8/1/22 at 9:00 AM at 8:00 AM, a review of Resident #131's medical record revealed that Resident #131 resided in the facility since June 2021 with diagnoses not limited to Alzheimer's dementia. The medical record revealed documentation that Resident #131 was cognitively impaired, dependent on staff for assistance with all ADLs (activities of daily living) and wore a right hand brace (splint) every day. Resident #131's quarterly assessment with an ARD (assessment date) of 3/17/22 documented Resident #131's BIMS (Brief Interview for Mental Status) Summary Score was 00, indicating the resident had severe cognitive impairment. Resident #131's most recent quarterly assessment with an ARD documented that a BIMS should not be conducted as the resident was rarely/never understood. Physician orders included, a 6/24/22 order, OT (occupational therapy) clarification: resting hand splint on right upper extremity, on AM/off PM; continue to check for skin irritations as needed, in the morning and remove per schedule, and a 6/24/22 order Remove brace on the right hand and perform skin checks every 2 hours every day and evening shift Review of Resident #131's record revealed a care plan, Decreased right hand mobility r/t (related to) weakness with the goal, Monitor for pain, and maximum mobility will be maintained, that had the interventions, 1. assess for pain, 2. Follow brace schedule as ordered, 3. Head CT scan, initiated 2/23/22, 4. 4. Monitor/cleanse skin, assess for redness or breakdown, initiated 2/23/22, 5. PT/OT consult as needed, initiated 2/23/22, and 6. X-ray done 2/23/22 The care plan goal was not measurable nor did it identify the resident's current level of function and the intervention to follow the brace schedule was not resident specific. The care plan failed to have individualized, resident centered interventions and approaches such as exercises to improve the resident's right hand mobility or measures to prevent, to the extent possible, decline or further decline in the resident's right hand mobility and range of motion, and there were no approaches to care to accommodate the resident's loss of ability. Resident #131 had a care plan, impaired cognitive function or impaired thought processes r/t Dementia, with the goal I will be able to communicate basic needs on a daily basis through the review date with one intervention Administer meds as ordered. The care plan failed to identify the resident's current level of cognitive function or measurable objectives to determine the resident's progress or lack of progress toward reaching his/her goal failed to have individualized, nonpharmacological interventions and approaches to care to accommodate the resident's loss of abilities. A concurrent review of Resident #131's care plan notes revealed that, on 6/16/22 at 10:17 AM, in a care plan note, the nurse wrote that Resident #131 was on medication for dementia and continue with current plan of care. There was no documentation if there were improvements, or if the resident remained stable or if the resident's cognitive function declined further. On 8/9/22 at 9:45 AM, Staff #23, LPN, Unit Manager, was made aware of the above care plan concerns. 5) On 8/3/22 at 11:45 AM, Resident #23 was observed lying on the bed belonging to another resident, in a room the resident did not reside in. Staff #23, RN, Unit Manager, was made aware the resident was in the room, entered the room, confirmed the resident was Resident #23, was he/she in the wrong room and lying on a bed that belonged to another resident. Staff #23 aroused the resident and accompanied him/her out of the room. At that time, during an interview, when asked what preventative measures were in place to deter residents from wandering into other resident rooms, Staff #23 stated the facility staff would redirect the wandering resident. When again asked if the facility staff implemented any other measures to prevent residents from wandering into other resident rooms, Staff #23 stated the unit was locked so residents couldn't wander in and out of the unit and indicated that, because the residents on the unit had advanced dementia and wandered, redirection was the only way to prevent them from wandering. On 8/5/22 at 1:00 PM, a review of Resident #23's medical record revealed documentation that Resident #23 had diagnoses that included dementia with behavioral disturbance. Review of Resident #23's most recent quarterly assessment revealed with an ARD of 8/5/22 revealed the resident had severe cognitive impairment, required supervision or assistance with all ADLs (activities of daily living), was able to walk with supervision and documented Resident #23 had wandering behavior that occurred daily. Review of Resident #23's progress notes revealed on 7/22/22 at 7:53 PM, in a health status note, the nurse wrote that the resident continued to wander the hallway and into the rooms of other residents. Review of Resident #23's care plans revealed a care plan, I am an elopement risk/wanderer, with the goals I will not leave facility unattended through the next review date, and My safety will be maintained through the next review date, with one intervention, Re-direct as needed. The care plan goal was not resident centered or measurable in relation to Resident #23's wandering behavior and failed to have resident specific approaches to care that addressed Resident #23's safety, the resident's wandering behavior or the resident's potential for unsafe wandering or elopement The facility failed to develop and implement a comprehensive care plan with measurable goals and individualized approaches to care to address Resident #23's wandering behavior, the resident's potentional for unsafe wandering, or the resident's potential for elopement. On 8/10/22 at approximately 10:00 AM, the Director of Nurses was made aware of the above concerns. 3) Resident #105 was observed on 7/26/22 at 9:29 AM alert, lying in bed. The resident was asking what day it was, the time of day and where they were. He/She was observed several additional times throughout the day, still in bed. Resident #105's medical record was reviewed on 7/26/22 at 10:23 AM. His/Her diagnoses included but were not limited to Dementia. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Review of Resident #105's Annual MDS assessment with an assessment reference date of 9/15/21 Section F: Preferences for Customary and Routine Activities revealed the resident indicated that it was very important to him/her to have books, newspapers, and magazines to read, listen to music he/she liked, be around animals such as pets, do things with groups of people, do his/her favorite activities such as keeping up with the news, going outside to get fresh air when the weather was good, and participating in religious services or practices, which were all coded as somewhat important. An Activities Initial Review dated 11/12/20, identified Resident #105's Past Activity interests were listening to big band music and enjoys going out for walks and reading about romance. [He/She] also enjoys everything that has to do with outdoors. Additional comments were [He/She] likes to play bingo and enjoys cooking when [he/she] can. Also loves to read the newspaper and keep up with the news. An activity care plan was initiated on 6/24/21 and revised on 9/23/21. The focus was: I have little or no activity involvement r/t Disinterest, Resident wishes not to participate, and confusion due to dementia diagnosis. The resident's goal was identified as: I will express satisfaction with type of activities and level of activity involvement when asked through the review date. The interventions that the facility implemented to assist the resident in reaching his/her goal were: Explain to me the importance of social interaction, leisure activity time, and Encourage my participation in activities. Invite/encourage my family members to attend activities with resident in order to support participation. The goal was not resident centered and did not include measurable objectives, it was unclear how the interventions would assist the resident in reaching their goal. The plan did not identify the activities of interest for Resident #105 nor how staff should offer, encourage, and provide Resident #105 with their activities of interest in an attempt to meet the resident's physical, mental and psychosocial needs. During an interview on 8/1/22 at 11:08 AM, Staff #6, the Activity Director indicated that he had worked in Activities for 8 years and as the Activities Director for the last 9 months, and that he was responsible for initiating the Activity Care Plans. He indicated that he is still learning about care plans, so nursing helps him with initiating the care plan. The Administrator was made aware of the above concerns during an interview on 8/2/22 at 11:19 AM. Cross reference F-679. Based on medical record review and interviews, it was determined that the facility failed to have an effective system in place to ensure that comprehensive care plans were established and implemented as evidenced by: failure to incorporate restorative nursing program into a resident's care plan (Resident #26); failure to ensure that goals related to mobility accurately reflected the resident's current status and interventions (Resident #48); failure to ensure that care plans addressing residents' assessed activity preferences was initiated and implemented (Resident #26 and #48) and failed to develop a resident centered activity care plan that addressed the resident's medical, physical, mental, and psychosocial needs and included measurable objectives. This was evident for 6 (Residents #23, # 26, # 48, #105, #21, #131 ) of 6 residents reviewed for care plans, 1 (#131) of 6 residents reviewed for and mobility and positioning, and 1 (#23) of 7 residents reviewed for accidents. The findings include: 1) Review of Resident #26's medical record revealed the resident had severely impaired cognitive skills, unclear speech, was rarely able to express ideas or wants. required extensive assist for bed mobility and total dependance on staff for transfers and bathing. The resident required a g-tube for nutrition due to dysphagia (problems with swallowing) and did not receive any food or fluids by mouth. a) On 7/25/22 at 2:37 PM review of Resident # 26's medical record revealed an order, dated 3/1/22, for OT [occupational therapy] clarification: OT recertification: tx [treat] 3x/week for 2 weeks then plan to discharge to RNP [restorative nursing program]; and an order dated 3/2/22, for PT [physical therapy] Clarification: PT recertification: tx 3x/week for 2 weeks then plan to discharge to RNP. Further review of the medical record, including the resident's current care plan, failed to reveal documentation to indicate that a restorative nursing program was established for the resident. b) Review of the Minimum Data Set assessment, with an assessment reference date of 2/8/22 revealed an interview for Activity Preferences was conducted with a family or significant other (close friend or other representative). This assessment revealed it was very important for Resident# 26 to listen to music s/he likes, do things with groups of people, go outside to get fresh air when the weather is good and to participate in religious services or practices. On 8/2/22, review of Resident #26's medical record failed to reveal a care plan to address the resident's activity preferences or needs. On 8/02/22 at 12:01 PM, surveyor reviewed with Administrator that no care plan for activities was found for this resident. On 8/12/22, further review of the medical record revealed that a care plan addressing activities was initiated by the Recreation Director (#6) on 8/11/22. The goal of the care plan was resident will initiate leisure activities 1-2x/day such as visiting with family/friends. The intervention included: Respect wishes to decline invitations when rest/leisure-type activities are preferred, no other interventions were included in the care plan. On 8/12/22 at approximately 10:30 AM, surveyor reviewed the concern with the Director of Nursing (DON) that the current care plan for activities failed to reflect the resident's assessment. Cross Reference to F 679 2) Review of Resident #48's medical record revealed that the resident resided at the facility for several years. The resident had several re-hospitalizations since their initial admission. A review of the 6/22 MInimum Data assessment revealed the resident required extensive assistance for bed mobility, transfers, locomotion and dressing. The resident also had an impairment in range of motion on one side for both upper and lower extremities. On 8/4/22, a further review of the medical record revealed that,prior to a hospitalization in June of 2020, the resident had a care plan addressing limited physical mobility that included a goal of The resident will increase level of mobility by ambulating 300 ft with no assistive device and modified independence by the next review date. Further review of the medical record revealed documentation to indicate the resident stopped participating in the walking program in 2018. The current version of the care plan, initiated in December 2021, included the same goal of ambulating 300 ft with no assistive device . but no interventions that would facilitate the goal of ambulating with no assistive device. On 8/10/22 at 12:24 PM, the surveyor reviewed with the Administrator the concern that the care plan goal, with a target date of 8/17/22, was for the resident to walk 300 ft with no assistive device but that goal did not not reflect the resident's current status or interventions. The Administrator reported that she had spoken with the unit manager about the care plan. Cross reference to F 688

Review of Resident #21's medical record revealed the resident had been admitted to the facility in 2021. The resident is dependent on staff, needing extensive assistance for transfers. The most recent Brief Interview for Mental Status (BIMS) score was 10 out of 15 indicating the resident had moderate cognitive impairment. The Minimum Data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. Review of the annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/15/2021 revealed the resident had participated in the assessment of Activity Preferences and had indicated it was very important to have books, newspapers and magazines to read, listen to music he/she likes, keep up with news, go outside for fresh air and participate in religious services. On 7/26/22 at 12:36PM and again on 7/29/22 at 8:02AM, the surveyor made observations of Resident #21 while in his/her room. The room was noted to be quiet with no visible books or magazines present and the TV was off. During an interview on 7/29/22 at 2:03 PM, Resident #21 described the activities offered at the facility as uninteresting and reported they often declined to participate. Resident #21 indicated that some of the activities are; Table top bowling and BINGO, which she/he had no desire to participate in. Resident #21 reported they enjoyed the visits from the in-house Chaplin. An interview with Administrator on 08/03/22 at 9:44 AM revealed the Chaplain was at the facility three days a week. The Chaplain visits residents independently but if a resident requests a visit, nursing can contact the Chaplin. On 7/28/22 01:28 PM, a review of the resident's electronic health record failed to reveal a care plan to address activities. A review of the electronic health record, life loop (an app utilized by activities staff), revealed resident likes; Televisions, Socializing, Shopping, and Listening to music. There were no indications that Resident #21 liked reading or participating in religious services as indicated on the MDS preferences section. There was no narrative note in the electronic health record by activity staff. The only documentation of activities offered and attended was found in life loop app. Review of the Life Loop Overview Report for the month of July 2022 revealed Resident #21 was offered Happy Greetings at 9am. The report indicated that Resident #21 attended 3 times and declined 11 times in the month of July. No other offerings were noted on report at 9am. On 8/01/22 11:08 AM, an interview was conducted with the Recreation Director (staff #6). Staff #6 indicated that all residents should have an activity care plan. The Recreation Director reported that he/she attends care plan meetings and addresses the activity needs for the residents. On 8/3/22, the Administrator was interviewed and validated that all residents should have activities in their care plans. The Administrator was made aware that Resident #21 did not have a care plan for activities and had declined many of the calendar activities offered. The Administrator was made aware that Resident #21 declined, Happy Greetings 11 times in the month of July. The administrator was asked what the activity of Happy Greetings entailed and the administrator stated there was no written description of the activities offered but would be working on that. The concern regarding failure to provide activities to meet the resident's interest and needs was reviewed with the Administrator during the interview. As 08/23/22 at 3:00 PM, during the exit interview, the facility staff had not presented any additional documentation related to detailed descriptions of activities services provided to its residents. Based on observation, medical record review and interview, it was determined that the facility failed to provide an ongoing resident centered activities program to improve or maintain the resident's physical, mental and psychosocial well-being, and independence, and failed to provide activities that reflected the resident interests and preferences. This was found to be evident for three out of six residents (Residents # 75, #105, #21) reviewed for activities during the investigative portion of the survey. The findings include: 1. Review of Resident #75's medical record revealed that the resident was admitted to the facility November 2021 with primary diagnoses of morbid obesity, partial paraplegia, and schizoaffective disorder, bipolar. The resident was dependent on staff, needing extensive assistance with daily care activities and transfers. The most recent Brief Interview for Mental Status (BIMS) score was 15 out 15. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. Review of the annual MDS revealed that the resident participated in the assessment of Activity Preferences on May 10, 2022, and indicated the following: Resident #75 stated that books, magazines, newspapers and the availability to read were very important to her/him and stated that listening to music she/he liked was very important to her/him as well as keeping up with the news. During the review of the resident's care plan on 08/09/22 at 11:05 AM, it revealed the following care plan problems and goals: I have adjustment issues due to admission to facility. Four of the resident's goals were to improve their ability to seek social contact and stimulation daily, provide the opportunity to communicate feelings, and communicate feeling regarding attended activities. The activities director and the activities were assigned as responsible for assisting the resident with encouraging participation in conversations with staff and other residents daily. The surveyor was provided hard copies of Resident 75s Life Loop Activities Report for the time period of August 15, 2021, through August 8, 2022. A review of the documents revealed that resident was not offered any activities from July 1 through 12th, 2022. The activities report showed the resident was offered the ability to attend five social related activities. The resident declined each one on the following dates, July 21, 25, 28, 29, 30, and 31, 2022. During the month of June 2022, the activities department offered the resident to participate in one social event on June 29, 2022, and the resident accepted. Per the activities attendance report, the resident refused coffee/tea cart on the following dates: June 7, 9, 14, 15, 21, 23, 28, 30, 2022. Additionally, the activities department failed to provide documentation that the facility offered personalized resident specific activity services on the other 22 days in June 2022. The facility failed to provide individualized preference based activities options to the resident. On 07/26/22 at 12:24 PM and on 08/01/22 at 09:05 AM, the surveyor observed the resident sitting upright in bed with head of her bed elevated and with street clothes on and appeared clean and well groomed. Also, the resident had an old laptop open on the table over her lap. On 07/26/22. at 12:25 PM, the resident stated that she had not been out of bed and did not know if she would be assisted out of bed that day. I write poetry on my laptop. I do not know about any of the unit activities or who the activities' staff members are. My personal laptop is old and not working well. Resident #75 responded that the social worker was difficult to get a hold of when the surveyor inquired if any staff members had offered to assist her with laptop issue. On 08/03/22 at 08:27 AM, during an interview with the social worker associate staff #11, she stated that she had met with the resident earlier this year regarding having a room with a window view. The resident was currently located by the door of the room she occupied. The new director of social work services, staff # 9, stated that she introduced herself to the resident when she was first hired. Both social work services employees denied having any contact with the resident within the last week. The social work employees were unaware of the resident's concerns with her personal laptop, the facility telephone outbound calls problem or the resident's desire to have a cell phone. On 08/03/22 at 10:48 AM while participating in an interview, the facility administrator stated that the activities director does not have detailed descriptions of the activities that the department provides to the residents. The administrator stated that staff #6, the director would have to remedy the lack of documentation of the specific activities offered to residents Resident #105 was observed on 7/26/22 at 09:29 AM in their room, alert, lying in bed. The resident repeatedly asked the surveyor what day it was, the time of day and where they were. A partially eaten breakfast tray was on the overbed table. The resident indicated that they were finished eating and did not have much of an appetite. There were no reading materials, no radio, television, or wheelchair in the room. Resident #105's medical record was reviewed on 7/26/22 at 10:23 AM. The resident's diagnoses included, but were not limited to, Dementia. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. An Annual MDS assessment with an assessment reference date of 9/15/21 Section F: Preferences for Customary and Routine Activities was reviewed. It revealed that Resident #105 indicated during the interview for activity preferences that it was very important to him/her to have books, newspapers, and magazines to read, listen to music he/she liked, be around animals such as pets, do things with groups of people, do his/her favorite activities. Keeping up with the news, going outside to get fresh air when the weather was good, and participating in religious services or practices were all coded as Somewhat important. The record review also revealed an Activities Initial Review, dated 11/12/20, which identified Resident #105's past activity interests as listening to big band music and enjoys going out for walks and reading about romance. [He/She] also enjoys everything that has to do with outdoors. Additional comments were [He/She] likes to play bingo and enjoys cooking when [he/she] can. Also loves to read the newspaper and keep up with the news. The Quarterly Review, dated 1/26/21, indicated that resident enjoyed 1:1 with staff, favorite activities included watching TV and visits from staff; The 7/18/21 quarterly review indicated that the resident enjoyed 1-1, and their favorite activities were watching tv, listening to music, eating snacks, and having 1-1 conversation. Quarterly review notes, dated 10/12/21 & 1/13/22, indicated that the resident's participation level was low, that his/her preference in activities included morning coffee social, Coffee, cocoa, and morning greetings. The most recent Quarterly review note, dated 7/12/22, indicated that the Resident's attendance and participation level was low due to preference and that his/her favorite activity was watching television. The additional comments section indicated Resident hasn't been interested in activities since admission. Additional observations were made of Resident #105 on 7/26/22 at 11:22 AM, 7/27/22 at 12:29 PM, 7/29/22 at 11:07 AM. During each observation, the resident was lying in bed and that he/she responded quickly when the surveyor knocked on the door and requested to enter the room. He/She repeatedly asked what day it was and where he/she was. The resident was not observed to be engaged in activity. There were no books, magazines, radio, or TV available in the resident's room. An interview was conducted with Staff #8 a Caring Partner (activity assistant) on 8/1/22 at 10:28 AM. She indicated that she was assigned to work on the 1 [NAME] unit, she had not worked in activities prior to starting at the facility 5 months ago and that she received on the job training at the facility. She was asked to explain how she knows which activities each resident on her unit is interested in. She indicated that she goes to their room every day, Monday - Friday. She was asked if she has been provided with specific instructions or a list of individual things to do with each resident, she indicated that she was not sure. She indicated that she does not attend care plan meetings and did not have access to the resident's care plans. She explained that the Caring Partners use a system called Live Loop to document resident visits and activity participation including declination. Staff #8 was asked which activities Resident #105 attended. She indicated that the resident didn't like to do activities, liked to read magazines, sometimes came to the dining room to eat lunch but no group activities. She indicated that she visited Resident #105 every day, but the resident didn't always like to talk and would ask her to leave. Review of Resident #105's Life Loop profile revealed Resident #105's birthdate, move-in date, room number, it listed 3 people and their phone numbers but did not identify their relationship to the resident. Under Likes and Dislikes it identified only that the resident Liked Socializing and Television. It did not reflect the activities of preference identified in the MDS and Activity assessments. Resident #105's Live Loop activity participation documentation revealed a list of activities offered to Resident #105, listing the type of activity, the date and time including y or n to indicate if the resident attended, reason and description. The documentation revealed that between 4/1/22 and 8/1/22 Resident #105 was offered Happy Greetings 38 times, Bingo 5 times, 1:1 Wellness 1 time, board games 1 time, morning exercise 3 times and Easter Egg Hunt 1 time; out of these activities, he/she attended Happy Greetings on 21 occasions. The activity documentation failed to reflect that staff offered Resident #105 magazines, newspapers, romance novels, big band music or television as identified as his/her activities of interest. No documentation was found in the resident's medical record to indicate that staff identified and addressed the residents declining interest in activities as possible withdrawal related to dementia, or that the treatment team including the resident's family were informed and the Activities plan of care evaluated and revised to address Resident #105's needs, preferences, and goals. An interview was conducted with Staff #6 the Activities Director on 8/1/22 at 11:08 AM. He indicated that he had worked in Activities at the facility for 8 years and has been the Activities Director for the last 9 months. He was asked where activities staff are expected to look to find the resident's activity interests and dislikes. He indicated in Life Loop. When asked if Life Loop information was available through the Electronic Medical Record system that the facility used, he indicated no, that it was rolled out about a year and a half ago and is in the process of being integrated. When asked about the training process for the Caring Partners, he indicated that they go through new employee orientation with (HR), Human Resources, he provides 1:1 teaching, and they shadow for 2-3 weeks. The Administrator was made aware of the above concerns during an interview on 8/2/22 at 11:19 AM. Cross reference F-656.

F689 Based on observation, staff interview, and record review, it was determined that the facility failed to maintain an environment free of hazards for residents as evidenced by a surveyor observation of a resident (Resident #113) with a fall risk bed that was not in lowest position. The findings include: On 8/01/22 at 5:48 AM, a tour of the 1 East Unit revealed Resident #113 lying sideways on the bed with his/her feet dangling off the side. Surveyor immediately alerted Geriatric Nursing Assistant (GNA) # 67. A subsequent observation of Resident #113 on 8/1/22 at 6:18 AM, revealed the resident was lying upright in bed, however the bed remained at waist level. An interview with GNA # 67 on 8/1/22 at 6:21 AM revealed that s/he did not know that Resident #113 was a fall risk. GNA # 67 and the surveyor walked to Resident #113's room and s/he confirmed the bed was not in the lowest position. GNA #67 reported that when she/he left the room Licensed Practical Nurse (LPN) #62 had been providing respiratory care to the resident, so she/he had not lowered the bed per staff #67. During an interview on 8/1/22 at 6:26 AM with LPN #66, who had been assigned to Resident #113, s/he confirmed that Resident #113 was a fall risk and the bed should be in the lowest position to prevent falls. LPN #62 was interviewed on 8/1/22 at 6:32 AM and s/he confirmed that s/he had been in Resident #113's room providing respiratory care. LPN #62 reported that s/he did not think that Resident #113 was a fall risk as Resident #113 had not had any falls since he/she had been at the facility. S/He confirmed that s/he had not lowered the bed prior to leaving the room. A record review on 8/1/22 at 8:13 AM revealed a progress note, dated 6/16/22 ,by the Attending Physician #55 that read Resident #113's family wanted palliative care (comfort measures) for resident. Further review revealed a Risk for falls care plan initiated on 6/15/22, with a goal to be free of injury through the next review period. The interventions included to place the bed in a low position. These concerns were discussed with the Director of Nursing on 8/12/22 at 10:32 AM.

4) On 8/15/22, a record review for Resident #133 revealed the resident was admitted in 2017. Further review revealed that the resident was seen by Physician # 55 on 6/6/2022, however, the Physicians note was signed and uploaded in the medical record on 6/21/2022. Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that physician progress notes were written, signed, and dated at each visit. This was evident for 2 (#33, #133) of 6 residents reviewed for positioning and mobility, and 1 (#23) of 7 residents reviewed for accidents. The findings include: 1) On 7/27/22 at 10:30 AM, a review of Resident #23's EMR (electronic medical record) revealed physician progress notes that were not written on the day that the resident was seen. There was a) a physician's progress note, with an effective date of 2/23/22 at 2:36 PM, that had a created date of 3/6/22 at 2:36 PM, b) a physician's progress note with an effective date of 4/25/22 at 9:11 PM that had a created date of 5/10/22 9:11 PM, and c) a physician's progress note, with an effective date of 6/9/22 at 7:56 PM, that had a created dated of 6/25/22 at 7:57 PM. 2) On 8/1/22 at 8:30 AM, a review of Resident #131's EMR revealed physician progress notes that were not written on the day the resident was seen. There was a) a physician's progress note, with an effective date of 2/6/22 at 6:04 PM, that had a created dated of 6/14/22 at 6:05 PM, b) a physician's progress note, with an effective date of 4/3/22 at 6:07 PM had a created dated of 6/14/22 at 6:10 PM, and c) a physician's progress note, with an effective date of 6/1/22 at 6:13 PM, had a created date of 6/14/22 at 6:15 PM. 3). On 8/5/22 at 1:00 PM, a review of Resident #23's medical record revealed Psychiatric Progress notes that were not written on the day the resident was seen by the psych practitioner: - A psych progress note with a DOS (date of service) of 1/15/22 was electronically signed by the NP (nurse practitioner) on 8/4/22 at 8:17 PM. - A psych progress note with a DOS of 4/23/22 was electronically signed by the NP on 7/25/22 at 11:48 PM. - A psych progress note with a DOS of 6/25/22 was electronically signed by the NP on 7/26/22 at 12:03 AM. - A psych progress note with a DOS of 7/10/22, was electronically signed by the NP on 8/4/22 at 8:31 PM. On 8/9/22 at approximately 10:00 AM, the DON (Director of Nurses) was made aware of the concerns related with the NP failing to write psych progress notes on the day the resident was seen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Residents (#132) was first admitted in 2017. Review of resident records on [DATE] revealed a physician's order, dated [DATE], for Full Code. This order was discontinued on [DATE]. An order for a Full Code means staff would perform cardiopulmonary resuscitation and other life-sustaining treatments in the event of cardiac arrest. Further review of Resident # 132's medical record revealed an additional physician order for DNR (Do Not Resuscitate)/DNI (Do Not Intubate) started on [DATE] and discontinued on [DATE]. An order for DNR means staff will not perform cardiopulmonary resuscitation or other life-sustaining treatments in the event of cardiac arrest. An order for DNI means comprehensive efforts may include limited ventilatory support, but do not intubate or insert a tube down the throat to provide breathing when the patient is not breathing by his/her own effort. On [DATE], surveyor reviewed the concern with the Director of Nursing regarding the conflicting CPR orders. 3) During an interview, on [DATE] at 12:17 PM, Resident #105's family member reported that they were not informed of the procedure for bringing Resident #105's clothing to the facility. They stated that when they inquired about the process, they were given contradictory advice, couldn't get a straight answer and couldn't find out from anybody how to get clothes to [Resident #105]. The family member reported that they delivered clothes about 1 year ago, but the resident has been wearing other residents' clothing and when they've inquired about the missing clothing, they were told it's in the laundry. An observation was made on [DATE] at 12:29 PM of Resident #105's room. The 2 wardrobes were located at the far end of the room; the wardrobe on the right contained a large amount of clothing neatly hung and labeled with Resident #105's roommates' name. The wardrobe on the left contained a folded red rollator walker, 2 purple heel protectors and a yellow and black gel cushion. A black suitcase was on the floor between the nightstand and the left side of the head of the resident's bed. Another observation was made, on [DATE] at 11:17 AM, with Staff #4 the Unit Manager and the DON. Staff #4 opened a plastic bag that was found on Resident #105's nightstand and confirmed that it contained 1 pair of denim shorts, 1 red sweatshirt with a white logo on the front and 1 pair of green socks - all were unlabeled, a brown paper towel with Resident #105's name and room number was also in the bag. 1 unlabeled pair of blue jeans and 1 cream colored long sleeve top labeled with the roommate's name were lying on top of Resident #105's nightstand. Staff #4 then opened the suitcase and revealed that it contained 1 pair of brown pants, 1 blue sweater and 1 purple T shirt. They were not labeled with a resident's name. Resident #105's belonging's inventory list was reviewed with the DON on [DATE] at 11:17 AM. She confirmed that there was 1 list, which was dated [DATE], and signed by Staff #40. It listed 1 Skirt and 2 sweaters. The listed clothing items were not described. There were no updates adding the suitcase, the unlabeled clothing found at the resident's bedside, nor the clothing the family member reported bringing in, about 1 year ago. The Administrator was made aware of the above concerns on [DATE] at 12:45 PM. Cross reference F-557. Based on medical record review and interview, it was determined that the facility failed to ensure that medical records were complete as evidenced by 1) the failure to ensure that documentation of the Physicians' Certification of Incapacity to Make an Informed Decision was kept in the facility's medical record (Resident #26); failed to ensure that old MOLSTs were voided when a new MOLST was completed (Resident #48). Additionally, based on interview and review of the medical record, it was determined that the facility staff failed to maintain accurately documented resident records by failing to maintain an accurate account of residents' personal property. This was evident for 1 (#105) of 2 residents reviewed for personal property. Also, based on record reviews it was determined that the facility failed to maintain accurate medical records, by having contradictory CPR (Cardio-Pulmonary Resuscitation) orders active in the medical record. This was evident for 1 resident (#132) out of 3 closed records reviewed as part of the long-term care survey process. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options. According to Maryland's Health Care Decision Act, unless otherwise provided in the document, an advance directive shall become effective when the declaration's attending physician and a second physician certify in writing that the patient is incapable of making an informed decision. 1) On [DATE], review of Resident #26's medical record revealed that the resident was initially admitted to the facility in [DATE]. Review of the MOLST revealed it was completed by the attending physician (#55) on [DATE] with the patient's health care agent as named in the patient's advance directive. Further review of the medical record for Resident#26 revealed a form that documented Physicians' Certification of Incapacity to Make an Informed Decision. This form had areas for Certification of the Attending Physician and Certification of the Second Physician. The form found in Resident #26's paper chart revealed certification by the Attending Physician (#55) on [DATE], however, the area for the certification by a Second Physician was blank. On [DATE] at 10:39 AM, surveyor reviewed the concern with the unit nurse manager (#4) that only one certification of incapacity could be found. The unit nurse manager indicated that the psychiatric provider may have completed the second certification. On [DATE] at 2:16 PM, surveyor informed the Administrator that the second certification of incapacity was not found in the medical record. On [DATE] at 8:20 AM, Social Service Director (SSD #9) presented a Physicians' Certification of Incapacity to Make an Informed Decision form with a date of [DATE]. This form only included information in the area for Certification of the Second Physician and was signed by a nurse practitioner. The SSD reported that she had contacted the nurse practitioner who sent over the form, the SSD was unable to confirm if the nurse practitioner had the original paperwork. Further review of this form failed to reveal documentation of the condition that caused the incapacity. On [DATE] at 4:00 PM, surveyor reviewed with the Director of Nursing the concern that the facility failed to ensure that documentation of the second certification of incapacity was in the medical record. 2) Review of Resident #48's medical record on [DATE] at 10:15 AM revealed the resident was originally admitted to the facility several years ago. Further review of the medical record revealed two MOLST forms, one signed on [DATE] and the other signed on [DATE]. Both of the MOLSTs included orders to attempt CPR, but the orders in sections 7 regarding fluids/nutrition and section 8 regarding dialysis were different. Once a MOLST order form is completed and signed, a new form should be completed and signed whenever there are any changes to any of the orders. To void the MOLST order form, a physician or nurse practitioner shall draw a diagonal line through the sheet, write VOID in large letters across the page and sign and date below the line. The voided order form should be kept in the patient's medical record. On [DATE] at 10:30 AM, the Medical Records (Staff #2) confirmed that there were two active current MOLSTs on the resident's paper chart. On [DATE] at 8:08 AM, the surveyor reviewed the concern with the Administrator regarding the presence of two valid MOLSTs and the failure to void previous MOLST when a new MOLST was established. The Administrator reported she was aware of the issue and indicated the new MOLST had been completed by the Hospitalist. Administrator also reported Medical Records (#2) has completed an audit regarding this issue.

Based on surveyor observation, record review and interview, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment by failing to have a process in place to accurately screen people entering the facility for signs and symptoms of COVID-19 and failing to monitor the screening results. This was evident during surveyor entrance to the facility and Infection Control review. The findings include: An observation was made upon entry to the facility on 7/26/22 at approximately 7:55 AM. Surveyor (#1) entered the front lobby and observed the reception desk to the left (approximately 40 feet from the front door) and main hallway to the elevators. The receptionist at the desk requested that the surveyor complete the screening process using a tablet kiosk located in front of the reception desk. A hand sanitizer dispenser was to the left of the kiosk. When the surveyor reached to apply hand sanitizer, a temperature reading, 96.3 F (degrees Fahrenheit) displayed on the front of the dispenser. The screening kiosk prompted the surveyor to answer screening questions regarding symptoms of COVID-19, possible exposure, and vaccination status and to enter the temperature reading. There was no prompt to indicate that the temperature was outside of parameters, too low or to do a temperature recheck. The receptionist was not alerted or aware of the temperature reading. At approximately 8:00 AM, another Surveyor (#2) entered the facility and completed the screening process. Her temperature reading was 94.6 F. Surveyor (#2) requested a temperature recheck with another thermometer, and a handheld thermometer was used to scan her forehead. Her recheck temperature was 97.1 F. At approximately 8:50 AM, Surveyor (#3) entered the facility, her screening temperature reading was 96.7 F. On 7/28/22 at approximately 8:10 AM, Surveyor (#1)'s temperature was 95.6 F and Surveyor (#4) had a reading of 96.6 F. These readings were entered and accepted in the screening kiosk with no alerts or requests by the receptionist or the kiosk to recheck. According to John Hopkins Medicine website: Normal body temperature ranges from 97.5 F (degrees Fahrenheit) to 98.9 F. It tends to be lower in the morning and higher in the evening. Most healthcare providers consider a fever to be 100.4 F or higher. An interview was conducted with the Administrator on 7/28/22 at 12:59 PM. She indicated that she did not have literature (such as an instruction booklet) for the screening thermometer. When asked how the facility staff would know the acceptable parameters for the thermometer, she indicated that, if anybody's temperature runs below 96.9 F, then a temperature was rechecked using a handheld thermometer. She was asked what temperature the facility used as an upper limit. She stated we haven't had anybody over 99 but will recheck at 99 degrees. If they are 99 or above, they cannot come in. She was asked how the facility monitors the staff/visitor screening responses. The Administrator indicated that she didn't have access to the kiosk information, that she had to ask the CEO for a random report about once a week, so they sent it, and she reviewed it. When asked how she would know if someone entering the facility was outside of acceptable screening parameters, she stated The receptionist would let me know. She added that someone is at the front desk from 6:45 AM until 8-9 PM then the front door is locked. The evening supervisor would let people in after hours and check to make sure they signed in and screened. She was made aware that the receptionist was not aware of the surveyor screening temperatures and that the one temperature that was rechecked was at the request of the surveyor. surveyor requested all of the screening audits the Administrator had received from the CEO. Two screening audits were provided by the Administrator on 7/28/22 at 1:43 PM. They were dated 4/27 and 5/10 the year was incomplete. The Administrator indicated that it was 2022 for both, that she knew because the facility got their new machine in April of 2022. The Administrator confirmed that these were the only audits that she received. The 4/27/22 audit reflected that 94 people were screened, 4 (4%) of the temperatures were below 96.9 F, no rechecks were recorded, the lowest was 96.5 F, the highest recorded temperature was 98.9 F for 2 people. The audit from 5/10/22 reflected that 101 people were screened, 3 (3%) of the temperatures were below 96.9 F with no rechecks recorded, all 3 low temperatures were 96.8 F; the highest temperature, 98.9 F, was recorded for 3 people. In an interview on 7/28/22 at 2:04 PM, the Administrator was asked how staff was alerted if a person completed the screening questions in a manner that would indicate that they should not enter. She provided a photo of the kiosk and indicated that if someone answering the screening questions entered information to indicate that they should not enter, a stop sign appeared on the screen indicating they should not enter. She was asked if the receptionist or other staff were alerted to this. She indicated no but the receptionist was at the desk. She confirmed that the receptionist sits behind the desk during the screening process and was not able to view the thermometer and kiosk screens. When asked what would prevent someone from entering the facility despite the stop sign, she stated I'd like to think that they would be honest. She was made aware of the surveyors' temperature readings on 7/25/22 and 7/26/22 and that the only recheck was done at Surveyor #2's request. The facility failed to provide ongoing monitoring of the COVID-19 screening information to ensure accuracy and to prohibit anyone with potential COVID-19 symptoms from entering the facility. An interview was conducted on 7/28/22 at 2:25 PM with Staff #27. He indicated that he set up the screening thermometer. When asked how he would know the accuracy of the thermometer, he indicated that if it reads high or low then the handheld machine was used. He was asked at what low temperature it would alarm. He stated Like below 95 or 96, it says low temperature, over 98, 99 or 100 it says high temperature. It will say high or low temperature and beeps. He indicated that he didn't have a way to set the high or low alarms and that he did not have paperwork or instructions for setting the temperatures. Screening logs were requested for everyone entering the facility on 7/25/22 and 7/26/22. Upon initial review, the surveyor identified that several temperatures were recorded below 96.9 on both days. During an interview on 7/29/22 at 9:00 AM, the Administrator confirmed that the only screening station for anyone entering the facility was in the front lobby at the reception desk and that everyone entering the facility must come though the front door. On 8/1/22, Surveyor #4 was able to enter the facility through the main entrance at approximately 5:10 AM without staff intervention. The surveyor completed COVID-19 self-screening at the reception desk then proceeded to the elevator and the 2nd floor. Staff #63, an LPN (Licensed Practical Nurse) the charge nurse on the 2 [NAME] unit was informed by Surveyor #4 at 5:15 AM that the surveyors were in the building. At 6:25 AM on 8/1/22, Surveyor #4 informed the Administrator that surveyors entered the facility without anyone stopping them. The Administrator indicated that the door should have been locked. Further review of the facility's COVID-19 screening logs for 7/25/22 and 7/26/22 was conducted on 8/22/22 at approximately 4:00 PM, the screening log for 7/25/22 revealed that 167 people were screened, 58 (35%) recorded temperatures below 96.9 F, the lowest recorded was 90.6 F. The highest temperature recorded was 98.9 F. The screening log for 7/26/22 revealed that 207 people were screened, 72 (35%) recorded temperatures below 96.9 F, the lowest recorded was 36.7 F. The highest temperature recorded was 98.9 F. The facility failed to ensure that a system was in place to assess accurate temperature screening for everyone entering the facility and failed to have a system for monitoring the COVID-19 screening results for everyone entering the facility.

Based on surveyor observation and interviews with facility staff, it was determined that the facility failed to provide personal privacy and confidentiality of patient information by discarding patient names and medication labels in the common trash. This finding was evident for 4 of 40 sampled residents (Residents #30, 35, 104, and 109) and on 2 of 5 medication carts reviewed for medication storage and labeling during the survey (carts #1 and #2) . The findings include: 1. On 12-05-19 at 11:35 AM, surveyor observation of 1 [NAME] unit's medication cart (cart #1) revealed medication labels with the names of residents #30 and #35 in the common trash. On 12-05-19 at 11:35 AM surveyor interview with the 1 [NAME] Unit Manager revealed it is the facility's protocol to discard medication labels with patient information in the secured shredder box. On 12-05-19 at 1:00 PM, interview with the Director of Nursing revealed no new information. 2. On 12-05-19 at 11:50 AM, surveyor observation of the 2 [NAME] unit's medication cart (cart #2) for rooms 265-277 revealed medication labels with the names of Residents #104 and #109 in the common trash. On 12-05-19 at 11:50 AM surveyor interview with the 2 [NAME] Unit Manager revealed it is facility protocol to discard medication labels with patient information in the secured shredder box. On 12-05-19 at 1:00 PM, interview with the Director of Nursing revealed no new information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with facility staff, it was determined that the facility failed to identify discharge plans in the comprehensive care plan. This finding was evident for 4 of 34 (#39, #75, #127, and #242) residents selected for review during the survey. The findings include: 1. On 12-05-19 at 1:00 PM, the review of Resident #242's clinical record revealed he/she was admitted to the facility in November 2019. There was no evidence that a care plan to address the resident's discharge plan was developed. On 12-05-19 at 2:00 PM, interview with the Director of Nursing revealed no additional information. 2. On 12-05-19 at 1:30 PM, a review of Resident #75's clinical record revealed he/she was admitted to the facility in July 2019. There was no evidence that a care plan to address the resident's discharge plan was developed. On 12-05-19 at 2:00 PM, interview with the Director of Nursing revealed no additional information. 3. On 12-05-19 at 1:45 PM, surveyor review of resident #127's clinical record revealed he/she was admitted to the facility on [DATE]. There was no evidence that a care plan to address the resident's discharge plan was developed. On 12-05-19 at 2 PM, interview with the Director of Nursing revealed no additional information.

Based on clinical record review and interviews with resident and staff, it was determined that the facility staff failed to follow physician's orders for 2 of 34 residents reviewed during the survey (Residents #192 and #442). The findings include: 1. On 12-03-19, clinical record review revealed that Resident #192 was admitted to the facility with multiple wounds. A review of the physician's orders for the resident revealed an order for barrier cream to be applied to the area of moisture associated skin damage (MASD). MASD is inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. Further review of the clinical record revealed Resident #192 had an initial wound evaluation and treatment on 11-27-19 by a wound physician. After evaluation, the wound physician ordered that Silver Sulfadiazine be applied on Resident #192's area of MASD twice daily. He had also ordered to float (off load) Resident #192's heels in bed. However, as of 12-04-19 there was no documented evidence that the facility staff treated the resident's wounds with Silver Sulfadiazine nor that the resident's heels were floated while in bed. On 12-04-19 at 11:28 AM, surveyor observed nursing staff providing incontinence care to Resident #192. Surveyor observed the facility staff did not apply Slver Sulfadiazine on the resident's area of MASD. Also, the facility staff did not float Resident #192's heels before leaving their room. On 12-04-19 at 12:00 PM, interview with Unit Manager RN Staff #7 revealed that the facility staff had not reviewed or followed up on the wound physician's orders and they were not aware that Resident #192 needed their heels floated or had an order for Slver Sulfadiazine to treat their wounds. On 12-05-19 at 1:00 PM, interview with DON (Director of Nursing) revealed no additional information. 2. On 12-03-19 at 08:50 AM, surveyor observed Resident #442 lying in bed with a nasal cannula (A nasal cannula is a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help. It consists of a lightweight tube which on one end split into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). The setting on the resident's oxygen concentrator was 3.5L (liters of oxygen per minute). On 12-03-19 at 4:04 PM, Resident #442 was observed sitting on the side of bed with a nasal cannula attached to a concentrator set to 3.5L. On 12-04-19 at 9:33 AM, surveyor observed Resident #442 lying in bed with a nasal cannula on, with the concentrator set to 3.5L. On 12-04-19 at 1:45 PM, Resident #442 was observed sitting in a wheelchair with a nasal cannula attached the resident's concentrator was set to 3.5L. On 12-04-19 A review of Resident #442's record revealed a physician's order for oxygen at 2L via nasal cannula to keep the resident's oxygen saturation above 90%. On 12-04-19 at 2:00 PM, surveyor interview with the 2 [NAME] Unit Manager revealed that she was unaware that the oxygen was set incorrectly and adjusted the oxygen level to 2L. On 12-04-19 at 5:00 PM surveyor interview with the DON and Administrator provided no additional information.

Based on the review of a clinical record and interviews with a resident and with the facility staff, it was determined that the facility staff failed to refer 1 of 1 residents, selected for communication-sensory review for, services (Residents #126). The findings include: On 12-03-19 at 9:47 AM, an interview was conducted with Resident #126. The resident was alert and oriented at the time of the interview. The surveyor was informed that the resident had poor vision and it was getting worse. The resident revealed that the facility was informed but noted that no follow up or information concerning an appointment was provided to the resident. On 12-04-19 a review of Resident #126's clinical record revealed a care plan for impaired visual function related to glaucoma, initiated on 03-25-19. On 12-04-19 at 3:30 PM, surveyor interview with the 2 [NAME] Unit Manager revealed that she was familiar with the needs of Resident #126 to be seen for a vision assessment. She stated We talked about it. Resident #126 is on the list for appointments. We recently made a change to vendors, which included our vision people. We have not scheduled new appointments. It should have been taken care of. On 12-04-19 at 5:00 PM, surveyor follow up interview with the 2 [NAME] Unit Manager revealed the facility had Resident #126 on a list of residents in need of appointments. There was no date, provider name/number or appointment time provided. On 12-05-19 at 5 PM, interview with the Administrator and the Director of Nursing (DON) revealed they would follow up with scheduling an appointment for the resident.

Based on clinical record review and interviews with facility staff, it was determined that the facility staff failed to document a resident's negative medical change leaving the clinical record incomplete. This finding was evident for 1 of 34 residents selected for review during the survey (Resident #126). The findings include: On 12-06-19, surveyor review of the clinical record for Resident #126 revealed diagnoses that included but were not limited to Parkinson's Disease, dementia, anxiety disorder, major depressive disorder, brief psychotic disorder and adjustment disorder with depressed mood. The resident was routinely seen by the facility's attending physician, a facility nurse practitioner, a psychiatrist, and a psychiatric nurse practitioner. Further review of Resident #126's record revealed that on 05-23-19, the psychiatrist added a physician certification of incapacity to make informed decisions form to Resident #126's record, declaring that the resident was incapable of making an informed decision for treatment(s) based on the condition of Parkinson's Disease and dementia. Following the psychiatrist's visit on 05-23-19 the attending physician saw the Resident #126 10 times between 05-27-19 and 10-24-19. There was no documentation by the attending physician regarding the designation of incapacity. On 12-09-19 at 11:20 AM, surveyor interview with 2 [NAME] Unit Manager revealed that the psychiatrist did flag the declaration of capacity for the attending physician to review but could not recall when or by whom it was returned to the chart. On 12-09-19 at 11:30 AM, surveyor interview with the Director of Nursing and Administrator provided no additional information. On 12-09-19 at 4:35 PM, surveyor interview with the attending physician revealed that the resident's chart may have been flagged by the psychiatrist. I don't necessarily document on assessments by another provider if I do not agree with it. [Resident #26] was not presenting to me as unable to make their own decision. The facility is very good about follow-up, so I can not be sure if this was missed or I did just not document on it.

Based on administrative record review, and staff interview, it was determined that the facility staff failed to review and revise the facility's Infection Prevention and Control Program (IPCP) policies and procedures annually. In addition, the facility staff also failed to put the date changed on oxygen tubing and nebulizer tubing (Nebulizer tubing is an essential accessory that connects nebulizer kit to nebulizer compressor) and store them to prevent possible infection. This finding was evident for 2 of 3 residents reviewed for respiratory care (Resident #442, Resident #34). The findings include: 1. On 12-09-19 administrative record review revealed that the facility staff reviewed and revised IPCP policies and procedures on 05-09-18. Per federal regulation, the facility staff must have reviewed and revised the IPCP policies and procedures on 05-09-19. However, there was no evidence that it was done annually. On 12-09-19 at 09:12 AM, interview with the Assistant Director of Nursing (ADON) revealed no additional information. 2a. On 12-02-19 at 9:35 AM surveyor observation revealed Resident #34 was using oxygen delivered via a nasal cannula (a lightweight tube connected to an oxygen source and delivers oxygen via a patient's nostrils) at two liters per minute with no label or date on the nasal cannula tubing. The tubing was observed on the floor. On 12-04-19 10:56 AM and at 2:04 PM surveyor observation revealed that Resident #34's oxygen tubing and nebulizer tubing with a kit and a mask were not dated. The respiratory care accessories were was placed over the resident's bedside table, and not stored in a secure disposable bag to prevent spread of infection, per standard precautions. On 12-04-19 at 2:15 PM, surveyor interview with ADON revealed there should be a label with a date on both oxygen tubing and nebulizer tubing that were in Resident #34's room and should be stored in a secure disposable bag when not in use per standard precaution. 2b. On 12-03-19 at 8:50 AM, surveyor observed Resident #442 lying in bed with a nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help. It consists of a lightweight tube which on one end split into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). The resident's oxygen tubing or the humidifier bottle were not labeled with a date of first use. On 12-03-19 at 4:04 PM, Resident #442 was observed sitting on the side of bed with a nasal cannula attached to an operational humidifier bottle. No dated label was noted to the tubing or bottle. On 12-04-19 at 9:33 AM, surveyor observed Resident #442 lying in bed with a nasal cannula on. There was no dated label to the tubing or bottle. On 12-04-19 at 1:45 PM, Resident #442 was observed sitting in a wheelchair with a nasal cannula attached. There was no dated label to the tubing or bottle. On 12-04-19 at 2 PM, surveyor interview of the 2 [NAME] Unit Manager revealed that she was unaware that the oxygen or humidifier were not correctly labeled. After surveyor intervention the identified concern was corrected. On 12-04-19 at 5 PM surveyor interview with the DON and Administrator provided no additional information.

Based on record review and surveyor interview, it was determined that the facility failed to administer influenza and pneumococcal immunizations and to provide education regarding benefits and potential side effects of each vaccination. This was evident for 2 of 7 residents selected for review of immunizations during this survey ( Residents #54 and #85). The findings include: 1. On 12-06-19 at 10:38 AM, surveyor review of Resident #54's clinical record revealed they did not receive the influenza immunization. There was no evidence that facility staff offered the influenza immunization to the resident. On 12-06-19 at 12:49 PM, interview with Staff #5 revealed that she did not know why Resident#54 had not received the Influenza immunization. On 12-09-19 at 09:35 AM interview with Director of Nursing (DON) revealed no further information. 2. On 12-06-19 at 12:49 PM, surveyor review of Resident #85's clinical record revealed they did not receive the pneumococcal immunization Resident #85's clinical record indicated the physician had placed an order on 10-14-19. However, there was no evidence that facility staff offered the pneumococcal immunization to Resident #85. On 12-06-19 at 12:55 PM, interview with Staff #5 revealed that she did not know why Resident #85 had not received the pneumococcal immunization. On 12-09-19 at 09:35 AM interview with DON revealed that she had no further information.

Based on surveyor observation and interviews with residents and facility staff, it was determined that the facility failed to ensure a resident's bed was in safe operating condition (Resident #242). This finding was evident for 1 of 93 rooms observed during the survey. The findings include: On 12-02-19 at 11 AM, surveyor observation of Resident #242's bed revealed the bed controller cord was frayed. On 12-02-19 at 11:05 AM, interview with Resident #242 revealed the bed controller intermittently worked and they reported the malfunctioning equipment to the staff last week but nothing had been done. On 12-02-19 at 02:55 PM, interview with the administrator revealed no new information.

Based on clinical record review and staff interviews, it was determined that the facility staff failed to invite residents and/or their representative for interdisciplinary care conferences (an interdisciplinary team is made of the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, the resident and the resident's representative if practicable) to review and revise residents' care plan after each assessment. This finding was evident for 4 of 34 residents reviewed for care plans (Resident #17, #39, #88, #126). The findings include: MDS (Minimum Data Set) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. Quarterly review assessment is an assessment due no less frequently than every 92 days. 1. On 12-04-19 clinical record review of Resident #88 revealed that they had MDS quarterly review assessments with an ARD (assessment reference date) of 05-22-19, 08-22-19, 09-20-19, and 10-25-19. However, there was no evidence in their clinical record that the facility staff invited Resident #88 and/or their representative for interdisciplinary care conferences conducted after each quarterly review assessment completed on the above listed dates. The review and revision of Resident #88's care plans were completed in an absence of the resident and/or the resident's representative. On 12-05-19 at 10:40 AM, interview with DON (Director of Nursing) revealed no additional information. 2. On 12-04-19 clinical record review of Resident #17 revealed the resident had MDS quarterly review assessment with an ARD of 09-03-19. However, there was no evidence in their clinical record that the facility staff invited Resident #17 and/or their representative to the interdisciplinary care conference conducted after quarterly review assessment completed on the above listed date.The review and revision of Resident #17's care plans were completed in an absence of the resident and/or the resident's representative. On 12-05-19 at 10:40 AM, interview with DON (Director of Nursing) revealed no additional information.3. On 12-05-19 at 8 AM, a review of Resident #39's clinical record revealed the last quarterly care plan meeting was performed on 05-09-19, which included staff from nursing and dietary as well as the resident's representative. The last quarterly MDS assessment had an ARD of 07-28-19 and the last annual MDS assessment had an ARD of 10-28-19. There was no evidence that the facility invited resident #39's representative to participate in any subsequent care plan review meetings after 05-09-19. On 12-05-19 at 8:45 AM, interview with the first floor social work designee #4 revealed there have been no further care plan review meetings with resident #39's representative since 05-09-19. On 12-05-19 at 10:40 AM, interview with the Director of Nursing and administrator revealed no additional information. 4. On 12-03-19 at 9:42 AM surveyor interview with Resident #126 revealed that the resident could not recall a care plan meeting being conducted that included themselves or their spouse in the last 6 months. A review of Resident #126's clinical record revealed no subsequent care plan meetings were held for the resident with the interdisciplinary care team since the inital meeting 04-04-19. Based on Resident #126's MDS history, the resident should have had a care plan meeting for comprehensive assessments or quarterly reviews on or about 06-22-19, 07-01-19, and 11-09-19. On 12-05-19 at 11:00 AM, surveyor interview with the 2 [NAME] social worker revealed that she had failed to include Resident #126 and the resident's family in the interdisciplinary care conferences process for the resident's care. On 12-05-19 at 5:00 PM, surveyor interview with the DON and Administrator provided no additional information.

8. On 12-05-19 the review of Resident #59's clinical record revealed that the resident was received antidepressant medications to manage their depression since March of 2019 per physician order. Further review revealed no evidence that the facility staff attempted nonpharmacological behavioral interventions. In addition, there was no evidence that the facility staff were monitoring Resident #59's behaviors to assess if the antidepressant medications were effective or not. On 12-05-19 at 5:00 PM interview with DON (Director of Nursing) revealed no additional information 2. On 12-04-19 at 12:29 PM, the review of Resident #26's clinical record revealed that the resident received psychotropic medications at the facility. Further review of clinical record revealed no documented evidence of monitoring behaviors to assess the efficacy of the psychotropic medication. In addition, there was no evidence that staff had implemented non-pharmacological approaches designed to meet the individual needs of Resident #26. On 12-09-19 at 09:45 AM, surveyor interview with Director of Nursing revealed no further information. 3. On 12-05-19 at 07:44 AM, the review of Resident #54's clinical record revealed that the resident received psychotropic medication at the facility. Further review of clinical record revealed no documented evidence of monitoring behaviors to assess the efficacy of the psychotropic medication. In addition, there was no evidence that staff had implemented non-pharmacological approaches designed to meet the individual needs of Resident #54. On 12-09-19 at 09:45 AM, surveyor interview with Director of Nursing revealed no further information. 4. On 12/05/19 at 07:44 AM, the review of Resident #343's clinical record revealed that the resident received psychotropic medications at the facility. Further review of the clinical record revealed no documented evidence of monitoring behaviors to assess the efficacy of the psychotropic medication. In addition, there was no evidence that staff had implemented non-pharmacological approaches designed to meet the individual needs of Resident #343. On 12-09-19 at 09:45 AM, surveyor interview with Director of Nursing revealed no further information. 5. On 12-06-19 01:18 PM, the review of Resident #37's clinical record revealed that the resident received psychotropic medications at the facility. Further review of clinical record revealed no documented evidence of monitoring behaviors to assess the efficacy of the psychotropic medication. In addition, there was no evidence that staff had implemented non-pharmacological approaches designed to meet the individual needs of resident #37. On 12-09-19 at 09:45 AM, surveyor interview with Director of Nursing revealed no further information. 6. On 12-06-19 at 01:29 PM, surveyor review of Resident #123's clinical record revealed that the resident received psychotropic medication at the facility. Further review of clinical record revealed no documented evidence of monitoring behaviors to assess the efficacy of the psychotropic medication. In addition, there was no evidence that staff had implemented non-pharmacological approaches designed to meet the individual needs of Resident #123. On 12-09-19 at 09:45 AM, surveyor interview with Director of Nursing revealed no further information. 7. On 12-06-19 at 01:44 PM, the review of Resident #85's clinical record revealed that the the resident received psychotropic medications at the facility. Further review of clinical record revealed no documented evidence of monitoring behaviors to assess the efficacy of the psychotropic medication. In addition, there was no evidence that staff had implemented non-pharmacological approaches designed to meet the individual needs of resident #85. On 12-09-19 at 09:45 AM, surveyor interview with Director of Nursing revealed no further information. Based clinical record review and interviews with facility staff, it was determined that the facility failed to provide behavioral monitoring and behavioral interventions for 10 of 11 residents selected for review of psychotropic medications (Residents #26, #37, #49, #54, #59, #85, #108, #123, #128, #343). The findings include: 1. On 12-04-19 at 09:50 AM, A review of Resident #108's clinical record revealed the resident was prescribed routine psychotropic medications in August 2019. Further review of the clinical record revealed no documented evidence that non-pharmacological behavioral interventions were attempted by the staff. Furthermore, there was no documented evidence that the facility staff were monitoring the resident's targeted behaviors to assess whether the psychotropic medications were effective or ineffective. On 12-04-19 at 02:30 PM, interview with the Director of Nursing revealed no additional information.

Based on surveyor observations, review of clinical records and interviews with facility staff, it was determined that the licensed facility staff failed to ensure nursing standards of practice in timely medication administration for residents. This finding was evident for 4 of the 29 residents on the 2 [NAME] unit selected for review. (#74, #146, #249, #250) The findings include: 1. On 01-03-19, surveyor review of the clinical record for resident #74 revealed the resident was scheduled for dialysis treatment located in the facility from 6AM -9AM on 01-03-19. Further review revealed that scheduled 9AM medications for administration were ordered. Medications are to be administered within 1 hour before or up to 1 hour after the scheduled time. Surveyor observations on 01-03-19 at 10:45AM and 11AM revealed that resident #74 had not returned to the resident's room from dialysis treatment. However, further review of the January 2019 MAR (Medication Administration Record) revealed no evidence that CMA (Certified Medication Aide) # 5 had documented whether or not the 9AM medications had been administered to resident #74 as scheduled, until surveyor intervention. The scheduled medications included medications for the treatment of high blood pressure, seizure, pain patch and supplements. In addition, there was no evidence in the clinical record that the licensed nurse had obtained clarification from the physician due to the late administration of the medications and/or to adjust the scheduled administration times due to dialysis treatment times. On 01-03-19 at 11:05AM, interview with the 2 [NAME] unit manager revealed that some of resident #74's medications had been adjusted due to dialysis times, however, some had not. No additional information was provided. On 01-03-19 at 4PM, surveyor interview with the Director of Nursing revealed no additional information. 2. On 01-03-19, surveyor review of the clinical record for resident #146 revealed that the resident was scheduled for dialysis treatment located in the facility from 11AM-2PM on 01-03-19. Further review revealed that scheduled 9AM medications for administration were ordered. Medications are to be administered within 1 hour before or up to 1 hour after the scheduled time. Surveyor observations on 01-03-19 at 10:45AM and 11AM revealed that resident #146 was in his/her room. However, further review of the January 2019 MAR (Medication Administration Record) revealed no evidence that CMA (Certified Medication Aide) #5 had documented whether or not the 9AM medications had been administered to resident #146 as scheduled, until surveyor intervention. The scheduled medications included medications for the treatment of high blood pressure, restless leg syndrome, supplement, and stroke prevention. In addition, there was no evidence in the clinical record that the licensed nurse had obtained clarification from the physician due to the late administration of the medications and/or to adjust the scheduled administration times due to dialysis treatment times. On 01-03-19 at 11:05AM, interview with the 2 [NAME] unit manager revealed that CMA # 5 had not administered resident 146's 9AM medications as scheduled. On 01-03-19 at 4PM, surveyor interview with the Director of Nursing revealed no additional information. 3. On 01-03-19, surveyor review of the clinical record for resident #249 revealed that the resident was scheduled for dialysis treatment located in the facility from 11AM-2PM on 01-03-19. Further review revealed scheduled 9AM medications for administration as ordered. Medications are to be administered within 1 hour before or up to 1 hour after the scheduled time. Surveyor observations on 01-03-19 at 10:45AM and 11AM revealed that resident #249 was in his/her room during observations. However, further review of the January 2019 MAR (Medication Administration Record) revealed no evidence that CMA (Certified Medication Aide) #5 had documented whether or not the 9AM medications had been administered to resident #249 as scheduled until surveyor intervention. The scheduled medications included medications for pain, anemia and depression. In addition, there was no evidence in the clinical record that the licensed nurse had obtained clarification from the physician due to the late administration of the medications and/or to adjust the scheduled administration times due to dialysis treatment times. On 01-03-19 at 11:05AM, interview with the 2 [NAME] unit manager revealed that CMA #5 had not administered resident #249's 9AM medications as scheduled. On 01-03-19 at 4PM, surveyor interview with the Director of Nursing revealed no additional information. 4. On 01-03-19 surveyor review of the clinical record for resident #250 revealed the resident was scheduled for dialysis treatment located in the facility from 3PM-6PM on 01-03-19. Further review revealed scheduled 9AM medications for administration were ordered. Medications are to be administered within 1 hour before or up to 1 hour after scheduled. Surveyor observations on 01-03-19 at 10:45AM and 11AM revealed that resident #250 was in his/her room. However, further review of the January 2019 MAR (Medication Administration Record) revealed no evidence that CMA (Certified Medication Aide) #5 had documented whether or not resident #250's 9AM medications had been administered as scheduled until surveyor intervention. The scheduled medications included medications for atrial fibrillation, blood pressure and an antibiotic. In addition, there was no evidence in the clinical record that the licensed nurse had obtained clarification from the physician due to the late administration of the medications and/or to adjust the scheduled administration times due to dialysis treatment times. On 01-03-19 at 11:05AM, interview with the 2 [NAME] unit manager revealed that CMA # 5 had not administered resident 250's 9AM medications as scheduled. On 01-03-19 at 4PM, surveyor interview with the Director of Nursing revealed no additional information. According to the Maryland Nurse Practice Act 10.27.10.03 D (1) (2) (3) (4) , the implementation of the nursing plan of care shall include, but is not limited to: recognizing the rights of the client, the family and significant others and providing a safe and therapeutic environment; the competent performance of the acts required to carry out the nursing plan; collection of data and reporting of problems that arise in the carrying out of the nursing plan; assisting in revising the nursing plan and providing viable alternatives if possible.

2. On 01-08-19, surveyor review of resident #134's medication administration record (MAR) for December 2018 and January 2019 revealed that a high blood pressure medication order written on 06-22-18, was to be administered three times a day. The medication was scheduled to be administered at 2 AM, 6 AM and 10 AM respectively. Additional record review revealed another physician's order that stated, Hold blood pressure medications 4 hours prior to dialysis on dialysis days. Further review of the MAR revealed that the high blood pressure medication that was to be administered at 10 AM was held on Tuesdays, Thursdays and Saturdays when the resident received dialysis treatments from 10:30AM to 1PM. However, there was no evidence in the clinical record that resident received the 10 AM dose of the blood pressure medication on dialysis days. The record indicated that resident #134 was administered blood pressure medication only two times a day on dialysis days, although the physician order was that the medication be administered three times a day. On 01-08-19 at 12:22 PM, surveyor interview with the unit manager and the Director of nursing revealed no additional information. 3. Based on surveyor review of the clinical record and interview of resident #134 and the facility staff, it was determined that the facility staff failed to ensure quality of care for resident #134 by waking up the resident at 2 AM to give medication with no adequate rationale. This finding was evident for 1 of 36 residents selected for review during the survey (#134). The findings include: On 01-08-19 at 08:20 AM, interview of resident #134 revealed that the resident was alert and oriented to self, place and time. Surveyor interview with resident #134 revealed that he/she is awakened at 2 AM daily for his/her blood pressure to be taken and blood pressure medication to be administered. The resident stated, I have a hard time falling asleep after the medication. Surveyor review of resident #134's medication administration record revealed a physician's order for blood pressure medication to be administered three times a day. The medication was scheduled to be administered at 2 AM, 6 AM and 10 AM respectively. The facility medication administration times for a medication scheduled three times daily was documented as 9 AM, 1 PM, and 6 PM. The facility failed to follow their own scheduled administration times. On 01-08-19 at 12:22 PM, surveyor interview with the unit manager and the Director of Nursing revealed no rationale for awakening resident #134 at 2 AM. Based on surveyor review of clinical records, and interview of residents and facility staff, it was determined that the facility staff failed to administer medications as ordered. This finding was evident in 2 of 36 residents selected for review during this survey (#58 & #134). The findings include: 1. On 01-03-19 at 9 AM, interview of resident #58 revealed the resident was alert and oriented to person and place only. Due to vision impairment, the resident required extensive assistance with meal preparation and activities of daily living (ADLs). On 01-08-19, review of the physician's order revealed that a suppository was ordered every 4 hours as needed for temperature above 100F in October 2018. In addition, an oral pain medication was ordered every 4 hours for pain or shortness of breath. However, review of January 2019 Medication Administration Record revealed that a suppository was given to resident #58 on 01-03-19 at 1: 30 PM for leg pain, which was inconsistent with the physician's order. On 01-08-19 at 3 PM, interview of the Director of Nursing revealed no additional information.