Based on observations, interviews and record reviews it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility's kitchen. The findings include: During the initial tour of the Kitchen with the Director of Dining on 6/03/25 at 9:06 AM there were foods found expired, and foods found open with no label showing expiration dates. The following foods were identified: In the Walk-in Refrigerator the following items were found expired. Meat wrapped in plastic and labeled Turkey, Cooked, Chilled, Use by Thursday 5/01. Cheese wrapped in plastic and labeled Cheese, opened (not in original package). Use by Tuesday 5/20. Seven Packs of Pepperjack Cheese in original packaging labeled Best by 5/22/25. A metal bin with cups of Salsa labeled Sauce, Tomato, Canned, opened, Use by Thursday 5/29. In the Walk-in Freezer the following items were found. A metal bin containing fish labeled Fish, Fresh, On ice, Use by 4/17. A clear bag of chicken legs was opened, undated and unlabeled. A clear bag of Chicken tenders was opened, undated and unlabeled. A clear bag of Riblets was opened, undated and unlabeled. In the Kitchen the following items were found expired: Two bags of Italian Steak Rolls dated as Best if used by May 29, one bag had bluish-green discoloration on the bread rolls. A bag of Rye bread labeled as Use by May 30. During an interview with the Director of Dining On 6/03/25 at 9:32 AM he confirmed the items found open should have been labeled and anything not in the original packaging should be labeled. He stated the items that had passed the Expiration, Use By and Best by dates should have been removed from food storage and discarded. During a review of a poster in the Kitchen labeled Temperature Control Safety (TCS) Food Labeling Guide on 6/04/25 at 11:43 AM it stated Labeling and storing TCS food correctly ensures our ingredients are safe to use in food served to customers. All TCS food we prepare must be labeled and used within 7 days. TCS food labels must include these 4 things. 1. Item 2. Preparation Date 3. Use by Date 4. Your Initials.

Based on observation and staff interview, it was determined that the facility staff failed to provide a resident with dignity and respect by dressing the resident in clothing that was labeled with the resident's name prominently displayed. This was evident for 3 (#42, #38, #33) of 3 residents observed wearing slipper socks during the annual survey. The findings include: On 12/1/21 at 9:48 AM observation was made of Resident #42 sitting in a wheelchair. Resident #42 was wearing slipper socks and the front shin area of the slipper socks was labeled with Resident #42's last name. On 12/3/21 at 12:48 PM observation was made of Resident #42 sitting in the dining room along with 2 other residents, Resident #38 and Resident #33. All 3 residents were wearing slipper socks and their names were prominently displayed on the front of the socks. On 12/3/21 at 1:16 PM the Social Worker was interviewed and stated, we label all their clothing. We have a label maker in laundry. The nursing assistants also put their name on their clothes and if there are missing items, we do a report. The Social Worker was asked where the resident's names were placed on the clothing and she replied, inside of the clothing. At that time the surveyor and the social worker walked to the unit and went into Resident #42's room. The Social Worker saw the resident's slipper socks with the name displayed on the front of the socks and said, oh no, that doesn't belong there. The Social Worker agreed that having the resident's name displayed on the front of the slipper socks was a dignity issue. The Director of Nursing was informed on 12/8/21 at 9:38 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 1 of 3 nursing wings observed during the survey. The findings include: 1) On 11/30/21 at 12:33 PM, in room [ROOM NUMBER], near B bed, an observation was made of a blue upholstered chair that had the fabric pulled down from the right top of the chair and the underlying foam padding was exposed. 2) On 12/01/21 at 9:33 AM, an observation was made of Resident #33 in his/her wheelchair. The fabric on wheelchair's left armrest was torn along the sides of the armrest and had stuffing exposed. The Administrator was made aware of these findings on 12/8/21 at approximately 1:15 PM during the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility investigative material and interview with staff, it was determined that the facility failed to ensure that residents were free from abuse when Resident #521 was verbally abused by Geriatric Nursing Assistant (GNA) #24. This was evident for 1 (Resident #521) of 14 residents reviewed for facility reported incidents of abuse during the annual survey. The findings include: On 12/7/21 at 1:00 PM, the surveyor reviewed the facility's investigation for the facility reported incident MD00132189. The investigation revealed that, in December, 2018, Geriatric Nursing Assistant (GNA) #24 was accused of being rough with Resident #521 during morning care and had hit the resident on the arm. Resident #52 also alleged that GNA #24 stated, they put old ladies like you in jail for saying things that are not true. The facility's investigation revealed that they were unable to substantiate that GNA #24 hit Resident #521, however GNA #24 told the Director of Nursing (DON), I did tell [name] that she wasn't too old to go to jail. The facility terminated GNA #24 for making that statement to a resident. The sheriff's office was also notified and the GNA was reported to the Board of Nursing. Discussed with the DON on 12/8/21 at 9:33 AM.

Based on review of facility investigation documentation, abuse policies and interviews with staff it was determined that the facility's policy on Resident Rights - Abuse of Residents failed to include the timeframe for sending the final investigation of alleged abuse to the state survey agency, the Office of Health Care Quality (OHCQ) within 5 days of the alleged incident. This had the potential to affect all residents of the facility. Additionally, it was determined that the facility failed to ensure all allegations of abuse were reported to OHCQ within the required time period. This was found to be evident for 1 (#501) of 13 residents reviewed for abuse during the survey. The findings include: Staff failed to implement the Resident Rights - Abuse of Residents policy by failing to immediately report to the facility administration alleged abuse. On 12/2/21 at 9:30 AM a review of the Resident Rights - Abuse of Residents policy revealed 1. Any witnessed or allegations of abuse, exploitation, neglect, misappropriation of resident property or an injury of unknown origin (collectively referred to as resident incident) must be reported to the Executive Director, Administrator, Director of Nursing or Charge Nurse/Nurse Supervisor. On 12/7/21 at 11:00 AM a review of facility reported incident MD00130336 revealed that a GNA reported to another staff member that another Geriatric Nursing Assistant (GNA) had in the past placed her finger on Resident #501's forehead and pushed/lifted [his/her] head backwards in an inappropriate fashion. The date of the alleged incident was unknown as the GNA failed to report the incident to the facility administration. On 12/7/21 at 3:53 PM an interview was conducted with GNA #26, and the description of the incident was acted out by the surveyor. GNA #26 stated it was abuse and she would report it immediately. The description of the incident was told to Licensed Practical Nurse (LPN) #27 who stated that it was abuse and that she would report it immediately. On 12/2/21 at 8:50 AM the concerns regarding failing to implement the policy for timely reporting were discussed with the Nursing Home Administrator (NHA) and Director of Nursing (DON).

Based on record review and staff interview, it was determined the facility failed to have documentation that the final report was submitted within 5 days of the allegation. This was evident for 1 (#501) of 13 residents reviewed for abuse during the annual survey. The findings include: Staff failed to immediately report to the facility administration alleged abuse. On 12/7/21 at 11:00 AM a review of facility reported incident MD00130336 revealed that a GNA (geriatric nursing assistant) reported to another staff member that another GNA had in the past placed her finger on Resident #501's forehead and pushed/lifted [his/her] head backwards in an inappropriate fashion. The date of the alleged incident was unknown as the GNA failed to report the incident to the facility administration. On 12/7/21 at 3:53 PM an interview was conducted with GNA #26, and the description of the incident was acted out by the surveyor. GNA #26 stated it was abuse and she would report it immediately. The description of the incident was told to Licensed Practical Nurse (LPN) #27 who stated that it was abuse and that she would report it immediately. On 12/2/21 at 8:50 AM the concerns regarding timely reporting were discussed with the Nursing Home Administrator (NHA) and Director of Nursing (DON).

Based on medical record review and interview it was determined that the facility failed to provide the written transfer notice to the resident and or the responsible representative. This was found to be evident for one out of three residents (Resident #52) selected for closed record review. The findings include: On 12/3/21 review of Resident #52's medical record revealed the resident was admitted to the facility in the spring of 2021 and was discharged to the hospital in October 2021. On 12/3/21 at 12:35 PM when asked about the process for when a resident is sent to the hospital unexpectedly, nurse #12 was able to produce a blank Notice of Proposed Facility-Initiated Discharge or Transfer. Nurse #12 reported that she believed a copy is made and put in the chart. Further review of the medical record failed to reveal documentation that the required transfer notice had been provided to the resident or the responsible representative. On 12/03/21 at 1:52 PM surveyor reviewed with the Director of Nursing the concern regarding failure to provide the transfer notice.

Based on medical record review and interview it was determined that the facility failed to provide the bed hold policy when a resident was discharged to the hospital. This was found to be evident for one out of three residents (Resident #52) selected for closed record review during the survey. The findings include: On 12/3/21 review of Resident #52's medical record revealed the resident was admitted to the facility in the spring of 2021 and was discharged to the hospital in October 2021. On 12/3/21 at 12:35 PM when asked about the process for when a resident is sent to the hospital unexpectedly, Nurse #12 reported the bed hold policy is provided but was unable to locate a copy of the bed hold policy. Nurse #12 was able to locate a Notice of Proposed Facility-Initiated Discharge or Transfer form, but review of this document failed to reveal information regarding the bed hold policy. Nurse #6, who was present during the interview with Nurse #12, confirmed that the Notice of Proposed Facility-Initiated Discharge or Transfer form is provided but indicated that she thought this was the bed hold notice also. On 12/3/21 at 1:03 PM the admissions coordinator (Staff #4) reported that the bed hold policy is sent with the resident to the hospital and then she will call and ask if they want to hold the bed. The admission coordinator confirmed that she documents these conversations and also makes a copy if a letter is sent. Surveyor reviewed the concern that the nurses were unable to locate the bed hold policy form and that no documentation was found in the medical record to indicate the bed hold policy had been provided. On 12/3/21 at 1:10 PM the admission coordinator reported she could not locate information about the bed hold policy for Resident #52. On 12/03/21 at 1:52 PM surveyor reviewed with the Director of Nursing (DON) the concern regarding failure to provide the bed hold policy. The DON confirmed a copy of the bed hold policy was not available at the nursing station; stating they must have sent last one.

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 1 (#34) of 1 resident reviewed for tube feedings, and 2 (#31, #41) of 7 residents reviewed for unnecessary medications and 1 (#34) of 1 resident reviewed for tube feedings. 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 these individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 11/30/21, at 12:34 PM, during an interview, Resident #34 stated that he/she was unable to eat or drink because he/she had a swallowing problem, and received tube feedings (liquid nutrition delivered through a feeding tube) (tube inserted through the abdomen, into the stomach). On 12/2/21 at 9:12 AM, a review of Resident #34's medical record revealed on 11/10/21, in a History and Physical note, the physician wrote that Resident #34 was admitted to the facility for rehab post hospitalization for diagnosis including dysphagia (difficulty swallowing). Review of Resident #34's November 2021 TAR revealed orders that indicated Resident #34 was NPO (nothing by mouth) and received tube feedings. enteral feedings via his/her feeding tube from 11/10/21 through 11/30/21, Review of Resident #1's admission MDS, with an ARD of 11/15/21, revealed the MDS was inaccurate. Section I, Active Diagnosis failed to capture Resident #34's diagnosis of dysphagia. The MDS coordinator was made aware of the MDS concern and confirmed the findings on 12/2/21, at 2:50 PM 3) On 12/3/21 at 9:32 AM a review of Resident #31's medical record revealed the resident was prescribed Methenamine Hippurate twice per day for urinary tract infection. The medication Methenamine Hippurate is an antibiotic that eliminates bacteria that can cause urinary tract infections. Methenamine Hippurate usually is used on a long-term basis to treat chronic infections and to prevent recurrence of infections. Review of Resident #31's May 2021 Medication Administration Record (MAR) documented Resident #31 received the Methenamine Hippurate on May 9, 10, 11, 12, and 13, 2021. Review of Resident #31's admission MDS assessment with an assessment reference date (ARD) of 5/13/21, Section N, failed to document the resident received the Methenamine Hippurate (antibiotic) during the 7-day lookback period of 5/7/21 to 5/13/21. Continued review of Resident #31's medical record revealed Resident #31's August, October and November 2021 MAR documented Resident #31 received Methenamine Hippurate twice per day. Review of Resident #31's quarterly MDS with an ARD of 8/13/21 and 11/5/21, Section N, failed to document that Resident #31 received the Methenamine Hippurate (antibiotic) during the 7-day lookback period of 8/7/21 to 8/13/21 and 10/30/21 to 11/5/21 respectively. On 12/8/21 at 9:38 AM the Director of Nursing was informed and confirmed the findings. 2) 2a. On 12/2/21 review of Resident #41's medical record revealed an order, dated 11/15/21, for levofloxacin 750 mg every two days for eight days starting 11/15/21. Levofloxacin is an antibiotic medication. Further review of the medical record revealed a Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/20/21. According to the MDS instructions, staff should document the number of days a resident received an antibiotic during the 7 days, or since admission if less than 7 days, up to and including the ARD. The 11/20/21 MDS indicated the resident had received 3 days of antibiotics during the look back period. Review of the Medication Administration Record (MAR) revealed the dose that was due on 11/15/21 was grayed out and a corresponding nursing note revealed the medication was not administered due to being not available. Further review of the MAR revealed documentation that the medication was administered on 11/17 and 11/19/21. No documentation was found to indicate an antibiotic was administered on more than 2 days during the look back period. 2b. Further review of Resident #41's medical record revealed the resident had an order, with a start date of 11/15/21, for escitalopram 10 mg one tablet every morning. This order was discontinued on 11/18/21. Escitalopram is an antidepressant medication. According to the MDS instructions, staff should document the number of days a resident received an antidepressant during the 7 days, or since admission if less than 7 days, up to and including the ARD. Review of the MDS with an ARD of 11/20/21 revealed documentation that the resident had received 4 days of antidepressant medication during the look back period. Review of the MAR revealed the doses due on 11/17 and 11/18 had been grayed out. The corresponding nursing note indicated the medication was not administered due to resident refusal. There was documentation to indicate the resident did receive the antidepressant as ordered on 11/15 and 11/16. No documentation was found to indicate the resident received an antidepressant on more than 2 days during the look back period. On 12/02/21 at 11:28 AM the MDS nurse coordinator (nurse # 8) reported that for assessment of the medications s/he reviews the signed MARs and counts back. Surveyor reviewed the concern that there were nursing notes corresponding to the grayed out documentation on the MAR that indicated the medications had not been administered. The MDS coordinator at first responded that her version of the electronic MAR does not show the grayed out documentation. At 11:45 AM the MDS nurse coordinator reported that the medications do show up grayed out on her version of the MAR and that moving forward she will know. On 12/2/21 at 10:48 AM surveyor reviewed the concern with the Director of Nursing regarding the MDS errors in assessment of medication administration.

2) On 11/30/21 at 12:30 PM, an observation was made of Resident #34 wearing an oxygen nasal cannula whose tubing was connected to a water humidifier bottle that was connected to an oxygen concentrator set at 3 LPM (liters per minute). Also, a bottle of Jevity (liquid food), was noted to be hanging from a pole near the resident. At that time, Resident #34 indicated he/she had difficulty swallowing, was unable to eat or drink, had a feeding tube (a tube inserted through the abdomen and into the stomach), (g-tube) (gastrostomy tube) and received tube feedings. 2a. On 12/2/21 at 8:30 AM, a review of Resident #34's medical record was conducted and revealed Resident #34 was admitted to the facility in early November following an acute hospital stay. On 11/10/21, in a History and Physical (H & P) note, the physician wrote that Resident #34 was admitted for rehab post-hospitalization for diagnosis that included aspiration pneumonia (lung infection that occurs when a person breathes something instead of swallowing it), ILD (interstitial lung disease) (large group of disorders which cause scarring of lung tissue), COPD (chronic obstructive pulmonary [lung] disease), chronic respiratory failure with hypoxia and indicated Resident #34 used a CPAP (continuous positive airway pressure) machine (treatment for sleep apnea) (disorder in which breathing repeatedly stops and starts). Review of Resident #34's November 2021 TAR (treatment administration record) revealed an order for oxygen at 3 LPM (liters per minute), that documented Resident #34 received oxygen continuously since his/her admission to the facility, and an order to change oxygen tubing and humidifier bottle every week; date and initial tubing and bottle which were in effect since 11/10/21. Also, the November 2021 TAR revealed Resident #34 had an order for a CPAP to be on at bedtime and taken off in the morning, initiated on 11/10/21, upon the resident's admission. Review of Resident #34's care plans failed to reveal a comprehensive, resident centered care plan had been developed to address Resident #34's respiratory status, oxygen therapy or use of a CPAP machine. 2b. Continued review of Resident #34's medical record, revealed, in the 11/10/21 History & Physical note, the physician documented Resident #34's had diagnosis that included, but were not limited to, dysphagia (difficulty swallowing), esophageal stricture (an abnormal narrowing of the esophagus which causes swallowing difficulties. and PEG (percutaneous endoscopic gastrostomy) (feeding tube). Review of Resident #34's November 2021 TAR revealed documentation that Resident #34 received enteral feedings (tube feedings) every day in November since his/her admission to the facility and had Enteral Tube Care orders to change g-tube drainage sponge daily and or as needed; cleanse skin around g-tube with NSS (normal saline), pat dry and apply drainage sponge and an order to flush the g-tube with 30 ml (milliliters) before and after administration of medications which had been in effect since 11/10/21. The TAR also documented, that since 11/10/21, Resident #34 received water flushes with orders to check g-tube placement every 4 hours, and, since 11/15/21, the TAR documented Resident #34 was to be NPO (have nothing by mouth). Review of Resident #34's care plans revealed an active care plan problem, Alteration in Nutrition R/T: related to dysphagia and aspiration pneumonitis with the goal, Resident #34 will tolerate tube feeding & water flushes well thru initial review and no episode of aspiration, that had four interventions, Provide tube feeding and water flushes as ordered, Monitor tolerance of TF & water flushes, Monitor weights on weekly basis x 4 weeks and Monitor for signs and symptoms of dehydration. The nutrition care plan interventions were generalized, not resident centered and, there were no interventions that addressed Resident #34's risk of aspiration in order to meet the resident's care plan goal of tolerating the tube feeding and water flushes, and no episode of aspiration. Continued review of Resident #34's care plans failed to reveal a comprehensive care plan had been developed with resident centered goals and interventions to address Resident #34's dysphagia, NPO status, and risk of aspiration, and no other care plan was found that addressed the resident's needs related to his/her feeding tube, including g-tube site care. 2c. Resident #34 had a care plan, Potential for dehydration R/T (related to), with the goal Resident will remain free of signs and symptoms of dehydration through initial review, that had six interventions, Encourage consistent completion of all beverages provided, Offer one glass of water/juice with each med pass, Encourage a variety of fluids, Provide beverages of choice with meals, ensure water is within reach in room, monitor for signs of dehydration. The care plan focus was incomplete and did not identify the reason for Resident #34's potential for dehydration and there were no comprehensive, resident centered interventions to meet the care plan goal. Resident #34's medical record documented the resident could take nothing by mouth, however 5 of the 6 interventions in the care plan indicated Resident #34 was to be offered and encouraged to drink fluids. The Director of Nurses was made aware of the above concerns and confirmed the findings on 12/2/21 at 1:51 PM. 3) On 12/7/21 at 10:28 AM, a review of facility reported incident MD00174221 revealed, Resident #38 was noted with a bruise to the base of the left finger second knuckle during the night of 11/13/21, the physician was notified, an x-ray was ordered, and the x-ray results reported Resident #38 had a left 2nd finger fracture. The facility report indicated the resident's care plan had been reviewed with the following changes, the side rails had been removed, the bed would be in the lowest position and fall mats will be placed by the bed. At that time, a review of Resident #38's medical record was conducted. Review of Resident #38's December 2021 TAR revealed an order for Brace, two times a day for starting 11/15/21, to Buddy tape left hand second digit to third digit for support. R/T (related to) recent fracture of 2nd digit. Ensure placement each shift. Reapply PRN that was signed off as done for 2 days in December, and a 12/3/21 order, Brace, two times a day for twelve days starting 12/3/21, Buddy tape left hand second digit to third digit for support. R/T (related to) recent fracture of 2nd digit. Ensure placement each shift. Reapply PRN. Total of 4 weeks, which was signed off as completed every day for 5 days. On 12/8/21 at 9:30 AM, during an interview, the Director of Nurses indicated that when Resident #38 fractured his/her left index finger, it was thought the resident had hit it against the side rails, so the side rails were removed, and fall mats and a contour mattress were initiated. On 12/8/21 at 12:38 PM, an observation of Resident #38's room & bed revealed there were no side rails on the resident's bed, a scoop mattress was on the bed and floor mats were on the floor on both sides of Resident #38's bed. Following the observation, a review Resident #38's care plans revealed a care plan , potential for fall or injury R/T (related to) need for assistance with ADL's (activities of daily living), dementia, decreased mobility, weakened condition, osteoporosis, with the goal, Resident #38, will remain free of falls and injury through the initial review, that had a goal date of 3/17/21. Under the goal, on 11/15/21 in a care plan note, the nurse wrote this nurse was notified by the GNA that resident has bruise to left hand second digit (index finger). Noted deep purple bruise to base phalange (bones that make up the fingers of the hand) and medial phalange. Resident moaned in pain with normal ROM (range of motion), shows no limit to ROM. Resident unable to follow commands to open and close fist. Swelling noted to entire digit. On Call system contacted, awaiting a return call, suggested order for Xray. Upon exam this nurse applied ice pack to area for 5 minutes, held in place by staff, resident tolerated well, continue with tx (treatment) every 6 hours to assist with pain and swelling. PRN Tylenol given for pain. The care plan goal was note comprehensive, and the goal did not address the injury to Resident #38's left index finger. The care plan had 4 interventions: Provide assistive device: w/c (wheelchair), Instruct [Resident #38] in use of call bell and give frequent reminders to utilize, and keep within reach, Physical therapy as ordered, sit to stand for all transfers. There were no care plan interventions that addressed the resident's left index finger fracture, and no interventions that addressed the resident's use of fall mats or a concave mattress. An intervention bed in lowest position with fall mats next to bed was created and discontinued on 11/15/21. Continued review of the medical record failed to reveal a comprehensive care plan with resident centered goals and interventions had been developed to address the Resident #38's left index finger fracture. On 12/8/21 at 12:45 PM, the Director of Nurses was made aware of the above concerns. Based on medical record review and staff interview it was determined that facility staff 1) failed to develop and initiate a comprehensive, resident centered care plan for a resident who received oxygen, and 2) failed to follow the care plan. This was evident for 2 (#12, #34) of 3 residents reviewed for respiratory care during the annual survey, and 1 (#100) of 3 residents reviewed for complaints. 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. 1) On 11/30/21 at 2:58 PM Resident #12 was observed lying in bed. There was an oxygen concentrator next to the bed with oxygen flowing at 2.5 Liters with oxygen tubing dated 11/17/21. Observation was made again on 11/30/21 at 3:55 PM with a second surveyor who confirmed that the oxygen tubing was dated 11/17/21. On 11/30/21 at 4:00 PM a review of Resident #12's medical record revealed Resident #12 was admitted to the facility in October 2020 from an acute care hospital where he/she had been treated for acute respiratory failure and congestive heart failure. Review of Resident #12's November/December 2021 physician's orders revealed orders for oxygen at 2 liters/minute as needed and change oxygen tubing and humidifier bottle every week. Date and initial tubing and bottle. The orders have been in effect since written on 6/4/21. Review of Resident #12's vital signs report from 9/1/21 to 12/7/21 documented daily oxygen saturation levels. The percentage of oxygen saturation levels ranged from 92 % to 100% during that time period, however there were only 6 out of the 98 days where it was noted if the resident was on room air (no oxygen) or was wearing oxygen. On 9/13, 10/5, 11/2 and 12/1 the wearing of oxygen was documented. On 9/17 and 10/3 it was documented that the saturation level was taken on room air. The remaining days were unknown if oxygen was utilized. Continued review of the medical record revealed care plans for Resident #12. There was no care plan for oxygen therapy for Resident #12. On 12/7/21 at 11:27 AM the Director of Nursing confirmed the findings.4) On 12/8/21 review of Resident #100's medical record revealed an admission in September 2019 with diagnosis that included but not limited to atrial fibrillation (Afib), high blood pressure, and the presence of a cardiac pacemaker. The resident was discharged in January 2020. A pacemaker is a small device implanted in the chest to help control the heartbeat. It is used to prevent the heart from beating too slowly. Review of the care plans revealed a plan to address the resident's cardiac pacemaker. One of the interventions was that skilled nursing staff would check the resident's apical pulse one time weekly starting 9/16/19 and notify the physician if the rate was below 60. An apical pulse is obtained using a stethoscope and listening to the heart at the point of maximal impulse. Further review of the medical record failed to reveal documentation that the apical pulse was obtained as indicated in the care plan. On 12/8/21 at approximately 1:00 PM surveyor reviewed with the Director of Nursing (DON) the concern regarding the failure to follow the care plan for assessing the apical pulse. The DON acknowledged the concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for a Resident (#25) with dysphagia. This was evident for 1 (#25) of 3 resident reviewed for dining during the annual survey. The findings include: Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meets and develops 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 of the resident and as needed to ensure the interventions on the care plan are accurate and appropriate for the resident. According to the National Institute of Deafness and Other Communication Disorders, dysphagia is difficulty swallowing. Some people may be completely unable to swallow or may have trouble safely swallowing liquids, foods, or saliva. When that happens, eating becomes a challenge. Often, dysphagia makes it difficult to take in enough calories and fluids to nourish the body and can lead to additional serious medical problems. On 12/8/21 at 7:59 AM observation was made of Resident #25 eating in his/her room. Resident #25 was eating an egg on a biscuit and had cranberry juice in a cup with a lid and a straw. On 12/8/21 at 8:10 AM a review of Resident #25's medical record revealed a December 2021 physician's order for diet which stated, regular solids, thin liquids via cup sip, no straws. The order was written on 7/14/21 and was still in effect. Continued review of the medical record revealed a care plan, Alteration in nutrition secondary to poor PO (by mouth), difficulty swallowing, refusal of thickened liquids or pureed foods for safety that had the interventions, assist with tray prep as needed, keep resident in upright position for meals for safer swallowing, provide beverages of choice with meals, offer 1 glass of water/juice with each medication pass, and regular diet per resident choice (aware of risk). The care plan was not updated to reflect that Resident #25 should not have straws. On 12/8/21 at 8:49 AM an interview was conducted with Staff #25 (geriatric nursing assistant GNA). Staff #25 was asked if she was aware that Resident #25 could not have straws and she said, yes. When asked how she knew she said, they just told me. When asked if there was any type of GNA [NAME] or care plan with that information she said, No, the nurses will tell us that information. Discussed with the Director of Nursing on 12/8/21 at 9:30 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Supplemental oxygen is an oxygen therapy treatment that provides you with extra oxygen to breathe in. The surveyor conducted a tour of the facility on 12/01/2021 at 9:15 a.m. During the tour, the surveyor noted resident #21 in room [ROOM NUMBER]A at the bedside wearing a nasal cannula connected to an operating oxygen tank. Further observation revealed the label on the tubing read 11/17/2021. A review of Resident #21's medical record was conducted on 12/01/2021 at 10 a.m. Further review of the medical record, revealed resident #21 had been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and chronic respiratory failure. Also revealed during resident #21's medical record review was a physician's order that started on 06/30/2021 that stated to Change O2 cannula and tubing weekly and as needed. A review of resident #21's electronic Treatment Administration Record (TAR) ON 12/01/2021 at 10:15 a.m. The medical record revealed that Registered Nurse (RN #28) documented that the oxygen tubing was changed on 11/24/2021 and on 12/01/2021. A subsequent observation of resident #21's room was conducted on 12/03/2021 at 10:30 a.m The surveyor observed resident #21's oxygen tubing labeled with a date of 11/17/2021. On 12/03/2021at 1:43 p.m. the facility provided the survey team with documents entitled November 2021 Treatments, December 2021 Treatments, and Care Plan Report for Resident #21. On 12/03/2021 at 2:30 p.m. during the interview, the Administrator and the Director of Nursing (DON) were made aware of the surveyors' observation of resident #21's oxygen tubing, the noted handwritten label dated 11/17/2021, and the review of the TAR with RN #28's signature where the nurse denoted the tubing changes were conducted for dates 11/24/2021 and 12/01/2021. 3) On 11/30/21 at 12:30 PM, an observation was made of Resident #34 was observed wearing oxygen nasal cannula whose tubing was connected to a water humidifier bottle that was connected to an oxygen concentrator set at 3 LPM (liters per minute). The oxygen tubing was labeled with the date 11/17/21. Review of Resident #34 's November 2021 TAR revealed an 11/10/21 order to change O2 tubing and humidifier bottle once a week; date and initial tubing and bottle . The order was signed off as done on 11/24/21, though the oxygen tubing was observed to be dated 11/17/21. The standard of practice for nursing is to label oxygen tubing with the date the tubing was changed. On 12/2/21 at 1:51 PM the Director of Nursing was made aware of the oxygen tubing not being changed when the nurse signed off that it was changed. Cross Reference F695 4) On 12/7/21 at 10:28 AM, a review of facility reported incident MD00174221 revealed, on the night of 11/13/21, Resident #38 was noted to have a bruise on the base of his second finger on his/her left hand. An x-ray of the resident's left, 2nd finger was obtained and, on 11/14/21 at 5:49 PM, in a Radiology Report, the physician reported Resident #34 had a had a fracture (broken bone) of his/her left, second finger. Review of Resident #38 ' s physician orders revealed an order for Brace (support), two times a daily starting 11/15/21 . Buddy tape (tape together) left hand second digit to third digit (finger) for support. R/T (related to) recent fracture of 2nd digit. Ensure placement each shift. Reapply PRN (as needed) , which was discontinued on 12/3/21 and an order to Brace, two times a daily for 12 days starting 12/3/21 . Buddy tape left hand second digit to third digit for support. R/T (related to) recent fracture of 2nd digit. Ensure placement each shift. Reapply PRN. Total 4 weeks . Review of Resident #38's Clinical Notes revealed on 12/7/21 at 10:20 AM, in a clinical note, the nurse wrote that bruising to left index finger resolving, slight swelling still noted; treatment in place and administered. On 12/7/21 at 11:00 AM, an observation of was made of Resident #38, in a wheelchair, in the day room. At that time, there was nothing in or on Resident #38 ' s left hand; the second and third fingers were not buddy taped together. On 12/7/21 at 12:00 PM, observation of Resident #38, in the dining room, by two surveyors revealed Resident #38 ' s left 2nd and 3rd fingers were not buddy taped together. On 12/7/21 at 3:00 PM, observation of Resident #38, in a wheelchair in the resident ' s room revealed Resident #38 ' s left 2nd and 3rd fingers were not buddy taped together Review of Resident #38's December 2021 TAR revealed an order to Buddy tape left hand second digit to third digit for support. R/T (related to) recent fracture of 2nd digit. Ensure placement each shift. Reapply PRN (as needed). The order was signed off as completed on 12/7/21, 7am-7pm, indicating that on 12/7/21, during the day, the treatment had been applied to Resident #38 ' s fingers. The nurse failed to follow the order to buddy tape Resident #38's left, 2nd and 3rd fingers as ordered, and failed to accurately document when the ordered treatment to buddy tape Resident #38's fingers was not completed. The Director of Nurses was made aware of the above findings on 12/7/21 at 3:50 PM Based on observation and medical record review, it was determined the facility staff failed to provide nursing care with the standards of practice as evidenced by 1) failing to follow physician orders, and 2) failing to accurately document in a resident's treatment record. This was evident for 3 (#12, #21, #34) of 3 residents reviewed for respiratory care and 1 (#38) of 13 residents reviewed for abuse. The findings include: 1) On 11/30/21 at 2:58 PM observation was made of Resident #12 lying in bed wearing a nasal cannula. A nasal cannula consists of a flexible tube that is placed under the nose. The tube includes two prongs that go inside the nostrils to deliver oxygen. There was an oxygen concentrator next to the bed with oxygen tubing dated 11/17/21. On 11/30/21 at 3:55 PM a second surveyor confirmed the date of 11/17/21 on the tubing. On 11/30/21 at 4:00 PM a review of Resident #12's medical record revealed November 2021 physician's orders that stated, change O2 (oxygen) tubing and humidifier bottle q (every) week; date and initial tubing and bottle which was initiated on 6/24/21. Review of Resident #12's Treatment Administration Record (TAR) revealed initials from the nurse that the oxygen tubing was changed on 11/24/21, even though the date that was observed on the oxygen tubing stated 11/17/21. The standard of practice for nursing is to label oxygen tubing with the date the tubing was changed. On 12/2/21 at 1:51 PM the Director of Nursing was made aware of the oxygen tubing not being changed when the nurse signed off that it was changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, it was determined the facility staff failed to follow the physician's order for a Resident (#25) with dysphagia. This was evident for 1 (#25) of 3 resident reviewed for dining during the annual survey. The findings include: According to the National Institute of Deafness and Other Communication Disorders, dysphagia is difficulty swallowing. Some people may be completely unable to swallow or may have trouble safely swallowing liquids, foods, or saliva. When that happens, eating becomes a challenge. Often, dysphagia makes it difficult to take in enough calories and fluids to nourish the body and can lead to additional serious medical problems. On 12/8/21 at 7:59 AM observation was made of Resident #25 eating in his/her room. Resident #25 was eating an egg on a biscuit and had cranberry juice in a cup with a lid and a straw. On 12/8/21 at 8:10 AM a review of Resident #25's medical record revealed a December 2021 physician's order for diet which stated, regular solids, thin liquids via cup sip, no straws. The order was written on 7/14/21 and was still in effect. On 12/8/21 at 8:25 AM the surveyor went to the resident's room with the Director of Nursing (DON). The surveyor had told the DON of the observation of a straw on the resident's table and that the physician's orders stated, regular solids, thin liquids via cup sip, no straws. The DON asked the resident if he/she knew that he/she was not supposed to have straws. Resident #25 stated, No, I wasn't aware of that. The DON explained why the resident could not have straws and Resident #25 said, OK. The DON put juice in a sippy cup for the resident. The DON and the surveyor observed another plastic cup with water on the top of the dresser with a straw in the cup. The DON removed the cup and straw from the resident's room. On 12/8/21 at 8:32 AM Staff #18 (LPN), who was assigned to Resident #25 that morning, was asked about the resident having straws and she said, Oh no, [he/she] is not supposed to have straws. On 12/8/21 at 8:49 AM an interview was conducted with Staff #25 (geriatric nursing assistant GNA). Staff #25 was asked if she was aware that Resident #25 could not have straws and she said, yes. When asked how she knew she said, they just told me. When asked if there was any type of GNA [NAME] or care plan with that information she said, No, the nurses will tell us that information. Discussed the concern with the DON on 12/8/21 at 9:30 AM.

Based on observation, medical record review and interview it was determined the facility 1) failed to follow physician's orders for labeling and dating oxygen tubing when changed, 2) failed to develop and implement a person-centered comprehensive care plan with resident centered goals for respiratory care to include oxygen therapy, and 3) failed to consistently document if a resident was administered oxygen. This was evident for 2 (#34, #12) of 3 residents reviewed for respiratory care during the annual survey. The findings include: 1) On 11/30/21 at 12:30 PM, an observation was made of Resident #34 wearing an oxygen nasal cannula whose tubing was connected to a water humidifier bottle that was connected to an oxygen concentrator set at 3 LPM (liters per minute). The oxygen tubing was labeled with the date 11/17/21. On 12/2/21 at 8:30 AM, a review of Resident #34's medical record revealed, on 11/10/21, in a History and Physical (H & P) note, the physician wrote Resident #34 was admitted for rehab post-hospitalization for diagnosis that included aspiration pneumonia (lung infection that occurs when a person breathes something instead of swallowing it), ILD (interstitial lung disease) (scarring of lung tissue), COPD (chronic obstructive pulmonary [lung] disease), chronic respiratory failure with hypoxia and indicated Resident #34 used a CPAP (continuous positive airway pressure) machine (treatment for sleep apnea) (disorder in which breathing repeatedly stops and starts). Review of Resident #34 's November 2021 TAR (treatment administration record) revealed an 11/10/21 order to change O2 tubing and humidifier bottle once a week. Date and initial tubing and bottle . The order was signed off as done on 11/24/21, though the oxygen tubing was observed to be dated 11/17/21. The standard of practice for nursing is to label oxygen tubing with the date the tubing was changed. Also, the November 2021 TAR revealed Resident #34 had an order for a CPAP to be on at bedtime and taken off in the morning, initiated on 11/10/21, upon the resident's admission. The TAR documented Resident #34 complied with wearing the CPAP on 11 of 15 days. Of the 5 nights the resident did not wear the CPAP, the TAR documented Resident #34 refused the CPAP, and on 2 nights, there was no explanation as to why the resident did not wear the CPAP. 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 #34's care plans failed to reveal a comprehensive, resident centered care plan had been developed to address Resident #34's respiratory status, oxygen therapy or use of a CPAP machine. On 12/2/21 at 1:51 PM, the Director of nurses was made aware of the above concerns related to Resident #34. Cross Reference F656, F658, F842 2) On 11/30/21 at 2:58 PM Resident #12 was observed lying in bed. There was an oxygen concentrator next to the bed with oxygen flowing at 2.5 Liters with oxygen tubing dated 11/17/21. Observation was made again on 11/30/21 at 3:55 PM with a second surveyor who confirmed that the oxygen tubing was dated 11/17/21. On 11/30/21 at 4:00 PM a review of Resident #12's medical record revealed Resident #12 was admitted to the facility in October 2020 from an acute care hospital where he/she had been treated for acute respiratory failure and congestive heart failure. Review of Resident #12's November/December 2021 physician's orders revealed orders for oxygen at 2 liters/minute as needed and change oxygen tubing and humidifier bottle every week. Date and initial tubing and bottle. The orders have been in effect since written on 6/4/21. Review of Resident #12's vital signs report from 9/1/21 to 12/7/21 documented daily oxygen saturation levels. The percentage of oxygen saturation levels ranged from 92 % to 100% during that time period, however there were only 6 out of the 98 days where it was noted if the resident was on room air (no oxygen) or was wearing oxygen. On 9/13, 10/5, 11/2 and 12/1 the wearing of oxygen was documented. On 9/17 and 10/3 it was documented that the saturation level was taken on room air. The remaining days were unknown if oxygen was utilized. Review of Treatment Administration Records (TAR) for September 2021 documented that Resident #12 was administered oxygen on 9/28/21 and 9/30/21, however there was no corresponding documentation related to why the resident was wearing oxygen. The October 2021 TAR was blank for oxygen administration, however the vital signs report documented on 10/5 that the resident was administered oxygen. The November 2021 TAR was blank for oxygen administration, however the vital signs report documented on 11/2 that the resident was administered oxygen. The December 2021 TAR was blank for oxygen administration, however the vital signs report documented on 12/1 that the resident was administered oxygen. Continued review of the medical record revealed care plans for Resident #12. 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. There was no care plan for oxygen therapy for Resident #12. Resident #12's medical record was void of ongoing respiratory assessments in response to the oxygen therapy. On 12/7/21 at 11:27 AM the issue was discussed with the Director of Nursing who confirmed the findings.

Based on medical record review and interview it was determined that the facility failed 1) to ensure staff completed the controlled drug count at the change of shift as evidenced by documentation by nursing staff that the count had been completed prior to the end of the shift; 2) to ensure regularly scheduled medications were re-ordered and obtained in a timely manner to prevent missed doses; and 3) to ensure medications available in the interim supply were accessed to prevent missed doses. This was found to be evident for of 1 out of 2 medication carts reviewed and 3 (#100, #41, #201) out of 34 residents reviewed during the survey The findings include: 1) Review of the facility's Controlled Medication policy revealed the following Procedure/Process: .3. Identified Controlled Medications will be counted by two licensed nurses at the beginning of each shift. One RN/LPN going off duty and one coming on duty RN/LPN must count and justify identified Controlled Medications for each resident at the change of shift. The on-coming shift nurse will verify the number on the narcotic count record and the off-going shift will verify the count in the card/vial/box. 4. After the count is complete and correct, each nurse must record the date and signature verifying that the count is correct. On 12/1/21 at 12:20 PM surveyor reviewed a Controlled Drug Count Verification (Shift Count Sheet for Narcotics) and found that Nurse #6 had already signed in the space for the off-going nurse for 12/1/21 at 7:00 PM. Interview with Nurse #6 on 12/1/21 at 12:20 PM confirmed that s/he had already signed for the end of shift count. On 12/01/21 at 2:45 PM surveyor reviewed with the Director of Nursing (DON) the concern regarding the day nurse presigning the Controlled Drug count verification. 2a) On 12/8/21 review of Resident #100's medical record revealed an admission in September 2019 with diagnosis that included but not limited to atrial fibrillation (Afib), high blood pressure, arthritis and chronic lung disease. Afib is an irregular and often rapid heart beat that can lead to blood clots. Review of the physician orders revealed an order dated 9/14/19 for propafenone 150 mg two times daily for afib. Propafenome is an antiarrhythmic medication that works by acting on the heart muscle to improve heart's rhythm. Review of the Medication Administration Record (MAR) revealed this medication was scheduled to be given at 9:00 AM and 9:00 PM. Further review of the MAR revealed documentation that the medication was not administered on the flowing occasions due to the medication not being available: -10/17/19 at 9:00 PM -10/19/19 at 9:00 AM -11/18/19 at 9:00 PM -11/19/19 at 9:00 AM Additional documentation was found regarding the 11/19/19 9:00 AM dose that indicated the pharmacy had been contacted and that there was a billing issue. Further review of the medical record failed to reveal documentation that the physician had been made aware of the missed doses. On 12/8/21 at approximately 1:00 PM surveyor reviewed the concern with the Director of Nursing regarding the failure to obtain the regularly scheduled medication for the treatment of afib resulting in missed doses for Resident #100. 2b. On 12/2/21 at 8:34 AM review of Resident #41's medical record revealed the resident was admitted in November 2021 with diagnosis that included but not limited to afib, hyperlipidemia (high cholesterol), diabetes and a urinary tract infection (UTI). Further review of the medical record revealed an order for Levemir Flexpen 100 units/ml solution 50 units two times a day starting on 11/15/21. Levemir is a long acting insulin. The Flexpen contains 3 ml of levemir, which is 300 units. According to the order each dose was 50 units which means one Flexpen would contain enough insulin for six doses. At two doses a day, each Flexpen would last for 3 days. Review of the Medication Administration Record (MAR) revealed the Levemir was administered as ordered on 11/16, 17 and 18. Further review of the MAR revealed documentation that the dose due on the morning of 11/19 was not administered due to not being available. Further review of the MAR revealed the Levemir was administered as ordered on 11/19 evening dose through the 11/28 morning dose (18 doses). Further review of the MAR revealed documentation that the dose due on 11/28 evening and 11/29 morning were not administered due to not being available. On 12/3/21 at 10:52 AM surveyor reviewed the concern with the Director of Nursing regarding the missed doses of regularly scheduled Levemir due to the medication not being available. 3) The facility has an Omnicell machine. An Omnicell is a machine that dispenses limited doses of medications that a resident may require prior to the ordered supply being delivered. This would be the interim medication supply. 3a. Review of Resident #201's medical record on 12/1/21 at 10:29 AM, revealed an order dated 11/29/21 for Eliquis 2.5 mg two times daily for Afib. Afib (atrial fibrillation) is an irregular and often rapid heartbeat that can lead to blood clots. Eliquis is an anticoagulant medication used to prevent blood clots from forming due to certain irregular heartbeats, such as Afib. Review of the Omnicell Item Table List Report on 12/2/21 revealed a supply of Eliquis 2.5 mg is kept available in the Omnicell. Review of the Medication Administration Record (MAR) revealed the Eliquis was not administered on 11/29/21 due to being not available. Further review of the medical record failed to reveal documentation to indicate the staff had attempted to obtain the Eliquis from the Omnicell on 11/29/21. On 12/02/21 at 11:27 AM surveyor reviewed with DON that the Eliquis had not been administered the day of admission. Further review of Resident #201's medical record revealed an order on 11/29/21 for doxycycline monohydrate 100 mg capsule every 12 hours for four days starting 11/29/21. Doxycycline monohydrate is an antibiotic. Review of the Omnicell Items Table List Report revealed a supply of doxycycline 100 mg capsules is kept in the Omnicell. Review of the MAR revealed documentation that the dose of this antibiotic that was due on the evening of 11/29/21 was not administered due to the medication not being available. Further review of the medical record failed to reveal documentation to indicate the staff had attempted to obtain the doxycycline from the Omnicell on 11/29/21. 3b. On 12/2/21 continued review of Resident #41's medical record revealed a nursing note written on 11/15/21 at 12 noon. This note revealed the resident had arrived at the facility at 8:15 AM and that the resident was continuing on levaquin (an antibiotic) for UTI. The nursing notes also indicate the interim supply of medication was accessed to obtain as needed pain medications during the day shift. Further review of the medical record revealed an order for levofloxacin 750 mg one tablet every two days for eight days starting 11/15/21 for a urinary tract infection. Levofloxacin is an antibiotic also know as Levoquin. Review of the MAR revealed the levofloxacin was scheduled to be administered on 11/15/21 at 6:00 PM but was not administered due to the medication not being available. Review of the Omnicell Items Table List Report revealed a supply of Levofloxacin 250 mg tablets is kept in the Omnicell. No documentation was found to indicate staff had attempted to obtain the medication from the Omnicell for the dose due on the evening of 11/15/21. Based on the review of the 11/15/21 levofloxacin order, the resident should of received four doses of the antibiotic. Further review of the MAR revealed documention of only 3 doses of the antibiotic, the first being administered on 11/17/21. Further review of the medical record revealed an order for Eliquis 5 mgs one tablet two times a day to start on 11/15/21. Review of the MAR revealed the Eliquis was administered in the morning of 11/15/21 but was not administered when due in the evening due to the medication not being available. Review of the Omnicell Items Table List Report revealed a supply of Eliquis 5 mg tablets is kept in the Omnicell. No documentation was found to indicate staff had attempted to obtain the medication from the Omnicell for the dose due on the evening of 11/15/21. Further review of the medical record revealed an order for gabapentin 300 mg one capsule three times a day starting 11/15/21. Review of the MAR revealed documentation that the gabapentin was administered when scheduled at 9:00 AM and 2:00 PM on 11/15 but was not administered when due in the evening due to the medication not being available. Review of the Omnicell Items Table List Report revealed a supply of gabapentin 300 mg capsules is kept in the Omnicell. No documentation was found to indicate staff had attempted to obtain the medication from the Omnicell for the dose due on the evening of 11/15/21. Further review of the medical record revealed an order for atorvastin 40 mg one tablet every day starting 11/15/21. Review of the MAR revealed documentation that the atorvastin was not administered when due in the evening of 11/15 due to the medication not being available. Review of the Omnicell Items Table List Report revealed a supply of atorvastin 10 mg tablets is kept in the Omnicell. No documentation was found to indicate staff had attempted to obtain the medication from the Omnicell for the dose due on the evening of 11/15/21. On 12/03/21 at 10:52 AM surveyor reviewed the concern with the Director of Nursing regarding medications not being administered despite being available in the Omnicell for Resident #41. As of time of exit on 12/8/21 no additional documentation was provided regarding the missed doses.

Based on observation, interview and medical record review it was determined that the facility failed to ensure residents were free from significant medication errors as evidenced by failure to administer medication for the treatment of atrial fibrillation as ordered on 3 occasions over a 3 day period. This was found to be evident for 1 (#201) of 4 residents observed during the medication observation task. The findings include: 1. Review of Resident #201's medical record on 12/1/21 at 10:29 AM, revealed an order dated 11/29/21 for Eliquis 2.5 mg two times daily for Afib. Afib (atrial fibrillation) is an irregular and often rapid heartbeat that can lead to blood clots in the heart. Eliquis is an anticoagulant medication used to prevent blood clots from forming due to certain irregular heartbeats, such as Afib. a. The facility has an Omnicell machine. An Omnicell is a machine that dispenses limited doses of medications that a resident may require prior to the ordered supply being delivered. Review of the Omnicell Item Table List Report on 12/2/21 revealed a supply of Eliquis 2.5 mg is kept available in the Omnicell. Review of the Medication Administration Record revealed the Eliquis was not administered on 11/29/21. Review of the nursing notes related to the doses scheduled for 11/29/21 revealed the medication was not administered due to being not available. Further review of the medical record failed to reveal documentation to indicate the staff had attempted to obtain the Eliquis from the Omnicell on 11/29/21. b. Review of the facility's Medication Administration Times policy and procedure (with a review date of June 2021) revealed a medication ordered to be given two times a day, for a resident in Resident #201's room, should be administered at 8:00 AM and 5:00 PM. Further review of the medical record failed to reveal documentation to indicate the Eliquis was administered on the morning of 11/30/21. Review of the Medication Administration Record (MAR) revealed the Eliquis was scheduled to be given at 5:00 PM and 8:00 PM. Documentation was found that the Eliquis had been administered on 11/30 at 5:00 PM and again at 8:00 PM. c. Surveyor observed certified medication aide (CMA #5) administer morning medications to Resident #201 on 12/1/21 at 8:38 AM. Surveyor did not observed Eliquis being administered to Resident #201 on the morning of 12/1/21. On 12/01/21 at 3:47 PM the Director of Nursing (DON) confirmed that a medication ordered two times a day should be administered in the AM and in the PM. Surveyor then reviewed the concern that MAR indicates the Eliquis was scheduled to be given at 5:00 PM and 8:00 PM. The DON indicated she would investigate. On 12/02/21 at 10:48 AM the DON reported there was a transcription error regarding the Eliquis, indicating 8:00 PM had been entered rather than 8:00 AM. On 12/2/21 further review of the medical record revealed a new order for Eliquis was put in place on 12/1/21. Review of the December MAR revealed the medication was now scheduled for 8:00 AM and 5:00 PM. There was a nursing note on the MAR that the dose due on 12/1/21 at 8:00 AM was not administered. On 12/02/21 at 11:27 AM surveyor reviewed with DON the concern regarding significant medication error related to Eliquis.

2) Oxygen (O2) tubing (nasal cannula) is a small, flexible tube that contains two open prongs intended to sit just inside of the nostrils. The other end of the tubing attaches to an oxygen source and delivers a steady stream of medical-grade oxygen to the nose. [Taber's Nursing Dictionary] Chronic Obstructive Pulmonary Disease (COPD) refers to a group of diseases that cause airflow blockage and breathing-related problems. [CDC.gov] The survey team conducted a tour of the facility on 12/01/2021 at 9:15 a.m. During the tour, the surveyor noted resident #21 in their assigned room at the bedside wearing a nasal cannula connected to an operating oxygen tank sitting nearby on the floor. Further observation revealed the label on the tubing read 11/17/2021. A review of Resident #21's medical record was conducted on 12/01/2021 at 10 a.m. Resident #21was admitted with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and chronic respiratory failure. A review of physician's orders for Resident #21 dated 06/30/2021 stated to: Change O2 cannula and tubing weekly and as needed. However, further review of the Treatment Administration Record (TAR) revealed that Registered Nurse (RN# 28) documented the changing of resident #21's oxygen tubing on 11/24/2021 and on 12/01/2021. However, a subsequent observation of resident #21 was conducted on 12/03/2021 at 10:30 a.m. The surveyor observed resident #21's oxygen tubing labeled with a date of 11/17/2021. On 12/03/2021 at 2:30 p.m. during the interview, the Administrator and the Director of Nursing (DON) were made aware of the surveyors' observation of Resident #21's oxygen tubing, the noted handwritten label dated 11/17/2021, and the review of the TAR with RN #28's signature where the nurse denoted the tubing changes were conducted for dates 11/24/2021 and 12/01/2021. 3) On 11/30/21, at 12:34 PM, an observation was made of Resident #34 wearing an oxygen nasal cannula whose tubing was connected to a water humidifier bottle that was connected to an oxygen concentrator set at 3 LPM (liters per minute). The oxygen tubing was dated 11/17/21. On 12/2/21 at 8:30 AM, a review of Resident #34's November 2021 TAR (treatment administration record) revealed an 11/10/21 order to change O2 tubing and humidifier bottle once a week; date and initial tubing and bottle. The order was signed off as done on 11/24/21, though the oxygen tubing was observed to be dated 11/17/21. The Director of Nurses was made aware of the documentation discrepancy on 12/2/21 at 11:30 AM. 4) On 12/7/21 at 10:28 AM, a review of Resident #38's medical record was conducted. Review of Resident #38's December 2021 TAR revealed an order to Buddy tape left hand second digit to third digit for support. R/T (related to) recent fracture of 2nd digit. Ensure placement each shift. Reapply PRN. The order was signed off as completed on 12/7/21, 7am-7pm, indicating that the treatment had been completed and Resident #38's fingers had been buddy taped together as ordered. On 12/7/21 at 11:00 AM, Resident #38 was observed sitting in a wheelchair, in the day room. At that time, Resident #38's left hand, 2nd and 3rd fingers were not buddy taped together. On 12/7/21 at 12:00 PM, two surveyors observed Resident #38 in the dining room. At that time, the resident's left 2nd and 3rd fingers were not buddy taped together. On 12/7/21 at 3:00 PM, Resident #38 was observed in his/her room, sitting in a wheelchair and his/her left 2nd and 3rd fingers were not buddy taped together. Multiple surveyor observations failed to reveal evidence that, on 12/7/21, 7am-7pm shift, the treatment to buddy tape Resident #38's left second and third fingers together had been completed as documented in the TAR. The Director of Nurses was made aware of the documentation discrepancy on 12/7/21 at 3:50 PM Cross Reference F 658Based on observation, medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 3 (#12, #21, #34) of 3 residents reviewed for respiratory care, 1 (#38) of 13 residents reviewed for abuse, and 5 (#41, #34, #18, #6, #33) of 5 residents reviewed for immunizations. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 11/30/21 at 2:58 PM observation was made of Resident #12 lying in bed wearing a nasal cannula. A nasal cannula consists of a flexible tube that is placed under the nose. The tube includes two prongs that go inside the nostrils to deliver oxygen. There was an oxygen concentrator next to the bed with oxygen tubing dated 11/17/21. On 11/30/21 at 3:55 PM a second surveyor confirmed the date of 11/17/21 on the tubing. On 11/30/21 at 4:00 PM a review of Resident #12's medical record revealed November 2021 physician's orders that stated, change O2 (oxygen) tubing and humidifier bottle q (every) week; date and initial tubing and bottle which was initiated on 6/24/21. Review of Resident #12's Treatment Administration Record (TAR) revealed initials from the nurse that the oxygen tubing was changed on 11/24/21, even though the date that was observed on the oxygen tubing stated 11/17/21. On 12/2/21 at 1:51 PM the Director of Nursing was made aware of the discrepancy in documentation. 5) When a vaccine is administered the lot number for that particular vaccine being administered is recorded in a resident's medical record. A COVID vaccine would have a different number than a pneumococcal vaccine. 5a. On 12/2/21 review of Resident #41's medical record revealed the resident had declined the pneumococcal vaccine on 11/16/21. Review of the Immunization Record in the electronic health record revealed documentation that the resident had received a pneumococcal vaccine and a COVID vaccine on 11/18/21. Further review of the immunization record documentation revealed the lot number documented for both the COVID and pneumococcal vaccine were the same number, indicating an error in documentation. On 12/2/21 at 3:00 PM the Director of Nursing reported that, according to the nurse who had completed the documentation, the documentation of the pneumococcal vaccine was completed by accident and the nurse couldn't figure out how to remove it from the record. 5b. On 12/7/21 review of Resident #34's medical record revealed documentation of both pneumococcal and COVID vaccine on 11/12/21. Both had the same lot number listed. 5c. On 12/7/21 review of Resident #18's medical record revealed documentation of both pneumococcal and COVID vaccine on 12/26/20 and again on 1/16/21. Both had the same lot number listed. 5d. On 12/7/21 review of Resident #6's medical record revealed documentation of both pneumococcal and COVID vaccine on 1/16/21. Both had the same lot number listed. 5e. On 12/7/21 review of Resident #33's medical record revealed documentation of both pneumococcal and COVID vaccine on 12/26/20 and 1/16/21. Both had the same lot number listed. On 12/7/21 at 9:26 AM the Director of Nursing reported there must be a glitch with the [electronic health record] system indicating that when a COVID vaccine is entered the pneumococcal is also documented. Cross reference for F 883

Based on observation and staff interview it was determined the facility failed to ensure an effective infection prevention and control program by failing to ensure that staff utilized personal protective equipment (PPE) in a manner that met minimum standards and minimized risk for infectious spread. The noncompliant practice within the facility infection prevention and control program left all residents, staff, and visitors at increased risk for infection. The findings include: Consistent with the 4/2/2020 CMS guidance, on 4/27/2021, the Centers for Disease Control and Prevention (CDC) published updated guidance which stated, In general, fully vaccinated HCP (health care provider) should continue to wear source control while at work. However, fully vaccinated HCP could dine and socialize together in break rooms and conduct in-person meetings without source control or physical distancing. On 5/4/2021 The Maryland Department of Health (MDH) Secretary issued an amended Directive and Order Regarding Nursing Home Matters. The 5/4/21 Directive and Order, finding it necessary for the prevention and control of 2019 Novel Coronavirus (SARS-CoV-2 or 2019-NCoV or COVID-19), and for the protection of the health and safety of patients, staff, and other individuals in Maryland, hereby authorize and order the following actions for the prevention and control of this infectious and contagious disease under the Governor's Declaration of Catastrophic Health Emergency. This Amended Directive and Order replaces and supersedes the Directives and Orders Regarding Nursing Home Matters, dated February 8, 2021, November 17, October 1, July 24, June 19, April 29, April 24, April 9, and April 5, 2020. 1C. documented, All staff, volunteers, vendors, visitors, and residents, shall follow CDC and CMS guidance on face covering usage when in the facility. 1) On 12/7/21 at 9:36 AM observation was made in the kitchen of the General Manager, Staff #16 walking around the kitchen with cardboard boxes. Staff #16 was wearing a face mask that was under his chin. Staff #16 walked past preparation tables. Also observed in the kitchen was a cell phone lying on the food preparation table. The cell phone was next to the bowl of icing where Staff #17 was dipping donut holes that were on a stick. 2) On 12/7/21 at 12:04 PM a second observation was made in the kitchen. Dietary Staff #20 was chopping carrots. He was not wearing a hairnet and his face mask was below his nose. Dietary Staff #21 was also observed in the kitchen with his mask below his chin. At that time Staff #16 was informed of the concern. Staff #16 asked Staff #21 if he had his mask below his chin. Staff #21 confirmed to Staff #16 that his mask was below the chin when the surveyor observed him. 3) On 12/8/21 at 7:50 AM observation was made in the kitchen of a black backpack lying next to the toaster along with a water bottle with an orange drink. There was also a cleaning cloth lying in front of a pan of bacon on the hot table. The Director of Nursing was informed of the observations on 12/8/21 at 9:38 AM. Based on observation and interview it was determined that the facility failed to ensure separation of clean and dirty portions of the laundry processing areas. This was found during an observation of the laundry and has the potential to affect all the residents. The findings include: 4) On 12/7/21 at 10:38 AM surveyor toured the laundry area with the housekeeping supervisor (Staff # 23). There was a large open doorway between the area with the dryers and the area containing the washing machines but no door or other physical barrier present in this open area. The laundry supervisor reported the open area has been like that since he has been at the faciltiy. Further observation of the laundry area revealed a door located next to the washing machines that was propped open with a door stop. This doorway led to the area where dirty laundry arrives via the laundry shoot. One green bag of dirty laundry was observed in this area by the surveyor and the supervisor. The supervisor removed the door stop and closed the door. On 12/7/21 at 11:30 AM surveyor reviewed the concern with the Director of Nursing regarding the observation of the door propped open between the washers and the laundry shoot and the lack of physical separation between the washer and dryer areas. 5) Failed to ensure staff wore masks in appropriate manner. On 12/1/21 at 9:25 AM housekeeping staff #22 was observed in the hallway near the main nursing unit with a mask below his/her nose. At 9:28 AM when surveyor asked about how the mask was being worn, the housekeeper responded that it had fell down and proceeded to move the mask over the nose. This observation was reviewed with the Director of Nursing on 12/8/21 at 9:34 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined the facility failed to have an effective system in place to assess residents' pneumonia vaccination status, adequate assessment of a resident's previous pneumonia vaccine administration is required in order to determine which pneumococcal vaccine is indicated and when it should be administered. This was found to be evident for 5 ( #34, #41, #18, #6,#33) of 5 residents reviewed for immunization status during the survey. The findings include: Review of the Pneumococcal Pneumonia Vaccination policy (revision date 10/1/21) revealed the facility will follow current CDC guidelines and best practices for the prevention and control of pneumococcal pneumonia. Procedures/Process includes: 1. During the admission process, the admitting nurse, or designee shall provide education on the benefits and risk of receiving the pneumococcal pneumonia vaccine. Consent to administer or statement of decline, with reason for decline, will be obtained from the resident, or the resident's responsible party 2. If the resident had previously received the pneumococcal pneumonia vaccine, the year it was received and the resident's age at the time it was received should be determined to the degree possible and documented. 3. The resident's electronic medical record includes documentation that indicates at a minimum, the following: That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of immunization: and that the resident either received the immunization or did not receive the immunization due to medical contraindications or refusals to include reason for the refusal. Review of the [facility name] Resident Pneumococcal Vaccination Consent/Decline Form revealed CDC recommends the following for adults over the age of 65: -Pneumococcal conjugate vaccine (PCV13), which protects against serious pneumococcal disease and pneumonia (recommended for all adults with a condition that weakens the immune system, cerebrospinal fluid leak, cochlear implant or living in a congragent/long term care home) --Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later. --If the resident already received PPSV23, give the dose of PCV 13 at least 1 year after they received the most recent dose of PPSV23. -Pneumococcal polysaccharide vaccine (PPSV23), which protects against serious pneumococcal disease, including meningitis and bloodstream infections. --Anyone who received any doses of PPSV23 before age [AGE] should receive 1 final dose of the vaccine at age [AGE] or older. Administer this last dose at least 5 years after the prior PPSV23 dose. Further review of the Resident Pneumococcal Vaccination Consent/Decline Form revealed an area to consent to the administration of the PCV13 and or the PPSV23. As well as an area to decline the vaccine. No area was found on the form to document the reason for the decline. No area was found to document if or when the resident received a previous dose of either the PCV13 or PPSV23. 1) On 12/7/21 review of Resident #34 medical record revealed a Resident Pneumococcal Vaccination Consent/Decline Form signed by the resident on 11/11/21. There is a check in the section under consent for the PPSV23, however there is also a handwritten note next to this section had it already. Further review of the medical record failed to reveal documentation as to when the PPSV23 had been administered or if there had been an assessment to determine if the PPV13 was currently indicated. Further review of Resident #34 electronic health record revealed documentation in the Immunization Record that a Pneumococcal vaccine had been administered on 11/12/21, However further review of the medical record revealed these dates and documented lot numbers corresponded to when the resident received the COVID vaccine. On 12/7/21 at 9:26 AM interview with the Director of Nursing revealed a data processing issue that was causing pneumococcal vaccine to be documented when the COVID vaccine was administered. Further review of the medical record failed to reveal documentation that the resident had received a pneumonia vaccine since the consent form had been signed on 11/11/21. 2) Review of Resident #41's medical record revealed a Resident Pneumococcal Vaccination Consent/Decline Form signed by the resident on 11/16/21. The form has a check in the section to decline the vaccine. There was a handwritten notation had it next to the mark indicating the vaccine was being declined. Further review of the medical record failed to reveal documentation as to whether the PPSV23, the PPV13 or both had been administered to the resident. No documentation was found to indicate an assessment had been completed to determine if one of the pneumococcal vaccines was currently indicated for the resident. Further review of Resident #41's electronic health record revealed documentation in the Immunization Record that a Pneumococcal vaccine had been administered on 11/18/21. However further review of the medical record revealed these dates and documented lot numbers corresponded to when the resident received the COVID vaccine. On 12/02/21 at 2:19 PM the Director of Nursing confirmed the resident did not receive the pneumococcal vaccine. 3) On 12/7/21 review of Resident #18's medical record revealed the resident had resided at the facility for more than one year. Further review of the medical record failed to reveal a signed Resident Pneumococcal Vaccination Consent/Decline Form. Further review of Resident #18's electronic medical record revealed documentation in the Immunization Record that Pneumococcal vaccine had been administered on 12/26/20 and 1/16/21. However further review of the medical record revealed these dates and documented lot numbers corresponded to when the resident received the COVID vaccine. 4) On 12/7/21 review of Resident #6's medical record revealed the resident had resided at the facility for more than one year. Further review of the medical record failed to reveal a signed Resident Pneumococcal Vaccination Consent/Decline Form. Further review of Resident #6's electronic medical record revealed documentation in the Immunization Record that Pneumococcal vaccine had been administered 1/16/21. However further review of the medical record revealed these dates and documented lot numbers corresponded to when the resident received the COVID vaccine. 5) On 12/7/21 review of Resident #33's medical record revealed the resident had resided at the facility for several years. Further review of Resident #33's electronic medical record revealed documentation in the Immunization Record that Pneumococcal vaccine had been administered on 12/26/20 and 1/16/21. However, further review of the medical record revealed these dates and documented lot numbers corresponded to when the resident received the COVID vaccine. Further review of the medical record failed to reveal documentation to indicate if the pneumococcal vaccine status of the resident had been assessed by the facility, or if a Resident Pneumococcal Vaccination Consent/Decline Form had been completed. On 12/7/21 at 9:45 AM surveyor reviewed the concern with the Director of Nursing regarding the monitoring, assessing and providing the pneumococcal vaccines. Cross reference to F 842.

Based on medical record review and staff interview it was determined the facility failed to ensure that a physician dated a Medical Order for Life-Sustaining Treatment (MOLST) for Resident #32. This was evident for 1 of 17 residents reviewed during the survey. The findings include: On 9/26/18 at 2:34 PM while reviewing the medical record of Resident #32, it was noted that the MOLST form was not dated. The MOLST is a medical order form that relays instructions between health professionals regarding a patient's care. It indicates the type of medical treatment to be accepted or refused including whether or not to receive cardiopulmonary resuscitation. In Maryland MOLST FAQs, a document developed by the Maryland MOLST Training Task Force and dated August 2018, it states on page 8, The form is a medical order and must be signed and dated by a Maryland-licensed physician, nurse practitioner, or physician assistant to be valid. The findings were confirmed during an interview with staff nurse #1. The facility must ensure that MOLST forms are dated to be valid.

Based on medical record review, it was determined that the facility staff failed to develop a Care Plan for Resident #188, related to the resident being on an anticoagulant medication. This was evident for 1 out of 17 residents investigated during the survey process. The findings include: On 10/2/18 around 1:45 PM, this surveyor was reviewing Resident #188's medications for unnecessary medications. The medical record revealed that the resident was on the anticoagulant (blood thinner) medication Heparin, 5000 units every 8 hours injected. A medication whose side effects may include easy bleeding and bruising; pain, redness, warmth, irritation, or skin changes where the medicine was injected; itching of your feet; or bluish-colored skin. A review of the resident's Plan of Care did not identify any interventions to address any possible side effects of taking this anticoagulant medication. The Director of Nursing was informed of the problem. It is the facility's responsibility to create a Plan of Care that addresses special care requirements for each of its residents

Based on observation, medical record review and staff interview, it was determined the facility failed to ensure that a Geriatric Nursing Assistant (GNA) wore appropriate Personal Protective Equipment (PPE) when handling soiled linens from Resident #138 who was in isolation. This was evident for 1 of 17 residents reviewed during the survey. The findings include: On 10/2/18 at 10:37 AM while observing staff nurse #3 passing medications, GNA # 4 was observed standing in the doorway of the room of Resident #138. The GNA was wearing gloves but no gown and was holding soiled linens. Staff nurse #3 was asked what type of isolation Resident # 138 was in and she stated, Contact Isolation. When asked if that meant the GNA should be wearing a gown, she stated, yes, the GNA should be wearing a gown when handling linens. When staff nurse #3 was asked why Resident #138 was in isolation, she stated it was for having MRSA (methicillin-resistant Staphylococcus aureus). in his left leg. According to the Centers for Disease Control and Prevention (CDC), MRSA is a type of staph bacteria that is resistant to several antibiotics. In the general community, MRSA most often causes skin infections. When the medical record was reviewed, it was noted that the resident had an order dated 9/25/18 stating he/she was to be in Contact Isolation for MRSA of the left lower extremity wound. When GNA #4 was asked why she wasn't wearing a gown, she stated that it was the first time she had the resident and that there weren't any gowns in the room to use. The facility is responsible to ensure that employees know when to use PPE and use it appropriately.