**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to inform the responsible party in advance, of the risks and benefits of proposed care, and treatment for one Resident (#22) out of a sample of 24 Residents. Specifically, the facility failed to inform Resident #22's responsible party of the risks and benefits of psychotropic medications and obtain consent prior to administering psychotropic medications. Findings include: Resident #22 was admitted to the facility in February 2014 with diagnoses including paranoid schizophrenia and major depressive disorder. A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. A review of the medical record indicated Resident #22 has a Health Care Proxy (a legal document that allows a Resident to choose someone they trust to make medical decisions if the Resident is unable to do so) that was invoked on 6/21/24. Further review of the Health Care Proxy (HCP) invocation form indicated the following reason to invoke the HCP by the physician: -Cause-Cognitive deficit. -Nature-Medical. -Extent-Mild to moderate. A review of Resident #22's May 2025 physician's orders indicated the following: -Risperidone (an antipsychotic medication) 0.25 milligrams, give 1 tablet by mouth at bedtime related to schizophrenia. Start date 6/29/23. -Trazodone 100 milligrams, give 1 tablet by mouth at bedtime related to major depressive disorder. Start date 6/29/23. -Trazodone 50 milligrams, give 0.5 tablet by mouth at bedtime related to major depressive disorder. Start date 6/29/23. A review of the May 2025 Medication Administration Record (MAR) indicated that Risperidone and Trazadone was administered as ordered. Further review of the medical record indicated psychotropic informed consent forms indicating the following: -Trazadone-signed and dated by Resident #22 on 9/18/24. -Risperidone-signed and dated by Resident #22 on 7/10/24. During an interview and record review on 5/21/25 at 9:52 A.M., Unit Manager #1 said Resident #22 signed the Trazadone and Risperidone psychotropic consent forms. Unit Manager #1 said Resident #22 has an invoked HCP. Unit Manager #1 said the HCP should have been informed of the psychotropic medications the Resident was taking so he/she could provide consent to continue to administer the psychotropic medications. During an interview on 5/21/25 at 10:11 A.M., the Social Worker said Resident #22's HCP should have provided consent prior to the administration of the psychotropic medications. The Social Worker said she just informed the HCP about the Resident taking psychotropic medications and the need to obtain consent from him/her. During an interview on 5/21/25 at 10:59 A.M., the Director of Nurses (DON) said residents' responsible parties should be informed of the residents' treatment and care. The DON said the HCP should have been informed of the facility administering psychotropic medications prior to administering the medications so he/she could provide consent. During a telephone interview on 5/23/25 at 2:02 P.M., the HCP said he/she was not aware of the specific psychotropic medications Resident #22 was taking. He/she said he/she got a call from the facility a day ago asking him/her to come into the facility to sign the psychotropic consents. The HCP said prior to that call, he/she was aware the Resident was taking medications in general, but had no knowledge of the specific psychotropic medications he/she was taking, their benefits, risks and side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a person-centered care plan for one Resident (#43) out of a sample of 24 residents. Specifically, the facility failed to develop a person-centered substance use care plan. Findings include: A review of the facility policy titled 'Mood & Behavior' effective 11/1/17 indicated the following: -It is the policy of the center that each resident must receive, and the center must provide the necessary behavioral health care services and medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. -The interdisciplinary team will document assessment findings, care plan approaches/interventions and behavior/mood tracking results in the medical record. Resident #43 was admitted to the facility in June 2021 with diagnoses including psychoactive substance use and bipolar disorder. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 indicating intact cognition. A review of the Social History-Initial assessment dated [DATE] indicated the following: -Does the Resident have a history of substance abuse? Past. -If past and/or current, has Resident participated in a treatment program? Yes. -Substance Abuse comments-Resident has been drug free for 8 years. Resident used to attend Narcotics Anonymous. A review of the behavioral health therapy progress note dated 5/1/25 indicated the following: -Substance use/Addiction history: history of drug use based on records Resident has been drug free for 8 years, Resident used to attend Narcotics Anonymous. Review of Resident #43's care plan failed to indicate a person-centered substance use care plan had been developed. During an interview and record review on 5/21/25 at 10:04 A.M., the Social Worker said a person-centered substance use care plan should be developed for Resident #43. She said the substance use care plan with interventions should be in place even if the Resident is not currently actively using substances. The Social Worker said the Resident has a risk of getting triggered to start using substances at any time which could trigger a relapse and a risk of an overdose. During an interview on 5/21/25 at 10:51 A.M., the Director of Nurses said a substance use care plan should be developed even if the Resident is not actively using substances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure Residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers from developing and worsening for one Resident (#15) out of a total sample of 24 Residents. Specifically, the facility failed to ensure a physician's order for an air mattress was complete resulting in the Resident's air mattress to be set to an incorrect pressure setting. Findings include: Review of the facility policy titled Air Mattress Overlay, undated, indicated the following: - An alternating air mattress overlay is used to prevent skin breakdown on the high risk resident and/or provide pressure relief for those residents with actual skin breakdown, in accordance with physician's order. - Procedure: Verify physician's order, Adjust the air pump to the specified setting if applicable and/or in accord with resident preferences for comfort. Resident #15 was admitted to the facility in April 2025 with diagnoses including pressure ulcer of right heel stage 4, pressure ulcer of sacral region stage 3 and congestive heart failure. Review of Resident #15's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 11 out of 15, indicating moderate cognitive impairment. Further review of the MDS indicated the Resident is at risk of developing pressure ulcers/injuries and has a stage 3 and stage 4 pressure ulcer. The surveyor made the following observations on 5/20/25: - At 8:03 A.M., Resident #15 was lying in his/her bed. An air mattress was present and operating at a setting of 450 pounds. Resident #15's right ankle was wrapped, and Resident #15 said his/her ankle has a pressure area. Resident #15 told the surveyor that his/her bed is not always comfortable. - At 10:54 A.M., Resident #15 was lying in his/her bed. An air mattress was present and operating at a setting of 450 pounds. - At 1:03 P.M., Resident #15 was lying in his/her bed. An air mattress was present and operating at a setting of 450 pounds. On 5/21/25 at 6:48 A.M., the surveyor observed Resident #15's air mattress pump set to 450 pounds. Resident #15 was not in his/her room. During the night shift on 5/20/25, Resident #15 was sent out of the facility on a Medical Leave of Absence. Review of Resident #15's physician's order dated 4/23/25 indicated the following: - Low Airloss mattress, check function and settings to (specify weight or comfort) every shift. Review of Resident #15's pressure injury development care plan dated 4/23/25 indicated the following interventions: - Administer treatments as ordered and monitor for effectiveness. - Low Airloss mattress, check function and settings to (specify weight or comfort) every shift. Review of Resident #15's Norton Scale Predicting Risk of Pressure ulcer scale (an assessment that indicates the risk of developing pressure ulcers) dated 4/23/25 indicated that the Resident scored a 10 which indicated that the Resident is at a high risk of developing pressure ulcers. Review of Resident #15's weight loss history indicated that the Resident's last documented weight on 5/12/25 was 164.1 lbs. (pounds). Review of Resident #15's Wound Evaluation and Management Summary assessed by the facility's wound physician indicated that the Resident currently has a stage 3 pressure ulcer to his/her coccyx and a stage 4 pressure ulcer to his/her right heel. During an interview on 5/21/25 at 9:59 A.M., Nurse #2 said air mattress settings should be specified by the physician's order. During an interview on 5/21/25 at 10:06 A.M., Nurse #1 said air mattresses in the facility are typically set to the resident's most recent weight. Nurse #1 and the surveyor reviewed Resident #15's physician's order, and she said it should specify a weight setting or comfort. Nurse #1 continued to say that 450 pounds was way too high of a setting for Resident #15's air mattress and it would be too firm. During an interview on 5/21/25 at 10:21 A.M., the Director of Nursing (DON) said Resident #15's physician's order needs to be clarified for the appropriate settings. The DON said Resident #15's air mattress set to 450 pounds is too high. During an interview on 5/21/25 at 11:02 A.M., the Administrator said he spoke with the company who provides the air mattresses for the facility and they are coming to review Resident #15's air mattress unit as it may be faulty.

The surveyor made the following observations: - On 6/11/24 at 8:44 A.M., a resident was observed laying in his/her bed, a staff member was feeding him/her while standing over the resident, not at eye level. - On 6/11/24 at 8:49 A.M., a resident was observed laying in his/her bed, a staff member was feeding him/her while standing over the resident, not at eye level. The staff member left the room and the resident had scrambled eggs and oatmeal on his/her face and chest. - On 6/12/24 at 12:51 P.M. in the third floor dining room, a staff member was observed standing over a resident, not at eye level, feeding the resident. During an interview on 6/13/24 at 8:42 A.M., Unit Manager #3 said staff should not be standing while feeding residents, they should be sitting at eye level. During an interview on 6/13/24 at 9:20 A.M., the Director of Nursing (DON) said staff should not be standing over residents while feeding them, they should be sitting at eye level with them. Based on interviews, observations, and policy review, the facility failed to ensure staff treated residents in a dignified manner during the dining experience. Specifically, for residents who were dependent on staff for assistance with meals, staff were standing over the residents while providing assistance with feeding, on the third floor unit. Findings include: Review of the facility policy titled Dignity, dated 6/6/22, indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. On 6/11/24 at 8:43 A.M., the surveyor observed a staff member standing while feeding a Resident in the third floor dining room. On 6/11/24 at 8:44 A.M., the surveyor observed a staff member standing while feeding a Resident in the third floor dining room. On 6/12/24 at 8:45 A.M., the surveyor observed a staff member standing while feeding a Resident that was in bed on the third floor. On 6/13/24 at 8:34 A.M., the surveyor and Unit Manager #3 observed a nurse standing while feeding a Resident that was in bed on the third floor. Unit Manager #3 said the nurse should be sitting in a chair and eye level with the resident but she is not.

Based on observations, interviews, record review, and policy review, the facility failed to identify and assess the use of pillows tucked underneath a fitted sheet below the side rails on both sides of the bed as a potential restraint for one Resident (#97) out of a total sample of 27 residents. Findings include: Review of the facility policy, Use of Restraints, dated as revised April 2017, indicated: - Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. - Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed; b. Tucking sheets so tightly that a bed-bound resident cannot move; 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. 14. Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. 15. Should a resident not be capable of making a decision, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. (Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident's medical symptoms.) 16. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms), but the underlying problems that may be causing the symptom(s). 18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. Resident #97 was admitted to the facility in March 2023 with diagnoses including blepharoconjunctivitis, dementia with behavioral disturbances, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 5/23/24, indicated Resident #97 had a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15 which indicated severe cognitive impairment. Resident #97 was dependent of staff for mobility and did not utilize a restraint. On 6/11/24 at 7:36 A.M., the surveyor observed Resident #97 in bed with his/her legs directly up against the side of his/her bed on three pillows tucked underneath the fitted sheet, below the side rail on the side of the bed closest to the door. There was a fall mat on the side of the bed closest to the door. On the other side of the bed there were two pillows tucked underneath the fitted sheet. On 6/11/24 at 9:03 A.M., the surveyors observed Certified Nurse Assistant (CNA) #4, enter Resident #97's bedroom. CNA #4 said the pillows are used to prevent Resident #4 from putting his/her legs over the edge of the bed and the pillows prevent him/her from falling. On 6/12/24 at 6:25 A.M. and 6/12/24 at 7:42 A.M., the surveyor observed Resident #97 is his/her bed, his/her legs are leaning up against two pillows tucked under the fitted sheet below the side rails on the side of the bed closest to the door. On the other side of the bed, below the side rails there are two pillows tucked under the fitted sheet. On 6/13/24 at 6:21 A.M., 6/13/24 at 7:12 A.M., and 6/13/24 at 8:34 A.M., the surveyor observed Resident #97 in his/her bed, his/her legs were leaning up against two pillows tucked under the fitted sheet below the side rails on the side of the bed closest to the the door. On the other side of the bed, below the side rails there were two pillows tucked under the fitted sheet. Review of Resident #97's active plan of care, paper chart, electronic medical record, assessments, and physician's orders on 6/13/24, failed to include any documentation to support the use of pillows tucked under a fitted sheet. Review of the plan of care related to falls, dated as initiated 12/29/23, indicated: - Lateral supports to perimeter of air mattress to define border edges. During an interview on 6/13/24 at 7:58 A.M., Nurse #5 said Resident #97 is a fall risk and has a fall mat. Nurse #5 said that Resident #97 has pillows tucked under his/her fitted sheets. During an interview on 6/13/24 at 8:25 A.M., Unit Manger #1 said that Resident #97 is a fall risk and he/she will put his/her feet on the ground, and that he/she uses a fall mat. Unit Manager #1 said that Resident #97's mattress has a lateral support for defining the perimeter of his/her bed. Unit Manager #1 said she was not aware that staff were using pillows under the fitted sheets, and she said that a restraint assessment was not completed for the use of pillows under the fitted sheets. Unit Manager #1 said there were no paper restraint assessments in the medical record. On 6/13/24 at 8:34 A.M., the surveyors and Unit Manger #1 observed Resident #97 in bed, on the side closest to the door there were two pillows below the side rail tucked under the fitted sheet. Unit Manager #1 showed the surveyors the lateral support devices that were used to define his/her edge of the bed and she said this is what Resident #97 was care planed for. Unit Manager #1 said that Resident #97 could not remove the pillows tucked under the fitted sheet. During an interview on 6/13/24 at 9:00 A.M., the Assistant Director of Nursing (ADON) said that if nursing is putting pillows under a fitted sheet, it should be care planed and assessed as a potential restraint. During an interview on 6/13/24 at 12:00 P.M., the Director of Nursing (DON) said nursing should have assessed the pillows tucked under the fitted sheet as a potential restraint but did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #13 was admitted to the facility in June 2021 with diagnoses that included Cerebrovascular Accident and Diabetes. a.) Review of Resident #13's Minimum Data Set (MDS) assessment, dated 2/29/24, indicated the following: - N0415F. Antibiotic-coded: yes Review of the physician's order, dated 2/25/24, indicated: - Tamiflu oral capsule 75 milligrams (mg). Give one capsule by mouth two times per day for prophylaxis for five days (antiviral medication). Review of Resident #13's Medication Administration Record (MAR), dated February 2024, indicated nursing administered tamiflu from 2/25/24 to 2/29/24. Further review Resident #13's MAR, dated February 2024, failed to include administration of an antibiotic to the Resident. During an interview on 6/13/24 at 11:58 A.M., the MDS Nurse said Resident #13's MDS was coded incorrectly as Tamiflu is not an antibiotic. b.) Review of Resident #13's MDS, dated [DATE], indicated the following: - M1040- coded: no (other ulcers, wounds, skin problems). - M1200G- coded: no (application of non-surgical dressing). Review of the wound care consultant documentation dated 5/23/24 indicated: - non-pressure wound of the right ischium. - xeroform gauze apply once daily for 30 days; Leptospermum honey apply once daily for 30 days. Review of Resident #13's physician's order, dated 5/24/24, indicated: -normal saline wash, pat dry, apply medihoney (ointment for wound care) followed by xeroform (non-surgical dressing to cover wound) cover with allevyn. (foam dressing) daily. Review of Resident #13's Treatment Administration Record (TAR) dated from 5/24/24 to 5/30/24, indicated nursing provided treatment of medihoney followed by xeroform with allevyn to a non-pressure wound. During an interview on 6/13/24 at 12:03 P.M., the MDS Nurse said Resident #13's wound and treatment were not coded on the MDS but should have been. During an interview on 6/13/24 at 11:34 A.M., the Director of Nurses (DON) said Resident #13's MDS should be coded according to Resident Assessment Instrument (RAI) Manual. Based on record review, review of the Resident Assessment Instrument (RAI) manual and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately completed to reflect the status of three residents (#100, #86 and #13) out of a total sample of 27 residents. Specifically, 1. For Resident #100, the facility failed to indicate on the MDS assessment that the resident had a fall with major injury; 2. For Resident #86, the facility failed to indicate on the MDS assessment that the resident had vision impairment; 3. For Resident #13, the facility failed to indicate on the MDS assessment that the resident was a) not on an antibiotic and b) had an alteration in skin integrity that required a wound dressing. Findings Include: Review of the Long-Term Care Resident Assessment Instrument (RAI) Manual 3.0, dated as October 2023, indicated that major injury after a fall includes bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematoma. The RAI manual further indicated that the Minimum Data Set (MDS) Assessment should be coded as one under the number of falls with injury or major injury if the resident has had one fall with major injury. 1. Resident #100 was admitted to the facility in January 2024 with diagnoses that include Parkinson's disease, dysphagia (difficulty swallowing), disturbances of salivary secretion and altered mental status. Review of Resident #100's most recent Minimum Data Set (MDS) assessment, dated 4/4/24, indicated he/she was unable to participate in the Brief Interview for Mental Status (BIMS) Exam and was assessed by staff to have severe cognitive impairment. The MDS further indicated that Resident #100 is dependent on staff for Activities of Daily living. The MDS Assessment failed to indicate that the Resident had a fall with a major injury. Review of Resident #100's progress notes indicated the following: - A progress note dated 2/14/24: At 4:55 P.M. staff reported that [Resident] was standing up loss [his/her] balance. Resident were observed lying on the floor on [his/her] right side. ROM [range of motion] with no s/s [signs or symptoms] of discomfort both extremities align equal no internal or external rotation of hip and leg. VS [vital signs] 128/72 89 20 90 R/A no C/C [complaints] of pain. Resident were assisted by two staff to get back in the chair. HCP [health care proxy]/on call NP [Nurses Practitioner] notified Continues to monitor. Neuro assessment initiated. Resident medicated as scheduled. at this time resident in bed resting. Safety maintained. [sic] - A progress note dated 3/8/24: Clinical @ Risk committee met 3/7/24 to discuss [Resident] and [his/her] recent fracture: Acute right pubic rami fractures, noted 3/4/24 . Action: X-ray done: Acute right pubic rami fractures. Review of the facility's report submitted to the state agency dated 3/8/24, indicated that the fracture occurred from the fall sustained on 2/14/24. Review of the MDS Assessment, dated 4/4/24, indicated that Resident #100 has had no falls with major injury. During an interview on 6/13/24 at 9:46 A.M., the Director of Nurses said that the investigation into the fracture led to the conclusion that it was from Resident #100's 2/14/24 fall. She said that she would expect that the MDS Assessment accurately document a fall with major injury. During an interview on 6/13/24 at 12:15 P.M., The MDS Nurse said that the MDS assessment is coded inaccurately and should reflect a fall with major injury. 2. Resident #86 was admitted to the facility in September 2023 with diagnoses that included dementia, diabetes and hypertension. Review of Resident #86's most recent Minimum Data Set (MDS) assessment, dated 3/14/24, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, indicating that the Resident has severe cognitive impairments. The MDS further indicated that Resident #86's vision is adequate. Review of a visit note from the contracted vision services for Resident #86, dated 1/5/24, indicated the following assessment: 1. Diabetes Type 2, without complications 2. Glaucoma (a condition where the eyes optic nerve is damaged), primary open angle; [Severe Stage]; Both eyes 3. Cataract (a cloudy area in the lens of the eye that leads to vision loss), mixed; Both eyes 4. Macular degeneration (a vision impairment resulting in deterioration of the retina), dry; L [left] eye; intermediate dry stage 5. Legal blindness, as defined in USA (United States of America) 6. Presbyopia (progressive loss of near focusing ability of the eye due to ageing) Review of the MDS assessment, dated 3/14/24, indicated that Resident #86's vision is adequate. During an interview on 6/12/24 at 12:29 P.M., the surveyor asked Resident #86 what he/she can see, and the Resident said, only shadows, I can see that someone comes in my room but I don't know who it is. During an interview on 6/13/24 at 9:46 A.M., the Director of Nurses said that she would expect that the MDS was accurately coded to indicate that Resident #86 has vision impairment. During an interview on 6/13/24 at 12:15 P.M., the MDS nurse said the MDS assessment was inaccurate, and Resident #86 does not have adequate vision based on diagnoses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interview and policy review, the facility failed to develop and implement a comprehensive and person-centered care plan for two Residents (#86 and #76) out of a total sample of 27 residents. Specifically, 1. For Resident #86, the facility failed to develop a plan of care for his/her vision impairment; 2. For Resident #76, the facility failed to implement a plan of care for a wander guard (part of a system to prevent resident elopement). Findings Include: 1. Resident #86 was admitted to the facility in September 2023 with diagnoses that include dementia, diabetes and hypertension. Review of Resident #86's most recent Minimum Data Set (MDS) Assessment, dated 3/14/24, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, indicating that the Resident has severe cognitive impairment. The MDS further indicated that Resident #86's vision is adequate. During an observation on 6/11/2024 at 8:47 A.M., Resident #86 was laying in his/her bed with his/her eyes open. Breakfast was set up and uncovered on the bedside table next to the Resident's bed. The surveyor asked the Resident if he/she knew their breakfast was on the bedside table next to him/her and the Resident said he/she did not know it was there and could not see it because he/she was blind. During an observation and interview on 6/12/24 at 12:29 P.M., the surveyor observed Resident #86 laying flat in bed. The surveyor asked the Resident if he/she knew his/her lunch was on the bedside table uncovered and the Resident said he/she did not know it was there. The surveyor asked Resident #86 what he/she can see and he/she said, only shadows, I can see that someone comes in my room but I don't know who it is On 6/13/24 at 8:32 A.M., the surveyor observed a Certified Nurses Aide (CNA) bring Resident #86's breakfast tray into his/her room. The CNA said your breakfast is here, uncovered the meal and left the tray on the bedside table next to the Resident's bed and walked out of the room without setting up the tray or providing any assistance. Review of a visit note for Resident #86 from the contracted vision services, dated 1/5/24 indicated the following assessment: 1. Diabetes Type 2, without complications 2. Glaucoma (a condition where the eyes optic nerve is damaged), primary open angle; [Severe Stage]; Both eyes 3. Cataract (a cloudy area in the lens of the eye that leads to vision loss), mixed; Both eyes 4. Macular degeneration (a vision impairment resulting in deterioration of the retina), dry; L [left] eye; intermediate dry stage 5. Legal blindness, as defined in USA (United States of America) 6. Presbyopia (progressive loss of near focusing ability of the eye due to ageing) Review of Resident #86's diagnoses list failed to indicate any diagnoses related to vision impairment. Review of Resident #86's MDS Assessment failed to indicate vision impairment. Review of Resident #86's Certified Nurses Aide (CNA) [NAME], undated, failed to indicate that the Resident had vision impairment. Review of Resident #86's active care plans failed to indicate a comprehensive person-centered plan of care for vision impairment. During an interview on 6/13/24 at 8:41 A.M., CNA #3 said that Resident #86's vision is not good. CNA #3 further said that they help Resident #86 with his/her daily care because of his/her vision, but otherwise there is nothing else that they have been instructed to do. During an interview on 6/13/24 at 8:45 A.M., Unit Manager #2 said that the facility's contracted vision services has seen Resident #86 and recommended medications for eye pressure. Unit Manager #2 further said that the Resident's diagnoses indicated on the eye doctor visit should have been added to the diagnosis list in the Resident record. Unit Manager #2 also said that there should be a plan of care in place to address vision loss. Unit Manager #2 reviewed Resident #86's care plan and said there was not a plan of care in place at this time. During an interview on 6/13/24 at 9:39 A.M., the Director of Nurses said that she would expect a plan of care in place for vision impairment to address the care needs of Resident #86. 2. Review of facility policy titled Elopement of Resident, dated as reviewed March 2022, indicated the following: B. All residents will be screened for potential elopement risk using the Elopement Risk Assessment in PCC [Point Click Care] (online medical record system) upon admission and with a significant change in status. D. For resident identified as at risk, an interdisciplinary safety care plan will be developed with family and resident participation. 1. Individual risk factors and patterns will be identified and addressed within the care plan. Resident #76 was admitted to the facility in December 2020 with diagnoses that include bipolar disorder, anxiety disorder and amnesia. Review of Resident #76's of the most recent Minimum Data Set (MDS) Assessment, dated 3/21/24, indicated a Brief Interview for Mental Status score of 1 out of a possible 15 which indicated that the Resident has severe cognitive impairment. The MDS further indicated that wandering behavior occurs daily for Resident #76. The surveyor made the following observations: - On 6/11/24 at 1:38 P.M., Resident #76 was observed sitting in the dining room, a wander guard was not in place to his/her right wrist. - On 6/12/24 at 8:23 A.M., and 10:48 A.M., Resident #76 was observed sitting in the dining room, a wander guard was not in place to his/her right wrist. - On 6/12/24 at 12:28 P.M., Resident #76 was observed eating lunch in the dining room, a wander guard was not in place to his/her right wrist. Review of Resident #76's active care plan indicated, I have a hx (history) of and potential for aimless wandering (within the unit), occasionally requiring redirection from staff. I wear a Wander Guard device, dated 12/22/20. Review of Resident #76's active physician's orders indicated: Wander Guard Bracelet on Right Wrist: Check placement and function every shift, dated 8/28/23. Review of Resident #76's June Treatment Administration Record (TAR) was signed off as indicating that the Wander Guard was in place on 6/11/24. Review of Resident #76's most recent elopement assessment, dated 12/18/23 indicated an elopement risk score of 22, indicating that Resident #76 is at high risk for elopement. Review of Resident #76's Certified Nurses Aide (CNA) [NAME], dated 8/22/23 indicated that the Resident is at risk for elopement and utilizes a wander guard. Review of Resident #76's progress notes indicated the following note written on 6/12/24 at 10:47 P.M., Resident didn't have his/her wander guard on, replaced by a new one. During an interview and observation on 6/12/24 at 1:34 P.M., the Assistant Director of Nurses (ADON) said that nursing staff should make sure that the wander guard is in place for any resident who has a physician's order for a wander guard. The ADON observed Resident #76 in his/her room and said that he/she did not have a wander guard in place. During an interview on 6/13/24 at 9:37 A.M., the Director of Nurses said that she would expect nurses to check placement and function every shift and accurately document the presence of a wander guard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure a physician's order was implemented for one Resident (#35) out of a total sample of 27 residents. Specifically, for Resident #35, the facility failed to implement off-loading his/her heels as ordered by the Physician. Findings include: 1. Resident #35 was admitted to the facility in December 2023 with diagnoses that included dementia, Parkinson's disease, type 2 diabetes. Review of Resident #35's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 1 out of a possible 15 on the Brief Interview of Mental Status (BIMS) exam indicating the Resident had severe cognitive impairment. Further review of the MDS indicated the Resident is at risk for developing pressure ulcers. On 6/11/24 at 8:29 A.M., and 12:35 P.M., the surveyor observed Resident #35 in bed with their heels directly on the mattress. On 6/12/24 at 8:18 A.M., and 12:34 P.M., the surveyor observed Resident #35 in bed with their heels directly on the mattress. On 6/13/24 at 8:39 A.M., the surveyor and Nurse #3 observed Resident #35 in bed with their heels directly on the mattress. Nurse #3 said Resident #35's heels are on the mattress and they should be floated on multiple pillows are ordered. Review of Resident #35's physician order, dated 12/23/23, indicated float bilateral heels on pillow while in bed every shift. Review of Resident #35's Norton Scale Predicting Risk of Pressure Ulcer, dated 3/19/24, indicated he/she scored a 7 indicating the Resident is at high risk of pressure ulcer development. Review of Resident #35's nursing progress notes from 6/3/24 to 6/13/24 did not indicate that Resident #35 refused to have his/her heels offloaded. During an interview on 6/13/24 at 8:37 A.M., Certified Nurses Aide (CNA) #1 said that if a resident has an order to off-load their heels then she would normally put the resident's legs up on multiple pillows so the heels are not touching the mattress. During an interview on 6/13/24 at 8:40 A.M. the Infection Control (ICP) Nurse said nurses are expected to follow each residents' care plan and doctors orders. The ICP Nurse said if a resident has an order to off load their heels then the nurses should be following the doctors orders and off-load the residents' heels. During an interview on 6/13/24 at 9:35 A.M., the Director of Nurses (DON) said if a resident has a physician order to off-load heels then the expectation is that the nurses follow the order and off-load the residents heels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure recommendations from the Monthly Medication Review conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for one Resident (#16) out of a total sample of 27 Residents. Findings include: Review of the facility policy titled Pharmacy Services Overview, revised and dated Arpil 2019, indicated the following: - The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, and are consistent with current standards of practice, and meet state and federal requirements. Resident #16 was admitted to the facility in May 2012 with diagnoses including intervertebral disc degeneration and personality disorder. Review of Resident #16's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of 15 indicating the Resident is cognitively intact. Review of Resident #16's physician's order dated 6/28/23 indicated the following: Omeprazole Cap (capsule) 20MG (milligrams) Review of the monthly Pharmacy Consultant progress notes indicated the following for 11/22/23, 12/21/23, 1/23/24, 2/21/24, 3/21/24 and 4/5/24: -Rec (Recommend): Narcan order, Rec: decrease omeprazole Review of the document titled Summary of Recommendations for DNS/Medical Director from the pharmacy dated 4/26/24 indicated that the Medical Doctor/Nurse Practitioner acknowledged the pharmacist's recommendation for a decrease in Omeprazole, about five months after the pharmacist made the initial recommendation on 11/22/23. Review of the Pharmacy Consultant progress note dated 5/15/24 indicated that the physician acknowledged the pharmacist recommendation for a Narcan order on 6/13/24, after the surveyor made the facility aware. Review of the document titled Note to Attending Physician/Prescriber dated 6/13/24 indicated that the Nurse Practitioner agreed with the pharmacist's recommendation for a Narcan order, about five months after the pharmacist made the initial recommendation. During an interview on 6/12/24 at 11:15 A.M., Unit Manager #3 said pharmacy services comes to the facility once a month to make recommendations which will go to the unit managers, director of nursing (DON) and to the doctor. Unit Manager #3 continued to say these recommendations typically get acknowledged within one week by the physician. During an interview on 6/12/24 at 1:17 P.M., the DON said the pharmacy recommendation system has been broken in the facility since they started using a different pharmacist. She continued to say that recommendations have not been followed up as timely as they should be. She continued to say that Resident #16's recommendations should have been addressed sooner. During an interview on 6/13/24 at 10:30 A.M., the DON said yesterday, the pharmacist noticed not all progress notes were acknowledged for the third-floor unit. The DON continued to say we know the pharmacy system has been broken and we started doing audits yesterday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, the facility failed to ensure the call light was accessible for two Residents (#5, #16) out of a total of 27 residents. Specifically, the facility failed to ensure that the call lights were within reach of Residents #5 and #16 while they were in bed. Findings include: Review of the facility policy titled Call System, Resident, dated September 2023, indicated the following: - Residents are provided with the means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. 1. Resident #5 was admitted to the facility in April 2015 with diagnoses including unspecified dementia, polyarthritis and age related osteoporosis. Review of Resident #5's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 3 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that Resident #5 is dependent on all activities of daily living. The surveyor made the following observations: - On 6/11/24 at 9:13 A.M., Resident #5 was laying in bed. The call light was clipped to the top of the wire where it comes out of the wall. The call light was not within an arm's reach of the resident. - On 6/12/24 at 7:25 A.M., Resident #5 was sleeping in bed. The call light was clipped to the top of the wire where it comes out of the wall. The call light was not within an arm's reach of the resident. - On 6/13/24 at 6:40 A.M., Resident #5 was sleeping in bed. The call light was clipped to the top of the wire where it comes out of the wall. The call light was not within an arm's reach of the resident. Review of Resident #5's [NAME] (nursing care card) indicated the following: - Safety: Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to call requests and assistance. - Safety: Encourage me to use bell to call for assistance and keep call bell within reach. Review of Resident #5's risk of falls care plan indicated the following intervention dated 4/25/15: - Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to call requests and assistance. Review of Resident #5's bladder incontinence r/t (related to) dementia care plan indicated the following intervention dated 12/11/20: - Encourage me to use bell to call for assistance and keep call bell within reach. During an interview on 6/13/24 at 7:33 A.M., Unit Manager #3 said all residents should have a call light within their reach and able to be used. The surveyor and Unit Manager #3 went into Resident #5's room while he/she was sleeping in bed. Unit Manager #3 said Resident #5's call light was not accessible to the resident, and it should be clipped to his/her linens so he/she can use it if needed. During an interview on 6/13/24 at 9:20 A.M., the Director of Nursing (DON) said call lights should be accessible and within reach for the residents to use them. The surveyor showed the DON photos of Resident #5's call light location and she said it is not within reach for him/her. 2. Resident #64 was admitted to the facility in March 2020 with diagnoses including Alzheimer's disease and unspecified dementia. Review of Resident #64's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident was unable to complete the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review of the MDS indicated that Resident #64 requires assistance with activities of daily living. The surveyor made the following observations: - On 6/11/24 at 9:40 A.M., Resident #64 was laying in bed. The call light was wrapped up and hanging on the wall behind the headboard of the bed. The call light button was dangling behind the headboard of the bed. - On 6/12/24 at 7:25 A.M., Resident #64 was sleeping in bed. The call light was wrapped up and hanging on the wall behind the headboard of the bed. The call light button was dangling behind the headboard of the bed. On the wall next to the call light that was out of reach for Resident #64, was a piece of paper in Spanish that translated to: Always remember to use the call light. Review of Resident #64's [NAME] (nursing care card) indicated the following: - Safety: Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to call requests and assistance. - Safety: Encourage me to use bell to call for assistance and keep call bell within reach. Review of Resident #64's risk of falls care plan indicated the following intervention dated 3/31/20: - Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to call requests and assistance. Review of Resident #64's incontinence of the bladder care plan indicated the following intervention dated 3/31/20: - Keep my call light/bell within reach at all times. Respond promptly to my request for assistance to toilet. During an interview on 6/13/24 at 7:33 A.M., Unit Manager #3 said all residents should have a call light within their reach and able to be used. The surveyor and Unit Manager #3 went into Resident #64's room while he/she was sleeping in bed. Unit Manager #3 said Resident #5's call light was not accessible to the resident, and it should be clipped to his/her linens so he/she can use it if needed. During an interview on 6/13/24 at 9:20 A.M., the Director of Nursing (DON) said call lights should be accessible and within reach for the residents to use them. The surveyor showed the DON photos of Resident #5's call light location and she said it is not within reach for him/her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #100 was admitted to the facility in January 2024 with diagnoses that include Parkinson's disease, dysphagia (difficulty swallowing), disturbances of salivary secretion and altered mental status. Review of Resident #100's most recent Minimum Data Set (MDS) Assessment, dated 4/4/24, indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as having severe cognitive impairment. The MDS Assessment further indicated that Resident #100 is dependent on staff for Activities of Daily living. During a continuous observation on 6/12/24 from 8:24 A.M. to 8:47 A.M., the following observations were made: -At 8:24 A.M., Resident #100 was observed by the surveyor in bed with his/her eyes closed, at an approximately 90-degree angle with his/her breakfast tray in front of him/her. No staff were present in the room. -At 8:39 A.M., no staff have gone into the room to check on the Resident or assist him/her with breakfast. Resident #100 had not initiated eating or drinking any of his/her breakfast. -At 8:47 A.M., a Certified Nurses Aide (CNA) entered the room and asked Resident #100 if he/she was done with breakfast, the Resident who remained with eyes closed, did not respond and the CNA took the untouched breakfast tray away without offering any assistance to eat. Review of Resident #100's active care plan indicated the following: -I have a swallowing problem r/t (related to) my dx (diagnosis) of Parkinson's dx (disease) with PMH (past medical history) of Coughing or choking during meals or swallowing med (medications), difficulty with thin liquids, and the potential for Holding food in mouth/cheeks (pocketing). Interventions in the care plan included I am to eat only with supervision, dated 4/5/24. -I am at nutritional risk related to disease process of Parkinson's dx with dysphagia and at risk for malnutrition. I require support at all eating opportunities, I have potential for skin impairment, dated 3/6/24. Review of Resident #100's CNA [NAME] (care card with instructions for care), dated 1/18/24, indicated that Resident #100 has aspiration precautions and should receive continual supervision at meals. During an interview on 6/12/24 at 1:01 P.M., the surveyor asked CNA #3 how she would know what kind of assistance a resident needs with meals, she said when she drops off the tray she asks them if they need help or not. CNA #3 was asked about any type of care card or [NAME] and she said there is one, but they are not always accurate, sometimes it says the resident is independent but they are weak that day and need help. During an interview on 6/13/24 at 8:52 A.M., Unit Manager #2 said that supervision means that someone should be with the resident either in their room or in the dining room with the resident. She further said that Resident #100 should have been assisted by staff in his/her room on 6/12/24. During an interview on 6/13/24 at 9:23 A.M., the Director of Nurses said that staff should be providing feeding assistance as needed or as per the plan of care. She said that a [NAME] is used so that staff know the level of care needed for each resident. She further said she expects that staff follow the plan of care and [NAME]. 1c. Resident #32 was admitted to the facility in October 2023 with diagnoses including hemiplegia and hemiparesis and dysphagia (difficulty swallowing). Review of Resident #32's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 5 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff for all activities of daily living including eating. The surveyor made the following observations: - On 6/11/24 from 8:49 A.M. to 8:54 A.M., Resident #32 was laying in his/her bed, feeding him/herself. There was scrambled egg and oatmeal on the side of his/her face and on his/her chest. Resident #32's hand was observed shaking when he/she was bringing the utensil of food to his/her mouth. - On 6/12/24 from 8:25 A.M. to 8:39 A.M., Resident #32 was laying in his/her bed, feeding him/herself with no staff assistance in the room. Pureed egg and sausage were observed on Resident #32's chest. Resident #32's hand was observed shaking when he/she was bringing the utensil of food to his/her mouth. - On 6/12/24 at 12:42 P.M., Resident #32 was sitting in his/her wheelchair in the dining room. A staff member was observed delivering his/her tray and said to eat up and walked away. At 12:50 P.M., Resident #32 was eating without staff assistance, pureed food was running down his/her mouth and chin. - On 6/13/24 from 8:18 A.M., to 8:31 A.M., Resident #32 was laying in bed eating breakfast without staff assistance. The Resident had pureed eggs and oatmeal on his/her face and chest. Review of Resident #32's [NAME] (nursing care card) indicated the following: - EATING: I require total assistance to eat. Review of Resident #32's ADL self care Performance Deficit care plan indicated the following intervention: - Dated 6/30/22: EATING: I require total assistance to eat. Review of Resident #32's nutritional risk care plan indicated the following intervention: - Dated 11/3/23: Monitor for signs/symptoms of aspiration During an interview on 6/13/24 at 8:31 A.M., Certified Nursing Assistant (CNA) #1 said Resident #32 does okay with feeding by him/herself but needs some encouragement. She continued to say he/she is dependent on staff for eating but it hard to help everyone during meal times since there are a lot of residents. During an interview on 6/13/24 at 8:42 A.M., Unit Manager #3 said resident dependent on staff for feeding should be getting help while they eat. She said if a resident is care planned for assistance with meals it should be happening. During an interview on 6/13/24 at 9:20 A.M. the Director of Nursing (DON) said residents who are dependent on staff for feeding should be receiving assistance while they eat. She continued to say Resident #32 should be receiving assistance while he/she eats. Based on observations, record review, policy review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for four Residents (#39, #163, #32, #100) out of a total sample of 27 residents. Specifically, 1a. For Resident #39, the facility failed to provide assistance with meals as per the plan of care; 1b. For Resident #163, the facility failed to provide assistance with meals as per the plan of care; 1c. For Resident #32, the facility failed to provide assistance with meals as per the plan of care; 2. For Resident #100, the facility failed to provide supervision with meals as per the plan of care. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs) Supporting, dated March 2018, indicated Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: d. Dining (meals and snacks). 1a. Resident #39 was admitted to the facility in June 2017 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphagia, and contractures. Review of Resident #39's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 3 out of a possible 15 indicating the Resident has severe cognitive impairment. Further review of the MDS indicated the Resident is dependent on staff for activities of daily living (ADLs). On 6/11/24 at 8:34 A.M., the surveyor observed Resident #39 in bed with their breakfast tray set up to consume without staff present in the room. The Resident was observed to not initiate self feeding. On 6/11/24 from 12:29 P.M. to 12:36 P.M., the surveyor observed Resident #39 in the dining room with their lunch tray set up to consume without staff assisting him/her. The Resident was observed to not initiate self feeding. On 6/12/24 from 8:35 A.M. to 8:45 A.M., the surveyor observed Resident #39 in his/her room with their breakfast tray set up to consume without staff present in the room. On 6/13/24 from 8:27 A.M. to 8:40 A.M., the surveyor observed Resident #39 in the dining room with their breakfast tray set up to consume without staff assisting him/her. The Resident was observed to drop food items off of their utensils at times. Review of Resident #39's activities of daily living (ADLs) care plan, dated 1/10/24, indicated EATING: I require physical assist to eat I choose to eat in the quiet of my own room cueing and adaptive feeding equipment are provided to support my eating efforts. Review of Resident #39's Certified Nurse Aide (CNA) [NAME], dated 6/12/24, indicated EATING: I require physical assist to eat I choose to eat in the quiet of my own room cueing and adaptive feeding equipment are provided to support my eating efforts. During an interview on 6/13/24 at 8:37 A.M., CNA #1 said that nursing staff are expected to be following the CNA [NAME]. CNA #1 said if a resident should be supervised then a staff member should be in the room supervising that resident and if the [NAME] says they should be assisted with meals then the resident should be assisted by a staff member with meals. During an interview on 6/13/24 at 8:40 A.M. the Infection Control (ICP) Nurse said nurses are expected to follow each residents care plan and doctors orders. The ICP Nurse said if a resident is care planned to be supervised with meals then a staff member should be in the room supervising the resident and if the care plan says the Resident should be fed then a staff member should be there assisting the resident with their meals. During an interview on 6/13/24 at 8:41 A.M., the Director of Rehab (DOR) said her staff works closely with nursing and are involved with care planning. The DOR said if a resident is care planned for supervision or assistance with meals then staff should be following that plan of care. During an interview on 6/13/24 at 8:43 A.M., the Registered Occupational Therapist (OT) said if a resident's care plan says they require staff assistance with meals then a staff member should be with the resident feeding them. 1b. Resident #163 was admitted to the facility in June 2024 with diagnoses that included severe protein-calorie malnutrition, type 2 diabetes, and chronic kidney disease. Review of Resident #163's Brief Interview for Mental Status (BIMS) exam, dated 6/11/24, indicated he/she scored a 12 out of a possible 15 on the BIMS indicating he/she had moderate cognitive impairment. On 6/11/24 from 8:31 A.M. to 8:36 A.M., the surveyor observed Resident #163 in bed with their breakfast tray set up to consume without staff present in the room. The Resident was observed to not initiate self feeding. On 6/11/24 from 12:33 P.M. to 12:41 P.M., the surveyor observed Resident #163 in the dining room with their lunch tray set up to consume without staff assisting the Resident. The Resident was observed to not initiate self feeding. On 6/12/24 from 8:17 A.M. to 8:24 A.M., the surveyor observed Resident #163 in bed with their privacy curtain pulled not able to see the Resident from the hallway. The breakfast tray was set up to consume without staff present in the room. On 6/12/24 from 12:35 P.M. to 12:43 P.M., the surveyor observed Resident #163 in the dining room with their lunch tray set up to consume without staff assisting the Resident. The Resident was observed to not initiate self feeding and calling out for staff to help. On 6/13/24 from 8:30 A.M. to 8:44 A.M., the surveyor observed Resident #163 in bed with their breakfast tray set up to consume without staff assisting the Resident. The Resident was observed to not initiate self feeding. On 6/13/24 at 8:45 A.M., the surveyor and the Registered Occupational Therapist (OT) observed Resident #163 in bed not initiating self feeding. The OT said someone should be helping him/her. Review of Resident #163's activities of daily living (ADLs) care plan, dated 6/5/24, indicated EATING: I require (x) staff participation to eat. Review of Resident #163's nursing progress note, dated 6/10/24, indicated Resident continues to require supportive care/assistance with ADLs due to decreased strength and endurance due to pneumonia, CVA with L (left) hemiplegia. Review of Resident #163's active CNA [NAME], dated 6/12/24, indicated EATING: I require (x) staff participation to eat. During an interview on 6/13/24 at 8:37 A.M., CNA #1 said that nursing staff are expected to follow the CNA [NAME]. CNA #1 said if the resident's [NAME] says they should be assisted with meals then the resident should be assisted by a staff member with meals. During an interview on 6/13/24 at 8:40 A.M. the Infection Control (ICP) Nurse said nurses are expected to follow each resident's care plan and doctors orders. The ICP Nurse said if a resident is care planned to be supervised then a staff member should be in the room supervising the resident and if the care plan says the Resident should be fed then a staff member should be there assisting the resident with their meals. During an interview on 6/13/24 at 8:41 A.M., the Director of Rehab (DOR) said her staff works closely with nursing and are involved with care planning. The DOR said if a resident is care planned for supervision or assistance with meals then staff should be following that plan of care. During an interview on 6/13/24 at 8:43 A.M., the OT said if a residents care plan says they require staff assistance with meals then a staff member should be with the resident feeding them. The OT said she is currently working with Resident #163 and said the Resident does need assistance and cueing with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #51 was admitted to the facility in May 2024 with diagnoses that included End Stage Renal Disease (ESRD-the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life), diabetes, and chronic diastolic heart failure (pressure builds up in the heart, which can lead to fluid buildup in the lungs, abdomen, and legs). Review of Resident #51's most recent Minimum Data Set (MDS) assessment, dated 5/17/24, indicated the Resident scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam indicating the Resident is cognitively intact. During observation on 6/11/24 at 9:01 A.M., and 6/12/24 at 8:00 A.M., the surveyor observed a sign over Resident #51's bed that indicated that BP (blood pressure) was not to be taken in left arm. Review of Resident #51's physician's order dated 3/15/24 and 5/8/24, indicated no BP or Blood Draw to Access Site Arm - Left arm. Review of Resident #51's Medication Administration Record (MAR), dated May and June 2024, indicated every shift nursing signed the physician order off as administered for no BP to access site left arm. Review of Resident #51's weights and vitals summary, dated May 2024 and June 2024, indicated on the following dates, blood pressure was taken in left arm: - Date: 5/1/24 at 9:54 P.M., - Date: 5/2/24 at 9:31 P.M., - Date: 5/8/24 at 11:25 P.M., - Date: 5/11/24 at 2:59 A.M., - Date: 5/11/24 at 10:53 A.M., - Date: 6/1/24 at 12:22 P.M., - Date: 6/2/24 at 9:39 P.M., - Date: 6/4/24 at 10:00 P.M., - Date: 6/5/24 at 8:14 P.M. - Date: 6/6/24 at 5:54 P.M., - Date: 6/7/24 at 8:39 P.M. During an interview on 6/12/24 at 4:16 P.M., Nurse #1 said she has been checking Resident #51's blood pressure on his/her left arm. During an interview on 6/13/24 at 6:57 A.M., the Director of Nursing (DON) said that if a physician's order says not to check BP on left arm, then it should not be checked on the left arm. Based on record review, interview and policy review, the facility failed to ensure services consistent with professional standards were provided for 3 Residents (#44, #263, #51) who required dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of total sample of 27 residents. Specifically, the facility failed to follow physician's orders to ensure that blood pressure readings were not taken on the arm where the dialysis shunt (an access point from the dialysis machine to a blood artery) is located. Findings include: Review of the facility policy titled Dialysis Policy, revised and dated 9/8/23, indicated the following: - Purpose: To provide necessary monitoring and follow-up treatment for residents who require dialysis. The goal of clinical management includes reducing the risk of complications and to coordinate/provide treatment for any complications that are identified. - Monitor vital signs per MD (Medical Doctor) order: Vital signs per MD order. No BP (blood pressure) in shunt extremity. 1. Resident #44 was admitted to the facility in September 2018 with diagnoses including end stage renal disease and heart failure. Review of Resident #44's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that the Resident requires assistance with activities of daily living and is currently receiving dialysis. Review of Resident #44's active physician's order dated 4/5/24, indicated the following: - No B/P (blood pressure) or blood draw to access site arm - right arm. Review of Resident #44's discontinued physician's orders indicated the following: - Dated from 2/7/24 - 3/23/24: No B/P (blood pressure) or blood draw to access site arm - right arm. - Dated from 6/9/23 - 2/1/24: No B/P (blood pressure) or blood draw to access site arm - right arm. Review of Resident #44's renal insufficiency r/t (related to) End Stage Renal Disease care plan indicated that the following intervention dated 9/24/18: - Monitor vital signs as ordered and PRN (as needed). Review of Resident #44's hemodialysis care plan indicated the following intervention dated 9/24/18: - Do not draw blood or take B/P in arm with graft. Review of Resident #44's Blood Pressure Summary indicated the following occurrences where Resident #44 was documented having his/her blood pressure taken on his/her right arm: - Date: 1/3/24, Position: lying r/arm (right arm) - Date: 1/6/24, Position: lying r/arm - Date: 1/7/24, Position: lying r/arm - Date: 1/14/24, Position: lying r/arm - Date: 1/15/24, Position: lying r/arm - Date: 1/23/24, Position: lying r/arm - Date: 1/23/24, Position: lying r/arm - Date: 1/28/24, Position: lying r/arm - Date: 2/13/24, Position: lying r/arm - Date: 2/23/24, Position: lying r/arm - Date: 3/12/24, Position: lying r/arm - Date: 3/12/24, Position: lying r/arm - Date: 3/13/24, Position: lying r/arm - Date: 3/21/24, Position: lying r/arm - Date: 4/5/24, Position: lying r/arm During an interview on 6/13/24 at 8:51 A.M., Nurse #4 said blood pressure readings should not be taken on arm of the dialysis access site as the resident would be at risk of bleeding. She continued to say that physician's orders should be followed at all times. During an interview on 6/13/24 at 9:20 A.M., the Director of Nursing (DON) said physician's orders should be followed and blood pressure readings should be obtained on the arm of the dialysis access site. 2. Resident #263 was admitted to the facility in December 2023 with diagnoses including end stage renal disease and hypertension. Review of Resident #263's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that the Resident is dependent on staff for activities of daily living and is currently receiving dialysis. Review of Resident #263's discontinued physician's orders dated from 12/2/23 through 5/18/24 indicated the following: - No blood pressure R (right) arm. Review of Resident #263's Renal failure r/t End Stage Kidney Disease care plan dated 4/25/18 indicated the following intervention: - No blood pressure or blood drawn on right arm. Review of Resident #263's Blood Pressure Summary indicated the following occurrences where Resident #263 was documented having his/her blood pressure taken on his/her right arm: - Date: 1/2/24, Position: lying r/arm (right arm) - Date: 1/16/24, Position: lying r/arm - Date: 1/17/24, Position: lying r/arm - Date: 1/31/24, Position: lying r/arm - Date: 2/4/24, Position: lying r/arm - Date: 2/24/24, Position: lying r/arm - Date: 3/8/24, Position: lying r/arm - Date: 3/14/24, Position: lying r/arm - Date: 5/9/24, Position: lying r/arm During an interview on 6/13/24 at 8:51 A.M., Nurse #4 said blood pressure readings should not be taken on arm of the dialysis access site as the resident would be at risk of bleeding. She continued to say that physician's orders should be followed at all times. During an interview on 6/13/24 at 9:20 A.M., the Director of Nursing (DON) said physician's orders should be followed and blood pressure readings should be obtained on the arm of the dialysis access site.

2. During a medication storage observation on 6/13/24 at 7:11 A.M., the surveyor was reviewing the medication cart on the high end of the third-floor unit. Nurse #4 walked away from the medication cart and left the surveyor with an unlocked and unattended medication cart. At 7:14 A.M., Nurse #4 returned to the medication cart after the surveyor asked another nurse where she had gone. Nurse #4 said that she should not have left the medication cart unlocked and unattended. During a medication storage observation on 6/13/24 at 7:21 A.M., the surveyor was reviewing the high-end medication cart on the second floor unit and made the following observations of the medication cart: -In the first drawer of the medication cart, a medication cup with applesauce in it as well as a dirty plastic spoon sitting in the top drawer of the medication cart were observed -In the third drawer of the medication cart two plastic cups filled with a clear liquid were observed During the medication cart observation on 6/13/24 at 7:21 A.M., the Nurse walked away from the medication cart leaving the medication cart unlocked and unsupervised. At 7:26 A.M., the Assistant Director of Nurses (ADON) walked by and locked the medication cart. She said that the medication cart should be locked when the assigned nurse is not at the cart and should not be left unattended. The ADON further said that cups of liquid, applesauce and dirty spoons should not be stored in the mediation cart. During an interview on 6/13/24 at 7:31 A.M., the Director of Nurses said that she would expect that nurses lock medication carts when they are unattended and that medication carts are kept clean. Based on observation, policy review and interview, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, 1. The facility failed to ensure nursing stored medications in accordance with State and Federal Laws. 2. The facility failed to properly secure medication carts on two of three units and ensure that medication carts were kept clean on one out of three medication carts reviewed. Findings Include: Review of facility policy titled Medication Storage in The Facility, dated January 2021, indicated the following: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Procedures: I. Medication storage areas are kept clean well-lit, and free of clutter and extreme temperatures and humidity. 1. On 6/12/24 at 2:04 P.M., the surveyor observed the following unattended on the first-floor nursing station: - one bottle of rhopressa eye drops - one brown paper bag On 6/12/24 at 2:14 P.M., the surveyor continued to observe the medications unattended at the nursing station. During the continuous observation the surveyor observed two different Certified Nursing Assistants, the Maintenance Director, and two therapists walk near the unattended medications at the nursing station. On 6/12/24 at 2:15 P.M., the surveyor observed the medications in the brown bag to include the following: - one bottle of brimonidine 0.2% ophthalmic solution, - one bottle of combigan solution 0.2/0.5% ophthalmic solution, - one bottle of prednisolone 1% ophthalmic solution, - one bottle of difluprednate emulsion 0.05% ophthalmic solution. On 6/12/24 at 2:19 P.M., Nurse #2 returned to the desk, and she said that medications should not be left unattended at the nursing station. During an interview on 6/13/24 at 8:49 A.M., Unit Manger #1 said the pharmacy comes daily at 2:00 P.M., and she said medications should not be left unattended at the nursing station. During an interview on 6/13/24 at 12:40 P.M., the Director of Nursing (DON) said medications should not be left unattended at the nurse's station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #106 was admitted to the facility in March 2023 with diagnoses including adult failure to thrive, unspecified protein calorie malnutrition and dysphagia (difficulty swallowing), oral phase. Review of Resident #106's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 which indicates he/she is cognitively intact. The MDS also indicates Resident #106 requires extensive assist of one person for self-feeding. On 4/19/23 at 8:13 A.M., Resident #106 was observed sitting in bed eating breakfast alone with oatmeal on his/her shirt. There was no staff present to provide assistance or supervision. On 04/20/23 09:15 A.M., Resident #106 was observed sitting in bed eating breakfast alone with food on his/her shirt. There was no staff present to provide assistance or supervision. Review of Resident 106's activity of daily living care plan indicated the following intervention: *Eating: I require total assistance to eat, date initiated 3/31/23. Review of Resident #106's most recent Activities of Daily Living (ADL) Care Card on 4/20/23 at 10:52 A.M., indicated resident requires assistance for self-feeding. Review of Resident #106's medical record on 4/20/23 at 11:18 A.M., indicated a Speech Language Pathology evaluation was completed on 3/27/23 with the recommendation for supervision for oral intake-close supervision. Further review of Resident #106's Speech Language Pathology notes indicated he/she requires verbal cues for bite size and rate of eating as well use of safe swallowing strategies. During an interview on 4/20/23 at 10:13 A.M., the Director of Nursing (DON) was asked what the expectation is if a resident requires total assistance for self-feeding. The DON said the resident would receive the assistance from staff during all meals. The DON was informed that Resident #106's current care plan and most recent MDS indicated he/she requires total assistance for self-feeding and was observed unsupervised the past 2 days during breakfast. During an interview on 4/20/23 at 1:00 P.M., The Regional Administrator and the Director of Nursing said the Speech Therapist has been working with Resident #106 and is demonstrating improvements with self-feeding. The Surveyor acknowledged the information provided by the Regional Administrator and Director of Nursing and expressed the most recent care plan interventions and MDS indicate Resident #106 requires extensive assist for self-feeding. Both acknowledged the care plan and the MDS should reflect the Resident's current level of assistance for self-feeding. Based on record review, interview and observation the facility failed to ensure they provided supervision and assistance with meals for 3 Residents (#51, #83, #106 ) out of a total sample of 23 Residents. Findings include: Review of the facility's policy titled Activities of Daily Living (ADLs) Supporting, dated 3/2018, indicated Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: D. Dining (meals and snacks) 1. Review of Resident #51's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated Resident #51 had a severe cognitive impairment. Further review of the MDS indicated Resident #51 required supervision with eating. Review of Resident #51's Activity of Daily Living Care Plan, dated 7/5/22, indicated Eating: I require physical assist to eat I choose to eat in the quiet of my own room cueing and adaptive feeding equipment are provided to support my eating efforts. During an observation on 4/19/23 from 8:56 A.M. to 9:00 A.M., Resident #51 was in his/her room eating his/her breakfast in a wheelchair with the privacy curtain pulled unable to see the resident from the hallway, without staff present. During an observation on 4/19/23 from 12:31 P.M. to 12:47 P.M., Resident #51 was in his/her room eating his/her lunch in a wheelchair with the privacy curtain pulled unable to see the resident from the hallway, without staff present. During an observation on 4/20/23 from 8:55 A.M. to 9:01 A.M., Resident #51 was in his/her room eating his/her breakfast in bed with the privacy curtain pulled unable to see the resident from the hallway, without staff present. During an observation and interview on 4/20/23 at 12:15 P.M., the Director of Nurses (DON) acknowledged that Resident #51's privacy curtain was pulled past the Resident and unable to view the Resident until you got to the end of his/her bed and no staff present to assist Resident #51. The DON said her expectation is for staff to follow the care plan and care card for each resident. During an interview on 4/20/23 at 12:16 P.M., Certified Nurse Aide (CNA) #1 said she does take care of Resident #51 at times and said he/she does not need assist or supervision for meals. CNA #1 said she does look at the Resident Care Card to know how to take care of the residents or would ask a nurse if unsure on how to care for a resident. 2. Review of Resident #83's most recent MDS dated [DATE], indicated Resident #83 was assessed by staff to have severe cognitive impairment. Further review of the MDS indicated he/she was dependent on staff for eating. Review of Resident #83's Activity of Daily Living (ADL) Care Plan, dated 12/20/22, indicated Eating: I require total staff participation to eat. with recent upgrade in diet texture, I am more engaged with eating, at times I can use utensils and eat a couple of bites by myself. Review of Resident #83's Nutrition Note, dated 3/28/23, indicated I had lengthy conversation with nursing. We are providing full physical support at all eating times we are aware of his/her favorite foods and provide such, he/she is now unable to hold cup or silverware. Review of Resident #83's Care Card, not dated, indicated Eating: Totally Dependent. During an observation on 4/19/23 from 8:56 A.M. to 9:00 A.M., Resident #83 was in bed eating with out any staff present, he/she was struggling to get food to their mouth at times. During an observation on 4/19/23 from 12:35 P.M. to 12:46 P.M., Resident #83 was in the dining room at a table with another resident who was eating their lunch meal, Resident #83's lunch tray was left in sight and in reach of the Resident but was not set up for the Resident to consume. Staff were observed assisting other residents at other tables. During an observation on 4/20/23 from 8:55 A.M. to 9:00 A.M., Resident #83 was in bed with their breakfast tray left on the over the bed table not set up to consume but in sight and in reach of him/her. Resident #83 was observed to reach for the tray at times, no staff were in the room assisting him/her. During an interview on 4/20/23 at 12:16 P.M., Certified Nurse Aide (CNA) #1 said she does look at the Resident Care Card to know how to take care of the residents and said she follows the Care Card for each resident or would ask a nurse if unsure on how to care for a resident. During interview on 4/20/23 at 12:18 P.M., the Director of Nurses (DON) said her expectation is for staff to follow the care plan and care card for each resident. The DON said that if a resident needs assist with eating, the meal tray should not be left in front of the resident, the meal should be delivered and the assist should happen at that time.