Based on record review and staff interview, the facility failed to ensure the court appointed legal guardian was fully informed in advance and given information necessary to make health care decisions to the extent required by the court, including the risk and benefits of psychotropic medication for one Resident (#7) from a total sample of 23 residents. Findings include: Review of the medical record indicated Resident #7 was admitted to the facility in January 2025 and had been declared an incapacitated person and had a legal guardian appointed by the court in September 2016. Guardianship protects the rights of the person who is unable to make or communicate decisions about everyday health, care, and safety. The guardian is responsible for and must be consulted for all healthcare decisions and required consents. The Guardian was granted court authorization on 1/24/2025 to admit Resident #7 to a nursing facility for short term services. Further review of the medical record indicated when Resident #7 was admitted to the facility, the court appointed guardian failed to sign all the necessary admission paperwork including consent for admission, treatment, and administration of psychotropic medication. All the paperwork was signed by the Resident, who had been deemed unable to make healthcare decisions. Review of Resident #7's current Physician's Orders indicated but were not limited to: -Fluoxetine (antidepressant) 30 milligrams (mg) daily, start date 1/25/25. Review of the Psychotropic Consent Form, dated 1/25/25, indicated Resident #7 signed the form which indicated he/she understood the listed risks and benefits for Fluoxetine 30 mg daily. Additional review of Resident #7's January 2025 through April 2025 Medication Administration Records (MAR) indicated the Resident was administered Fluoxetine as ordered. During an interview on 4/30/25 at 10:47 A.M., Unit Manager #1 said all admission paperwork including the Psychotropic Consent Form should have been signed by the Guardian on admission but was not; Resident #7 signed all the necessary admission forms. During an interview on 4/30/25 at 11:15 A.M., the Director of Nursing said all admission paperwork, including the Psychotropic Consent Form should have been signed by the legal guardian upon Resident #7's admission to the facility.

Based on observation, record review, and interview, the facility failed to ensure the physician ordered pain medication Oxycodone 5 milligrams(mg), were administered every four hours as prescribed for one Resident (#263) out of a total sample of 23 residents. Specifically, the facility failed to administer on 4/29/25 the 8:00 A.M. prescribed dose of Oxycodone 5 mg for effective pain control. Findings include: Review of the facility policy titled, Pain Assessment and Management, dated 2001, indicated but was not limited to the following: -The medication regime is implemented as ordered. -Results of the interventions are documented in communicated directly to the provider when appropriate. -Ongoing communication between the prescriber and the staff is necessary for optimal and judicious use of pain medications. Resident #263 was admitted to the facility in April 2025 with diagnoses which included: squamous cell carcinoma of the skin of the scalp and neck, non-pressure chronic ulcer of skin, complex regional pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 4/18/25, indicated Resident #263 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #56 had moderate cognitive impairment. Review of Nursing Rights of Medication Administration, (https://www.ncbi.nlm.nih.gov), indicated it is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. The five traditional rights in the traditional sequence include: -'Right patient' - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. -'Right drug' - ensuring that the medication to be administered is identical to the drug name that was prescribed. -'Right Route' - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration. -'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. -'Right dose'-- Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. During an interview on 4/29/25 at 11:57 P.M., Resident #263 was observed lying in bed with his/her dressing off and said please, please, you must help me with pain. Resident #263 said the Oxycodone doesn't work; he/she needs help with his/her pain medication. Review of Skin and Wound Note, dated 4/16/2025, indicated but was not limited to the following: -New consult for patient with known squamous cell carcinoma to the right scalp/face. Now with a large open area that is quite tender with all parts of exam. -Wound assessment: - Location right scalp/face -Primary etiology: Carcinoma -Size 11 centimeters by 11 centimeters by .4 cm depth calculated area is 121 square centimeters -Wound pained at rest: 6. Review of physician orders indicated but was not limited to: -Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 4 hours for Pain related to squamous cell carcinoma of the skin and scalp and neck, date initiated 4/24/25. -Scheduled administration is pain 12:00 A.M., 4 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Review of the facility narcotic book for Resident #263 Indicated but was not limited to the following: -4/29/25 indicated at 4:13 A.M., Oxycodone 5 mg was administered. -4/29/25 indicated at 8:00 A.M., Resident #263 was not administered Oxycodone 5 mg. -4/29/25 indicated at 12:00 P.M., Oxycodone 5 mg was administered. Review of Resident #263's Medication Administration Record (MAR) indicated but was not limited to the following: -Scheduled 8:00 A.M. dose of Oxycodone 5 mg was not administered. -Scheduled 12:00 P.M. dose of Oxycodone 5 mg was administered with a pain level recorded of 10 (severe pain). During an interview on 4/29/25 at 12:02 P.M., Consultant Nurse said Resident #263 just told her, he/she only wants Tylenol because the other medication makes him/her too sleepy. During an interview on 4/29/25 at 12:08 P.M., Nurse #2 said the last time Resident #263 received pain medication was at 4:13 A.M., when he/she received 5 mg of Oxycodone. Nurse #2 said Resident #263 did not receive his/her scheduled dose of Oxycodone at 8:00 A.M., because she was behind schedule. During an interview on 4/30/25 at 8:18 A.M., the Assistant Director of Nursing (ADON) said Resident #263's pain medication was not given in the morning as it should have been. ADON said the physician was made aware and Resident #263 was administered his/her 12:00 P.M. dose of Oxycodone 5 mg. During an interview on 04/30/25 at 12:59 A.M., the Director of Nurses said medications should be administered following the physician orders.

Based on observation, record review, and interview the facility failed to ensure it was free from a medication error rate of greater than 5% when one of two nurses observed during the medication pass made two errors out of 26 opportunities, resulting in a medication error rate of 7.69%. Those errors impacted two Residents (#82 and #27). Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018, indicated but was not limited to the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. Review of the facility policy titled Administering Oral Medications, dated as last revised October 2010 indicated but was not limited to the following: -The purpose of this procedure is to provide guidelines for the safe administration of oral medications. -Steps in the Procedure: Place Medication Administration Record (MAR) within easy viewing distance, Select the drug from the drawer, Check the label on the medication and confirm the medication name and dose with the MAR, Check the medication dose, and Re-check to confirm the proper dose. a. Resident #82 was admitted to the facility in May 2023 with diagnoses which include atrioventricular heart block and hypertensive heart disease. Surveyor observation during the medication administration pass included but were not limited to the following: 4/29/24 at 8:54 A.M., Nurse #1poured an Enteric Coated (EC) Aspirin 81milligram (mg) tablet into the medication cup with Resident #82's other morning medications and administered the medications to Resident #82. Review of the Physician Orders indicated but were not limited to the following: -Aspirin 81mg oral tablet Chewable Give one tablet by mouth one time a day for Myocardial Infarction (MI-heart attack) prophylaxis. (5/20/23) Review of the MAR indicated but was not limited to the following: -Aspirin 81mg oral tablet Chewable was signed off as administered. b. Resident #27 was admitted to the facility in April 2019 with diagnoses which include cerebrovascular disease. Surveyor observation during the medication administration pass included but were not limited to the following: 4/29/24 at 9:07 A.M., Nurse #1 poured an EC Aspirin 81mg tablet into the medication cup with Resident #27's other morning medications and administered the medications to Resident #27. Review of the Physician Orders indicated but were not limited to the following: -Aspirin Tablet Chewable 81mg Give one tablet by mouth one time a day related to cerebrovascular disease. (12/15/20) Review of the MAR indicated but was not limited to the following: -Aspirin Tablet Chewable 81mg was signed off as administered. During an interview on 4/29/25 at 1:28 P.M., Nurse #1 said she administered EC Aspirin to both Resident #82 and #27 and not Chewable Aspirin as ordered. During an interview on 4/29/25 at 4:05 P.M., Unit Manager #1 said EC Aspirin and Chewable Aspirin are not the same and cannot be used interchangeably. She said the nurse should be administering the medication per the physician order. During an interview on 4/29/25 at 4:33 P.M., the Director of Nurses said EC Aspirin and Chewable Aspirin are not interchangeable. She said the nurses should only be administering exactly what was ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide equal access to physical and occupational services for two Residents (#56 and #262) out of a sample of 23 residents. Specifically, the facility: 1. Limited Resident #56's physical and occupational therapy based on having Medicaid insurance to two times a week for two weeks. 2. Limited Resident #262's physical and occupational therapy based on having Medicaid insurance to two times a week for two weeks. Findings include: 1. Resident #56 was admitted [DATE] with the following diagnosis: left lower extremity deep vein thrombosis (blood clot), Type 2 diabetes mellitus with diabetic neuropathy (nerve damage), muscle weakness, difficulty walking, and unsteadiness on feet. Review of the Minimum Data Set (MDS) assessment, dated 4/2/25, indicated Resident #56 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #56 was cognitively intact. Review of Resident's primary insurance indicated Resident was covered by Medicaid. Review of the Facility Grievance/Concern Report dated 3/31/25 indicated but was not limited to the following: -Individual initiating concern: Resident and Resident representative; relationship Family Member #1. -Print individual's name: Resident #56 -Concern reported to: Social worker, and Director of Nurses. -Describe concern using factual terms: Have not seen anyone from rehab, staff nervous about getting resident up and out of bed since not seen yet. -What other action was taken to resolve this concern? Rehab evaluation completed 3/31/25. Review of physician orders indicated but was not limited to the following: -Occupational (OT), Physical (PT), and/or Speech evaluation and treat as needed dated 3/28/2025. -Skilled OT effective 4/1/2025 2 x week, times 2 weeks to include: activity training, therapeutic exercises, therapeutic activities, group therapy, wheelchair management, neuromuscular re-education, end date 4/15/2025. - Effective 3/31/2025, skilled physical therapy evaluation and treat 2 x week, times 2 weeks for treatment to include gait training, therapeutic exercises, therapeutic activity, neuromuscular re-education, end date 4/14/2025. -Re-certification clarification order for skilled PT 2 x/week for 2 weeks to include therapeutic exercises, therapeutic activities, gait training, neuromuscular re-ed, group, and wheelchair management. During an interview on 4/23/25 at 2:05 P.M., with Resident #56 present, Family Member #2 said Resident #56 went to the hospital because he/she needed rehab to help him/her walk and manage the pain in the left leg. FM #2 said the left leg swells and is red in color. FM #2 said Resident #56 is not getting enough rehab, he/she only gets rehab on Monday and Tuesday and then no more rehab for the rest of the week, it's not enough. During a telephonic interview on 4/23/25 at 2:15 P.M., FM #1 said Nursing Consultant #1 told him/her it was a Medicaid insurance issue and Resident #56 can only have PT two times a week. FM #1 said we are hoping to get different insurance to get more services, so Resident #56 can return home. Review of the rehabilitation services indicated but was not limited to the following: Physical Therapy Services: 3/31/25 (Monday)- Evaluation/treatment 4/1/25 (Tuesday)- Treatment 4/7/25 (Monday) - Treatment 4/10/25(Thursday)-Treatment 4/14/25 (Monday)- Treatment 4/17/25 (Thursday)- Treatment 4/21/25 (Monday)- Treatment Since admission a total of 7 visits in 22 days. Occupational Therapy Services: 4/1/25 (Tuesday)-Evaluation 4/9/25 (Wednesday)- Treatment 4/11/25 (Friday)- Treatment 4/15/25(Tuesday)- Treatment 4/16/25 (Wednesday) Treatment 4/23/25 (Wednesday)- treatment Since admission a total of 6 visits in 24 days. 2. Resident #262 was admitted to the facility March 2025 with the following diagnosis: Left hip replacement and left hip osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 4/16/25, indicated Resident #262 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #56 was cognitively intact. During an on 4/23/25 at 2:02 P.M., Resident #262 said my biggest problem is I only get physical therapy two times a week and I have been here for two weeks. Resident #262 said it is ridiculous, I came here for rehab, and I am going home tomorrow. Review of the rehabilitation services indicated but was not limited to the following: Physical Therapy Services: 4/13/25 (Sunday)- Evaluation/treatment 4/15/25 (Tuesday)- Treatment 4/20/25 (Sunday)-Treatment Since admission a total of 3 visits in 13 days. Occupational Therapy Services: 4/11/25 ()-Evaluation/treatment 414/25 (Wednesday)- Treatment 4/18/25 (Friday)- Treatment Since admission a total of 3 visits in 13 days. During an interview on 4/24/25 at 4:00 P.M., the Rehabilitation (Rehab) Director said residents get rehab depending on the insurance they have. The Rehab Director said if a resident has Medicare A insurance, they are put on rehab 5 x week, and if they are Medicaid insurance, they are approved for 2 x week for 2 weeks for both PT and OT. The Rehab Director said the Administrator has it set up this way. She said after two weeks Medicaid residents can be re-evaluated and get an additional 2 x week for two weeks. Rehab Director said she was aware Resident #262 thought he/she was not getting enough rehab. During an interview on 4/24/25 at 4:05 P.M., Rehab Staff #1 said he saw Resident #262 two times a week for occupational therapy and discharged Resident #262 today, reaching all his/her goals. Rehab Staff #1 said Resident #262 was discharged at a supervision level in the shower and set up for dressing, and the last time he/she was seen for OT services was 4/18/25 (6 days ago). Rehab Staff #1 said the Administrator controls the visits. During an interview on 4/24/25 at 4:20 P.M., the Administrator said they get whatever therapy they need and said it doesn't matter what insurance they have. The Administrator said initially, Medicaid patients are initially two times a week for two weeks, then they are re-assessed. During a telephonic interview on 4/24/25 at 4:32 P.M., Rehab Staff #2 said she completed the physical therapy evaluation on Resident #262 and wrote up his/her evaluation for two times a week for two weeks. Rehab Staff #2 said when she comes to this building, she can only care-plan evaluations for all Medicaid patients two times a week for two weeks, and then they are re-evaluated for an additional 2 x week for 2 weeks. Rehab Staff #2 said she also completed the physical therapy evaluation for Resident #56, who was more involved than Resident #262. Rehab Staff #2 said she also care planned Resident #56 for physical therapy two times a week for two weeks. Rehab Staff #2 said it is specific to this building, all Medicaid evaluations care plans can only be written two times a week for two weeks. Rehab Staff #2 said a Medicaid patient can't be put on therapy five times a week. During an interview on 4/30/25 at 9:14 A.M., Physician #1 said it is his expectation his residents admitted here for rehabilitation are seen daily. Physician #1 said he was not aware that only Medicaid patients were put on rehab 2 x a week for two weeks and then reevaluated. Physician #1 said he was not aware of any regulations that Medicaid patients are limited in their rehab compared to other insurances, he would have to investigate it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure professional standards of practice were followed for seven Residents (#2, #25, #29, #263, #265, #82, and #27) out of total of 23 residents. Specifically, the facility failed to: 1. For 1a. Resident #2, 1b. Resident #25, 1c. Resident #29 , 1d. Resident # 262, and 1e. Resident #265, the facility failed to ensure physician prescribed medications were administered within an acceptable time frame; and 2. For Resident #82 and #27 to administer medication per the physician order. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of Nursing Rights of Medication Administration, (https://www.ncbi.nlm.nih.gov), indicated it is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. The five traditional rights in the traditional sequence include: -'Right patient' - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. -'Right drug' - ensuring that the medication to be administered is identical to the drug name that was prescribed. -'Right Route' - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration. -'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. -'Right dose'-- Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. 1a. Review of Resident #2 Medication Administration Record (MAR) indicated the following: a. Aspirin 81 milligrams (mg) by mouth one time a day at 9:00 A.M. b. Lamotrigine tablet 100 mg give 100 mg by mouth at 9:00 A.M. c. Metoprolol succinate extended-release tablet extended release 24 hours 50 mg at 9:00 A.M. d. Ocuvite-lutein capsule, give 1 capsule by mouth at 9:00 A.M. e. Polyethylene Glycol 3350 powder 17 GM/scoop, give one scoop at 9:00 A.M. f. Senna tablet 8.6 mg, give one tablet at 9:00 A.M. g. Spiriva handihaler capsule 18 MCG, one dose inhale orally one time a day at 9:00 A.M. h. Vitamin D3 tablet, give 1000 units by mouth one time a day at 9:00 A.M. I. Docusate Sodium give 100 mg by mouth two times a day at 8:00 A.M. and 8:00 P.M. J. Eliquis tablet give 5 mg by mouth every 12 hours for anticoagulant at 8:00 AM and 8:00 P.M. k. Furosemide tablet 20 mg give 3 tablets by mouth two times a day at 8:00 A.M. and 8:00 P.M. l. Potassium Chloride extended relief 20 MEQ give 2 tabs two times a day for hypokalemia at 9:00 A.M. and 8:00 P.M. Review of the MAR printed on 4/29/25 at 1:01 P.M indicated the above listed medications had not been administered as orderd. 1b. Review of Resident #25 Medication Administration Record (MAR) indicated the following: a. Aspirin 81 milligrams (mg) by mouth one time a day at 9:00 A.M. b. Furosemide tablet 20 mg give 1 tablet by mouth one time a day at 8:00 A.M. c. Lantus subcutaneous solution 100 unit/ML, inject 12 units subcutaneously one time a day at 8:00 A.M. d. Lisinopril tablet 5 mg for hypertension at 9:00 A.M. e. Metformin HCI oral solution 500 mg/5ML, give 10ML by mouth for diabetes at 9:00 A.M. f. Colace capsule 100 mg at 9:00 A.M. and 5:00 P.M. g. Glucerna three times a day for a supplement at 10;00 A.M., at 10 A.M., 4:00 P.M., and 8:00 P.M. Review of the MAR printed on 4/29/25 at 12:39 P.M indicated the above listed medications had not been administered as orderd. 1c. Review of Resident #29 Medication Administration Record (MAR) indicated the following: a. Amlodipine Besylate oral tablet 5 mg, give one tablet one time a day for hypertension at 9:00 A.M. b. Atorvastatin Calcium oral tablet 10 mg, give one tablet by mouth one time a day for high cholesterol at 9:00 A.M. c. Lisinopril oral tablet 40 mg, give one tablet by mouth on time a day for hypertension at 9:00 A.M. d. Metoprolol Succinate ER oral tablet extended release 24-hour 25 mg, give by mouth one time a day at 9:00 A.M. e. Oxybutynin Chloride ER oral tablet extended release 24-hour release 10 mg, give one time a day at 9:00 A.M. f. Glycolax powder give 17 grams by mouth two times a day at 8:00 A.M. and 5:00 P.M. g. Muscle rub cream 10 to 15% applied to back and neck two times a day at 9:00 A.M and 5:00 P.M. Review of the MAR printed on 4/29/25 at 12:57 P.M indicated the above listed medications had not been administered as ordered. 1d. Review of Resident #263 Medication Administration Record (MAR) indicated the following: a. Duloxetine HCL oral capsule delayed release particles 60 mg, give 1 capsule by mouth one time a day at 9:00 A.M. b. Ensure one time a day for 237 ml 1 x day at 10:00 A.M. c. Protein liquid one time a day for 30 ml at 10:00 A.M. d. Oxycodone HCL oral tablet 5 mg, give 5mg by mouth every 4 hours for pain 12:00 A.M., 4 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Review of Resident #263's medication administration with Nurse #2 indicated he/she had not received the prescribed morning medications, including the Oxycodone HCL oral tablet 5 mg. 1e. Review of Resident #265 Medication Administration Record (MAR) indicated the following: a. Aspirin 81 milligrams (mg) by mouth one time a day for heart attack at 9:00 A.M. b. Folic Acid oral tablet 1 mg, give tablet by mouth one time a day at 9:00 A.M. c. Glucerna one time a day for supplement at 10:00 A.M. d. Iron oral tablet 325 mg, give 1 tablet by mouth at 8:00 A.M. e. Protein liquid one time a day 30ml's at 10 A.M. f. Revefenacin inhalation solution 175 mcg/3ml, 3 ml inhale orally via nebulizer one time a day for chronic obstructive pulmonary disease (COPD) at 9:00 A.M. g. Risperidone oral tablet 0.25 mg, give 1 tablet by mouth one time a day at 9:00 A.M. h. Vitamin D325 MCGs for a supplement at 9:00 AM i. Budesonide inhalation suspension 0.5 mg/2ml, 2 ml inhale orally via nebulizer two times a day for COPD at 9:00 A.M. j. Lamotrigine oral tablet 150 mg, give 1 tabby mouth two times a day for mood disorder at 9:00 A.M. and 8:00 P.M. k. Miconazole Nitrate external cream 2 %, apply to Peri-stoma topically two times a day for abdominal skin irritation at 9:00 A.M. and 5:00 P.M. l. Olanzapine oral tablet 5 mg, give 0.5 tablet by mouth two times a day for psychotic disturbance at 9:00 A.M. and 10:00 P.M. Review of the MAR printed on 4/29/25 at 12:59 P.M indicated the above listed medications had not been administered as ordered. During an interview on 4/29/25 at 12:31 P.M., Nurse #2 said she is behind giving medications because she did not get access code until close to 8:00 A.M. and has had to ask for some medication from the Pyxis machine (automated medication dispensing system). Nurse #2 said she is now giving out her morning and afternoon medications together. Nurse #2 said she gave Resident # 263 his/her morning medications late, which included 5 mg of oxycodone scheduled for 8:00 A.M. Nurse #2 said she still has to give out morning medications for Resident #2, #25, #29, and #265. During an interview on 04/30/25 at 12:59 P.M., the Director of Nurses said medications should be administered following the physician orders. She said the nurse should have notified us she was having difficulty, and we would have provided help. 2a. Resident #82 was admitted to the facility in May 2023 with diagnoses which include atrioventricular heart block and hypertensive heart disease. Surveyor observation during the medication administration pass included but were not limited to the following: 4/29/24 at 8:54 A.M., Nurse #1 poured an Enteric Coated (EC) Aspirin 81milligrams (mg) tablet into the medication cup with Resident #82's other morning medications and administered the medications to Resident #82. Review of the Physician Orders indicated but were not limited to the following: -Aspirin 81mg oral tablet Chewable Give one tablet by mouth one time a day for Myocardial Infarction (MI-heart attack) prophylaxis. (5/20/23) Review of the MAR indicated but was not limited to the following: -Aspirin 81mg oral tablet Chewable was signed off as administered. 2b. Resident #27 was admitted to the facility in April 2019 with diagnoses which include cerebrovascular disease. Surveyor observation during the medication administration pass included but were not limited to the following: 4/29/24 at 9:07 A.M., Nurse #1 poured an EC Aspirin 81mg tablet into the medication cup with Resident #27's other morning medications and administered the medications to Resident #27. Review of the Physician Orders indicated but were not limited to the following: -Aspirin Tablet Chewable 81mg Give one tablet by mouth one time a day related to cerebrovascular disease (12/15/20). Review of the MAR indicated but was not limited to the following: -Aspirin Tablet Chewable 81mg was signed off as administered. During an interview on 4/29/25 at 1:28 P.M., Nurse #1 said she administered EC Aspirin to both Resident #82 and #27 and their orders were both for Chewable Aspirin. She said there was Crushable Aspirin in the mediation cart and removed a bottle of Chewable Aspirin 81mg tablets. She said she only uses the Chewable Aspirin if a resident needs their medications crushed otherwise she administers regular Aspirin (EC Aspirin). She said they really are not the same thing, but that is what she always does. During an interview on 4/29/25 at 4:05 P.M., Unit Manager #1 said EC Aspirin and Chewable Aspirin are not the same and cannot be used interchangeably. She said the nurse should be administering the medication per the physician order. During an interview on 4/29/25 at 4:33 P.M., the Director of Nurses said EC Aspirin and Chewable Aspirin are not the interchangeable. She said the nurses should only be administering exactly what was ordered by the physician.

Based on staff interviews and review of the facility policy, the facility failed to track and analyze data, including the progress and outcome of projects identified in the facility's Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), revised February 2020, indicated the following: Policy statement: This facility shall develop, implement, and maintain an ongoing, facility wide, data-driven QAPI program that is based on indicators of outcomes of care and quality of life for our residents. -The objective of the QAPI program is to: 1. Provide a means to measure current and potential indicators for outcomes of quality of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Established systems through which to monitor and evaluate corrective actions. Implementation: -The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance measurements: c. Identify and prioritize quality deficiencies: d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action and performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. -The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. Coordination: -The QAPI coordinator assists other committees, individuals, departments, and/or services and developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan. During an interview on 4/30/25 at 2:00 P.M., The Administrator said the QAPI committee meets monthly, and she goes over the QAPI plan. She said she takes notes on the programs they are working on but does not have any data for review. The Administrator said one of her current QAPI programs is staff appreciation, which they review monthly looking at what can be done for staff, and she gave examples which included providing lunches and different recognition ideas. The Administrator said there is no data or outlined goals for staff appreciation. The Administrator gave a second example of a current QAPI program, which was for the environment of the first-floor unit. She said they have been working on it for the last year. The Administrator things they have focused on was hanging new pictures, ongoing painting and fixing the edges of the furniture. The Administrator had no data or outlined goals for the improvements on the first-floor unit. The Director of Nurses (DON) joined the QAPI meeting and provided the surveyor with a completed QAPI project related to one Resident receiving a burn from a hot liquid. The DON was unable to provide any data driven out comes. The Administrator and the DON said they do not have any other QAPI projects ongoing at this time. The Administrator said she does not have any past QAPI projects that are data-driven with outcomes at this time. Review of the facilities QAPI program failed to provide evidence of an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality

Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility's Infection Preventionist failed to attend two of the last three quarterly QAPI meetings. Findings include: Review of the facility's policy titled Quality Assessment and Performance (QAPI), revised February 2020, 11/19/24, indicated but was not limited to: - Policy: This facility shall develop, implement, and maintain an ongoing, facility wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life of our residents. -The Administrator is responsible for ensuring that this facility's QAPI program complies with federal, state, and local Regulatory agency requirements. Review of the QAPI Attendance Sheets, dated 7/25/24 and 10/30/24, failed to indicate the Infection Preventionist was in attendance. During an interview on 4/30/25 at 2:00 P.M., the Administrator and the surveyor reviewed the QAPI Attendance Sheets, dated 7/25/24 and 10/30/24. The Administrator could not identify the Infection Preventionist signature at either meeting.

Based on observation, interview, and policy review, the facility failed to ensure a reasonable accommodation was made for one Resident (#207), out of a total sample of 22 residents. Specifically, the facility failed to ensure the Resident was provided with a call bell device that was within reach and able to be used if the Resident desired to call for assistance. Findings include: Review of the facility's policy titled Answering the Call Light, revised March 2021, indicated but was not limited to the following: -Upon admission and periodically as needed, explain, and demonstrate use of the call light to the resident. -Ask the resident to return the demonstration. -When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. -Some residents may not be able to use their call light. Be sure you check on these residents frequently. Resident #207 was admitted to the facility in April 2024 and had diagnoses including unspecified fracture of left femur, closed fracture with routine healing, aftercare following joint replacement surgery, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke) affecting the left non-dominant side, osteoarthritis, and transient cerebral ischemic attack. Review of the Minimum Data Set (MDS) assessment, dated 4/17/24, indicated Resident #207 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an observation with interview on 4/18/24 at 3:30 P.M., the surveyor observed Resident #207 lying in bed. His/her left arm and hand were contracted upward toward his/her chest. The Resident's call bell control device was observed on top of the bed linens on the Resident's left side. Resident #207 said he/she could somewhat reach the call bell with his/her right hand but was unable to, saying ow and it's terrible, while attempting to reach over to grab it. During an observation on 4/19/24 at 10:56 A.M., the surveyor observed Resident #207 seated in a wheelchair (with the bed to his/her left) playing a puzzle game on his/her tablet on an overbed table utilizing a stylus with the right hand. The Resident's left arm and hand were contracted upward toward the chest. A call bell control device was observed lying on the bed to the Resident's left side. During an observation with interview on 4/22/24 at 7:07 A.M., the surveyor observed Resident #207 lying in bed. His/her left arm and hand were contracted upward toward the chest. A call bell control device was observed lying on the bed to the Resident's left side. Resident #207 was unable to demonstrate for the surveyor his/her ability to reach it with the right hand and said he/she could not push the buttons. During an observation with interview on 4/22/24 at 9:01 A.M., the surveyor observed Resident #207 seated in a wheelchair (with the bed to his/her left) eating breakfast with his/her right hand. The Resident's left arm and hand were contracted upward toward the chest. The call bell control device was not within reach of the Resident and was observed positioned on the opposite side of the bed under a blanket. Resident #207 said he/she must yell down the hallway if he/she needs someone. During an interview on 4/22/24 at 3:15 P.M., Certified Nursing Assistant (CNA) #2 said Resident #207 had recent hip surgery and the call bell should be within reach but the Resident would call if he/she needed staff assistance. CNA #2 said the Resident had no deficits that she knew of and wasn't sure of the level of assistance needed. On 4/23/24 at 8:50 A.M., the surveyor observed Resident #207 seated in a wheelchair (with the bed to his/her left) eating breakfast with his/her right hand. The Resident's left arm and hand were contracted upward toward the chest. The call bell control device was not within reach of the Resident and was observed positioned on top of the mattress to the Resident's left side. During an observation with interview on 4/23/24 at 9:30 A.M., the surveyor observed Resident #207 seated in a wheelchair (with the bed to his/her left) in his/her room. The Resident's left arm and hand were contracted upward toward the chest. The call bell control device was not within reach of the Resident and was observed positioned on top of the mattress to the Resident's left side. Resident #207 said he/she could not reach it. The Resident said even if he/she could reach it, it's difficult to push the buttons to call for help because of arthritis and decreased strength in his/her fingers. The Resident said sometimes he/she can get the television on but then can't turn it off. CNA #3 entered the Resident's room and said the call bell should have been within reach of the Resident but it was not. During an interview on 4/23/24 at 10:04 A.M., Nurse #5 said the Resident had left sided weakness and a left-hand contracture and the call bell device should be placed to the Resident's right, not his/her left, and it was a long one so should be next to him/her as much as possible and within reach. Nurse #5 said the Resident should be able to use it and, if not, then staff should accommodate his/her needs. Nurse #4 said he was not sure if the Resident was assessed for his/her ability to use it. On 4/23/24 at 10:21 A.M., the surveyor and Nurse #5 entered the Resident's room. Resident #207 was seated in a wheelchair (with the bed to his/her left) in his/her room playing a game on his/her tablet on an overbed table utilizing a stylus with the right hand. The Resident's left arm and hand were contracted upward toward the chest. Resident #207's call bell control device was positioned closely to his/her left side on top of the bed. Resident #207 demonstrated using the end of his/her stylus to push the red nurse call bell button on the call bell control device. Resident #207 said he/she couldn't press the buttons with his/her fingers because of arthritis and decreased strength. The Resident said no other call bell device had been offered or provided to him/her. During an interview on 4/23/24 at 1:11 P.M., the Director of Nursing (DON) said on admission it's standard practice to make sure residents can use their call light. She said the call bell should be within the resident's reach including when out of bed. The DON said the facility had adaptive call lights they could provide if needed but staff did not identify the need for this Resident.

Based on records reviewed, policy review, and interviews, for one Resident (#207), of 22 sampled residents, the facility failed to implement an individualized, person-centered care plan. Specifically, the facility failed, for Resident #207, who was status post partial left hip replacement, to implement the intervention for the use of an abductor wedge pillow to maintain anterior hip precautions. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated as revised March 2022, indicated but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident -The comprehensive, person-centered care plan: describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change Resident #207 was admitted to the facility in April 2024 and had diagnoses including unspecified fracture of left femur, closed fracture with routine healing, and aftercare following joint replacement surgery. Review of the Minimum Data Set (MDS) assessment, dated 4/17/24, indicated Resident #207 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of current Physician's Orders indicated the following: -Maintain anterior hip precautions (to keep the hip within safe positions while it heals); abductor wedge pillow (device to support limb alignment, helps to prevent your hip from turning in or away from your body) while in bed every shift for left hip fracture for six (6) weeks, 4/15/24 Review of the Surgical Incision to Left Hip care plan, initiated 4/17/24, indicated the following interventions: -Abductor wedge pillow in bed x 6 weeks, 4/17/24 -Anterior hip precautions, 4/17/24 During an observation with interview on 4/18/24 at 3:33 P.M., the surveyor observed Resident #207 lying in bed. His/her legs were not abducted away from the midline of his/her body. An abductor wedge pillow device was observed resting on top of the Resident's dresser and not positioned between the Resident's legs. Resident #207 said he/she was supposed to have the wedge pillow between his/her legs to help with positioning, but no one put it there and said, my knee goes this way pointing to the left knee then inward toward the right. During an observation with interview on 4/22/24 at 7:07 A.M., the surveyor observed Resident #207 lying in bed on his/her back. The Resident's legs were elevated on two pillows and not abducted away from the midline of his/her body. An abductor wedge pillow device was observed resting on top of the Resident's dresser. Resident #207 said he/she didn't have the wedge pillow but was supposed to be using it to keep his/her legs separated. During an interview on 4/22/24 at 3:15 P.M., Certified Nursing Assistant (CNA) #2 said she was assigned to the Resident that day and that Resident #207 was supposed to have the wedge pillow between his/her legs while in bed. During an interview on 4/23/24 at 10:04 A.M., Nurse #5 said Resident #207 had a left hip fracture after a fall at home and came to the facility on hip precautions. He said the Resident was supposed to have the abductor pillow between the legs while in bed. Nurse #5 said staff were expected to implement care planned interventions and apply the wedge pillow per physician's orders. During an interview on 4/23/24 at 1:11 P.M., the Director of Nursing (DON) said Resident #207 arrived at the facility following joint surgery for a left femur fracture and was on anterior hip precautions requiring an abductor wedge pillow while in bed x 6 weeks. She said the Resident needed the wedge pillow to keep his/her legs a certain distance apart to prevent leg crossing and avoid leg/hip rotation. She said interventions should have been implemented per physician's orders and the current care plan. During an interview on 4/23/24 at 2:52 P.M., the Rehab Director said Resident #207 had a fall at home and had hip surgery. She said the Resident was on hip precautions and always needed an abductor wedge pillow between the legs when in bed to keep the legs from getting too close together which could pop the hip back out. The Rehab Director said the Resident should not be bending forward greater than 90 degrees, twisting, or crossing his/her legs to keep the legs abducted (away from the midline of the body).

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for one Resident (#206), out of a total sample of 22 residents. Specifically, the facility failed to administer medications per physician's orders and manufacturer's instructions for use. Findings include: Review of the facility's policy titled Administering Medications, revised April 2022, indicated but was not limited to the following: -Medications are administered in a timely manner, and as prescribed. -Medications are administered in accordance with prescriber orders, including any required time frame. -The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #206 was admitted to the facility in April 2024 with diagnoses including benign prostatic hypertension (BPH) (enlarged prostate), acute embolism and thrombosis of unspecified deep veins of right lower extremity, Alzheimer's disease, and dementia. Review of current Physician's Orders indicated the following: -May change form of medication as needed (liquid), 4/12/24 -May crush meds, combine and mix with food according to crush guidelines or use liquid equivalent, 4/12/24 -Aspirin 81 milligrams (mg) oral tablet, delayed release, give one tablet by mouth one time a day, 4/12/24 -tamsulosin HCL (Flomax) oral capsule 0.4 mg, give 1 capsule by mouth one time a day for BPH, 4/12/24 On 4/18/24 at 9:52 A.M., the surveyor observed Nurse #4 prepare Resident #206's 9:00 A.M. medications and observed the following: 9:52 A.M. - Nurse #4 opened an over-the-counter bottle of chewable Aspirin 81 mg from the top drawer of her medication cart and added one whole tablet into a medication cup along with one whole tamsulosin HCL (Flomax) 0.4 mg capsule. Nine other whole tablets and two whole capsules were also added to the medication cup. 10:03 A.M. - Nurse #4 said she wasn't familiar with the Resident and wasn't sure how he/she took his/her pills and asked another staff member who said to just ask the Resident. 10:14 A.M. - Nurse #4 asked the Resident how he/she took his/her medications, but the Resident did not answer. He/she was observed playing with a straw inside a plastic cup. 10:17 A.M. - Nurse #4 asked Unit Manager (UM) #3 who said the Resident needed his/her medications crushed. Nurse #4 crushed all the medication tablets including the Aspirin and added the contents to approximately 1 tablespoon (tbs.) of applesauce. Nurse #4 opened the tamsulosin HCL capsule and sprinkled it onto the applesauce. She did not consult with the physician prior. Nurse #4 entered the room to administer the medications to the Resident. The surveyor asked Nurse #4 if all the medications were able to be either crushed or opened. Nurse #4 said yes. 10:32 A.M. - Nurse #4 attempted to administer the medications to Resident #206 approximately 3-4 times but the Resident refused shaking his/her head no. Review of the manufacturer's Patient Information document, revised November 2009, indicated the following: Flomax is a prescription alpha blocker medicine used to treat the signs and symptoms of benign prostatic hyperplasia (BPH), a condition your doctor may refer to as an enlarged prostate. How should I take Flomax? -Take Flomax as prescribed by your doctor -Do not crush, chew, or open Flomax capsules What are the possible side effects of Flomax capsules? -Decreased blood pressure when changing positions. Flomax may cause a sudden drop in blood pressure upon standing, especially after the first dose or when changing doses. -Fainting -Dizziness -Lightheadedness During an interview on 4/18/24 at 10:38 P.M., the surveyor reviewed the physician's orders with Nurse #4 who said she didn't use the right Aspirin bottle. She said she did not follow physician's orders for a delayed release tablet, instead dispensing a chewable tablet. Nurse #4 said there was an order to crush the medications but not an order to open the tamsulosin HCL delayed release capsule. During an interview on 4/22/24 at 11:53 A.M., Nurse #4 said there were no facility guidelines that she followed for opening medication capsules and no increased side effects she was aware of for opening the tamsulosin HCL delayed release capsule. Nurse #4 said she was not aware of the potential side effects of the medication or if the capsule should not be opened. She said she just did it. During an interview on 4/23/24 at 11:35 A.M., the Pharmacist said tamsulosin HCL is a time release capsule and opening it can cause a rapid drug release which could be an issue. She said the physician should be aware the capsules are being opened by staff and even though there are trials out there, the current recommendation is to not open, crush, or chew it. The Pharmacist said the physician could override this if other alternatives were tried and nothing else worked. During a telephone interview on 4/23/24 at 12:28 P.M., Physician #1 said he was not aware staff were opening any of the capsules. He said the Resident arrived from the hospital and his/her medications were just continued from there with no changes. Physician #1 said there had not been anything else tried in place of the tamsulosin HCL capsule, the medication was just continued. During an interview on 4/23/24 at 12:50 P.M., the Director of Nursing (DON) said the Aspirin and tamsulosin HCL should have been administered per physician's orders. She said anything like that with a discrepancy should have been clarified with the physician and an order obtained. She said this way if staff need to open a capsule, then they have the order. The DON said the nurse should have clarified with the physician that it was okay to open the capsule prior to opening and attempting to administer it. She said opening the capsule can change how the medication is absorbed, in theory it would be quicker. The DON said all medications should be administered to residents per the five rights.

Based on records reviewed, policy review, and interview for three Residents (#9, #35, and #75), of 22 sampled residents, the facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications. Specifically, for Residents #9, #35, and #75, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed. Findings include: Review of the facility's policy titled Use of Psychotropic Medication, undated, indicated but was not limited to: -Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, every six months, with a significant change in condition, change in antipsychotic medication, as needed or as per facility policy. 1. Resident #9 was admitted in February 2023 with diagnoses that included unspecified dementia, mood disturbance, anxiety disorder, other specified depressive episodes, and bipolar disorder. Review of Resident #9's Minimum Data Set (MDS) assessment, dated 3/28/24, indicated the Resident scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review indicated that the Resident was receiving antipsychotic medication on a regular basis. Review of Resident #9's active Physician's Orders indicated but was not limited to, the following: -Risperdone Oral Solution, 1 milligram (mg)/milliliter (ml). Give 0.5 ml by mouth three times a day for bipolar disorder. Review of Resident #9's Medication Administration Record (MAR) for the months of March and April 2024 indicated the Resident was routinely given their medication as ordered by the physician. Review of Resident #9's medical record, indicated an AIMS test was completed on the following dates: 3/9/23 7/7/23 9/9/23 During an interview on 4/23/24 at 3:40 P.M., the Director of Nursing (DON) said an AIMS test should have been performed in March 2024, per policy, for Resident #9. 2. Resident #35 was admitted in January 2016 with diagnoses that included unspecified major depressive disorder, dementia with psychotic disturbance, and anxiety. Review of Resident #35's MDS assessment, dated 11/9/23, indicated the Resident scored 0 out of 15 on the BIMS indicating severe cognitive impairment. Further review indicated that the Resident was receiving antipsychotic medication on a regular basis. Review of Resident #35's active physician's order indicated, but was not limited to, the following: -Olanzapine Tablet, 5 mg. Give one tablet by mouth one time a day related to unspecified psychosis. Review of Resident #35's medical record, indicated an AIMS test was completed on the following dates: 2/23/23 11/10/23 During an interview on 4/23/24 at 3:40 P.M., the DON said the AIMS test was completed 2/23/23 and 11/10/23 for Resident #35. The DON said, per policy, AIMS testing should be completed every six months and there was a greater than six-month gap in AIMS testing for Resident #35. The DON said an AIMS test should have been performed in August 2023, per policy, for Resident #35.3. Resident #75 was admitted to the facility in May 2021 with the following diagnoses: Alzheimer's disease, dementia, and anxiety. Review of the MDS assessment, dated 3/28/24, indicated Resident #75 was severely cognitively impaired as evidenced by a BIMS score of 0 out of 15, and received antipsychotic medication on a routine basis. Review of Resident #75's Physician's Orders indicated but was not limited to: -Olanzapine (anti-psychotic) 5 mg by mouth two times a day, 3/9/24 - 3/25/24 -Olanzapine 5 mg by mouth at bedtime, 3/25/24 - 3/27/24 -Olanzapine 2.5 mg by mouth once daily, 3/26/24 - 3/27/24 -Olanzapine 5 mg by mouth at bedtime, 3/27/24 - 4/12/24 -Olanzapine 2.5 mg by mouth once daily, 3/28/24- 4/12/24 -Olanzapine 2.5 mg by mouth once daily, 3/28/24 - 4/12/24 -Olanzapine 5 mg by mouth at bedtime, 4/12/24 -Olanzapine 1.25 mg by mouth once daily, 4/13/24 Review of Resident #75's MAR for March and April 2024 indicated he/she received Olanzapine per physician's orders. Review of Resident #75's Practitioner Notes/Psychiatric Follow-ups, dated 3/25/24 and 4/8/24, failed to indicate an AIMS assessment had been completed. Review of Resident #75's medical record indicated an AIMS assessment had been completed on 4/23/24 (45 days after the anti-psychotic medication was initiated). During an interview on 4/23/24 at 1:20 P.M., Unit Manager #2 and the surveyor reviewed the medical record and could not locate an AIMS assessment prior to the one completed on 4/23/24. Unit Manager #2 said she had just completed the AIMS assessment and it should have been completed when the medication was started. During an interview on 4/23/24 at 3:10 P.M., the DON said Resident #75 started Olanzapine upon return from the hospital in March 2024, the DON said an AIMS assessment should have been completed when the medication was initiated.

Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility. Specifically, the facility failed to adhere to infection control practices for hand hygiene while preparing medications. Findings include: Review of the facility's policy titled Administering Medications, revised 2022, indicated but was not limited to the following: -Staff follows established facility infection control procedures (e.g. handwashing) for the administration of medications, as applicable. Review of the facility's policy titled Handwashing/Hand Hygiene, revised March 2023, indicated but was not limited to the following: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: after removing gloves. On 4/22/24 at 9:26 A.M., the surveyor observed Nurse #5 prepare a resident's 9:00 A.M. medications at his medication cart. Nurse #5 donned (put on) a pair of gloves to crush the resident's medications in a plastic medication pouch, poured the contents into applesauce, then doffed (took off) the gloves in the adjacent trash receptacle. Nurse #5 did not perform hand hygiene after removing the gloves or before donning a new pair of gloves to pour a bottle of Ensure (nutrition shake) into a plastic cup. Nurse #5 doffed the second set of gloves then administered the resident's medications without performing hand hygiene prior. During an interview on 4/22/24 at 9:28 A.M., Nurse #5 said he should have performed hand hygiene each time he removed his gloves and before he administered the medications to the resident. During an interview on 4/23/24 at 12:50 P.M., the Director of Nursing said staff should be performing hand hygiene any time before and after donning and doffing gloves in general and during med pass.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and policy review, the facility failed to ensure staff properly labeled all drugs and biologicals used in the facility in accordance with currently accepted principles. Specifically, the facility failed to: 1. Ensure staff properly labeled the packaging box and/or its multidose vial of Tubersol (tuberculin) (purified protein derivative, a combination of proteins that are used in the diagnosis of tuberculosis) stored inside two of three medication room storage refrigerators reviewed; and 2. Ensure staff properly labeled all medications stored in one of three medication carts reviewed once opened. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised February 2018, indicated but was not limited to the following: -Certain medications or package types, such as multiple dose injectable vials, certain ophthalmic (per manufacturer specifications), once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated, if applicable, for medications requiring a shortened expiration date. -The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration, if applicable. 1. Review of the facility's document titled Medications with Shortened Expiration Dates, revised September 2023, indicated but was not limited to the following: -Tubersol (tuberculin PPD Mantoux injection), discard vials in use after 30 days a. [NAME] Unit Medication Storage Room During an observation with interview with Nurse #6 on 4/18/24 at 11:18 A.M., the surveyor observed one opened packaging box of Tubersol with a multidose vial inside with the pop top removed indicating it had been used. Neither the packaging box nor the vial was labeled with the open date, or the new expiration date once opened. Nurse #6 said the vial should have been labeled when opened but wasn't, and that it was only good for 30 days once opened. b. Grove Unit Medication Storage Room During an observation with interview with Nurse #8 on 4/18/24 at 1:14 P.M., the surveyor observed one opened packaging box of Tubersol with a multidose vial inside with the pop top removed indicating it had been used. Neither the packaging box nor the vial was labeled with the open date, or the new expiration date once opened. Nurse #8 said the vial had been used and should have been labeled with the open date and expiration date but wasn't. She said the packaging box should have also been labeled. She said the vial was only good for 30 days once opened. During an interview on 4/18/24 at 1:29 P.M., Unit Manager #3 said the Tubersol boxes should have been labeled with the dates when opened and the expiration dates. She said she wasn't sure how long the vials would be good for once opened. 2. Review of manufacturer's instructions, dated February 2023, indicated but was not limited to the following: Indications for Use: -Rhopressa (netarsudil ophthalmic solution) 0.02% is indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. How Supplied/Storage and Handling: -Store at 2 degrees Celsius (C) to 8 degrees C (36 degrees Fahrenheit (F) to 46 degrees F) until opened. After opening, the product may be kept at 2 degrees C to 25 degrees C (26 degrees F to 77 degrees F) for up to six weeks. On 4/18/24 at 12:46 P.M., the surveyor reviewed the Meadows Unit low side medication cart with Nurse #7 and observed the following: -one opened bottle of Rhopressa ophthalmic solution 0.02%, not stored inside its packaging box, seal broken, labeled with a resident's name, bottle not labeled with the date when opened or the new expiration date once opened. During an interview on 4/18/24 at 12:46 P.M., Nurse #7 said the bottle had been opened and did not know the facility's policy for labeling but said it should have been labeled when opened. He said the medication had a shortened expiration of 30 days after opening. During an interview on 4/23/24 at 12:59 P.M., the Director of Nursing (DON) said the Tubersol packaging boxes and multidose vials stored inside should have been labeled with the open dates and expiration dates. She said the Rhopressa eye drop bottle should have also been labeled with the open date and expiration date. She said both medications have a shortened expiration once opened but was not sure how many days. The DON said the shortened expiration is to preserve the efficacy of the medication.

Based on interviews and records reviewed for one of three sampled residents (Resident #1) who on 12/14/22 during the 7:00 A.M. to 3:00 P.M. shift accused Certified Nurse Aide (CNA) #1 of abusing him/her and reported the allegation to the Director of Nursing, the Facility failed to ensure that the allegation of physical abuse was reported to the Department of Public Health (DPH) within 2 hours in accordance with the Facility Policy and Federal regulations. Findings include: Review of the Facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Policy, dated as revised April 2021, indicated that the Administrator or designee reported allegations of resident abuse to the State Agency within 2 hours. Review of Resident #1's medical record indicated he/she was admitted to the Facility during September 2022 and diagnoses included depression and traumatic subdural hemorrhage (brain bleed). Review of Resident's most recent Quarterly Minimum Data Set Assessment, dated 12/22/22, indicated that his/her long and short term memory skills were intact. Review of a Nursing Progress Note, dated 12/14/22, indicated that during a visit with Activity Aide #1, Resident #1 accused a staff member of abuse. During an interview on 1/25/23 at 4:30 P.M., Activity Aide #1 said that on 12/14/22 Resident #1 told her that he/she asked a staff member to close his/her privacy curtain and the staff member hit him/her on the head. Activity Aide #1 said that she reported Resident #1's allegation of abuse to the Activity Director. During an interview on 1/23/23 at 10:50 A.M., the Activity Director said that on 12/14/22, Activity Aide #1 told her that Resident #1 alleged he/she was abused by a staff member. The Activity Director said that she spoke to Resident #1 and said Resident #1 told her that he/she had been hit by a staff member on the face or head. The Activity Director said that she reported Resident #1's allegation of abuse to the Director of Nursing. During an interview on 1/23/23 at 12:30 P.M., the Director of Nursing said that on 12/14/22 the Activity Director reported that Resident #1 alleged abuse by a staff member. The Director of Nursing said that she spoke with Resident #1 and said Resident #1 identified CNA #1 as the implicated staff member. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) regarding Resident #1's allegation of physical abuse indicated that the Facility submitted the report on 12/21/22 at 10:19 A.M., seven days after Resident #1's allegation of abuse was initially reported to the Director of Nursing. The Director of Nursing said that the allegation that CNA #1 abused Resident #1 on 12/14/221 was not submitted by the Facility to the DPH within 2 hours per Facility Policy and Federal Regulation.

Based on record review, policy review, and staff interview, the facility failed to ensure the resident and/or the resident representative had information in advance to exercise the resident's rights for one Resident (#22), out of a total sample of 27 residents. Specifically, the facility failed to ensure the Resident's Health Care Proxy (HCP) and Resident #22 were given information necessary to make health care decisions, including the risks and benefits of psychotropic medications and provide consent for its use, prior to administration. Findings include: Review of the facility's policy titled Resident Representative, dated February 2021, indicated the facility treats the decisions of the resident representative as the decisions of the resident in accordance with applicable law. It further indicated but was not limited to: - the resident representative is an individual chosen by the resident to act on behalf of the resident in order to support the resident's decision-making capability - the facility staff respects the delegated resident representative's decisions regarding the resident's wishes and preferences Resident #22 was admitted to the facility in August 2022 with diagnoses including Parkinson's disease, encephalopathy of unclear etiology, and anxiety. Resident #22's family member was designated/activated as the Resident's Health Care Proxy (HCP, a resident's designated authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) on 8/1/22. Review of the medical record indicated the following Physician's Orders for psychotropic medications: -Seroquel (an antipsychotic) 100 milligrams (mg) at bedtime for mood disorder (from 8/6/22 thru 10/3/22). -Buspar (an antianxiety) 10 mg at bedtime for anxiety (from 10/3/22 thru current). Review of the August through November 2022 Medication Administration Records indicated Seroquel and Buspar were administered as ordered by the Physician. Review of Resident #22's medical record indicated a consent for Seroquel was started on 8/1/22 but did not disclose the purpose of the antipsychotic. A consent for Buspar was started on 8/1/22 but was not signed by either the HCP or a facility representative. During an interview on 11/4/22 at 10:45 A.M., Family Member #1 (Resident #22's HCP) said the Resident told her he/she is on medication for anxiety, but she was not made aware of the use of Buspar, and she was never provided any information on the medication, nor did she provide consent for its use. She said she believes she was asked to sign a consent for the Seroquel, but she was not informed what the purpose of the medication was and was told that the Resident required it and it had been ordered by the physician. During an interview on 11/8/22 at 12:28 P.M., the Assistant Director of Nurses (ADON) reviewed the consent forms for the medication use with the surveyor and said the forms were not completed appropriately and informed consent was not obtained prior to the use of the medications. She said the consent for Buspar should have been completed prior to even one dose of the medication being administered. She also said the Seroquel consent was not complete with purpose, and the Seroquel should also have not been administered without informed consent. Further review of the medical record failed to indicate any further information on informed consent and decision making by the Resident's HCP regarding the use of either psychotropic medication. She said the process for psychotropic medication consent was not completed with the HCP as it should have been.

Based on record review, interview, and policy review, the facility failed to ensure the resident and/or their representative were fully informed in advance and given information necessary to make health care decisions, including the purpose for psychotropic medications as well as the risks and benefits, prior to their use for three Residents (#19, #24, and #71), out of a total sample of 27 residents. Findings include: Review of the facility's policies titled Antipsychotic Medication Use, dated December 2016, and Behavioral Assessment, Intervention, and Monitoring, revised March 2019, included but was not limited to the following: -The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated -The resident and family/representative will be informed of the resident's condition as well as the potential risks and benefits -When medications are prescribed for behavioral symptoms, documentation will include a rationale for use and potential risks/benefits of medication discussed with the resident and/or family 1. Resident #19 was admitted to the facility with diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 9/22/22, indicated Resident #19 was moderately impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15 and was on antipsychotic and antidepressant medications. Review of the current Physician's Orders indicated the following: -Duloxetine HCL (Cymbalta) (antidepressant, also used for nerve pain) capsule delayed release sprinkle 30 milligrams (mg), give 1 capsule by mouth one time a day for nerve pain, start 3/31/22 -Risperidone (antipsychotic) tablet 0.25 mg, give 0.25 mg by mouth at bedtime for agitation, start 4/1/22 -Risperidone tablet 0.25 mg, give 1 tablet by mouth two times a day for antipsychotics, start 4/7/22 Review of the October and November 2022 Medication Administration Records indicated Resident #19 received the Duloxetine and Risperidone as ordered by the physician. Review of the Informed Consent for Psychotropic Administration Forms failed to indicate the purpose of the medications, indication that the listed risks and benefits of the medications were explained and understood by the Resident and/or Health Care Proxy (HCP), and a checked box authorizing consent for the medications per the anticipated dosage prior to their administration. The consents were signed by Resident #19's HCP on 3/30/22, however, the Resident's medical record failed to indicate the HCP was invoked (determined in writing by the attending physician that the resident does not have the temporary or permanent capacity to make their own health decisions). Further review of the medical record failed to indicate documentation that Resident #19 wished to have the HCP be involved with decision making and sign consents on his/her behalf. During an interview of 11/8/22 at 9:15 A.M., Unit Manager (UM) #1 said in order to be considered an informed consent, the forms should have had a purpose completed as well as the box checked by a nurse indicating the Resident and/or the HCP gave consent prior to administration of the medications. During an interview on 11/9/22 at 2:05 P.M., the surveyor reviewed the medical record with UM #1 who said there should have been a social service's note addressing the HCP signing the consents if the HCP was not invoked, but UM #1 said there was none. During an interview on 11/9/22 at 2:24 P.M., the Social Worker said if the HCP was signing due to cognitive impairment by the Resident, then the HCP should have been invoked. She said if there was a verbal arrangement made by the Resident then there should have been documentation to support that but there was not. During an interview on 11/9/22 at 2:37 P.M., the Director of Nursing (DON) said if the Resident was able to sign then he/she should have. If not, then the HCP needed to be invoked prior to signing the psychotropic medication consents. The DON said if Resident #19 wished to have the HCP involved in his/her care and sign consents, then two nurses' signatures would be required who heard the conversation. The surveyor reviewed the consent forms with the DON who said they were not complete but should have been. 2. Resident #24 was admitted to the facility with diagnoses including major depressive disorder. Review of the current Physician's Orders indicated the following: -Citalopram Hydrobromide (antidepressant) tablet 40 mg, give 1 tablet by mouth one time a day related to major depressive disorder, start 5/22/22 -Trazodone HCL (antidepressant and sedative) tablet 150 mg, give 0.5 mg tablet by mouth at bedtime for insomnia, total dose 75 mg, start 7/1/22 -Trazodone HCL tablet 50 mg, give 0.5 mg tablet by mouth one time a day for anxiety, total dose 25 mg, start 4/21/22 Review of the October and November 2022 Medication Administration Records indicated Resident #24 received the Citalopram and Trazodone as ordered by the physician. Review of the Informed Consent for Psychotropic Administration Forms failed to indicate the purpose of the medications. During an interview on 11/9/22 at 2:58 P.M., the DON said the consents were not complete but should have been. 3. Resident #71 was admitted to the facility with diagnoses including depression. Review of the current Physician's Orders indicated the following: -Sertraline HCL (antidepressant) tablet 50 mg, give 1 tablet by mouth at bedtime for depression, start 3/25/22 Review of the October and November 2022 Medication Administration Records indicated Resident #71 received the Sertraline as ordered by the physician. Review of the Informed Consent for Psychotropic Administration Form failed to indicate the purpose of the medications. During an interview on 11/9/22 at 11:40 A.M., UM #1 said Resident #71 could make his/her own decisions and the purpose of the medication should have been indicated and explained to the Resident prior to its administration.

Based on record review, interview, and policy review, the facility failed to accurately reflect the updated Medical Orders for Life-Sustaining Treatment (MOLST)/Advanced Directive in the medical record for one Resident (#51), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Advanced Directives, revised December 2016, indicated but was not limited to the following: -The interdisciplinary team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record. Resident #51 was admitted to the facility with diagnoses including congestive heart failure (chronic condition where heart does not pump blood as well as it should), anxiety disorder, obstructive sleep apnea (intermittent airflow blockage during sleep), depression, atherosclerotic heart disease (build- up of fats, cholesterol, and other substances in and on the artery walls), and chronic obstructive pulmonary disease (lung disease that blocks airflow). Review of current Physician's Orders indicated the following: -Attempt resuscitation, Intubate and Ventilate, Use Non-Invasive Ventilation, Transfer to Hospital, start date 5/31/22 Review of the medical record indicated Resident #51 had a MOLST (standardized form that documents discussions about appropriate life-sustaining treatment) in place, signed and dated 6/2/22 by the physician and the Resident. The MOLST indicated Resident #51 was a Do Not Resuscitate (DNR), Do Not Intubate and Ventilate, and Do Not Use Non-Invasive Ventilation. Review of Resident #51's Advanced Directive care plan, initiated 6/15/22, indicated the following: Focus -Resident is a FULL CODE. Health Care Proxy on file, not activated at this time Interventions/Tasks -Staff will work with family to assist with their decision The physician's orders and Advanced Directive care plan failed to reflect the updated status of Resident #51's MOLST that was dated and signed on 6/2/22. During an interview on 11/10/22 at 7:54 A.M., Unit Manager (UM) #1 said the Resident's medical record did not reflect the change but should have. UM #1 said the Social Worker was responsible for updating the care plan when there is a change in a resident's code status, but this was not done for Resident #51. During an interview on 11/10/22 at 8:09 A.M., the Social Worker said social services should have updated the Resident's care plan but did not. During an interview on 11/10/22 at 8:34 A.M., the Director of Nursing reviewed the clinical record with the surveyor and said the physician's orders did not reflect the current MOLST for Resident #51 and the care plan should have been revised but was not.

Resident #64 was admitted to the facility in June 2021 with a diagnosis of epilepsy. Review of the medical record for Resident #64 indicated a potential for injury related to seizure disorder and included the following interventions: -monitor blood levels for therapeutic doses as ordered -in the event of a seizure: loosen clothing, lower to floor if not in bed, protect head, do not restrain, note and record length of seizure and body involvement Review of the current Physician's Orders indicated Resident #64 received Depakote (an anticonvulsant) sprinkles 4 capsule 125 milligrams (mg). Review of the Nursing Progress Note indicated on 10/11/22 at 6:30 A.M. Resident #64 had a mild seizure for less than a minute during care and included vital signs and that no safety issues were noted. Review of the paper and electronic medical record indicated the last physician's visit was on 9/29/22. Review of the medical record indicated the last therapeutic levels for Depakote (Valproic Acid) were collected on 11/11/21; used to monitor the level of medication in the blood to maintain effective use. During an interview on 11/3/22 at 3:15 P.M., Unit Manager #2 said Resident #64 had been seen by the Nurse Practitioner on 10/27/22 but was unable to obtain the documentation at this time due to a dictation issue. During an interview on 11/4/22 at 9:47 A.M., the Nurse Practitioner said she had not known Resident #64 had a seizure on 10/11/22 and had she or the physician known, than a laboratory value to obtain therapeutic levels of Valproic Acid would have been ordered. She said her visit with the Resident on 10/27/22 was not in regards to the seizure. She said if she was not notified of it, then she would not know it happened. During an interview on 11/8/22 at 9:35 A.M., the Assistant Director of Nurses said the physician of Resident #64 had not been notified of the seizure on 10/11/22. Based on observations, record reviews, and interviews, the facility failed to notify the Physician of seizure activity for one Resident (#64), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Change in a Resident's Condition or Status, last revised February 2021, included, but was not limited to: -Our facility promptly notifies the resident, his or her attending Physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). -The nurse will notify the resident's attending Physician or Physician on call when there has been a: -accident or incident involving the resident; -discovery of injuries of an unknown source; -significant change in the resident's physical/emotional/mental condition; -need to alter the resident's medical treatment significantly; -specific instruction to notify the Physician of changes in the resident's condition -The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for one Resident (#32), from a total sample of 27 residents. Specifically, the facility failed to ensure staff did not communicate Resident #32's private health information and images of his/her body with his/her Physician via text messaging utilizing an unsecured mobile phone platform. Findings include: Resident #32 was admitted to the facility in September 2022 with diagnoses including dementia. During an interview on 11/9/22 at 11:05 A.M., Physician #1 said that he was on vacation from 11/3/22 to 11/6/22 and had text message communication with Unit Manager #2 on 11/4/22 and 11/7/22 regarding a change in condition for Resident #32. The Physician opened his mobile phone and reviewed the text message exchanges with the surveyor. The text messages included, but was not limited to: -Resident's first and last name -Resident's date of birth -Resident's admission date -Resident's gender -Resident's race -the name of the facility and location of where the Resident lives within the facility -names of medications the Resident is prescribed -documentation that Resident #32 alleged physical abuse -documentation of a course of treatment -a photograph of diagnostic testing results -a photograph of the Resident's left hand The Physician said his mobile phone platform is not secure and the Resident's private health information was compromised. During an interview on 11/10/22 at 2:45 P.M., Unit Manager #2 said that her personal mobile phone platform is not secure and she should not have written Resident #32's private health information in a text message to his/her physician.

Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#15), out of a total sample of 27 residents, and for one allegation brought forward during a Resident Council Meeting. Specifically, the facility failed: 1. For Resident #15, to follow their policy for investigating and reporting a bruise of unknown origin; and 2. To follow their policy for reporting and investigating an allegation of neglect that was documented in Resident Council Minutes. Findings include: 1. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated as revised April 2021, included, but was not limited to the following: -The program consists of a facility-wide commitment and resource allocation to support the following objectives: -Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone; - Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. -Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation or resident property. -Investigate and report any allegations within timeframes required by federal requirements. -Protect residents from any further harm during investigations. Review of the facility's policy titled Investigations- How to Conduct, dated as revised November 2019, indicated the following: -the supervising nurse begins the investigation immediately and completes the incident report -conducts interviews, with written statements of potential witnesses -identify who was involved -identify what occurred -summarize analysis of facts gathered Resident #15 was admitted to the facility in August 2016 with diagnoses including Alzheimer's disease and cognitive communication disorder. Review of the Minimum Data Set (MDS) assessment, dated 8/11/22, indicated Resident #15 had both long- and short-term memory problems, severely impaired cognitive skills for daily decision making, and was dependent on staff for bed mobility, transfers, and all activities of daily living. Review of the medical record indicated a 10/26/22 Nursing Progress note written by Unit Manager #1: -While doing diabetic foot care, the Resident was noted to have a small hematoma to the side of the left big toe, blood was coming out from underneath the nail and the toe is swelling and painful to the touch. Also noted an open scab to the right knee. Review of the Health Care Facility Reporting System (a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) on 11/4/22 at 3:00 P.M., failed to indicate the bruise of unknown origin to Resident #15's left big toe and scab to his/her right knee identified on 10/26/22 were reported to the Department of Public Health (DPH) as required. During an interview on 11/4/22 at 10:43 A.M., Unit Manager #2 said she does not know how the bruise, swelling, and bleeding to Resident #15's left toe occurred and no investigation was conducted. During an interview on 11/7/22 at 7:20 A.M., the surveyor and Assistant Director of Nursing reviewed Resident #15's medical record. She said there was no investigation or report for a bruise of unknown origin for Resident #15 identified on 10/26/22. 2. Review of Resident Council Minutes, dated 8/16/22, indicated one resident in attendance reported having difficulty putting cream on his/her feet, and when he/she asked staff for help, staff responded, You can do it on your own. Further review of the minutes indicated the Director of Nursing was notified of the resident's report. Review of the Health Care Facility Reporting System on 11/9/22 at 11:30 A.M., failed to indicate the resident's report of staff refusing to provide care during the 8/16/22 Resident Council Meeting was reported to DPH as required. During an interview on 11/9/22 at 2:45 P.M., the Activities Director said that she did not realize the resident's report of staff refusing to provide care was neglect and should have been reported and investigated.

Based on interviews, record review, and policy review, the facility failed to ensure allegations of abuse were reported to the State Agency, for one Resident (#15), out of a total sample of 27 residents, and for one allegation brought forward during a Resident Council Meeting. Specifically, the facility failed to report: 1. a bruise of unknown origin for Resident #15; and 2. an allegation of neglect that was documented in Resident Council Minutes. Findings include: 1. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated as revised in April 2021, included but was not limited to the following: -Investigate and report any allegations within timeframes required by federal requirements (no later than 2 hours) Resident #15 was admitted to the facility in August 2016 with diagnoses including Alzheimer's disease and cognitive communication disorder. Review of the Minimum Data Set (MDS) assessment, dated 8/11/22, indicated Resident #15 had both long- and short-term memory problems, severely impaired cognitive skills for daily decision making, and was dependent on staff for bed mobility, transfers, and all activities of daily living. Review of the medical record indicated a 10/26/22 Nursing Progress Note written by Unit Manager #1: -While doing diabetic foot care, the Resident was noted to have a small hematoma to the side of the left big toe, blood was coming out from underneath the nail and the toe is swelling and painful to the touch. Also noted an open scab to the right knee. Review of the Health Care Facility Reporting System (a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) on 11/4/22 at 3:00 P.M., failed to indicate the bruise of unknown origin to Resident #15's left big toe and scab to his/her right knee identified on 10/26/22 were reported to the Department of Public Health (DPH) as required. During an interview on 11/4/22 at 10:43 A.M., Unit Manager #2 said she did not report the bruise of unknown origin. During an interview on 11/7/22 at 7:20 A.M., the Assistant Director of Nursing said the bruise of unknown origin should have been reported to the State Agency within two hours. 2. Review of Resident Council Minutes, dated 8/16/22, indicated one resident in attendance reported having difficulty putting cream on his/her feet, and when he/she asked staff for help, staff responded, You can do it on your own. Further review of the minutes indicated the Director of Nursing was notified of the resident's report. Review of the Health Care Facility Reporting System on 11/9/22 at 11:30 A.M., failed to indicate the resident's report of staff refusing to provide care during the 8/16/22 Resident Council Meeting was reported to DPH as required. During an interview on 11/9/22 at 2:45 P.M., the Activities Director said that she did not realize the resident's report of staff refusing to provide care was considered neglect and should have been reported.

Based on interviews, record review, and policy review, the facility failed to ensure allegations of abuse were investigated and residents protected from further harm for two Residents (#15 and #32), out of a sample of 27 residents, and for one allegation brought forward during a Resident Council Meeting. Specifically, the facility failed to investigate and protect: 1. Resident #15, for a bruise of unknown origin; 2. Resident #32, for an allegation of abuse; and 3. A Resident identified in the August 2022 Resident Council Minutes that alleged neglect. Findings include: Review of the facility's policy titled Investigations- How to Conduct, dated as revised November 2019, indicated the following: -the supervising nurse begins the investigation immediately and completes the incident report -conducts interviews, with written statements of potential witnesses -identify who was involved -identify what occurred -summarize analysis of facts gathered 1. Resident #15 was admitted to the facility in August 2016 with diagnoses including Alzheimer's disease and cognitive communication disorder. Review of the Minimum Data Set (MDS) assessment, dated 8/11/22, indicated Resident #15 had both long- and short-term memory problems, severely impaired cognitive skills for daily decision making and was dependent on staff for bed mobility, transfers, and all activities of daily living. Review of the medical record indicated a 10/26/22 Nursing Progress Note written by Unit Manager #1: -While doing diabetic foot care, the Resident was noted to have a small hematoma to the side of the left big toe, blood was coming out from underneath the nail and the toe is swelling and painful to the touch. An open scab to the right knee was also identified. During an interview on 11/4/22 at 10:43 A.M., Unit Manager #2 said she does not know how the bruise, swelling, and bleeding to Resident #15's left toe occurred and no investigation was conducted. During an interview on 11/7/22 at 7:20 A.M., the surveyor and Assistant Director of Nursing reviewed Resident #15's medical record. She said there was no investigation for the bruise of unknown origin for Resident #15 identified on 10/26/22. 2. Resident #32 was admitted to the facility in September 2022 with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 9/27/22, indicated Resident #32's cognitive status was not assessed, required extensive assistance of 2 or more staff for bed mobility, transfers and was dependent on staff for bathing and dressing. During an interview on 11/9/22 at 11:05 A.M., Physician #1 said that he was on vacation from 11/3/22 to 11/6/22 and had text message communication with Unit Manager #2 on 11/4/22 and 11/7/22 regarding a change in condition (hematoma (bruise) on right hand) for Resident #32. The Physician opened his mobile phone and reviewed the text message exchanges with the surveyor. A text message sent from Unit Manager #2 to Physician #1 on 11/4/22 at 9:43 A.M. indicated: Now the [resident] is saying that somebody beat [him/her]. Physician #1 responded, Ok please call office I am away till Monday. During an interview on 11/10/22 at 2:45 P.M., Unit Manager #2 said the allegation was not addressed and no investigation was conducted regarding the Resident's allegation of abuse. 3. Review of Resident Council Minutes, dated 8/16/22, indicated one resident in attendance reported having difficulty putting cream on his/her feet, and when he/she asked staff for help, staff responded, You can do it on your own. Further review of the minutes indicated the Director of Nursing was notified of the resident's report. During an interview on 11/9/22 at 2:45 P.M., the Activities Director said that she did not realize the resident's report of staff refusing to provide care was neglect and should have been investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure that its staff issued transfer notices to two Residents (#32 and #543) or Resident Representatives, out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Transfer or Discharge (last revised March 2021) included but was not limited to: -The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: 1. name, address, email and telephone number of the entity which receives appeal hearing requests; 2. information about how to obtain, complete and submit an appeal request; and 3. how to get assistance completing the appeal process e. The facility bed-hold policy; and f. the name, address, email and telephone number of the Office of the State Long-Term Care Ombudsman 1. Resident #32 was admitted to the facility in September 2022 and had an activated Health Care Proxy. Review of the medical record indicated Resident #32 was transferred to the hospital on [DATE] and 11/4/22. Further review of the medical record indicated no evidence that transfer notices for the above dates were issued to the Resident or Resident Representative as required. During an interview on 11/10/22 at 9:19 A.M., the surveyor reviewed Resident #32's medical record with Nurse #10, Medial Records staff #1, and the Assistant Director of Nursing. They could not find evidence that the transfer notices were issued as required. During an interview on 11/10/22 at 9:32 A.M., Unit Manager #2 said she found a transfer notice for 11/4/22 in her office, but it was not provided to Resident #32's representative as required. During a telephone interview on 11/10/22 at 10:17 A.M., Resident Representative #1 said she had not received a transfer notice for either the 10/8/22 or 11/4/22 hospitalization. During a telephone interview on 11/20/22 at 12:40 P.M., Resident Representative #2 said she had not received a transfer notice for either the 10/8/22 or 11/4/22 hospitalization. 2. Resident #543 was admitted to the facility in March 2015 with diagnoses including chronic kidney disease. Review of the medical record indicated Resident #543 was transferred to the hospital on [DATE]. Further review of the medical record indicated no evidence that transfer notices for the above date was issued to the Resident or Resident Representative as required. During an interview on 11/10/22 at 9:42 A.M., the surveyor reviewed Resident #543's medical record with Unit Manager #1 and the Assistant Director of Nursing. They said they could not find evidence that a transfer notice was completed and provided to either Resident #543 or his/her representative as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure the resident and/or the resident's representative was provided a written notice of a bed hold transfer as required for two Residents (#32 and #543), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Transfer or Discharge (last revised March 2021) included but was not limited to: -The resident and representative are notified in writing of the following information: -The facility bed-hold policy 1. Resident #32 was admitted to the facility in September 2022 and had an activated Health Care Proxy. Review of the medical record indicated Resident #32 was transferred to the hospital on [DATE] and 11/4/22. Further review of the medical record indicated no evidence that a facility bed-hold notice for the above dates was issued to the Resident or Resident Representative as required. During an interview on 11/10/22 at 9:19 A.M., the surveyor reviewed Resident #32's medical record with Nurse #10, Medial Records staff #1, and the Assistant Director of Nursing. They could not find evidence that the facility bed-hold notices were issued as required. During an interview on 11/10/22 at 9:32 A.M., Unit Manager #2 said she found a transfer notice for 11/4/22 in her office, but it was not provided to Resident #32's representative as required. During a telephone interview on 11/10/22 at 10:17 A.M., Resident Representative #1 said she had not received a facility bed-hold notice for either the 10/8/22 or 11/4/22 hospitalization. During a telephone interview on 11/20/22 at 12:40 P.M., Resident Representative #2 said she had not received a facility bed-hold notice for either the 10/8/22 or 11/4/22 hospitalization. 2. Resident #543 was admitted to the facility in March 2015 with diagnoses including chronic kidney disease. Review of the medical record indicated Resident #543 was transferred to the hospital on [DATE]. Further review of the medical record indicated no evidence that a bed hold notice for the above date was issued to the Resident or Resident Representative as required. During an interview on 11/10/22 at 9:42 A.M., the surveyor reviewed Resident #543's medical record with Unit Manager #1 and the Assistant Director of Nursing. They said they could not find evidence that a facility bed hold notice was completed and provided to either Resident #543 or his/her representative as required.

Based on record review and interview, the facility failed to ensure that staff developed and implemented a baseline care plan within 48 hours of the resident's admission, that included the instructions needed to provide effective and person-centered care to the resident that meet professional standards of quality care and provide the resident and his or her representative, if applicable, with a written summary of the baseline care plan for one Resident (#243), in a total sample of 27 residents. Specifically, the facility failed to develop a baseline care plan for anticoagulation therapy. Findings include: Resident #243 was admitted to the facility in November 2022 with diagnoses including cerebral vascular accident. Review of the medical record indicated a Physician's Order for the following: -Heparin (anticoagulant) 5000 units/milliliter. Inject 5000 units subcutaneously three times a day (start date 11/4/22) Further record review indicated that there was no documentation in the medical record that a 48-hour care plan with initial goals, services and treatments to be administered by the facility had been developed and provided to the Resident and/or their representative. During an interview on 11/7/22 at 11:58 A.M., Nurse #6 reviewed the medical record for Resident #243 and said there was no baseline care plan in place to address the Resident's anticoagulation use.

Based on observation, interview, record review, and policy review, the facility failed to review and revise the care plan for one Resident (#54)'s nephrostomy tube (thin plastic tube that is passed from the back, through the skin and then through the kidney where the urine collects) based on their changing needs/status, out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, indicated but was not limited to the following: -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change -The interdisciplinary team reviews and updates the care plan when the desired outcome is not met -The comprehensive, person-centered care plan describes services that would otherwise be provided but are not provided due to the resident exercising his or her rights, including the right to refuse treatment Resident #54 was admitted to the facility with diagnoses including openings of urinary tract, malignant neoplasm of right kidney, and acquired absence of a kidney. Review of Resident #54's External Urinary Device (Nephrostomy) Care Plan indicated the following: Focus -Resident requires external urinary device (Nephrostomy) secondary to other artificial openings of urinary tract, initiated 10/11/22 Goal -The resident will remain free of infection x 90 days, initiated 10/11/22 Interventions/Tasks -Teach resident self-care techniques as appropriate, initiated 10/11/22 Review of current Physician's Orders indicated the following: -Telephone Order (TO), urinalysis and culture and sensitivity for increased confusion, dated 10/28/22 -Augmentin (antibiotic) tablet 875-125 milligrams (mg), give 1 tablet by mouth two times a day for urinary tract infection (UTI) x 7 days, start date 11/2/22 During an observation with interview on 11/2/22 at 10:44 A.M., the surveyor observed Resident #54 lying in bed with his/her nephrostomy collection bag resting on top of his/her chest, above the level of the kidney. It was not secured. Resident #54 said he/she had a history of kidney cancer and had had the right nephrostomy tube for about a year now and self-emptied. Resident #54 said he/she knew the bag should have been hanging low but wanted it on his/her chest. During an observation with interview on 11/3/22 at 3:23 P.M., the surveyor observed Resident #54 sitting at the side of the bed. His/her nephrostomy tube/bag was not visible to the surveyor. Resident #54 said he/she put it on top of the bed behind his/her back. During an interview on 11/3/22 at 3:38 P.M., the surveyor reviewed the nephrostomy bag placement with Nurse #4 who said it should have been hanging lower to prevent complications. Nurse #4 said Resident #54 refused care at times and was currently being treated for a UTI. She said the care plan should have been revised to reflect the current UTI and interventions to address refusal of care and treatment. During an interview on 11/3/22 at 3:51 P.M., the Assistant Director of Nursing said she was aware the Resident was refusing care and the care plan should have been revised to reflect new interventions to help reduce the risk of further potential complications but was not.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#51), out of a total sample of 27 residents, received the proper treatment to maintain hearing abilities. Findings include: Review of the facility's policy titled Hearing-Impaired Resident, Care Of, revised February 2018, indicated but was not limited to the following: -Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents, and visitors -Staff will assist the resident with locating available resources, scheduling appointments and arranging transportation to obtain needed services -When interacting with the hearing- impaired resident, staff will implement the following: a. Evaluate the resident's preferred method of communication (lip reading, tablet, etc.) with staff and other residents b. Determine the resident's awareness of and adaptation to hearing loss d. Regularly engage the resident in conversation using whatever communication method he or she prefers g. When speaking, enunciate clearly, slowly, and in a normal tone j. Evaluate resident's adaptive needs and progress at regular intervals Review of the Minimum Data Set (MDS) assessment, dated 9/16/22, indicated Resident #51 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and indicated Resident #51 had adequate hearing and did not have hearing aids. During an interview on 11/2/22 at 12:17 P.M., the surveyor observed Resident #51 in his/her bed bending forward while the surveyor was speaking. The Resident asked the surveyor to come closer because he/she was having difficulty hearing often saying What? and Huh?. Resident #51 told the surveyor his/her hearing had gotten worse since being at the facility and felt he/she needed hearing aids to assist with communication with staff and other residents. The Resident said staff was aware and told him/her that the facility did not have a specialist he/she could see and did not assist him/her with obtaining services. The Resident further said it was difficult participating in activities because he/she could not hear well and could read lips, but due to the mask mandate, was unable to do so. During an interview on 11/7/22 at 1:55 P.M., Unit Manager (UM) #1 said the Resident and/or family could have told staff he/she was having difficulty hearing but did not. UM #1 said sometimes when she spoke to the Resident, she needed to get close for the Resident to hear her and it was difficult at times for the Resident to communicate due to staff wearing facemasks. UM #1 said the Resident's hearing was not a concern at admission, but he/she had not been further evaluated for hearing loss and did not have a consent in his/her medical record to receive services. During an interview on 11/7/22 at 1:18 P.M., the surveyor observed Resident #51 sitting in his/her wheelchair next to his/her bed. The Resident was having difficulty hearing the surveyor and asked the surveyor to come closer, approximately within two feet, and said his/her left ear was worse than the right and it had worsened since being admitted . The Resident said he/she must ask staff to come closer when they speak to him/her because they do not do it on their own. Resident #51 said staff is aware he/she cannot hear well but said they say nothing, It's ignored. The Resident said it makes him/her feel small and angry. Resident #51 said if he/she could hear better it would make him/her happy. During an interview on 11/8/22 at 8:04 A.M., Certified Nursing Assistant (CNA) #6 said the Resident was hard of hearing and she had to get close to him/her for a while now, and said staff knew about it. CNA #6 said she did not say anything because staff already knew about it. During an interview on 11/9/22 at 12:16 P.M., the Activities Director said Resident #51 had a hearing deficit for sure and needed to be placed near the activities being held to better hear and to be able to fully participate. During an interview on 11/9/22 at 2:43 P.M., the Director of Nursing (DON) said the consent for auditory services should have been completed and signed by the Resident upon admission so he/she could see an audiologist but was not. The DON said if staff were aware of a hearing deficit then they should have obtained the consent and assisted the Resident in making an appointment with an audiologist and arranged for transportation to receive the proper treatment to maintain his/her hearing abilities.

Based on observation, interview, and record review, the facility failed to provide treatment and services for one Resident (#54), out of 27 sampled residents, with a nephrostomy tube (thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where urine collects). Specifically, the facility failed to securely anchor the nephrostomy tube to help prevent inadvertent dislodgment, provide ongoing assessment, and educate the Resident on self-care to help prevent catheter-related urinary tract infections. Findings include: Review of the facility's policy titled Catheter Care, Urinary, revised September 2014, indicated but was not limited to the following: -The purpose of this procedure is to prevent catheter-associated urinary tract infections Maintaining Unobstructed Urine Flow -Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks -The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder -Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site Documentation -If the resident refused the procedure, the reason(s) why and the intervention taken -Notify the supervisor if the resident refuses the procedure Resident #54 was admitted to the facility with diagnoses including openings of urinary tract, malignant neoplasm of right kidney, and acquired absence of kidney. Review of Resident #54's External Urinary Device (Nephrostomy) care plan indicated the following: Focus -Resident requires external urinary device (Nephrostomy) secondary to other artificial openings of urinary tract, initiated 10/11/22 Goal -The resident will remain free of infection x 90 days, initiated 10/11/22 Interventions/Tasks -Teach resident self-care techniques as appropriate, initiated 10/11/22 Review of current Physician's Orders indicated the following: -Telephone Order (TO), urinalysis and culture and sensitivity for increased confusion, dated 10/28/22 -Augmentin (antibiotic) tablet 875-125mg, give 1 tablet by mouth two times a day for urinary tract infection (UTI) x 7 days, start date 11/2/22 During an interview on 11/2/22 at 10:44 A.M., the surveyor observed Resident #54 lying in bed with his/her nephrostomy bag resting on top of his/her chest, above the level of the kidney. The tube was not securely anchored to help prevent inadvertent dislodgement. Resident #54 said he/she had a history of kidney cancer and had had the right nephrostomy tube for about a year now and self-emptied the urinary collection bag. Resident #54 said staff had not educated him/her on self-care or potential complications, but he/she knew the bag should be hanging low. He/she said no one told him/her otherwise. During an observation with interview on 11/3/22 at 3:23 P.M., the surveyor observed Resident #54 sitting at the side of the bed. His/her nephrostomy tube was not visible to the surveyor. Resident #54 said he/she placed the collection bag on top of the bed behind his/her back. During an observation with interview on 11/3/22 at 3:38 P.M., the surveyor reviewed the nephrostomy tube insertion site and bag placement with Nurse #4. The catheter tube was sutured to the skin on the Resident's right side but was not securely anchored to help prevent inadvertent dislodgement. Nurse #4 said it should have been anchored and the collection bag should have been hanging lower to prevent complications. Nurse #4 said Resident #54 was non-compliant with care and was currently being treated for a UTI. During an interview on 11/7/22 at 9:00 A.M., the surveyor observed Resident #54 lying in bed. Resident #54 said the nephrostomy tube and collection bag were underneath his/her back somewhere and had not received education about it by staff. Review of the medical record failed to indicate documentation of education to the Resident related to self-care of the nephrostomy tube or the Resident's refusal of care or treatments. The physician's orders failed to indicate an order to secure the tube or anchor the bag until 11/4/22. During an interview on 11/3/22 at 3:51 P.M., the Assistant Director of Nursing said Resident #54 was non-compliant with nephrostomy care and there should have been documentation of education in the clinical record regarding self-care but failed to provide any to the surveyor upon request. During an interview on 11/9/22 at 3:15 P.M., the Director of Nursing said Resident #54's care plan should have been revised if the resident was refusing care but was not.

Based on observation, interview, and policy review, the facility failed to ensure the cleaning of respiratory care equipment for one Resident #78, in a total sample of 27 residents. Findings include: Review of the facility's policy titled Respiratory Therapy Prevention of Infection, dated November 2011, indicated for oxygen administration to wash the filters from the oxygen concentrators every seven days with soap and water; rinse and squeeze dry. Resident #78 was admitted to the facility in March 2022 with a diagnosis of chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe). Review of the Physician's Orders for Resident #78 indicated the Resident was receiving 3 liters of Oxygen, continuously through a nasal cannula. Review of the orders included an order to change and date the tubing once per week. On 11/03/22 at 7:35 A.M., the surveyor observed the oxygen concentrator for Resident #78 to be in use by the Resident. On the side of the concentrator was a filter (normally black in color) which was tan in color due to the dust. On 11/08/22 at 11:27 A.M., the surveyor observed Resident #78 utilizing the oxygen concentrator. The oxygen tubing was dated as changed on 11/7/22. The filter continued to be tan in color and laden with dust. During an interview at this time, Unit Manager #1 said the process for cleaning the filter was to change it once per month when changing the tubing. She said this was not on the order, so she was not sure how the nurse would know when it needed to be changed.

Based on observation, interview, and policy review, the facility failed to ensure for one Resident (#543) of one resident receiving hemodialysis treatment, care and services were consistent with professional standards of practice. Specifically, the facility failed to ensure ongoing communication and collaboration with the dialysis center regarding care and services was maintained. Findings include: Review of the facility's policy titled Dialysis Management, dated as revised on 5/2019, indicated but was not limited to the following: -Facility will establish open communication with the Resident's dialysis center utilizing a dialysis communication book completing the dialysis communication form -The nurse will establish pre-dialysis vital signs (blood pressure, temperature, pulse and respirations), advanced directives and any pertinent resident information -On return from the dialysis center the nurse will review the communication returning from the dialysis center Resident #543 was admitted to the facility in March 2015 with diagnoses including chronic kidney disease. Review of the Matrix for Providers (used to identify pertinent resident care categories) provided to the survey team on 11/2/22, indicated Resident #543 received hemodialysis. Review of interdisciplinary care plans included but was not limited to: -Focus: Resident exhibits or is at risk for impaired renal function and is at risk for complications related to hemodialysis (4/29/19) -Interventions/Tasks: Transfer to hemodialysis at local dialysis center via ambulance on Tuesday, Thursday, and Saturday for treatment (4/29/19) -Goals: Resident will not experience any complications related to chronic insufficiency X 90 days (4/29/19) Further review of the medical record failed to indicate a Physician's order for hemodialysis treatment. Review of Resident #543's dialysis communication book indicated 30 communication forms from April 2022 to October 2022 that were blank and not completed by the dialysis center post-dialysis and two forms that were blank not completed by the facility prior to dialysis. During an interview on 11/08/22 at 12:33 P.M., Unit Manager #1 said there is supposed to be a physician's order for the Resident to receive dialysis. She said Nursing staff is supposed to complete the pre-dialysis portion of the communication form and send it with the Resident to the dialysis center and the center is expected to complete the post-dialysis section and send it back with the Resident each day of dialysis. She said the forms are not being completed as they should be.

Based on interviews and record reviews, the facility failed to ensure the physician reviewed the total program of care for two Residents (#64 and #69), out of a total sample of 27 residents. Specifically, the physician failed to review the following total programs of care for: 1. Resident #64 with a diagnosis of epilepsy and use of an anticonvulsant medication; and 2. Resident #69 with a pacemaker. Findings include: 1. Resident #64 was admitted to the facility in June 2021 with a diagnosis of epilepsy. Review of the Physician's Orders indicated Resident #64 received Depakote (an anticonvulsant) sprinkles capsule 125 milligrams (mg), give 4 capsules twice per day for seizures. Review of the medical record indicated the last therapeutic levels for Depakote (Valproic Acid) were collected on 11/11/21. Review of the Physician's Progress note, dated 3/2/22, failed to indicate Resident #64 had a seizure disorder and was taking an anticonvulsant medication. Review of the History and Physical, dated 7/14/22, failed to indicate any history of seizure disorder. Review of the Nurse Practitioner's (NP) progress note, dated 9/29/22, indicated Resident #64 had dementia with anxiety and was taking Depakote for this; there was no indication of a seizure disorder. During an interview on 11/4/22 at 11:47 A.M., the Health Care Proxy of Resident #64 said the Resident had started having seizures a couple of years prior. Review of the Nursing Progress notes indicated on 10/11/22 at 6:30 A.M., Resident #64 had a mild seizure for less than a minute during care and included vital signs and that there were no safety issues noted. The next nursing note at 8:43 P.M. indicated Resident #64 returned from the hospital status post fall. During an interview on 11/4/22 at 9:47 A.M., the Nurse Practitioner said she had seen Resident #64 on 10/27/22 and had not addressed the seizure that occurred on 10/11/22. 2. Resident #69 was admitted to the facility in September 2022 with a diagnosis of atrial fibrillation and had a pacemaker. Review of the medical record included documentation from the transferring facility of Resident #69. Review of the documentation from the transferring facility indicated Resident #69 had a pacemaker which was checked in August 2022 at his/her cardiologist and included the model of the pacemaker and the serial number. Review of the Physician's Orders and diagnoses failed to include any indication Resident #69 had a pacemaker. Review of the History and Physical, dated 9/22/22, indicated Resident #69 had a diagnosis of atrial fibrillation, was on an anticoagulant, and the staff should continue to monitor. Review of the physician's visit, dated 9/29/22, failed to indicate Resident #69 had a pacemaker. Review of the entire medical record failed to indicate the physician was aware Resident #69 had a pacemaker.

Based on interviews and record review, the facility failed to ensure one Resident (#64), in a sample of 27 residents, had been seen by a physician every sixty days and that required visits alternated between the Physician and the Nurse Practitioner. Findings include: Resident #64 was admitted to the facility in June 2021 with a diagnosis of epilepsy, dementia, and diabetes. Review of the medical record for Resident #64 indicated the Resident had been seen by the Physician on 3/3/22. The following visits were conducted by the Nurse Practitioner: 7/14/22, 8/27/22, and 9/29/22. The electronic and paper medical record failed to include any other progress notes from the Physician or the Nurse Practitioner. During an interview on 11/3/22 at 3:40 P.M., the Medical Record staff said there were no additional Physician or NP progress notes available for Resident #64. During an interview on 11/8/22 at 1:15 P.M., the Assistant Director of Nurses said Resident #64 was last seen by the Physician on 3/3/22 (8 months prior) and the required visits should have alternated between the Physician and the Nurse Practitioner.

Based on interview and record review, the facility failed to ensure one Residents #63 was free from unnecessary psychotropic medications, in a sample of five residents reviewed for unnecessary medication. Specifically, for Resident #63, the facility failed to ensure a.) an antipsychotic was given to treat a specific condition and was given in the lowest possible dosage for the shortest period of time, and b.) an as needed (PRN) psychotropic medication was limited to 14 days. Resident #63 was admitted to the facility in July 2022 with a diagnosis dementia, major depressive disorder, recurrent severe without psychotic features, and anxiety. a. Review of the Physician's Orders indicated an order initiated on 7/12/22 for Olanzapine (antipsychotic) 5 milligrams (mg) three times per day for mood disorder. Review of the Psychiatric Nurse Practitioner's (NP) progress notes indicated the following: 7/15/22: check mark indicated psychosis was absent (no indication of audio or visual hallucinations or delusions); 7/29/22: check mark indicated psychosis was absent, noted as no delusions or hallucinations; 8/19/22: check mark indicated psychosis was absent, noted as anxious, weepy, no overt psychosis; 9/16/22: check mark indicated psychosis was absent, noted as anxious, agitated, no overt psychosis. Review of the medical record failed to indicate the medical rational for the use of an antipsychotic medication and failed to indicate a gradual dose reduction had been attempted. During an interview on 11/8/22 at 2:11 P.M., Unit Manager #2 said Resident #63 was on an antipsychotic medication due to exhibiting anxiety and a long history of panic attacks. She said the family had reported that when the Resident was living at home, he/she felt the family was taking his/her belongings. The Unit Manager said the Resident will exhibit this now when they come out of their room and ask where their sweater is and then they find the sweater in the pillowcase and the Resident could not remember putting it there. The Unit Manager said the Resident had not exhibited any auditory or visual hallucinations or delusions. She said the process to determine if a gradual dose reduction should be attempted was for the staff to notify the Psychiatric NP if the staff thought there would be any changes. She said there was no regular process to determine when gradual dose reductions should be conducted. b. Review of the Physician's Orders included an order written 9/16/22 for Trazodone 25 mg twice per day as needed for anxiety. The order failed to include a stop date or a re-evaluation date. During an interview on 11/9/22 at 11:03 A.M., the Director of Nurses said she had reviewed the PRN Trazodone order for Resident #63 and confirmed there was no stop date. She said the medication had been ordered without a re-evaluation date and had not been re-evaluated by the physician for use since it was initiated 7 weeks prior.

Based on observation, interview, record review, and policy review, the facility failed to provide routine dental services to meets the needs for one Resident (#51), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Dental Examination/Assessment, revised December 2013, indicated but was not limited to the following: -Resident shall be offered dental services as needed -Dental examinations will be made by the resident's personal dentist or by the facility's consultant dentist -Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist Resident #51 was admitted to the facility with diagnoses including dysphagia (difficulty swallowing), dyskinesia (uncontrolled, involuntary muscle movement) of the esophagus, and gastro-esophageal reflux disease (GERD). Review of the Minimum Data Set (MDS) assessment, dated 9/16/22, indicated Resident #51 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and did not have loosely fitting full or partial dentures. During an observation with interview on 11/2/22 at 12:24 P.M., Resident #51 said he/she had full dentures and they did not fit right and had difficulty chewing certain types of foods such as meats. The surveyor observed Resident #51 easily take out his/her dentures. They were not affixed with denture adhesive. No denture care supplies were observed in the Resident's room such as a denture cup, adhesive, or denture cleaner. Resident #51 said he/she had not seen a dentist since being admitted to the facility. Review of the Admission/readmission Nursing Assessment, dated 9/15/22, indicated Resident #51 had his/her own teeth and did not have a chewing or swallowing problem. Review of the Speech Therapy Evaluation and Plan of Treatment, dated 11/1/22, indicated that during an oral exam the Resident was edentulous with full upper and lower dentures which appeared loose-fitting. During an interview on 11/8/22 at 8:48 A.M., Nurse #11 said she was familiar with the Resident and knew he/she had dentures but did not know they were loose. During an interview on 11/7/22 at 1:32 P.M., Resident #51 said he/she needed better fitting dentures and food had to be cooked soft or he/she would have to chew a lot. The surveyor did not observe any denture supplies in the Resident's room. Resident #51 said he/she did not have any and just rinsed them off with a toothbrush and did not have any glue, so they just popped right out. He/she said staff knew he/she had dentures because they made him/her take them out to show them when he/she was admitted . The Resident said staff had not assisted him/her in obtaining the needed dental services. During an interview on 11/7/22 at 1:55 P.M., Unit Manager (UM) #1 said she did not know the Resident had dentures and did not have a consent for dental services in the medical record. UM #1 said the Resident's family member was very involved with his/her care and did not say anything, so she did not know. UM #1 said she should have known, however, that the Resident had dentures. During an interview on 11/8/22 at 8:13 A.M., Certified Nursing Assistant #6 said she was not sure if the Resident had dentures and had not provided mouth care before to the Resident but then said she had. During an interview on 11/9/22 at 2:52 P.M., the Director of Nursing said she was not aware of any dental issues but staff should have known the Resident had dentures so the Resident could receive the proper care and services to meet the needs of the Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide skilled rehabilitative services following an appeal decision for one Resident (#22), out of a total sample of 27 residents. Findings include: Resident #22 was admitted to the facility in August 2022 with diagnoses including Parkinson's disease, encephalopathy of unclear etiology, reduced mobility, and abnormalities of gait and mobility. Review of the current Physician's Orders indicated the following rehabilitative (rehab) order: - (8/1/22) Occupational Therapy (OT), Physical Therapy (PT), and/or Speech Therapy (ST) to evaluate and treat as needed Review of skilled rehab documentation indicated Resident #22 was on OT services from 8/2/22 - 9/29/22 and PT services from 8/30/22 - 9/30/22; was hospitalized a short time on 9/30/22 and received skilled OT a second time from 10/4/22 - 10/17/22 and PT services a second time from 10/6/22 - 10/20/22. Review of the OT Discharge summary, dated [DATE], indicated but was not limited to the following: - Resident agreeable to the idea of rehab services but not compliant with actual physical participation - Limited progress made - From 10/4/22 - 10/17/22 no progress towards goals was made in bathing or upper body dressing - Sitting balance was improved from unable to poor with tolerance of sitting increased to supported for one hour - Hygiene and grooming improved from maximum (max) assist to moderate assist - Recommend on discharge: handout provided for bilateral upper extremity exercises, no restorative or functional maintenance program indicated, encourage Resident out of bed daily Review of the PT Discharge summary, dated [DATE], indicated but was not limited to the following: - Resident has reached maximum potential with skilled services - From 10/6/22 - 10/20/22 no progress was made in functional transfers - Bed mobility improved from total dependence without attempts to initiate to max assist - Tolerance out of bed improved from unable to rarely agreeable to out of bed; requires mechanical lift by staff from bed to wheelchair - Recommend on discharge: home exercise program (HEP) provided to spouse and Resident, encourage participation in HEP, encourage out of bed with use of mechanical lift - No restorative or functional maintenance program indicated During an interview on 11/3/22 at 9:26 A.M., Family member #1 said the Resident is not on skilled rehab services and was removed from rehab services for insurance reasons. She said the family appealed the facility decision to remove the Resident from skilled rehab services, but skilled rehab services were not continued or restarted. Review of the medical record indicated a Notice of Medicare non-coverage (NOMNC) provided to the Resident on 10/17/22, and an immediate appeal of the decision was requested by the Resident to Kepro. The NOMNC was provided to discharge the Resident from skilled rehab services. Review of the facility's policy titled Transfer or Discharge notice, dated March 2021, indicated but was not limited to the following: - Residents have the right to appeal a facility-initiated transfer or discharge through the state agency that handles appeals - If a resident chooses to appeal a discharge, the facility will not discharge the resident while the appeal is pending Kepro is the beneficiary and family centered care quality improvement organization authorized by Medicare to review inpatient services. By law, Kepro reviews Medicare cases to determine if the services meet acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. A review of the Kepro appeal decision, dated 10/25/22, indicated but was not limited to the following: According to the Kepro physician's review of the medical record, ending services is not appropriate During a follow up interview on 11/4/22 at 10:45 A.M., Family member #1 said once she received the information that they had won the appeal she assumed the Resident would be put back on rehab services. She said she was told that the Resident would not qualify and has a progressive illness which will continue to prevent them from making progress. She said the Resident is willing to work with rehab services but gets frustrated during sessions related to a language barrier and then just shuts down. She said she is looking into other options for rehab services and placement because the Resident is not getting what they need at the facility. During an interview on 11/8/22 at 8:01 A.M., Physical Therapy Assistant (PTA) #1 said he worked with the Resident a few times and believes the decision was made to take the Resident off of services because they were not making enough progress. He said he does not speak the dominant language of the Resident but would use one word instructions or hand gestures to communicate to the Resident what they needed to do and did not think it caused any difficulty. He said he was unaware that the Resident had appealed the decision to be taken off skilled services and was unaware of the outcome. During an interview on 11/8/22 at 9:15 A.M., the Admissions Director said she receives the appeals decision notices electronically and then shares them with the team. She said the team includes: social services, rehab director, administrator, director of nurses, and medical records. During an interview on 11/8/22 at 10:01 A.M., the Director of Rehab Services (DOR) said once a decision is made to take someone off skilled services a letter of notice is provided to the resident and their family at least two days before the discharge date . She said if the resident or their family appeal the decision they remain on services with rehab until the appeal information is received. She said Resident #22 was removed from skilled services for not making enough progress. She said PT discharged the Resident on 10/20/22 and OT discharged the Resident on 10/17/22. She said she was not aware that Resident #22 appealed the decision to be removed from skilled rehab services and was unaware the decision was made by Kepro in favor of the Resident. She said the Resident was discharged and never placed back on services and is not currently on skilled services. She said the Resident should never have been removed from services and should have been given the opportunity they deserved after winning their appeal. She said Resident #22's right to appeal and receive further treatment upon winning the appeal were violated, and they should be on skilled services. During an interview on 11/8/22 at 10:41 A.M., Social Worker (SW) #1 said she provides the letters of non-coverage for skilled services and received notification the Resident won their appeal on 10/25/22. She could not explain why the Resident was not placed back on skilled services. She said the process was broken and the Resident should have been given the opportunity to continue rehab services according to the appeal letter. During an interview on 11/8/22 at 2:02 P.M., the Administrator said the facility would typically not remove a Resident from skilled rehab services pending their appeal. She said an error was made in this case and because of poor communication the Resident missed out on their right to use their Medicare benefit and receive skilled rehab services after winning their appeal.

Based on interviews and record review, the facility failed to ensure its staff maintained accurate documentation for two Residents (#72, #1B), out of a total of 24 residents. Specifically, the facility failed to: 1. For Resident #72, ensure the Resident's comprehensive care plan did not include a cardiac monitoring device when the Resident did not have one; and 2. For Resident #1B, accurately identify the rationale/diagnosis for the use of the medication Valproic Acid. Findings include: 1. Resident #72 was admitted to the facility in October 2020. Review of the Resident's Comprehensive Care Plans included but was not limited to: -Focus: The Resident has a zio patch external monitor (single-use monitor designed to improve patient compliance while maximizing diagnostic yield) to left upper chest related to recent hospitalization related to myxedema coma (severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs) and for post hospitalization cardiac monitoring (12/22/22) -Interventions: Ensure the monitor remains adhered to chest as per order (12/22/22); Ensure the transmitter remains within 10 feet of resident as per order (12/22/22) -Goal: The Resident will remain free of signs/symptoms of altered cardiac output through review date (12/22/22) Further review of the medical record failed to indicate Resident #72 was hospitalized for myxedema coma and had a zio patch external monitor to his/her left upper chest. During an interview on 1/9/23 at 2:39 P.M., the surveyor reviewed Resident #72's medical record with Nurse #4 and Nurse #5. They said Resident #72 does not have a zio patch or any type of cardiac monitoring device and was not hospitalized for myxedema coma. During interviews on 1/9/23 at 2:43 P.M. and 3:55 P.M., the surveyor reviewed Resident #72's medical record with the Director of Nursing (DON). She said Resident #72 was not hospitalized for myxedema coma and does not have a zio patch. She said the care plan for the zio patch was inaccurate, meant for another resident and should not have been in Resident #72's medical record. 2. Resident #1B was admitted to the facility in January 2023 with diagnoses including schizophrenia and was developmentally disabled. Review of the January 2023 Medication Administration Record (MAR) indicated the following: Valproic Acid (antiseizure medication, but can also be used for mood stabilization/bipolar disorder) 250 milligrams (mg), give two capsules by mouth two times a day for seizure disorder. Record review indicated that the Resident did not have a diagnosis of seizure disorder. Review of the Informed Consent for Psychotropic Administration Form indicated the purpose of the medication was behavior management, mood stabilizer. During an interview on 1/11/23 at 11:00 A.M., the Regional Nurse Consultant said that the Resident did not have a diagnosis of a seizure disorder.

Based on record review and interview, the facility failed to ensure that services were coordinated with the Hospice provider to implement the resident's plan of care as required in the provider contract agreement for two Residents (#10 and #72), of a total sample of 27 residents. Specifically, the facility failed to ensure: 1. For Resident #10: a. an integrated care plan was developed to accurately reflect services provided by both the Hospice provider and facility staff, and b. the Hospice provider's plan of care for Home Health Aide services was implemented and documented in the medical record; and 2. For Resident #72: a. to ensure an integrated care plan was developed to accurately reflect services provided by both the Hospice provider and facility staff, and b. the Hospice provider's plan of care for Home Health Aide services was implemented and documented in the medical record. Findings include: Review of the Hospice Care Services Agreement, signed June 23, 2021, included but was not limited to: -The Hospice provider shall coordinate with the facility in the admission process and development and implementation of the resident's plan of care -The parties will collaborate in jointly coordinating the implementation, evaluation, and modification, as needed of the Plan of Care on an ongoing basis -Will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care. Review of the facility's policy titled Hospice Program, last revised July 2017, included but was not limited to: -The facility is responsible for ensuring coordinated plans of care for residents receiving Hospice services will include the most recent Hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. 1. Resident #10 was admitted to the facility in May 2019 with diagnoses including peripheral vascular disease and congestive heart failure. Review of Resident #10's medical record indicated the Resident was admitted to Hospice care on 3/30/22. Review of the Resident's Hospice binder included an initial certification and frequency of Hospice services dated 3/30/22. Hospice services were last recertified on 9/14/22 and signed by the Physician on 9/15/22 for the period 9/26/22 to 11/24/22 and indicated the following Hospice services: -Skilled Nursing one time a week for nine weeks, and three as needed visits -Home Health Aide (HHA) two times a week for nine weeks -Social Work one time a month for two months, and three as needed visits -Chaplain- declined a. Review of the Interdisciplinary Care Plans included but was not limited to: -Focus: Care and comfort measures in place. admitted to Hospice services on 3/30/22 (initiated 3/31/22) -Interventions/Tasks: Arrange visits with pastoral care, social worker, psychological services as indicated and desired (3/31/22) -Goal: Staff will try to maintain the highest possible level of functioning and comfort for the Resident through next review (3/31/22); Resident will be free of pain/discomfort through the next review (3/31/22) The Hospice care plan failed to identify the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions that have been agreed upon to maintain the Resident's highest practicable physical, mental, and psychosocial well-being. b. Review of the Hospice provider's Facility Care Coordination document indicated a Notice to Facility Staff including but not limited to: -Hospice staff will make regular visits to the resident and will coordinate with your staff during each visit -Hospice staff will review and document in the resident's facility medical record Review of the Hospice provider's HHA Visit Record (sign in sheets) failed to indicate the Hospice Home Health Aide made any visits to Resident #10 from 9/28/22 to 10/11/22 and from 10/13/22 to 11/10/22. There was no documentation in the medical record to indicate the Hospice HHA provided services to the Resident during those time periods and why the plan of care was not implemented as ordered. 2. Resident #72 was admitted to the facility in October 2020 with diagnoses including history of a stroke and diabetes. Review of Resident #72's medical record indicated the Resident was admitted to Hospice care on 3/23/22. Review of the Resident's Hospice binder included an initial certification and frequency of Hospice services dated 3/23/22. Hospice services were last recertified on 9/14/22 and signed by the Physician on 9/15/22 for the period 9/29/22 to 11/17/22 and indicated the following Hospice services: -Skilled Nursing one time a week for nine weeks, and three as needed visits -Home Health Aide (HHA) three times a week for eight weeks, two times a week for one week -Social Work one time a month for one month and three as needed visits -Chaplain- declined a. Review of the Interdisciplinary Care Plans included but was not limited to: -Focus: Care and comfort measures in place. admitted to Hospice services on 3/23/22 (initiated 3/31/22) -Interventions/Tasks: Arrange visits with pastoral care, social worker, psychological services as indicated and desired (3/31/22) -Goal: Staff will try to maintain the highest possible level of functioning and comfort for the Resident through next review (3/31/22); Resident will be free of pain/discomfort through the next review (3/31/22) The Hospice care plan failed to identify the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions that have been agreed upon to maintain the Resident's highest practicable physical, mental, and psychosocial well-being. b. Review of the Hospice provider's Facility Care Coordination document indicated a Notice to Facility Staff including but not limited to: -Hospice staff will make regular visits to the resident and will coordinate with your staff during each visit -Hospice staff will review and document in the resident's facility medical record Review of the Hospice provider's HHA Visit Record (sign in sheets) failed to indicate the Hospice Home Health Aide made any visits to Resident #72. During an interview on 11/04/22 at 10:43 A.M., Unit Manager #2 said the facility did not develop an integrated care plan that outlines services provided by the Hospice staff such as nursing, HHA, and social work for Residents #10 and #72. She could not confirm the Hospice HHA had come to provide service to Resident #10 from 9/28/22 to 10/11/22 and from 10/13/22 to 11/10/22. The Unit Manager could not explain why there was no HHA documentation in either Resident #10 or Resident #72's medical record to reflect implementation of the plan of care.

Based on record review, policy review, and interview, the facility failed to document the administration and results of a COVID-19 test for one Resident (#51), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Coronavirus Disease - Testing Residents, dated September 2021, indicated but was not limited to the following: - all COVID-19 tests conducted for residents, including results are documented - documentation includes the date and time the test was conducted and results obtained Review of the facility's Resident Testing Logs indicated Resident #51 was COVID-19 positive on 9/1/22. Review of the medical record for Resident #51 failed to indicate a COVID-19 test had been conducted on 9/1/22. During an interview on 11/9/22 at 7:43 A.M., the Infection Preventionist (IP) reviewed the facility testing logs and said Resident #51 was positive for COVID-19 on 9/1/22. Upon reviewing the medical record, she said the staff did not document on the Treatment Administration Record or in the progress notes that a COVID-19 test was conducted on 9/1/22. She said there was a note on 9/2/22 indicating the Resident was suffering from COVID-19, but no other information. She said the documentation for COVID-19 testing for Resident #51 did not meet the expectation or follow the policy for documenting COVID-19 tests as it should.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that dignity was provided during the dining experience for four Residents (#15, #32, #84, and #89), out of a total sample of 27 residents. Specifically, the facility failed to ensure that staff: 1. For Resident #15, did not stand over the Resident while assisting him/her to eat in the Unit dining room; 2. For Residents #32, a. delivered meals to all residents seated at his/her table simultaneously and did not wait an extended period of time to receive his/her meal while watching tablemates eat, and b. did not stand over the Resident while feeding him/her in the dining room; 3. For Resident #84, delivered meals to all residents seated at his/her table simultaneously and did not wait an extended period of time to receive his/her meal while watching tablemates eat; 4. For Resident #89, a. delivered meals to all residents seated at his/her table simultaneously and did not wait an extended period of time to receive his/her meal while watching tablemates eat, b. did not stand over the Resident while feeding him/her in the dining room. Findings include: 1. On 11/2/22 at 12:00 P.M., the surveyor observed Resident #15 seated at a table in the [NAME] Unit dining room with three other residents. Unit Manager #2 stood over Resident #15 while feeding him/her their meal. The Unit Manager remained standing alongside the Resident feeding him/her for the duration of the meal. 2. a. On 11/2/22 at 12:00 P.M. the surveyor observed Resident #32 seated at a table in the [NAME] Unit dining room with three other residents. Resident #32 was sitting idly and watching three residents seated at the table eat their lunch meal. At 12:47 P.M., Nurse #10 placed a lunch tray in front of Resident #32. b. Nurse #10 stood next to Resident #32 and began to feed him/her their meal. The Nurse remained standing alongside the Resident feeding him/her for the duration of the meal. 3. On 11/2/22 at 12:00 P.M., the surveyor observed Resident #84 seated in a Broda chair (positioning chair) at a table in the [NAME] Unit dining room with two other residents. Resident #84 was sitting idly watching two residents seated at the table eat their lunch meal. At 12:30 P.M., the surveyor observed Resident #84 tell Certified Nursing Assistant (CNA) #8 that he/she had not eaten yet. The CNA brought the Resident a personal size container of applesauce. At 12:44 P.M., CNA #8 moved the Resident across the room to a different table. At 12:45 P.M., the Resident received his/her lunch meal and began to eat. 4. a. On 11/2/22 at 12:00 P.M., the surveyor observed Resident #89 seated at a table in the dining room with three other residents. Resident #89 was sitting idly while three residents seated at the table ate their lunch meal. At 12:26 P.M., a lunch meal was placed in front of Resident #89. b. Unit Manager #2 stood next to the Resident and began to feed him/her their meal. The Unit Manager remained standing alongside the Resident feeding him/her for the duration of the meal. During an interview on 11/2/22 at 1:30 P.M., Nurse #10 said that it would be better if residents seated at the same table ate at the same time and staff should not stand over residents while feeding them.

Based on a resident group meeting, staff interviews, policy and document review, the facility failed to ensure grievances and concerns from the Resident Council regarding a lack of face cloths and towels was acted upon timely. Findings include: Review of the facility's policy titled Nursing Home Resident's Rights: Grievances, undated, included but was not limited to: -The facility must make prompt efforts to resolve grievances the resident may have; the resident has the right to receive the written result of the grievance -Standard grievances must be resolved within 5 - 7 business days Review of the Resident Council Minutes, dated 8/16/22, indicated residents had concerns about difficulty in getting face cloths or towels when they need them. Review of the Resident Council Minutes, dated 9/2/22, indicated residents had concerns about difficulty in getting face cloths and towels when they need them. Review of the Resident Council Minutes, dated 10/10/22, indicated residents had concerns about difficulty in getting face cloths and towels when they need them. During a Resident group interview on 11/4/22 at 1:00 P.M., 10 out of 10 residents in attendance said that face cloths and towels are in short supply and oftentimes they have to use blankets or pillowcases as towels or face cloths. They said it has been an ongoing problem for several months and still has not been resolved. During an interview on 11/10/22 at 2:40 P.M., the Activity Director said that she did not have any supporting documentation to indicate the concerns brought forward during Resident Council had been addressed by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to develop and implement individual person-centered care plans for seven Residents (#56, #22, #51, #54, #29, #32, and #89), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #56, to develop a person-centered plan of care to monitor suicidal ideation; 2. For Resident #22, to develop and implement an individualized care plan for healthcare proxy activation and language barrier; 3. For Resident #51, to develop a comprehensive care plan for both hearing loss and denture use; 4. For Resident #54, to develop a comprehensive plan of care for an abdominal wound; 5. For Resident #29, to develop and implement an individualized plan of care for communication needs; 6. For Resident #32, to develop and consistently implement a comprehensive care plan for: a. a blood clot in the left basilic vein, anticoagulant therapy and a hematoma to the right hand; b. dietary preferences related to the Resident's culture; c. activities; and d. communication (Resident speaks Taishanese); and 7. For Resident #89, to develop and consistently implement a comprehensive care plan for: a. dietary preferences related to the Resident's culture; b. communication (Resident speaks Cantonese); c. legal blindness; and d. activities. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated March 2022, indicated comprehensive person-centered care plans will include measurable objectives and timetables to meet a resident's physical, psychological, and functional needs. It further indicated but was not limited to the following: - care plan interventions are derived from a thorough analysis of the information gathered as part of a comprehensive assessment - care plans will build on resident's strengths - current recognized standards of practice for problem areas or concerns will be addressed - interventions will address underlying sources of problem areas - the comprehensive person-centered care plan will include services to be furnished to maintain or attain a resident's highest practicable well-being 1. Resident #56 was admitted to the facility in July 2022 with diagnoses including adjustment disorder with mixed anxiety and depressed mood, suicidal ideation, and acute stress reaction. Review of the current Physician's Orders, dated 11/10/22, indicated Resident #56 was monitored for behaviors that included: disrobing, wandering off unit, sexual inappropriate behavior, intrusive towards others. Further record review indicated Resident #56 was sent to the emergency room in September 2022 for suicidal statements and returned to the facility with no new orders and a discharge diagnosis of adjustment disorder. Review of Psychiatric Consult Notes indicated the Resident was seen by psych services at the facility on 10/7/22 and recommendations were made to document mood and behavior changes. Review of the current November 2022 Plan of Care for Resident #56 indicated two care plans that addressed mood: A. Resident has potential for a sad mood/withdrawn related to placement in the center and will show no signs of sad mood through next review date. Interventions included: - assess for resident's response to new situations - explain all routine and procedures to the resident B. Resident requires psychotropic medications secondary to mood disorder and will have the smallest most effective dose without side effects. Interventions included: - administer medications as ordered and monitor for effectiveness - ensure informed consent is signed - monitor for signs and symptoms of mood disorder and any behavior problems and report problems to social services - praise resident's positive mood and behavior During an interview on 11/8/22 at 2:34 P.M., Social Worker (SW) #1 reviewed the care plans and behavior documentation and said the Resident was not capable of wandering or being intrusive to others as he/she was non-ambulatory, and the Resident did not have any evidence that he/she was monitored for suicidal ideation. She said the Resident has behaviors of suicidal statements and verbal aggression and the care plan is not accurate for this Resident and did not reflect the Resident's psychological needs. 2. Resident #22 was admitted to the facility in August 2022 with diagnoses including Parkinson's disease, encephalopathy of unclear etiology, and anxiety. Review of Resident #22's Comprehensive Nursing Assessment, completed on 8/1/22, indicated: the Resident's daughter was the activated healthcare proxy (HCP), the Resident's dominant language was foreign to the facility, the Resident preferred to have his/her educational information provided verbally, a diagnosis of anxiety with no behaviors exhibited by the Resident. Review of the current Physician's Orders, dated 11/4/22, indicated Resident #22 was monitored for behaviors that included: disrobing, wandering off unit, sexual inappropriate behavior, intrusive towards others. Review of the current November 2022 Plan of Care for Resident #22 indicated but was not limited to the following care plans that addressed healthcare proxy activation and communication deficits related to foreign language: A. Resident is a full code (will have life saving measures performed as needed), with a HCP on file that is not activated and is his/her spouse and the Resident and family will participate towards safe discharge planning. The only intervention indicated: - make appropriate referrals for services in the community Review of the HCP for Resident #22 indicated his/her daughter was the HCP and a physician progress note for HCP activation was completed on 8/1/22. During an interview on 11/08/22 at 12:28 P.M., the Assistant Director of Nurses (ADON) reviewed the medical record for the Resident and said the HCP is activated and designated as the Resident's daughter. She said the care plan is incorrect regarding the Resident's HCP. B. Communication alteration potential related to primary language of Portuguese. Resident will be able to communicate needs and preferences effectively to personnel by use of interpreters, gestures, and communication cards in both languages. Interventions include: - utilize interpreters and other assistive language devices as needed, access interpreters by language line - use simple words and phrases - involve family to assist with translating when available - allow time for Resident to express his/her needs - develop communication cards for use to list words such as pain, bathroom, thirst, etc . During an interview on 11/3/22 at 8:40 A.M., Resident #22 said they speak Portuguese and very little English, Family Member #2 was at the bedside and said there was only one staff member who can communicate with the Resident in Portuguese. During an interview on 11/3/22 at 9:38 A.M., the surveyor did not observe any communication cards in the Resident's room. Family member #1 said she has never seen any communication cards or word boards of common words for the Resident to be able to effectively communicate with the staff routinely. She said there are only two people who work at the facility that she knows of who can communicate with the Resident, and the lack of communication is very frustrating for the Resident. She said in her experience it is not common that the facility staff use the language line to communicate with the Resident. During an interview on 11/4/22 at 8:47 A.M., Family member #2 said he looked for the communication cards but there are none available for the staff to use. He said he knows they have a language line, but he does not think they use it and has never seen it used by a staff member who does not speak or understand Portuguese. During an interview on 11/4/22 at 8:51 A.M., Certified Nursing Assistant (CNA) #1 said there are no communication cards, books or lists that she can use to communicate with the Resident, and she does not speak Portuguese. She said she has never used the language line and relies on hand gestures to try to figure out what the Resident may want or looks for a staff member who can speak Portuguese. She said the Resident doesn't seem to understand too much English. During an interview on 11/4/22 at 9:15 A.M., Nurse #8 said she cares for the Resident routinely and uses one word or hand gestures to communicate with the Resident because she does not speak Portuguese. She said the language line is available but not used for quick things and she will look for a staff member that speaks Portuguese or contact the family if she has any issues. She said she has never seen or been aware of any communication cards or devices for the staff to use instead of the language line to communicate with the Resident. During an interview on 11/8/22 at 8:40 A.M., SW #1 said she created and implemented Portuguese communication flash cards for the Resident and staff using common words on Friday, 11/4/22. She said the intervention of communication cards on the care plan was dated as implemented in August 2022, but it was incorrect; that intervention was not implemented prior to her implementing it on 11/4/22. 3a. Review of the Minimum Data Set (MDS) assessment, dated 9/16/22, indicated Resident #51 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had adequate hearing, and did not have hearing aids. During an interview on 11/2/22 at 12:17 P.M., the surveyor observed Resident #51 in his/her bed bending forward while the surveyor was speaking. The Resident asked the surveyor to come closer because he/she was having difficulty hearing often saying What? and Huh?. Resident #51 told the surveyor their hearing had gotten worse since being at the facility and felt he/she needed hearing aids to assist with communication with staff and other residents. The Resident said staff was aware and he/she could read lips, but due to the mask mandate was unable to do so. During an interview on 11/7/22 at 1:55 P.M., Unit Manager (UM) #1 said sometimes when she spoke to the Resident, she needed to get close in order for the Resident to hear her and it was difficult at times for the Resident to communicate due to staff wearing facemasks. During an interview on 11/7/22 at 1:18 P.M., the surveyor observed Resident #51 sitting in their wheelchair next to his/her bed. The Resident was having difficulty hearing and asked the surveyor to come closer, approximately within two feet, and said his/her left ear was worse than the right and it had worsened since being admitted . The Resident said he/she must ask staff to come closer when they speak to him/her because they do not do it on their own and if he/she could hear better it would make him/her happy. During an interview on 11/8/22 at 8:04 A.M., CNA #6 said the Resident was hard of hearing and she has had to get close to him/her when speaking for a while now. During an interview on 11/9/22 at 12:16 P.M., the Activities Director said Resident #51 had a hearing deficit for sure and needed to be placed near the activities being held to better hear and to be able to fully participate. Review of the interdisciplinary comprehensive care plans failed to indicate a care plan for the Resident's hearing loss had been developed and implemented to include risks, needs, preferences, measurable goals, objectives, and timetables. b. Resident #51 was admitted to the facility with diagnoses including dysphagia (difficulty swallowing), dyskinesia (uncontrolled, involuntary muscle movement) of the esophagus, and gastro-esophageal reflux disease (GERD). During an interview on 11/2/22 at 12:24 P.M., Resident #51 said he/she had full dentures and they did not fit right, and he/she had difficulty chewing certain types of foods such as meats. The surveyor observed Resident #51 easily take out his/her dentures. They were not affixed with denture adhesive. No denture care supplies were observed in the Resident's room such as a denture cup, adhesive, or denture cleaner. Review of the Admission/readmission Nursing Assessment, dated 9/15/22, indicated Resident #51 had his/her own teeth and did not have a chewing or swallowing problem. Review of a Speech Therapy Evaluation and Plan of Treatment, dated 11/1/22, indicated that during an oral exam the Resident was edentulous with full upper and lower dentures which appeared loose-fitting. During an interview on 11/8/22 at 8:48 A.M., Nurse #11 said she was familiar with the Resident and knew he/she had dentures but did not know they were loose. During an interview on 11/7/22 at 1:32 P.M., Resident #51 said he/she needed better fitting dentures and food had to be cooked soft or he/she would have to chew a lot. The surveyor did not observe any denture supplies in the Resident's room. Resident #51 said he/she did not have any and just rinsed them off with a toothbrush and did not have any glue, so they just popped right out. The Resident said staff knew of the dentures because they made him/her take them out to show them when he/she was admitted . During an interview on 11/7/22 at 1:55 P.M., Unit Manager #1 said she did not know the Resident had dentures but should have. Review of the interdisciplinary comprehensive care plans failed to indicate a care plan for the Resident's dentures had been developed and implemented to include risks, needs, preferences, measurable goals, objectives, and timetables. During an interview on 11/9/22 at 2:43 P.M., the Director of Nursing (DON) said Resident #51 should have been care planned for his/her hearing loss and dentures but was not. 4. Review of the Admission/readmission Nursing Assessment, dated 9/22/22, indicated Resident #54 had a non-pressure wound in the abdominal area. Review of the Nurse Practitioner's Skin/Wound Notes indicated the following: 10/5/22, Wound #1 Abdomen -Patient scratches and takes every dressing that is put on the wound. Patient currently refusing a dressing over the wound. Recommend keeping nails cut and educate patient. 10/12/22, Wound #1 Abdomen -Midline is a chronic full thickness dermatologic/rash and has received a status of not healed. Multiple open areas on the abdomen. Diagnosis: unspecified open wound of abdominal wall. Patient currently refusing any dressing over wound. Review of Care Plan Meeting progress notes, dated 10/6/22, indicated Resident #54 tended to refuse care. During an interview on 11/2/22 at 10:44 A.M., the surveyor observed Resident #54 lying in bed with a large square sponge dressing partially adhered to the abdominal wound. Resident #54 took off the dressing exposing the wound. Multiple open areas were noted with small amounts of dried serosanguinous (both blood and liquid part of blood, serum) fluid. A smaller white dressing was observed adhered to the lower right abdomen. During an interview on 11/3/22 at 3:36 P.M., the surveyor and Nurse #4 observed the Resident lying in bed with the bed linens off. Resident #54 did not have an abdominal dressing in place. Nurse #4 was unable to locate the dressing in the bed and said it must have come off. Nurse #4 said Resident #54 was non-compliant with care and often refused dressing changes or would take off the dressing once applied. Review of the medical record failed to indicate an interdisciplinary care plan for Resident #54's abdominal wound had been developed and implemented to include risks, needs, preferences, measurable goals, objectives, timetables, and behavioral interventions to reflect the Resident's refusal of care. During an interview on 11/9/22 at 3:11 P.M., the surveyor reviewed the medical record with the DON who said Resident #54 should have been care planned for his/her abdominal wound that included interventions to address the refusal of care/treatment but was not. 5. Resident #29 was admitted to the facility with diagnoses including cognitive communication deficit, dementia, and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of the MDS assessment, dated 10/3/22, indicated Resident #29 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score not being performed due to the Resident being rarely understood. The MDS indicated Resident #29 was of Asian descent with Cantonese as his/her primary language and needed or wanted an interpreter to communicate with a doctor or health care staff. On 11/2/22 at 12:31 P.M., the surveyor did not observe any assistive communication devices in Resident #29's room. On 11/7/22 at 8:30 A.M., the surveyor observed a picture board above the Resident's bedside table in his/her room. A staff member was assisting the Resident with breakfast but was not observed utilizing the picture board to aid in communication. The staff member was not interacting with the Resident and the Resident was observed staring straight ahead. During an interview on 11/10/22 at 7:27 A.M., CNA #7 said the Resident spoke Chinese but did not respond to staff. CNA #7 said she communicated with the Resident based on his/her facial expressions and his/her reactions and gestures but had to use the Resident's gaze to see what he/she really needed. CNA #7 said she relied on the Resident's family member to help when she was there. During an interview on 11/10/22 at 7:37 A.M., Nurse #4 said she could not answer what the Resident's cultural preferences were. Review of the interdisciplinary care plans failed to indicate a care plan had been developed and implemented to reflect Resident #29's cultural/communication needs including risks, preferences, measurable goals, objectives, and timetables. During an interview on 11/10/22 at 7:42 A.M., Unit Manager (UM) #1 said she had not received any cultural training to better determine Resident #29's needs and preferences and went by what the family member said. UM #1 said the Resident should have been care planned for culture/communication but was not. During an interview on 11/10/22 at 8:36 A.M., the DON said the Resident should have been care planned for culture/communication but was not. 6. Resident #32 was admitted to the facility in September 2022 with diagnoses including congestive heart disease, adjustment disorder, and atrial fibrillation. Review of the MDS assessment, dated 9/27/22, indicated Resident #32 speaks Chinese and requires an interpreter to communicate with his/her Physician and health care staff. a. Review of the medical record indicated: - A 10/17/22 venous Doppler study which indicated Resident #32 had a superficial venous thrombosis (blood clot) including non-compressibility in the left basilic vein -A Physician's order for Heparin (anticoagulant) 5000 units/milliliter, inject 5000 units subcutaneously three times a day (started 10/8/22). -On 11/4/22, facility staff identified an injury to the Resident's right hand and developed a hematoma measuring 4.1 X 2.1 X 4.3 centimeters dorsally that was dark purple in color, swollen, and painful. Review of interdisciplinary care plans failed to indicate a care plan was developed for the blood clot, the use of anticoagulant therapy, and a hematoma to the right hand. During an interview on 11/7/22 at 9:15 A.M., Unit Manager #2 said that care plans had not been developed for Resident #32's blood clot, anticoagulant use, and hematoma to the right hand. b. During an interview on 11/10/22 at 12:40 P.M., Resident Representative #2 said she is concerned because the Resident does not like American food, and that is the only food served at the facility. She also said that, as is typical for his/her culture, the Resident does not like cold drinks, and he/she will only drink room temperature beverages. She said no one from the facility has contacted the family about Resident #32's food preferences taking into consideration his/her Chinese culture. Review of the interdisciplinary care plans failed to indicate a care plan had been developed to address his/her dietary preferences reflective of his/her Chinese culture. During interviews with the Dietitian on 11/4/22 at 2:42 P.M. and the Food Service Manager on 11/8/22 at 1:07 P.M., they said they have not met with either Resident #32 or his/her Representative to discuss food preferences and cultural considerations. c. Review of interdisciplinary care plans included but was not limited to: -Focus: Resident is pleasant, social, alert with some confusion. In the past, he/she enjoyed spending time watching Chinese TV game shows (9/26/22) -Interventions/Tasks: Call interpreter services, language Chinese (9/27/22); offer materials of interest such as snacks and drinks and offer to watch his/her preferred shows such as Chinese game shows on the iPad (9/26/22) -Goal: While Resident is in the facility, he/she will be encouraged to maintain current activity patterns and preferences such as watching TV, one to one visits with activities staff, drinks from activity cart 3-4 times a month X 90 days (9/26/22) On 11/3/22 at 10:43 A.M., the surveyor observed Resident #32 seated in a wheelchair at the back of the [NAME] unit dayroom in the vicinity of two other residents in wheelchairs that were sleeping. There was no activity going on and no staff interaction. Resident #32 was not provided a snack, drink or encouraged to watch Chinese game shows on an iPad. During an interview on 11/4/22 at 11:15 A.M., the surveyor and Activities Director reviewed Resident #32's Activity care plan. She said she spoke to the maintenance department who said they were unable to get any Chinese channels on television. The surveyor asked about utilizing an iPad to watch Chinese games shows and she said had not done that. d. Review of the interdisciplinary care plans included but was not limited to: -Focus: Communication alteration potential related to resident's primary language is Chinese (9/23/22) -Interventions/Tasks: Access interpreter services; develop communication cards using English and resident's primary language to list words (i.e., pain/location, bathroom, thirst, etc.); utilize interpreters and other assistive language devices as needed (9/23/22) -Goal: Resident will communicate needs and preferences effectively to personnel via use of interpreters, gestures, communication cards with common words in both languages (9/23/22) On 11/2/22 at 9:28 A.M., the surveyor observed Resident #32 sitting upright in bed. The Resident was speaking in Chinese and gesturing. At 9:30 A.M., the surveyor informed Unit Manager #2 that the Resident may need assistance but could not communicate his/her needs due to a language barrier. At 9:33 A.M., CNA #4 came into the room and said she does not speak Chinese. The CNA looked around the Resident's room, bureau and bedside table and was unable to locate a communication book or cards for the Resident. During an interview on 11/9/22 at 11:09 A.M., Social Worker #1 said she has not gotten around to putting together any communication books or communication cards for Resident #32 to communicate his/her needs to staff as indicated in the care plan. 7. Resident #89 was admitted to the facility in September 2022 with diagnoses including legal blindness. Review of the MDS assessment, dated 9/27/22, indicated Resident #89 speaks Chinese and requires an interpreter to communicate with his/her Physician and health care staff. a. Review of comprehensive care plans failed to indicate a care plan for food preferences taking into consideration the Resident's culture. During interviews with the Dietitian on 11/4/22 at 2:42 P.M. and the Food Service Manager on 11/8/22 at 1:07 P.M., they said they have not met with either Resident #89 or his/her family to discuss food preferences and cultural considerations. b. Review of comprehensive care plans failed to indicate a care plan for communication. During an interview on 11/9/22 at 11:09 A.M., Social Worker #1 said that she has not gotten around to developing a care plan to meet Resident #89's communication needs. c. Review of comprehensive care plans failed to indicate a care plan for the Resident's diagnosis of legal blindness. During an interview on 11/8/22 at 1:20 P.M., the surveyor and Unit Manager #2 reviewed Resident #89's medical record. She said a care plan had not been developed for Resident #89's legal blindness. d. Review of comprehensive care plans included but was not limited to: Focus: Resident is pleasant, alert and here for long term care. Enjoys listening to Chinese news on his/her [NAME] (name of Amazon's personal digital assistant, which lets you use voice commands to control a compatible device for features like streaming, news reports or even to turn on your smart lights) in his/her room (9/28/22) -Interventions: Interpreter services; Resident will be offered materials of interest (none identified); Resident will be given monthly activity calendar (Resident cannot read English and is blind) and encouraged to attend groups (9/28/22) During an interview on 11/4/22 at 11:15 A.M., the Activity Director said she did not know how to use the [NAME] device. She also said she has not been able to develop anything specific to meet the Resident's activity needs. During an interview on 11/9/22 at 9:59 A.M., Activity Assistant #1 said she did not know anything about an [NAME] device for Resident #89 to listen to Chinese news.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of the facility's policy titled Pacemaker, Care of a Resident With, revised 2015, indicated but was not limited to the following: -The two most common arrhythmias that require a pacemaker are sinus bradycardia and heart block -Heart block occurs when there is a slowing or complete blockage of the electrical conductivity in the heart -If the pulse generator or battery fails, or if the leads become displaced the pacemaker may not work properly, leading to bradyarrhythmia's Monitoring -The pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this -The resident will have an EKG annually, or as ordered, to monitor for changes in the heart's electrical activity -Make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well Documentation -For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address and telephone number of the cardiologist; b. Type of pacemaker; c. Type of leads; d. Manufacturer and model; e. Serial number; f. Date of implant; and g. Paced rate Designed to operate for 3 to 20 years, a permanent pacemaker is a self-contained device that provides electrical stimulation to the myocardium. The surgeon implants the pacemaker in a pocket beneath the patient's skin. Permanent pacemakers function in the demand mode, allowing the patient's heart to beat on its own but preventing it from falling below the preset rate. Pacing electrodes can be placed in the atria, the ventricles, or both chambers. Check Ups -Be sure to schedule a follow-up visit, and keep regular checkup appointments with your practitioner -If your practitioner monitors your pacemaker status remotely by wireless telemetry, keep your transmission schedule and instructions handy Lippincott Nursing Procedures, 8th Edition, 2019 Resident #24 was admitted to the facility with diagnoses including the presence of a cardiac pacemaker. Review of current Physician's Orders indicated the following: -Keep mobile monitor fully charged at all times. As needed for status post pacemaker generator, start date 9/24/22 -May have cardiology evaluation and treatment as indicated for surgical clearance, start date 12/5/21 -May have follow up cardiology appointment, start date 4/12/22 Review of Resident #24's care plan for a cardiac pacemaker indicated the following: Focus -Resident at risk for complications related to pacemaker, revised 5/11/22 Goal -Resident will not develop any pacemaker related complications over the next 30 days, revised 9/2/22 Interventions/Tasks -Pacemaker checks as ordered, initiated 4/26/22 Review of the Surgical Case Record indicated Resident #24 had a dual chamber pacemaker inserted on 8/7/09 for a diagnosis of heart block. During an interview on 11/7/22 at 9:06 A.M., Resident #24 said he/she had a cardiac pacemaker implanted in his/her right chest wall. The surveyor observed a pacemaker monitoring device in the shape of a cell phone resting on top of the Resident's side table unplugged. Resident #24 asked the surveyor to plug it in and hand it to him/her. The monitoring device failed to turn on immediately. The battery indicator light illuminated red indicating the battery life had depleted. Resident #24 said the device was of no use to staff if the battery was dead and it should have remained plugged in. During an interview on 11/9/22 at 10:38 A.M., Unit Manager (UM) #1 said the Resident was sent out for an in-clinic cardiology appointment on 8/9/22 but there was not an office visit note in the medical record. UM #1 said the appointment after that had been cancelled and rescheduled. UM #1 said the Resident was supposed to go to the rescheduled appointment the day prior, but it was cancelled due to transport arriving too late for pick up. She said the appointment was rescheduled again but was not sure when. During an interview on 11/9/22 at 10:50 A.M., the surveyor and Nurse #11 entered Resident #24's room. Nurse #11 was unable to locate the monitoring device and asked the Resident where it was. The device was located across the room on his/her roommate's dresser charging. Nurse #11 said it should always be plugged in in case staff needed to use it and it should have been located at the Resident's bedside but was not. Nurse #11 said she did not know how to use the device and did not receive instruction. Nurse #11 located a pacemaker device box in the top drawer of the Resident's bureau that contained an Implanted Device Identification Card, dated 8/7/09. During an interview on 11/9/22 at 11:11 A.M., UM #1 said Resident #24 was not seen by cardiology on 8/9/22 as she had previously stated. UM #1 was unable to provide to the surveyor any cardiology notes from the medical record from previous visits and was unable to provide more detailed information about the care and treatment of Resident #24's implanted pacemaker. UM #1 said the cellular monitoring device found in the Resident's room was not related to the Resident's pacemaker but if it was, then it should have been fully charged. She said the Resident's family member brought it in but did not give information about it. UM #1 said she did not know how or when to use it. During an interview on 11/9/22 at 11:20 A.M., UM #1 said the original pacemaker was implanted in 2009 but it may have been replaced over the summer. UM #1 said she had no information on that and there was no documentation in the medical record to indicate Resident #24 had a new pacemaker. Review of the medical record failed to indicate documentation of the name, address, and telephone number of the cardiologist, type of pacemaker, type of leads, manufacturer and model, serial number, date of implant, and the paced rate per facility policy. The medical record also failed to include cardiology notes for the management and frequency of telephonic/office pacemaker monitoring and battery life as well as future appointment dates to ensure the implanted device was working properly. During an interview on 11/9/22 at 11:50 A.M., the attending physician said he was not sure when the Resident was last seen by the cardiologist or when the next follow up appointment was and asked UM #1 who said she did not know. The attending physician was unable to locate cardiology notes in the Resident's medical record and asked UM #1 where they were. UM #1 said she did not have them. The attending physician said he did not know if the Resident's pacemaker had been replaced since 2009 and said he would go speak to the Resident. During an interview on 11/9/22 at 12:00 P.M., the attending physician said the Resident told him he was seen by the cardiologist two months ago for a follow up visit but said he did not know when the pacemaker was replaced or what type it was. The attending physician said he would follow recommendations made by the cardiologist regarding in-clinic or remote monitoring but did not have any in the medical record to refer to. He said he did not know what the monitoring device was in the room, but it should have been fully charged. During an interview on 11/9/22 at 2:59 P.M., the Director of Nursing (DON) said there should have been additional orders in the medical record to identify the type of pacemaker, when it was implanted, the type of monitoring required, and frequency of cardiology follow up visits but there was not. She said she was not sure what monitoring device the Resident had in his/her room, but staff should have followed physician's orders to keep it fully charged and should have known how to use it. The DON said there had been no education that she knew of. She further said the attending physician should have had all the information readily available in the medical record to determine the type of care needed for the Resident. During an interview on 11/10/22 at 7:46 A.M., Resident #24 said he/she needed surgical clearance for his/her shoulder surgery and, while at the cardiologist's office, it was determined that he/she needed a new pacemaker implanted first. Resident #24 said the pacemaker was replaced in August or September of 2022 and staff including the attending physician should have known this. 5. Resident #64 was admitted to the facility in June 2021 with a diagnosis of epilepsy. Review of the Physician's Orders indicated Resident #64 received Depakote (an anticonvulsant) sprinkles capsule 125 mg (milligrams), give 4 capsules twice per day for seizures. Review of the medical record indicated the last therapeutic levels for Depakote (Valproic Acid) were collected on 11/11/21; used to monitor the level of medication in the blood to maintain effective use. Review of the History and Physical, dated 7/14/22, failed to indicate any history of seizure disorder. Review of the Nurse Practitioner's (NP) progress note, dated 9/29/22, indicated Resident #64 had dementia with anxiety and was taking Depakote for this; there was no indication of a seizure disorder. During an interview on 11/4/22 at 11:47 A.M., the Health Care Proxy of Resident #64 said the Resident had started having seizures a couple of years prior. She said the Resident previously had a seizure, had fallen and broken their hip and had a fall during a seizure at a previous facility. Review of the Nursing Progress Notes indicated on 10/11/22 at 6:30 A.M. Resident #64 had a mild seizure for less than a minute during care and included vital signs; there were no safety issues noted. The next Nursing Note at 8:43 P.M. indicated Resident #64 returned from the hospital status post fall. Review of the Fall Investigation information, provided by the facility, indicated Resident #64 slid out of their wheelchair around 1:00 P.M. The information provided included a skin check, an Interact Transfer Form, a nurse's note, and staff statements. None of the documentation provided indicated the Resident had a seizure that morning or if any seizure activity had occurred during the fall. Review of the 10/11/22 statement of Certified Nursing Assist #5 indicated she was in the room when Resident #64 fell, and she had turned around and did not see the fall. There was no documentation to indicate the movement of Resident #64 that contributed to the fall and if seizure activity occurred. Review of the hospital paperwork indicated Resident #64 was sent to the hospital related to complaints of pain following the fall on 10/11/22. The hospital paperwork did not indicate they were aware Resident #64 had a seizure disorder and had a seizure that morning. During an interview on 11/4/22 at 9:47 A.M., the Nurse Practitioner said therapeutic valproic acid levels for the Resident on an anticonvulsant should be taken every 3 to 6 months depending on the stability of the Resident and there should have been a standing order in place. She said if she had been notified of the seizure activity for Resident #64, she would have ordered laboratory work. During an interview on 11/4/22 at 10:44 A.M., the Assistant Director of Nurses said the nurse should have informed the hospital of the active seizure for Resident #64 that occurred on 10/11/22 and should have documented if any seizure activity occurred during the fall on the same day. 6. Resident #69 was admitted to the facility in September 2022 with a diagnosis of atrial fibrillation. Review of the medical record included documentation from a previous facility where Resident #69 was transferred from. Review of the documentation from the transferring facility indicated Resident #69 had a pacemaker which was checked in August 2022 by his/her cardiologist and included the model of the pacemaker and the serial number. Review of the admission Nursing Assessment, dated the day of admission, included a cardiovascular section with an area to indicate if the Resident had a pacemaker, the type of pacemaker and the last time it was checked. This section was blank, and no pacemaker was indicated for Resident #69. Review of the History and Physical, dated 9/22/22, indicated Resident #69 had a diagnosis of atrial fibrillation, was on an anticoagulant, and the staff should continue to monitor. There was no indication Resident #69 had a pacemaker. Review of the Nursing Progress Note, dated 9/27/22, indicated the family of Resident #69 was having the pacemaker equipment sent to their home and they would bring it in to the facility. During an interview on 11/8/22 at 2:15 P.M., Unit Manager #2 said she would have to follow up with the surveyor on what the plan was for the pacemaker. During an interview on 11/8/22 at 5:15 P.M., Unit Manager #2 said she called the Health Care Proxy of Resident #69 following the inquiry from the surveyor. She said Resident #69 had a pacemaker and the documentation should have been reflected in the medical record to demonstrate that the Resident needed follow-up with the cardiologist every six months.Based on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for eight Residents (#32, #72, #89, #543, #64, #69, #395, #24), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #32, to ensure physician's orders were obtained for transfer to the hospital and treatment/monitoring of a left hand hematoma and Physician notification via unsecured personal mobile device (texting); 2. For Resident #72, to ensure orders were in place for monitoring hyper/hypoglycemia and treatment interventions to address the potential for hyper/hypoglycemia; 3. For Resident #89, to ensure orders were in place for monitoring hyper/hypoglycemia and treatment interventions to address the potential for hyper/hypoglycemia; 4. For Resident #543, to ensure orders were in place for fingerstick blood tests and treatment interventions were in place to address the potential for hyper/hypoglycemia; 5. For Resident #64, to ensure he/she, who was receiving an anticonvulsant for a seizure disorder, was appropriately monitored and that an active seizure was reported to a receiving hospital; 6. For Resident #69, to ensure monitoring of a pacemaker device; 7. For Resident #395, to ensure a physician's order was transcribed as per the acceptable professional standards of clinical practice; and 8. For Resident #24, to ensure a pacemaker was monitored and evaluated as per the facility policy and standards of practice. Findings include: 1. Resident #32 was admitted to the facility in September 2022 with diagnoses including atrial fibrillation. Review of the November 2022 Physician's Orders indicated: -Heparin (anticoagulant) 5000 units/milliliter, inject 5000 units subcutaneously three times a day (started 10/11/22). Review of the medical record failed to indicate a signed order for Resident #32 to be transferred to the hospital for further evaluation of a right hand hematoma identified by facility staff on 11/4/22. Review of the Hospital Emergency Department Documentation included, but was not limited to: -Resident presenting to the emergency department with a large hematoma on the dorsum of the right hand; -The hematoma is a fluid collection in the right hand measuring 4.1 X 2.1 X 4.3 centimeters dorsally; -Patient is complaining of worsening pain The Resident was discharged back to the facility on [DATE]. Review of the medical record indicated an order (unsigned) to stop Heparin and start Eliquis (anticoagulant) 2.5 milligrams twice daily (11/4/22). On 11/7/22 at 8:45 A.M., the surveyor observed Resident #32 lying in bed supine moaning with his/her right hand elevated on a pillow with a towel covering it. The top of the Resident's hand had a large dark bluish/black blood filled hematoma that extended from the Resident's wrist to the base of his/her fingers and encompassed the entire dorsal aspect of the Resident's right hand. The observation reflects an increase in size of the hematoma as documented in the hospital emergency room report. During an interview on 11/7/22 at 9:11 A.M., Unit Manager (UM) #2 said the hematoma to Resident #32's right hand is larger today than it was when he/she went to the hospital on [DATE]. She said the Resident's Physician is on vacation, but she spoke to him on Friday and he said to send the Resident to the hospital. She also said she spoke to him again this morning and obtained orders for care and monitoring of the hematoma (ice, elevation of the hand, monitor radial pulse, monitor right hand color, sensation and movement, monitor worsening signs/symptoms of right hand hematoma), three days after the hematoma was identified. Unit Manager #2 was unable to provide documentation to indicate Resident #32's Physician was aware of his/her change in condition, gave an order to transfer the Resident to the hospital, and gave orders for monitoring the hematoma. Review of the November 2022 Physician's Orders indicated: -Apply ice to right hand as tolerated for 15 minutes at a time every 2 hours as needed for right hand swelling management (11/7/22) -Elevate right upper extremity/hand as tolerated every shift (11/7/22) -Monitor radial pulse right upper extremity every shift (11/7/22) -Monitor right hand color, sensation, and movement; report any abnormal findings to Physician (11/7/22) -Monitor/document for any worsening signs/symptoms of right hand hematoma. Report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to MD (11/7/22) -Acetaminophen 325 mg, give 2 tablets by mouth four times a day for pain management (11/7/22) During telephone interviews on 11/7/22 at 1:01 P.M. and 1:54 P.M., Physician #1's office staff indicated Resident #32's Physician is on vacation and has been since 11/3/22 and will return on 11/8/22. She said neither the covering Physician's office nor the Nurse Practitioner had been contacted by the facility regarding Resident #32 and don't know anything about the Resident. During a telephone interview on 11/8/22 at 10:45 A.M., Physician #1 said that he has been on vacation since 11/3/22 and returned today. He said he was not contacted by anyone from the facility while he was on vacation and was unaware Resident #32 had a hematoma and was sent to the hospital on [DATE]. He said he learned about the hospitalization when he retrieved his messages this morning. Physician #1 said he did not give orders for Resident #32 to be sent to the hospital or for care and treatment of the Resident's hematoma. He said he would be in the facility to see Resident #32 on 11/9/22. During an interview on 11/9/22 at 11:10 A.M., Physician #1 said that he recalls receiving a text from Unit Manager #2 while he was on vacation. He showed the surveyor the text message exchange between him and Unit Manager #2. Physician #1 said that his mobile phone utilizes an unsecured platform. The texts dated 11/4/22 include, but are not limited to: 11/4/22: -UM #2 to Physician #1: photograph of Resident #32's right hand showing bruising and a fluid filled blister on the top of the hand -UM #2 to Physician #1: Guardian Center. It's (UM #2), 1st floor, (Resident's race identified), (Resident's name identified), you saw (his/her) chart on Wednesday and discontinued Lasix 60 mg. (He/she) is on Heparin three times a day. What is this? What do we do?; -UM #2 to Physician #1: a copy of venous Doppler study results of the Resident's left hand, dated 10/17/22; -UM #2 to Physician #1: This was x-ray of (his/her) left hand. The bruising in on (his/her) right hand (UM #2 erroneously identified the Doppler results as x-ray results of the Resident's left hand) -Physician #1 to UM #2: Eliquis 2.5 mg twice daily stop heparin; -UM #2 to Physician #1: Is that a hematoma from the heparin? DON (Director of Nursing) said if we can get an x-ray. Now the (Resident) is saying that somebody beat (him/her). -Physician #1 to UM #2: Ok please call office I am away till Monday. 11/7/22: -UM #2 to Physician #1: Hi, it's (UM #2) from Guardian Center, 1st floor. The patient (name identified) went out to (local hospital) Friday evening for worsening right hand hematoma. (He/she) returned Saturday morning. (He/she) is negative for fracture or DVT (deep vein thrombosis). I told the state I spoke to you for follow up care and wrote orders today for scheduled Tylenol 650 mg QID (four times a day) and ice for swelling and pain management. -Physician #1 to UM #2: K -UM #2 to Physician #1: Thanks During an interview on 11/10/22 at 2:35 P.M., UM #2 said that she did not obtain a Physician's order for Resident #32 to be transferred to the hospital for evaluation on 11/4/22, did not obtain Physician's orders according to professional standards of practice for the discontinuation of Heparin and initiation of Eliquis, did not obtain Physician's orders for interventions and monitoring of the Resident's right hand and should have contacted the covering Physician. She said her mobile phone platform was unsecured and she should not have communicated private information. 2. Resident #72 was admitted to the facility in October 2020 with diagnoses including diabetes mellitus, type 2. Review of the November 2022 Physician's Orders indicated the following antidiabetic medication: -Insulin Glargine Solution 100 unit/milliliters (mL), inject 10 units subcutaneously one time a day (12/2/21) The physician's orders failed to include an order to monitor for hyper/hypoglycemia and failed to include any interventions to address potential serious side effects of hyper/hypoglycemia. 3. Resident #89 was admitted to the facility in September 2022 with diagnoses including diabetes mellitus, type 2. Review of the November 2022 Physician's Orders indicated the following antidiabetic medication: -Metformin HCI tablet 1000 milligrams (mg), give 1 tablet two times a day (9/23/22) The physician's orders failed to include an order to monitor for hyper/hypoglycemia and failed to include any interventions to address potential serious side effects of hyper/hypoglycemia. 4. Resident #543 was admitted to the facility in March 2015 with diagnoses including diabetes mellitus, type 2. Review of the November 2022 Physician's Orders indicated the following orders for antidiabetic medication: -Admelog SoloStar Solution Pen-Injector 100 unit/mL, inject subcutaneously per sliding scale: if 151-100=1 unit 200-249=2 units 250-200=3 units 300-349=4 units 350+=5 units and notify Physician/Nurse Practitioner The Physician's orders failed to include an order for fingerstick blood test (method to test blood sugars) to determine whether or not the Resident needed sliding scale insulin and failed to include any interventions to address potential serious side effects of hyper/hypoglycemia. During an interview on 11/8/22 at 12:33 P.M., Unit Manager #1 said that Resident #543 has no orders in place to indicate when to do a fingerstick blood test to determine when the sliding scale insulin is needed but should there be. She said all diabetic residents, including Residents #72 and #89 should have orders in place to monitor for hyper/hypoglycemia and orders for interventions in place to address potential serious side effects of hyper/hypoglycemia. 7. Resident #395 was admitted to the facility in October 2022 with medical diagnoses of chronic obstructive pulmonary disease, Parkinson's disease, and adult failure to thrive. Review of the Physician's Orders, dated 10/29/22, included but was not limited to: -Myrbetriq Tablet Extended Release 24-hour, 50 MG (Miregron ER) Give 1 tablet via G-Tube one time a day for urinary antispasmodics, (10/29/22). On 11/3/22 at 09:47 A.M., the surveyor observed Nurse #6 on the Grove Unit administering medications to Resident #395 via Gastrostomy-Tube. Upon reviewing the medication poured, Nurse #6 said Myrbetriq (used to treat overactive bladder) 50 MG tablet was not available. Nurse #6 said this medication is not available in an Emergency Kit/ house stock. Review of the Medication Administration Record, dated 10/29/22 to 10/31/22, failed to indicate that Myrbetriq was administered to the Resident as ordered on 10/30/22 and 10/31/22. Review of the Medication Administration Record, dated November 2022, failed to indicate that Myrbetriq was administered to the Resident as ordered on 11/1/22, 11/2/22, and 11/3/22. During an interview on 11/3/22 at 9:35 A.M., Nurse #6 said the medication was not received from the pharmacy. Nursing staff failed to follow up on the medication and did not notify the physician about the missing doses of the Myrbetriq. During an interview on 11/3/22 at 10:30 A.M., the Assistant Director of Nursing said nursing staff failed to transcribe and administer the medication as ordered. She said the physician should have been notified that the medication was not being administered to the Resident as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed for four Residents (#22, #29, #69, and #89) to provide an ongoing activity program to meet and support the individual preferences of the residents, out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #22, to provide support to pursue their one to one (1:1) preferred activities of choice in his/her room; 2. For Resident #29, to support their choice for independent activities; 3. For Resident #69, to encourage and support their choice of group and independent activities and interaction with his/her peers that met their cultural and cognitive needs; and 4. For Resident #89, to develop and provide a program of ongoing resident-centered activities that takes into account the Resident's interests, needs, and cultural preferences to maintain or improve the resident's physical, mental and psychosocial well-being and independence. Findings include: Review of the facility's policy titled Activity Evaluation, dated June 2018, indicated but was not limited to the following: - an activity evaluation is conducted and maintained to promote the physical, mental, and psychosocial well-being of residents - an activity evaluation is conducted as part of a comprehensive assessment to develop an activities plan that reflects the choices and interests of the resident - each activities care plan will be related to their comprehensive assessment and reflect their individual needs - a resident's lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences are included as part of the evaluation - an individual activity care plan is developed to allow residents to participate in activities of his/her choice interests 1. Resident #22 was admitted to the facility in August 2022 with diagnoses including Parkinson's disease, encephalopathy of unclear etiology, and anxiety. Review of the most recently completed Activity Assessment for Resident #22 indicated the following: - Resident's primary language is Portuguese, and he/she will need an interpreter to make his/her needs known - Favorite activities include cards (no other activities are noted here) - Preferred activity setting is his/her own room - Resident would like staff to play cards in his/her room with them - Resident is oriented to self, place and time and cooperative - Resident will be encouraged to maintain their current level of activity interest such as playing card games Review of Resident #22's current Care [NAME] (summary of resident's care and preferences), dated 11/8/22, indicated under activities: Group programs, self-directed or staff assisted activities, 1:1 activities. During an interview on 11/3/22 at 9:17 A.M., Resident #22 said he/she does not want to get out of bed for activities but would like people to stop in and chat or play cards with him/her. He/she said there is nothing particular they wish to chat about but wishes people would socialize with him/her more and that he/she enjoys it very much when they do. He/she said they have not crocheted since being at the facility and is not enjoying television, but having someone to chat with or play cards within their dominant language is enjoyable and he/she would like that more often. He/she said many people can't talk to them because he/she speaks Portuguese but there is one girl who has come a few times. During an interview on 11/03/22 at 9:26 A.M., Family Member #1 said Resident #22 would benefit immensely from someone he/she could speak with. She said the Resident is frustrated by the language barrier and would like more social interaction. She said she is not aware of anyone coming to play cards with the Resident or spending time with him/her just to socialize but having that social interaction with someone would be beneficial to help the Resident's mood and feel less isolated. Review of the Care Plan for Activity and Psychosocial Pursuits indicated the Resident preferred to be called by their first name, is alert pleasant and social, enjoys time in their room playing card games with others or crocheting with a primary language of Portuguese and need for a translator. The goal was for Resident to be encouraged to maintain their current activity interests such as playing any card games. Interventions included the following: - Give monthly activity calendar - Give positive encouragement for support - Offer materials of interest - Interpreter services with language line, language Portuguese - Limited indoor and outdoor group programs with social distancing and wearing a mask related to weather and COVID-19 restrictions Review of the Individual activity participation record for Resident #22, from August 2022 thru current (11/4/22) indicated the following: - card games were not offered or participated in throughout the 95 days of the look back period - 1:1 visits/media cart was only offered twice in the 95 days look back - participated in am visits 33 out of 95 days - participated in 8 of 12 offered afternoon visits Review of the Activities/Recreational Notes for Resident #22 indicated the Resident has been seen five times in the last 95 days for a 1:1 visit and was offered some independent activities, but no indication that anyone played cards with the Resident as per their documented preference. During an interview on 11/4/22 at 1:46 P.M., the Activity Director (AD) said the care plan is not reflective of the Resident's assessed preferences for activities. She said the am visits last about 1 minute and is a hello greeting and offer of coffee; the afternoon visits are similar and offer snacks. She could not explain why the Resident was not consistently offered someone to play cards with them or why he/she was only seen for 1:1 visits that included a quick chat and dropping off independent materials only five times since August 2022. She said the staff member who performed the five activity visits is the only staff member she has that speaks Portuguese and that may have played a part in the limited interactions. She said activities involvement with the Resident needed to be improved upon. 2. Resident #29 was admitted to the facility with diagnoses including cognitive communication deficit, dementia, and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of the Minimum Data Set (MDS) assessment, dated 10/3/22, indicated Resident #29 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score not being performed due to the Resident being rarely understood. The MDS indicated Resident #29 was of Asian descent with Cantonese as his/her primary language and needed or wanted an interpreter to communicate with a doctor or health care staff. Review of the admission Activity Assessment, dated 9/29/22, indicated Resident #29 was originally from China and speaks both Cantonese and Mandarin but his/her primary language was Cantonese and needed a translator to communicate verbally. Resident #29's favorite activities included Bingo and television but also liked music, games, coloring, walking, reading a book, and going outside. Review of Resident #29's Activities Care Plan included the following: Focus -Resident enjoys playing Bingo, games, listening to music, coloring, exercising, arranging flowers, working with clay, and going outside in nicer weather and any activity in social settings. Family is very important to him/her. His/her primary language is Cantonese, initiated 9/28/22 Goal -Resident will be encouraged to maintain his/her current recreational interests such as playing Bingo, games, listening to music, coloring, walking, exercising, reading books, visited for 1:1 visits, and going outside in the nice weather, revised 10/13/22 Interventions/Tasks -Resident will be given positive encouragement for support from staff and family, initiated 9/28/22 -Resident will be offered materials of interest such as coloring activity packets On 11/2/22 at 1:50 P.M., the surveyor observed Resident #29 sitting alone in his/her wheelchair in front of the nurses' station. Staff did not interact with or engage the Resident. There were no materials of interest, food, or refreshments offered or provided. On 11/3/22 at 10:06 A.M., the surveyor observed Resident #29 sitting alone in his/her wheelchair in front of the nurses' station. An overbed tray table was located directly in front of the Resident without anything on it. Staff was not observed interacting with or engaging the Resident. There were no materials of interest, food, or refreshments offered or provided. On 11/9/22 at 10:30 A.M., the surveyor observed Resident #29 sitting alone in his/her wheelchair in front of the nurses' station. Staff was not observed engaging the Resident. The Resident then fell asleep. The surveyor observed an overbed tray table directly in front of the Resident without anything on it. During an interview on 11/9/22 at 12:21 P.M., the Activities Director said Resident #29 participated in group activities, but when not in group activities enjoyed coloring, flower arranging, and watching television. The Activities Director said she did not have documentation to provide to the surveyor to indicate Resident #29 had any 1:1 activities scheduled or performed and said staff should have been engaging and offering independent activities to the Resident based on his/her preferences. Review of the main dining room on the Meadows Unit indicated five shelves of activity resources including music, games, and books. During an interview on 11/10/22 at 7:42 A.M., Unit Manager (UM) #1 said staff should have engaged the Resident and provided materials based on the Resident's preferences. During an interview on 11/10/22 at 8:36 A.M., the Director of Nursing (DON) said staff should have been engaging the Resident and utilizing resources for independent or 1:1 activities. 3. Resident #69 was admitted to the facility in September 2022 with a diagnosis of dementia. Review of the Recreation Comprehensive Assessment, dated 9/23/22, indicated the family of Resident #69 had spoken with the Activity Staff and indicated the following activity preferences (scaled as very important, somewhat important, not very important, not important at all): -occasionally likes to flip and rip magazines -being around animals was somewhat important -keeping up with the news was somewhat important (through television) -doing things with groups of people was very important (note indicated enjoyed being social and spending time talking with staff, peers, and family). -other interests included fidget toys -watching TV was somewhat important -favorite activities (fidget toys and Chinese or Vietnamese documentaries) were somewhat important -going outside was somewhat important Review of the Care Plans for Resident #69 indicated the Resident spoke Cantonese and Vietnamese and was at the facility for long term care and to encourage attendance at preferred activities/socialization with other residents. Review of the Activities/Recreation notes for Resident #69 indicated the following: 9/23/22: enjoys spending time watching television and Chinese or Vietnamese documentaries, having snacks, playing with fidget toys, socializing with peers, staff and family, as well as relaxing in the comfort of his/her room 10/18/22: visited by staff for music therapy and listened to Catholic Chinese songs and he/she appreciated this 10/19/22: visited by guitar player 10/25/22: music therapy with Catholic Chinese songs and he/she appreciated this 11/7/22: watched a Chinese documentation on the laptop Review of the October Activity Individual Participation Record indicated the following: - AM visits 25 out of 31 days -music/entertainment 3 out of 31 days -one to one (1:1) visits 5 out of 31 days -snack/ice cream 1 out of 31 days Review of the November Activity Individual Participation Record (as of 11/7/22) indicated the following: -AM visits 7 out of 7 days -1:1 visits 2 out of 7 days -documentary 1 out of 7 days On 11/2/22 at 8:30 A.M., the surveyor observed Resident #69 in bed, the light was on, and his/her eyes were open. There was no television on and no music playing. There was one television in the room, facing the bed of the roommate. There was one radio in the room, on the roommate's nightstand. At 11:08 A.M. and at 11:44 A.M. Resident #69 was still in bed, with no changes. During an interview on 11/2/22 at 12:00 P.M., Certified Nursing Assistant (CNA) #4 said Resident #69 does not get out of bed. On 11/03/22 at 2:15 P.M., the surveyor observed Resident #69 in bed with their eyes open. There was no television or music playing. On 11/4/22 at 11:40 A.M., the surveyor observed Resident #69 lying in bed with his/her eyes open and staring straight ahead. The radio on the roommate's nightstand (the roommate was not in the room) was on quietly and was playing a Creole speaking station. On 11/08/22 at 11:35 A.M., the surveyor observed Resident #69 lying in bed with his/her eyes open and staring at his/her hands. There was no television on, and the roommate's radio was playing a Creole speaking channel. During an interview on 11/8/22 at 12:10 P.M., the Activity Director said Resident #69 did not get out of bed and was not participating in any group activities or socializing with peers. She said the AM visits were done by the activity staff and they would go and say hello and sometimes bring snacks or coffee. She said Resident #69 loved Chinese Catholic music, which the activity staff had played for him/her on the facility iPad. Review of the Participation Record with the Activity Director indicated this occurred twice in October 2022. She said the unit staff did not have access to the iPad and this could only be done with the activity staff. She said Resident #69 did not have a television or a radio, so unless activity staff were with him/her, this was unavailable to the Resident. She said she had not thought about obtaining a radio or CD of Chinese music for the Resident. She said she would have to call the family to supply a television to the Resident as the facility did not assist long term care residents with room televisions, only residents on the short-term unit. She said the activity staff had set-up a documentary for Resident #69 to watch the previous day (11/7/22) and review of the Participation Record indicated this was the first time that had occurred in the six weeks since admission to the facility. 4. Resident #89 was admitted the facility in September 2022 with diagnoses including legal blindness. Review of the Minimum Data Set (MDS) assessment, dated 9/27/22, indicated Resident #89 speaks Chinese and needs/wants an interpreter for communication with his/her Physician and health care staff. There was no assessment of the Resident's cognitive status. Activity preferences indicated it is very important to Resident #89 to keep up with the news. Review of the Activities Assessment Note, dated 9/27/22, indicated the Resident enjoys listening to Chinese news on an [NAME] device (name of Amazon's personal digital assistant, which lets you use voice commands to control a compatible device for features like streaming, news reports or even to turn on your smart lights) in his/her room; staff will encourage him/her to maintain his/her current activity interests. Resident #89's Care Plan for Activities, initiated 9/28/22, indicated the Resident prefers to stay in the comfort of his/her room and enjoys listening to Chinese news on his/her [NAME]. However, there was no documentation to indicate how Resident #89 would be assisted by staff to utilize the [NAME] due to his/her blindness. The care plan also indicated the Resident would be offered materials of interest. However, it did not identify what materials are of interest to the Resident. A 10/13/22 Care Plan Meeting Note indicated Resident #89 has been offered out of room activities, however he/she prefers to stay in his/her room and listen to Chinese news on an [NAME] device in his/her room. On 11/2/22 at 9:14 A.M., the surveyor observed Resident #89 lying in bed awake. An electronic device was noted on the bedside table, but it was unplugged from the electrical outlet and the screen was dark. During an interview on 11/3/22 at 2:37 P.M., the surveyor pointed to the electronic device on the bedside table and asked CNA #8 what it was. She said it was a clock, but it doesn't work. On 11/4/22 at 9:24 A.M. and 10:10 A.M., the surveyor observed Resident #89 sleeping while seated in a wheelchair in the unit dining room facing the wall. There was nothing on the table in front of the Resident. During an interview on 11/4/22 at 11:15 A.M., the Activity Director (AD) said that she doesn't know anything about the electronic device on the Resident's bedside table. The surveyor and AD went to Resident #89's room. She looked at the electronic device on the bedside table and said she was not sure if it was an [NAME] or not. She tried the power button, and it did not turn on. She said she is new at working with Chinese residents and has not been able to develop anything specific to meet Resident #89's needs. On 11/9/22 at 9:36 A.M., the surveyor observed Resident #89 seated at a table in the unit dining room sleeping. A plastic children's construction toolset including a saw, tape measure, wrench, hammer, and screwdriver was placed on the table in front of the Resident. During an interview 11/9/22 at 9:59 A.M., Activity Assistant #1 said she is not aware of his/her activity preferences and cannot communicate with him/her because she does not speak Chinese. She said the Resident should have sensory items because he/she is blind. The surveyor asked if the children's plastic construction set is an appropriate activity for Resident #89 and she said, No. The Activity Assistant said she was not aware that Resident #89 had an [NAME] device and that he/she enjoyed listening to Chinese news on his/her [NAME] device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and policy review, the facility failed to provide an environment which would remain free of accidents and hazards including for two Residents (#64, #10), in a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #64, to conduct a fall risk assessment and implement interventions following a fall; 2. For Resident #10, ensure hazardous items were not left at the bedside and accessible to wandering residents on the unit; and 3. Ensure (a.) one housekeeping closet and (b.) one supply closet were locked, and hazardous/toxic items chemicals were not accessible to wandering residents on the [NAME] Unit. Findings include: 1. Review of the facility's policy titled Falls-Clinical Protocol, dated as revised in March 2018, indicated the following: -staff will ask the resident or family about history of falling -staff will assess and document the following: vitals, recent injury, musculoskeletal function, change in cognition, neurological status, pain, frequency of falls since last physician visit, precipitating factors, all current medications and all active diagnoses -the staff and practitioner will review each resident's risk factors for falling and document in the medical record -for a resident who has fallen, the staff will begin to identify possible causes of fall within 24 hours -after a fall the physician will review the resident's gait, balance, and current medications that may be associated with falling -the staff or physician will identify pertinent interventions to try to prevent subsequent falls and address the risk of falls Resident #64 was admitted to the facility in June 2021 with a diagnosis of epilepsy and a history of multiple falls. During an interview on 11/4/22 at 11:47 A.M., the Health Care Proxy of Resident #64 said the Resident had started having seizures a couple of years prior. She said the Resident previously had a seizure, had fallen and broken their hip, and had a fall during a seizure at a previous facility. Resident #64 was observed at this time to be seated in a Broda (reclining/tilting) chair. The Health Care Proxy said this was not the chair the Resident had fallen out of on 10/11/22. Review of the Care Plans for Resident #64 indicated the Resident had a history of falls, dated upon admission with interventions all dated 7/14/21. There was no indication the interventions for fall risk had been changed since July 2021. Review of all the assessments for Resident #64, back to admission in June 2021, failed to indicate a fall risk assessment was ever completed for Resident #64. Review of the Nursing Progress Note indicated on 10/11/22 at 6:30 A.M., Resident #64 had a mild seizure for less than a minute during care and included vital signs and that there was no safety issues noted. The next nursing note at 8:43 P.M. indicated Resident #64 returned from the hospital status post fall. Review of the fall investigation information, provided by the facility, indicated Resident #64 slid out of their wheelchair around 1:00 P.M. on 10/11/22. The information provided included a skin check, an Interact Transfer Form (to hospital), a nurse's note, and staff statements. None of the documentation provided indicated the Resident had a seizure that morning, if any seizure activity had occurred during the fall, or the type of wheelchair the Resident was utilizing. Review of the 10/11/22 statement of Certified Nursing Assist #5 indicated she was in the room when Resident #64 fell, and she had turned around and did not see the fall. There was no documentation to indicate the movement of Resident #64 that contributed to the fall and if seizure activity occurred. During an interview on 11/4/22 at 9:47 A.M., the Nurse Practitioner said she had seen the Resident on 10/27/22 and had not reviewed any information regarding the fall or the seizure on 10/11/22. During an interview on 11/4/22 at 10:44 A.M., the Assistant Director of Nurses (ADON) said the information provided to the surveyor regarding the fall was the only information available. She said the nurse who was working when the Resident fell should have completed an incident report, a fall risk assessment, and a pain assessment. She said she was unable to determine what intervention was implemented and when Resident #64 had started utilizing a different type of wheelchair (regular vs. Broda). During an interview on 11/8/22 at 1:12 P.M., the ADON reviewed the electronic medical record with the surveyor. She said she was unable to locate any fall risk assessments for Resident #64 since admission and said there was no nursing admission assessment in the electronic medical record. She confirmed no interventions were implemented to prevent additional falls for Resident #64. 2. On 11/4/22 at 10:10 A.M., the surveyor observed three residents wandering the hallways on the [NAME] unit. On 11/4/22 at 10:15 A.M., the surveyor observed one disposable razor and two pairs of scissors on the top of Resident #10's bureau. The door to the Resident's room was open and easily accessible to wandering residents on the unit. During an interview on 11/4/22 at 10:27 A.M., the surveyor and Nurse #14 observed the razor and scissors on Resident #10's bureau. She said the items should have been properly stored, and not left out at the bedside, especially on a unit with wandering residents. 3. a. On 11/4/22 at 9:30 A.M., the surveyor observed four residents wandering the hallways on the [NAME] unit. On 11/2/22 at 9:36 A.M., the surveyor observed housekeeper #1 exit a housekeeping closet on the [NAME] Unit. The door to the closet did not latch shut. The surveyor pushed open the door and observed the following items: -four-gallon sized bottles of chemicals attached to a diluting station (Windex disinfectant, Neutral Cleaner, Bacterial enzyme culture, Window & glass cleaner) -Two open boxes containing bottles of Purell hand sanitizer. On 11/2/22 at 12:18 P.M., the surveyor observed the housekeeping closet door not fully closed and easily pushed open by the surveyor. b. On 11/2/22 at 9:38 A.M., the surveyor observed a large, opened closet behind a satellite nursing desk at the end of the [NAME] Unit hallway. The door to access the satellite nursing desk was opened and the open closet was easily accessible to wandering residents. A countertop with office supplies on it was positioned along the left wall of the closet and held three pairs of scissors. The right side of the closet had a small shelf and file cabinet. The following items were on the shelf and cabinet: -one spray bottle of Clorox Clean Up disinfectant cleaner with bleach -one canister of Clorox Germicidal Wipes -one gallon jug of Pine Q Detergent/Disinfectant -one bottle of Betco Spot remover -two canisters of aerosol Febreze air freshener. During an interview on 11/2/22 at 12:52 P.M., Maintenance staff #1 and the Housekeeping Manager observed the unsecured items in the open closet behind the satellite nursing desk and the unsecured housekeeping closet. They said the rooms should be locked and not accessible to wandering residents on the unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and policy review, the facility failed to a. Ensure an opened Insulin Emergency Kit was returned to the Pharmacy in exchange for a new kit; b. Ensure an expired medication was not administered to a resident; and c. Dispose of an overflow of non-controlled medications in the collection receptacle. Findings include: On [DATE] at 12:20 P.M., the surveyor reviewed the Medication Storage Room on the second floor Meadows Unit with Unit Manager (UM) #1. Upon reviewing the refrigerator, the surveyor observed the following: a. Insulin (regulates blood sugar level) Emergency Kit #Il092, no expiration date, was opened. The kit failed to include documentation on when and why it was opened. Review of the Emergency Kit Exchange Form inside the e-kit was blank. The kit was not returned to pharmacy to be replaced. During an interview, UM #1 said she did not know when and why the e-kit was opened. b. Omeprazole (used to treat certain conditions where there is too much acid in the stomach) 2/ML dated [DATE] used for 30 days. Review of a Pharmacy note indicated do not use after [DATE], but was still being used and administered to Resident #46. UM #1 said she did not know that the expired Omeprazole was being administered to the Resident. During an interview on [DATE] at 2:15 P.M., UM #1 said the medication was expired and the facility failed to discard the rest of the medication as per the pharmacy's instructions and continued administering it to the Resident. c. Review of the facility's policy titled Discarding and Destroying Medications, dated [DATE], indicated but was not limited to the following: -Both controlled and non-controlled substances may be disposed of in the collection receptacle -The collector will be responsible for managing the collection receptacles, including picking up and properly disposing of medications collected in the receptacles and training facility staff on the procedures associated with collection and storage of controlled awaiting disposal On [DATE] at 1:00 P.M., the surveyor reviewed the Medication Storage Room on the third floor Grove Unit with Nurse #2. Upon reviewing the refrigerator, the surveyor observed the following: - Arformoterol Tartrate (used to control wheezing, shortness of breath, and chest tightness caused by chronic obstructive pulmonary disease) 15 MCG/2 ML (microgram/milliliter) 40 of them in total for Resident #194. Review of the medical record indicated Resident #194 was discharged in [DATE]. - Two bags of intravenous medication: Vancomycin 200ml/100MG no longer in use - Formoterol 20MCG/2ML vial, 19 of them were retrieved in the refrigerator, the Vancomycin was dispensed on [DATE] and was to be used within seven days. Nurse #2 said Resident #195 was no longer receiving the antibiotic and had been discharged from the facility. The surveyor observed multiple medications that should have been discarded and destroyed. The medications were all over the medication room sink, on top of the refrigerator, and some were in a plastic shopping bag on the floor next to the refrigerator. During an interview on [DATE] at 1:40 P.M., Nurse #2 said she was a new nurse at the facility was not too sure about the policy on discarding and destroying medications. The Nurse said the medications that are no longer in use should not be kept in the refrigerator nor in the medication room.

Based on record review, policy review, and staff interviews, the facility failed to ensure medication irregularities identified during the Pharmacist's Drug Regimen Review were reported and acted upon for two Residents (#73 and #63), out of five residents sampled for unnecessary medication reviews. Findings include: Review of the facility's policy titled Medication Regimen Reviews, dated May 2019, indicated the following process: -within 24 hours the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. -if the physician does not provide a timely or adequate response, the consultant identifies no action has been taken, the medical director or the administrator will be contacted. -the attending physician documents in the medical record that the irregularity has been reviewed and what action was taken to address it. -the consultant pharmacist provides the director of nurses with a written signed and dated copy of all medication regimen reports. 1. Resident #73 was admitted to the facility in February 2022 with a diagnosis of diabetes and history of a stroke. Review of the medical record for Resident #73 included monthly Medication Regimen Reviews by the Pharmacy Consultant. The Pharmacist progress notes indicated the following dates in which recommendations were made 4/25/22, 5/20/22, 6/22/22, 7/21/22, and 8/29/22. Review of the electronic and paper medical record for Resident #73 failed to include any consultant pharmacy recommendations. The recommendations were requested from the Assistant Director of Nurses (ADON). During an interview on 11/8/22 at 12:16 P.M., the ADON said the Director of Nurses (DON) was unable to locate any of the pharmacy recommendations for Resident #73 and none of the recommendations were addressed. On 11/9/22 at 8:35 A.M., the surveyor requested the Director of Nurses contact the pharmacy for the recommendations. During an interview on 11/9/22 at 9:24 A.M., the DON said the process was that the pharmacy consultant emailed her with any recommendations and reports. She said she had been receiving the recommendations from April 2022 and was not sure why she could not access the recommendations for Resident #73. 2. Resident #63 was admitted to the facility in July 2022 with a diagnosis of gastro-esophageal reflux disease (GERD). Review of the medical record for Resident #63 included monthly Medication Regimen Reviews by the Pharmacy Consultant. The Pharmacist progress notes indicated recommendations were made on 9/28/22 and 10/27/22. Review of the electronic and paper medical records failed to include the recommendations. During an interview on 11/4/22 at 11:32 A.M., the ADON said the pharmacy recommendations were sent via email to the DON, then printed and then provided to the physicians. She said she did not have a password to access the pharmacy recommendations and would request one from the pharmacist. During an interview on 11/4/22 at 3:05 P.M., the ADON provided copies of the recommendations for Resident #63 and said the recommendations had not been reviewed by a physician. Review of the Consultant Pharmacist Recommendation to Prescriber, dated 9/28/22, indicated Resident #63 took a proton-pump inhibitor (PPI) (Prilosec) which was not indicated for long term use. The recommendation was to consider tapering and discontinue the medication. The form was not signed and had no indication it had been reviewed by the physician. The same recommendation was made on 10/27/22. Review of the Consultant Pharmacist Monthly Activity Report for the Director of Nurses, dated 9/29/22, indicated the follow-up from the last visit's recommendations was determined to be 72.4%. Review of the Consultant Pharmacist Monthly Activity Report for the Director of Nurses, dated 11/1/22, indicated follow-up from the last visit's recommendations was determined to be 13.6%. During an interview on 11/9/22 at 10:27 A.M., the DON said she did not know she was supposed to print the pharmacy recommendation forms and provide them to the physicians and that was why the recommendations had not been reviewed.

5. Resident #73 was admitted to the facility in February 2022 with a history of a stroke. Review of the Nurse Practitioner's Progress Note, dated 10/27/22, indicated Resident #73 continued on an anticoagulant (Eliquis) for stroke management. Review of the Physician's Orders indicated Resident #73 received Eliquis 5 mg twice per day for prevention. Review of the Physician's Orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to include any documentation to indicate the nursing staff were monitoring for the side effects of taking an anticoagulant medication. During an interview on 11/10/22 at 8:56 A.M., Nurse #10 said if a resident was on an anticoagulation medication than the nursing staff would document on the MAR or TAR that they are monitoring for any side effects, such as bleeding or bruising. Nurse #10 reviewed the physician's orders, MARs and TARs for Resident #73 and was unable to locate an order to monitor for anticoagulation medication side effects. Nurse #10 said it was noted as an intervention on the care plan for Resident #73 to monitor for signs and symptoms of active bleeding and she was not sure why the monitoring was not documented. Based on record review, policy review, and interview, the facility failed to monitor for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant agent prescribed for five Residents (#10, #32 #72, #401 and #73), from a total sample of 27 residents. Findings include: Review of the facility's policy titled Anticoagulation-Clinical Protocol, last revised 11/2018, included but was not limited to: Assessment and Recognition -As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; a. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications b. Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug (for example, a resident with an above therapeutic level of an anticoagulant medication should be assessed for bleeding) -The Physician will collaborate with the consultant pharmacist and nursing staff to identify potentially serious medication interactions with anticoagulants; for example Digoxin, Dilantin, Amiodarone, and many antibiotics. -The Physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; -The staff and Physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the Physician before giving the next scheduled dose of anticoagulant. b. The Physician will order measures to address any complications, including holding or discontinuing the anticoagulant as indicated. Findings include: 1. Resident #10 was admitted to the facility in May 2019 with diagnoses including atrial fibrillation. Review of November 2022 Physician's Orders included but was not limited to: -Eliquis 2.5 milligrams (mg) twice daily (5/10/22) Review of May 2022 through November 2022 Medication Administration Records (MAR) indicated that Eliquis was administered as ordered by the Physician. Review of interdisciplinary care plans included but was not limited to: -Focus: Potential for injury related to the use of anticoagulant therapy; Eliquis (2/14/22) -Interventions/Tasks: Monitor for active bleeding, i.e., hematuria, bruising, guaiac + stool, nose bleeds, bleeding gums, etc. (2/14/22) Further review of the medical record failed to indicate that staff monitored the Resident for signs of bleeding as required. 2. Resident #32 was admitted to the facility in September 2022 with diagnoses including congestive heart failure. Review of November 2022 Physician's Orders included but was not limited to: -Heparin 5000 units/milliliters (mL), inject 5000 units subcutaneously three times a day (10/11/22) Further review of the medical record failed to indicate that staff monitored the Resident for signs of bleeding as required. 3. Resident #72 was admitted to the facility in October 2020 with diagnoses including a history of stroke. Review of November 2022 Physician's Orders included but was not limited to: -Eliquis 5 mg two times a day (9/29/22) Review of September 2022 through November 2022 MARs indicated that Eliquis was administered as ordered by the Physician. Review of interdisciplinary care plans included but was not limited to: -Focus: Resident is at risk for injury or complications related to the use of anticoagulant therapy; Eliquis (10/16/20) -Interventions/Tasks: Monitor for active bleeding, i.e., hematuria, bruising, guaiac + stool, nose bleeds, bleeding gums, etc. (4/14/21) Further review of the medical record failed to indicate that staff monitored the Resident for signs of bleeding as required. During an interview on 11/04/22 at 10:43 A.M., the surveyor and Unit Manager #2 reviewed Residents #10, #32, and #72's medical record. She said they should be monitoring each Resident on anticoagulant therapy for bleeding and other adverse effects, but they do not. 4. Resident #401 was admitted to the facility in October 2022 with diagnoses including acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Review of November 2022 Physician's Orders included but was not limited to: -Heparin 5000 units/mL, inject 1 mL subcutaneously two times a day (10/26/22) Review of October 2022 and November 2022 MARs indicated that Heparin was administered as ordered by the Physician. Further review of the medical record failed to indicate that staff monitored the Resident for signs of bleeding as required. During an interview on 11/7/22 at 11:46 A.M., the surveyor and Nurse #8 reviewed Resident #401's medical record. She confirmed the Resident was administered an anticoagulant and said that there was no monitoring for adverse consequences of anticoagulant use but there should be.

Based on interview, observation, and policy review, the facility failed to store medications and biologicals in a safe manner. Specifically, the facility failed: 1. For Resident #10, to ensure wound treatment supplies were not left out and unsecured in the Resident's room; 2. For Resident #32, to ensure treatment supplies were not left out and unsecured in the Resident's room; and 3. To label refrigerated medications appropriately, store and label Tuberculin (used in a test by hypodermic injection for infection with or immunity to tuberculosis) vials appropriately and ensure medications in the active medication cart were not expired. Findings include: Review of the facility's policy titled Storage of Medications, revised November 2020, indicated but was not limited to the following: -With the exception of Emergency Drug Kits, drugs and biological used in the facility are stored in a locked compartment under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. - the nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Medications requiring refrigeration will be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. 1. Resident #10 was admitted to the facility in May 2019 with diagnoses including peripheral vascular disease. On 11/4/22 at 10:15 A.M., the surveyor observed the following items on the Resident's bureau: -2 boxes of calcium alginate wound dressing -1 spray bottle of Derma Klenz wound cleaner -1 bottle of miconazole antifungal powder -1 tube of zinc oxide cream (skin protectant) -1 tube of barrier cream (skin protectant) -2 individual packages of lidocaine patches (topical analgesic) -4 individual packets of skin prep (skin protectant) 2. Resident #32 was admitted to the facility in September 2022 with diagnoses including congestive heart failure. On 11/4/22 at 10:25 A.M., the surveyor observed 10 packets of skin prep on the Resident's bureau. During an interview on 11/4/22 at 10:27 A.M. and 11:00 A.M., the surveyor and Nurse #14 observed the above listed items on Resident #10's and Resident #32's bureaus. She said the treatments should have been properly stored, and not left out at the bedside, especially on a unit with wandering residents. 3. On 11/02/22 at 1:00 P.M., the surveyor reviewed the Medication Storage Room on the third floor of the Grove Unit with Nurse #2. Upon reviewing the refrigerator, the surveyor observed the following: - 8 vials of Tuberculin 1 milliliter vial to equal 10 doses at 0.1 each test opened and unlabeled were found in the refrigerator. - 5 Vials of Tuberculin one Milliliter vial to equal 10 doses at 0.1 each were found in the refrigerator opened and not labeled with a discard date. During an interview on 11/2/22 at 1:50 P.M., Nurse #2 said the facility failed to follow its own policy for storage of medications. On 11/03/22 at 10:33 A.M., the surveyor reviewed the medication cart with Nurse #7 on the first floor Dementia Care Unit and observed the following: - Insulin Regular for Resident #73 labeled 11/2/22-12/2/22 over 28 days Valproic Acid (used to treat seizures and bipolar disorder) 250/5ML, Give 10 milliliters by mouth two times a day for partial seizure. (5/19/22)- was opened and undated During an interview on 11/03/22 at 10:45 A.M., Nurse #7 said she did not know that regular insulin was good for 28 days after opening. The Nurse said she thought all insulins were good for 30 days after opening. She added, the Valproic acid was not labeled with an open and discard date.

Based on document review and interview, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day to day care of the population the facility currently serves. Findings include: Review of the Facility Assessment, dated 10/7/22, failed to address the following areas: - COVID-19 management, preparations, staffing needs and supply needs - Potential needs for residents who may require isolation or quarantine for infectious diseases - Average resident acuity for those receiving BiPap/CPaP (non-invasive respiratory ventilation), intravenous medications, and injectable medications, - Behavioral health needs of residents who experience substance use disorders Further review of the Facility Assessment and educational trainings provided to staff indicated the facility did not implement its plan for communication and cultural competencies for residents who are non-English speaking or have cultural needs and specifications uncommon to the facility and surrounding community. Review of the 2022 In-service Education Book provided by the facility failed to demonstrate any cultural competencies or cultural sensitivity and foreign language communication trainings had been completed for 2022. During an interview on 11/10/22 at 9:51 A.M., the Staff Development Coordinator reviewed the annual in-service and education book and confirmed the facility has not provided the staff with any trainings on cultural competency, cultural sensitivity, or foreign language communication with residents. During an interview on 11/09/22 at 2:10 P.M., the Administrator, the Director of Nurses, and Consulting Staff #1 reviewed the Facility Assessment with the surveyor. They said the sections regarding resident acuity, behavioral health needs for substance use, and isolation were incomplete. They said the facility did not address the necessary supplies and staff required during a COVID-19 outbreak and that the resources certainly exceed those of everyday use, and it should be addressed specifically in the Facility Assessment. Further review of the Facility Assessment Under Section Two failed to account for a recent influx of Asian and foreign speaking residents; there were no changes to the assessment to accommodate this large cultural change in the facility. They said they were aware that the cultural competencies and education were not provided to the staff as it should have been prior to or upon the admission of this new diverse community of residents and it would be difficult for the staff to provide the social and culturally competent care and linguistic needs of this community without this education. The Administrator said the facility assessment needed work and was not a full accurate reflection of the facility or the current population it serves.

Based on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, indicated but was not limited to the following: -The facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents -The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee -The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program -The administrator is responsible for assuring that the facility's QAPI program complies with federal, state, and local regulatory agency requirements -The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurement; c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systemic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed The facility failed to provide the surveyor upon request with a written plan describing the specifics of their QAPI program. During an interview on 11/10/22 at 11:31 A.M., the surveyor met with the Administrator, the Director of Nursing, and Consulting Staff #1 to discuss the QAPI program. The Administrator was unable to discuss key components of their program such as tracking, and measurement of their performance improvement projects as well as how the facility systematically analyzed underlying causes of systemic quality deficiencies or corrective actions. The Administrator said she could not measure its success or track performance to ensure improvements were realized and sustained because there were no completed projects. She said the projects were all ongoing, so the facility had no data to review with the surveyor. The Administrator and Consulting Staff #1 said the facility did not have a written QAPI plan or an agenda to follow that included the goals and various elements to implement and maintain a comprehensive program.

Based on document review, interview, and policy review, the facility failed to develop and implement a comprehensive quality assurance and performance improvement (QAPI) plan to address the full range of care and services provided by the facility. Specifically, the facility failed to: 1. Measure the success of performance improvement projects (PIPs), actions taken, track performance, and regularly review, analyze and act on data collected; and 2. Ensure the quality assurance committee identified quality deficient areas identified during the survey period to develop and implement an appropriate corrective action plan to ensure satisfactory outcomes. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, indicated but was not limited to the following: -The facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents -The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program -The administrator is responsible for assuring that the facility's QAPI program complies with federal, state, and local regulatory agency requirements Implementation: -The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee -The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan -The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurement; c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systemic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed 1. The facility failed to provide a written plan describing the specifics of their QAPI program to the surveyor for review. During an interview on 11/10/22 at 11:31 A.M., the Administrator and Consulting Staff #1 said the facility did not have a written QAPI plan or an agenda to follow to implement and maintain a comprehensive program. The Administrator said the quality assessment and assurance (QAA) committee members met monthly, quarterly, and as needed to identify issues and coordinate and evaluate QAPI activities but not all the required members were present for the quarterly meetings. The Administrator discussed the Performance Improvement Projects (PIPs) that the facility was conducting but was unable to discuss key components such as tracking and measurement of their PIPs as well as how the facility systematically analyzed underlying causes of systemic quality deficiencies or corrective actions. The Administrator said she could not measure its success or track performance of the PIPs to ensure improvements were realized and sustained because they did not meet the target completion dates and were still ongoing. The Administrator said because the projects were all ongoing, she had no data to show and review with the surveyor. 2. During an interview on 11/10/22 at 11:31 A.M., the Administrator, Director of Nursing, and Consulting Staff #1 failed to indicate concerns identified by the surveyors during the survey period had been addressed and reviewed by the QAA committee such as concerns with: a. care and services/quality of care to meet the needs of the residents including culturally competent care, language/communication, activities, and behavioral health services according to the plan of care, facility protocols, and professional standards of practice; b. infection control projects related to the current COVID-19 pandemic including COVID-19 testing and staff vaccination protocols for exemptions; c. implementation of the facility's abuse policy; d. repeated grievances and concerns from the Resident Council not acted upon timely; e. review and revision of facility policies and procedures since the change of ownership on 8/1/22; and f. physician notification of changes in resident health conditions The Administrator said there was no documented evidence of data collection to develop and implement an appropriate corrective action plan to ensure satisfactory outcomes for the identified areas of concern by the surveyors.

Based on policy review, document review, and interview, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee that included the required members at their meetings. Findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program Governance and Leadership, revised March 2020, indicated but was not limited to: -The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body -The committee meets at least quarterly (or more often as necessary). Committee members are reminded of meeting day, time and location via e-mail at least two business days prior to the meeting -The committee has the full authority to oversee the implementation of the QAPI program, including, but not limited to the following: a. Establishing performance and outcome indicators for quality of care and services delivered in the facility; b. Choosing and implementing tools that best capture and measure data about the chosen indicators; c. Appropriately interpreting data within the context of standards of care, benchmarks, targets and the strengths and challenges of the facility; and d. Communicating the information gathered and their interpretation to the owner/governing board (body) The following individuals serve on the committee: -Administrator, or a designee who is in a leadership role; -Medical Director; -Director of Nursing Services (DON); -Infection Preventionist; and -Representatives of the following departments, as requested by the administrator; (1) Pharmacy (2) Social services (3) Activity services (4) Environmental service (5) Human resources; and (6) Medical records Review of QAPI attendance sign-in sheets indicated the following required members were NOT in attendance: -2/28/22 (monthly): Medical Director, consultant Pharmacist, Social Services, Human Resources, Medical Records, no food service personnel or Dietitian -3/31/22 (quarterly): Medical Director, consultant Pharmacist, Environmental service, Human Resources, no food service personnel or Dietitian -4/28/22 (monthly): Infection Preventionist, Medical Records, consultant Pharmacist, no food service personnel or Dietitian -5/26/22 (monthly): Infection Preventionist, consultant Pharmacist, Social Services, Human Resources, Medical Records, no food service personnel or Dietitian -6/11/22 (quarterly): Director of Nursing, consultant Pharmacist, Environmental Services, Medical Records -7/28/22 (monthly): Director of Nursing, consultant Pharmacist, Environmental Services, Medical Records, no food service personnel of Dietitian -8/31/22 (monthly): Administrator, consultant Pharmacist, Medical Records -9/20/22 (quarterly): Medical Director, Director of Nursing, Infection Preventionist, consultant Pharmacist, Human Resources, Medical Records, no food service personnel or Dietitian -10/26/22 (monthly): consultant Pharmacist, Environmental Services, Medical Records During an interview on 10/10/22 at 11:31 A.M., the surveyor and Administrator reviewed the QAPI committee policy and the attendance sign-in sheets. She said the required staff should have been in attendance for all quarterly QAPI meetings but were not. The DON said the Infection Preventionist should have been regularly attending the meetings as well as Unit Managers and department heads. She said she needs to work on educating staff and consultants on QAPI and encourage meeting attendance. The DON further said pharmacy, radiology, cardiology, and infection control provided quarterly reports that tracked adverse events, analyzed their causes, and implemented preventive actions and mechanisms that included feedback and learning, but the last quarterly reports obtained were from June 2022. She said September's quarterly reports were not in the book and were not available for surveyor review.

Based on interview, policy review, and document review, the facility failed to implement their policy to grant COVID-19 vaccination exemptions for staff. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services guidance titled Revised Guidance for Staff Vaccination Requirements, dated October 26, 2022, indicated but was not limited to the following: - Facilities must have a process by which staff may request exemption from COVID-19 vaccination based on an applicable Federal law. This process should clearly identify how an exemption is requested, and to whom the request must be made. Additionally, facilities must have a process for collecting and evaluating such requests, including the tracking and secure documentation of information provided by those staff who have requested exemption, the facility's determination of the request, and any accommodations that are granted. - Medical exemption documentation must specify which authorized or licensed COVID-19 vaccine is clinically contraindicated for the staff member and the recognized clinical reasons for the contraindication. The documentation must also include a statement recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements based on the medical contraindications. - Requests for non-medical exemptions, such as a religious exemption in accordance with Title VII, must be documented and evaluated in accordance with applicable federal law and each facility's policies and procedures. We direct providers and suppliers to the Equal Employment Opportunity Commission (EEOC) Compliance Manual on Religious Discrimination for information on evaluating and responding to such requests. Review of the facility's policy titled Coronavirus Disease, Vaccinations of staff, dated January 2022, indicated but was not limited to the following: - The facility recognizes that certain allergies, recognized medical conditions, and some religious belief observances or practices may provide lawful grounds for exemption. Medical Exemptions and delays: requests for medical exemptions based on clinical contraindications to receiving the COVID-19 vaccine must include the following: - information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reason for contraindication - statement by the authenticating practitioner recommending that the staff member be exempt from the facility's COVID-19 vaccination requirements based on recognized clinical contraindications - all requests for medical exemptions and delays based on clinical contraindications will be reviewed on an individual basis by the infection preventionist and the medical director Religious Exemptions: requests for religious exemptions must be completed on the Request for religious exemptions form and the information will be used to assess whether the request is based on a sincerely held religious belief to determine eligibility for religious exemption. These exemptions include the following: - requests for religious exemptions will be evaluated on an individual basis by the compliance and ethics committee or governing board - the infection preventionist and medical director will review all exemptions to determine the most appropriate placement and precautions for unvaccinated staff members to minimize the risk of transmission to residents and other staff Review of the facility provided COVID-19 Staff Vaccination Matrix indicated four employees were exempt from vaccination, but not the reason for exemption. During an interview on 11/3/22 at 2:04 P.M., the Infection Preventionist (IP) said there were four employees who had letters from their religious institutions for a non-medical exemption and one employee who provided a letter from their physician for a medical exemption from COVID-19 vaccination. She said the staff did not apply for an exemption, they simply provided documents to the facility. The IP said there is no documentation that indicates the exemptions were reviewed for approval or whether the exemptions were considered as granted or not granted and she has not participated in any discussions regarding COVID-19 vaccination exemptions. Review of the employee COVID-19 vaccination exemption documents for Nurse #12 indicated Nurse #12 had a severe allergic reaction after a previous dose or to a component of the vaccine. The document failed to indicate which of the authorized COVID-19 vaccinations were clinically contraindicated. Review of the employee COVID-19 vaccination exemption documents for Nurse #9 indicated Nurse #9 provided a letter requesting exemption from COVID-19 based on religious beliefs. The document failed to indicate whether a review of the information was completed or whether the exemption was granted. Review of the employee COVID-19 vaccination exemption documents for Staff #2 indicated Staff #2 provided a letter requesting exemption from COVID-19 based on religious beliefs. The document failed to indicate whether a review of the information was completed or whether or not the exemption was granted. Review of the employee COVID-19 vaccination exemption documents for Nurse #13 indicated Nurse #13 provided a letter requesting exemption from COVID-19 based on religious beliefs. The document failed to indicate whether a review of the information was completed or whether or not the exemption was granted. Review of the employee COVID-19 vaccination exemption documents for Staff #3 indicated Staff #3 provided a letter requesting exemption from COVID-19 based on religious beliefs. The document failed to indicate whether a review of the information was completed or whether or not the exemption was granted. During a follow up interview on 11/8/22 at 4:20 P.M., the IP reviewed the documents, COVID-19 vaccination exemptions, and said the process was not followed and the exemptions were incomplete. During an interview on 11/8/22 at 4:34 P.M., the Administrator was made aware of the staff COVID-19 exemption concerns and said the facility failed to implement their policy for reviewing and granting staff COVID-19 exemptions.

Based on interview and policy review, the facility failed to ensure, as part of its quality assurance and performance improvement (QAPI) program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program was conducted. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program Governance and Leadership, revised March 2020, indicated but was not limited to the following: -The governing body is responsible for ensuring that the QAPI program is adequately resourced and funded including training and staff coverage sufficient to conduct the activities of the program During the recertification survey, the facility failed to provide the surveyor with QAPI training or sign in sheets on the facility's QAPI program. During an interview on 11/10/22 at 11:31 A.M., Consulting Staff #1 said QAPI training was in the works by corporate. The Administrator and Consulting Staff #1 said they did not have documentation of mandatory QAPI training or sign in sheets on the facility's QAPI program that included the goals and various elements of the program and how it intended to implement the program.

Based on document review and interview, the facility failed to develop and implement a comprehensive ethics and compliance training program. Findings include: Review of the facility's policy titled Compliance and Ethics Program Components, dated December 2020, indicated but was not limited to the following: - the purpose of the compliance and ethics program is to prevent and detect criminal, civil and administrative violations and to ensure quality of resident care - the facility is committed to integrity, transparency and accountability to promote a culture of ethical and lawful practices - the program includes the following components: 1. a compliance and ethics committee 2. communication and education including ongoing in-service training, risk specific job training, and program orientation During an interview on 11/9/22 at 1:42 P.M., the Staff Development Coordinator said the facility has not provided any trainings to the staff on ethics or compliance, and she is not aware of the existence of a facility Ethics Committee. During an interview on 11/10/22 at 12:36 P.M., the Administrator said the facility has an outside company that completes their compliance requirements. She said they do not have a facility Ethics Committee and she has not attended or hosted any ethics meetings for the facility staff. She said the ethics committee process is in the early stages of development. During an interview on 11/10/22 at 1:14 P.M., the Consultant Nurse and the Chief Operating Officer said, at the facility level, there is not an ethics committee, and any ethical concerns would be brought forth through the Quality assurance performance improvement committee. They said there is not a separate committee for ethical discussions or any education regarding ethics that is provided to the facility staff.