Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who requested staff assistance with toileting care needs, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 10/05/24, Resident #1 used the call light to request assistance to walk to the bathroom, and a Certified Nurse Aide (later identified as CNA #1) refused his/her request and told him/her that he/she could use the bed pan or urinate in his/her bed. Resident #1 said he/she was in a position where he/she had to rely on other people to help him/her, and that CNA #1's response made him/her feel humiliated. Findings include: Review of the Facility Policy titled Resident Rights Under Federal Law, dated as revised 02/01/23, indicated residents have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social and spiritual values. The Policy indicated its purpose was to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. Resident #1 was admitted to the Facility in September 2024, diagnoses included myocardial infarction (heart attack) and osteoarthritis in the right hip. Resident #1's admission Minimum Data Set (MDS) Assessment, dated 09/28/24, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS Assessment indicated he/she was frequently incontinent of bowel and bladder and required substantial assistance from staff with toileting care needs and ambulation. Review of the Facility's Internal Investigation, undated, indicated that on 10/05/24 during the 11:00 P.M. to 7:00 A.M. shift (exact time unknown), when Resident #1 asked CNA #1 for assistance to walk to the bathroom, CNA#1 refused and told him/her that he/she could either go in the bed pan or in his/her bed. Further review of the Investigation indicated that Resident #1's roommate (Resident #4) witnessed the incident. Review of Resident #4's Medical Record indicated he/she was cognitively intact. During an interview on 10/31/24 at 8:50 A.M., Resident #1 said that when he/she activated the call light during the overnight shift on 10/05/24, and asked CNA #1 to assist him/her in the bathroom, CNA #1 responded No, you are going to use the bed pan. Resident #1 said that when he/she told CNA #1 that he/she did not want to use a bed pan, she responded, you either go [urinate] in the bed pan or you go in your bed. Resident #1 said that he/she reluctantly used the bed pan, and that when he/she could not urinate due to discomfort, CNA #1 told him/her I guess now you will have to go in your bed. Resident #1 said that although he/she eventually used the bathroom and did not have to urinate in his/her bed, the incident with CNA #1 left him/her feeling distraught and humiliated. Resident #1 said tearfully I don't like to talk about it [the incident]. The Surveyor was unable to interview Certified Nurse Aide (CNA) #1 as she did not respond to the Department of Public Health's telephone or letter requests for an interview. During a telephone interview on 10/31/24 at 12:05 P.M., Resident #4 said he/she witnessed an altercation between CNA #1 and Resident #1, and that he/she did not recall the exact date of the altercation, although he/she remembered it occurred during the overnight shift, on a weekend. Resident #4 said that when CNA #1 responded to the call light, Resident #1 asked for assistance to get out of his/her bed and walk to the bathroom. Resident #4 said CNA #1 told Resident #1 that it had been less than two hours since he/she had last used the bathroom and that his/her choices were to go in a bed pan or go in the bed. Resident #4 said that Resident #1 tried using the bed pan, and that when he/she was unsuccessful because it was pinching, CNA #1 told him/her that he/she would have to go in his/her bed. During an interview on 10/31/24 at 10:50 A.M., the Social Worker said that on 10/07/24, when she interviewed several residents on CNA #1's assignment, two residents complained about a female CNA (who fit CNA #1's description) on the overnight shift, that was tough acting and could be rough with care. During an interview on 10/31/24 at 12:45 P.M., the Administrator said the outcome of the Facility's Internal Investigation was that CNA #1 did not treat Resident #1 in a dignified and respectful manner during care.

3. Resident #27 was admitted to the facility in June 2024 and was discharged from the facility on 7/5/24. Review of the medical record for Resident #27 indicated: >A primary payor source of Medicare Plan was in place for the duration of the inpatient stay. >Resident #27 had a discharge plan documented by Social Services on 7/3/24 to be discharged home for 7/5/24. >No evidence that a Notice of NOMNC was issued. During an interview on 10/7/24 at 3:15 P.M., the MDS Nurse said that she was ultimately responsible for NOMNC completion. The MDS Nurse said that Resident #27 had a discharge plan in place as of 7/3/24 to return home on 7/5/24, therefore Resident #27 should have been issued the NOMNC on 7/3/24. The MDS Nurse said Resident #27 did not receive a NOMNC two days prior to ending Medicare covered services but should have. Based on interview, and record review, the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC: notice issued to a resident who is receiving benefits under Medicare Part A when all covered services end) and/or Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for three Residents (#81, #82 and #27), out of four residents reviewed. Specifically, the facility failed to issue the: 1. NOMNC notice two calendar days prior to Resident #81's termination of Medicare benefits, as required. 2. SNF ABN notice to Resident #82 so the Resident/Resident Representative could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume. 3. NOMNC notice to Resident #27 prior to his/her Medicare benefits ending, as required. Findings include: 1. Resident #81 was admitted to the facility in June 2024 and was discharged from the facility on 8/14/24. Review of the SNF Beneficiary Protection Notification Review form, completed by the facility, indicated Resident #81 received Medicare A Skilled Benefits from 6/25/24 until 8/13/24, when services were terminated. The SNF Beneficiary Protection Notification Review form indicated the facility initiated the discharge from Medicare A when benefits were not exhausted and that a NOMNC was provided. Review of the NOMNC indicated it was signed by the Resident's Representative on 8/14/24 (the day after the Resident's Medicare A benefit was terminated and not two calendar days notice as required). On 10/7/24 at 10:28 AM, the Minimum Data Set (MDS) Nurse said she issues the notices to residents when their Medicare benefits are ending. During a review of the forms provided to the surveyor for Resident #81, the MDS Nurse said the NOMNC should have been provided two days prior to the Resident's Medicare benefit ending. The surveyor and the MDS Nurse reviewed the provided forms and she said there was no evidence that a telephone conversation had occurred, and it appeared that the notice was provided to the Resident Representative on the date of the Resident's discharge (8/14/24). The MDS Nurse said when she provides notices, she calls the Resident Representative and will document the conversation on the NOMNC form, and then will mail out the form or leave it in an envelope for them to sign when they come into the facility. The MDS Nurse further said she did not send the notices out to the Resident Representative through certified mail. 2. Resident #82 was admitted to the facility in May 2024 and was discharged from the facility on 5/24/24. Review of the SNF Beneficiary Protection Notification Review form, completed by the facility, indicated Resident #82 received Medicare A Skilled Benefits from 5/7/24 until 5/21/24. The SNF Beneficiary Protection Notification Review form indicated the facility initiated the discharge from Medicare A when benefits were not exhausted and that a NOMNC was provided. The SNF Beneficiary Protection Notification Review form also indicated that a SNF ABN was not provided because the Resident was discharged from the facility and did not receive non-covered services. On 10/7/24 at 10:41 A.M., the MDS Nurse said when Resident #82's Medicare benefit was ending and he/she was not discharged from the facility the next day (after skilled benefits had ended), a SNF ABN form should have been provided. The MDS Nurse said the SNF ABN form was important because it provided the Resident/Resident Representative notification of what services/care they would be responsible for monetarily if they continued to stay in the facility. During a follow-up interview on 10/7/24 at 1:49 P.M., the MDS Nurse said therapy ended services on 5/22/24 and Resident #82 was discharged from the facility on 5/24/24. The MDS Nurse said the SNF ABN notice should have been provided to Resident #82 but was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a plan of care was developed for monitoring of psychotropic (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medications for side effects and response for one Resident (#7), out of five applicable residents reviewed for unnecessary medication review, out of a total sample of 12 residents. Specifically, for Resident #7, the facility failed to develop a plan of care relative to the Resident's use of the antidepressant medications, including monitoring for potential medication side effects and response. Findings include: Resident #7 was admitted to the facility in March 2024 with diagnoses of Altered Mental Status (AMS - a general term for a change in mental function that can affect a person's awareness, movement, and behavior) and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #7: -had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 10 out of 15. -had delusions and received an antidepressant medication during the reference period. Review of Resident #7's October 2024 Physician's orders indicated the following: -Trazodone (antidepressant medication), 25 milligrams (mg), at bedtime for sleep, initiated 8/19/24 -Mirtazapine (antidepressant medication), 7.5 mg, at bedtime for Dementia, initiated 7/16/24 Review of the clinical record indicated no documented evidence that a care plan had been developed relative to the Resident's use of the psychotropic medication that included potential side effects. During an interview on 10/7/24 at 2:00 P.M., the MDS Nurse said that when a Resident was prescribed a psychotropic medication, an order is entered in the Physician's order to monitor for signs and symptoms of side effects from the medication and that the Nurses would monitor the Resident every shift. The MDS Nurse said there should also be a care plan developed relative to the use of the psychotropic medications. The MDS Nurse said she reviewed Resident #7's clinical record and there were no Physician's order or a care plan in place to address the use of psychotropic medication monitoring and there should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure interventions were reviewed/revised pertaining to falls for one Resident (#15), out of a total sample of 12 residents. Specifically, the facility failed to review and revise the fall interventions after Resident #15 experienced an unwitnessed fall to decrease the risk of re-occurrence of falls. Findings include: Review of the facility policy titled Accidents/Incidents, revised 3/1/24, indicated the facility will report, review and investigate all accidents/incidents which occurred, or allegedly occurred, on or off the facility property involving, or allegedly involving, a patient who is receiving services. The policy also included the following: -an accident is defined as any unexpected or unintentional incident which may result in injury or illness to a patient. -the licensed nurse will: > report accidents/incidents and assist with completion of a timely investigation to determine the root cause, > take immediate post-accident/incident measures as deemed appropriate, > implement appropriate interventions based on conclusions, > update the care plan and communicate with the patient and appropriate Representative, > complete appropriate nursing intervention and change of condition -the Administrator, Director of Nursing (DON), or designee will: > make every effort to ascertain the cause of the accident/incident > initiate a timeline chronology > observe the environment, assess the available documentation and previous accidents/incidents as appropriate > conduct witness interviews from all staff and visitors who may have knowledge of the accident/incident > document the root cause and initiate actions to prevent or reduce recurrence of further accidents/incidents Resident #15 was admitted to the facility in October 2022, with diagnoses including Parkinsonism (refers to brain conditions that cause slowed movements, rigidity (stiffness) and tremors), Atrial Fibrillation (A-fib: irregular, rapid heartbeat that can lead to blood clots and other heart related complications), Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), unsteadiness on feet and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #15: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of 15. -had no behaviors. -was dependent on staff for toileting and required substantial/maximum assistance of staff with transfers. Review of the Nursing Progress Note dated 7/16/24, indicated a Certified Nurses Aide (CNA) notified the Nurse that the Resident was lying on his/her right side with his/her head against the side table. The Nursing Progress Note indicated the Resident was without obvious injuries. The Physician, DON and the Resident Representative were notified, and the Physician gave an order to send the Resident to the emergency room (ER) for evaluation due to anticoagulant use (medication used to prevent blood clots from forming). Review of a subsequent Nurse's Progress Note indicated the Resident returned to the facility at 10:30 P.M. without any new Physician orders. Review of the facility investigation dated 7/16/24 at 2:45 P.M., did not indicate a root cause for the Resident's fall, witness statements, nor intervention (s) added after the fall to prevent re-occurrence. Review of the Resident's Fall Care Plan, initiated 10/11/22 and revised 5/21/23, indicated Resident #15 was at risk for falls due to cognitive loss and lack of safety awareness and included the following interventions: -ambulation with assistance of 1 staff and walker, initiated 10/11/22 -provide verbal cues for safety and sequencing when needed, initiated 10/11/22 -assist Resident to organize belongings for a clutter-free environment in the room and consistent furniture arrangement, initiated 10/11/22 -obtain and record blood glucose (sugar) levels as ordered and evaluate in relation to fall risk, initiated 10/11/22 -obtain laboratory test results and report abnormal results, initiated 10/11/22 -grippy socks on while in bed only when Resident is not wearing shoes, initiated 7/24/23 -implement the following safety precautions: provide Resident with slipper socks while in bed, initiated 7/24/23 -curtain should remain open as allowed when Resident is in bed for optimal monitoring ., initiated 11/24/23 -when Resident is in bed or bed side chair, place personal items and call light within reach, initiated 1/15/24 -bed in low position, initiated 1/19/24 Further review of the Fall Care Plan indicated no documented evidence that any updated interventions or revisions occurred after the Resident's fall on 7/16/24. During an interview on 10/3/24 at 11:52 A.M., Resident #15's Representative said he/she was concerned because Resident #15 has had multiple falls since admission to the facility. The Resident Representative said the facility staff notify him/her when the Resident falls, but are unable to provide answers to questions he/she has about the details of the falls. Resident Representative said he/she has visited the Resident, and it can be several hours before facility staff check in with Resident #15. On 10/3/24 at 11:37 A.M., the surveyor observed Resident #15 lying in bed with the head of the bed slightly elevated and bilateral side rails in place. The surveyor observed that Housekeeping staff were in the Resident's room mopping the floor. During an interview on 10/4/24 at 12:30 P.M., the Corporate Clinical Specialist (who provided the surveyor with Resident #15's requested fall investigation from 7/16/24) said interventions would be added to the Resident's Fall Care Plan after the investigation was completed. The Corporate Clinical Specialist said he would check with the Assistant Director of Nursing (ADON) if there was additional information pertaining to the 7/16/24 fall incident for Resident #15. During an interview on 10/4/24 at 2:37 P.M., the surveyor asked the ADON if the investigation dated 7/16/24 was the complete investigation. The ADON said he would check and get back to the surveyor. The ADON further said that if a Resident falls, he/she would be assessed by the Nurse and if the fall was unwitnessed, neurological checks would be completed. The ADON said the Resident Representative, the DON and the Physician would be updated about the fall and a facility investigation would be completed. The ADON said the clinical team, which includes administrative staff, would review the completed fall investigation, determine the cause, and if an intervention was not added by the Nurse completing the assessment, then an intervention that was appropriate would be added by the clinical review team in an attempt to prevent further falls. The ADON said he would look for additional information relative to Resident #15's fall on 7/16/24. The ADON said an intervention should have been added to the Resident's Fall Care Plan. On 10/7/24 at 10:58 A.M., the surveyor requested additional information about Resident #15's fall from 7/16/24 from the Unit Manager (UM) who had completed the fall investigation. The UM said she would look to see if there were additional information, including witness statements for the 7/16/24 fall investigation, and would also see if an intervention was added. The facility did not provide any additional information relative to Resident #15's fall from 7/16/24 to the survey team at the time of survey exit on 10/7/24 at 6:40 P.M.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to assess and provide treatment in accordance with professional standards of practice relative to wound care and assessment for one Resident (#132) out of a total sample of 12 residents placing the Resident at risk for complications of wound healing. Specifically, for Resident #132, the facility failed to: -complete skin and wound assessments upon the Resident's admission to the facility resulting in the delayed management of wound care. -obtain wound care treatment orders as recommended by the discharge facility to provide wound care timely for the Resident. Findings include: Review of facility policy titled Skin Integrity and Wound Management, dated 7/1/01 with revision date of 5/1/24, indicated: -It is the purpose of the policy to provide safe and effective care to promote optimal skin health, prevent pressure injuries and promote healing .to all patients. -The facility will complete a comprehensive evaluation of the patient upon admission/readmission. -The facility will identify patients skin integrity status and need for .treatment intervention through review of all appropriate assessment information. -The Licensed Nurse will perform and document skin inspection on all newly admitted patients. -The Licensed Nurse will perform daily monitoring of wounds or dressings and document daily monitoring of ulcer/wound site with or without dressings. -The Licensed Nurse will notify the Physician to obtain orders. Resident #132 was admitted to the facility in September 2024, with diagnoses including bilateral (both left and right side) leg wounds and Cellulitis (potentially serious bacterial infection that affects the deep layers of the skin and underlying tissues of the skin) of Left Lower Limb (leg). Review of the Resident's medical record included a Hospital Discharge summary, dated [DATE], that indicated Resident #132 had been admitted to the hospital for bilateral leg wounds with treatment including antibiotics for cellulitis of the lower extremity and the following discharge instructions that included: >Continued medication of Cefdinir (antibiotic to treat bacterial infection) 300 mg (milligram) by mouth every 12 hours for 14 doses (7 days). >Wound treatment indications for: -Left leg ulcer: Aquacell Ag (an absorbent dressing containing silver to kill bacteria) and Xeroform (protective dressing that prevents bacterial growth). -Left foot ulcer: Betadine (a medicated solution that reduces the growth of bacteria) and gauze. -Left heel pressure ulcer: Offload (minimizing or removal of contact/pressure) with pillow. -Left buttocks pressure ulcer: Z-guard (barrier cream) and Allevyn (protective silicone bandage). -Right heel pressure ulcer: Mepilex (protective foam dressing). -Right leg venous insufficiency (pooling of blood in the veins): Vaseline and Xeroform gauze. On 10/1/24 at 10:16 A.M., the surveyor observed Resident #132 lying in bed with bilateral lower legs wrapped in white gauze dressings from the knees to below the toes and secured in place with tape that was dated prior to the Resident's admission to the facility and written in black ink. On 10/2/24 at 9:57 A.M., the surveyor observed Resident #132 eating breakfast in bed with bilateral lower legs wrapped in white gauze dressings from the knees to below the toes and secured in place with the same tape from the previous day that was written in black ink and dated prior to Resident's admission to the facility. During an interview on 10/2/24 at 1:15 P.M., Nurse #1, who was providing care for Resident #132, said the Nurse that was working at the time of the Resident's admission was responsible for completing the skin assessment. Nurse #1 said the admitting Nurses should look at all of the Resident skin areas, and would need to remove all dressings in place upon admission in order to complete a full skin assessment. Nurse #1 said she was not the admitting Nurse for Resident #132 and was unaware that he/she had dressings in place or when the dressings needed to be changed. During an observation and interview on 10/2/24 at 1:20 P.M., at the Resident's bedside with Nurse #1, Nurse #1 said Resident #132 had dressings in place to the bilateral lower extremities that were dated 9/29/24, but she had not seen the dressings previously. Nurse #1 said the dressings had not been removed for the completion of the Resident's skin assessment when he/she was admitted to the facility and should have been. Nurse #1 said the Assistant Director of Nursing (ADON) had assisted with the Resident's admission and may know more. During an interview on 10/2/24 at 1:30P.M., Consutling Staff #1 said Resident #132 was admitted to the facility with wounds to the bilateral lower extremities and coccyx which had been reported on the Resident's discharge summary from the hospital. Consulting Staff #1 said the admitting Nurse should have removed all the dressings, assessed all the wounds, and then contacted the Physician for wound care orders at the time of the Resident's admission. During an interview on 10/2/24 at 2:14 P.M., the ADON said that he had completed most of the order entry and paper assessments for Resident #132 at the time of the admission but directed the Unit Nurse on duty to complete the bedside skin assessment. The ADON said the Unit Nurse should have removed all the dressings and documented the Resident's skin conditions, including measurements, in the admission skin assessment and obtained orders for the skin areas, but this did not occur. The ADON said the Resident did not have wound measurements documented or wound care orders in place since he/she was admitted to the facility and should have. The ADON said it was important to do a complete skin assessment on admission for all Residents so that if wounds were identified, the Nurses know how to care for the Residents and so the wound areas do not deteriorate. During an interview on 10/2/24 at 3:09 P.M., Unit Manager (UM) #1 said a head-to-toe systems assessment which included assessing the Resident's skin should occur on admission for all Residents. UM #1 said if Resident #132 was admitted with dressings in place, the Nurse should have removed the dressings to look at the skin and taken wound measurements. UM #1 said there were no wound measurements or treatments in place for Resident #132 and there should have been. UM #1 said skin is the largest organ on the body and should be assessed so that wounds get identified and tracked in order to determine if the wounds are improving or deteriorating. On 10/2/24 at 3:30 P.M., the surveyor, the ADON, UM #1, and Consulting Staff #1 observed initial wound care being provided to Resident #132 by Nurse #1 after the surveyor brought concerns to the facility staff. The surveyor observed the following wound care process: -Nurse #1 cleansed her hands with soap and water and put on (donned) gloves and a gown. -Nurse #1 removed the dressings from the Resident's lower legs and discarded the old dressings into the trash container. -Nurse #1 then removed her gloves, cleansed her hands with alcohol hand sanitizer and put on clean gloves. -Nurse #1 then cleansed the wounds to the lower legs by cleansing from the center of the wound and then outwards. -Nurse #1 then removed (doffed) her gloves, cleansed her hands with alcohol hand sanitizer and donned a pair of clean gloves to measure the wounds. -Wound measurements recorded as follows: >Left, dorsal (top surface) foot wound: 3.7 cm (centimeters) x 3 cm x 0.3 cm. *Wound bed 80% black necrosis (dead tissue) and 20% red. *Peri-wound (around the wound area) skin was within normal limits (WNL- as expected to be without alterations). >Left inner ankle and upward on the lower leg was a clustered (group) wound of 13 open areas of varied sizes measuring in its entirety 11.4 cm x 5 cm x 0.1 cm., with the largest opening measuring 2.5 cm round at the most inferior (lowest) location in the cluster. *All clustered wound beds were 100% red with macerated (white and softened by moisture) peri-wound skin. >Right lower leg was macerated and intact (no open wounds). -Nurse #1 then doffed her gloves, cleansed her hands with alcohol hand sanitizer and donned clean gloves. -Nurse #1 applied dressings to all open wounds as ordered, secured the dressings with tape, and dated the dressings. -Nurse #1 doffed her gloves, cleansed her hands with alcohol hand sanitizer and donned clean gloves. The Resident was positioned onto his/her side with assistance of two staff members for wound care of the buttocks. -Nurse #1 cleansed the skin area with saline, doffed her gloves and cleansed her hands and donned clean gloves. -The Left inner buttock wound was measured by Nurse #1: 0.8 cm x 1.5 cm x 0.1 cm and presented 100% red wound bed and small bloody drainage. -Nurse #1 doffed her gloves, cleansed her hands with alcohol hand sanitizer and donned clean gloves. -Nurse #1 then applied dressings to the wound as ordered and dated the dressings.

Based on observation, interview, record and policy review, the facility failed to ensure professional standards of practice relative to identification and prevention of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin and often develop on the heels, ankles, hips and tailbone) for one Residents (#22), out of a total sample of 12 residents. Specifically, for Resident #22, the facility failed to ensure monitoring and interventions were implemented to prevent a pressure ulcer on his/her upper ears from developing, when the Resident complained of discomfort and pain caused by the use of a nasal cannula (a thin flexible tube that provides supplemental oxygen through the nose via nasal prongs) to those areas. Findings include: Review of the facility policy titled Skin Integrity and Wound Management, revised 5/1/24, indicated the purpose of the policy was to provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. The policy also included the following: -a comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed, -Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. -identify patient's skin integrity status and need for prevention or treatment interventions through review of all appropriate assessment information -the nursing assistant will observe skin daily and report any changes or concerns to the nurse -the licensed nurse will: >perform and document skin inspection on all newly/readmitted patients weekly thereafter and with any significant change of condition >evaluate any reported or suspected skin changes or wounds . >notify interdisciplinary team members for a comprehensive approach to care including prevention and wound treatments, as indicated >review the care plan and revise as indicated Review of the facility procedure titled Oxygen: Nasal Cannula included the following instructions relative to applying oxygen therapy: -inspect condition of the skin around the nose and ears -monitor patient for skin around nose and ears for irritation and breakdown Resident # 22 was admitted to the facility in August 2024, with diagnoses including Chronic Respiratory Failure with Hypoxia (a condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue), Pneumonia (a serious infection of one or both of the lungs caused by bacteria, viruses, or fungi in which the air sacs fill with pus or other liquid), and dependence on supplemental Oxygen. Review of the Skin Breakdown Care Plan, initiated 8/3/24, indicated Resident #22 had a history of pressure ulcers and included the following interventions: -observe skin condition daily with activities of daily living (ADL: activities related to personal care including bathing, dressing, grooming, eating) care and report abnormalities (initiated 8/3/24) Review of the Minimum Data Set (MDS) Assessment, dated 8/6/24, indicated Resident #22: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of 15 -had no behaviors -was at risk for pressure ulcers -and received oxygen therapy Review of the October 2024 Physician's orders included the following: -Oxygen at 4 - 6 liters per minute (LPM: flow rate of how much oxygen is being delivered) via nasal cannula continuously, every shift . evaluate . skin color, initiated 8/2/24 On 10/1/24 at 7:51 A.M., the surveyor observed Resident #22 awake and lying in bed. Oxygen tubing and nasal cannula were observed under the Resident's chin and was connected to an oxygen concentrator (medical device that uses air in the atmosphere, filters it, and delivers air that is 90 - 95% oxygen concentrated) set at 2.5 LPM. During an interview at the time, the Resident said the Oxygen was new to him/her. When the surveyor asked about the oxygen tubing/ nasal cannula under his/her chin, the Resident was observed to re-apply the nasal cannula to his/her nose and put the tubing up and over his/her ears. Resident #22 said the tubing hurts the back of his/her ears, so he/she removes it. The surveyor observed white colored gauze covered with clear tape wrapped around the oxygen tubing which was positioned on either side of the Residents cheeks when he/she had the nasal cannula in place. On 10/3/24 at 7:40 A.M., the surveyor observed the Resident lying in bed watching television. Oxygen was being administered via a nasal cannula and the tubing was observed up and over the tops of the Resident's ears. The white colored gauze covered with clear tape was observed on the oxygen tubing and was positioned on both sides of the Resident's cheeks. During an interview on 10/3/24 at 2:37 P.M., Certified Nurses Aide (CNA) #1 said Resident #22 has Oxygen which he/she refused to wear at times. CNA #1 said the Resident complained that the Oxygen bothered his/her nose and ears which the CNA told the Nurses. CNA #1 said he thought someone put something on the oxygen tubing for Resident #22 to help with the ear discomfort. On 10/3/24 at 2:39 P.M., the surveyor and Nurse #4 observed Resident #22 who was lying in bed with the oxygen tubing/ nasal cannula around his/her chin. Resident #22 asked Nurse #4 for assistance in re-applying the nasal cannula as the oxygen tubing was tangled in his/her shirt. During an interview at the time, Resident #22 said the oxygen tubing hurt his/her ears and that the gauze wrap around the tubing and the nasal prongs did not fit correctly. The surveyor asked Nurse #4 to inspect behind the Resident's ears at this time. The surveyor observed that both tops of the Resident's ears were red, and an oval shaped open area approximately 0.5 centimeter (cm) - 1 cm in length was observed on the back of the Resident's right ear and had red skin surrounding the area. Nurse #4 said she was not aware that Resident #22 had complained of ear pain from the oxygen tubing. Nurse #4 said the tubing caused an open area on the Resident's ears and she would contact the Physician to get a treatment for the open area. During an interview on 10/3/24 at 3:27 P.M., CNA #3 said Resident #22 sometimes removed the Oxygen and she had to remind him/her to reapply it. When the surveyor asked if there was a reason the Resident took the Oxygen off, CNA #3 said he/she said it bothered his/her ears. CNA #3 said the Resident's ears have been tender and red for about a month and she did notify the Nurse about the Resident's complaints. CNA #3 said the skin behind the Resident's ears looked red and irritated and the tubing had caused an indentation so she would reposition the gauze so that it was protecting his/her ears. During a follow-up interview on 10/3/24 at 3:32 P.M., Nurse #4 said that if she had been made aware that the Resident was complaining of pain from the oxygen tubing, she would have assessed the Resident's skin. Nurse #4 said the 11:00 P.M. to 7:00 A.M. Nurses change the tubing weekly, and she was not sure who put the gauze covered with clear tape on the Resident's tubing. During an interview on 10/7/24 at 11:11 A.M., Unit Manager (UM) #1 said she was notified about the open areas behind Resident #22's ears. UM #1 said once the facility staff were made aware that the Resident was complaining of pain/discomfort to his/her ears and nose, the Nurse should have assessed those areas. UM #1 said once she was notified of the Resident's open areas, she assessed the Resident's skin, added soft foam ear protectors, and obtained orders from the Physician for a treatment to the open areas. UM #1 said it appeared that someone knew that the Resident had complaints about ear pain and added a thick wrap of gauze and tape around the tubing, but she did not know who did this. UM #1 further said she would need to provide education to the facility staff because the foam ear protectors were soft, more appropriate, and would prevent further skin breakdown.

Based on observation, interview, record and policy review, the facility failed to ensure that weights were monitored as ordered by the Physician and professional standards of practice for one Resident (#15) who was identified as at risk for malnutrition, had a history of weight loss and was determined to be underweight, out of a total sample of 12 residents. Specifically, for Resident #15, the facility failed to: -identify a significant weight change timely. -obtain a re-weight when the significant weight change was identified by the Registered Dietitian (RD). -obtain a monthly weight as ordered by the Physician. Findings include: Review of the facility policy titled Weights and Heights, revised 6/15/22, indicated patients are weighed upon admission and/or readmission, then weekly for four weeks and monthly thereafter. The policy also included the following under procedure: -significant weight changes will be reviewed by the Licensed Nurse for assessment -significant weight change is defined as 5% in one month and 10% in six months Resident #15 was admitted to the facility in October 2022, with diagnoses including Severe Protein-Calorie Malnutrition (patient has two or more of the following characteristics: obvious significant muscle wasting, loss of subcutaneous fat; nutritional intake of less than 50 percent (%) of recommended intake for 2 weeks or more; bedridden or otherwise significantly reduced functional capacity; weight loss of greater than 2% in 1 week, 5% in 1 month, or 7.5% in 3 months), Dysphagia (difficulty swallowing), and Dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of the Resident #15's Minimum Data Set (MDS) Assessment, dated 7/11/24, indicated the following: -exhibited severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of 15 -had no behaviors -required supervision of staff with meals -was 118 pounds (lbs.) during the assessment reference period -did not experience significant weight change -was on a mechanically altered diet (diet consistency that is altered to allow for ease of chewing or swallowing) Review of the Nutrition Care Plan, initiated 10/14/22, indicated Resident #15: -was at nutritional risk related to weight loss despite good intakes with meals -Dementia -underweight status -mechanically altered diet consistency -goals included for the Resident to have a stable weight without significant changes Review of the October 2024 Physician's orders, included the following: -obtain weight monthly, on the first of the month, initiated 7/1/23 Review of the Resident's weight record included the following weights: -118.2 lbs. on 6/1/24 -117.5 lbs. on 7/1/24 -117.0 lbs. on 8/11/24 -128.2 lbs. on 9/1/24 Review of an RD Progress Note, dated 9/15/24, indicated Resident #15 had an 11.2 lbs. weight gain over a three-week period (a gain of 9.6%) which was identified as significant. The RD indicated she notified the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), and requested a re-weigh to be completed. Review of the Resident's clinical record indicated no weights were obtained after the 9/1/24 weight of 128.2 lbs. On 10/1/24 at 7:56 A.M., the surveyor observed Resident #15 was dressed and seated in a wheelchair near the nurses station. The surveyor observed that the Resident was very thin in appearance. During an interview on 10/4/24 at 11:41 A.M., Resident #15's Representative said the Resident had lost a lot of weight since he/she was admitted to the facility. The Resident Representative said he/she had concerns about how much assistance was provided during meals for the Resident. The Resident Representative said the Resident used to weigh 150 lbs., went down to 140 lbs., and was about mid 130 lbs. when admitted to the facility. The Resident Representative said he/she was made aware by the facility staff that Resident's #15's weight was around 118 lbs. but was not updated on what the most recent weight was. During an interview on 10/4/24 at 1:22 P.M , Certified Nurses Aide (CNA) #2 said Resident weights are obtained monthly or more frequently depending on the Physician's orders. CNA #2 said the Nurses give a list of Resident weights that need to be obtained, the CNAs get those weights, and then provide them to the Nurses who enter them into the Resident's clinical record. CNA #2 said the Nurses would review the weights and would request follow-up weights to be obtained if needed. CNA #2 further said the RD comes to the facility on Tuesdays and will ask about Residents and will send an email about weight discrepancies. During an interview on 10/4/24 at 2:37 P.M., the ADON said the CNAs would obtain Residents weights and provide them to the Nurses who enter them into the Resident's clinical record. The ADON said if there was a weight discrepancy, the Nurse should request the Resident to be re-weighed, and that re-weighs should occur within 24 hours. The ADON said once the weight had been obtained and it was determined that the weight was accurate, and a weight change was identified, the Physician, Resident Representative and the RD would be notified. The ADON said he received notifications from the RD weekly via email about Resident changes and requests for Resident re-weights. The facility did not provide documented evidence to the survey team that a re-weight had been obtained or had been attempted to be obtained for Resident #15 at the time of the survey exit.

Based on observation, interview, record and policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice relative to the use of supplemental Oxygen (a drug that is a vital and essential medication, usually prescribed to treat cardiac and respiratory conditions) for one Resident (#22), of one applicable resident receiving oxygen therapy, out of a total sample of 12 residents. Specifically, for Resident #22, the facility failed to: -administer supplemental Oxygen in accordance with the Physician's orders. -indicate the flow rate of Oxygen utilized when the oxygen saturations levels (SpO2/ O2 Sat - measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) were obtained by the nursing staff. Findings include: Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014 at: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicated the following: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with physicians' orders or inadequate instruction for oxygen therapy. -There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia [high carbon dioxide levels in the blood) and chronic obstructive pulmonary disease that oxygen administration may lead to an increase in PaCO2. -Equipment maintenance and supervision: >All oxygen delivery equipment should be checked at least once daily >Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. Review of the facility procedure titled Oxygen: Nasal Cannula (pronged tube inserted into the nose to provide supplemental Oxygen), revised 8/7/23, included the following: -verify order [Physician's Order] -determine appropriate oxygen source . -connect the cannula . and set the flow rate (a measurement of how much oxygen is being delivered) to the prescribed liter flow. -monitor the patient's response to oxygen therapy: respiratory rate (number of breaths per minute), heart rate (number of heart beats per minute), breath sounds, breathing pattern, oxygen saturation level, skin color . -document: method of administration, liter flow, patient's response to therapy, evaluation of heart rate, respiratory rate, oxygen saturation levels, skin color and breath sounds . Resident #22 was admitted to the facility in August 2024, with diagnoses including Chronic Respiratory Failure with Hypoxia (a condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue), Pneumonia (a serious infection of one or both lungs caused by bacteria, viruses, or fungi in which the air sacs fill with pus or other liquid), and dependence on supplemental Oxygen. Review of the Minimum Data Set (MDS) Assessment, dated 8/6/24, indicated Resident #22: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of 15 -had no behaviors -received oxygen therapy Review of the Resident's Respiratory Care Plan, initiated 8/3/24, included the following intervention: -administer Oxygen as ordered/indicated (dated 8/3/24) Review of the October 2024 Physician's orders included the following: -Oxygen saturation/Pulse every shift, dated 8/2/24 -Oxygen at 4-6 liters per minute (LPM - flow rate that Oxygen is set to be delivered at) via nasal cannula continuously, every shift. Post treatment: evaluate heart rate, respiratory rate, pulse oximetry (oxygen saturation level), skin color, and breath sounds, dated 8/2/24 Review of the October 2024 Medication Administration Record (MAR) indicated the Oxygen was signed off as administered at the prescribed rates every shift from 10/1/24 through 10/3/24 on the 7:00 A.M. to 3:00 P.M. shift. Further review of the October 2024 MAR indicated oxygen saturation levels were obtained every shift as ordered, but did not include documented evidence of what the oxygen liter flow rate was at the time the oxygen saturation measurement was obtained. On 10/1/24 at 7:51 A.M., the surveyor observed Resident #22 awake and lying in bed with the nasal cannula positioned under the Resident's chin and not applied into his/her nose. The surveyor observed that the oxygen tubing was connected to the oxygen concentrator (medical device that uses air in the atmosphere, filters it, and delivers air that is 90 - 95% oxygen concentrated to the patient) positioned near the bed and was set at a flow rate of 2.5 LPM. During an interview at the time, Resident #22 said the supplemental oxygen was new for him/her and that he/she would re-apply it, but the tubing hurt his/her ears. The surveyor observed the Resident re-apply the nasal cannula at the time without issues. On 10/3/24 at 7:40 A.M., the surveyor observed the Resident lying in bed with the Oxygen administered via a nasal cannula that was connected to an oxygen concentrator which was set at a flow rate of 2.5 LPM. On 10/3/24 at 2:36 P.M., the surveyor and Nurse #4 observed Resident #22. The Resident was observed lying in bed with the oxygen tubing around his/her chin and asked Nurse #4 for assistance in re-applying the nasal cannula. During an interview after the observation, Nurse #4 said the Resident's Oxygen flow rate was set at 2.5 LPM. Nurse #4 reviewed the Physician's orders at this time and said the Physician's order indicated the Oxygen should be set between 4-6 LPM continuously (24/7). Nurse #4 further said there was no Physician's order for the Oxygen to be titrated (adjust the flow rate of the Oxygen being administered) below 4 LPM. During a follow-up interview on 10/3/24 at 3:32 P.M., the surveyor and Nurse #4 reviewed the October 2024 Physician's orders and MAR. Nurse #4 said Resident #22 was prescribed a range of 4-6 LPM for the liter flow of Oxygen. Nurse #4 said when oxygen saturation levels are obtained, the flow rate of the Oxygen being delivered should be documented so tolerance to oxygen therapy can be monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility failed to obtain consent for the use of bed rails for one Resident (#7), out of a total sample of 12 residents. Specifically, for Resident #7, the facility failed to obtain informed consent that included notification of the risks and benefits for the use of the bed rails from the Resident Representative prior to use. Findings include: Review of the facility policy titled Bed Rails, revised 9/1/22, indicated the facility will only use bed rails as mobility enablers. The policy also included the following: -Complete the Bed Rail Evaluation to determine the need for bed rails. If the Evaluation determines that the patient would benefit from bed rails: >use the Bed Safety Action Grid to ensure the bed's dimensions are appropriate for the patient's size and height for the safety and convenience of the patient >review the risks and benefits of bed rails with the patient or, if applicable, patient representative, prior to installation using the Consent for Use of Bed Rails form . >obtain Physician order for the use of the bed rail >update the care plan and the [NAME] (information about the residents for the Certified Nurse Aides) to reflect the use of the bed rail >notify the Maintenance Department to install bed rails or unsecured and inspect fixed bed rails . Resident #7 was admitted to the facility in March 2024, with diagnoses including Altered Mental Status (AMS - a general term for a change in mental function that can affect a person's awareness, movement, and behavior), abnormal gait and mobility, falls and Urinary Retention (difficulty urinating and completely emptying the bladder). Review of Resident #7's Consent for Use of Bed Rails form, signed by Resident Representative on 3/15/24, indicated the bed rails were to be secured in the down position (were not to be used). Review of the Minimum Data Set (MDS) Assessment, dated 9/12/24, indicated Resident #7: -had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 10 out of 15 -had delusions -required supervision from staff when rolling left and right, when sitting to lying down, when lying down to sitting up -required partial/moderate assistance from staff when going from sitting to standing and from transferring from the bed to the chair and from the chair to the bed -had an indwelling catheter (tube inserted into the urethra to allow urine to flow out of the body) Review of the Bed Rail Evaluation, effective 9/19/24, indicated Resident #7 was assessed for the use of the bed rails and it was determined that the use of the bed rails were not required. On 10/1/24 at 8:19 A.M., the surveyor observed Resident #7 lying in bed with bilateral beds rails in the up position. The surveyor observed the call light cord and the urinary catheter tubing were wrapped around the Resident's left bed rail. On 10/2/24 at 1:39 P.M., the surveyor observed the Resident lying in bed with eyes closed with bilateral bed rails observed in the up position. On 10/3/24 at 7:23 A.M., and 8:56 A.M., the surveyor observed the Resident lying in bed with eyes closed and bilateral bed rails were in the up position. Review of the Resident #7's October 2024 Physician's orders included the following: -Health Care Proxy (HCP: person to legally make healthcare decisions on behalf of the patient, when the patient is incapable) was invoked as of 3/25/24 due to the Resident's cognitive loss -no order for the use of the bilateral bed rails Review of Resident #7's active Care Plans indicated no documented evidence that bed rails were to be used. Review of the clinical record indicated no documented evidence that the use of the bed rails for Resident #7 was assessed, and that informed consent was obtained from the Resident Representative prior to their use. On 10/4/24 at 3:10 P.M., the surveyor, Nurse #5 and the Assistant Director of Nursing (ADON) observed Resident #7 lying in bed and bilateral bed rails were in place. Nurse #5 said Resident #7 had bilateral bed rails in use. Nurse #5 reviewed the Consent for Use of Bed Rails form, dated 3/15/24, and said the form indicated that the bed rails should not be used. During an interview on 10/4/24 at 3:13 P.M., the ADON said the bed rails were assessed on admission and periodically thereafter. The ADON said if a Resident was assessed for the use of the bed rails, and the bed rails were recommended, the Maintenance staff would check to ensure there was no entrapment risk. The ADON said informed consent should be obtained from the Resident/Resident Representative prior to bed rail use. The ADON said he did not think there needed to be a Physician's order for the use of the bed rails but said the use of bed rails should be included on the Resident's care plan. The ADON reviewed Resident #7's consent dated 3/15/24, and said Resident #7 did not have informed consent for the use of the bed rails.

Based on interview, record and policy review, the facility failed to ensure the Medication Regimen Review (MRR) conducted by the Consultant Pharmacist was reviewed and addressed timely by the facility for two Residents (#8 and #15), of five residents reviewed for unnecessary medications, out of a total sample of 12 residents. Specifically, the facility failed to: 1. For Resident #8, ensure the MRR completed by the Consultant Pharmacist on 9/4/24, pertaining to Seroquel (antipsychotic medication) was in the clinical record and was addressed by the Physician. 2. For Resident #15, ensure the MRR completed by the Consultant Pharmacist on 9/11/24 was in the clinical record and indicated a response by the Physician/facility. Findings include: Review of the facility policy titled Medication Monitoring: Medication Regimen Review and Reporting, dated January 2024, indicated the MRR was a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The policy also included the following: -the MRR includes a review of the medical record in order to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities -the MRR involves collaborating with the other members of the Interdisciplinary Team (IDT) -the findings from the MRR are communicated to the Director of Nursing (DON) or designee and the Medical Director (MD). These findings are documented and filed with the other Consultant Pharmacist recommendations in the residents' chart. -resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or Physician. -the nursing center follows up on the recommendations to verify that appropriate action has been taken. -Recommendations should be acted upon within 30 calendar days . -for those issues that require Physician intervention, the attending Physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record. -for recommendations that do not require Physician intervention, the DON or licensed designee will address the recommendation. 1. Resident #8 was admitted to the facility in January 2019, with diagnoses including Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Depression and Mood disorder (affective disorder, is any of a group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood) Review of the Minimum Data Set (MDS) Assessment, dated 8/8/24, indicated Resident #8: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -had no behaviors -received an antipsychotic medication (class of psychotropic medication primarily used to manage psychosis, principally in Schizophrenia [a mood disorder that affects a person's ability to think, feel, and behave clearly] but also in a range of other psychotic disorders) on a routine basis during the assessment period. Review of the September 2024 Physician's orders included the following: -Seroquel (antipsychotic medication) 25 milligrams (mg) at bedtime for Depression, initiated 7/12/24 Review of the September 2024 Medication Administration Record (MAR) indicated the Seroquel was administered as ordered from 9/1/24 through 9/30/24. Review of Resident #8's clinical record indicated a MRR was completed by the Consultant Pharmacist on 9/4/24 and a recommendation was made. Further review of the clinical record indicated no documented evidence of the Consultant Pharmacist's recommendation and/or any response by the facility. Review of the October 2024 Physician's orders included the following: -Seroquel 12.5 mg at bedtime for Depression, initiated 10/1/24 On 10/7/24 at 4:54 P.M., Unit Manager (UM) #1 provided the surveyor with the Consultant Pharmacist recommendation dated 9/4/24. Review of the Consultant Pharmacist recommendation indicated the following: -recommendation addressed for the DON and the MD (Physician): >Resident is receiving the antipsychotic Seroquel. The medication should only be used for the listed conditions/diagnoses. Please check the appropriate indication for the medication use for this Resident . -recommendation was not signed by the Physician and there were no condition/diagnoses indicated for the use of the Seroquel (the form was blank). During an interview on 10/7/24 at 4:54 P.M., UM #1 said she was not sure if the MRR/ Consultant Pharmacist recommendation was addressed and would look into it. During a follow-up interview on 10/7/24 at 5:08 P.M., UM #1 said the Physician addressed the recommendation today and a diagnosis was added for the Resident's use of Seroquel. UM #1 said the Consultant Pharmacist MRR should have been addressed by the facility within 30 days and she was unable to find documented evidence that it was addressed prior to today (10/7/24). 2. Resident #15 was admitted to the facility in October 2022, with diagnoses including Type 2 Diabetes (long-term condition where the pancreas is unable to produce enough insulin to regulate blood glucose [sugar] levels resulting in higher than normal blood sugar levels), Severe Protein-Calorie Malnutrition (patient has two or more of the following characteristics: obvious significant muscle wasting, loss of subcutaneous fat; nutritional intake of less than 50%), Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations) and other behavioral disturbance, and Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]). Review of the Resident's clinical record indicated the Consultant Pharmacist made a recommendation on 9/11/24. Further review of the clinical record indicated no evidence of the Consultant Pharmacist recommendation made and/or the response from the Provider (Physician). During an interview on 10/4/24 at 2:12 P.M., the Consultant Nurse said the Consultant Pharmacist MRRs were emailed to the DON, who prints the MRRs out and addresses them with the Provider. The Consultant Nurse said once the MRR was addressed, they were filed in the Resident's clinical record. The Consultant Nurse said he was unable to locate the Consultant Pharmacist MRR dated 9/11/24 and had contacted the pharmacy to have them fax it over to the facility. The facility did not provide the requested MRR dated 9/11/24 to the survey team prior to the survey exit on 10/7/24 at 6:40 P.M.

Based on interview, record and policy review, the facility failed to follow professional standards of practice relative to the transcription of Physician orders for one Resident (#15), of five residents reviewed for unnecessary medications, out of a total sample of 12 residents. Specifically, the facility failed to that ensure laboratory orders and Psychiatric Consult recommendation obtained by the Physician after a Medication Regimen Review (MRR) conducted by the Consultant Pharmacist were completed for Resident #15. Findings include: Review of the facility policy titled Transcription of Orders, revised 5/1/23, included the following: -orders from an authorized Licensed Independent Practitioner (Physician, Nurse Practitioner or Physician Assistant) are accepted by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) . -transcribing is the recording of the orders by the RN or LPN . Review of the facility policy titled Medication Monitoring: Medication Regimen Review (MRR) and Reporting, dated January 2024, indicated the MRR was a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The policy also included the following: -the MRR includes a review of the medical record in order to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities -resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. -for those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record. Resident #15 was admitted to the facility in October 2022, with diagnoses including Type 2 Diabetes (long-term condition where the pancreas is unable to produce enough insulin to regulate blood glucose [sugar] levels resulting in higher than normal blood sugar levels), Severe Protein-Calorie Malnutrition (patient has two or more of the following characteristics: obvious significant muscle wasting, loss of subcutaneous fat; nutritional intake of less than 50%), Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations and other behavioral disturbance, and Bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]). Review of the Resident's clinical record indicated the Consultant Pharmacist conducted MRRs and made recommendations on the following dates: -3/11/24 -4/8/24 -7/2/24 -8/1/24 Review of the MRR, dated 3/11/24, included the following recommendation: -close monitoring should accompany any change in diabetic medication therapy and to guide further adjustments. -the Physician addressed the recommendation on 3/20/24, and provided a written order to obtain the following lab work on Monday (3/25/24): >Complete Blood Count (CBC: full blood count, is a set of medical laboratory tests that provide information about the cells in a person's blood) >Comprehensive Metabolic Panel (CMP: routine blood test that measures 14 different substances in a sample of your blood) >A1c [sic] (hemoglobin A1C (HbA1C): test is a blood test that shows what your average blood sugar (glucose) level was over the past two to three months) -the Director of Nursing signed and dated the MRR on 3/26/24 indicating the order was updated in the Resident's record. Review of the Resident's clinical record indicated no documented evidence that the requested lab work was obtained on 3/25/24 as ordered by the Physician. Review of the MRR, dated 4/8/24, included the following recommendations: -CBC, CMP and A1c were ordered on 3/20/24 in response to a Pharmacy Recommendation and were unavailable in the Resident's medical record. Unless otherwise indicated, please ensure that ordered labs are obtained . -the DON initialed the MRR on 4/9/24, and wrote on the MRR form that lab work was re-ordered. Review of the Resident's clinical record indicated no documented evidence that the CMP lab work was obtained by the facility in April 2024. Review of the MRR, dated 7/2/24, included the following recommendations: -Resident has diabetes and has an abnormally high A1c level of 9.4%, please add an order for an A1c lab to be drawn .until this Resident's diabetes is better controlled -the Provider (Physician/Nurse Practitioner/ Physician Assistant) signed the MRR and indicated for an A1c to be drawn on the next lab day. -the DON signed and dated on MRR on 7/5/24, and indicated an A1c was ordered to be obtained on the next scheduled lab day. Review of the Resident's clinical record indicated no documented evidence that lab work was obtained by the facility in July 2024. Review of the MRR, dated 8/1/24, included the following recommendations: -consider baseline and annual Liver Function Tests (LFTs: blood tests that measure different substances made by your liver) and lipid panel (blood test that healthcare providers use to monitor and screen for your risk of cardiovascular disease) to monitor therapeutic side effects of Lipitor (medication used to lower the amount of cholesterol in the blood). -the recommendation response by the facility indicated lab work would be obtained on the next lab day and was signed on 8/4/24, by the DON. The Provider initialed the recommendation response. Further review of the medical record indicated another MRR, dated 8/1/24, that included the following recommendation: -the Resident is receiving psychotropic medications (medication used to treat mental health disorders) including Zyprexa (antipsychotic) and Zoloft (antidepressant), dose evaluation is recommended periodically in order to determine the lowest effective dose .Please have a Psychiatric Consult to evaluate the need for a gradual dose reduction (GDR: stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued). -the Provider (Physician, Physician Assistant or Nurse Practitioner) signed the recommendation. Review of the Resident's clinical record indicated no documented evidence that the LFT lab work or a Psychiatric Consult to review for a GDR of the identified medications had been obtained. During an interview on 10/4/24 at 2:12 P.M., the Consultant Nurse said the Consultant Pharmacist MRRs are emailed to the DON, who prints the MRRs out and addresses them with the Provider. The Consultant Nurse said once the MRRs are addressed, they are filed in the Resident's clinical record. During an interview on 10/4/24 at 2:33 P.M., Unit Manager (UM) #1 reviewed the MRRs dated 3/11/24, 4/8/24, 7/2/24, and 8/1/24, and said some MRRs were initialed by the Physician Assistant and some were signed by the Physician. UM #1 said she would look to see if she could locate the ordered lab work and if the Psychiatric Consult had been completed. On 10/4/24 at 4:19 P.M., the surveyor requested evidence from the facility that the lab work and the Psychiatric Consult for Resident #15 were obtained as ordered by the Providers on the indicated MRRs. During an interview on 10/7/24 at 4:00 P.M., the Consultant Nurse and UM #1 said they were unable to find additional lab work that corresponded with the MRRs from 3/11/24, 4/8/24, 7/2/24, and 8/1/24 or that a Psychiatric Consult had been obtained. The Consultant Nurse said the current process for the Consultant Pharmacist MRRs was broken.

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staffing levels with the appropriate competencies and experience to provide nursing and related services to the facility residents. Specifically, the facility failed to: 1. provide staffing levels in accordance with the facility assessment for 23 out of 36 days for the period 9/1/24 -10/6/24, placing the facility residents at risk for impeded delivery of care and inability to meet the specific needs and concerns of each resident. 2. provide a sufficient number of nursing staff to provide basic care and respond timely per Resident Council concerns voiced. 3. provide sufficient staffing to assist timely with ADL care for: -Resident's #8, #84, and #5 -Resident Representative (requesting anonymous consideration) advocating for family. -Direct care staff concerns. Findings include: 1. Review of the Facility Assessment indicated the following staffing needs were identified as necessary per the staffing sufficiency analysis dated, 10/8/23 through 10/7/24 on page 22: -One Director of Nursing (DON): Monday through Friday, 8 hours a day. -One Assistant DON: Monday through Friday, 8 hours/day. -One Licensed Nurse on each unit (2 Units: East and West): daily on the 7:00 A.M. to 3:00 P.M. [Day shift] and the 3:00 P.M. to 11:00 P.M. [Evening shift] shifts. -One Certified Nurses Aide (CNA) for every 10-12 residents: daily on the 7:00 A.M. to 3:00 P.M. and the 3:00 P.M. to 11:00 P.M. shifts. -One Licensed Nurse for the 11:00 P.M. to 7:00 A.M. shift. [Night shift] -One CNA for every 10-17 residents: on the 11:00 P.M. to 7:00 A.M. shift. Review of the facility's staffing schedules and census (number of residents in the facility) data provided to the surveyor dated 9/1/24 through 10/6/24 indicated the following unmet staffing pattern needs based on the facility's staffing analysis and in house census: >Licensed Nurse staffing needs were not met on: -9/9/24: Facility census - 28, no Licensed Nurse scheduled between 1:00 P.M. - 3:00 P.M. on the East Unit. -9/19/24: Facility census - 21, no Licensed Nurse scheduled between 1:00 P.M. - 3:00 P.M. on the [NAME] Unit. -9/21/24: Facility census - 21, no Licensed Nurse scheduled between 3:00 P.M. - 11:00 P.M. on the [NAME] Unit. -9/23/24: Facility census - 21, no Licensed Nurse scheduled between 1:00 P.M. - 3:00 P.M. on the East Unit. -9/24/24: Facility census - 23, no Licensed Nurse scheduled between 7:00 P.M. - 3:00 P.M. on the [NAME] Unit. -9/25/24: Facility census - 22, no Licensed Nurse scheduled between 11:00 A.M. - 3:00 P.M. on the East Unit. -9/26/24: Facility census - 23, no Licensed Nurse scheduled between 7:00 A.M. - 3:00 P.M. on the [NAME] Unit. -9/27/24: Facility census - 23, no Licensed Nurse scheduled between 12:00 P.M. - 3:00 P.M. on the [NAME] Unit. -9/28/24: Facility census - 28, no Licensed Nurse scheduled between 7:00 A.M. - 3:00 P.M. on the [NAME] Unit. -9/29/24: Facility census - 23, no Licensed Nurse scheduled between 7:00 A.M. - 3:00 P.M. on the [NAME] Unit. -9/30/24: Facility census - 23, no Licensed Nurse scheduled between 7:00 A.M. - 3:00 P.M. on the [NAME] Unit. -10/2/24: Facility census - 25, no Licensed Nurse scheduled between 7:30 P.M. - 11:00 P.M. on the East Unit. -10/3/24: Facility census - 25, no Licensed Nurse scheduled between 7:30 P.M. - 11:00 P.M. on the East Unit. -10/3/24: Facility census - 25, no Licensed Nurse scheduled between 1:00 P.M. - 3:00 P.M. on the [NAME] Unit -10/4/24: Facility census - 25, no Licensed Nurse scheduled between 1:00 P.M. - 3:00 P.M. on the East Unit -10/6/24: Facility census - 26, no Licensed Nurse scheduled between 8:00 P.M. - 11:00 P.M. on the East Unit >CNA staffing needs were not met on: -9/1/24: Facility census - 29, 2 CNA staff scheduled between 3:00 P.M -11:00 P.M. in the facility (Facility assessment indicated 1 CNA for every 10-12 residents) -9/2/24: Facility census - 28, 2 CNA staff scheduled between 3:00 P.M -11:00 P.M. in the facility (Facility assessment indicated 1 CNA for every 10-12 residents) -9/4/24: Facility census - 27, 2 CNA staff scheduled between 3:00 P.M -11:00 P.M. in the facility (Facility assessment indicated 1 CNA for every 10-12 residents) -9/10/24: Facility census - 28, 2 CNA staff scheduled between 3:00 P.M -11:00 P.M. in the facility (Facility assessment indicated 1 CNA for every 10-12 residents) -9/11/24: Facility census - 27, 2 CNA staff scheduled between 3:00 P.M -11:00 P.M. in the facility (Facility assessment indicated 1 CNA for every 10-12 residents) -9/15/24: Facility census - 26, 2 CNA staff scheduled between 3:00 P.M -11:00 P.M. in the facility (Facility assessment indicated 1 CNA for every 10-12 residents) and 1 CNA scheduled between 11:00 P.M. - 7:00 A.M. (Facility assessment indicated 1 CNA for every 10 - 17 residents) -9/16/24: Facility census - 25, 2 CNA staff scheduled between 3:00 P.M -11:00 P.M. in the facility (Facility assessment indicated 1 CNA for every 10-12 residents) and 1 CNA scheduled between 11:00 P.M. - 7:00 A.M. (Facility assessment indicated 1 CNA for every 10 - 17 residents) -9/17/24: Facility census - 25, 2 CNA staff scheduled between 3:00 P.M -11:00 P.M. in the facility (Facility assessment indicated 1 CNA for every 10-12 residents) -9/25/24: Facility census - 22, 1 CNA staff scheduled between 3:00 P.M -5:00 P.M. in the facility (Facility assessment indicated 1 CNA for every 10-12 residents) -10/6/24: Facility census - 26, 2 CNA staff scheduled between 7:00 A.M. - 3:00 P.M. and 1 CNA staff scheduled between 3:00 P.M -11:00 P.M. in the facility (Facility assessment indicated 1 CNA for every 10-12 residents) During an interview on 10/7/24 at 4:03 P.M., Consultant Nurse #1 said the facility had very good staffing and was one of the highest staffed buildings that he oversees. Consultant Nurse #1 said the staff believe they do not have enough help, but they do. Consultant Nurse #1 said he gets weekly updates from the facility administration about staffing and no staffing concerns had been identified in the weekly updates during the 9/1/24 through 10/6/24 time period. 2. On 10/2/24 from 2:00 P.M. to 3:00 P.M., the surveyor conducted a Resident Council meeting with seven Residents and the following were discussed relative to call light response in the facility: -Two Residents said it took a long time for staff to answer the call lights. -One Resident said he/she felt the facility was understaffed: *that the staff did the best they could to assist residents but there were not enough of them. *The Resident further said that there were times when he/she had to wait 15 minutes for staff to answer his/her call light, and when the staff do answer, they say they will be right back and sometimes that did not always occur. *The Resident further said that sometimes it took over 1/2 hour for staff to assist with his/her toileting needs. *The Resident said there was another resident who required the assistance of two staff to get him/her out of the wheelchair and into bed, and he/she had observed times when the resident was waiting in the hallway seated in his/her wheel chair for extended periods of time because it was difficult to find the two staff to assist him/her back to his/her bed. 3a. Resident #8 was admitted to the facility in December 2020 with diagnoses of Multiple Sclerosis (a disease that affects central nervous system where the immune system attacks the myelin [the protective layer around nerve fibers] and causes inflammation and lesions which makes it makes it difficult for the brain to send signals to rest of the body). Review of the Minimum Data Set (MDS) Assessment, dated 8/8/24 indicated Resident #8: -understands and was understood -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -had bilateral lower extremity range of motion impairments -utilized a wheel chair -was dependent on staff for toileting -was frequently incontinent of bowels On 10/2/24 from 1:20 P.M. until 1:38 P.M., the surveyor observed the following relative to Resident #8: -1:20 P.M.: Resident #8 was seated in a specialized wheelchair positioned outside of the doorway to his/her room. A Hoyer pad (a sling utilized for transferring with a mechanical lift device) was under the Resident. -1:25 P.M.: Resident #8 propelled him/herself from the outside of the room and was observed to approach CNA #1 and ask him for assistance back to bed. CNA #1 was observed saying to Resident #8 that he will assist the Resident after and that he had five other residents to take care of prior to assisting him/her. The Resident returned to the doorway to his/her room and was heard telling facility staff about the need to return to bed because he/she was going to have a bowel movement on him/herself. The facility staff member said they would try to find someone to assist. -1:29 P.M.: the Resident propelled down the hallway towards the other unit. After a few minutes, Resident #8 returned while talking to the Activities Staff about needing assistance back to bed. -1:36 P.M.: Activities Staff approached CNA #1 and relayed that Resident #8 was requesting to go back to bed. The CNA was observed to state that he was aware in a gruff tone, and after the Activities Staff walked away, CNA #1 said his blood pressure was elevated. -1:38 P.M.: (18 minutes later) Resident #8 was outside of his/her room and CNA #1 and CNA #2 approached with the mechanical lift device. At this time, the Resident was transferred back to his/her bed. During an interview on 10/2/24 at 4:51 P.M., Resident #8 said he/she felt anxious because he/she needed to have a bowel movement and did not want to be incontinent in his/her brief and needed staff to assist him/her back to bed. 3b. Resident #84 was admitted to the facility in October 2024. On 10/3/24, the surveyor observed the following relative to Resident #84: -9:35 A.M.: call light was observed to be on. The surveyor knocked, entered the room and observed the Resident lying in bed, dressed in a hospital gown and a commode was positioned near the Resident's bed. During an interview at the time, the Resident said he/she needed to use the commode, was unable to do it on his/her own and needed staff assistance. The surveyor said she would alert the staff. After exiting the room, the surveyor walked down the entire length of the hallway (from [NAME] Unit side to the East Unit side), was unable to find a CNA, and relayed the Resident's request to Nurse #4. -9:37 A.M.:Nurse #4 knocked and entered Resident #84's room and was heard to tell him/her that someone would be there soon to help. -9:41 A.M.: the Administrator knocked and entered the Resident's room. The Resident's call light remained on. The Administer was heard telling the Resident he would locate a staff member to assist him/her. The surveyor observed the Administrator exit the room and walk down the hallway. -9:44 A.M. the Administrator re-entered the Resident's room and left shortly after. The call light remained on. -9:49 A.M. the Resident's call light remained on. The surveyor heard him/her call out for help. -9:50 A.M. (a total of 15 minutes later) Nurse #1 knocked and entered the Resident's room. The surveyor heard Resident #84 say in a loud, frustrated tone that he/she needed to use the commode right now and told Nurse #1 not to leave the room until she provided help. At the time, the surveyor observed Nurse #1 pull the privacy curtain fully around the Resident's bed and verbal instruction was provided to assist the Resident to the commode. During an interview after exiting the Resident's room, Nurse #1 said she was not familiar with Resident #84 because he/she was not her Resident. Nurse #1 said she was not sure how long the call light had been on, but the Resident sounded upset and frustrated when she went in the room to answer the call light. During an interview on 10/3/24 at 11:09 A.M., Resident #84 said what occurred that morning was ridiculous. He/she said several people came into the room because the call light was on, and it took forever for someone to finally assist him/her. The Resident said he/she almost did not make it to the commode in time. During an interview on 10/3/24 at 11:17 A.M., the Administrator said he responded to the Resident's call light, then left to try to find a staff person to assist him/her. The Administrator said he told one of the CNA's who was in another resident's room providing care, and the CNA told him that he would assist the Resident shortly. The Administrator said he returned to the Resident's room to relay this message. The Administrator said he was not aware of how long Resident #84's call light was on and when he attempted to find staff to assist him/her, he was unable to because they were all assisting other residents. 3c. During an interview on 10/3/24 at 11:52 A.M., with a Resident Representative (who requested to remain anonymous pertaining to the Resident) and indicated hesistancy to speak to the surveyor. The Resident Representative said it can take up to 20 minutes for his/her family member to receive assistance from staff at times. The Resident Representative said there are times when he/she visits with his/her family member and facility staff do not check in on the Resident for hours. The Resident Representative said he/she was concerned that his/her family member was not receiving personal care like nail care, showers and feeding assistance as he/she needed. 3d. Resident #5 was admitted to the facility in July 2024, with diagnoses including history of fall with arm fracture, unsteadiness on his/her feet, Hypertension (high blood pressure/HTN: When the blood pressure measures consistently above 130/80 millimeters of mercury [mm Hg]) and Atherosclerotic Heart Disease (a condition where the arteries become narrowed and hardened due to buildup of plaque [fats] in the artery wall). Review of the MDS Assessment, dated 7/22/24, indicated Resident #5: -undertands and was understood -was cognitively intact as evidenced by a BIMS score of 13 out of 15 -had no behaviors -was dependent on staff for toileting, bathing, transfers -and required substantial/maximum assistance from staff with personal hygiene and repositioning During an interview on 10/2/24 at 1:47 P.M., CNA #1 said he provided care to Resident #5 frequently. CNA #1 said the Resident required staff assistance for care and repositioning from side to side. CNA #1 said he attempts to reposition the Resident every 2 hours, but sometimes it was not manageable because he was taking care of other residents. During an interview on 10/3/24 at 3:32 P.M., Resident #5 said he/she needed to get changed, had asked two facility staff members about 15 minutes ago and no one had returned to assist him/her. The surveyor initiated the call light for Resident #5 at this time and by 3:34 P.M., he/she was assisted with care. 3e. During an interview on 10/4/24 at 1:30 P.M., CNA #2 said the staffing for the facility was based on the resident census and that it was usually not staffed the way it was when the Department of Public Health (DPH) was in the building. CNA #2 said there were days when he/she was the only CNA working with one Nurse on the Unit, and there were times when the Nurse was told to leave early because of the census which leaves one Nurse taking care of all the residents. CNA #2 said it can be difficult to take care of the residents because he/she would need the Nurse's help to assist with care and the Nurses have their own work to complete. CNA #2 said the way the building was shaped made it difficult to attend to all of the residents and answer the call lights timely. During an interview on 10/4/24 at 3:43 P.M., Nurse #4 said although the facility was small, the set-up of the facility made it difficult to do the work that needed to be done. Nurse #4 said there were times when she was told to leave early, still had work to complete, would ask for assistance from the ADON and was told that he could not help. Nurse #4 said there were several weekends when there were 2 CNAs scheduled for the 7:00 A.M to 3:00 P.M. and 3:00 P.M. to 11:00 P.M. shifts. Nurse #4 said when staffing concerns were discussed with Administration, the staff are told that the facility was overstaffed not understaffed. Nurse #4 said she felt bad for the CNAs because they had a lot of work to do and there are some Nurses who will not assist the CNAs when they need assistance, and there may be the only CNA scheduled on the unit for that shift. Nurse #4 said the staffing always looked different when DPH was in the building. During an interview on 10/7/24 at 3:37 P.M., Nurse #2 said there are many times that she and other staff are asked and worked multiple shifts in a row because of the facility staffing and on occasions, there may be only one Nurse working in the building. Nurse #2 said there were many days/shifts when there was only 1 CNA assigned to each unit, which made it very difficult to care for the residents. Nurse #2 said there was work that was not being completed and documentation that was not occurring because of the staffing and she had had to prioritize what needed to be completed. Nurse #2 said she did relay her concerns about the facility staffing and the response from Administration was about the Per Patient Day number (PPD: calculations that determine the number of clinical staff caring for residents during each shift based on the census). During an interview on 10/7/24 at 5:44 P.M., the Consultant Nurse said staffing for the facility was based on the PPD and also included the acuity of the residents. The Consultant Nurse said the facility staff think they are understaffed when they are staffed better than most facilities. The surveyors relayed concerns about staffing that were observed at this time. The Consultant Nurse said he was not aware of days/shifts that the facility was not meeting the staffing needs based on what was determined in the facility assessment.

Based on interview, record and policy review, the facility failed to ensure that one Resident (#8), of five applicable residents reviewed for unnecessary medications, out of a total sample of 12 residents, did not recieve medications outside of the Physician ordered parameters. Specifically, for Resident #8, the facility failed to ensure that Tramadol (an opioid medication used to relieve moderate to moderately severe pain) was administered within the parameters (moderate and severe pain) prescribed by the Physician. Findings include: Review of the facility policy titled Pain Management, revised 11/1/23, indicated staff will continuously observe and monitor patients for comfort and presence of pain and will implement strategies in accordance with professional standards of practice, the patient-centered plan of care, and the patient's choices related to pain management. The policy also included the following: -when opioids are used, the lowest possible effective dosage should be prescribed for the shortest amount of time possible after considering all medication needs -an individualized, interdisciplinary, person-centered care plan will be developed and include: non-pharmacological and pharmacological approaches -PRN (as needed) pain medications will: >be documented in the Medication Administration Record (MAR) >have defined parameters for use, >have reasons for PRN medication requests documented, and effectiveness and/or side effects/adverse drug reactions will be assessed and documented -patients receiving interventions for pain will be monitored for the effectiveness and/or side effects/adverse drug reactions . and document: -non-pharmacological interventions and effectiveness, -effectiveness of PRN medications -ineffectiveness of routine or PRN medications . Review of the Geriatric Pain.org Information for Clinicians document titled, Numeric Rating Scale (NRS) Instructions, dated 2023, indicated the following to determine levels of pain for cognitively intact older adults: -0 = no pain, 1-3 = mild, 4-6 = moderate, 7-10 = severe Resident #8 was admitted to the facility in January 2019, with diagnoses including Multiple Sclerosis (a disease of the central nervous system marked by numbness, weakness, loss of muscle coordination, and problems with vision, speech, and bladder control, a chronic autoimmune disorder affecting movement, sensation, and bodily functions) and chronic pain syndrome. Review of the Resident #8's Pain Care Plan, initiated 1/24/19, indicated the Resident had an alteration of his/her comfort due to chronic pain. The care plan included the following interventions: -medicate Resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to the Physician as indicated (revised 8/21/23) -assist Resident to a position of comfort, utilizing pillows and appropriate positioning devices (revised 8/21/23) -monitor for continued need of medication as related to behavior and mood (dated 1/22/19) Review of the Minimum Data Set (MDS) Assessment, dated 8/8/24, indicated Resident #8: -was able to make him/herself understood and understands -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -and received opioid medication during the assessment period Review of the October 2024 Physician's orders included the following: -Pain monitoring every shift, initiated 6/23/21 -Acetaminophen (an analgesic drug used to relieve mild or chronic pain) 325 milligrams (mg), give 2 tablets (650 mg) every 4 hours as needed for mild pain . initiated 6/23/21 -Tramadol 50 mg daily PRN for moderate and severe pain at bedtime, initiated 2/19/24 Review of the July 2024 through September 2024 MARs indicated the PRN Tramadol was administered outside of the Physician's Orders parameters for moderate to severe pain on the following dates: -7/21/24 for pain = 0 -7/25/24 for pain = 0 -8/1/24 for pain = 3 -8/3/24 for pain = 0 -8/10/24 for pain = 0 -8/11/24 for pain = 0 -8/14/24 for pain = 0 -8/15/24 for pain =0 -8/16/24 for pain =0 -8/28/24 for pain = 3 -9/28/24 for pain = 1 -9/29/24 for pain = 0 Further review of the July 2024 through September 2024 MARs indicated no PRN Acetaminophen was administered on the above listed days. During an interview on 10/2/24 at 9:46 A.M., the surveyor observed Resident #8 lying in bed. The Resident said he/she had pain but received medication that was effective. During an interview on 10/7/24 at 3:29 P.M., Nurse #2 said she asks Resident #8 about his/her pain frequently, and he/she was able to respond by giving a verbal indicator of his/her pain. Nurse #2 said the Resident has a Physician's order for Acetaminophen and Tramadol for pain and that the Resident will express which pain medication he/she would like to receive. When the surveyor asked about the Resident's PRN order for Tramadol which indicated it was to be administered for moderate to severe pain, Nurse #2 said moderate pain would be on a numeric scale of 4-7 and severe pain would be 8-10. Nurse #2 further said if the Resident verbalized that he/she had pain from 4-10, it would be appropriate to administer the Tramadol. Nurse #2 said if the Resident did not verbalize pain, then non-pharmacological measures to assist with comfort would be offered. Nurse #2 said that the Resident does ask for the Tramadol at night to help him/her sleep, but said this was not good practice because it could create a dependency on the medication.

Based on record review, and interview, the facility failed to complete a performance review at least once every 12 months for four Certified Nurses Aides [CNA's] (#1, #2, #4 and #5) out of four employee records reviewed. Specifically, the facility failed to complete annual performance evaluations for Certified Nurses Aides (CNA's) #1, #2, #4 and #5 as required placing the facility residents at risk for unevaluated delivery of care. Findings include: Review of the facility policy titled Performance Appraisal, dated 12/1/07 with revision date of 7/1/22, indicated: -Managers will meet with their employees at least annually to conduct performance reviews or have performance-based conversation. -This policy applies to all employees. Review of the facility employee records indicated that CNA #1 was hired on 7/9/21, CNA #2 was hired on 7/6/90, CNA #4 was hired on 5/9/23 and CNA #5 was hired on 4/30/21 without indication of performance evaluations in the record for the past 12 months. During an interview on 10/07/24 at 5:40 P.M., Nurse Consultant #1 said the DON was currently on leave of absence, but he had spoken with the DON via telephone today. Nurse Consultant #1 said that he had confirmed with the DON that performance reviews had not been completed for any CNA staff since March 2020. Nurse Consultant #1 said that each department head was responsible to complete annual performance evaluations for their employees, and the DON should have completed these reviews for the licensed staff (nurses and CNAs) as required upon their 12-month anniversary dates annually, to ensure competency and performance of duty was appropriate.

Based on interview, and record review, the facility failed to ensure that an Antibiotic Stewardship Program (ASP-a coordinated effort to improve how antibiotics are prescribed and used in a Heathcare setting) was in place for antibiotic use protocols and monitoring. Specifically, the facility failed to conduct antibiotic monitoring for the facility, placing residents at risk for complications related to antibiotic usage. Findings include: Review of facility policy titled Antibiotic Stewardship, dated 12/31/16 with revision date of 10/24/22 and review date on 11/15/22, indicated: -Centers (the facility) will implement an Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and systems for monitoring antibiotic use. -Core elements of the ASP include leadership, accountability, drug expertise, action, tracking, reporting, and education. -The Infection Preventionist (IP) is responsible to monitor and support the ASP through rounds, review of Provider orders, medical record documentation, and available reports. The Infection Preventionist tracks antibiotic starts through use of line listing and pharmacy reports. During an interview on 10/7/24 at 3:54 P.M., the IP said he was responsible for monitoring antibiotic use and maintaining line listings for tracking antibiotic use in the facility but had not performed antibiotic monitoring or tracking since being in his new role as the IP as of 8/9/24. The IP said the Director of Nursing (DON) was responsible for the role prior to him being in the IP position but the DON was out on medical leave and was only available by phone. During a follow-up interview on 10/7/24 at 4:40 P.M., the IP said he was unable to provide evidence of antibiotic monitoring or line listing for the past year in the facility. The IP said it was important to track antibiotic use in the facility to ensure that residents were getting the correct medication, improving with the prescribed treatment, and were not receiving unnecessary antibiotics.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for a Dysphagia Advanced Diet, required supervision during meals, and was not to be served bread products (which included rolls) the facility failed to ensure his/her safety was adequately maintained related to meal preparation and meal service, in an effort to prevent an incident of choking. On 11/27/23 the kitchen did not use the correct meal ticket when preparing Resident #1's breakfast tray, after the meal truck was delivered to Resident #1's unit, the nurse checking the trays prior to service, did not notice that a croissant type roll had been put on his/her tray, he/she consumed the roll, started to choke and required the Heimlich maneuver. Findings include: Resident #1 was admitted to the Facility in May 2021, diagnoses included gastroesophageal reflux disease (GERD), diabetes and dysphagia (difficulty swallowing). Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/06/23, indicated he/she was moderately cognitively impaired with a BIMS score of 9 out of 15 (0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, 12-15 indicates cognitively intact). The MDS indicated Resident #1 required supervision of one staff member while eating. Review of Resident #1's Medical Record indicated his/her Health Care Proxy had been activated as of 06/02/21. Review of Resident #1's Physician's Orders related to diet, dated 10/07/23, indicated he/she required a dysphagia puree texture for choking risk. Review of Resident #1's Physician's Orders related to diet, dated 10/11/23, indicated his/her orders were changed to a dysphagia advanced diet with no rolls and close supervision for all meals. Review of Resident #1's Care Plan, dated as revised 10/30/23, indicated interventions included no bread products or rolls, which also included that hot dog and hamburger rolls were not to be put on his/her tray. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/27/23, indicated Resident #1 was served a croissant (type of roll) instead of his/her physicians ordered no bread /roll products on his/her breakfast tray, he/she choked on the croissant and required the Heimlich Maneuver to dislodge it. During an interview on 12/21/23 at 10:59 A.M., Nurse #1 said she was in Resident #1's room on 11/27/23 supervising him/her while he/she was eating breakfast when he/she began choking . Nurse #1 said his/her skin color became blue, she immediately performed the Heimlich maneuver, and a small piece of croissant came out. Nurse #1 said that on the dietary slip it did not say no bread products but in the computer system and physician's orders it said no bread products or rolls. Review of Resident #1's Speech Language Pathologist's Evaluation, dated 11/28/23, indicated his/her diet order prior to the choking incident on 11/27/23 was dysphagia advanced consistency, with no rolls. During an interview on 12/21/23 at 1:12 P.M., the Speech Language Pathologist (SLP) said Resident #1's diet order was dysphagia advanced with no rolls. During a telephone interview on 12/21/23 at 11:48 A.M., the Dietician said the breakfast plate served to Resident #1 on 11/27/23, was an advanced dysphagia diet, however the croissant roll that he/she was given would be considered a bread product with a flaky consistency and his/her diet order was dysphagia advanced with no bread or rolls. The Dietician said that on occasion a glitch occurs in the system and the diet order does not always print on the dietary ticket and the Food Service Director has a list of the current diet orders in case of a glitch in the system. During a telephone interview on 12/21/23 at 1:13 P.M., the Food Service Director (FSD) said Resident #1 had numerous diet changes and that residents on dysphagia advanced diets can have some bread products and the cook mistakenly thought it was alright to give Resident #1 the croissant. The FSD said Resident #1's diet order was not followed as the order included no bread or rolls. The Food Service Director said it is the Facility's expectation that all resident's meal trays be checked for the correct food items and consistency before being served to any resident. During an interview on 12/21/23 at 8:20 A.M., the Director of Nursing (DON) said she reported Resident #1's choking incident in the Health Care Facility Reporting System (HCFRS), and said it was unclear if a croissant roll was considered a bread product. The DON said after the choking incident Resident #1 had his/her diet downgraded to pureed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to complete Self-Administration Medication Assessments for two Residents (#7 and #8), out of a total sample of 12 residents. Specifically, the facility failed to complete Self-Administration Medication Assessments for the administration of topical medications for Resident's #7 and #8. Findings include: Review of the facility's policy titled Medications: Self-Administration, revised 3/1/22, indicated, but was not limited to: -A physician/advanced practice provider (APP) order is required. -Self-administration and medication self-storage must be care planned. -When applicable, patient must be provided with a secure, locked area to maintain medications. -Patient must be instructed in self-administration. -Evaluation of capability must be performed initially, quarterly, and with any significant change in condition. 1. Resident #7 was admitted to the facility in November 2022 with a diagnosis of Respiratory Failure (the lungs cannot get enough oxygen into the blood) with Hypoxia (low levels of oxygen in the blood). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #7 was moderately, cognitively impaired as evidenced by a score of 11 out of 15 on a Brief Interview for Mental Status (BIMS) assessment. On 8/2/23 at 8:58 A.M., the surveyor observed the Resident awake and resting in bed. On the overbed tray table in front of the Resident was a tube of Cortisone Cream (used to relieve redness, itching or other discomfort caused by skin conditions). During an interview at the time, the Resident said he/she has itchiness at night in the groin area and applies the Cortisone Cream him/herself. Review of the medical record did not indicate a Physician order for the use or self-administration of the Cortisone Cream nor the completion of a Self- Administration Assessment. On 8/3/23 at 11:00 A.M., the surveyor and Nurse #2 observed the Resident resting in bed. The Cortisone Cream was on the overbed tray table that was in front of the Resident. During an interview at the time, Nurse #2 said the Cortisone Cream should not be left at the Resident's bedside until a Physician's order was obtained and a Self- Medication Assessment was completed and that was not done, as required. 2. Resident #8 was admitted to the facility in March 2023 with diagnoses including: Hypertension (HTN- high blood pressure), Transient Ischemic Attack (TIA-a temporary period of symptoms similar to a stroke) and Cerebral Infarction (a stroke). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #8 was moderately, cognitively impaired as evidenced by a score of 10 out of 15 on a Brief Interview for Mental Status (BIMS) assessment. On 8/2/23 at 9:51 A.M., the surveyor observed the Resident awake and resting in bed. On the overbed tray table in front of the Resident, the surveyor observed the following: -tube of Cortisone-10 Cream (an over the counter (OTC) used to treat a variety of skin conditions) -tube of Eczema Cream -tube of Hydrocortisone Cream (reduces swelling, itchiness and redness in skin conditions) -tube of an Anti-Itch Cream During an interview at the time, the Resident said he/she has terrible itchiness across his/her back and arms and he/she applies the creams him/herself. On 8/2/23 at 11:00 A.M., the surveyor observed the Resident's spouse sitting at the bedside. During an interview at the time, the spouse said he/she had brought the creams in for the Resident to use as the Resident has had itchiness for many years. The spouse further said he/she did not inform the staff when he/she brought the creams into the facility. Review of the medical record did not indicate a Physician's order for the use or self-administration of the four creams nor the completion of a Self-Administration Assessment for Resident #8. On 8/3/23 at 10:50 A.M., the surveyor and Nurse #2 observed the Resident lying in bed with eyes closed. Four tubes of creams were observed on the overbed tray table in front of the Resident. During an interview at the time, Nurse #2 said the creams should not be left at the Resident's bedside until Physician orders were obtained and a Self-Medication Assessment was completed, and that was not done as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow a plan of care for one Resident (#7), out of a total sample of 12 residents. Specifically, the facility staff failed to ensure the correct setting of a Low Air Loss (LAL- mattress designed to distribute the resident's body over a broad surface area and help prevent skin breakdown) mattress was properly maintained for the Resident. Findins include: Resident #7 was admitted to the facility in November 2022 with a diagnosis of Respiratory Failure (the lungs cannot get enough oxygen into the blood) with Hypoxia (low levels of oxygen in the blood). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #7 was moderately cognitively impaired as evidenced by a score of 11 out of 15 on a Brief Interview for Mental Status (BIMS) assessment. On 8/2/23 at 8:58 A.M., the surveyor observed the Resident resting in bed on a LAL mattress. The LAL machine was set for a weight of 160 pounds. During an interview at the time, the Resident said he/she does not like the mattress as he/she is uncomfortable and it makes him/her sweat. During an interview on 8/3/23 at 11:00 A.M., the surveyor observed the Resident awake and resting in bed. The Resident said he/she was uncomfortable and that the mattress was too firm. Review of the medical record indicated the last weight obtained for the Resident was on 1/3/23, and documented as 120.3 pounds. Weights were discontinued on 2/1/23. Review of a Physician's order dated 4/28/23, indicated: -a LAL to be applied to the bed. -Settings based on weight. -Check settings and functions every shift. During an interview on 8/3/23 at 11:20 A.M., the Clinical Resource Manager said the LAL mattress should have been set for a lower weight as the Resident complained of discomfort and firmness and the last recorded weight for Resident #7 was much less than 160 pounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide the necessary emergency equipment at the bedside for the care and services of a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) tube per professional standards, for one Resident (#19) out of one applicable Resident, out of a total sample of 12 residents. Findings include: Resident #19 was admitted to the facility in July 2022 with diagnoses including Pulmonary Hypertension (high blood pressure that affects the arteries in the lungs and in the heart), sleep apnea (sleeping disorder in which breathing repeatedly stops and restarts), and status Tracheostomy. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/6/23, indicated that Resident #19 was cognitively intact as evidenced by a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, and received tracheostomy care. On 8/2/23 at 8:33 A.M., the surveyor observed the Resident sitting up in his/her bed eating breakfast. The Resident had a metal tracheostomy (trach) tube in place. During an interview at the time, the Resident said he/she has had a trach in place for a long time. There were no spare tracheostomy tubes and Ambu bag (handheld device which delivers manual breaths when someone has insufficient or ineffective breaths) observed in the Resident's room, equipment which would be needed in the event of an airway emergency. Review of the medical record indicated the Resident had a [NAME] (stainless steel type of trach without cuff or inner cannula) #7 trach in place and had been using that type of trach tube for over 20 years. According to the Tracheostomy Education titled, Emergency Equipment for Individuals with Tracheostomy (2019)-https://tracheostomyeducation.com/emergency-equipment/, included, but not limited to the following: -At a minimum a replacement tracheostomy tube of the same size and one of a smaller size should be available at bedside. -An Ambu bag or a bag valve mask (BVM-sometimes referred to as Ambu bag) should be with the patient at all times in case of emergency. -A small size 6.0 endotracheal tube should be available as this can be inserted into the stoma if necessary. -Oxygen masks for the tracheostomy and face should be available. Laryngeal mask airways (LMA-can be placed into the larynx/upper trachea) and pediatric airways can be used to oxygenate and ventilate the stoma (tracheostomy opening) and should also be available for all patients with tracheostomy. Oral and nasal airways should also be available. -Other equipment includes water soluble lubricating jelly, tracheostomy tube ties, dressings, scissors and 10 milliliters (ml) syringe. The water soluble lubricating jelly is for easier placement of the tracheostomy tube during insertion, trach tube ties/ dressings to stabilize the trach tube, scissors to cut the ties if needed and 10 ml syringe to inflate the cuff of replacement trach tube as needed. On 8/4/23 at 2:09 P.M., during an observation and interview with Nurse #2 in Resident #19's room, the Resident was awake and resting in bed. Nurse #2 searched the room and was unable to locate any emergency equipment. Nurse #2 said an Ambu bag and an emergency trach should always be at the Resident's bedside and these items were not found in the Resident's room as required.

Based on policy review, observation and interview, the facility failed to ensure that its staff distributed food in accordance with professional standards for food service safety. Specifically, two dietary staff members failed to wear beard restraints during the food preparation process. Findings include: Review of the facility's policy titled Staff Attire, dated May 2014, indicated, but was not limited to: -It is the center policy that all employees wear approved attire for the performance of their duties. -The Food Service Director insures that all staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. 1. On 8/2/23 at 7:15 A.M., the surveyor observed Dietary Staff #1 in the kitchen, he had a beard with no beard restraint on. Dietary Staff #1 said he was the [NAME] for that morning. The surveyor observed him preparing breakfast. 2. On 8/4/23 at 11:38 A.M., during a follow-up visit to the kitchen, the surveyor observed Dietary Staff #2 in the kitchen, assisting with the preparation of lunch service. Dietary Staff #2 had a beard with no beard restraint on. During an interview on 8/4/23 at 11:55 A.M., Dietary Staff #2 said that if his beard was more out he would have to wear a beard restraint. The surveyor asked if more out meant longer, and Dietary Staff #2 said yes, he thought his beard would have to be longer, for him to be required to wear a beard restraint.

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2), whose Health Care Proxy's had been activated, the Facility staff failed to ensure they obtained informed consent prior to the administration of haloperidol (an antipsychotic medication). Findings include: Review of the Facility's Policy, titled Behaviors, Management and Symptoms, dated as revised 10/24/22, indicated when medication is ordered for behavioral symptoms, consent must be obtained. 1). Resident #1 was admitted to the Facility in November 2022, medical diagnoses included adult failure to thrive and congestive heart failure. Review of Resident #1's Medical Record indicated his/her Health Care Proxy (HCP) was activated on 01/17/23, and therefore, his/her Health Care Agent (HCA) needed to be contacted and provide consent for health care related issues, including the administration of an antipsychotic medication. Further review of the Record indicated there was no documentation to support that the HCA was contacted or gave informed consent for the administration of haloperidol. Review of Resident #1's Physician's Orders, for January 2023, indicated he/she had orders dated effective 01/19/23, for haloperidol lactate concentrate 2 milligrams/milliliter (mg/ml), give 0.5 ml by mouth every four hours, as needed (prn), for anxiety, agitation, and delirium for 14 days. Review of Resident #1's Medication Administration Record (MAR), for January 2023, indicated he/she was administered 0.5 ml of haloperidol lactate concentrate, on 01/19/23, 01/21/23, 01/22/23, 01/23/23, 01/24/23 and 01/25/23. 2). Resident #2 was admitted to the Facility in December 2022, medical diagnoses including dementia, depression, and encounter for palliative care. Review of Resident #2's Medical Record indicated his/her HCP was activated on 12/21/22, and therefore, his/her HCA needed to be contacted and provide consent for health care related issues, including the administration of an antipsychotic medication. Further review of the Record indicated there was no documentation to support that the HCA was contacted or gave informed consent for the administration of haloperidol. Review of Resident #2's Physician's Orders, for January 2023, indicated he/she had orders dated effective 01/04/23, for haloperidol 0.5 mg by mouth every 6 hours prn for anxiety for 14 days. The Order was renewed on 01/09/23, 01/26/23, and 01/30/23. Review of Resident #2's MAR, for January 2023, indicated he/she was administered 0.5 mg of haloperidol on 01/19/23, 01/20/23, 01/22/23, 01/27/23, 01/28/23, and 01/31/23. Review of Resident #2's MAR, for February 2023, indicated he/she was administered 0.5 mg of haloperidol on 02/01/23 and 02/02/23. During an interview on 02/02/2023 at 3:08 P.M., Nurse #2 said that when an order is obtained for an antipsychotic medication, it is the charge nurse's responsibility to obtain informed consent from the Resident or from the HCA when the HCP is activated prior to initiating the medication. During an interview on 02/02/23 at 3:40 P.M., the Director of Nurses (DON) said it is the charge nurse's responsibility to obtain informed consent from a Resident or their activated HCA prior to the administration of an antipsychotic medication. The DON said the expectation, if verbal consent is obtained, that it is verified and documented by two nurses and written consent is then obtained within 24 hours. The DON said consent from the HCA's for the use of haloperidol should have been obtained for both Resident #1 and Resident #2, but she had no documentation to support that consent was obtained to administer haloperidol to either resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of neglect to the Administrator or designee. When on 01/11/23, during the overnight shift Nurse #1 was made aware of an allegation of possible resident neglect made against Certified Nurse Aide (CNA) #1. However, the Facility administration was not made aware of the allegation until 01/12/23 at 3:00 P.M., when another staff member reported the allegation to the covering Director of Nurses (DON), therefore, placing other residents at risk for potential neglect. Findings include: Review of the Facility's Policy, titled Abuse Prohibition, dated as revised 10/24/22, included the following: -Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately regardless of the shift worked. -The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. -The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/19/23, indicated that on 01/11/23 at 11:00 P.M., Resident #1 alleged that CNA #1 refused to assist him/her with toileting and addressed him/her with a derogatory term. Resident #1 was admitted to the Facility in November 2022, medical diagnoses included adult failure to thrive and congestive heart failure. The admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively intact, and required extensive assistance with transfers and toileting. During an interview on 02/03/23 at 10:38 A.M., Certified Nurse Aide (CNA) #2 said she worked from 3:00 P.M. on 01/11/23 through 7:00 A.M. on 01/12/23. CNA #2 said that around 11:00 P.M., Resident #1 alleged that CNA #1 refused to assist him/her with toileting and told him/her to soil his/her incontinence brief. CNA #2 said Resident #1 also alleged that CNA #1 called him/her a dirty old man/woman. CNA #2 said she asked Nurse #1 to assist her with changing Resident #1's brief, while CNA #1 was on break. CNA #2 said that while repositioning Resident #1, he/she told Nurse #1 about his/her allegation against CNA #1. During an interview on 02/03/23 at 2:50 P.M., Nurse #1 said she worked the overnight shift on 01/12/23, when CNA #2 asked her to change Resident #1's wound dressing, around 11:30 P.M., because it was soiled. Nurse #1 said that while she changed Resident #1's dressing, Resident #1 alleged that CNA #1 refused to provide incontinence care and called him/her a grumpy old man/woman. CNA #2 said she came to the Facility before starting her evening shift at 3:00 P.M., on 1/12/23, and reported Resident #1's allegation of neglect to the covering DON. Nurse #1 said she did not report Resident #1's allegation against CNA #1, to the on-call supervisor. Nurse #1 said the covering DON called her, on the afternoon of 01/12/23, to request a written statement about the alleged incident involving Resident #1 and CNA #1. During an interview on 02/02/23 at 3:30 P.M. the Director of Nurses (DON) said she was on vacation at the time the incident allegedly occurred between Resident #1 and CNA #1 and said the covering DON conducted the investigation. The DON said the Facility's expectation from staff is when an allegation of potential neglect is made, is for the accused staff member to be removed from duty pending investigation and to immediately report the allegation to the supervisor. The DON said it is the supervisor's responsibility to notify the Administrator, DON, or designee. During an interview on 02/02/23 at 12:56 P.M., the covering Director of Nurses (DON) said she was covering for the DON's vacation, when CNA #2 reported to her, on 01/12/23 at 3:00 P.M., that Resident #1 alleged that CNA #1 refused to provide toileting assistance on 01/11/23 during the night shift and called him/her an old man/woman. The covering DON said that this was the first time she was made aware of the alleged incident. Review of the covering DON's Written Summary of her interview with Resident #1, dated 01/12/23, indicated Resident #1 told her that on 01/11/23 between 10:00 P.M. and 11:00 P.M., he/she told CNA #1 that he/she needed to have a bowel movement and CNA #1 allegedly told him/her to go in his/her pants and she would clean him/her up later. Resident #1 also told the covering DON that CNA #1 allegedly said shut up old man/woman, you don't know what you are doing. The covering DON said Nurse #1 should have reported the allegation immediately, so the accused CNA could have been immediately removed from duty pending further investigation, to protect residents from potential neglect. The covering DON said CNA #1 worked the remainder of her 11:00 P.M. to 7:00 A.M. shift on 01/11/23 and was not removed from the schedule until 3:00 P.M. on 01/12/23, when she had been made aware of the alleged incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure an allegation of possible neglect, without major injury, was reported to the Department of Public Health (DPH) within 24 hours, and failed ensure the Police were also notified, as required by Facility Policy and Federal Regulations, when the covering Director of Nurses (DON) became aware of the allegation. On 01/12/23 at 3:00 P.M., Certified Nurse Aide (CNA) #2 reported to the covering DON, that Resident #1 alleged that CNA #1 neglected him/her on 01/11/23 during the night shift. The Facility did not report the allegation to DPH until 01/19/23 at 1:49 P.M., seven days after the alleged incident occurred, and there was no documentation to support the Police had been notified of the allegation. Findings include: Review of the Facility's Policy, titled Abuse Prohibition, dated as revised 10/24/22, indicated when there is no serious bodily injury an abuse allegation must be reported by the Administrator or Director of Nurses immediately, but not later than 24 hours after forming the suspicion, to the state survey agency and law enforcement (i.e., police, public safety officers, medical examiners). Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/19/23 and time stamped 1:49 P.M., indicated that the Assistant Director of Nurses (ADON) reported the allegation to DPH, that occurred on 01/11/23 at 11:00 P.M., when Resident #1 alleged that CNA #1 refused to assist him/her with toileting and addressed him/her with a derogatory term. The Facility submitted the HCFRS report of Resident #1's allegation seven days after CNA #2 initially reported the allegation to the covering Director of Nurses. Resident #1 was admitted to the Facility in November 2022, medical diagnoses included adult failure to thrive and congestive heart failure. The admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively intact, and required extensive assistance with transfers and toileting. During an interview on 02/03/23 at 10:38 A.M., Certified Nurse Aide (CNA) #2 said she worked from 3:00 P.M. on 01/11/23 through 7:00 A.M. on 01/12/23. CNA #2 said that around 11:00 P.M., Resident #1 alleged that CNA #1 refused to assist him/her with toileting and told him/her to soil his/her incontinence brief. CNA #2 said Resident #1 also alleged that CNA #1 called him/her a dirty old man/woman. CNA #2 said she came to the Facility before starting her evening shift at 3:00 P.M., on 1/12/23, and reported Resident #1's allegation to the covering DON. During an interview on 02/03/23 at 2:50 P.M., Nurse #1 said she worked the overnight shift on 01/12/23, when CNA #2 asked her to change Resident #1's wound dressing, around 11:30 P.M., because it was soiled. Nurse #1 said that while she changed Resident #1's dressing, Resident #1 alleged that CNA #1 refused to provide incontinence care and called him/her a grumpy old man/woman. Nurse #1 said she did not report Resident #1's allegation to the on-call supervisor. Nurse #1 said the covering DON called her, on the afternoon of 01/12/23, to request a written statement about the alleged incident involving Resident #1 and CNA #1. During an interview on 02/02/23 at 12:56 P.M., the covering Director of Nurses (DON) said she was covering for the DON's vacation, when CNA #2 reported to her, on 01/12/23 at 3:00 P.M., that Resident #1 alleged that CNA #1 neglected him/her on 01/11/23 during the night shift. The covering DON said that this was the first time she heard about the allegation. Review of the covering DON's Written Summary of her interview with Resident #1, dated 01/12/23, indicated Resident #1 told her that on 01/11/23 between 10:00 P.M. and 11:00 P.M., he/she told CNA #1 that he/she needed to have a bowel movement and CNA #1 allegedly told him/her to go in his/her pants and she would clean him/her up later. The Summary also indicated Resident #1 told the covering DON that CNA #1 allegedly said shut up old man/woman, you don't know what you are doing. During an interview on 02/02/23 at 3:30 P.M. the Director of Nurses (DON) said she was on vacation at the time the incident allegedly occurred between Resident #1 and CNA #1, and said the covering DON conducted the investigation. The DON said the Facility's expectation is that when an allegation of potential neglect is made, it is the responsibility of the Administrator or the designee to report the allegation to the Department of Public Health within the required time frame. During an interview on 02/02/23 at 2:00 P.M. the Assistant Director of Nurses (ADON) said that around 5:00 P.M. on 1/12/23, the covering DON told her about Resident #1's allegation of neglect. The ADON said she was new to reporting in the HCFRS system and never hit the submit button until she completed the findings portion of the report on 01/19/23, therefore, DPH did not receive the report of the alleged incident, until 1/19/23, a week after the alleged incident was reported by CNA #2. The ADON said the Police were called on 01/12/23. However, there was no documentation to indicate and the Facility was unable to provide documentation that the Police were notified of the allegation. The covering DON said Nurse #1 should have reported the allegation immediately, so the investigation would have been initiated and the allegation reported to DPH within the required time frame. The covering DON also said she was told the Police had been notified but said she was at the Facility until late in the evening on 01/12/23 and the Police did not come. The covering DON said she told the ADON she should call and get the police report reference number as evidence that the allegation was reported to the Police. The DON said the allegation of neglect should have been reported to the local Police but when she called the local police department for a reference number for the report, they told her they had no record of the alleged incident being reported to them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure that its staff provided a privacy bag for an indwelling Foley catheter (tube inserted into the bladder to allow urine flow) for one Resident (#10) out of a total sample of 12 residents. Findings include: Review of the facility policy titled Treatment: Considerate and Respectful, last revised 7/1/19, indicated that staff will refrain from practices that are demeaning to patients such as keeping urinary bags uncovered. Resident #10 was admitted to the facility in June 2022 with diagnoses including Urinary Tract Infection (UTI) and Malignant Neoplasm (abnormal mass of tissue) of the Prostate. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #10 was cognitively intact as evidenced by a Brief Interview of Mental Status Score (BIMS) of 12 out of 15. Further review of the MDS indicated that Resident #10 has an indwelling Foley catheter, and requires extensive assistance for toilet use, personal hygiene, and dressing. Review of Resident #10's care plan for indwelling Foley catheter, last revised 6/29/22, indicated an intervention to provide a privacy bag. On 8/24/22 at 8:35 A.M., the surveyor observed Resident #10 lying in bed with the catheter bag clipped to the side of his/her bed. There was no privacy bag covering the catheter bag. On 8/25/22 at 7:17 A.M., the surveyor observed Resident #10 lying in bed with the catheter bag clipped to the side of his/her bed. There was no privacy bag covering the catheter bag. During an interview on 8/25/22 at 7:19 A.M., the Director of Nurses said that all catheter bags should have a privacy cover.

Based on interviews and record review, the facility failed to ensure that its staff notified one sampled Resident's (#24) Responsible Party of a change in medical condition, out of a total of 12 sampled residents. Findings include: Review of the facility policy titled Notification of Change in Condition, revised 6/1/21, indicated the facility must immediately inform the Resident, consult with the Physician and notify consistent with his/her authority, the Resident's Health Care Agent (Responsible Party) where there is an accident involving the patient which results in injury and has the potential for requiring a Physician intervention, and/or a need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment) . Resident #24 was admitted to the facility in October 2021. Review of the Situation Background Appearance and Review/Notify (SBAR) Note dated 8/20/22, indicated Resident #24 experienced a fall and complained of left knee pain. The SBAR Note indicated the Physician was notified at 9:45 P.M. of the Resident's fall and instructed staff to monitor and report any abnormalities from the Resident's baseline status. Further review of the SBAR Note indicated the Resident's Responsible Party would be notified the in the morning of the previous night's fall. Review of a Nurse's Note dated 8/22/22, indicated Resident #24 continued to complain of left knee pain, the Physician was notified and ordered an X-Ray. Review of the clinical record indicated no documented evidence that the Resident's Responsible Party was notified of his/her fall on 8/20/22. During an interview on 8/24/22 at 2:04 P.M., Resident #24's Responsible Party indicated she was the Health Care Proxy (HCP) for the Resident, that he/she had recently fallen, and she was never notified by the facility. The Resident's Responsible Party further said that the facility never contacted her about the fall, and that she heard about it from another family member who visited with the Resident. She said the Resident told the visiting family member about the fall, who then informed her, the Resident's Responsible Party. During an interview and review of the Resident's clinical record on 8/26/22 at 12:54 P.M., the Director of Nurses (DON) said that there was no evidence that the Resident's Responsible Party was notified of the fall on 8/20/22 and that it must have been missed. She said that if any changes in a Resident's condition occurred, like a fall for example, the Physician and the Responsible Party would be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that its staff limited a PRN (as needed) Antipsychotic (medication used to manage/treat psychosis and other psychotic disorders) to 14 days as required, for one Resident (#16), out of a total of 12 sampled residents. Findings include: Review of the facility policy titled Psychotherapeutic Medication (used to treat problems in thought processes of individuals with both perceptual and behavioral disorders) Use, revised 11/28/17, indicated PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending Physician or prescribing Practitioner evaluated the patient for the appropriateness of that medication . Resident #16 was admitted to the facility in May 2021 with diagnoses including Dementia with Behavioral Disturbances, Bipolar Disorder and Post Traumatic Stress Disorder (PTSD). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident received seven days of antipsychotic medications during the reference period and that antipsychotic medications were administered on a routine basis only. Review of the 8/2022 Physician's Orders indicated an order, initiated 6/15/22, for Seroquel (an antipsychotic medication used to treat Bipolar Disorder) 25 milligrams (mg) daily and every 12 hours as needed for hallucinations/agitation. Review of the Pharmacist Recommendations, dated 6/2/22 and 7/12/22, indicated all PRN antipsychotic medications were limited to a duration of 14 days and required a re-examination/re-assessment by the Prescriber. The Pharmacist recommended to discontinue the PRN Seroquel and if the PRN antipsychotic could not be discontinued, the regulations required that the prescriber directly examine the resident to determine if the antipsychotic was still needed and document the specific condition being treated prior to issuing a new PRN order. Further review of the Physician's response to the Pharmacist Recommendations indicated the he/she declined the recommendations and provided a rationale. Review of the clinical record indicated the Nurse Practitioner (NP) assessed Resident #16 on 8/1/22 and indicated to continue the Seroquel medication orders. There was no further documented evidence that the Physician or NP reassessed the Resident's PRN Seroquel after 8/14/22. Review of the Medication Administration Record (MARs) for June 2022 through August 2022 indicated PRN Seroquel was administered once on 7/28/22 at 3:17 A.M. and the dose was ineffective. During an interview and review of the clinical record on 8/26/22 at 8:32 A.M., the Director of Nurses (DON) said the Physician or NP would need to evaluate the order for the Resident's PRN Seroquel and discontinue the medication if it had not been utilized or was ineffective.

Based on policy review, record review and interview, the facility failed to ensure that its staff offered the pneumococcal vaccine and educational vaccine information to two Residents (#20 and #176), out of 12 sampled residents. Findings include: Review of the facility's Pneumococcal Vaccination policy, dated 4/1/22, indicated the following: -Centers will provide the opportunity to receive the pneumococcal vaccine to all residents. -Upon admission, obtain pneumococcal vaccination history of all patients and document under Vaccination History. -Based on the resident's pneumococcal vaccination history, offer .the appropriate vaccination following the recommended schedule. -For adults who have a history of receiving a previous Prevnar 13 (PCV13) vaccine should complete the recommended Pneumococcal Polysaccharide 23 Valent vaccine (PPSV23) one year or greater after their PCV13 vaccination. 1. Resident #20 was admitted to the facility in March 2022. Review of the vaccination history indicated the Resident received the PCV13 on 9/14/16. Further review of the clinical record indicated no evidence the PPSV23 was offered to the Resident. 2. Resident #176 was admitted to the facility in August 2022. Review of the vaccination history indicated the Resident received the PCV13 on 10/4/18. Further review of the clinical record indicated no evidence the PPSV23 was offered to the Resident. During an interview on 8/24/22 at 3:34 P.M., the Infection Preventionist (IP) said the two Residents (#20 and #176) were eligible for the PPSV23 but were not offered it and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review and interview, the facility failed to ensure that its staff: 1) Offered the COVID-19 vaccine booster to one Resident (#176), out of five applicable sampled residents, and 2) Offered the COVID-19 vaccine booster to two out of two applicable sampled staff. Findings include: Review of the facility's COVID-19 Vaccination policy, dated 11/15/21, indicated the following: -Centers will provide the opportunity to receive COVID-19 vaccinations for all doses (this included dose 1, dose 2, additional dose, booster, and any future doses) following the Centers for Disease Control and Prevention (CDC) recommendations, to residents, employees, and visitors . -Provide the patient/employee the Federal Drug Administration (FDA) Fact Sheet for Vaccine Recipients and Caregivers for the COVID-19 Vaccine as education regarding the benefits and potential side effects of vaccination. -Document education, including Fact Sheet provided, in Immunization Record for patients and in the electronic employee record for employees. -If a patient refuses vaccination, document declination in the Nurse's notes and the Immunization Record. -If an employee refuses vaccination, document declination on the COVID-19 Vaccine Informed Declination in the electronic employee record. Review of the CDC website, Interim Clinical Considerations for Use of COVID-19 Vaccines, indicated the following: -For people age [AGE]-49, a total of three COVID-19 vaccines is recommended; two in the initial series and one booster dose. The booster dose should be administered at least five months after the second initial dose. -For people over age [AGE], a total of four COVID-19 vaccines is recommended; two in the initial series and two booster doses. The first booster should be administered at least five months after the second initial dose and the second booster should be administered at least four months from the first booster. 1. Resident #176 was admitted to the facility in August 2022. Review of the Resident's Immunization History indicated the Resident received a COVID-19 vaccine first dose of the initial series on 5/12/21 and a second dose of the initial series on 6/9/21 (eligible for the first booster after 11/9/21). Further review of the clinical record indicated no evidence that a COVID-19 booster was offered to the Resident, if the Fact Sheet was provided, or if the Resident declined the booster. 2. Review of the Employee Vaccination Batch-Entry, provided by the facility, indicated the following: A. Staff #1 received a COVID-19 vaccine first dose of the initial series on 11/17/21 and a second dose of the initial series on 12/21/21. The column for Education Fact Sheet Provided was left blank and there was no evidence if Staff #1 was offered a booster or declined a booster. B. Staff #2 received a COVID-19 vaccine first dose of the initial series on 1/07/21, second dose of the initial series on 1/28/21, and the first booster on 9/28/21. Further review indicated that Staff #2 received one of two booster doses that she was eligible for. The column for Education Fact Sheet Provided was left blank, there was no evidence Staff #2 was offered a second booster or declined a second booster. During an interview on 8/24/22 at 3:34 P.M., the Infection Preventionist (IP) said she was unable to provide evidence that the Resident and staff members listed above were offered the COVID-19 booster, or had declined, and had been provided the Education Fact Sheet. She said she was unaware it was in their policy to keep a record of declinations.