**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability and/or serious mental illness and needed further evaluation) for two Residents (#3 and #16), out of a total sample of 15 residents. Findings include: 1.For Resident #3 the facility failed to complete a level 1 preadmission screening and Resident Review. Resident #3 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD). Review of Resident #3 most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of possible 15 indicating he/she was cognitively intact. Further review of the MDS indicated the Resident did not have any behaviors no hallucinations or delusions and had an active diagnosis of post-traumatic stress disorder. Review of Resident #3's medical record failed to indicate a Level 1 Preadmission Screening and Resident Review (PASARR) had been completed prior to admission to the facility. During an interview on 9/15/23 at 9:09 A.M ., the Director of Nursing said the facility does not complete PASARR prior to admission as all the residents admitted to the facility are either on Medicare or private pay. 2. For Resident #16 the facility failed to complete a level 1 preadmission screening and Resident Review. Resident #16 was admitted to the facility in February 2023 with diagnoses including Parkinson's disease, bipolar disorder, major depressive disorder and anxiety. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] indicated Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated Resident #16 had taken an antidepressant and antipsychotic medication within the last 7 days. Review of Resident #16's medical record failed to indicate a Level 1 Preadmission Screening and Resident Review (PASARR) had been completed prior to admission to the facility. During an interview on 9/15/23 at 9:09 A.M ., the Director of Nursing said the facility does not complete PASARR prior to admission as all the residents admitted to the facility are either on Medicare or private pay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement the care plan for an air mattress setting causing one Resident (#21) increased pain/discomfort out of a total sample of 15 residents. Resident #21 was admitted to the facility in October 2022 with diagnoses including Chronic Obstructive Pulmonary Disease, hypertension, and muscle weakness. Review of the Most Recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 15 out of possible 15 indicating intact cognition. On 9/13/23 at 8:48 A.M., the surveyor observed Resident #21 sitting up in bed eating breakfast with an air mattress set to 400 lbs. Additional observations of the air mattress set to 400 pounds (lbs.). were made on 9/13/23 at 11:18 A.M. and 3:10 P.M., 9/14/23 at 12:27 P.M. On 9/15/23 at 7:40 A.M., the surveyor observed Resident #21 lying in bed with an air mattress set to 400 lbs. Resident #21 said he/she was not comfortable in the bed. Review of Resident #21's medical record indicated the following: -Physician Order dated, 12/12/22 for a low air loss therapy mattress at all times set between 210-250 check placement and function each shift. -A Care Plan identified pressure ulcers as a problem with an intervention including low air loss therapy mattress set between 210-250 lbs. -A Care Plan identified alteration in comfort/pain with interventions including, monitor for indicators of pain, interview for pain symptoms, causes and relief patterns, and document. Assess the location and duration of pain and any contributing factors. -A nursing note dated 9/6/23 indicated Air Mattress not functioning delivery of new one expected tomorrow. -A Physician note dated 9/14/23 indicated Resident #21 was evaluated because of newly reported left anterior chest wall pain wrapping to axilla Resident #21 indicated symptoms started about the time he/she received a new mattress. Exam pain worsened with palpation and with range of motion on left shoulder, appears to most consistent with a mechanical injury and not cardiac etiology. During an observation and interview on 9/15/23 at 8:10 A.M., the surveyor observed the Director of Nursing (DON) enter Resident #21's room, check the air mattress setting and change it. The DON said the air mattress was set to the wrong setting. The DON asked Resident #21 if he/she had been uncomfortable and Resident #21 indicated he/she had. During an interview on 9/15/23 at 8:12 A.M., Resident #21 said he/he received a new air mattress maybe a week or two ago and it has been rigid. Resident #21 said the mattress now was a little softer. Resident #21 said he/she has been uncomfortable in the bed and when asked if he/she had told anyone about it said, two to three nights ago I was wild with pain. (Pain Assessment from 9/13/23 indicated Resident had pain two nights ago.) Resident #21 said he/she asked for voltaren pain gel yesterday for pain and once he/she got out of bed and sat up he/she felt better. Review of Resident #21's nursing pain record indicated the following: -9/6/23 on the 3-11 P.M. shift Resident #21 had a pain score of 4/10 and required pain medication. -9/13/23 on the 3-11 P.M. shift Resident #21 had a pain score of 5/10 and required pain medication. During an interview on 9/15/23 at 8:24 A.M., Nurse #1 said Resident #21's mattress had been replaced due to it not functioning but was unsure when it got changed out. Nurse #1 said the expectation for physicians' orders is to follow them as ordered. Nurse #1 looked at the Medication Administration Record (MAR) with the surveyor and said he omitted the order to check the air mattress function and setting. Nurse #1 said he failed to look at the air mattress for correct setting on 9/14/23. Nurse #1 said Resident #21 had expressed discomfort on 9/14/23 and he contacted the physician to assess the Resident. Nurse #1 said once Resident #21 got out of bed and was sitting in his/her wheelchair on 9/14/23 the discomfort cleared. During an interview on 9/15/23 at 9:04 A.M., the DON said the expectation is for nursing staff to follow physician's orders. The DON was unsure why the air mattress was set to 400 lbs. for the duration of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically providing assistance with grooming, for one Resident (#17) out of a total sample of 15 residents. Review of the facility policy titled Activities of Daily Living (ADL), last revised 3/2018, indicated the following: Policy Statement: *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation: *2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care) Resident #17 was admitted to the facility in August 2023 with diagnoses including unspecified fracture of upper end of right humerus, bicondylar fracture of tibia, and muscle weakness. Review of Resident #17's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that he/she had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 which indicated that he/she has moderate cognitive impairment. The MDS also indicated Resident #17 requires extensive assistance of one person for daily self-care. On 9/13/23 9:39 A.M., Resident #17 was observed sitting in his/her room washed and dressed and had long facial hair on his/her chin. Resident #17 was asked about his/her facial hair and said he/she prefers no chin hair. Resident #17 was asked if he/she would like it removed, he/she said yes. On 9/14/23 at 8:34 A.M., and 9/15/23 at 8:26 A.M., Resident #17 was observed sitting in his/her wheelchair washed and dressed and had long facial hair on his/her chin. Resident #17 was asked if he/she was asked if he/she would like their facial hair removed during morning care, he/she said no. Review of Resident #17's Activity of Daily Living care plan, initiated 8/16/23, indicated the following intervention: *Hygiene: assist of 1 staff. Record review on 9/15/23 at 9:36 A.M., failed to indicate Resident #17 had any refusals or behaviors impeding morning care. During an interview on 9/15/23 at 8:55 A.M., Certified Nursing Assistant (CNA) #1 said facial hair removal is part of a resident's care and they should be asked if they would like it removed. CNA #1 was asked if she offered to remove Resident #17's facial hair during morning care. CNA #1 said not this morning. During an interview on 9/15/23 at 9:10 A.M., The Director of Nursing said removing unwanted facial hair is part of the daily care provided to residents and should be removed with the Resident's permission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#3), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total 15 sampled residents. Findings include: Review of the facility policy titled 'Trauma Informed and Culturally Competent Care' revised August 2022, indicated the following but not limited to: *To guide staff in providing care that is culturally competent and trauma- informed in accordance with professional standards of practice. *To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. *Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Resident #3 was admitted to the facility on [DATE] with diagnoses including post traumatic stress disorder (PTSD). Review of Resident #3 most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of possible 15 indicating he/she was cognitively intact. Further review of the MDS indicated the Resident did not have any behaviors, no hallucinations or delusions, and had an active diagnosis of post traumatic stress disorder. Review of Resident #3's medical record failed to indicate a trauma informed care plan. During an interview on 9/15/23 at 9:09 A.M ., the Director of Nursing said that social services will see the residents if they have a diagnosis of PTSD and a care plan is developed. She further said Resident #3 should have a trauma informed care plan.

Based on observation, interview, and policy review, the facility failed to ensure medications 1. were stored properly and labeled 2. once opened, were dated as required for 2 out of 2 observed medication carts. Findings include: Review of the facility policy titled, Medication Labeling and storage revision date February 2023 included the following: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. -Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. On 9/14/23 at 10:05 A.M., the surveyor observed the following while observing a medication pass on the A Unit: -An incruse inhaler, opened and undated. On 9/15/23 at 12:51 P.M., the surveyor observed the following on the B side medication cart: -Advair discus, open and undated. -Glargine insulin, with an open date of 8/15/23. During an interview on 9/15/23 at 12:51 P.M., Nurse #2 said insulin is good for 28 days once opened and the insulin should be discarded, and inhalers should be dated when opened. During an interview on 9/15/23 at 1:38 P.M., Unit Manager #1 said insulin is good for 28 days once opened and inhalers should be dated when opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics and failed to complete Antibiotic usage audit tools (Line Listings), which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program for one resident (#16) out of a total sample of 15 residents. Findings include: Review of facility policy titled, Infection Control and Antibiotic Stewardship Program undated included the following: -Infection preventionist have been assigned responsibility for promoting an overseeing the antibiotic stewardship program, -Tracking as part of current surveillance the number of doses of each specific antibiotic and the site will be recorded. -Monthly surveillance reports are presented at the Infection Control and antibiotic stewardship committee and QAPI. Resident #16 was admitted to the facility in February 2023 with diagnoses including Parkinson's disease and atrial fibrillation. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] indicated Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated Resident #16 was always incontinent. During an interview on 9/13/23 at 11:42 A.M., Resident #16's family member said he/she has had 4-5 Urinary Tract Infections (UTI) since admission in February 2023. Resident #16's family member said he/she was unsure why Resident #16 continued getting UTI's. Review of Resident #16's Physician Progress Notes dated 9/11/23 indicated the following: -3/22/23 urinalysis, culture pending, will start vantin as awaiting culture and sensitivity results. -4/7/23, since last seen has completed a course of vantin. Back at baseline. -4/21/23, recent confusion x2 days. Check urinalysis, culture and sensitivity will start vantin course and monitor. -6/13/23, Urinalysis suggestive of UTI will begin course of vantin. -6/28/23, Has had 3 UTI's since admission. -9/6/23, Asked to evaluate as has had blood in urine, mildly confused from baseline. Will obtain Urinalysis Culture and Sensitivity, likely UTI. -9/8/23, urine sent to evaluate hematuria for UTI. -9/11/23, Started on vantin, urine culture pending. Review of the Infection Preventionist (IP) line listing of infections indicated Resident #16 had a UTI with antibiotic use in March 2023 and June 2023. Line Listings failed to indicate infection in month of April 2023 and September 2023 with antibiotic use. During an interview on 9/15/23 at 12:09 P.M., the Infection Preventionist (IP) said she obtained information on who has been started on an antibiotic primarily from other staff. The IP said she has her line listing is a combination of on the computer and on paper. The IP said she has not done any specific education with physician or staff on antibiotic stewardship besides handing them a blank McGeer's form (A form that helps identify if antibiotics should be used for symptoms). The IP was unable to say if she had questioned Resident #16 being placed directly on an antibiotic multiple times prior to culture results coming back. The IP said she missed that Resident #16 was on antibiotics for a UTI in the month of April. Review of Resident #16's medical record indicated the following: -Physician order dated 9/8/23 cefpodoxime 100 milligram (mg) tablet by mouth twice a day for UTI, last dose 9/13/23. -Lab Results preliminary 9/11/23 resulted Klebsiella Pneumoniae ssp pneumoniae, did not indicate treatment of cefpodoxime as susceptible. -Lab Results dated 9/12/23 preliminary resulted Klebsiella Pneumoniae ESBL. Lab results noted that Resident is being treated with Vantin 100 mg BID until 9/14/23. Susceptible antibiotics failed to indicate Vantin (Cefpodoxime) as appropriate medication.

Based on record review and interview, the facility failed to transmit discharge Minimum Data Sets (MDS's) within 14 days after completion for 22 Residents (#9, #6, #23, #4, #3, #25, #18, #22, #26, #21, #19, #7, #20, #13, #11, #14, #5, #15, #12, #8, #16, and #10) out of a total sample of 34 residents. Findings include: Review of the Minimum Data Sets for the following residents indicated that a discharge MDS had been started, and not transmitted within 14 days, on the following dates: - Resident #9 had a discharge MDS initiated on 3/8/22. - Resident #6 had a discharge MDS initiated on 3/28/22. - Resident #23 had a discharge MDS initiated on 4/3/22. - Resident #4 had a discharge MDS initiated on 3/5/22. - Resident #3 had a discharge MDS initiated on 2/18/22. - Resident #25 had a discharge MDS initiated on 8/6/22. - Resident #18 had a discharge MDS initiated on 3/16/22. - Resident #22 had a discharge MDS initiated on 5/6/22. - Resident #26 had a discharge MDS initiated on 4/13/22. - Resident #21 had a discharge MDS initiated on 3/18/22. - Resident #19 had a discharge MDS initiated on 3/30/22. - Resident #7 had a discharge MDS initiated on 3/24/22. - Resident #20 had a discharge MDS initiated on 5/6/22. - Resident #13 had a discharge MDS initiated on 3/4/22. - Resident #11 had a discharge MDS initiated on 3/3/22. - Resident #14 had a discharge MDS initiated on 3/21/22. - Resident #5 had a discharge MDS initiated on 3/7/22. - Resident #15 had a discharge MDS initiated on 3/12/22. - Resident #12 had a discharge MDS initiated on 3/31/22. - Resident #8 had a discharge MDS initiated on 4/20/22. - Resident #16 had a discharge MDS initiated on 4/20/22. - Resident #10 had a discharge MDS initiated on 3/30/22. During an interview on 8/10/22 at 10:04 AM the MDS coordinator said that the discharge MDS should have been submitted and wasn't. She said that the staff has been busy with everything after COVID and it probably slipped through the cracks.