**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a responsible party (RP)/family member/Durable Power of Attorney (DPOA) was notified when a resident left the facility against medical advice (AMA) for one resident (R111) of one reviewed for notification of changes. Findings include: A record review of R111's electronic medical record revealed the following progress note, 8/13/24 02:53 AM: 8/12/24, around 20:40 (8:40 PM) [R111] stated to writer that [they] [were] leaving [Nursing Home] tonight with [their two friends]. [R111] stated that [they] [were] going to the [Upper Peninsula] and [they] will not be returning to [nursing home]. Conversation had with [R111] encouraging [them] to stay at facility and [they] continued to refuse. [R111] asked plans for transportation, where [they] will be staying once [they] left the facility as well as who is going to provide care for [them] when needed. [R111] stated that [their] friend [had] transportation, provides shelter and her two friends will help care for [R111] DON (Director of Nursing) contacted regarding situation and spoke directly with [R111] about [their] decision to leave AMA. DON suggested to [R111] that [they] stay tonight so our team can speak with [them] in the morning, make proper arrangements for possible homecare and provide all available resources to guest before leaving against medical advice and [R111} continued to refuse. [R111] made aware of the importance of medication compliance and that [they] [had] prescription medications that will need to be filled by a doctor. [R111] made aware that [they] need a physician overseeing [their] care and also made aware that [they] need someone to help provide care for [their] basic needs and medical needs. [R111] claimed [that their] pain medications [they] received here do not work for [them] anyway's and [that they] do not need a doctor. [R111] also claims that [they] have [their] two friends that can help with [their] care and [they] can also provide [their] own care for [themselves], as [they] [have] always done so before. [R111] continued to refuse to stay at [nursing home] despite multiple attempts and conversations with writer and DON. MD (Medical Doctor) contacted by DON, notified of situation and said 'Okay it is AMA.' [R111] signed face sheet stating [they were] leaving against medical advice on 8/12/2024 at 21:20. Further record review revealed the following email sent to R111's designated responsible party (RP) C by Social Services Director (SSD) A on 8/13/24 at 9:39 AM, Wanted to let you know that to my surprise, found out this morning that [R111] is no longer at the facility. I'm not sure if you were aware of that. [R111] checked [them self] out last night, stated [they] [were] going to live with friends. Several staff members had discussions with [R111] but [R111] [insisted] on leaving . Further review of R111's progress notes revealed the following, On 8/16/24 1421 (2:21 PM) Phone call received from [Social Worker] from an [out of state hospital] stating that [R111] had arrived at the emergency room (ER), 'caked in urine and feces' with [their] [friend]. [Friend] stated that [R111] was unable to transfer from vehicle to the restroom and [that they] [were] unable to transfer [R111]. [R111] had not exited vehicle since leaving [nursing home] [Social Worker] stated that [R111] provided phone number for [RP/Family member] and requested writer to confirm phone number. [Social Worker] also requested rx (prescription) list and DPOA (durable power of attorney) papers to assist w (with)/ initiation of care and discharge planning. Writer sent information to [Social Worker]. Continued review of R111's EMR revealed family member C was indicated in R111's record to be the responsible party and DPOA. A document titled, .DPOA For Healthcare was signed by family member C and dated 7/19/22. Per review of R111's EMR, R111 was originally admitted to the facility on [DATE] with diagnoses that included Multiple sclerosis (autoimmune disease) and Chronic obstructive pulmonary disease (COPD) (lung disease). R111's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R111 had a moderately impaired cognition, was dependent for toileting, and required assistance with showering, bathing, and dressing. On 10/9/24 at 4:04 PM, Registered Nurse (RN) B was interviewed by phone and asked about the discharge of R111 from the facility on 8/12/24. RN B indicated that R111 made the decision to leave the facility and discharge with a friend on, the spur of the moment. RN B was asked if R111's RP/DPOA/Family member C was contacted regarding R111's discharge from the facility. RN B' was not able to provide an answer to this question. On 10/10/24 at 12:12 PM, R111's RP/DPOA/Family member C was contacted by phone and asked about R111's discharging from the facility on 8/12/24. Family member C stated, This is a messed up situation. They shouldn't have let [R111] go without notifying me. [R111] left with someone I consider to be a stranger. Family member C indicated that they had not spoken to [R111] in over three weeks and were unaware of [R111's] current whereabouts. Family member C indicated that [R111] was incontinent and dependent upon others for their care. Family member C stated, I'm very upset that the [nursing home] let [R111] leave their facility without notifying me. On 10/10/24 at 12:47 PM, The Social Service Director (SSD) A was interviewed about R111 leaving the facility AMA and asked if the RP/Family Member/DPOA should have been contacted upon R111 leaving the facility. SSD A stated, [R111] was her own RP when they left the facility. The business office changed it, I had nothing to do with it. SSD A was further interviewed and asked if they had any documentation to provide which indicated that R111 was their own RP on 8/12/24 when they left the facility AMA. SSD A was unable to provide any documentation to the surveyor regarding this issue. On 10/10/24 at 1:16 PM, the Director of Nursing (DON) was interviewed about R111 leaving the facility AMA and asked if the RP/Family Member/DPOA should have been contacted upon R111 leaving the facility. The DON stated, [R111] was cognitively intact. The DON further indicated that they felt that it was unnecessary to contact [R111's] RP/Family Member/DPOA regarding [R111] leaving the facility AMA. A facility policy titled, Discharge or Transfer of Resident Effective: 10/24/17 was reviewed and revealed the following, Purpose: To provide safe departure from the center .To provide guidelines to ensure the proper steps are taken should a resident .request to be discharged from the center against medical advice (AMA). Discharge Against Medical Advice: 1. The resident/guest/and/or family legal representative should be informed of the risk involved, the benefits of staying at the facility and alternatives to do both .2. Document in the Medical Record regarding the information was presented to .the family responsible party if needed. 3. Notify Adult Protective Services .if self-neglect is suspected and document as needed. A facility policy titled, Change of Condition Resident Family/Responsible Party Notification Revision Date: 4/12/16 was reviewed and revealed the following, Purpose: Family and/or responsible party are notified anytime there is a change in the resident's condition or plan of care. Procedure: 1. Notification of any change in the resident's condition will be done in a timely manner .Check the medical record for specific family/responsible party instructions regarding notification. 2. Notify appropriate party and record in resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure interventions for repositioning were implemented for care of a pressure injury (skin impairment) for one resident (R35) of three reviewed for pressure ulcer care. Findings include: On 10/08/24 at 10:38 AM, R35 was observed to be on their back in bed with the head of the bed elevated around thirty degrees; their lower legs were elevated on a pillow and an active low air loss mattress was in place. On 10/08/24 at 12:07 PM, R35 was observed to be in bed as before, legs elevated, and the head of the bed elevated around thirty degrees. At 12:43 PM, R35 appeared positioned in bed as before. Licensed Practical Nurse (LPN) D nurse raised the bed a little higher to around 45 degrees and stood next the bed to assist R35 to eat. On 10/08/24 at 1:33 PM, resident observed to be awake, eyes open with the TV on. R35 was observed to be in bed on their back with the head of the bed elevated around 30 to 45 degrees. The legs appeared elevated. R35 reported they were generally not feeling well. At 4:21 PM and 4:40 PM, R35 was observed to be in bed on their backside with the legs elevated. R35 appeared positoned in bed as before. A review of the progress notes revealed no documented refusal to be repostioned. On 10/09/24 at 8:35 AM, 9:06 AM, 10:36 AM, 10:48 AM, and 11:29 AM, R35 was turned toward they're right side with a pillow on the left side behind the torso. R35 appeared asleep with their head toward the right side of pillow. At 10:48 AM and 11:29 AM the heels were on the bed surface. Review of the record for R35 revealed R35 was admitted into the facility on [DATE]. Diagnoses included Falls and Stroke with weakness and paralysis which affected the left side. The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and the need for partial/moderate assistance for toileting hygiene and total dependence for transfer, toilet transfer, sit to stand, and walking. The nursing care plan Actual skin impairment (related to) terminal pressure injury on sacrum (buttocks) and DTI (deep tissue injury) left heel. Revised 10/06/24 indicated, .turn side to side to stay off sacral wound as tolerated . Also indicated were PRAFO (Pressure Relief Ankle Foot Orthosis) boots while in bed A review of the October 2024 Treatment Administration Record (TAR) and Medication Administration Record (MAR) documented, Turn side to side to stay off sacral wound as tolerated and use positioning device if needed for support as tolerated two times a day. A review of a physician note dated 09/30/24 documented, .Pressure induced deep tissue damage left heel, Patient with noted DTI (non-blanchable deep red, purple, or maroon areas of intact skin) of left heel and stage I pressure ulcer (non-blanchable reddened areas of intact skin) right heel also sacral [NAME] (non healing) ulcer. Patient has declined significantly under hospice care, patient with end-stage skin breakdown/failure. Continue with the frequent position change and also try to keep pressure off of both heels by floating. On 10/10/24 at 8:31 AM, Licensed Practical Nurse (LPN) G indicated R35's sacral area appeared to have improved and did not feel R35 would reposition independently. On 10/10/24 at 11:40 AM, the Director of Physical Therapy reviewed the most recent therapy notes and reported R35 was max assist for transfer, walking and bed mobility. On 10/10/24 at 3:25 PM, the identified concerns were reviewed with the Director of Nursing (DON). The wound pictures of the sacral area were reviewed and indicated the wound had been open and closed but the purple discoloration remained. The DON reported the aide should attempt to reposition the resident on rounds which should be at least every two hours. A review of the Pressure Ulcer Risk Assessment policy revised October 2010 revealed, .Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time .Pressure ulcers are often made worse by continual pressure .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00146218. Based on observation, interview, and record review, the facility failed to document targeted behavior and non-pharmacological intervention attempts and prior to use of a psychotropic medication (ativan/lorazepam) for one resident (R35) of three reviewed for medication use. Findings include: On 10/08/24 at 10:38 AM, R35 was observed to be awake and alert and easily answered yes and no questions and provided detail to answers. At 1:33 PM, R35 was observed to be awake, eyes open with the TV on. R35 reported they were generally not feeling well but was awake and alert. At 4:21 PM and 4:40 PM, R35 was observed to be in bed. At 4:40 PM, R35 had two visitors and was engaged in a conversation. On 10/09/24 at 4:50 PM, R35 appeared asleep on each encounter and did not remain awake or with eyes open after query. On 10/10/24 R35 appeared asleep and did not open their eyes to a knock on the door or a call of their name. At 11:24 PM, the visitor indicated R35 did not awaken to their voice. R35 did not awaken to a knock on the door or a call of their name. R35 appeared to remain asleep and did they open their eyes nor move during the conversation with the visitor. A review of the physician orders for R35 revealed: An order dated 09/05/24 which documented, Lorazepam Oral Tablet 0.5 (milligrams) MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety. The order did not have a 14 day stop date. An order with start date of 09/23/24 for Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety for 6 Months. Document 3 non-pharm interventions prior to giving. An order with start date of 10/07/24 documented, Ativan oral tablet, 0.5 MG Lorazepam, Give one tablet four times daily for anxiety. A review of the September 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed: The Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety did not have a 14 day stop date. The progress notes indicated upon a pharmacy review dated 09/23/24 the order was discontinued on 09/23/24. No as needed administrations were documented during this time. The Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety for 6 Months Document 3 non-pharm interventions prior to giving was documented as given two times on 09/29/24. A review of the progress notes and September 2024 MAR and TAR revealed no indications of anxiety or non-pharmacological interventions attempted. Further review of the September 2024 MAR documented, (Ativan) Lorazepam Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to Anxiety Disorder was last given 09/16/24. A review of the October 2024 MAR revealed, Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety for 6 Months Document 3 non-pharm interventions prior to giving was documented as given on 10/03/24 and 10/07/24. A review of the progress notes and October 2024 MAR and TAR revealed no indications of anxiety or non-pharmacological interventions attempted. A physician note was dated 09/30/24 and did not indicate increased episodes of anxiety. A nurse note dated 10/07/24 documented weight warning and the request to have the ativan scheduled. It was was further documented the Ativan scheduled four times a day was given on 10/07/24 and had continued four times a day on 10/08/24 and 10/09/24 and had been given at midnight and six AM on 10/10/24. A progress note date 10/07/2024 at 10:44 AM by Licensed Practical Nurse (LPN) E revealed, .Family requesting Ativan to be ordered scheduled as well as (as needed) PRN due to guests recent agitation. Hospice aware. Order ok by (Nurse Practitioner) NP and (doctor) Dr. and hospice. Placing order at this time . The prior note was a weight change warning note dated 10/03/24. No indication of restlessness or anxiety was noted. A review of the hospice note dated 09/26/24 documented, has been more awake and talking since reducing meds .speech has been easier for (R35) . Further review of the Nurse Practitioner and Physician notes dated 07/11/24, 08/02/24 and 08/07/24 documented the chief complaint as fatigue. The 08/07/24 visit note documented a daughter's concern for medication related sedation. A review of the record for R35 revealed R35 was admitted into the facility on [DATE]. Diagnoses included Anxiety Disorder, Bipolar Disorder, Falls and Stroke. The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and the need for partial/moderate assistance for toileting hygiene and total dependence for transfer. The nursing care plan At risk for changes in mood (related to) r/t Adjustment (Disorder) d/o with anxiety and depressed mood initiated 09/24/21, revised 08/21/24 revealed, .Observe for potential side effects of psychotropic medication prescribed for anxiety, such as drowsiness, fatigue, headache, dizziness, and weight changes. On 10/10/24 at 3:25 PM, the identified concerns were reviewed with the Director of Nursing (DON). The DON was asked about the ativan scheduled four times a day when the as needed had only been used three times and indicated it was related hospice care and the family concerns. The DON was also asked about the missing documentation for the indication for use of a psychotropic medication and documentation of non pharmacological interventions prior to as needed administration of the ativan. The DON indicated they would look into it. No further documentation or information was provided prior to exit. On 10/10/24 at 3:52 PM, the observed sedation of R35 was noted to the Hospice Registered Nurse (RN) F. RN F was asked about the scheduled ativan four times a day and the indications for administration of the as needed Ativan as only three Ativan administrations had been documented. RN F noted the recent discontinuation of many of R35's psych medications and they try to consider resident and family requests to provide comfort for the resident. A review of the policy titled, Palliative/End of Life Care - Clinical Protocol revised October 2010 revealed, .The hospice and facility will communicate with each other when any changes are indicated or made to the plan of care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00143027, MI00143206, and MI00142945. Based on observation, interview, and record review the facility failed to protect and report an allegation of abuse to the abuse coordinator in a timely manner, for one resident (R902) of three residents reviewed for abuse. Findings include: A review of the Intake revealed, It was alleged the resident was physically and verbally abused by an employee. A review of R902's medical record revealed, R902 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. A review of R902's Minimum Data Set (MDS) assessment dated [DATE] noted, R902 with an intact cognition and dependent of staff to complete activities of daily living. On [DATE] at 10:50 AM, R902 was observed sitting on the side of the bed. R902's face was observed with bruising around both of their eyes. R902 was asked how their eyes became bruised. R902 explained that they didn't know, but it was not related to this incident (physical abuse) and that they bruise easily. R902 was asked about the incident with Certified Nursing Assistant (CNA A). R902 explained that CNA A punched them in their left arm and grabbed them hard. R902 continued and stated that this was the first time something like this had happened. R902 explained, that they were up that night and couldn't sleep and that they pressed their call light, and it seemed that CNA A had a problem with them pressing the light. R902 was asked the time the incident occurred and explained they couldn't remember but it was late around 1:00 AM on [DATE]. R902 was asked if they reported the incident right away and stated, Yes. R902 explained they reported the incident to their nurse. R902 added that they always offer the CNAs candy after the care, but they did not offer CNA A any after this incident. On [DATE] at 12:24 PM, CNA A was interviewed via phone and was asked about the incident with R902. CNA A explained that the incident was on a Friday night. They were short staffed and that they had been in (R902's) room one time for care. CNA A stated, Because we were so short (staffed), I had two hallways. When you go in R902's room [R902] is always at the bottom of the bed. I pulled [R902] up and changed them. After I was done [R902] asked me to turn off their decorative lights and to hand them a heart frame picture that had their deceased family in it with them. CNA A stated, [R902] had said they [family member] had just passed away. I said I was so sorry and after I was done [R902] offered me a (chocolate) kiss, but I declined. CNA A was asked around what time did this interaction occur, CNA A stated, around 1:45 AM. CNA A explained that sometime after that R902 put the light on and requested a pain pill. CNA A said they told Nurse B and they replied that R902 had to wait 30 minutes before they could get the pain pill. CNA A stated they think they went back and told R902 what Nurse B said about the pill. CNA A stated, Around 1:55 AM, I reminded Nurse B to give R902 the pain pill. After Nurse B came out, Nurse B told me [R902] said I punched [them]. CNA A then explained that Nurse B implied that they didn't believe R902, but to not go back to R902's room. CNA A further explained that next day they received a call from them Director of Nursing (DON) around 1:00 PM, about the allegations and that they were suspended because of the allegations. CNA A was asked if they worked the rest of their shift after Nurse B reported the allegation to them. CNA A stated, I worked 7pm-7am the entire shift. I was just told not to go back to that room. CNA A was asked if they went back into R902's room. CNA A stated, Yes, to check on the roommate. On [DATE] at 12:06 PM, Nurse B was called for an interview, a voice message was left for a return call. A review of the facility's investigation statement by Nurse B revealed, On the night of [DATE] going into [DATE] writer was nurse on shift on 200 hall. On [DATE] a few hours into the shift, the [CNA A], came to writer and said [R902] wanted to speak to nurse. Writer went into guest's bedroom, guest was lying in bed, vitals were taken and blood pressure was slightly elevated ., writer asked guest if [R902] was okay because a few hours earlier, guest blood pressure was lower ., guest informed writer [R902] did not feel safe with that aide. And guest expressed how at times [CNA A] will refuse to change guests brief, and when [CNA A] does change guests brief, guest states she is too rough with me, these bruises are probably from her. Guest expressed to writer that any time aide works 200 hall , aide is rude to guest, rough with care with guest ., she says she has too many people to change.Writer informed guest that she would speak with aide and make sure aide did not enter guests' room to perform care for the rest of the shift. Writer went into hallway after departure from guest's room to find CNA, CNA was sitting in chair in the hallway, on her laptop, head down. Writer told CNA that if a call light for [R902' room] goes off, to inform writer or the other CNA on shift and care will be provided from writer or other CNA, writer told CNA that guest does not want CNA back in room . Writer arrived for night shift on [DATE], writer was getting report from off going nurse . Nurse expressed to writer that this morning, the guest in [R902's room] informed her that after the writer left the guests room last night, CNA went back in guests' room, after the writer spoke with the CNA instructed her to not to enter guests' room . On [DATE] at 1:20 PM, the DON was asked the facility's procedure after an allegation of abuse from staff is made by a resident. The DON explained that the staff is sent home and that the allegation is reported to the abuse coordinator, which is the Nursing Home Administrator (NHA). The DON further explained that they didn't get the report of abuse until the next day. The DON was asked if Nurse B followed the facility's procedure with this allegation. The DON explained that Nurse B did not and that they were educated on the abuse policy and procedure. On [DATE], at 2:12 PM., the NHA was asked the facility's expectation regarding reporting allegations of abuse. The NHA explained, the Nurse should have called us right away. She had both of our personal numbers. A review of the facility's investigation documentation noted, a timeline by the NHA that revealed, [DATE] 12:44 PM, Notified of an allegation of abuse by the DON. DON stated she initiated investigation, suspended CNA and will interview resident for her statement . [DATE] 3:38 PM Reported to [local police department] and asked for an officer to be sent to the facility . A review of the facility's policy titled ABUSE, NEGLECT AND/OR MISAPPROPRIATION OF RESIDENT FUNDS OR PROPERTY dated, [DATE] revealed, . d) PROTECTION & IDENTIFICATION i) The Administrator and/or Director of Nursing (DON) must be notified of all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown origin and misappropriation of resident property immediately. If the events that cause the allegation involve abuse or result in serious bodily injury, the facility administrator or DON will report to appropriate licensing agencies and local officials immediately but not later than 2 hours and not later than twenty four (24) hours if the events that cause the allegation does not involve abuse and did not result in serious bodily injury. ii) . Managed Communities will take all action necessary to prevent the abuse, neglect, or misappropriation of the resident ' s funds or property from occurring while it is conducting its investigation of the incident, and will also take appropriate action to attempt to prevent similar incidents in the future. (1) Protect the Resident. (a) If the resident is injured as a result of the alleged or suspected abuse or neglect, the center shall take immediate action to treat the resident. If appropriate, the center shall send the resident to the hospital for an examination. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Protection from retaliation; and -Providing emotional support and counseling to the resident during and after the investigation, as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a care plan to address the feeding assistance requirements and interventions for one (R92) of five residents reviewed for plans of care, resulting in the potential for unmet care needs. Findings include: Review of the facility record for R92 revealed an initial admission date of 07/14/22 with the most recent admission being 03/25/23 with diagnoses that included Vascular Dementia, Osteomyelitis of the Ankle/Foot and Diabetes Mellitus. The Minimum Data Set (MDS) assessment dated [DATE] (Significant Change in Status Assessment) indicated R92 required partial/moderate assistance for eating. The Brief Interview for Mental Status (BIMS) assessment score of 0/15 indicated severe cognitive impairment. On 08/14/23 at 9:21 AM, R92 was observed receiving assistance for eating breakfast. They required consistent cueing for alertness and appeared to be very minimally able to participate. On 08/15/23 at 4:02 PM, R92 was observed sitting up in the wheelchair in their room alone. R92 was intermittently responsive to voice and was leaning to the left side against the armrest. There was spilled food, a napkin and a spilled water cup laying on the floor near their feet. On 08/16/23 at 9:00 AM, R92 was observed laying in bed with the head of the bed elevated approximately 45 degrees. The breakfast tray was set up on the over-bed table and was uneaten. The coffee cup was empty and the tray was covered with coffee. The serving dishes, bowls and utensils were sitting in the spilled coffee. At 9:26 AM, R92 remained directly observed and had not been checked on or assisted since 9AM. At 9:29 AM, an unkown staff entered/exited R92's room without any interaction/assistance provided to R92. At 9:45 AM, R92 was observed in the previous position with the food tray unchanged. When asked if they were hungry R92 stated You're damn right I am. When asked if they could try to eat some food R92 was not able to respond clearly. At 9:49 AM, Licensed Practical Nurse (LPN) G and a Certified Nurse Assistant (CNA) entered R92's room together. At 9:59 AM, LPN G exited R92's room with the breakfast tray. During interview with LPN G it was observed that the breakfast remained uneaten. LPN G was asked if R92 required or was care planned for feeding assistance and LPN G stated Yes and reported that R92 sometimes accepts the feeding assistance and sometimes they do not. LPN G was asked if assistance had been attempted with this meal and they stated Yes, but it didn't go too well. Review of R92's Activites of Daily Living (ADL) Care Plan dated 07/28/23 revealed no interventions that addressed eating/feeding assistance. Review of R92's Dietary Profile dated 07/30/23 indicates that R92 requires Partial assistance with eating consistent with the MDS assessment. On 08/16/23 at 12:09 PM, the facility Director of Nursing (DON) reviewed R92's care plan and agreed that feeding assistance was not directly addressed on the care plan. Review of the undated facility policy titled Care Planning - Interdisciplinary Team revealed the following Policy Statement: Our facility's care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer intravenous (IV) medication per professional standards of nursing practice for one resident (R278) of five reviewed for medications, resulting in the potential for error and/or adverse reactions. Findings include: On 8/14/23 at 10:47 AM, R278 gave this surveyor their name during initial tour screening. R278 was noted to have an intravenous (IV) medication infusing through a PICC (peripherally inserted central catheter) line in their left arm. Closer observation of the label on the medication bag revealed an almost empty bag of Daptomycin (antibiotic) - 1000 milligrams (mg) per 50 milliliters (mL). The full patient name written on the bag did not match the name of R278. (same first name as R278; different last name). The medication was administered through dial-flow tubing. Registered Nurse (RN) A was nearby and was asked to enter the room at this time. RN A confirmed that the name on the IV medication bag did not match R278's name. A review of R278's record revealed that the resident was admitted on [DATE] with diagnoses of Local Skin and Subcutaneous Tissue Infection, Acute Embolism and Thrombosis of Left Femoral Vein, and Hypertension. Further review revealed the following medication order: Daptomycin Intravenous Solution Reconstituted - Use 900 mg intravenously in the morning for Left knee periprosthetic infection until 09/11/2023 .Active .Start Date: 8/11/2023 07:00 . On 8/14/23 at 10:53 AM, R278's assigned nurse, Licensed Practical Nurse (LPN) C, was interviewed and confirmed that the name on the IV medication bag did not match R278's name. LPN C claimed she had reconstituted the medication correctly per R278's order and added that she must have only looked at the first name listed on the bag. When queried regarding how nurses are supposed to identify they have the right patient before administering a medication, LPN C stated that there are photos in the residents' electronic medical records (EMRs). On 8/16/23 at 10:22 AM, the Director of Nursing (DON) was interviewed and indicated that RN A had done an immediate 1:1 education on 8/14/23 with LPN C regarding the rights of medication administration (right patient, right drug, right dose, right route, right time, right documentation) and labeling. The DON added that starting on 8/14/23, all staff nurses were receiving in-service education on medication administration. A review of the facility's policy/procedure titled, Medication Administration General Guidelines, dated 01/21, revealed, Policy: Medications are administered as prescribed in accordance with .good nursing principles and practices .Residents are identified before medication is administered using at least two resident identifiers .Medications supplied for one resident are never administered to another resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review, the facility failed to provide timely nail care for one (R67) of five residents reviewed, resulting in the nails of the contracted left hand embedding into the skin of the palm and the potential for skin breakdown. Findings include: Review of the facility record for R67 revealed an initial admission date of 08/29/22 with the most recent admission being 03/03/23 with diagnoses that included Respiratory Failure with Hypoxia, Heart Failure, Rheumatoid Arthritis and Hand [left] Contracture. The Minimum Data Set (MDS) assessment dated [DATE] indicated R67 required moderate/maximum assistance with most self care activities. The Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition. On 08/14/23 at 11:54 AM, R67 was observed to be wearing a left hand palm protector. R67 demonstrated that their fingers did not open on that hand and they reported that they were able to take the palm protector on and off independently. On 08/15/23 at 11:59 AM, R67 was observed laying in bed without the left hand palm protector on. R67 was able to hold the left hand up and manually open the fingers to allow observation of the palm which was significantly red and had nail indentations from digits four and five (ring and pinky fingers). R67 reported that their nails were digging into the palm and stated I like to have the nails on that hand kept shorter but they haven't been cut in awhile. The nails were observed to be approximately one half inch beyond the finger tips and with sharp corners. The hand and nails did appear clean and there was no foul odor. On 08/16/23 at 8:57 AM, R67 was observed sitting up at the edge of the bed eating breakfast. R67 reported that their nails on the left hand had been cut yesterday afternoon after they asked the nurse about it. The palm protector was not on and the hand could be observed to see that the nails had been cut and that the palm continued to have residual nail indentations from digits four and five. Review of R67's facility Care Plan dated 05/26/23 revealed, in the ADL (activities of daily living) focus area, inclusion of the goal [resident]Will be neat, clean and well groomed daily and the related intervention of Provide nailcare as needed. Review of R67's facility [NAME] revealed, under the Resident Care category, inclusion of the statement Keep fingernails short. On 08/16/23 at 11:50 AM, the facility Director of Nursing (DON) reported that R67's daughters often assist with their nail care however they hadn't been visiting as often during the summer. Review of the facility policy provided to address ADL care which is titled Quality of Life - Dignity and is undated, includes the statement 3. Residents shall be groomed as they wish to be groomed (hairstyles, nails, facial hair, etc.). On 08/16/23 at 12:59 PM, the facility DON was asked if they would expect that R67's nails would be kept short enough to not imbed into the palm and they stated Yes, as long as the resident is compliant with the nail care. Sometimes residents are resistive to having the nail care and if that's the case we use a non-compliance care plan. Based on observation, interview, and record review, the facility failed to provide assistance during meals for one sampled resident (R68) of three reviewed for activities of daily living (ADLs), resulting in difficulty eating and the potential for discomfort. Findings include: On 8/14/23 at 8:43 AM, R68 was observed in bed sitting in a fowler's position (semi-sitting position at a 45-60 degree angle) with a cushion device underneath their knees. Two call lights were clipped/hanging behind the resident's bed and out of reach. R68 was attempting to eat breakfast and had spilled a cup of fruit onto the table in front of them. R68 struggled to pick up pieces of spilled fruit to try and eat. No staff were present to assist the resident. When queried if they were comfortable, R68 stated, Not in this position, no. R68 was somewhat confused but was oriented to person and place when queried throughout the interview. A review of R68's record revealed that the resident was initially admitted into the facility on 7/7/17 and re-admitted on [DATE]. R68 started receiving hospice services on 6/15/23. A review of R68's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is moderately cognitively impaired with medical diagnoses of Arthritis, Dementia, Seizures, and Anxiety. A review of R68's care plan revealed: -Goal: Will receive assist with meals, as needed. Date Initiated: 02/01/2021 Revision on: 07/20/2023. -Intervention: Staff providing set up, encouragement, total assist with meals, as needed. Date Initiated: 02/01/2021. Further review of R68's record revealed the following progress notes: -8/8/2023 14:20 (2:20 PM) Skilled Charting Note Text: guest states I'm having a harder time using my hand, I can't grip things like I use to, referral to therapy. -8/8/2023 14:34 (2:34 PM) Skilled Charting Note Text: Guest on hospice, guest to be a assist feed. On 8/14/23 at 12:52 PM, R68 remained in bed in a semi-sitting position with a cushion under their knees. R68 was observed eating lunch with no staff assistance. R68 had successfully eaten some lunch on their own but was unable to reach some of the cups placed at the back of their lunch tray. On 8/14/23 at 1:01 PM, R68 was observed struggling to feed themselves a red-colored food item from a cup and remained unable to reach the items at the back of the tray. No staff were present or observed rounding to assist the resident. On 8/15/23 at 8:15 AM, R68 was observed lying in bed in a semi-upright position with their heels on the mattress. R68 had some eggs left on their adaptive plate, but was observed to have a dropped both a full piece and half piece of toast and other food debris onto themselves (onto their sheet in bed). R68's adaptive cup was also lying on its side in their bed next to them. R68 was asked if someone had helped them eat breakfast this morning. R68 indicated that no one had helped them and asked if this surveyor would help them finish eating. On 8/15/23 at 8:29 AM, staff was observed taking R68's breakfast tray away without the resident receiving assistance to finish their meal. On 8/15/23 at 12:12 PM, R68 was observed sitting upright in their wheelchair in the dining room. R68 sat at a table and was observed feeding themselves lunch without much difficulty. Staff was observed walking by periodically to check on R68 and the other residents in the dining room. On 8/15/23 at 1:16 PM, Certified Nursing Assistant (CNA) D was interviewed and queried regarding R68's level of assistance required during meals. CNA D stated that R68 has some good days and some bad days, i.e. days they need more assistance than others. CNA D pointed out that today seemed like a better day for R68 in terms of being able to feed themselves. CNA D stated that sometimes R68 does not want to get up out of bed for meals and that if R68 is eating a meal while in bed, the resident has to be sitting completely upright with nothing underneath their legs. On 8/16/23 at 10:22 AM, the Director of Nursing (DON) was interviewed and queried regarding R68's level of assistance required during meals. The DON indicated that there are days the resident can feed themselves and staff tries to encourage that. The DON added that she expects staff to set up R68's tray and make rounds to check on the resident and others who may require assistance eating, and offer assistance if needed. A review of the facility's policy/procedure titled, Assisting the Nurse in Examining and Assessing the Resident, revised October 2010, revealed, .During your daily contact with the resident, be observant of the resident's level of independence in performing ADL. As you observe the resident, note if the resident performs activities of daily living a. With assistance, b. With some assistance, or c. With total assistance; .Eating: As you serve the resident his or her meals, you should note: a. assistance needed with eating .b. The amount and types of food eaten; and c. Any changes in the resident's eating habits .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently implement effective fall prevention interventions and adequately supervise one (R125) of three closed record residents reviewed, resulting in multiple falls. Findings include: A review of R125's census information revealed that the resident was originally admitted into the facility on 5/18/23 and transferred to the hospital less than 24 hours later. The resident was then re-admitted on [DATE] and transferred to the hospital on 7/4/23. R125 was again re-admitted on [DATE] and passed away in the facility on 7/22/23. An initial record review revealed that R125 experienced five falls during their admission on the following dates: 5/25/23 (unwitnessed), 6/3/23 (unwitnessed), 6/13/23 (witnessed), 6/20/23 (unwitnessed), and 6/22/23 (witnessed). The resident's diagnoses while in the facility included Traumatic Subdural Hemorrhage With Loss Of Consciousness Of 6 Hours To 24 Hours, Subsequent Encounter, Muscle Weakness, Dementia, Altered Mental Status, and Anemia. A review of R125's admission fall risk assessment dated [DATE] categorized the resident as being at High Risk for falls with the following details noted: -History of Falls within the last six months: Multiple Falls . -Memory and Recall Ability: In the last 7 days: recalls three out of the four of the following; current season, that he/she is in a nursing home, location of room, staff names/faces: Never . -Gait Analysis: Exhibits loss of balance while standing, Decrease in muscle coordination .Intervention/Comment: Guest educated to use call light when assistance is needed . A review of R125's progress notes revealed the following: -5/18/2023 22:56 (11:56 PM) admission Summary .Guest is here with a primary diagnosis of fall, weakness from hospital. Guest has wound in the top of her head with 6 staple from prior fall . -5/25/2023 11:00 (AM) Skilled Charting Late Entry: Note Text: Patient was in her room with her husband. At some point, the patients husband left to return home and the patient was left sleeping in bed. The RN (Registered Nurse) and Aide were unaware that the patients husband had left. Upon walking past the room, the aide noticed the patient sitting on the floor directly beside the bed on her bottom. Aide called nurse into room. The nurse assessed patient for injury. No signs of injury present. Patient unable to state if she was injured or lost consciousness. Vital signs were taken and within normal limitations. Skin assessment performed with no new wounds noted. Nurse and aide assisted patient into wheelchair and brought out of room to sit with nurse/aide for further supervision. Patient husband notified. DON (Director of Nursing) notified. MD (Physician) notified. Received orders for PRN (as needed) Xanax (antianxiety). -5/26/2023 11:44 (AM) Physician Progress Note .[Resident with] past medical history of hypertension, atrial fibrillation and dementia initially was hospitalized with fall and subdural hematoma. Patient was at SAR (sub acute rehab-facility) sent back to the hospital same night with possible seizure-like activity. Patient now is back .for rehab. Patient is being seen today to follow-up on a fall that occurred yesterday evening as well as noted increased anxiety. On assessment patient is resting sitting upright in her wheelchair and appears comfortable. She remains confused her baseline cognitive status and is pleasant and cooperative on assessment this morning. Nursing staff is reported that patient has had intermittent anxiety, restlessness and occasional combative behavior. Assessment/plan: .Contusion of right lower leg- Patient with small area of contusion to right lower extremity on shin. No pain or tenderness with palpation. Uncertain if related to fall or if patient may have come in contact with furniture in her room while self-propelling in her wheelchair. Discussed with nursing staff to monitor site . -6/3/2023 14:45 (2:45 PM) Incident Note .Writer noticed guest on floor on buttocks at table near nurses' station at approximately 1300 (1 PM). Writer assessed guest for any major or minor injuries, vitals taken. Staff assisted guest off floor into wheelchair. Guest Vitals stable .No major or minor injuries noted. Guest unable to verbalize if she hit her head. Neuro checks initiated. Guest husband .on call physician, and DON notified. Guest currently in chair near nurse station with no noticeable concerns from normal baseline . -6/6/2023 21:01 (9:01 PM) Incident Note .Investigation Summary: On 5/25/23 at approximately 15:58 (3:58 PM), guest was in her room with her husband. At some point, guest's husband left to return home and the guest was left sleeping in bed. The RN and Aide were unaware that the guest's husband had left. Upon walking past the room, the aide noticed the guest sitting on the floor directly beside the bed on her bottom. Aide called nurse into room. When asked what happened, guest was unable to answer, guest historically with marked confusion. The nurse assessed guest for injury. No signs of injury present. Guest unable to state if she was injured or lost consciousness. Vital signs were taken and within normal limitations. Skin assessment performed with no new wounds noted. Neuro checks started and was within baseline .Range of motion (ROM) assessed and was within baseline .Nurse and aide then 2PA (two person assist) assisted guest into wheelchair and brought out of room to sit with nurse/aide for further supervision and safety .Received orders for PRN Xanax. Orders placed for Post Fall charting x 3 days. Care plan updated, intervention is to keep guest in common area for safety when family is not visiting to monitor guest -6/6/2023 16:28 (4:28 PM) .Investigation Summary- On 06/03/2023 at approximately 1300 the nurse observed the guest on the floor near the nurse cart. The guest was sitting on her buttocks with her legs fully extended in front of her. The nurse assessed for immediate injury and no injury was noted. The guest was unable to recall what happened. The nurse asked the guest if she had pain and the guest did not verbalize pain. ROM to bilateral upper and lower extremities performed with no c/o (complaints of) pain voiced. Neuro checks initiated and were within the guest baseline. The guest was assisted off of the floor and into the wheelchair. The physician was notified and no new orders were given. The guest spouse was notified. Interventions in placed and care plan updated. Intervention is to encourage and offer guest activities while in common area . -6/13/2023 23:01 (11:01 PM) Skilled Charting Note Text: Writer was notified by staff that guest had fall in common area. Guest was assessed for ROM and skin assessment performed. Guest has small skin tear to left forearm with treatment order in place. Guest was assisted back into wheelchair and remains out in common area with staff .Fall was witnessed by staff and guest did not hit head. VSS (Vital signs stable). -6/14/2023 10:20 (AM) Physician Progress Note .Patient with a witnessed fall in commons area yesterday evening. Sustained small skin tear to left forearm but no other evidence of injury. Patient with underlying Alzheimer's dementia and significant baseline confusion. Patient with very poor safety awareness and frequent impulsive behavior which places patient at increased risk for falls. Continue frequent reminders to patient utilize call button to request staff assistance. Fall precautions reviewed with both patient as well as nursing staff . -6/20/2023 11:08 (AM) .Investigation Summary: On 6/13/23 at approximately 2253 (10:53 PM), guest was witnessed by another nurse stand up and fall in the common area as she was sitting in front of 200 Hall, charting. Staff immediately alerted nurse and the nurse went to assess guest. Guest had a small skin tear to L (left) elbow. Witness stated that guest did not hit her head. Guest was then assessed for further injuries, no other injuries noted. Guest with severe confusion and was unable to answer when asked why she stood up and fell. Guest was 1PA (one person) assisted back to wheelchair and guest to remain in common area in front of 300 Hall. VSS. Neuro checks initiated and were (normal) .ROM assessed and were within baseline .Skin tear to L elbow was cleaned .On call MD .notified, orders received to continue neuro checks and monitor guest at this time. DON notified. Husband .called and notified of situation. Orders placed for Post Fall charting x 3 days. Care plan updated, intervention is to ensure that guest is wearing proper non-skin footwear while in wheelchair and to ensure that guest stay in the common area for closer monitoring . -6/20/2023 13:20 (1:20 PM) Skilled Charting Note Text: Guest was seen by writer at 1300 (1 PM) sitting on her right hip sitting up on floor near dining room area/Nurses' area. Guests' feet were curled up underneath her. Guest sitting up with no signs of hitting head. Nothing near guest. Guest sitting near window. Immediately PROM completed with no S/S of pain. Guests Vitals checked on floor and (normal). Guest was 2pa assisted into chair where she was further evaluated. Guests Nueros (sic) completed and at this time normal. MD notified. Guests Husband calleld (sic) . -6/21/2023 10:12 (AM) Skilled Charting .s/p (status post) fall - neuro check WNL (within normal limits) for guest. VSS. No new obvious injuries noted. Guest still attempts to get out of wheelchair with no supervision. Guest currently sitting in common area with writer. -6/22/2023 23:01 (11:01 PM) Skilled Charting Note Text: At approx. 2050 (8:50 PM) CNA (Certified Nursing Assistant) alerted writer that guest had fallen out of wheelchair. CNA stated they brought guest in wheel chair to 400 hall to check out the food and guest leaned forward to reach her feet and fell forward onto her knees and then on to her side. Guest was assessed for injury/pain. ROM completed and guest was assisted back into wheelchair. On-call notified and husband .Guest has no injuries and shows no s/s (signs/symptoms) of pain or discomfort. Guest is now out in common area with staff . Further review of R125's progress notes revealed that the resident continued to be anxious with continued attempts at standing and self-transferring. Additional review revealed: -6/27/2023 13:38 (1:38 PM) .Investigation Summary: On 6/20/23 at approximately 1300 (1 PM), guest was observed by staff sitting on the floor near the dining table in the common area. Staff alerted nurse and nurse came immediately and observed the guest sitting on right hip near dining room table with legs curled under bottom. Guest was sitting near the window prior to time of fall. Guest sitting up, wheelchair in locked position right beside guest. Guest was unable to give statement as to what happened due to guest's severe confusion. Guest was immediately assessed for injuries, no injuries noted Care plan updated, intervention is to encourage and provide guest activities and distractions while guest is sitting in common area for safety . -6/28/2023 16:45 (4:45 PM) .Investigation Summary: On 6/22/23 at approximately 2050, CNA was walking towards 400 hall to investigate refreshments arranged for CNA week, pushing guest while she was on her wheelchair. CNA stated that while she was pushing the wheelchair, guest leaned forward to reach for her feet and fell forward off of the wheelchair and then on to her knees and to her right side. CNA immediately alerted the nurse and the nurse came to assess guest right away. Guest with marked confusion and is unable to give an answer as to why she was reaching for her feet. Guest was 1PA assisted back to her chair. VS obtained and were WNLs. ROM assessed and were within guest's baseline, able to move all extremities without complaints of pain .orders received to continue monitoring guest at this time intervention is to apply non skid wheelchair mat as guest tolerates to prevent sliding . -7/4/2023 13:42 (1:42 PM) Skilled Charting Note Text: Guest was noted at 1330 sitting in wheelchair in nurses' area with head dangling laying back in chair .Sternal rubs given to guest and guest continues to be nonverbal nonresponsive. MD requested guest to be sent out ASAP. 911 called. Guest with staff at entire time .(Sent to hospital) . -7/15/2023 18:59 (6:59 PM) Skilled Charting Note Text: Guest arrived via stretcher @ (at) approximately 1615 (4:15 PM .s/p (status-post) hospital stay r/t (related to) L femur Fx (left femur fracture) . -7/16/2023 00:42 (12:42 AM) Skilled Charting Note Text: Resident is alert with confusion. Admitting DX (diagnoses) of Left Femur Fx, Acute cystitis .mental status altered .Resident has 17 staples to left hip, and thigh open to air, 0 drainage noted, 0 redness to area. Small skin tear to right forearm allevyn placed . -7/17/2023 14:30 (2:30 PM) .Physician Progress Note .Patient's records from recent hospitalization reviewed, patient resting in bed does not seem in distress but does not follow any verbal commands. According nursing staff patient being very lethargic with minimal oral intake now. Unclear etiology, patient has been declining rapidly has very poor prognosis .Patient is more appropriate for hospice/palliative care . -7/18/2023 07:50 (AM) Skilled Charting Note Text: Guest noted with Temp 101.4, R34, spo2 84% while on 5 lpm (liters per minute) (all vital signs outside of normal limits) via N/C (nasal cannula). Husband .was notified and husband request that (resident) not be sent to (hospital) and to make guest comfortable . -7/22/2023 04:15 (AM) Skilled Charting Note Text: Guest passed peacefully at 0400 (AM) . On 8/15/23 at 1:11 PM, the Medical Director was interviewed and queried regarding the etiology of R125's left femur fracture. The Medical Director reviewed the hospital documentation scanned by the facility into R125's record upon the resident's readmission. An indication of how the fracture occurred was not found at this time. R125's hospital records from 7/4/23 - discharge were obtained and reviewed. The hospital records did not indicate R125 sustained a fall or trauma after arriving at the hospital. Consultation notes after the resident's arrival indicated that the resident was guarding her left hip. An X-Ray of the resident's left hip was performed in the hospital on 7/5/23 at 10:51 PM and found the following: Imaging: Hip Left 2-3 Views with Pelvis: 7/5/23 10:51 PM Indication: .Hip pain, left Comparison: Pelvis radiograph dated 5/12/2023 Findings: There is a comminuted fracture involving the left femur neck and intratrochanteric region with associated soft tissue swelling. There is superior displacement of the distal fracture fragment. Mild diffuse osteopenia. Mild degenerative changes of both hip articulations with mild narrowing of the joint spaces. There are degenerative changes of the sacroiliac articulations. Assessment and Recommendations: Left displaced IT (intertrochanteric) hip fracture. Secondary to the debility associated with non-operative care, surgical treatment is recommended. I would recommend an intramedullary nail . Per Cleveland Clinic and John Hopkins, A comminuted fracture is a type of broken bone. The bone is broken into more than two pieces. It takes a lot of force for someone to get a comminuted fracture. A car accident or serious fall, for instance, can cause this type of break. Someone with a comminuted fracture will probably need surgery. On 8/15/23 at 1:55 PM, Licensed Practical Nurse (LPN) H, who frequently cared for R125, was interviewed. LPN H was queried regarding fall precautions for R125. LPN H described the resident as being very anxious and at times aggressive. LPN H stated that the resident was often placed in a common area where many staff walk through and could monitor her. LPN H added that the resident made frequent attempts to stand up even when staff attempted to redirect. LPN H stated, As soon as we walked away she would stand back up again. LPN H added that staff tried to give the resident fidget toys or other items, but the resident would sometimes just throw the items at the staff. LPN H indicated through interview that the resident did receive visits from her husband and attend activities, typically in the morning. When queried regarding other options for increased supervision of R125, LPN H stated that the facility's staffing did not allow for assigned 1:1 supervision. On 8/15/23 at 2:19 PM, CNA B was called for interview, however, this surveyor was unable to leave a voicemail. CNA B was identified by the facility as being the CNA with R125 on 6/22/23. On 8/16/23 at 9:40 AM, CNA B was called for interview and a voicemail was left for call back. No return call received prior to survey exit. On 8/16/23 at 10:22 AM, the Director of Nursing (DON) was interviewed. When queried regarding R125 experiencing multiple falls at the facility, the DON stated that she felt the facility did everything they could to prevent them. The DON stated that staff could be sitting next to the resident and there would be no indication of when she was going to try to stand up. The DON stated that the staff tried to give the resident things to distract her, and tried to keep her somewhat near a table so if she stood up, she would at least have the table as support for her hands. When queried regarding leg rests on R125's wheelchair when the resident fell forward on 6/22/23, the DON stated that leg rests were not present due to being an environmental hazard to the resident since she constantly tried to stand up. The DON stated that the CNA took the resident with her to an event and that R125 leaned forward and toppled over, and added that the resident was very thin. On 8/16/23 at 11:35 AM, the Nursing Home Administrator (NHA) and DON were interviewed during the Quality Assurance Performance Improvement (QAPI) task review. They were asked how the facility determines that fall prevention interventions are effective. The DON replied that the facility monitors whether falls are continuing and if they are, what additional interventions are needed; The results of the interventions are monitored and addressed in the QAPI meeting. The DON stated that they are not able to provide 1:1, so if that is the indication the facility offers for the family to assist or to hire a private sitter. The NHA and DON were then asked what facility process to is address a resident who experiencing multiple falls. The DON stated they follow the protocol for increased fall prevention and leading to the 1:1 described above which they do not provide. A review of R125's care plan revealed: Goal: Minimize risk for falls Date Initiated: 05/18/2023. Interventions: -2PA for transfers, ambulation with therapy only. Date Initiated: 07/15/2023 -Administer medications as ordered by physician Date Initiated: 05/18/2023 -Apply Non Skid wheelchair mat as guest tolerates Date Initiated: 06/20/2023 -Encourage and offer guest activities while in common area Date Initiated: 06/03/2023 -Ensure guest is wearing nonslip footwear when up out of bed Date Initiated: 06/13/2023 -May use w/c (wheelchair) for mobility Date Initiated: 05/19/2023 -Neuro checks per protocol Date Initiated: 05/18/2023 -Reinforce need to call for assistance Date Initiated: 05/18/2023 -Sit in common area Date Initiated: 06/03/2023 -Use leg rests at all times when transporting guest Date Initiated: 06/22/2023 -Weight Bearing Status: WBAT (weight-bearing as tolerated) Date Initiated: 05/18/2023. A review of the facility's policy/procedure titled, Falls Reduction Program, revised 9/25/2016, revealed, Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury .2. Implement and indicate individualized interventions on Care Plan/[NAME] .

Based on observation, interview, and record review, the facility failed to obtain a physician order for oxygen use and store oxygen equipment in a sanitary manner for one resident (R70) of one reviewed for oxygen use, resulting in the potential for equipment contamination and unmonitored oxygen utilization. Findings include: On 8/14/23 at 11:10 AM, R70 was interviewed and indicated they were drowsy but having some pain. R70 was noted to be receiving hospice services. Nasal cannula oxygen tubing was noted lying on the residents bed and connected to a concentrator at two liters per minute (2L). R70 complained of a scab in their nose that is irritated by the oxygen. R70's CPAP (continuous positive airway pressure machine for sleep apnea) mask was observed hanging over their bedside dresser without a storage barrier. R70 repeated that they were feeling drowsy and indicated they wanted their oxygen applied. A review of R70's record did not reveal a physician's order for oxygen administration. Further review revealed that the resident is cognitively intact and was admitted into the facility on 5/15/23 with medical diagnoses of Malignant Cancer, Anxiety, Mild Intermittent Asthma, and Obstructive Sleep Apnea. On 8/14/23 at 2:29 PM, R70 was observed sleeping in bed. The resident now had their oxygen applied. On 8/15/23 at 9:30 AM, R70 was observed sitting up in their wheelchair in their room. R70 continued to talk about the irritation in their nostril and stated they believe it is from the oxygen tubing. R70 confirmed that they do require the application of supplemental oxygen via nasal cannula at times. The resident's CPAP mask was observed hanging on their bedside dresser with the left side of the mask touching the dresser without a barrier. R70's oxygen tubing was observed curled up and directly touching the carpeted floor. When the tubing being on the floor was mentioned to the resident, they replied, That's probably how you pick up things (germs), it's probably not supposed to be on the floor. An clear empty storage bag was observed hanging on the concentrator. On 8/15/23 at 9:46 AM, Licensed Practical Nurse (LPN) E was interviewed and confirmed the observations of R70's oxygen tubing and CPAP mask. LPN E stated she didn't think anything was wrong with the mask storage but stated that the oxygen tubing should not be on the floor. When queried if supplemental oxygen use requires a physician order, LPN E replied, Yes, I believe so. A review of the facility's policy/procedure titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised August 2012, revealed, .8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one resident (R#61) of one residents reviewed for self-administration, was assessed for the safe self-administration of medication. Findings include: On 6/13/22 at approximately 10:50 a.m., R61 was observed in their room, lying on their bed. R61 was observed to have a bottle of Vicks Vapor Rub (Camphor 4.8% (Cough Suppressant and Topical Analgesic), Eucalyptus Oil 1.2% (Cough Suppressant), Menthol 2.6% (Cough Suppressant and Topical Analgesic)) and Thera Tears (Sodium Carboxymethylcellulose) on their bedside table. R61 was queried regarding the medications and indicated that they use the eye drops so the Nurses do not have to do it and use the vapor rub when they get a stuffy nose. On 6/14/22 at approximately 10:35 a.m., R61 was still observed with the Vicks vapor rub and the Thera tears on their bedside table in the same spot as 6/13/22. R61 was queried if they Nursing staff knew they had the medications and they indicated they did and have had them for weeks. R61 was queried when the last time they had used the medications and they indicated that their memory is not good and did not remember. On 6/14/22 at approximately 10:38 a.m., Nurse B was queried regarding the Vicks vapor rub and Thera tears observed on R61's bedside table and Indicated they would have to go in and address the medications. On 6/14/22 at approximately 1:45 p.m., Nurse B was queried regarding the disposition of the Vicks vapor rub and Thera tears that had been observed on R61's bedside table. Nurse B indicated they had confiscated the medications and had locked them in R61's medication cabinet. Nurse B indicated that the medications needed to be locked up and had written a message for the Physician to get an order for the medications. Nurse B indicated they had not noticed them before. Nurse B was queried regarding the ability for R61 to self-administer both the medications and indicated that R61 had dementia and would not be able to administer them correctly. Nurse B indicated the medications needed to be locked up due to R61's dementia and other residents that may come into the room and see them. Nurse B was queried if R61 had been assessed for self-administration of the medicine and they indicated they had not. On 6/14/22 the medical record was reviewed and revealed that R61 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Heart Disease. A review of R61's minimum data set with an assessment reference date of 5/5/22 revealed R61 needed extensive assistance with most of their activities of daily living. R61's BIMS score (brief interview of mental status) of 12 indicating moderately impaired cognition. A progress note dated 6/14/22 at 2:04 p.m., revealed the following: Guest had several over the counter medications at bedside. Writer explained to guest that all medications need to be locked up. She was educated about potential interactions with other medications ordered. Physician gave order for over the counter eye drops which writer entered. Guest had Vicks vapo rub at bedside (writer locked up with medications) and writer explained that if guest is feeling congested or not feeling well it would be harder for her nurses and doctor to know if she was using the Vicks vapo rub . A review of R61's Physician orders did not reveal any orders for the Self-Administration of R61's vapor rub or eye drops. A review of R61's care plan did not reveal any documentation that the self-administration of vapor rub or eye drops was part of their plan of care. On 6/15/22 at approximately 11:14 a.m., Staff Development/Nurse Manger A (SD/NM A) was queried regarding the Nursing expectations/procedures for the self-administration of medications at the bedside. SD/NM A indicated that residents should not have medications at the bedside and that the Nurses should have had them locked up and obtained an order from the Physician to self-administer. SD/NM A was queried regarding the observations of R61 having the Vicks Vapor Rub and Thera tears on the bedside table and they indicated that an investigation should be done to determine how they got the medications and they should be locked up. They were queried if R61 had the ability to self administer the medications and they shook their head no and indicated that R61 would have had to have been assessed to self administer them. On 6/15/22 a facility document titled Medication Administration (Self-Administration) was reviewed and revealed the following: POLICY: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe. PROCEDURES l . If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2, The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process. The nursing care center may use the following as a guideline or establish an alternate procedure: a. The resident is instructed in the use of the package, purpose of the medication, of reading of the label, and scheduling of medication doses. b. The resident is then requested to read the label on each package and indicate at what time the medication should be taken and any other special instructions for use. c. The resident is asked to demonstrate the removal of the medication from the package and, in the case of nonsolid dosage forms such as an inhaler, to verbalize the steps involved in administration. d. The resident is asked to complete a bedside record indicating the administration of the medication. 3. The results of the interdisciplinary team assessment are recorded on the Medication Self Administration Assessment, which is placed in the resident's medical record. 4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control standards and practices were consistently followed throughout the facility for seven of seven residents (R3, R10, R13, R14, R31, R63, and R77) reviewed for transmission-based precautions related to suspected COVID-19 exposure. Findings include: According to the facility's Pandemic Response Plan updated 3/9/22: .Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection - HCP (Health Care Personnel) caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) .Ideally, a resident with suspected SARS-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending .In general, it is recommended that the door to the room remain closed to reduce transmission of SARS-CoV-2. This is especially important for residents with suspected or confirmed SARS-CoV-2 infection being cared for outside of the COVID-19 care unit .If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location pending return of test results .Roommates of residents with SARS-CoV-2 infection should be managed as described in Section: Manage Residents who have had Close Contact with Someone with SARS-CoV-2 Infection .Manage Residents with Close Contact Manage Residents who had Close Contact with Someone with SARS-CoV-2 Infection .Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator) .Quarantine might also be considered if the resident is moderately to severely immunocompromised .Symptomatic residents, regardless of vaccination status, should be restricted to their rooms and cared for by HCP using a NIOSH-approved N95 or equivalent or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face) gloves, and a gown pending evaluation for SARS-CoV-2 infection . Review of an alert initiated by the Director of Nursing (DON) to staff on 6/6/22 via the facility's electronic medical record system identified the facility had a resident that was positive for COVID-19 and also had a total of eight staff that were positive for COVID-19 and encouraged them to wear their mask, wash hands, and also to wear goggles/face shields. On 6/13/22 at 10:00 AM, R63's room was observed to have a sign on the door which indicated they were on contact and droplet TBP. There was personal protective equipment (PPE) available in storage containers outside of the room. Upon further review, this room was shared by R31 who was not on TBP and in order to gain access to R31, staff had to enter and go past R63's room. R63 was observed seated in a wheelchair in the room, not wearing any PPE. On 6/13/22 at 10:08 AM, R63 was observed to self-propel via the wheelchair out of their room, into the hallway and going up to another resident in the hallway. R63 was not wearing any facemask while in the hallway. Additionally, there were no staff present in the hallway at this time to redirect the resident back to their room or encourage to wear a face mask. On 6/13/22 at 10:14 AM, Staff 'O' approached R63 in the hallway and stated to R63 that the choir group was there, then placed a surgical mask on R63 (who did not appear upset or attempt to remove when placed) and the resident was brought to the group activity located on another hallway in the facility's common lounge area with several other residents and visitors. On 6/13/22 at 10:52 AM, R63 was observed in the hallway with a surgical mask pulled down under their nose. There were several staff observed in the hallway (from various departments), that interacted with R63, however no one identified any concerns that R63 was in the hallway, not properly wearing PPE, or encourage the resident to return to their room. On 6/13/22 at 10:04 AM, Certified Nursing Assistant (CNA 'Q') was observed at the bedside of R31 (roommate of R63 who was on TBP for COVID-19) wearing goggles, gloves and a surgical mask that was below their nose. CNA 'Q' was observed to be providing care to R31 from behind the privacy curtain, but also went back and forth from the resident's closet and opening the curtains. At 10:14 AM, upon CNA 'Q's exit from the room, they were asked about the room and to explain what specific TBP were in place and if they knew the specific reason. CNA 'Q' reported that only R63 was on TBP's and stated they didn't know what they were for since they (facility) don't give that information. When asked about having to pass through R63's room to access R31 that was not on TBP, CNA 'Q' stated sometimes it was like that where you had to go by someone on precautions to get to someone that was not. When asked about whether their mask should be under their nose, or covering, they indicated Above and when they went to touch their mask stated they didn't know it was down. On 6/13/22 at 10:21 AM, R63 was observed seated directly in between two other residents, and several visitors and other residents were also in attendance. On 6/13/22 at 10:36 AM, Staff 'O' was observed walking with R77 who was overheard voicing to Staff 'O' that they were chilled and had a runny nose. Staff 'O' continued to encourage R77 to walk with them to the choir activity and stated, It's allergy season. On 6/13/22 at 10:38 AM, an interview was conducted with Staff 'O'. When asked about whether or not they were aware R63 was on TBP for suspected COVID-19, Staff 'O' reported they were not aware and that the resident was in the hallway and tending to go to those types of group activities and doesn't usually stay in their room. On 6/13/22 at 10:45 AM, Staff 'O' was observed taking R63 to their room and upon entering the room, did not don/doff any additional PPE. Staff 'O' was then observed to pull their surgical mask down and offer the resident some chocolates, ice cream and water to drink. Staff 'O' was not observed to use hand sanitizer, or wash hands upon exiting the room to head back towards the group activity. On 6/13/22 at 12:10 PM, R77 was observed seated at a table eating lunch. R63 was observed seated at the table, just to the left of R77. R63 had not been served yet, but their surgical mask was off and placed on top of the table. There were five other residents eating in the common dining area. On 6/13/22 at 12:25 PM, R63 asked various staff about when they were going to get their meal and no staff were observed to identify any concerns that R63 was seated in common area. On 6/13/22 at 12:33 PM, a dietary staff was observed to enter the room of R10 who was identified as being on TBP for COVID-19 exposure. Although the proper PPE was donned, upon exiting the room, staff was observed to carry a silver covered plate and cup of juice out of the room, place on the chair just behind R77 and was not observed to wash hands or use hand sanitizer upon exit from the room. On 6/13/22 at approximately 1:30 PM, R63 was observed self-propelling throughout their hallway without a mask. There were no staff in the area, but there were several other residents. On 6/13/22 at approximately 1:35 PM, an interview was conducted with the Infection Control Preventionist (Nurse 'A') who reported they had been in that role for about four years. When asked about how the facility handled residents on TBP, Nurse 'A' reported residents that were being monitored for suspected COVID-19 due to exposure would have two signs which identified what was required for donning prior to providing care which included N95 masks, gowns, glove, goggle, or face shield. When asked if residents on TBP for suspected COVID-19 came out of their room, what PPE would they be expected to wear, Nurse 'A' reported the residents should be encouraged to wear an N95. When asked if resident's on TBP for suspected COVID-19 should be encouraged to come to communal dining or group activities, Nurse 'A' reported they might have dementia and might not understand, so should be encouraged to stay in room as much as they can. On 6/14/22 at 9:27 AM, an interview was conducted with Nurse 'A'. When asked why R63 was on TBP, they reported it was for possible exposure from a staff that tested positive for COVID-19. When asked why they were allowed to remain in the same room with R31 (who was not placed on TBP), Nurse 'A' reported they could remain in the same room but the curtain had to be closed. When asked about having to pass by R63 who was on TBP to get to R31 who was not, Nurse 'A' reported as long as the curtain was pulled, that would be ok. At that time, Nurse 'A' was informed of the multiple observations of concerns with infection control practices. Nurse 'A' was asked to provide any documentation for R77 that indicated staff had been notified of their complaint of being chilled and runny nose, and upon viewing the clinical record they indicated there was no documentation. When asked what should have occurred, Nurse 'A' reported they would follow up and the nurse should've been notified immediately. Nurse 'A' was asked how staff became aware of changes such as residents that needed to be on TBP, and reported they do education with orientation and post on the dashboard which CNAs have access to. When informed that CNA 'Q' reported they were not aware, Nurse 'A' reported they would follow up. On 6/14/22 at 11:17 AM, observations of the same hallway on 6/13/22 now had TBPs removed for R10 and R63, but now had droplet and contact TBPs for suspected COVID-19 for R77 who shared a room with R14 (not on TBP) and R13 and R3. These rooms were identified via signage and PPE bins outside the room. On 6/14/22 11:19 AM, CNA 'R' was approached by Vendor 'S' who was pushing a cart which contained clean oxygen supplies who asked if it was ok to go into the room. CNA 'R' proceeded to enter the room of R13 and R3 without donning/doffing any PPE, exited the room and informed Vendor 'S' there was no patient care being provided and would be ok for them to go in. At that time, Vendor 'S' entered the room while bringing their entire cart of oxygen supplies and did not don/doff any PPE. At that time, when CNA 'R' (who was just outside of the room) was asked about why they entered the room without PPE and also why they did not address Vendor 'S' going into the room without PPE, CNA 'R' reported they should've put on PPE and reported Vendor 'S' had only asked if any patient care was going on and told them no. CNA 'R' proceeded to re-enter R13 and R3's room without donning/doffing PPE and stated, we were supposed to tell you that you had to get a gown to go in and put on. Vendor 'S' proceeded to exit the room and don PPE, but when queried about the oxygen supplies on the cart and why they brought it into the room with them, Vendor 'S' only reported they were cleaning the machines and making sure the filters were wiped down. On 6/14/22 at 11:24 AM, an interview was conducted with Nurse 'A'. When asked about the change to the TBPs for Rs: 3, 10, 13, 14, 31, 63 and 77, Nurse 'A' reported R10 and R63 were finished with their precautions so those were discontinued. Nurse 'A' further reported that R13 had a fever, and R77 was due to the complaints of chills and runny nose yesterday. When asked if the roommates for R13 and R77 were also placed on precautions, Nurse 'A' reported there was only one of the residents in each of the rooms because they were double vaxxed. On 6/14/22 at 11:57 AM, an email request was sent to the Administrator, Director of Nursing (DON) and Nurse 'A' to provide the guidance the facility used to determine placing residents on TBPs. On 6/14/22 at 4:20 PM, during a discussion with the Corporate Clinical Staff (Staff 'T'), when informed that the request for what guidance was used for choosing to cohort residents that were and were not on TBP for suspected COVID-19 exposure was not provided yet, Staff 'T' reported that unless there were no additional beds available, the residents should not be kept in the same room as this was also in their policy and had provided education to the facility staff and that R77 was moved to a room by themselves and the decision was made to keep R13 and R3 together since R3 began showing symptoms of oxygen desaturation and were unsure if due to clinical diagnoses or possible COVID-19 symptoms. On 6/15/22 at 10:28 AM, an emailed response from Nurse 'A' deferred to their Pandemic Response Plan as what should be followed. Record Reviews: R3: Review of the clinical record revealed R3 was admitted into the facility on 7/23/18, readmitted on [DATE] with diagnoses that included: systemic lupus erythematosus, fibromyalgia, metabolic encephalopathy, chronic respiratory failure with hypoxia, malignant neoplasm of uterus, epilepsy, discoid lupus erythematosus, and chronic obstructive pulmonary disease. Review of the physician orders included: STAT CBC and BMP STAT for elevated Temp on 6/14/22 at 10:22 AM. Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition, you must wear an N-95 in the patient's room . were started on 6/14/22 at 2:00 PM. R10: Review of the clinical record revealed R10 was admitted into the facility on 3/3/22 with diagnoses that included: pneumonia, and acute respiratory failure with hypoxia. Review of the physician orders included: Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition, you must wear an N-95 in the patient's room . were started on 6/8/22 and discontinued (d/c'd) on 6/14/22). F13: Review of the clinical record revealed R13 was admitted into the facility on 9/12/19, readmitted on [DATE] with hospice services with diagnoses that included: chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, personal history of covid-19 (12/20/21), and congestive heart failure. Review of the physician orders included: Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition you must wear an N-95 in the patient's room . were started on 6/14/22 at 2:00 PM. R14: Review of the clinical record revealed R14 was admitted into the facility on 3/10/22 with diagnoses that included: acute on systolic heart failure, chronic kidney disease, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. Review of the physician orders revealed there were no TBPs initiated. R31: Review of the clinical record revealed R31 was admitted into the facility on 6/3/21 and readmitted on [DATE] with hospice services. Diagnoses included: Alzheimer's disease, acute kidney failure, dementia without behavioral disturbance, and other seizures. Review of the physician orders revealed there were no TBPs initiated. R63: Review of the clinical record revealed R63 was admitted into the facility on 1/25/18 and readmitted on [DATE] with diagnoses that included: Alzheimer's disease with late onset. Review of the physician orders included: Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition you must wear an N-95 in the patient's room . were started on 6/8/22 and d/c'd on 6/14/22. R77: Review of the clinical record revealed R77 was admitted into the facility on 5/5/22 with diagnoses that included: dementia without behavioral disturbance, Alzheimer's disease with late onset, dementia without behavioral disturbance, congestive heart failure, and pulmonary hypertension. Review of the physician orders included: Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition you must wear an N-95 in the patient's room . were started on 6/14/22 at 2:00 PM.