**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of transfer/discharge for one (R92) of two reviewed. Findings include: Review of the medical record revealed R92 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and multiple rib fractures. Review of the Health Status Note dated 12/31/24 revealed R92 was transferred to the emergency room for evaluation due to behaviors and refusals of care. R92 did not return to the facility. Review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/24 revealed R92 had an unplanned discharge with return not anticipated. The medical record did not indicate a written notice of transfer/discharge was provided. In an interview on 03/05/25 at 10:20 AM, Director of Nursing (DON) B reported they were not able to locate a written notice of transfer/discharge for R92.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of bed hold policy upon transfer for one (R92) of two reviewed. Findings include: Review of the medical record revealed R92 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and multiple rib fractures. Review of the Health Status Note dated 12/31/24 revealed R92 was transferred to the emergency room for evaluation due to behaviors and refusals of care. R92 did not return to the facility. Review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/24 revealed R92 had an unplanned discharge with return not anticipated. The medical record did not indicate a written notice of bed hold policy was provided upon transfer. In an interview on 03/05/25 at 10:20 AM, Director of Nursing (DON) B reported they were not able to locate a written notice of bed hold policy upon transfer for R92.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure enteral nutrition was administered as ordered and weights were monitored for two (R33 and R41) of four reviewed. Findings include Resident #33 (R33) Review of the medical record revealed R33 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/3/24 revealed R33 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of Physician's Order dated 11/27/24 revealed an order for Jevity 1.5 cal (tube feeding formula) run at 55 milliliters (mL) per hour continuous via PEG tube (percutaneous endoscopic gastrostomy/feeding tube) for total of 1320 mL of formula per day. On 03/03/25 at 09:27 AM, R33 was observed lying in bed. An empty bottle of Jevity 1.5 cal was hanging from the tube feeding pump. The pump was off. At 9:43 AM, a new bottle of Jevity 1.5 cal was observed sitting on R33's nightstand. The empty bottle had been discarded. R33 did not have the tube feed formula running as ordered. At 10:23 AM, the new bottle was still on the nightstand and R33 did not have the tube feed formula running as ordered. On 03/03/25 at 11:41 AM, R33's Jevity 1.5 cal was started after not receiving the tube feed for over 2 hours. Review of the Weight Change Note dated 2/28/25 revealed R33's weight was 150.5 pounds which was a significant weight gain and was over R33's usual body weight of approximately 140 pounds. The note revealed new weight to be obtained for confirmation .Possible need for reduction to total formula pending confirmation of weight gain .Will reassess for quarterly next week and make updates. R33 did not have another weight obtained to confirm the significant weight gain. In an interview on 03/05/25 at 10:32 AM, Registered Dietitian (RD) E reported R33 receives enteral nutrition continuously and they were not aware of any reason as to why R33 would have not received their nutrition for over two hours on 3/3/25. RD E reported R33's last weight obtained was on 2/27/25. RD E reported they asked for a re-weigh which they would have expected to be obtained by now. RD E reported they were completing R33's quarterly evaluation today and would ask staff to weigh R33. In an interview on 03/05/25 at 11:22 AM, Director of Nursing (DON) B reported re-weights should be completed the same day or next day. Resident #41 (R41) Review of the medical record revealed R41 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included dysphagia and moderate protein-calorie malnutrition. The Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 11/23/24 revealed R41 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had a feeding tube. Review of the Physician's Order dated 10/8/24 revealed an order for monthly weights. R41's last documented weight was on 1/6/25 at 123.5 pounds. Review of the Physician's Order dated 12/31/24 revealed an order to run Jevity 1.5 cal at 70 mL per hour continuous for 16 hours for a total of 1120 mL of formula daily. The tube feeding was scheduled to begin each day at 6:00 PM and end at 10:00 AM. On 03/03/25 at 09:46 AM, R41 was observed in bed with a 1000 mL bottle of Jevity 1.5 cal hanging and running at 70 mL per hour. The bottle was not dated or timed. On 03/03/25 at 10:27 AM, R41's tube feeding pump indicated they had received 930 mL total of Jevity 1.5 cal. On 03/03/25 at 11:38 AM, R41 was observed awake in bed. The tube feeding was turned off. At this point, R41 would have received approximately 1010 mL of Jevity 1.5 cal which was not the ordered 1120 mL . On 03/04/25 at 09:23 AM, R41 was observed asleep in bed with a 1000 mL bottle of Jevity 1.5 cal running at 70 mL per hour. The bottle was dated 3/3/25 at 6:00 PM. The tube feeding pump reflected a total amount fed as 1820 mL, indicating the pump most likely was not reset when the tube feeding was started on 3/3/25 at 6:00 PM In an interview on 03/04/25 at 09:43 AM, Licensed Practical Nurse (LPN) F reported R41 started their tube feeding each day at 6:00 PM and then stopped the tube feeding the next morning at 10:00 AM. When asked about the total amount administered during that time, LPN F calculated the total to be 880 mL. When asked if the pump indicated the total milliliters administered, LPN F stated I don't think so. LPN F then entered R41's room to observe the pump. LPN F reported the pump indicated R41 had received 1858 mL and reported the pump must not have been reset when the tube feeding was started the prior evening. LPN F reported R41 was due to come off the tube feeding at this time. LPN F reported it appeared R41 had received approximately 820 mL because there was a little less than 200 mL left in the bottle that was dated 3/3/25 at 6:00 PM. LPN F reported R41 usually only received one bottle of Jevity 1.5, but they usually had to discard some when the tube feeding was disconnected each day at 10:00 AM. On 03/04/25 at 10:32 AM, LPN F reported R41 was taken off the tube feed already. LPN F reported they left the bottle hanging on R41's pump. The 1000 mL bottle of Jevity 1.5 cal was observed with approximately 180 mL left in the bottle. On 3/4/25 at 12:58 PM, R41's tube feeding bottle was still hanging with approximately 180 mL of formula left in the bottle. R41 did not receive the ordered 1120 mL of feeding formula. On 03/05/25 at 09:15 AM, R41 was observed asleep in bed. R41's tube feed was observed as a Jevity 1.5 cal 1000 mL bottle (33.8 ounces/1.05 quarts/1 liter) dated 3/4/25 at 6:00 PM. The tube feed was running at 70 mL/hour. According to the pump, the total administered at that time was 815 mL. In an interview on 03/05/25 at 09:17 AM, LPN F reported they usually turned off R41's tube feeding between 9:45 AM and 10:00 AM. LPN F reported at that time, R41 would have received just under 880 mL of tube feeding formula, which is what LPN F calculated as being needed. On 03/05/25 at 09:53 AM, LPN F reported they hung R41's tube feed formula on 3/4/25 at 6:00 PM and cleared the pump to zero. LPN F reported the tube feeding formula bottle hanging was the one that they personally hung on 3/4/25 at 6:00 PM. LPN F was observed turning off R41's tube feeding as scheduled for 10:00 AM. The pump was observed to have administered 861 mL of feeding formula. The feeding formula bottle had approximately 200-250 mL of formula remaining in the bottle. R41 did not receive the ordered 1120 mL of feeding formula. In an interview on 03/05/25 at 10:32 AM, RD E reported R41 should be weighed monthly and agreed the last documented weight for R41 was 1/6/25 at 123.5 pounds. RD E reported R41 was ordered to receive a total of 1120 mL of Jevity 1.5 cal over a period of 16 hours. RD E reported the facility previously had 1500 mL bottles of Jevity 1.5 cal, but if they were currently using the 1000 mL bottles, R41 would require a second bottle to receive the ordered total of 1120 mL. RD E went to R41's room and confirmed there was still approximately 200-250 mL of formula remaining in the bottle. On 03/05/25 at 10:44 AM, Jevity 1.5 cal was observed in the medication room. There were 1000 mL bottles available. LPN F reported they did not have 1500 mL bottles in the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure monitoring of psychotropic medications was completed as ordered for one (Resident #74) of five reviewed. Findings include: Review of the medical record reflected Resident #74 (R74) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included bipolar disorder, schizophrenia, anxiety disorder, other recurrent depressive disorders and bipolar type schizoaffective disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/9/25, reflected R74 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). A Physician's Order, dated 4/10/24, reflected orthostatic blood pressures (monitoring for blood pressure changes that occur when transitioning from lying down to standing) were to be obtained monthly for psychotropic medication monitoring. Further review of Physician's Orders reflected R74 routinely received Buspirone (medication used to treat anxiety), Venlafaxine (antidepressant medication) and Risperidone (antipsychotic medication). A Progress Note for 10/11/24 reflected R74's blood pressure was obtained while lying down, sitting and standing. A Progress Note for 12/11/25 reflected R74's blood pressures were obtained while lying down and after standing for one minute and two minutes. A Progress Note for 2/11/25 reflected R74's blood pressures were obtained while sitting down and while standing. The medical record was not reflective of orthostatic blood monitoring for 11/2024 or 1/2025. On 03/05/25 at 1:39 PM, a request was made for R74's orthostatic blood pressures for the previous six months. During an interview on 03/05/25 at 1:55 PM, Director of Nursing (DON) B reported there was documentation of R74's blood pressures but not while lying, sitting and standing. DON B reported R74 was able to stand, but it was possible they were refusing to stand (for blood pressures). DON B stated there was no documentation of refusals. On 03/05/25 at 2:10 PM, DON B reported they located orthostatic blood pressures for 10/11/24 and 12/11/24 but were not able to locate any additional. DON B reported the purpose of orthostatic blood pressures was for medication monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for one (Resident #90) of 18 reviewed. Findings include: Review of the medical record reflected Resident #90 (R90) was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation, retention of urine and urinary tract infection. R90's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/4/25, was in progress (not complete). On 03/03/25 at 9:56 AM, R90 was observed seated in a recliner, in their room. R90 reported they had open areas on their buttocks, since admitting to the facility. R90 believed cream and a bandage were being applied to the open areas. A Progress Note for 2/26/25 at 5:54 PM reflected R90 admitted from the hospital following a urinary tract infection and atrial fibrillation. Open areas were noted to R90's bilateral (both sides) buttocks, according to the note. The admission skin assessment for 2/26/25 reflected R90 had pressure ulcers to their bilateral buttocks. There was no further documentation pertaining to the pressure ulcers, including wound measurements, wound staging or wound characteristics. A Physician's Order with a start date of 2/26/25 reflected the open area on the bilateral buttocks was to be cleansed with normal saline and patted dry. Barrier cream was to be applied, then covered with a sacral dressing, every shift and as needed. In an interview on 03/04/25 at 3:52 PM, Licensed Practical Nurse (LPN) N reported being unsure of the appearance of R90's pressure ulcers, stating R90's treatment was not scheduled on their shift. Upon review of the treatment order, LPN N reported R90's treatment was for cream only. LPN N then identified the treatment order included application of a dressing. LPN N stated they had not yet performed R90's treatment that day. The March 2025 Treatment Administration Record (TAR) reflected R90's bilateral buttocks treatment was signed out as completed for the 6 AM to 6 PM shift on 3/4/25 by LPN N. The Medication Administration Audit Report reflected LPN N signed the treatment out as being completed on 3/4/25 at 8:24 AM. During an interview on 03/05/25 at 10:45 AM, Unit Manager (UM) P reported assessing R90's skin upon admission to the facility. UM P stated R90's pressure ulcer presented as a stage two (partial-thickness loss of skin, presenting as a shallow open ulcer) upon admission. UM P reported they assessed R90's pressure ulcer on 3/4/25, and it was healed. UM P reported when completing their weekly wound assessments, they compared their assessment from the week prior. A late entry Progress Note for 2/26/25, entered by UM P on 3/4/2025 reflected R90's buttocks was assessed upon admission to the facility. The note reflected there were peeling areas, open areas and several scattered, small open areas, which were in different stages of healing. According to the note, stage two pressure ulcers were present upon admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a homelike environment for up to 84 residents residing at the facility, resulting in residents being subjected to numerous loud overhead paging throughout the day. Findings: During an observation on 3/3/25 at 8:31 AM on North 2 unit, during initial resident screening heard very loud overhead speaker announcement made through facility, [named staff] to dietary. During an observation on 3/3/25 at 8:41 AM, overheard very loud overhead announcement, Maintenance to back hall for delivery. During an observation on 3/03/25 at 9:12 AM, overheard very loud overhead announcement throughout facility. During an observation on 3/03/25 9:at 21 AM , overheard very loud overhead announcement throughout facility, Wander risk front lobby. During an observation on 3/03/25 at 9:34 AM, resident # 35 granted permission to enter room and reported door was closed because overhead paging was so loud and was annoying to her. During an observation on 3/03/25 at 9:39 AM, overheard very loud overhead announcement throughout facility, [name] to front office. During an observation on 3/03/25 at 9:45 AM, overheard very loud overhead announcement throughout facility. During an observation on 3/03/25 at 10:02 AM, overheard very loud overhead announcement throughout facility, Doctor call . During an observation on 3/03/25 at 12:12 PM, overheard very loud overhead announcement throughout facility, beep noise, followed by sound of phone hanging up. During an interview on 3/03/25 at 12:52 PM, R20 family reported visits facility often and reported have observed R20 startled by overhead announcement because they are so loud. During an observation on 3/03/25 at 1:07 PM, overheard very loud overhead announcement throughout facility. During an observation on 3/03/25 at 1:57 PM, overheard very loud overhead announcement throughout facility. During an observation on 3/03/25 at 2:02 PM, overheard very loud overhead announcement throughout facility. During observations on 3/4/25, overheard several overhead announcements. During an observation on 3/05/25 at 9:09 AM, overheard very loud overhead announcement throughout facility, [stated name] to front office. Review of the, Phone extentions for ., provided to survey team 3/3/25, also included staff contact information. The Document indicated in bold, red print, TO PAGE OVERHEAD - DIAL *460 . During an interview on 3/05/25 at 9:30 AM, Nursing Home Administrator (NHA) A reported reviewed General Maintenance Policy yesterday that spoke about, Homelike Environment that included limiting overhead announcements and verified facility paged too frequently overhead and should limit to emergencies only. NHA A reported planned to limit overhead announcements starting today (3/5/25). NHA A reported he had just tuned out noise but agreed that frequent overhead paging was not homelike.

Based observation, interview, and record review the facility failed to ensure proper storage of medication in one of three medication carts and one medication room of three reviewed for medication storage. Findings include: During an observation and interview on 3/04/25 at 12:32 PM, Licensed Practical Nurse(LPN) R unlocked the South 1 medication cart. Located in the medication cart was an open resident Albuterol 90mcg, dated on box 2/21/24. LPN R verified date and inhaler was open and reported should have been discarded 12 months after open date. LPN R verified the LOT#(batch number) on the inhaler and the box were not the same and reported should match. Observed open bottle of Timolol Mateate eye drops with no open date. LPN R verified eye drops open and should have been labeled with open date. Observed Glucose Gel in cart with manufacturer expiration date of 7/2024. LPN R reported planned to discard. During an interview on 3/05/25 at 11:45 AM, Director of Nursing (DON) B reported would expect nursing staff to date medications when opened. DON B reported Pharmacy and Unit Managers routinely check medications carts for outdated items. During an observation and interview on 3/05/25 at 1:27 PM, Registered Nurse (RN) S unlocked the South 2 medication room. Several (more than 20) yellow Heparin 100units/1 ml syringes were observed in bin with manufacturer expiration date of 6/30/23. RN S reported was unsure what they were used for and reported plan to dispose. Unit Manager T arrived and verified Heparin syringes should have been discarded according to manufacture date 6/30/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation and interview on 3/04/25 at 11:51 AM, Licensed Practical Nurse (LPN) F was preparing medications for resident on North 1 unit. LPN F reported plan to administer insulin via insulin pen. LPN F removed the cap from the Humalog insulin pen and twisted needle on the end of the pen without cleaning rubber tip first with alcohol wipe. During an interview on 3/05/25 at 11:45 AM, Director of Nursing (DON) B reported would expect nurse to clean tip of insulin pen prior to attaching new needle every time. Based on observation, interview and record review, the facility failed to ensure appropriate use of Personal Protective Equipment (PPE-protective garments or equipment designed to protect the wearer from injury or infection) and hand hygiene for Transmission-Based Precautions (TBP-used for patients known or suspected to be infected or colonized with infectious agents) for one (Resident #4) of two reviewed. Findings include: Review of the medical record reflected Resident #4 (R4) admitted to the facility on [DATE], with diagnoses that included congestive heart failure and carrier of Carbapenem-resistant Acinetobacter baumannii (a multi-drug resistant bacteria). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/24, reflected R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). A Physician's Order, dated 12/5/24, reflected R4 was on Contact Precautions (a type of TBP) for a multi-drug resistant organism (MDRO). According to the Centers for Disease Control and Prevention (CDC), .Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning [putting on] PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens . (https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html) On 03/03/25 at 9:34 AM, PPE was observed hanging on the exterior of R4's room door. A sign for Contact Precautions was posted on the exterior of the door, which reflected two STOP signs and notation of, CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . On 03/03/25 at 9:34 AM, Licensed Practical Nurse (LPN) I reported R4 was on Contact Precautions for methicillin-resistant Staphylococcus aureus (MRSA-an infection caused by a type of staph bacteria that is resistant to many antibiotics) in their urine, and a gown and gloves were to be worn into R4's room. During an observation on 03/03/25 at 12:02 PM, Certified Nurse Aide (CNA) J entered R4's room with a lunch tray. CNA J did not wear PPE into the room and closed the door behind them. CNA J exited the room at 12:02 PM and proceeded to the meal cart in the hallway. On 03/03/25 at 12:04 PM, CNA J reported they would wear gloves when going into R4's room and would wear a gown and gloves if doing perineal care for R4 or anything related to toileting. CNA J stated they were supposed to wear gloves to pass the room tray due to an MDRO in R4's urine. CNA J indicated they forgot to put PPE on prior to passing R4's lunch tray. CNA J also reported they did not perform hand hygiene upon exiting R4's room. On 03/03/25 at 2:30 PM, R4 was observed seated in a recliner, in their room. R4 stated staff only wore a gown and gloves when assisting them in the bathroom. A box of empty pop cans was observed on the lid of the trash can, near the inside of R4's room door, which was designated for disposal of PPE. In an interview on 03/05/25 at 9:36 AM, Director of Nursing (DON) B reported if a resident was on Contact Precautions, a gown and gloves should have been worn any time someone entered the resident's room. In an interview on 03/05/25 at 11:21 AM, Unit Manager (UM) Q reported R4 had a history of an MDRO in their urine, for which staff was to wear a gown and gloves for any care. UM Q indicated they were attempting to determine if R4 was to be on Enhanced Barrier Precautions (EBP-use of gowns and gloves during high-contact resident care activities for residents known to be colonized or infected with a MDRO and/or residents at an increased risk of acquiring an MDRO).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 84 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 03/03/25 at 07:30 A.M., An initial tour of the food service was conducted with Dietary Aide C. The following items were noted: Ice [NAME] were observed protruding from the Walk-In Freezer Freon refrigerant inlet supply lines. The Walk-In Freezer ceiling surface was also observed with accumulated ice droplets, adjacent to the refrigeration fan unit. The Can Opener Assembly was observed soiled with accumulated and encrusted food residue. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The Microwave Oven door face plate was observed (etched, scored, particulate, corroded). The damaged face plate surface measured approximately 0.5 - inches-wide by 4-6 inches-long. The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 03/03/25 at 08:35 A.M., An initial tour of the food service was continued with Director of Food Services D. The following items were noted: The three-compartment sink rinse and sanitizer basin faucet assembly was observed leaking water from the chemical diversion valve. Director of Food Services D indicated he would contact Ecolab for necessary repairs as soon as possible. The 2022 FDA Model Food Code section 5-205.15 states: A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. One of two Dish Machine Room overhead spray arm valve assemblies were observed soiled with accumulated and encrusted food residue. Director of Food Services D indicated he would have dietary staff thoroughly clean and sanitize the soiled spray arm valve assembly as soon as possible. West Wing Dining Room: The microwave oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. Director of Food Services D indicated he would have dietary staff thoroughly clean and sanitize the soiled microwave oven as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 03/05/25 at 08:30 A.M., Record review of the Policy/Procedure entitled: Equipment dated 5/2014 revealed under Policy Statement: It is the center policy that all food service equipment is clean, sanitary, and in proper working order. Record review of the Policy/Procedure entitled: Equipment dated 5/2014 further revealed under Action Steps: (1) The Food Services Director will ensure that all equipment is routinely cleaned and maintained in accordance with manufacturer directions and training materials. (4) The Food Services Director ensures that all non-food contact equipment is clean. On 03/05/25 at 08:45 A.M., Record review of the Policy/Procedure entitled: Environment dated 5/2014 revealed under Policy: It is the center policy that all food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition. Record review of the Policy/Procedure entitled: Environment dated 5/2014 further revealed under Action Steps: (1) The Food Service Director will ensure that the physical plant is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00147519 Based on observation, interview and record review the facility failed to implement, revise and evaluate effectiveness of the care plan for one of two sampled residents (Residents #4) reviewed for falls resulting in unnecessary falls and hospitalization with major injury. Findings include: Resident #4 (R4) Review of the medical record reflected R4 was an initial admission to the facility on [DATE]. Diagnoses of [NAME] Matter Disease, Dementia with behavioral disturbance, Anxiety, Delusional Disorder, Restlessness and Agitation, Muscle Weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/09/2024, revealed R4 had a Brief Interview of Mental Status (BIMS) of 06 (severe cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R4 requires substantial assistance with personal care. During an interview on 10/22/24 at 1:08PM, Social Worker (SW) L stated with R4's falls, they met every week to review falls, go over the interventions in place. SW L also stated they have him on psych services and increased the involvement of activities. Also stated R4 was in the military service and the sound of alarms increases his anxiety. SW L stated that the family of R4 are the ones who initiated the discharge planning process. SW L also stated that the family were upset that R4 had had so many falls at this facility. SW L also added that the facility did not have enough staff to be with him 24/7 to watch him. SW L stated that the staff did every 15 minutes checks on him and periods of one on one, and ensuring the alarms were on him and working well and continue to observe. Writer asked who provided the one-on-one staff for him, SW L stated to check with the Director of Nursing (DON) B as SW L did not provide that. SW L stated that nursing was the discipline that addresses falls, and she only addressed cognition. Record review of activity log for one-on-one visits, revealed no interactions for the last 30 days. During an interview on 10/22/24 at 1:38 PM, DON B was asked who puts interventions in place following a fall. DON B stated the reason the writer could not see them is because the family was not on board. DON B then stated they were using alarms, offering snacks, brought down to the nurse's station, brought out in the day room, was very common for them, not specific. DON B stated she talked to the family of R4 about his anxiety and was not in agreement to psych medications. DON B also stated that care conferences were not productive as family would yell at them and hang up the phone on them. DON B added several suggestions, but family did not want them. Writer asked for documentation of the suggestions and where family refused. DON B was looking for documentation that family were in agreement or not in agreement to the suggestions. DON B was unable to find any in the medical record, she stated she thought Unit Manager J put them in her notes. During the phone call from DON B to Unit Manager J, stated the last care conference on 08/29/24 did not include any documentation that family were not in agreement with suggestions. Unit Manager J came into DON B office. Writer asked for the care conference notes for 10/10/24. DON B provided the documentation which showed that social work section was the only section completed, nursing did not have anything documented, area was blank. Writer asked for the 15-minute check log for R4, Unit Manager J stated she had paper copies and went to get them. Writer asked DON B for the one-on-one log as it was documented they would provide if R4 got anxious or restless. DON B stated they would have someone watching him, not like a 24/7 thing, staff just knew if R4 got anxious, like taking him to the nursing station, have staff follow him around, but it wasn't documented or tracked. Unit Manager J provided the 15-minute checks log. The 15 minutes checks were from the date 10/19/24 at 1545 (3:45 PM) through 10/19/24 at 2000 (8:00 PM). The 15 minutes started back up on 10/20/24 at 6:00 AM until R4 was hospitalized on [DATE] at 1530 (3:30 PM). No 15-minute checks following any of the other falls. Writer asked DON B again about not updating the care plan with new interventions following each fall. DON B stated the fall on 10/12/24 alarm was alerting them, but they could not get to him in time to prevent the fall. Unit Manger J stated it was her responsibility to update the care plans. Unit Manager J also stated she didn't have anything more to put on it. Writer asked DON B and Unit Manager J why there wasn't anything added to the fall section on the care plan or [NAME] since admission of 07/05/24, no response. During an interview on 10/23/24 at 08:00 AM via email to DON B requested to see the incident reports on the falls for R4 since July of 2024. Record review revealed that the incident reports for the falls on R4 included 8 separate falls from 07/19/24 through 10/19/24 which resulted in a hospitalization with a femur fracture. Fall on 07/19/24 at 18:45, R4 found sitting on the floor beside his recliner, no injuries. Fall on 08/30/24 at 03:30, R4 found sitting on the floor on buttocks in his room leaning up against the bathroom door. Bed alarm was alerting, staff did not get there in time to prevent the fall. Fall on 09/22/24 at 20:20, R4 got out of bed, bed alarm was alerting, he was walking to the bathroom, was assisted by CNA to the toilet, CNA stepped out and R4 slid off the toilet. Found in a seated position in front of the toilet. Fall on 09/30/24 at 00:19, fell to the floor, skin tear to the right knee. Fall on 10/9/24 at 21:41, R4 became aggressive towards staff and lost balance and fell onto his knees. Fall on 10/12/24 at 14:36, fell to the floor and hit his head on the floor resulting in a small lump forming to the right side of his head. Fall on 10/13/24 at 01:58, fell to the floor, hit his forehead, was bleeding, R4 was unable to give a pain level, sent out to emergency department. Fall on 10/19/24 at 03:53, fell to the floor in front of his bed, bed alarm did not alert staff that R4 got out of bed, wheelchair was beside R4 with the brakes unlocked. Record review revealed on 10/19/24 at 10:30 AM, R4 complained of left hip/femur pain, not able to lift left leg, would cry out when the left leg was moved. R4 sent out to emergency department for X-rays. Review of the X-ray results, R4 did not get his left hip or femur X-rayed, only head to lower spine was X-rayed. On 10/21/24 at 10:47 AM, R4 was still complaining of pain in his left hip/leg. On 10/21/24 at 12:35 PM, Nurse Practitioner (NP) Q assessed R4, ordered a stat X-ray of his left hip, pelvis and femur. On 10/21/24 at 15:28 PM, Stat X-ray results for R4's left hip, pelvis and femur came back with R4 having a left subcapital fracture (neck of femur fracture) and fracture involving the left proximal femur (break in the upper quarter of the thighbone, near the hip joint). R4 was sent to the hospital and admitted with a hip fracture. Record review revealed the care plan for falls, was not updated with any changes, revised or additions to the interventions after these 8 falls. Record review did not reveal any changes to R4's care plan, [NAME] or task sheet in effort to prevent these falls from admission date of 07/03/24 to being hospitalized for fractures on 10/21/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00147519 Based on observation, interview and record review, the facility failed to initiate new interventions to prevent falls for one resident (Resident #4) of two reviewed for falls, from a total sample of 5, resulting in continued falls and hospitalization for major injury. Findings include: Resident #4 (R4) Review of the medical record reflected R4 was an initial admission to the facility on [DATE]. Diagnoses of [NAME] Matter Disease, Dementia with behavioral disturbance, Anxiety, Delusional Disorder, Restlessness and Agitation, Muscle Weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/09/2024, revealed R4 had a Brief Interview of Mental Status (BIMS) of 06 (severe cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R4 requires substantial assistance with personal care. During an interview and observation on 10/18/24 at 11:46 AM, R4 was sleeping in his bed fully dressed, hair was matted, face was scruffy from not being shaved. Noted the call light was out of reach for him, water glass on the over the bed table was room temperature with no date or time on the cup. Writer tried waking R4 up with verbal stimulation and tactile, he opened his eyes and then went back to sleep. During an interview and observation on 10/18/24 at 1:34 PM, Licensed Practical Nurse (LPN) O stated R4 was safe sitting in his wheelchair with an alarm under him. Writer observed R4 sitting in his wheelchair sitting in the hallway. Writer asked LPN O who provides the one-on-one supervision as documented in the progress notes. LPN O stated she didn't know they provided that because they do not have enough staff to provide that. Writer asked when R4 had his last shower, LPN O stated on 10/14/24, and blamed R4's behaviors made it hard to provide. Writer asked LPN O what other interventions they had tried to get him to take a shower. LPN O stated they just left him alone for a while and then try again. Writer asked if R4 would be getting a shower today as he appeared dirty. LPN O stated I am sure the CNA washed him up this morning. During an interview on 10/22/24 at 1:08PM, Social Worker (SW) L stated with R4's falls, they met every week to review falls and go over the interventions in place. SW L also stated they had him on psych services and increased the involvement of activities. Also stated R4 was in the military service and the sound of alarms increases his anxiety. SW L stated that the family of R4 are the ones who initiated the discharge planning process. SW L also stated that the family were upset that R4 had had so many falls at this facility. SW L also added that the facility did not have enough staff to be with him 24/7 to watch him. SW L stated that the staff did every 15 minutes checks on him and periods of one on one, and ensuring the alarms were on him and working well and continued to observe. Writer asked who provided the one-on-one for him, SW L stated to check with the Director of Nursing (DON) B as SW L did not provide that. SW L stated that nursing was the discipline that addresses falls, and she only addressed cognition. Record review of activity log for one-on-one visits, revealed no interactions for the last 30 days. During an interview on 10/22/24 at 1:38 PM, DON B was asked who puts interventions in place following a fall. DON B stated the reason the writer could not see them is because the family was not on board. DON B then stated they were using alarms, offering snacks, brought down to the nurse's station, brought out in the day room, was very common for them, not specific. DON B stated she talked to the family of R4 about his anxiety and was not in agreement to psych medications. DON B also stated that care conferences were not productive as family would yell at them and hang up the phone on them. DON B added that several suggestions, but family did not want them. Writer asked for documentation of the suggestions and where family refused. DON B was looking for documentation in the medical record that family were not in agreement to the suggestions. DON B was unable to find any, she stated she thought Unit Manager J put them in her notes. During the phone call from DON B to Unit Manager J, stated the last care conference on 08/29/24 did not include any documentation that family were in agreement or not in agreement with suggestions. Unit Manager J came into DON B office. Writer asked for the care conference notes for 10/10/24. DON B provided the documentation which showed that social work section was the only section completed, nursing did not have anything documented, area was blank. Writer asked for the 15-minute check log for R4, Unit Manager J stated she had paper copies and went to get them. Writer asked DON B for the one-on-one log as it was documented they would provide if R4 got anxious or restless. DON B stated they would have someone watching him, not like a 24/7 thing, staff just knew if R4 got anxious, like taking him to the nursing station, have staff follow him around, but it wasn't documented or tracked. Unit Manager J provided the 15-minute checks log. The 15 minutes checks were from the date 10/19/24 at 15:45 (3:45 PM) through 10/19/24 at 2000 (8:00 PM). The 15 minutes started back up on 10/20/24 at 6:00 AM until R4 was hospitalized on [DATE] at 1530 (3:30 PM). No 15-minute checks following any of the other falls. Writer asked DON B again about not updating the care plan with new interventions or revisions following each fall. DON B stated the fall on 10/12/24, alarm was alerting them, but they could not get to him in time to prevent the fall. Unit Manger J stated it was her responsibility to update the care plans. Unit Manager J also stated she didn't have anything more to put on it. Writer asked DON B and Unit Manager J why there wasn't anything added to the fall section on the care plan or [NAME] since admission of 07/05/24, no response. During an interview on 10/23/24 at 0800 AM via email to DON B requested to see the incident reports on the falls for R4 since admission in July 2024. Record review revealed that the incident reports for the falls on R4 included 8 separate falls from 07/19/24 through 10/19/24 which resulted in a hospitalization with a femur fracture. Fall on 07/19/24 at 18:45 PM, R4 found sitting on the floor beside his recliner, no injuries. Fall on 08/30/24 at 03:30 AM, R4 found sitting on the floor on buttocks in his room leaning up against the bathroom door. Bed alarm was alerting, staff did not get there in time to prevent the fall. Fall on 09/22/24 at 20:20 PM, R4 got out of bed, bed alarm was alerting, he was walking to the bathroom, was assisted by CNA to the toilet, CNA stepped out and R4 slid off the toilet. Found in a seated position in front of the toilet. Fall on 09/30/24 at 00:19 AM, fell to the floor,skin tear to the right knee. Fall on 10/9/24 at 21:41 PM, R4 became aggressive towards staff and lost balance and fell onto his knees. Fall on 10/12/24 at 14:36 PM, fell to the floor and hit his head on the floor resulting in a small lump forming to the right side of his head. Fall on 10/13/24 at 01:58 AM, fell to the floor, hit his forehead, was bleeding, R4 was unable to give a pain level, sent out to emergency department. Fall on 10/19/24 at 03:53 AM, fell to the floor in front of his bed, bed alarm did not alert staff that R4 got out of bed, wheelchair was beside R4 with the brakes unlocked. Record review revealed on 10/19/24 at 10:30 AM, R4 complained of left hip/femur pain, not able to lift left leg, would cry out when the left leg was moved. R4 sent out to emergency department for X-rays. Review of the X-ray results, R4 did not get his left hip or femur X-rayed, only head to lower spine was X-rayed. On 10/21/24 at 10:47 AM, R4 was still complaining of pain in his left hip/leg. On 10/21/24 at 12:35 PM, Nurse Practitioner (NP) Q assessed R4, ordered a stat X-ray of his left hip, pelvis and femur. On 10/21/24 at 15:28 PM, Stat X-ray results for R4's left hip, pelvis and femur came back with R4 having a left subcapital fracture (neck of femur fracture) and fracture involving the left proximal femur (break in the upper quarter of the thighbone, near the hip joint). R4 was sent to the hospital and admitted with a hip fracture. Record review revealed the care plan for falls, were not updated with any changes or additions to the interventions after these 8 falls. Record review did not reveal any changes to R4's care plan, [NAME] or task sheet in effort to prevent these falls from admission date of 07/03/24 to being hospitalized for fractures on 10/21/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of transfer for one resident (Resident #20) of two reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the reason for the transfer. Findings include: Resident #20(R20) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R20's admission date was 1/12/2024. Brief Interview for Mental Status (BIMS) score was a 14, which indicated her cognition was intact. Resident was discharged to the hospital on 2/26/2024 and returned to the facility on 3/2/2024 with a diagnosis of pulmonary embolism. During an interview on 3/26/2024 in the afternoon, R20 stated that she went to the hospital recently and she was very scared because she thought she was going to die. R20 said she was feeling better and would be discharging from the facility on 3/28/2024. R20 couldn't remember if she received a written transfer notice when she went to the hospital. Review of R20's chart revealed no evidence that R20 received a written notice of transfer to include the following information: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. During an interview on 3/28/2024 at 11:22 AM, Director of Nursing (DON) B stated that she wasn't sure if the transfer notice was given to R20. DON B said she couldn't find a Transfer/Discharge Policy. During an interview on 3/28/2024 at 11:49 AM, Registered Nurse (RN) J stated that she has to gather blank forms from the file cabinet since packets aren't made up and has to fill them out and send the forms with the resident to the hospital. RN J wasn't aware of the written transfer/discharge notice and stated that she doesn't give that to residents when they transfer out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident of the facility bed hold policy and provide a written copy upon hospital transfer for one resident (Resident #20) of two reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the bed hold policy. Findings include: Resident #20(R20) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R20's admission date was 1/12/2024. Brief Interview for Mental Status (BIMS) score was a 14 which indicated her cognition. Resident was discharged to the hospital on 2/26/2024 and returned to the facility on 3/2/2024 with a diagnosis of pulmonary embolism. During an interview on 3/26/2024 in the afternoon, R20 stated that she went to the hospital recently and she was very scared because she thought she was going to die. R20 said she was feeling better and would be discharging from the facility on 3/28/2024. R20 couldn't remember if she received a written bed hold notice when she went to the hospital. Review of the chart revealed no documentation that R20 received a written bed hold policy. Review of R20's chart on 2/28/2024 revealed a Social Services Narrative note written by Admission's Director (AD) I that stated, (R20) will be holding her bed until return from Hospital. During an interview on 3/28/2024 at 10:10 AM, AD I stated that upon admission the bed hold process is discussed if they were to go to the hospital so they are aware of it if that occurs. AD I said that either the Payroll Staff (PC) X or she would call and speak to the resident regarding the bed hold when the resident was at the hospital and would make a note in the chart. AD I stated that they call as soon as the resident goes to the hospital and sometimes it may take a few days to get a hold of them. When asked if a written bed hold notice was given to R20, AD I said that she wasn't aware a written notice had to be given. AD I also stated that she didn't know if anyone else on other shifts or the nurses know that the bed hold notice must be discussed and the resident must be given a written notice. AD I' said she was going to write a new SOP (Standards of Procedure) since she wasn't aware of this regulation and would complete training with nurses on all shifts for when she wasn't there. During an interview on 3/28/2024 at 11:22 AM, Director of Nursing (DON) B stated that she thought that the nurses sent a packet with the written bed hold policy when a resident transfers to the hospital. During an interview on 3/28/2024 at 11:49 AM, Registered Nurse (RN) J stated that she gathers blank forms from the file cabinet since packets aren't made up and has to fill them out and send the forms with the resident to the hospital. RN J' said that the forms she gathers doesn't always include the written bed hold notice when they transfer out. RN J also said she doesn't discuss the bed hold notice with the resident or resident representative because she isn't sure of the facility rate. RN J stated that when there is an emergent situation then the bed hold isn't discussed and a written notice isn't given.

Based on observation, interview, and record review the facility failed to follow pharmacy policy and acceptable clinical practice for maintaining controlled medication for three of four medication carts, record controlled medication for one resident (#24) in a timely manner, and failed to destroy medication for one resident (#77) in an acceptable clinical practice resulting in the potential for controlled medication diversion. Findings Included: Resident #24 (R24) Review of the medical record demonstrated R24 was admitted to the facility 10/15/2021 with diagnoses that included Alzheimer's Disease, dementia, and anxiety. The most recent Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 01/22/2024, demonstrated R24 had a Brief Interview for Mental Status (BIMS) that was not assessed because she rarely/never could be understood. Resident #77 (R77) Review of the medical record demonstrated R77 was admitted to the facility 10/29/2023 with diagnoses that included dementia, anxiety, and hypertension. The most recent Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 02/02/2024, demonstrated R77 had a Brief Interview for Mental Status (BIMS) of 8 (moderately impaired cognition) out of 15. During observation on 03/28/2024 at 08:14 a.m. of medication administration Licensed Practical Nurse (LPN) K was observed dispensing medication from a medication cup into the Sharps container located on 1 North Medication Cart. When LPN K was asked why she was discarding medication in the Sharps container of 1 North medication cart, she responded that resident R77 was not available to take his morning medication so they destroyed them by placing them in the 1 north medication sharps container. She explained that she would be re-dispensing R77's medication later when he was available and would need to prepare new morning medication. Review of North One Medication Cart's Narcotic Count Sheet on 03/28/2024 at 08:26 a.m. demonstrated that the outgoing nurse signed the document at 06:00 a.m. on 03/28/2024. No signature of the on coming nurse was present on that document. In an interview on 03/28/2024 at 08:26 a.m. Licensed Practical Nurse (LPN) K explained that she should have signed her signature at the time that Controlled Medication was counted at 06:00 a.m. on 03/28/2024. LPN K could not explain why she had not documented her signature demonstrating proof that the Controlled Medication was accurate. During observation of medication administration on 03/28/2024 at 08:32 a.m. Licensed Practical Nurse (LPN) M was observed to remove Tramadol HCL (Hydrochloride) 50mg (Milligrams) during R24 medication administration. LPN M did not sign out the Tramadol HCL 50mg on R24's Controlled Substance Proof-OF-Use Record. At the completion of R24's medication administration LPN M did not sign out Tramadol HCL 50mg before starting medication administration with another resident. In an interview on 03/2/2024 at 08:40 a.m. Licensed Practical Nurse M explained that it was the facility policy that Tramadol HCL 50mg should have been signed for at the time that it was removed from the controlled storage drawer of the medication cart. LPN M could not explain why she had not followed the facility policy. Review of North Two Medication Cart's Narcotic Count Sheet on 03/28/2028 at 08:45 a.m. demonstrated that the outgoing nurse signed the document at 06:00 a.m. on 03/28/2024. No signature of the on coming nurse was present on that document. In an interview on 03/28/2024 at 08:46 a.m. Licensed Practical Nurse (LPN) M explained that she should have signed at the time that Controlled Medication was counted at 06:00 a.m. on 03/28/2024. LPN M could not explain why she had not documented her signature demonstrating proof that the Controlled Medication was accurate. Review of South One Medication Cart's Narcotic Count Sheet on 03/28/2024 at 08:58 a.m. demonstrated that the outgoing nurse signed the document at 06:00 a.m. on 03/28/2024. No signature of the on coming nurse was present on that document. In an interview on 03/28/2024 at 08:59 a.m. Licensed Practical Nurse (LPN) N explained that she should have signed at the time the Controlled Medication was counted at 06:00 a.m. on 03/28/2024. LPN N could not explain why she had not documented her signature demonstrating proof that the Controlled Medication was accurate. During an Interview on 03/28/2024 at 09:08 a.m. Director of Nursing (DON) B explained that all medication that needed to be destroyed was to be placed in a Drug Buster (container that inactivates medication), which is kept in each medication rooms. During the same interview, DON B could not explain a reason why a nurse was observed placing medication in the Sharps container attached to the side of a medication cart. DON B explained that it was facility policy and professional practice that all controlled medication was to be signed out on the resident Controlled Substance Proof-Of-Use Record at the time that the controlled medication was removed from the drawer of the medication cart. During the same interview DON B explained that it was facility policy and professional practice that controlled medications are to be counted at the start and end of each nursing shift. She explained that the out going nurse and the on coming nurse were expected to count the medication and that both nurses had to sign the Narcotic Count Sheet at the end of the controlled medication count. DON B could not explain why that process had not been followed for 3 of 4 Medication Cart's Narcotic Count Sheet on 03/28/2024 06:00 a.m. DON B explained that it would be necessary for her to re-count the controlled medication in each medication cart to determine accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address medication irregularities for one (Resident #37) of five reviewed. Findings include: Review of the medical record revealed Resident #37 (R37) was admitted to the facility on [DATE] with diagnoses that included a history of pulmonary embolism and atrial fibrillation. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/23 revealed R37 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R37's Physician's Order dated 12/21/23 revealed Xarelto 20 milligrams (mg) was ordered daily and scheduled to be administered in the evening between 6:00 PM and 11:00 PM. Review of the pharmacy's Note to Attending Physician/Prescriber dated 10/3/23 revealed Xarelto doses equal to or greater than 15 mg should be administered with the largest meal of the day to increase bioavailability [the extent a substance or drug becomes completely available to its intended biological destination]. The suggestion was to schedule Xarelto with dinner. The physician agreed with the recommendation and signed the form. The order and timing of Xarelto was not changed. Review of the pharmacy's Note to Attending Physician/Prescriber dated 2/2/24 revealed Xarelto doses equal to or greater than 15 mg should be administered with the largest meal of the day to increase bioavailability. The physician agreed with the recommendation and signed the form. The order and timing of Xarelto was not changed. In an interview on 03/28/24 at 9:49 AM, R37 reported she did not take her Xarelto with dinner. R37 reported her night medications were occasionally not administered until almost 11:00 PM. Review of Medication Admin Audit Report dated 3/1/24 through 3/28/24 revealed Xarelto was scheduled for PM PA and the following administration times were documented: 3/1/24 at 11:03 PM, 3/2/24 at 10:09 PM, 3/3/24 at 8:52 PM, 3/4/24 at 7:16 PM, 3/5/24 at 7:40 PM, 3/6/24 at 8:27 PM, 3/7/24 at 10:14 PM, 3/8/24 at 11:24 PM, 3/9/24 at 8:59 PM, 3/10/24 at 9:57 PM, 3/11/24 at 8:44 PM, 3/12/24 at 8:22 PM, 3/13/24 at 9:36 PM, 3/14/24 at 8:13 PM, 3/15/24 at 11:35 PM, 3/16/24 at 10:22 PM, 3/17/24 at 9:09 PM, 3/18/24 at 9:16 PM, 3/19/24 at 8:44 PM, 3/20/24 at 9:11 PM, 3/21/24 at 11:00 PM, 3/22/24 at 11:14 PM, 3/23/24 at 8:45 PM, 3/24/24 at 10:32 PM, 3/25/24 at 10:40 PM, 3/26/24 at 9:08 PM, and 3/27/24 at 10:26 PM. In an interview on 03/27/24 at 3:00 PM, Director of Nursing (DON) B reported the PM PA medication administration time could be any time between 6:00 PM and 11:00 PM. Review of the facility's Meal & Cart Times revealed dinner was served between 5:00 PM and 6:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #16 (R16): Review of the medical record reflected R16 was [AGE] years old and admitted to the facility on [DATE], with diagnoses that included congestive heart failure, chronic kidney disease and hypertension (high blood pressure). R16's medical record reflected pneumococcal vaccinations PCV13 and PPSV23 were declined 6/8/21. R16's medical record did not reflect that they had been offered any additional pneumococcal vaccinations. Per the CDC PneumoRecs Vax Advisor, the recommendation for R16 was, Give one dose of PCV15 or PCV20 .If PCV20 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV23 to complete their pneumococcal vaccinations . On 03/27/24 at 11:18 AM, further information was requested from DON B regarding R16's pneumococcal vaccines. The information was not provided prior to the survey exit. Based on interview and record review, the facility failed to offer pneumococcal immunizations per Centers for Disease Control and Prevention (CDC) recommendations for two (Resident #16 and Resident #37) of five reviewed. Findings include: Resident #37 (R37) Review of the medical record revealed R37 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), history of pulmonary embolism, type 2 diabetes mellitus, asthma, congestive heart failure (CHF), and chronic kidney disease. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/23 revealed R37 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was up to date with pneumococcal vaccines. Review of R37's pneumococcal vaccine history revealed they received the PPSV23 on 11/1/16, before the age of 65, and received the PCV14 on 8/16/18. The medical record did not show that any further pneumococcal vaccines were offered. Per the CDC PneumoRecs Vax Advisor, the recommendation for R37 was Give one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. OR Give one more dose of PPSV23 at least 1 year after PCV13 and at least 5 years after previous PPSV23 dose. Review of facility's Pneumococcal Vaccine dated 3/1/21 revealed It is our policy to offer our residents immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations .The type of pneumococcal vaccine (PCV13, PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. The policy did not reflect that the PCV15 or 20 are used/offered. On 03/27/24 at 11:18 AM, Director of Nursing (DON) B the facility did not have a consent or declination form for further pneumococcal vaccines for R37. On 03/28/24 at 10:17 AM, DON B and Unit Manager (UM) O reported the facility offered the PCV20 pneumococcal vaccine. DON B reported the policy was reviewed this year, but they must have missed the policy update to reflect the current CDC recommendations. Further information regarding R37's pneumococcal vaccines was requested, but not received prior to the survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #27 (R27): Review of the medical record reflected R27 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included generalized atherosclerosis and hypertension (high blood pressure). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/12/24, reflected R27 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R27's medical record reflected medicaid hospice was effective 7/7/23. The significant change in status MDS, with an ARD of 7/14/23, did not reflect coding for hospice services. During an interview on 03/27/24 at 01:36 PM, MDS Nurse C reported hospice should have been coded on R27's significant change in status MDS, with an ARD of 7/14/23. Resident #59 (R59): Review of the medical record reflected R59 admitted to the facility on [DATE], with diagnoses that included cerebral infarction, pseudobulbar affect, major depressive disorder, unspecified psychosis not due to a substance or known physiological condition and bipolar disorder. The admission MDS, with an ARD of 12/29/23, reflected R59 scored 15 out of 15 (cognitively intact) on the BIMS. R59's admission MDS was coded No for A1500. Preadmission Screening and Resident Review (PASRR), Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The same MDS reflected, A1510. Level II Preadmission Screening and Resident Review (PASRR) Conditions, question, A. Level II PASRR conditions: Serious Mental Illness was disabled (no response required) by the response for question A1500. R59's medical record reflected a Change in Condition PASARR, dated 12/28/23, which was reflective of mental illness and treatment of mental illness. A Level II evaluation, dated 6/5/23, was noted in R59's medical record. During an interview on 03/27/24 at 04:11 PM, Director of Social Services (SS) D reported she may have misunderstood MDS question A1500. SS D reported R59 would need a level II evaluation again when her annual was up. Based on observation, interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for four (Resident #22, #27, #36, #59) of 18 reviewed. Findings include: Resident #22 (R22) Review of the medical record revealed R22 was admitted to the facility on [DATE] with a diagnosis that included vascular dementia. The MDS with an Assessment Reference Date (ARD) of 1/5/24 revealed R22 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Section P of the MDS was coded as bed rails used daily as a physical restraint. On 03/26/24 at 9:49 AM, R22 was observed in bed with grab bars attached to both sides of the bed. Resident #36 (R36) Review of the medical record revealed R36 was admitted to the facility on [DATE]. The MDS with an ARD of 1/3/24 revealed R36 scored 15 out of 15 (cognitively intact) on the BIMS. Section P of the MDS was coded as bed rails used daily as a physical restraint. On 03/26/24 at 10:51 AM, R36 was observed in bed with grab bars attached to both sides of the bed. In an interview on 03/27/24 at 1:35 PM, MDS Nurse C reported she coded assist/grab bars on beds as restraints. MDS Nurse C reported she did not believe the bars were restraints. On 03/27/24 at 4:08 PM, MDS Nurse C reported every resident who had bed rails/assist bars/grab bars in the building were not restrained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 03/26/24 at 01:40 P.M., An environmental tour of the facility Laundry Service was conducted with Director of Housekeeping and Laundry Services G. The following item was noted: Clean Laundry Room: The drywall surface was observed (etched, scored, particulate), adjacent to the exterior window. The damaged drywall surface measured approximately 12-inches-wide by 36-inches-long. On 03/27/24 at 09:40 A.M., A common area environmental tour was conducted with Director of Maintenance H and Director of Housekeeping and Laundry Services G. The following items were noted: West Unit (South) Occupational/Physical Therapy: Restroom: Two 24-inch-wide by 48-inch-long acoustical ceiling tiles were observed stained from a previous moisture leak. Director of Maintenance H indicated he would have staff replace the damaged ceiling tiles as soon as possible. The microwave oven interior was observed (etched, scored, particulate). The damaged interior surface measured approximately 1-inch-wide by 3-inches-long. Director of Maintenance H indicated he would remove and replace the damaged microwave oven as soon as possible. West Unit (North) South Unit 1: Beauty Shop: The oscillating floor fan was observed soiled with accumulated dust and dirt deposits. Staff Break Room: The General Electric Harvest Gold Refrigerator interior light bulb was observed non-functional. The General Electric Harvest Gold Refrigerator freezing compartment was also observed with accumulated ice [NAME]. Director of Housekeeping and Laundry Services G indicated she would have staff defrost the refrigerator freezing compartment as soon as possible. South Unit 2: Soiled Utility Room: One acoustical ceiling tile was observed stained from a previous moisture leak. Main Dining Room: Numerous pieces of used adhesive tape were observed attached to the wall surfaces. Director of Housekeeping and Laundry Services G indicated she would have staff remove the adhesive tape and thoroughly clean and sanitize the wall surfaces as soon as possible. North Unit 1: Restroom: The commode seat was observed loose-to-mount. North Unit 2: Dining Room: The corner Formica laminate edge strip was observed (etched, scored, particulate). The damaged laminate surface measured approximately 2-inches-wide by 24-inches-long. Director of Maintenance H indicated he would have staff replace the damaged laminate edge strip as soon as possible. Nursing Station: 1 of 3 chairs were observed (etched, scored, particulate). 1 of 3 chairs were also observed missing arm rest padded sections, exposing the inner metal support brace. Soiled Utility Room: 2 of 2 overhead clear plastic light lens covers were observed soiled with numerous dead insect carcasses. Storage Room: The room was observed in severe disarray. Director of Housekeeping and Laundry Services G indicated she would have staff thoroughly clean and sanitize the storage room as soon as possible. On 03/27/24 at 01:10 P.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance H and Director of Housekeeping and Laundry Services G. The following items were noted: 9: The Bed 1 lower 48-inch-wide fluorescent overbed light bulb was observed non-functional. 26: The Bed 1 overbed light assembly actuation switch was observed broken and loose-to-mount. Director of Maintenance H indicated he would have staff replace the faulty switch as soon as possible. 36: The restroom hand sink faucet assembly was observed loose-to-mount. 49: The Bed 1 upper overbed light assembly bulb was observed non-functional. 53: The oscillating floor fan was observed soiled with accumulated dust and dirt deposits. The restroom hand sink faucet assembly was also observed loose-to-mount. 60: The restroom overhead light assembly was observed non-functional. 1 of 2 restroom over sink basin light bulbs were observed non-functional. 63: The restroom over sink basin light assembly was observed non-functional. 74: The oscillating floor fan was observed soiled with dust and dirt deposits. On 03/27/24 at 03:10 P.M., An interview was conducted with Director of Maintenance H regarding the facility maintenance work order system. Director of Maintenance H stated: We have a maintenance logbook at each nursing station. Director of Maintenance H further stated: I believe we have five logbooks total. On 03/28/24 at 10:00 A.M., Record review of the Policy/Procedure entitled: Resident General Room Cleaning dated 12/2020 revealed under Policy: Resident rooms are cleaned daily and deep cleaned monthly. Record review of the Policy/Procedure entitled: Resident General Room Cleaning dated 12/2020 further revealed under Purpose: To provide guidelines for cleaning resident rooms. Procedures: (5) Dust vents, furniture, and all surfaces; (12) If there are any maintenance issues write them in maintenance log. On 03/28/24 at 10:15 A.M., Record review of the Policy/Procedure entitled: Resident Room Cleaning - Total/discharged Room dated 12/2020 revealed under Policy: Rooms are deep cleaned after any resident is discharged . On 03/28/24 at 10:30 A.M., Record review of the Maintenance Work Order Logbooks for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and toxic chemical residue. Findings include: On 03/26/24 at 08:53 A.M., An initial tour of the food service was conducted with Director of Food Services E. The following items were noted: The three-compartment sink sanitizer concentration was observed slightly excessive. The sanitizing product ((Manufacturer's Name) Sink & Surface Cleaner Sanitizer) test strip was also observed to read approximately 800 parts-per-million (ppm) instead of the manufacturer's recommended concentration of 272-700 parts-per-million (ppm). Director of Food Services E indicated he would contact Contractual Vendor Company Name as soon as possible for adjustments. The 2017 FDA Model Food Code section 4-501.114 states: A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart; 138 Concentration Range (MG/L) Minimum Temperature PH 10 or less °C (°F) Minimum Temperature PH 8 or less °C (°F) 25 - 49 49 (120) 49 (120) 50 - 99 38 (100) 24 (75) 100 13 (55) 13 (55) (B) An iodine solution shall have a: (1) Minimum temperature of 20°C (68°F), (2) PH of 5.0 or less or a PH no higher than the level for which the manufacturer specifies the solution is effective, and (3) Concentration between 12.5 MG/L and 25 MG/L; (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling, and (3) Be used only in water with 500 MG/L hardness or less or in water having a hardness no greater than specified by the EPA-registered label use instructions; (D) If another solution of a chemical specified under (A) - (C) of this section is used, the PERMIT HOLDER shall demonstrate to the REGULATORY AUTHORITY that the solution achieves SANITIZATION and the use of the solution shall be APPROVED; (E) If a chemical SANITIZER other than chlorine, iodine, or a quaternary ammonium compound is used, it shall be applied in accordance with the EPA-registered label use instructions; and (F) If a chemical SANITIZER is generated by a device located on-site at the FOOD ESTABLISHMENT it shall be used as specified 139 in (A) - (D) of this section and shall be produced by a device that: (1) Complies with regulation as specified in §§ 2(q)(1) and 12 of the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), (2) Complies with 40 CFR 152.500 Requirement for Devices and 40 CFR 156.10 Labeling Requirements, (3) Displays the EPA device manufacturing facility registration number on the device, and (4) Is operated and maintained in accordance with manufacturer's instructions. The microwave oven interior (ceiling and side walls) was observed heavily soiled with accumulated and encrusted food residue. Director of Food Services E indicated he would have staff thoroughly clean and sanitize the microwave oven interior as soon as possible. The mechanical dish machine ventilation hood was observed heavily soiled with accumulated and encrusted corrosive deposits. Director of Food Services E indicated he would have staff thoroughly clean and sanitize the soiled ventilation hood as soon as possible. Walk-In Freezer: Ice [NAME] were observed directly beneath the refrigeration unit. Ice dam pyramids were also observed on two cookie sheets beneath the refrigeration unit. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 2 of 4 stainless steel non-insulated transportation carts were observed with doors that will not remain closed during meal tray transit. Director of Food Services E indicated he would have to send the transportation carts out for repair one cart at a time. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 03/28/24 at 09:00 A.M., Record review of the Policy/Procedure entitled: Equipment dated May 2014 revealed under Policy Statement: It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order. On 03/28/24 at 09:15 A.M., Record review of the Policy/Procedure entitled: Environment dated May 2014 revealed under Policy: It is the center policy that all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Record review of the Policy/Procedure entitled: Environment dated May 2014 further revealed under Action Steps: (1) The Food Service Director will ensure that the physical plant is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. (2) The Food Service Director will ensure that all employees are knowledgeable in the proper procedures for cleaning all food services equipment and surfaces. (3) The Food Service Director will ensure that all food contact surfaces are cleaned and sanitized with manufacturer recommended contact times after each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a call light within reach for one (Resident # 53) resident of three residents reviewed for accommodation of needs, resulting in impaired resident access to request and receive assist. Findings include: Review of the medical record revealed that Resident #53 (R53) was admitted to facility 4/20/22 with diagnoses including vascular dementia, weakness, and adjustment disorder with anxiety. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/23 revealed R53 to have a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 5 (severe cognitive impairment) but had clear speech and was able to be understood by and understand others. Section G of MDS reflected that R53 was independent with transfers, was independent with eating and toilet use after set up and required supervision with bed mobility after set up. In an observation on 3/27/23 at 11:12 AM, R53 was observed sitting at the edge of the bed with over the bed table positioned in front of him. R53 stated that he was hungry and awaiting lunch. R53's call light was noted to be out of resident reach as was observed to be attached to the bulletin board on the wall above the head of the bed. In an observation on 3/28/23 at 12:11 PM, R53 was observed lying in bed on left side watching TV. Call light was observed to be out of R53's reach as was noted to be attached to the bulletin board on the wall above the head of the bed. In an observation on 3/28/23 at 2:11 PM, R53 was observed lying in bed, on back, watching TV. Call light was noted to remain out of R53's reach as was observed to be attached to the bulletin board on the wall above the head of the bed. In an observation on 3/29/23 at 7:48 AM, R53 was observed sitting at the edge of the bed with an over the bed table positioned in front of him. Call light was noted to be out of R53's reach as was noted to remain attached to the bulletin board on the wall above the head of the bed. In an observation on 03/29/23 at 10:06 AM, R53 was observed lying in bed, on back, watching TV. Call light was noted to remain out of R53's reach as was observed attached to the bulletin board on the wall above the head of the bed. In an interview and observation on 3/29/23 at 10:08 AM, Licensed Practical Nurse (LPN) X confirmed that she was familiar with R53 as was assigned to the same unit on most shifts that she worked. LPN X stated that she would utilize the resident [NAME] to determine resident care needs including call light placement if a resident requested placement in a certain location. LPN X stated that R53 had baseline confusion but that he was able to and did use his call light intermittently generally to make certain food or snack requests. Per LPN X, R53 did not have a preference as to the placement of the call light, that he independently transferred making placement difficult at times, but that when he was in bed the call light should be placed at bedside within his reach. Upon review of R53's [NAME], LPN X confirmed that the [NAME] did indicate to keep the call light within reach. In the presence of LPN X, knocked on closed door and entered room with R53 noted to be lying in bed. LPN X was observed to look for call light on R53's bed and floor before looking up and seeing it attached to the bulletin board. LPN X stated this is crazy and proceeded to question R53 as to the call light location with resident stating that he did not know where it was. LPN X confirmed that the call light positioning on the bulletin board above the head of the bed was not accessible to R53 from his bed and was observed to remove call light from the bulletin board and provide to R53. Review of R53's Care Plan Focus Resident makes needs known . with a 4/20/22 date of initiation and 5/3/22 revision date indicated an intervention that Staff will need to anticipate needs and place call light within reach with a 4/20/22 date of initiation indicated. Review of R53's Care Plan Focus Risk for falls . with a 4/20/22 date of initiation and 1/25/23 revision date indicated an associated intervention to Reinforce use of call light and keep in reach at all times with a 4/20/22 date of initiation indicated. Review of R53's [NAME] within the section titled Safety indicated guidance to Reinforce use of call light and keep in reach at all times. Review of the facility's policy titled Call Lights: Accessibility and Timely Response dated 2/2020 and reviewed 11/2022 stated, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance .Policy Explanation and Compliance Guidelines .5. Staff will ensure the call light is within reach of resident and secured .6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an elopement of one (Resident #39) of three reviewed for reporting, resulting in an elopement that was unreported to the State Agency and the potential for further elopements to go unreported to the State Agency. Findings include: Resident #39 Review of an admission Record revealed Resident #39 (R39) admitted to the facility on [DATE] with pertinent diagnoses which included unspecified fracture of second lumbar vertebra, hallucinations, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and type two diabetes without complications. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/18/23 reflected R39 scored four out of 15 (severely cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R39 required extensive assistance of two or more people for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), extensive assistance of two or more people for transferring (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and total dependence from staff for tasks such as eating and drinking. Review of a Health Status Note dated 1/24/2023 at 4:41 PM revealed Resident [R39] exit [sic] the building, made it to parking lot attempt to open company van drivers door. placed wonder [wander] guard on resident. Review of a Social Services note dated 1/25/2023 at 10:10 AM revealed Resident [R39] was observed by staff on 1/24/2023, exiting the facility through the lobby door and making his way to the parking lot, along with attempting to open the door of a vehicle. Per staff, they observed resident immediately as he stepped outside the lobby exit and followed him, by assisting him back into the campus. Resident has a wander guard in place at this time r/t [related to] impaired safety awareness. Resident can be triggered when feeling unsure of his surroundings r/t his confusion/dementia and wantingto [sic] go home to be with his wife. Care plans has been updated. Will continue to observe. In an interview on 03/27/23 at 02:26 PM, Certified Nursing Assistant (CNA) S reported R39 was sitting in the hallway in his wheelchair with Licensed Practical Nurse (LPN) DD when LPN DD looked away for a minute and R39 had escaped. CNA S reported she exited the bathroom and did not see R39 in the hallway sitting in his wheelchair where he was prior to going into the bathroom. CNA S then observed R39 out front in the parking lot by a van so CNA S ran out to the parking lot to R39. CNA S stated that she was the first person to make it to R39 and the elopement from the facility was unwitnessed by any other staff as she was the first on scene. CNA S reported the van the R39 was attempting to open the drivers side door to was parked in the front row of the facility and not directly in front of the facility and R39 independently ambulated out to the parking lot with no assistive devices. In an interview on 03/27/23 at 03:02 PM, LPN DD reported on the day of the elopement the unit she was assigned to work on (R39's) was really busy. R39 had been restless and busy, and at one point, was caught independently ambulating to the front lobby desk so the staff decided to seat R39 in his wheelchair in the hallway to provide more supervision. LPN DD stated CNA S was sitting with R39 to help provide redirection and distraction in an attempt to keep R39 from wandering. LPN DD reported that she was answering a call light and when she returned to the hallway, R39 was no longer in his wheelchair and everyone was rushing around looking for him. LPN DD reported we looked out the window (out of the front lobby doors and windows) and saw [R39]. I said, Oh my God and ran out to the parking lot. It was scary because no one saw him get outside and he could have fell. R39 independently ambulated out to the parking lot without any assistive devices. LPN DD stated that R39 was outside for up to a minute and upon entry back into the facility, staff placed a wander guard on his wrist. In an interview on 03/27/23 at 02:00 PM, Family Member (FM) Q reported that R39 had gotten out at home when R39 resided with FM Q. There was a time when R39 unknowingly left his prior residence and walked to a park. FM Q reported R39 is restless and the incident where he had unknowingly left the residence was one of the reasons why he had to be admitted to the facility for long term care. Review of the Elopement Care Plan initiated 1/25/23 revealed R39 demonstrates exit seeking behaviors. Staff have observed resident trying to exit through the therapy doors and exiting the facility through the lobby doors and making his to the parking lot, along with attempting to open the door of a vehicle. Resident is at risk for eloping r/t [related to] impaired safety awareness. Resident is triggered to wander when feeling unsure of his surroundings, wanting to go home . Relevant interventions dated 1/25/23 included elopement risk quarterly, and prn [as needed], redirect resident away from doors/exits as needed, please ensure wander guard to right wrist is working properly . Review of the Generalized Anxiety Disorder Care Plan initiated 1/13/23 revealed R39 was known to exhibit symptoms of agitation, anxiousness, and restlessness. R39 had periods of yelling out when feeling unsure of his surroundings .per the family, R39 feels anxious related to ongoing health issues, confusion, feeling unsure of his surroundings, and missing his family and home. Review of the Activities of Daily Living (ADL) Care Plan initiated 1/13/23 revealed R39 required assistance with mobility and ADLS. Interventions dated 3/1/23 included I have a wander guard on my right wrist. Review of the Physician revealed an order to ensure R39's wander guard is on and functioning every shift wasn't ordered until 3/15/23. In an interview on 03/29/23 at 04:03 PM, Director of Nursing (DON) B stated that R39 had eloped the facility after R39's family member had left the facility after visiting R39. DON B reported that the facility is aware that in the event of an elopement, the incident needed to be reported to the State Agency, but no one felt it was a necessary thing to do because the facility was under the impression that the elopement from the facility by R39 was witnessed by staff. DON B reported that the intervention implemented after the incident was to place a wander guard on R39 on 1/24/23 but the care plan was not updated to include the intervention until 3/1/23. Review of the facility's Abuse, Neglect, and Exploitation Policy dated 2-1-2018 and revised on 2-2023 revealed reporting of all alleged violations to the Administrator, state agency, adult protective services .within specified timeframes: Immediately, but not later than 2 hours after the allegation is made . not later than 24 hours if the event that causes the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided in resident's clinical record and care plans to coordinate hospice care for one resident of one resident (R24) reviewed for hospice services. This deficient practice resulted in the potential for care not being provided, lack of continuity of care between the hospice provider and the facility. Findings include: Resident #24 (R24) Review of the medical record reflected R24 was an initial admission to the facility on [DATE] with a re-admission on [DATE] then admitted to hospice on 11/5/21. Diagnoses of Transient Cerebral Ischemic Attack (CVA), Dysphagia (difficulty swallowing), Vascular Dementia, anxiety, Depression, weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/06/2023, revealed R24 had a Brief Interview of Mental Status (BIMS) of 03 (severe impairment) out of 15. Under section G0110, Activities of Daily Living (ADL) Assistance reveals R24 is dependent on all care provided. Under section M0100. Determination of Pressure Ulcer/Injury Risk, A revealed R24 did not have a pressure injury on this date. B did reveal R24 is at risk for developing them. Under section O0100. Special Treatments, Procedures and Programs revealed R24 is not on hospice, however R24 was admitted to hospice on 11/05/21. MSD assessment dated [DATE] did reflect R24 having hospice services. Record review on 03/28/23 at 12:52 PM, revealed R24 was admitted to (hospice organization) on 11/05/21. R24's hospice binder revealed March calendar reflecting R24 gets her certified nursing assistants CNA visit from hospice on Monday and Thursday's. Hospice nurse visits on Friday's. Care plan was not updated since admission. No hospice visit notes were found in the hospice binder or in the electronic medical record (EMR). During an interview on 03/28/23 at 01:01 PM, CNA J stated they did not shower R24 unless hospice CNA could not make it. Including hospice CNA showers R24 on Monday and Thursday, so that's when she is showered. When asked what days the facility CNA showers R22, CNA J stated they didn't shower her unless hospice aide couldn't make it. Record review reflected the shower task were signed off on Monday and Thursday by facility CNA's when it was hospice CNA that gave the shower. During an interview on 03/28/23 at 02:18 PM, CNA H stated hospice CNA I schedule matches the days that the facility had R24 down for showers, Monday and Thursday. CNA H stated they are heavy with showers on the 1st shift, not so much on 2nd shift. We can give her a bath in between if we need to. When asked if it states that on the care plan? CNA H stated Yes, I do believe it does, we have a list behind the nurse's station with the list of showers for day shift. Record review did not reveal modifications to the care plan to reflect shower days and preference for hospice CNA to provide them. Record review reveals there were not hospice visit notes in the chart for R24. The hospice binder behind the nurse's station contained a brief comment on the visits from disciplines, but lacked assessments, updated care plan or collaboration with the facility. During an interview on 03/28/23 at 3:41 PM, Director of Nursing (DON) B stated the requested last 60 days of hospice notes were in the hospice binder behind the nurse's station. DON B emailed writer the information from the hospice binder that included outdated care plan, quick comment from hospice caregivers who provide care where several caregivers sign on the same sheet. Did not reveal any disciplinary visit notes. DON B also told writer to look under the miscellaneous tab in the electronic medical record, stated there was a hospice note dated 3/8/23, containing the hospice covered med report. There was a clinical note in that document. Under this tab in EMR, there were not any hospice notes scanned into the R24 chart. During an interview on 03/28/23 at 6:24 PM, hospice CNA I, Stated she provided showers/baths for R24 two times weekly, Mondays and Thursdays or Tuesday and Fridays. Also stated she was asked to set her schedule based off the facility scheduled baths. When asked if she replaced the showers the facility was to provide, she stated yes, including that she was aware that they were supposed to provide showers to R24 as well. When asked who looked at the pressure ulcers after the shower she given, CNA I stated she notified the facility nurse, and she would look at the area and put the any dressings or treatment over the area. CNA I stated she follows the hospice care plan, adding she did not have access to the facility EMR to see their care plan or information. CNA I stated she follows the hospice care plan set up by hospice nurse. Also stated she reported off to the facility CNA, nurse and hospice nurse after care was provided. When asked if she documented in the hospice binder at the nurse's station, stated no, she didn't know there was one. Included that she had asked at one time, but nobody showed her where it was. Also stated she documented in her own EMR. When asked if her agency faxed the visit notes to the facility, stated she didn't know what the agency did with the information after visits. When asked if she knew that hospice services were to be a service above what the facility provides, included bathes, she stated yes, but I am the only one that does them. Record review did not reflect modifications to the care plan for hospice CNA to notify facility nurse to perform dressing changes following the shower. During an interview and observation on 03/29/23 at 07:56 AM, DON B was observed replacing the hospice binder back on the shelf for R24. Hospice binder now contains an updated care plan, and sign in area for all visits. Hospice binder still contains no visit notes, just the sign in form. During an interview on 03/29/23 at 09:28 AM, Social Worker (SW) K stated, hospice used to join in the care conferences before Covid, as well as activities. Also stated hospice have their own Interdisciplinary team meetings (IDT), since Covid they don't participate. SW K added that hospice will call if there is a change, or a concern and she does talk to the hospice social worker. Anyone can update the care plan to reflect changes or preferences. During an interview on 03/29/23 at 04:17 PM, DON B stated the hospice CNA are doing all the baths/showers 2 times a week. Writer clarified that facility CNAs are not providing bathes but signing them out in the electronic medical record (EMR) on the date's hospice aide provided them. DON B stated she would talk to the unit manager to clarify information. No clarification given, care plan does not reflect this process. During an interview and observation on 04/03/23 at 10:14 AM, LPN M Stated the hospice CNAs was giving R24 a shower at this time. Also stated she went in the shower room to provide wound care to the pressure ulcer. Writer asked if the 2 scabs were present beside the open pressure ulcer, M stated yes. Included she applied a barrier cream to the area and then applied a dressing over the open pressure ulcer, not the 2 stabbed ones. Observation of the hospice CNA bringing R24 out of the shower room with wet hair and wheeled her to her room. Record review on 04/04/23 does not reflect any hospice visit notes in the hospice binder or in the EMR from notes scanned in. Nor did it reflect any combined interdisciplinary team meetings or jointed case conferences. Record review of R24 care plan with focus of hospice was initiated on 11/05/21. Goal was initiated on 11/05/21, revision on 12/28/22 and target date of 04/30/23 with no changes to this goal. Interventions initiated on 11/05/21 with six basic hospice interventions. No changes, additions or updates after 11/05/21. Did not reflect any coordination of care with hospice care including both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Hospice binder reflected a totally different plan of care that the hospice team follows.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent the elopement of one (Resident #39) of 16 reviewed for accidents and supervision, resulting in elopement and the potential for harm. Findings include: Resident #39 Review of an admission Record revealed Resident #39 (R39) admitted to the facility on [DATE] with pertinent diagnoses which included unspecified fracture of second lumbar vertebra, hallucinations, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and type two diabetes without complications. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/18/23 reflected R39 scored four out of 15 (severely cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R39 required extensive assistance of two or more people for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), extensive assistance of two or more people for transferring (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and total dependence from staff for tasks such as eating and drinking. Review of a Health Status Note dated 1/24/2023 at 4:41 PM revealed Resident [R39] exit [sic] the building, made it to parking lot attempt to open company van drivers door. placed wonder [wander] guard on resident. Review of a Social Services note dated 1/25/2023 at 10:10 AM revealed Resident [R39] was observed by staff on 1/24/2023, exiting the facility through the lobby door and making his way to the parking lot, along with attempting to open the door of a vehicle. Per staff, they observed resident immediately as he stepped outside the lobby exit and followed him, by assisting him back into the campus. Resident has a wander guard in place at this time r/t [related to] impaired safety awareness. Resident can be triggered when feeling unsure of his surroundings r/t his confusion/dementia and wantingto [sic] go home to be with his wife. Care plans has been updated. Will continue to observe. In an interview on 03/27/23 at 02:26 PM, Certified Nursing Assistant (CNA) S reported R39 was sitting in the hallway in his wheelchair with Licensed Practical Nurse DD when LPN DD looked away for a minute and R39 had escaped. CNA S reported she exited the bathroom and did not see R39 in the hallway sitting in his wheelchair where he was prior to going into the bathroom. CNA S then observed R39 out front in the parking lot by a van so CNA S started running out to the parking lot to R39. CNA S stated that she was the first person to make it to R39 and the elopement from the facility was unwitnessed by any other staff as she was the first on scene. CNA S reported the van the R39 was attempting to open the drivers side door to was parked in the front row of the facility and not directly in front of the facility and R39 independently ambulated out to the parking lot with no assistive devices. In an interview on 03/27/23 at 03:02 PM, LPN DD reported on the day of the elopement the unit she was assigned to work was really busy. R39 had been restless and busy, and at one point, was caught independently ambulating to the front lobby desk so the staff decided to seat R39 in his wheelchair in the hallway to provide more supervision. LPN DD stated CNA S was sitting with R39 to help provide redirection and distraction in an attempt to keep R39 from wandering. LPN DD reported that she was answering a call light and when she returned to the hallway, R39 was no in his wheelchair and everyone was rushing around looking for him. LPN DD reported we looked out the window (out of the front lobby doors and windows) and saw [R39]. I said, Oh my God and ran out to the parking lot. It was a scary because no one saw him get outside and he could have fell. R39 independently ambulated out to the parking lot without any assistive devices. LPN DD stated that R39 was outside for up to a minute and upon entry back into the facility, staff placed a wander guard on his wrist. In an interview on 03/27/23 at 02:00 PM, Family Member (FM) Q reported that R39 had gotten out at home when R39 resided with FM Q. There was a time when R39 unknowingly left his prior residence and walked to a park. FM Q reported R39 is restless and the incident where he had unknowingly left the residence was one of the reasons why he had to be admitted to the facility for long term care. Review of the Elopement Care Plan initiated 1/25/23 revealed R39 demonstrates exit seeking behaviors. Staff have observed resident trying to exit through the therapy doors and exiting the facility through the lobby doors and making his to the parking lot, along with attempting to open the door of a vehicle. Resident is at risk for eloping r/t [related to] impaired safety awareness. Resident is triggered to wander when feeling unsure of his surroundings, wanting to go home . Relevant interventions dated 1/25/23 included elopement risk quarterly, and prn [as needed], redirect resident away from doors/exits as needed, please ensure wander guard to right wrist is working properly . Review of the Generalized Anxiety Disorder Care Plan initiated 1/13/23 revealed R39 was known to exhibits symptoms of agitation, anxiousness, and restlessness. R39 had periods of yelling out when feeling unsure of his surroundings .per the family, R39 feels anxious related to ongoing health issues, confusion, feeling unsure of his surroundings, and missing his family and home. Review of the Activities of Daily Living (ADL) Care Plan initiated 1/13/23 revealed R39 required assistance with mobility and ADLS. Interventions dated 3/1/23 included I have a wander guard on my right wrist. Review of the Physician revealed an order to ensure R39's wander guard is on and functioning every shift wasn't ordered until 3/15/23. In an interview on 03/29/23 at 04:03 PM, Director of Nursing (DON) B stated that R39 had eloped the facility after R39's family member had left the facility after visiting R39. DON B reported that the facility is aware that in the event of an elopement, the incident needed to be reported to the State Agency, but no one felt it was a necessary thing to do because the facility was under the impression that the elopement from the facility by R39 was witnessed by staff. DON B reported that the intervention implemented after the incident was to place a wander guard on R39 on 1/24/23 but the care plan was not updated to include the intervention until 3/1/23. Review of the facility's Elopement and Wandering Resident Policy dated 8/2022 and reviewed on 2/2023 revealed This facility ensures that residents who exhibit wandering behavior and/are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services and assistance to restore continence (Resident #13 and #20) and to provide intermittent catheter services per professional standards of care (Resident #33), resulting in risk for urinary tract infections (R33) and continued incontinence (Resident #13 and #20). Findings include: Resident #13 (R13) On 3/28/23 at 8:30 AM, R13 was observed sitting in a recliner chair in her room and stated when she was assisted to the toilet, at times had to wait approximately 45 minutes to receive help, R13 stated she would prefer staff wait a few minutes for her to use the toilet and assist her right away. R13 was observed sitting in recliner chair eating breakfast, wearing blue socks on both feet. R13's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 15 (cognitively intact). The same MDS indicated R13 was occasionally incontinent (less than 7 episodes of incontinence during a 7-day look-back period) of bladder and no trial of a toileting program (scheduled toileting, prompted voiding, or bladder training) had been attempted on admission or re-entry or since urinary incontinence was noted in the facility. R13 MDS indicated she was occasionally incontinent of bowel (one episode of bowel incontinence during a 7-day look-back period) and was not on a bowel training program. R13's medical record revealed she had diagnoses of heart failure, depression, high blood pressure, and chronic kidney disease. Activities of Daily Living (ADL) care plan dated 6/07/21 did not indicate R20 was incontinent of bowel and bladder or include toileting interventions. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, indicated incontinence increased the risk of falls and injuries and many incontinent residents (including those with dementia) respond to a toileting programs, especially during the day. During an interview on 3/29/23 at 8:41 AM Assistant Director of Nursing (ADON) V was interviewed and stated R13 was alert and orientated and was able to use the call light. ADON V stated the facility did not have a bowel and bladder training program. Resident #20 (R20) R20's MDS assessment dated [DATE] revealed a BIMS score of 13 (13-15 Cognitively Intact) and limited assistance for toilet use, was frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) and always incontinent of bowel. No trial of a toileting program (scheduled toileting, prompted voiding, or bladder training) had been attempted on admission or re-entry or since urinary incontinence was noted in the facility. R20's same MDS indicated she was not on a bowel training program. R20 was interviewed on 3/28/23 at 9:40 AM and stated she had never have been asked about trying a program to improve continence. R20's Activates of Daily Living (ADL) care plan dated 1/13/21 revealed she required assistance with ADL's and mobility related to history of compression fracture and pain; the ADL care plan did not include incontinence or toileting interventions. ADON V was interviewed on 3/29/23 at 8:39 AM and indicated the facility had completed bladder scans for post void residuals (PVR), mostly for short term residents. ADON V stated R20 did not have a pattern assessment/diary, and bladder scans had not been considered. Resident #33 (R33) R33's MDS dated [DATE] revealed he had diagnoses of Parkinson's, renal insufficiency and a neurogenic bladder. R33 had a BIMS score of 10 (08-12 Moderate Impairment). The same MDS indicated he required limited assistance with personal hygiene and required intermittent catheterization (catheter inserted to empty bladder and then removed). Straight Catheter Care Plan dated 5/09/22 revealed R33's goal was to not have any adverse effects or infections from straight catheter. R33's October 2022 Medication Administration Record (MAR) reflected Cipro 500 milligrams (mg) was ordered twice a day on 10/26/22. R33's December 2022 and January 2023 MAR reflected Cipro 250 mg was ordered for 7 days was and started on 12/31/22, then in January, was continued for 90 days for recurrent UTI. Physician Order dated 1/09/23 at 9:06 PM indicated order to straight catheter R33 every 8 hours and as needed and to use 10 French catheters. ADON V was interviewed on 3/29/23 at 8:11 AM and stated R33 was taking an antibiotic prophylactically due to recurrent urinary tract infections (UTI). ADON V stated she didn't feel the UTI's were from contamination during intermittent catheter procedure. ADON V stated R33 had an UTI October and December 2022 and the organism for both infections were K Pneumonia. ADON V stated she had observed multiple nurses perform straight catheter procedure and but did not have any audit documentation or nurse competencies completed. ADON V stated she did not keep track of urine analysis ordered; if the physician treats the urine, then she logged it. On 3/29/23 at 2:33 PM, during an observation, R33 was observed lying in bed prior to intermittent catheterization procedure. R33's did not receive peri care prior to procedure. Licensed Practical Nurse (LPN) AA opened a catheter kit and stated the kit did not include a catheter. LPN AA opened another catheter kit, removed sterile gloves, donned the right glove, the package wrapper folded back on top of the other glove, potentially contaminating the left glove. LPN AA' cleansed the glans and added lubricant to catheter. LPN AA inserted the catheter stated she had met resistance and pulled the catheter out and then back in without success. LPN AA removed the catheter and obtained more supplies to attempt catheterization again. LPN AA opened a sterile 10 French catheter approximately one inch from the end of the catheter and left the catheter in the package. LPN AA donned sterile gloves, after donning the right glove, the wrapper folded over the left glove, potentially contaminating the left glove. LPN AA opened the iodine swabs and lubricant package; then dispensed lubricant onto the glove wrapper. LPN AA attempted to remove the catheter from the package by shaking the package (that had been stored in resident's nightstand) over the field the lubricant was dispensed on and touched the catheter on the over-the-bed table. LPN AA touched the outside of the catheter package with her sterile hand. Catheterization of a male policy, reviewed 2/2022, indicated urinary catheters would be performed in accordance with current standards of practice to minimize the risk for bacterial contamination; and perineal care would be performed prior to catheterization. According to the Centers for Disease Control and Prevention website, some Klebsiella bacteria have become highly resistant to antibiotics. Klebsiella pneumoniae produce an enzyme known as a carbapenemase (referred to as KPC-producing organisms), then the class of antibiotics called carbapenems will not work to kill the bacteria and treat the infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #39 Review of an admission Record revealed Resident #39 (R39) admitted to the facility on [DATE] with pertinent diagnoses which included unspecified fracture of second lumbar vertebra, hallucinations, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and type two diabetes without complications. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/18/23 reflected R39 scored four out of 15 (severely cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R39 required extensive assistance of two or more people for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), extensive assistance of two or more people for transferring (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and total dependence from staff for tasks such as eating and drinking. In an observation and interview 03/27/23 at 12:47 PM, Family Member (FM) Q stated that she was concerned about R39's weight loss and whether R39 was receiving enough fluids throughout the day. FM Q discovered R39's Styrofoam cup of water on his bedside table was full. An observation was made of R39's bedside water cup dated 3/27/23 which was confirmed to be full of water. FM Q reported that R39 has bilateral arm weakness and is unable to reach for the cup. R39 is reliant on staff to have fluids offered. FM Q also reported that she tries to come to the facility daily to feed R39 his lunch but was late today. Review of R39's weight history reflected the following: 1/12/23- 219.3 Lbs (pounds) 1/13/23- 219.5 Lbs 1/15/23- 215.1 Lbs 1/16/23- 212.9 Lbs 1/23/23- 214.7 Lbs 1/30/23- 208.4 Lbs 2/6/23- 208.0 Lbs 3/1/23- 201.9 Lbs 3/15/23- 201.6 Lbs Review of the Potential for altered nutrition/hydration Care Plan initiated 1/13/23 revealed R39 revealed R39 required assistance with meals and pressure ulcers on admission increased estimated needs. Relevant interventions dated 1/13/23 included .provide assistance with meals, encouraged to take meals in dining room, provide supplements as ordered, and weight obtained and monitored for significant changes . Review of a Weight Change note dated 3/3/23 revealed R39 was triggered for significant weight loss with a 7.8% weight loss since admission. The Weight Change note revealed that the resident had no open areas or edema noted and resident is likely meeting estimated needs with supplement intake and current PO (by mouth) intake. No additional interventions were implemented despite the significant weight loss. In an interview on 03/29/23 at 12:26 PM, Certified Nursing Assistant (CNA) R reported that R39 previously received supplements at dinner but, he doesn't like them, so we stopped giving them to him. In an interview on 3/29/23 at 1:28 PM, Registered Dietician (RD) G reported that a nutritional assessment is completed with each new admission to the facility. The nutritional assessment includes obtaining a weigh, asking the resident what their food preferences are, and reviewing nursing notes for any needs that may impact nutritional status. RD G stated that if a resident admits with edema, she can anticipate a three-to-five-pound weight loss if the edema is resolved. RD G reported when R39 admitted , a nutritional intervention of providing an Ensure with his dinner was added. No interventions were added after the initial intervention. Regarding R39's continued weight loss, RD G reported that she is now questioning the effectiveness of the one nutritional intervention of an Ensure supplement and would reevaluate R39. Based on observation, interview and record review, the facility failed to implement nutritional interventions in two of four residents reviewed for weight loss (Resident #33 & #39), resulting in avoidable weight loss. Findings include: Resident #33 (R33) On 3/28/23 at 12:15 PM resident lunches were delivered in a cart to North 1 unit. Residents that were eating in their rooms had their trays delivered first. R33's lunch was served in a dining area across from the North 1 nurses' station 35 minutes after the cart was delivered to the unit. R33 sat at a table with another resident that had finished his lunch prior to R33 receiving his tray. R33 received set up assistance, staff opened a carton of magic shake, but did not insert a straw or pour the shake into a glass to ease consumption of the nutritional supplement. R33's Minimum Data Set (MDS) assessment dated [DATE] revealed he had diagnoses of Parkinson's, depression, renal insufficiency, and a neurogenic bladder. R33 had a Brief Interview for Mental Status (BIMS) score of 10 (08-12 Moderate Impairment). R33's October 2022 Medication Administration Record (MAR) reflected Cipro 500 milligrams (mg) was ordered twice a day on 10/26/22. R33's December 2022 and January 2023 MAR reflected Cipro 250 mg was ordered for 7 days was and started on 12/31/22, then in January, was continued for 90 days for recurrent urinary tract infections (UTI). R33's potential risk for alteration in nutrition/hydration status care plan dated 11/10/22 indicated he had a history of weight fluctuations with current trends down and a supplement in place. R33 had a goal for weight stability. R33's electronic medical record, underweight summary, indicated on 2/01/23, he weighed 191.9 pounds (lbs.). and on 3/01/23, he weighed 174.2 lbs. which was a 9.22 percent (%) severe loss in one month. R33's weight on 9/01/22, was 207.1 lbs. which was a 15.89 % severe loss in 6 months. Progress Note dated 3/06/23 at 11:52 AM indicated R33 was triggering for significant weight changes. Current Body Weight (CBW) was documented as 174.2 lbs. which was a weight loss of 9.2% in 30 days, and 15.8% loss over 180 days. R33 has had more frequent fluctuations recently with 182-201 lbs. being documented over the last 3 months. New weight was lower than usual body weight range. Cottage cheese was added to R33's lunch tray. R33's oral intake per food acceptance record averaged around 75% and a few meals consumed 0 to 25% which was a decrease. A mighty shake was added to R33's lunch and dinner tray for additional 400 calories. R33 was observed on 3/28/23 at 8:08 AM sitting in his wheelchair in his room eating breakfast on the over-the-bed table. R33's call light was not in reach; it was clipped to cord on the wall. R33's plate cover was on floor. R33 repeated a request and stated brown sugar, brown sugar repeatedly. A staff member walked by R33's room, stated good morning to this writer, but didn't seem to hear R33 asking for brown sugar. Registered Dietician (RD) G was interviewed on 3/29/23 at 1:03 PM and stated staff did not document R33's acceptance of mighty shakes, that she would ask the nurse assistant the intake. RD G stated if R33 wanted a nighttime snack, they could get one. RD G had not considered a sandwich or more substantial nighttime snack. In review of R33's snack food acceptance in the last 30 days, there were no snack acceptance documented or that R33 refused a snack.

Based on interview and record review, the facility failed to have sufficient nursing staff and ensure appropriate competencies and skills to provide related services in a census of 63 residents, resulting in the potential for decreased quality of care. Findings include: Licensed Practical Nurse X and certified nurse assistant GG employee files were reviewed and did not contain any competencies/skills check-off review. During an interview with Director of Nursing (DON) B on 3/39/23 at approximately 3:00 PM, there were no competencies/skill checks for nurses or nurse assistance completed upon hire or annually with evaluations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that medications were accurately labeled and stored in one of two medication carts reviewed, resulting in the potential for cross contamination, decreased medication efficacy, and adverse side effects in a current facility census of 63 residents. Findings include: On [DATE] at 12:21 PM, the North 1 Unit medication cart was reviewed in the presence of Licensed Practical Nurse (LPN) Y. During the review, an Artificial Tears Lubricant Eye Drop box was noted with the hand labeled name of Resident # 33 (R33) and a handwritten date of [DATE]. The undated opened Artificial Tears Lubricant Eye Drop bottle within the same box contained a pharmacy printed label with the name of Resident # 20 (R20). LPN Y reviewed the box and bottle label, confirmed that both R33 and R20 had an active order for the eye drops, and reviewed the remaining Artificial Tears Lubricant Eye Drop boxes within the medication cart confirming that no additional supply of eye drops noted within cart for either resident. LPN Y stated that he was unaware of how the eye drop bottle labeled for R20 ended up in the box labeled for R33, was going to throw away both the eye drop bottle and box, and order a new bottle of eye drops for both R20 and R33. During the same medication cart review, a Latanoprost 0.005% Ophthalmic Solution box labeled with Resident #4's (R4's) name was noted with a handwritten open date of [DATE] and a handwritten expiration date of [DATE] with the eye drop bottle within box indicating the same [DATE] open date. A pharmacy label on the box contained printed instructions to Store opened @ (at) RM (room) temp. (temperature). Discard after 6 weeks. LPN Y confirmed that the handwritten expiration date of [DATE] was incorrect and was going to dispose of and order new eye drops from pharmacy as the current bottle had expired on [DATE] (6 weeks after the indicated [DATE] open date). In an interview on [DATE] at 9:44 AM, Director of Nursing (DON) B stated that the nurse assigned to the medication cart labeled medications with both an open and an expiration date at the time the medication was opened and that the managers audited the medication carts and medication rooms at least monthly for correct labeling and dating. DON B further stated that, to her knowledge, Latanoprost Eye Drops expired 6 weeks after opening. In a document titled Rx (prescription) Dating and Storage Guide provided by DON B and confirmed to be utilized by facility for pharmacy services indicated, Xalatan (Latanoprost) opth. (ophthalmic) with instruction to Store in refrigerator until opened. Discard 6 weeks after open and store in med (medication) cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided in resident's clinical record and care plans to coordinate hospice care for one resident of one resident (R24) reviewed for hospice services. This deficient practice resulted in the potential for care not being provided, lack of continuity of care between the hospice provider and the facility. Findings include: Resident #24 (R24) Review of the medical record reflected R24 was an initial admission to the facility on [DATE] with a re-admission on [DATE] then admitted to hospice on 11/5/21. Diagnoses of Transient Cerebral Ischemic Attack (CVA), Dysphagia (difficulty swallowing), Vascular Dementia, anxiety, Depression, weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/06/2023, revealed R24 had a Brief Interview of Mental Status (BIMS) of 03 (severe impairment) out of 15. Under section G0110, Activities of Daily Living (ADL) Assistance reveals R24 is dependent on all care provided. Under section M0100. Determination of Pressure Ulcer/Injury Risk, A revealed R24 did not have a pressure injury on this date. B did reveal R24 is at risk for developing them. Under section O0100. Special Treatments, Procedures and Programs revealed R24 is not on hospice, however R24 was admitted to hospice on 11/05/21. MSD assessment dated [DATE] did reflect R24 having hospice services. Record review on 03/28/23 at 12:52 PM, revealed R24 was admitted to (hospice organization) on 11/05/21. R24's hospice binder revealed March calendar reflecting R24 gets her certified nursing assistants CNA visit from hospice on Monday and Thursday's. Hospice nurse visits on Friday's. Care plan was not updated since admission. No hospice visit notes were found in the hospice binder or in the electronic medical record (EMR). During an interview on 03/28/23 at 01:01 PM, CNA J stated they did not shower R24 unless hospice CNA could not make it. Including hospice CNA showers R24 on Monday and Thursday, so that's when she is showered. When asked what days the facility CNA showers R22, CNA J stated they didn't shower her unless hospice aide couldn't make it. Record review reflected the shower task were signed off on Monday and Thursday by facility CNA's when it was hospice CNA that gave the shower. During an interview on 03/28/23 at 02:18 PM, CNA H stated hospice CNA I schedule matches the days that the facility had R24 down for showers, Monday and Thursday. CNA H stated they are heavy with showers on the 1st shift, not so much on 2nd shift. We can give her a bath in between if we need to. When asked if it states that on the care plan? CNA H stated Yes, I do believe it does, we have a list behind the nurse's station with the list of showers for day shift. Record review reveals there were not hospice visit notes in the chart for R24. The hospice binder behind the nurse's station contained a brief comment on the visits from disciplines, but lacked assessments, updated care plan or collaboration with the facility. During an interview on 03/28/23 at 3:41 PM, Director of Nursing (DON) B stated the requested last 60 days of hospice notes were in the hospice binder behind the nurse's station. DON B emailed writer the information from the hospice binder that included outdated care plan, quick comment from hospice caregivers who provide care where several caregivers sign on the same sheet. Did not reveal any disciplinary visit notes. DON B also told writer to look under the miscellaneous tab in the electronic medical record, stated there was a hospice note dated 3/8/23, containing the hospice covered med report. There was a clinical note in that document. Under this tab in EMR, there were not any hospice notes scanned into the R24 chart. During an interview on 03/28/23 at 6:24 PM, hospice CNA I, Stated she provided showers/baths for R24 two times weekly, Mondays and Thursdays or Tuesday and Fridays. Also stated she was asked to set her schedule based off the facility scheduled baths. When asked if she replaced the showers the facility was to provide, she stated yes, including that she was aware that they were supposed to provide showers to R24 as well. When asked who looked at the pressure ulcers after the shower she given, CNA I stated she notified the facility nurse, and she would look at the area and put the any dressings or treatment over the area. CNA I stated she follows the hospice care plan, adding she did not have access to the facility EMR to see their care plan or information. CNA I stated she follows the hospice care plan set up by hospice nurse. Also stated she reported off to the facility CNA, nurse and hospice nurse after care was provided. When asked if she documented in the hospice binder at the nurse's station, stated no, she didn't know there was one. Included that she had asked at one time, but nobody showed her where it was. Also stated she documented in her own EMR. When asked if her agency faxed the visit notes to the facility, stated she didn't know what the agency did with the information after visits. When asked if she knew that hospice services were to be a service above what the facility provides, included bathes, she stated yes, but I am the only one that does them. During an interview and observation on 03/29/23 at 07:56 AM, DON B was observed replacing the hospice binder back on the shelf for R24. Hospice binder now contains an updated care plan, and sign in area for all visits. Hospice binder still contains no visit notes, just the sign in form. During an interview on 03/29/23 at 09:28 AM, Social Worker (SW) K stated, hospice used to join in the care conferences before Covid, as well as activities. Also stated hospice have their own Interdisciplinary team meetings (IDT), since Covid they don't participate. SW K added that hospice will call if there is a change, or a concern and she does talk to the hospice social worker. During an interview on 03/29/23 at 04:17 PM, DON B stated the hospice CNA are doing all the baths/showers 2 times a week. Writer clarified that facility CNAs are not providing bathes but signing them out in the electronic medical record (EMR) on the date's hospice aide provided them. DON B stated she would talk to the unit manager to clarify information. During an interview and observation on 04/03/23 at 10:14 AM, LPN M Stated the hospice CNAs was giving R24 a shower at this time. Also stated she went in the shower room to provide wound care to the pressure ulcer. Writer asked if the 2 scabs were present beside the open pressure ulcer, M stated yes. Included she applied a barrier cream to the area and then applied a dressing over the open pressure ulcer, not the 2 stabbed ones. Observation of the hospice CNA bringing R24 out of the shower room with wet hair and wheeled her to her room. Record review on 04/04/23 does not reflect any hospice visit notes in the hospice binder or in the EMR from notes scanned in. Nor did it reflect any combined interdisciplinary team meetings or jointed case conferences. Record review of R24 care plan with focus of hospice was initiated on 11/05/21. Goal was initiated on 11/05/21, revision on 12/28/22 and target date of 04/30/23 with no changes to this goal. Interventions initiated on 11/05/21 with six basic hospice interventions. No changes, additions or updates after 11/05/21. Did not reflect any coordination of care with hospice care including both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Hospice binder reflected a totally different plan of care that the hospice team follows.

Based on observation, interview, and record review, the facility failed to maintain infection control practices during wound care for one (Resident # 13) resident and failed to label/store oxygen tubing in a sanitary manner for one (Resident # 27) resident out of 16 residents reviewed for infection control standards, resulting in the potential for cross contamination and increased risk of facility acquired infections. Findings include: Review of the medical record revealed that Resident #27 (R27) initially admitted to facility 11/23/21 with most recent facility readmission 5/21/22 with diagnoses including vascular dementia, congestive heart failure, chronic obstructive pulmonary disease, and acute and chronic respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/15/23 revealed that R27 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 5 (severe cognitive impairment). Section G of MDS revealed that R27 required two-person extensive assist with bed mobility, transfers, and toilet use and was independent with eating after set up. Section O of same MDS indicated that R27 utilized oxygen while a resident at the facility. On 3/27/23 at 12:50 PM, Resident # 27 (R27) was observed sitting at the edge of the bed with the over the bed table positioned directly in front of her. An oxygen concentrator was noted at the bedside positioned by the wall at the foot of bed. Undated nasal cannula oxygen tubing was connected to the concentrator and laying on the floor. R27 stated that she intermittently wore oxygen and had worn off and on over the last few days. An oxygen tubing storage bag was not noted attached to or around the concentrator. During on observation on 3/27/23 at 1:40 PM, R27 was observed lying in bed, on back, in personal nightgown. Oxygen concentrator remained off with the undated oxygen tubing connected and draped across bedside chair positioned beside the concentrator. Licensed Practical Nurse (LPN) W was observed to enter room, obtain vital signs, turn oxygen concentrator on, pick up oxygen tubing off of bedside chair and assist R27 with placement of nasal cannula tubing at nose as stated that R27's oxygen saturation was 85% (percent) on room air. On 3/28/23 at 8:28 AM, R27 was observed lying in bed watching TV. Undated oxygen tubing was observed to be attached to the concentrator at the foot of bed and draped across bedside chair positioned directly beside concentrator. An oxygen tubing storage bag was not noted attached to or around the concentrator. In an interview on 3/28/23 at 3:14 PM, DON B stated that the facilities oxygen services were contracted and that a technician from the contracted company changed oxygen tubing, cleaned concentrator filters, and replaced portable oxygen tanks on a weekly basis. DON B stated that the technician placed printed stickers on the oxygen tubing which indicated the date changed and attached a plastic bag to the concentrator for the storage of the oxygen tubing when not in use. DON B further stated that if R27's oxygen tubing had been replaced by the contracted oxygen company, a printed label that contained the date would have been attached and there would have been a plastic bag attached to the concentrator for storage of the oxygen tubing when not in use. Per DON B, the expectation would be for oxygen tubing to be dated and stored in the bag attached to the concentrator when not in use and replaced prior to resident use if noted to be undated or observed on the floor or furniture. In a policy titled, Job Title: Nursing Home Supply Technician Responsibility Outline provided by DON B and confirmed to be utilized by the facility for oxygen procedures stated, SUMMARY: To accurately monitor the shipping, receiving, and stocking of inventory to meet the needs of all nursing homes, ESSENTIAL DUTIES AND RESPONSIBILITIES: Includes the following .Identifying all oxygen clients within the Nursing Homes, changing all related tubing, masks, cannula .Responsible for clearly labeling all new tubing and supplies with the date/initials for nebulizer's and oxygen . Resident #13 (R13) On 3/29/23 at 2:09 PM R13 was observed sitting in her recliner chair waiting for treatment to her pressure ulcer on her right heel. Licensed Practical Nurse (LPN) X placed paper towel on floor and placed clean dressing supplies on top of the paper towel. LPN X placed gloves on the paper towel. Fingers of the gloves had touched the carpet. Director of Nursing (DON) B was interviewed on 3/29/23 at 4:40 PM and it was not acceptable to set up dressing change supplies on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #27 (R27) Review of the medical record revealed that R27 initially admitted to facility 11/23/21 with most recent facility readmission on [DATE] with diagnoses including vascular dementia, congestive heart failure, chronic obstructive pulmonary disease, and acute and chronic respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/15/23 revealed that R27 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 5 (severe cognitive impairment). Section G of MDS revealed that R27 required two-person extensive assist with bed mobility, transfers, and toilet use and was independent with eating after set up. Section H of same MDS revealed that R27 was always incontinent of bowel and bladder. Review of R27's medical record completed with the following findings noted: Order dated 3/8/23 at 11:21 AM stated, Ampicillin Capsule 500 MG (milligrams). Give 1 capsule by mouth three time a day for uti (urinary tract infection) for 5 days with a 3/8/23 1600 (4:00 PM) start date and a 3/13/23 end date noted. Medication Administration Record (MAR) dated 3/1/2023-3/31/2023 reflected order for Ampicillin Capsule 500 MG. Give 1 capsule by mouth three times a day for uti for 5 days with a start date of 3/8/23 at 1600 with corresponding administration times of 0800 (8:00 AM), 1600 (4:00 PM), and 2000 (8:00 PM). The 3/8/23 1600 and 2000 administration boxes noted to be blank reflecting that the antibiotic was not administered with the 3/9/23 0800 through 3/13/23 0800 boxes initialed by assigned nurse as administered. In an interview on 3/29/23 at 11:40 AM, Assistant Director of Nursing (ADON) V stated that upon review of resident specific symptoms and the urine culture and sensitivity report, the prescribing physician would generally order antibiotic treatment for a specific frequency and duration and that if any doses of the treatment course were missed, for any reason, that the physician should be updated so that the duration of the antibiotic course could be extended to complete the entire treatment course. Upon review of R27's ordered antibiotic treatment course, ADON V confirmed that the initial 2 doses were missed, stated that the physician should have been contacted and that the order should have been rewritten so that the full five-day antibiotic course was received. ADON V confirmed that only 13 of the 15 ordered antibiotic doses were administered contributing to the potential for ineffective infection treatment and the return of R27's UTI symptoms. Based on observation, interview, and record review, the facility failed to monitor antibiotic regimen in 2 of 5 residents reviewed for unnecessary medications (Resident #27 & #33), resulting in increased risk of development of multiple drug resistant organisms and complications related to antibiotic use. Findings include: Resident #33 (R33) On 3/28/23 at 12:27 PM, R33 was observed sitting in a wheelchair in his room. R33's Minimum Data Set (MDS) assessment dated [DATE] revealed he had diagnoses of Parkinson's, depression, renal insufficiency, and a neurogenic bladder. R33 had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 10 (08-12 Moderate Impairment). R33's October 2022 Medication Administration Record (MAR) reflected Cipro 500 milligrams (mg) was ordered twice a day on 10/26/22. R33's December 2022 and January 2023 MAR reflected Cipro 250 mg was ordered for 7 days was and started on 12/31/22, then in January, was continued for 90 days for recurrent UTI. Physician Order dated 1/09/23 at 9:06 PM indicated order to straight catheter R33 every 8 hours and as needed and to use 10 French catheters. Assistant Director of Nursing (ADON) V was interviewed on 3/29/23 at 8:11 AM and stated R33 was taking an antibiotic prophylactically due to recurrent urinary tract infections (UTI). ADON V stated she didn't feel the UTI's were from contamination during intermittent catheter procedure. ADON V stated R33 had an UTI October and December 2022 and the organism for both infections were K Pneumonia. Revised McGeer Criteria for Infection Surveillance Checklist form indicated R33's date of infection was 10/26/22. There were no symptoms checked. On the bottom of the same form indicated Cipro ordered for UTI prophylaxis, urinalysis pending, increased confusion. Revised McGeer Criteria for Infection Surveillance Checklist for UTI without indwelling catheter criteria must fulfill both 1 and 2: 1. At least one of the following: 1. acute pain/swelling/tenderness of testes/epididymis, or prostate; fever or leukocytosis and at least one of following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency new or marked increase in frequency; if no fever or leukocytosis, the 2 or more of following: suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency. 2. At least one of microbiologic criteria. Physician Progress Note dated 10/26/22 revealed under plan was Patient reported to have increased confusion, recent fall, also cloudy and malodorous urine, patient with neurogenic bladder requiring intermittent straight cath [catheter], increased risk of urinary tract infection, UA was collected, pending results, will give one one-time dose of ciprofloxfloxacin 500 mg p.o. [by mouth], will await for culture and sensitivity. R33's Laboratory Report, date of collection was 10/24/22, indicated he did meet microbiologic criteria. During the same interview, 3/29/23 at 8:11 AM, ADON V stated she did not keep track of urine analysis (UA) that were ordered; if the physician treated the urine, then she logged it on McGreer's documentation sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 10 (Resident #5, #13, #22, #24, #27, #28, #39, #47, #48, #58) of 16 reviewed, resulting in the potential for unmet care needs. Findings include: Resident # 5 Review of the medical record reflected that Resident # 5 (R5) admitted to facility 5/22/21 with diagnoses including stage 2 pressure ulcer, type 2 diabetes mellitus, anemia, and muscle weakness. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/2/23 revealed that R5 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 9 (moderate cognitive impairment). Section G of MDS revealed that R5 required two-person extensive assist with bed mobility, transfers, toilet use, and supervision with meals after setup. Section M of same MDS indicated that R5 was at risk for developing pressure injuries and was not on a turning/repositioning program. In an observation on 3/27/23 at 11:54 AM, R5 was observed sitting in a Broda (wheelchair that provides supportive positioning) wheelchair in dining room with soft green padded boots in place at bilateral heels. Licensed Practical Nurse (LPN) Z confirmed that she was familiar with R5 and that resident had a left heel pressure ulcer, a surgical wound at right great toe, a healed pressure ulcer to coccyx, and a healed right thigh abrasion. Review of R5's Health Status Note dated 3/3/23 at 10:30 AM stated, .Staff also detected an open area to the left heel. Measurements are 4.0cm L x 3.0 cm W. No depth. Area appears to be a blister that is now open. Loose skin around edges, wound bed pink to dark red. Resident does have diabetic shoes but has not been wearing these. She does [NAME] slippers on most days. Resident has an APM (alternating pressure mattress) to her bed resident does wear heel lift boots when she is in her chair . R5's Health Status Note dated 3/15/23 at 9:59 AM stated, IDT met to discuss the treatment on the Left heel .New order to apply green boots at all times to protect the heel from pressure R/T (related to) this resident is not moving as much at this time . R5's Health Status Note dated 3/16/23 at 4:08 PM stated, The resident has a wound to the Left heel. The peri wound is pink in color with a small amount of bloody drainage that has no Oder (odor) present. The wound bed is filled with dry Eschar, the measurement to the peri wound is 3.0cm L x 3.0cm W and the Eschar is 2.7cm L x 2.7 W . R5's Health Status Note dated 3/24/23 at 12:46 PM stated, The resident Left heel has dry Eschar noted with no drainage or odor at this time. This area of eschar measures 2.7L cm x 2.7W cm . Review of R5's comprehensive care plans revealed a Care Plan Focus, I am at risk Skin integrity impairment . with 5/23/21 initiation and 11/29/22 revision date; a Care Plan Goal, My skin will remain intact but if I develop skin breakdown it will resolve without complication with 5/23/21 initiation and 11/29/22 revision date; and Care Plan Interventions to Apply barrier cream with brief changes as needed, Encourage to turn and reposition resident as she will tolerate, and a newly initiated intervention on 3/3/23 I wear Bilateral [NAME] boots while in bed to protect bilateral heels and since revised to reflect 3/14/23 order I wear Bilateral [NAME] boots at all times to protect bilateral heels. A review of call Care Plan Interventions for the I am at risk Skin integrity impairment Care Plan Focus was not noted to include any additional resident centered pressure reduction interventions that were in place including the APM (alternating pressure mattress) or gel cushion. A review of all care plans revealed that no care plan had been formulated at the time of the 3/3/23 identification, or since, to reflect R5's actual impairment in skin integrity--the left heel pressure injury. In an interview on 3/28/23 at 2:52 PM, DON B stated that she was familiar with R5, had assessed and documented on her left heel wound at onset but that LPN/UM O had since assumed R5's wound management. DON B stated that she was informed of R5's left heel wound by the assigned nurse on 3/3/23 and confirmed that R5's wound presented as a facility acquired pressure injury with the 3/3/23 assessment. Per DON B, although R5's care plan did not reflect, an APM mattress and gel cushion in wheelchair had been in place prior to the formation of the left heel ulcer but that no intervention had been in place to offload heels prior to the formation of the left heel wound as the soft green boots were implemented at the time of the ulcer identification. DON B also acknowledged that a care plan to reflect R5's actual impairment in skin integrity had not been developed upon the 3/3/23 identification, or since, to reflect the ongoing left heel pressure injury. Resident #27 Review of the medical record revealed that Resident #27 (R27) initially admitted to facility 11/23/21 with most recent facility readmission 5/21/22 with diagnoses including vascular dementia, congestive heart failure, chronic obstructive pulmonary disease, and acute and chronic respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/15/23 revealed that R27 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 5 (severe cognitive impairment). Section G of MDS revealed that R27 required two-person extensive assist with bed mobility, transfers, and toilet use and was independent with eating after set up. Section O of MDS indicated that R27 utilized oxygen while a resident at the facility. Section J of same MDS reflected that R27 experienced occasional pain and received scheduled pain medication. On 3/27/23 at 12:50 PM, R27 was observed sitting at the edge of the bed with the over the bed table positioned directly in front of her. An oxygen concentrator was noted at the bedside positioned by the wall at the foot of bed. Undated nasal cannula oxygen tubing was connected to the concentrator and laying on the floor. R27 stated that she intermittently wore oxygen and had worn off and on over the last few days. During on observation on 3/27/23 at 1:40 PM, R27 was observed lying in bed, on back, in personal nightgown. Oxygen concentrator remained off with the undated oxygen tubing connected and draped across bedside chair positioned beside the concentrator. Licensed Practical Nurse (LPN) W was observed to enter room, obtain vital signs, turn oxygen concentrator on, pick up oxygen tubing off of bedside chair and assist R27 with placement of nasal cannula tubing at nose as stated that R27's oxygen saturation was 85% (percent) on room air. Review of R27's medical record completed with the following findings noted: Order dated 6/15/22 at 10:54 AM stated, Oxygen 3L (liters) continuous every shift for SPO2 (percentage of oxygen in blood) level above 90. Medication Administration Record (MAR) dated 3/1/23 - 3/31/23 indicated multiple dates where R27's oxygen level was documented to be at 90% (percent) or below including 3/2 = 90%, 3/6 = 90%, 3/9 = 90%, 3/11 = 90%, 3/12 = 90% and 89%, 3/13 = 87%, 3/14 = 90%, 3/15 = 90%, 3/16 = 90%, 3/19 = 85%, 3/20 = 90% and 88%, 3/21 = 90%, 3/22 = 90%, 3/23 = 90%, 3/24 = 90%, 3/25 = 90%, 3/26 = 90%, 3/27 = 90%, 3/28 = 90%. Order dated 3/20/23 at 11:18 AM stated, Hydrocodone-Acetaminophen Tablet 5-325 (an opioid pain reliever for moderate to severe pain) MG (milligram). Give 1 tablet by mouth three times a day for chronic back pain. Order dated 2/24/23 at 12:35 PM and discontinued 3/20/23 stated, Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet three times a day for Pain AND Give 1 tablet by mouth every 12 hours as needed for KNEE PAIN for 2 days. Order dated 2/24/23 at 12:33 PM stated, Aspercreme Lidocaine External Patch 4% (topical pain relief patch). Apply to LEFT KNEE topically one time a day for PAIN. Order dated 11/23/21 at 12:43 PM stated Gabapentin Capsule (medication used in the treatment of nerve pain) 400 MG. Give 1 tablet by mouth three times a day for Pain. Order dated 11/23/21 at 12:43 PM stated, Acetaminophen Tablet 650 MG (a pain medication used to treat mild or chronic pain). Give 1 tablet by mouth every 4 hours as needed for General Discomfort. MAR dated 3/1/23 - 3/31/23 reflected that R27 received as needed Acetaminophen four times from 3/2/23 to 3/19/23 for breakthrough pain. Health Status Note dated 3/4/23 at 6:53 PM stated, .needs to be reminded to leave her oxygen on. Default PN (progress note) Type for eMAR (electronic medication administration record) dated 3/4/23 at 8:30 PM stated, .Encouraged to keep oxygen in place. Heath Status Note dated 3/9/23 at 7:03 PM stated, .when staff goes in room, we remind and help her to get her oxygen on. Default PN Type for eMar dated 3/12/23 at 8:33 PM stated, .O2 (oxygen) applied. Default PN Type for eMar dated 3/13/23 at 9:16 PM stated, .O2 applied. Health Status Note dated 3/19/23 at 2:12 PM stated, .has allowed us to put her cannula on but she only wear it for a few minutes before removing it again. Pain assessment dated [DATE] and 8/29/22 reflected that R27 had frequent pain rated at a 5 (moderately strong pain) on a numeric rating scale of 0 to 10. Pain assessment dated [DATE] reflected that R27 had frequent pain rated at a 6 (moderately strong pain that interferes with normal daily activities) on a numeric rating scale of 0 to 10. Pain assessment dated [DATE] reflected that R27 had occasional pain rated at a 6 on a numeric rating scale of 0 to 10. Review of all active care plans reflected no pain/discomfort care plan focus, goal, or interventions for R27's ongoing pain with no other active care plan noted to include active interventions to address the pain. Review of all active care plans reflected no respiratory or oxygen related care plan focus, goal, or interventions for R27's ongoing oxygen order and usage with no other active care plan noted to include an active intervention for oxygen usage. In an interview on 3/29/23 at 8:38 AM, Certified Nurse Aide (CNA) J confirmed familiarity with R27 although stated that she was not assigned to her that shift. CNA J stated that R27 was supposed to wear oxygen but that she did not always like to so, we encourage it as much as we possibly can. CNA J stated that she would review the Kardex to identify a resident's care needs and stated that she was aware of R27's oxygen needs as she believed that it was listed on the Kardex. Upon review of R27's Kardex, CNA J stated, It looks like I misspoke. That would be something that I would have to ask the nurse about as confirmed that the Kardex did not indicate oxygen usage. CNA J acknowledged that she would have no way of knowing R27's oxygen requirements based on review of the Kardex. In an interview on 3/29/23 at 11:40 AM, Assistant Director of Nursing (ADON) V stated that R27's oxygen related care plan had been resolved in November of 2022 as resident was routinely refusing to wear oxygen. Per ADON V, R27's oxygen order remained active, at that time, as was ordered by the pulmonologist and although oxygen was not being utilized, the physician did not want it discontinued. ADON V reviewed March 2023 nursing progress notes, confirmed that resident had been wearing the ordered oxygen, and stated that a care plan would be formulated to reflect R27's oxygen usage. In a follow up interview on 3/29/23 at 1:00 PM, ADON V stated that an individualized comprehensive care plan would be formulated based on a resident's assessment and that typically each resident would have a care plan for activities of daily living, falls, skin, and pain. ADON V stated that R27 would have a pain care plan, proceeded to review all of R27's active care plans, and confirmed absence of a pain care plan. ADON V stated that she did not know why R27's pain care plan would have been resolved as pain continued to be an active issue for resident and stated that she would be formulating an active pain care plan for R27. ADON V stated that part of the comprehensive assessment process included the review of all care plans and that care plans were typically revised or initiated, as warranted, at that time. ADON V further stated that care plans were reviewed and revised at the daily IDT (interdisciplinary) meeting based on the MDS schedule, as well. Resident #47 Review of the medical record reflected that Resident #47 (R47) was readmitted to facility on 9/9/22 with diagnoses including Alzheimer's disease, muscle weakness, difficulty in walking, osteoarthritis, and peripheral autonomic neuropathy. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/19/23 revealed that R47 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 7 (severe cognitive impairment). Section G of MDS revealed that R47 required one-person extensive assist with bed mobility, two-person extensive assist with transfers and toilet use, and supervision with meals after set up. Section H of MDS revealed that R47 was always incontinent of bowel and bladder. Section M of same MDS reflected that R47 was at risk for developing pressure injuries, had one Stage 2 pressure injury that was not present upon admission/entry or reentry, was receiving pressure injury care, and was not on a turning/repositioning schedule. The MDS with an ARD of 12/17/22 indicated that R47 was at risk for developing pressure injuries, had one stage 2 pressure injury that was not present upon admission/entry or reentry, was receiving pressure injury care and was not on a turning/repositioning program. In an observation on 3/27/23 at 11:23 AM, R47 was observed sleeping in bed, on back, dressed in facility gown. The foot and head of bed was noted to be elevated slightly with R47's legs observed to be extended straight out. In an observation and interview on 3/30/23 at 10:36 AM, Licensed Practical Nurse (LPN) Z was observed to complete R47's wound care. LPN Z was observed to assist R47 to a left side lying position, unfasten brief with gloved hands, and remove foam bordered dressing from coccyx. Coccyx observed to present with small superficial wound with pink epithelial tissue in base. Tissue surrounding wound noted to present with intact skin normal flesh tone in appearance. LPN Z stated that R47's wound location was at his coccyx and that the wound was continuing to gradually improve. Review of R47's medical record completed with the following findings noted: Nursing readmission assessment and nursing readmission progress note both dated 9/9/22 at 10:30 PM indicated coccyx redness. Review of progress notes from 9/10/22 through 10/25/22 complete with no further noted assessment of skin integrity to coccyx/buttock region. Health Status note dated 10/26/22 at 3:02 PM stated, Res (resident) noted to have open area to bilateral buttocks and coccyx with staging and measurements as follows: Left buttocks stage II (2) 0.6cm (centimeters) x 0.7cm and stage II 1.9cm x 1.0cm both wound beds are pink with no drainage or foul odor noted. Left buttocks Stage II 0.2cm x 0.2cm and Stage II 0.4cm x 0.2cm both wound beds pink with no drainage or foul odor noted. Coccyx 2.2cm x 1.0cm with small amount of yellow/white area of slough noted in wound bed. Resident denied pain with assessment and measurement of wounds. Tx (treatment) orders written and gel cushion in place in w/c (wheelchair). Nurse Practitioner Progress Note dated 10/28/22 stated, .History of Present Illness .Patient seen today to evaluate on coccyx and buttock ulcer .Physical Exam .Skin: Warm and dry, coccyx wound with some yellowish and pinkish base, bilateral gluteal fold open area with pinkish base .Diagnosis and Assessment .Decubitus ulcer of coccyx .Decubitus ulcer, buttock . Nurse Practitioner Progress Note dated 10/31/22 stated, .Physical Exam .Skin: Warm and dry, coccyx wound with some yellowish and pinkish base, bilateral gluteal fold open area with pinkish base, no surrounding erythema or drainage . Skin/Wound Note dated 11/4/22 at 4:04 PM stated, Per nurse on unit resident skin impairments on buttocks have improved significantly. Dressings were changed yesterday and duoderm (wound dressing used for partial and full-thickness wounds with exudate) remain in place. Resident cooperative with care at this time. Will continue to monitor for any concerns. Skin/Wound Note dated 11/11/22 at 1:39 PM stated, Wound assessment complete. No open areas noted to buttocks. All healed. Coccyx area is 0.5cm L (length) x 0.1 W (width) with no depth. Wound bed is pink/silver and healing. Current treatment is effective and will continue until healed. Resident has gel cushion to chair and can shift his position . Skin/Wound Note dated 11/29/22 at 10:03 AM stated, Wound assessment complete. Measurements today are 2.5cm L x 1.0cm W < (less than) 0.2cm D (depth) .No drainage noted, no odor noted. Current treatment does seem to be effective with cleaning up the wound bed which is light yellow, firmly adhered to base. Small areas of pink tissue noted around perimeter of the wound bed .We will encourage resident to allow head of bed to be decreased and order APM (alternating pressure mattress) . Skin/Wound Note dated 12/9/22 at 2:57 PM stated, Assessment of coccyx wound. Wound measure 2.5cm L x 0.5cm W which is an improvement. Wound bed is clearing up with pink/white areas present. No yellow noted this date .APM is now in place . Skin/Wound Note dated 12/16/22 at 11:15 AM stated, Wound assessment complete. Buttock wound measures 2.0cm L x 0.7cm W - located on left buttock upper area close to gluteal cleft, but tucked inside left side. Wound bed is white today - no odor or pain noted with care. Will continue current treatment for another week to see if wound bed cleans up. If not, then treatment will be changed . Skin/Wound Note dated 12/29/22 at 11:00 AM stated, Wound assessment complete. Wound to coccyx measuring 2.0cm L x 0.7cm W x <0.1 cm D. Wound bed is pink/silver and has moved closer to the surface. No slough noted . Skin/Wound Note dated 1/13/23 at 10:40 AM stated, Assessment of open area to gluteal cleft. Area measuring 1.7cm L x 0.7cm W x <0.1cm D. Wound is decreased in size since last measurement. There is a small streak of tissue running down the center of the wound that is epithelial tissue and showing signs of healing. No drainage noted . Skin/Wound Note dated 1/20/23 at 2:00 PM stated, Assessment of coccyx wound. Measurements today are 1.5cm L x 0.5cm W. with less than 0.2 D. Wound bed is 50% pink (on the right side) and 50% yellow (on the left side.) No drainage noted . Skin/Wound Note dated 1/27/23 at 1:15 PM stated, Wound assessment to coccyx. Area measuring 1.7cm L x 0.7cm W with <0.2cm D .Slough noted to wound bed some firmly attached, some loosening up in other areas .Wound appears to be stalled. Will consult with physician to see if a collagen dressing might be beneficial in prompting healing . Skin/Wound Note dated 2/3/23 at 1:20 PM stated, Wound assessment complete. Wound measurements today are 2.0cm L x 0.5cm W <0.2cm D. Wound bed is cleaner this assessment. New pink tissue present along with decreased slough .Will continue with current treatment and continue to assess for progress . Skin/Wound Note dated 2/10/23 at 1:15 PM stated, Wound assessment complete. Wound measurements today are 1.5cm L x 0.5cm W x <0.2cm D. Wound bed continues with pink wound bed. Measurements are smaller this assessment . Skin/Wound Note dated 2/17/23 at 10:00 AM stated, Assessment of coccyx area. Wound continues to decrease in size with measurements today of 1.3cm L x 0.3cm W x <0.2cm D. Wound bed pink with very small silver/white area to the center of the wound .Current treatment will continue . Skin/Wound Note dated 2/24/23 at 3:31 PM stated, Coccyx area assessed today. Area measures 1.3cm L x 0.3cm W. wound bed is moving closer to the surface. Wound bed is pink . Skin/Wound Note dated 3/3/23 at 10:30 AM stated, Assessment to inner buttock gluteal area complete. Measurement today at 1.5cm L x 0.3cm W with <0.2cm depth noted. Wound continues to remain stalled. Wound bed is pink with some white areas noted .Treatment changed to collagen matrix dressing . Health Status Note dated 3/15/23 at 9:40 AM stated, IDT (interdisciplinary team) met to discuss the wound to the left gluteal fold. This residents wound is pink in the wound bed and has no drainage noted at this time . Health Status Note dated 3/16/23 at 12:42 PM stated, This resident has a wound to the left inner buttock gluteal that measures in size 1.5cm l x 0.2w. The wound bed remains pink . Health Status Noted dated 3/23/23 at 2:34 PM stated, This resident has a open area on the left gluteal fold with measurements of 1.5cm L x 0.2cm W. The area remains pink in color in the wound bed .Treatment was changed to clean with soap and water, pat dry then apply Calazime (a zinc oxide skin protectant cream) and barrier cream to the area and cover with proximal (a foam bordered dressing). Review of R47's comprehensive care plans revealed a Care Plan Focus, SKIN INTEGRITY - I am at risk for impaired skin integrity R/T (related to): Impaired Mobility with Goal My skin will remain intact and free of pressure ulcers/injuries, and other skin impairments with Interventions Assist me with frequent turning and repositioning as I will allow; Be sure to dry my skin thoroughly after bathing, especially in skin folds; Observe skin daily for changes such as redness, maceration, open areas. Report to my nurse; Provide diet and supplements as ordered; and Use a skin barrier cream to my buttocks and peri area. The Care Plan Focus, Care Plan Goal, and Care Plan Interventions were all indicated to have an 8/29/22 date of initiation with no revision dates or updates reflecting implementation of additional interventions at the time of R47's 9/9/22 facility readmission or at the time of the 10/26/22 identification of coccyx/buttock pressure injuries. A review of all care plans revealed that no care plan had been formulated at the time of the 10/26/22 identification, or since, to reflect R47's actual alteration in skin integrity-the coccyx/buttock pressure injuries. In an interview on 3/30/23 at 2:04 PM, Assistant Director of Nursing (ADON) V confirmed that R47 did not have a pressure injury to the coccyx/buttock region at 9/9/22 facility readmission stating that the MDS with an ARD of 9/16/22 reflected the Stage 2 pressure injury to the foot that R47 was readmitted with. ADON V Stated that a Certified Nurse Aide alerted her to R47's alterations in skin integrity on 10/26/22 and that upon assessment, noted several pressure injuries to coccyx and buttock region, followed up with physician, and initiated treatments. ADON V stated that she also would have reviewed R47's pressure reduction precautions, at that time, but stated that she did not recall whether a gel cushion was already in place or was implemented at that time and did not know when the APM mattress was implemented as the care plan did not reflect interventions for either and acknowledged that there was no evidence that any pressure reduction devices were in place at R47's 9/9/23 readmission and that no care plan had been formulated at time of identification, or since, to reflect R47's coccyx/buttock pressure injury. In an email received on 3/28/23 at 4:30 PM, DON B indicated that the facility utilizes that RAI (Resident Assessment Instrument) for care plan development and revision. Review of the CMS's (Centers for Medicare & Medicaid Services) RAI Version 3.0 Manual dated October 2019 revealed, 4.7 The RAI and Care Planning .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving . Resident #22 Review of an admission Record revealed Resident #22 (R22) admitted to the facility on [DATE] with pertinent diagnoses which included displaced intertrochanteric fracture of the left femur, subsequent encounter for closed fracture with routine healing, iron deficiency, osteoporosis, hypothyroidism, and anxiety. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/1/23, reflected R22 scored 10 out of 15 (moderately cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R22 required limited assist of one staff member to ambulate, toilet, and perform personal hygiene tasks but required extensive assistance of one person for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) needs. In an observation and interview on 03/27/23 at 10:24 AM, R22 was sitting in her recliner chair, watching television. R22 was wearing standard socks and did not have her heels floated. R22 reported that she is just sitting here, making my butt more sore and getting more sores. I just sit on my bottom all the time. I sit on a special cushion, but it still doesn't make it comfortable. R22 also reported that she has a special mattress on her bed but they can't get me to sleep in the bed. It's just me, the chair is more uncomfortable, but I just prefer it. The bed is worse [than the chair], it really hurts my back. When asked if R22 had ever tried sleeping in her bed, she reported that she slept in her bed one time and will not do it again. Review of a Health Status Note on 1/31/2023 at 6:30 PM revealed upon admission, R22 was reported to have bilateral buttocks and midline spine are red, barrier cream order completed. Resident has a L (left) hip incision with 23 staples, well approximated, no drainage noted. Review of the Initial Nursing assessment dated [DATE] revealed at the time of admission, R22's skin assessment revealed no pressure ulcers, only evidence of bilateral buttocks, red dry skin healed. Review of a Care Conference note dated 2/8/23 revealed R22's present problem list included anemia, hypothyroidism, HTN (hypertension), anxiety, low body weight. Has surgical wound, healed pressure wound. Review of the at Skin Integrity Impairment Care Plan initiated 2/1/23 revealed R22 had actual skin integrity impairment due to a surgical incision and bruising. Interventions dated 2/1/23 included apply protective barrier cream after peri care and prn (as needed), assist with frequent position changes while in bed and up in chair, encourage me to float heels while in bed and off of the footrest of the recliner, keep my skin clean and dry, monitor my skin with routine care and report any open areas, redness, or areas of concern to my nurse, provide and encourage adequate nutrition and hydration, and skin assessment to be completed on first shower day of the week. There was no indication of a turning and repositioning program on the MDS or a pressure reduction mattress or gel cushion for the wheelchair or recliner upon admission. Furthermore, there were no additional interventions added after the discovery of the worsening of R22's pressure ulcers. In an observation on 03/28/23 at 11:27 AM, R22 was seated in her recliner with her feet on the ground and leaning over onto her left hip. R22 was wearing standard socks and did not have her heels floated. When asked R22 why she was leaning onto her left side, R22 stated it's this chair. R22 reported that staff does not encourage her to shift her weight or lean side to side in her chair, but her (family member) will remind her when he comes in to visit. In an observation on 03/28/23 at 02:28 PM, R22 was seated in her recliner, feet planted on the ground without her heels being floated. R22 was observed in the same position as the previous observation; leaned over onto her left side. In an observation on 03/28/23 at 04:27 PM, R22 was seen seated in her recliner with her feet on the ground, watching television. R22 did not have her heels floated and was leaned over onto her left side, in the same position as the previous two observations. Review of R22's medical record revealed the following Health Status Notes regarding skin assessments and pressure ulcer characteristics: 2/1/2023 at 5:15 PM . Pt (patient) has a blister to left buttock. 3/13/23 at 3:15 PM .assessed (R22's) buttock wound, observing left side of buttock is red in color, dry, with peeling skin present, one area that is open and red on left buttock measuring 0.8cm (centimeters) x 0.8 cm, no drainage. Medial coccyx open area measuring 1.8cm x 0.8cm, wound bed yellow slough no drainage present. Small open area below other coccyx wound measuring 0.5cm x 0.3cm, wound bed red. No odor to wound, slightly painful to resident at times when sitting. (R22) has gel cushion in place asresident [sic] spends a lot of time in her recliner. 3/24/23 at 11:14 AM .assessed (R22's) bottom, area remains. (R22) has open area in the medial coccyx. Area measures 2.0L X 0.5W X0.2D, wound bed is now covered in slough .wound appears to have gotten worse from last measurements, and nowhas [sic] depth to the wound. (R22) had a small area below this that was open, this area is now included into the entire wound. (R22) has a small open area on the left buttock, measurements are 0.5x0.5m, wound bed is red, with no slough present .she prefers to remain in herrecliner [sic] for most of her days and nights. 3/30/2023 at 3:26 PM . assessed (R22) buttock wound, located on the coccyx. Wound measures 2.2cm X 1.2 cm, wound bed is covered in slough, this wound is considered unstageable. Wound bed has no odor after cleaning, no drainage present on calcium alginate that wasremoved [sic]. Peri wound is intact, slightly dry but getting better. New tx (treatment) in place r/t (related to) not making good progress . Review of the Care Plan and Kardax revealed no gel cushion in the recliner listed as an intervention for wound and wound prevention. In an interview on 03/29/23 at 03:36 PM, Unit Manager (UM) T reported R22 had reddened areas when she came in but no open pressure ulcers upon admission. Interventions at the time of admission included barrier cream, ensuring R22 had a gel cushion on her chair, and a turning and repositioning schedule. UM T also reported that R22 can stand and move about and walk to and from places to get the circulation going. We've instructed her that she needs to do that. UM T also reported that Care Plans are updated as a team and current interventions should be included in the care plan. Review of the facility's Care Plan Policy d[TRUNCATED]

Based on interview and record review, the facility failed to have sufficient nursing staff to provide care and feeding assistance in a census of 63, resident council, and in two of 16 residents interviewed regarding staffing (Resident #13 & #39), resulting in long wait times for assistance, discomfort, and the potential for decreased quality of care. Findings include: During an interview on 3/27/23 at 10:30 AM, Resident #36 (R36) stated it took one hour to get a response to answer the call light, and it was worse on weekends. R36 stated on Saturday there were 2 certified nurse assistants (CNAs) on the unit, and they shared one nurse with another unit. Resident #13 (R13) was interviewed on 3/28/23 at 8:30 AM and stated she often would be left sitting on the toilet to long, for about 45 minutes, waiting for staff assitance. During a confidential staff interview during the survey from 3/27/23 to 4/04/23, staff stated they were short on staff, and they need more help. During a confidential staff interview during the survey from 3/27/23 to 4/04/23, staff on North 1 stated they did not get a lunch break on the day of the interview due to staffing needs. During a confidential resident council meeting on 3/27/23 at 1:30 PM with nine residents in attendance, they stated the biggest concern was not having enough help. The wait for assistance to and from the bathroom was a half hour to 45 minutes; all residents in meeting were in agreement. A resident stated staff didn't have time to wait for her to go the bathroom, staff had to leave and help someone else before they could assist her again. Resident Council stated weekend staffing was worse. In review of 12/21/22 Resident Council minutes, a resident stated that sometimes the bathroom schedule was hard because four women shared the same bathroom, and they seem to all have to go at the same time. 2/20/23 Resident Council minutes revealed a concern that there were not enough CNAs at night. In review of 1/24/22 Resident Council minutes, New Business revealed .Call light times and waiting to get in bathroom or get out of bathroom were discussed as an ongoing issue . Confidential staff was interviewed during the survey from 3/27/23 to 4/04/23 stated. second shift was the toughest to meet care needs, two CNA's have 15 to 20 residents on North 2 unit. On 3/29/23 at 12:15 the lunch meal cart was observed delivered on North 2 unit. There were no trays being passed in the North 2 dining room, 7 residents were waiting for lunch to be served. 3/29/23 at 12:26 PM Licensed Practical Nurse (LPN) W stated North 2 unit had 2 CNA's working, one was in with another resident. LPN W stated they passed all the trays to residents that did not require assistance first, residents that needed assist were passed last. On 3/29/23 at 12:41 PM, all residents on North 2 unit except for one were served lunch. One certified nurse assistant (CNA) was observed feeding one resident that required assistance. 2 call lights were on at this time. On 3/29/23 at 12:43 PM 3 residents were observed not eating at all. One resident had chicken that was cut up for her but was spooning her chicken into her desert. Another resident not eating had a supplement shake on her tray that was not opened. Another resident was sitting at a table waiting for the nurse, the nurse was crushing her medications and put them into her ensure supplement. Both CNAs were in the dining room assisting residents. On 3/29/23 at 12:54 PM CNA had stopped assisting one resident with her lunch to help another resident at another table. The resident the CNA had left to feed herself started coughing, the CNA left other resident she was feeding to go back to assist the resident who had started coughing. During an interview with Scheduler FF, on 3/29/23 at 9:24 AM, stated they mandate nurses for 4 hours, and certified nurse assistants (CNA's) for up to 8 hours. They use agency nurses to fill in as needed and did not use agency for CNA needs. Scheduler FF stated the Director of Nursing (DON) determined staffing and would add extra as needed. On the same day as the interview, Scheduler stated had 9 CNAs scheduled, for day shift, but had 2 call in's; they did not mandate because they aim to staff higher than needed. Scheduler FF stated on this same day, 3/29/23, they had 2 CNAs on the [NAME] unit (rehabilitation unit) for 12 residents, 1 CNA on the South unit for 4 residents, 2 CNAs were working on North 1 unit with 24 residents, North 2 unit had 2 CNAs for 21 residents. On 3/29/23 had an extra nurse floating, total of 4 nurses and 1 in training. Scheduler FF stated afternoon shift was always the hardest to staff. During an interview with DON B and Nursing Home Administrator A on 4/04/23 at 9:14 AM, DON B stated the south wing was not open yet, the goal was to spread residents out. DON B stated they had increased the pay scale and incentives; and worked on atmosphere. DON B stated if staff needed help feeding residents, they could call the nursing office for assistance.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 63 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased interior food service equipment illumination. Findings include: On 03/27/23 at 09:44 A.M., An initial tour of the food service was conducted with Director of Food Services E and Dietary [NAME] F. The following items were noted: The interior and exterior surfaces of the microwave oven were observed heavily soiled with accumulated and encrusted food residue. The interior ceiling surface was also observed extremely soiled with dried accumulated and encrusted food residue. The Globe stand mixer (backsplash and spindle gear assembly) were observed soiled with accumulated and encrusted food residue. The interior and exterior surfaces of the Vulcan convection oven(s) were observed soiled with accumulated and encrusted food residue. The can opener assembly was observed heavily soiled with accumulated and encrusted food residue. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The interior light bulbs of the Vulcan convection oven(s) were observed non-functional. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. The wall surface was observed soiled with accumulated food splash, directly behind the twin Cobra Head beverage dispensing assemblies. The 2017 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. The return-air exhaust ventilation grill above the serving line was observed heavily soiled with dust and dirt deposits. The grill assembly measured approximately 24-inches-wide by 30-inches-long. Food Service Director E indicated he would have maintenance thoroughly clean the soiled return-air exhaust ventilation grill as soon as possible. The mechanical dish machine room return air exhaust ventilation grill was observed heavily soiled with dust and dirt deposits. The grill assembly measured approximately 12-inches-wide by 12-inches-long. The 2017 FDA Model Food Code section 6-501.14 states: (A) Intake and exhaust air ducts shall be cleaned, and filters changed so they are not a source of contamination by dust, dirt, and other materials. (B) If vented to the outside, ventilation systems may not create a public health HAZARD or nuisance or unlawful discharge. On 03/27/23 at 12:18 P.M., The Main Dining Room hot soup dispenser metal lid was observed open, allowing potential contamination to enter the hot soup dispenser unit. Food Service Director E stated: I will educate staff today. The 2017 FDA Model Food Code section 3-307.11 states: FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 -3-306. On 03/28/23 at 04:30 P.M., Record review of the Policy/Procedure entitled: Equipment dated 09/2017 revealed under Policy Statement: All food service equipment will be clean, sanitary, and in proper working order. Record review of the Policy/Procedure entitled: Equipment dated 09/2017 further revealed under Procedures: (1) All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. (2) All staff members will be properly trained in the cleaning and maintenance of all equipment. (3) All food contact equipment surfaces will be cleaned and sanitized after every use. (4) All non-food contact equipment surfaces will be clean and free of debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 63 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 03/28/23 at 08:32 A.M., A common area environmental tour was conducted with Maintenance Director C and Maintenance Technician D. The following items were noted: (North) [NAME] Unit Nursing Station: The hand sink basin countertop surface was observed cracked and separated along the right-hand corner edge. The damaged countertop surface measured approximately 24-inches-wide by 30-inches-long. The return-air ventilation exhaust grill was also observed soiled with accumulated dust and dirt deposits. Maintenance Director C indicated he would have staff replace the damaged countertop slab as soon as possible. Shower Room: The return-air exhaust ventilation grill was observed soiled with accumulated dust and dirt deposits. Soiled Utility Room: The return-air exhaust ventilation grill was observed soiled with accumulated dust and dirt deposits. (South) [NAME] Unit Nursing Station: 1 of 2 chairs were observed etched, scored, worn, torn, exposing the inner Styrofoam padding. Jacuzzi Room: The return-air exhaust ventilation grill was observed soiled with accumulated dust and dirt deposits. Occupational/Physical Therapy: The freezer unit containing therapy cold packs was observed with ice [NAME] protruding from the interior ceiling and from an interior shelving assembly. Maintenance Director C indicated he would have staff defrost the freezing unit as soon as possible. (North) 1 Unit Nursing Station Restroom: The return-air exhaust ventilation grill was observed soiled with accumulated dust and dirt deposits. (North) 2 Unit Shower Room: The shower control valve assembly cover plate was observed etched, scored, corroded. Maintenance Director C stated: We will replace the control valve. Nursing Station: The oscillating floor fan was observed soiled with accumulated dust and dirt deposits. (South) 1 Unit Activities Room: 1 of 2 plexiglass door panels were observed broken on the facility Popcorn Machine. The interior surfaces of the Popcorn Machine were also observed soiled with accumulated and encrusted food residue. The interior surfaces of the Microwave Oven were additionally observed soiled with accumulated food residue. Staff Break Room: The interior surfaces of the Microwave Oven were observed soiled with accumulated and encrusted food residue. The carpeted hallway corridor flooring surface was observed stained, directly outside of resident room [ROOM NUMBER]. The stained surface measured approximately 18-inches-wide by 24-inches-long. (South) 2 Unit Housekeeping Closet: The mop sink basin was observed heavily soiled with accumulated and encrusted soil deposits. The carpeted hallway flooring surface was observed stained in numerous locations, adjacent to the North 2 Dining Room. On 03/28/23 at 01:00 P.M., An environmental tour of sampled resident rooms was conducted with Maintenance Director C and Maintenance Technician D. The following items were noted: 30: The flooring surface was observed stained and soiled with accumulated dirt and debris (paper products, Hershey Chocolate Bar wrapper, etc.). 34: The oscillating floor fan was observed soiled with accumulated dust and dirt deposits. 35: The oscillating desk fan was observed heavily soiled with accumulated dust and dirt deposits. 41: The flooring surface directly in front of the bed was observed soiled with accumulated food debris. The oscillating desk fan was also observed soiled with accumulated dust and dirt deposits. 50: The wall surface paint was observed etched, scored, peeling, directly beneath the restroom windowsill. 51: The wall surface paint was observed etched, scored, peeling, adjacent to the restroom exhaust ventilation fan assembly. 53: The oscillating floor fan was observed soiled with accumulated dust and dirt deposits. The carpeted flooring surface was also observed stained in four separate locations directly in front of the Bed. 73: One stained acoustical restroom ceiling tile was observed stained from a previous moisture exposure. 75: The carpeted flooring surface was observed stained in several locations. The wall surface was also observed etched, scored, particulate in two locations, directly behind the power lift chair. Maintenance Director C indicated he would have staff repair the damaged wall surface as soon as possible. On 03/28/23 at 04:45 P.M., Record review of the Maintenance Work Order Log Sheets for the last 45 days revealed no specific entries related to the aforementioned maintenance concerns. On 03/28/23 at 05:00 P.M., Record review of the Policy/Procedure entitled: Carpet Vacuuming dated 12/2020 revealed under Policy: To improve carpet cleanliness and longevity by routinely cleaning to provide a healthy and attractive environment. On 03/28/23 at 05:15 P.M., Record review of the Policy/Procedure entitled: Resident General Room Cleaning dated 12/2020 revealed under Policy: Resident rooms are cleaned daily and deep cleaned monthly.