**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat one of three residents (Resident #8) with dignity. Findings: Resident #8 (R8) Review of an admission Record revealed R8 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of dementia. During an observation on 8/22/25 at 8:57 AM, R8 sat at the dining table in the common area of the yellow unit eating breakfast. R8 asked Certified Nurse Aide (CNA) G to warm up his eggs, they are ice cold. CNA G responded to him and told R8 that the microwave was broken. CNA G then turned and left the area. R8 did not finish his breakfast. During an interview on 8/22/25 at 9:15 AM, Dietary Manager (DM) O stated that there was a working microwave in the kitchen. During an interview on 8/26/25 at 9:10 AM, R8 recalled the incident on 8/22/25 (when his eggs were cold and he asked the aide to warm them up) and stated that CNA G sometimes did not help him. During an interview on 8/26/25 at 10:00 AM, the Administrator indicated that CNA G 's interaction with R8 on 8-22-25 was not acceptable and not how staff were expected to treat residents.

Based on observation, interview, and record review, the facility failed to assess one resident (R66) for self-administration of medication and failed to track and record medication use. Findings: Review of the Electronic Medical Record (EMR) reflected R66 was admitted to the facility 5/1/25 with pertinent diagnoses that included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD), and Emphysema. On 6/11/25 at 9:43 AM, R66 was observed in a recliner chair receiving supplemental oxygen through a nasal cannula. Also observed were a nebulizer machine, a device like a Continuous Positive Airway Pressure (CPAP) machine and an Albuterol multidose inhaler on the over-the-bed table next to the Resident. On 6/12/25 at 2:34 PM an observation and interview were conducted with R66 in his room. The Albuterol multi-use inhaler was again observed on the over the bed table next to R66. R66 reported he used the inhaler sometimes a couple of times a day. R66 reported staff had not asked him if he had used it or how often. R66 indicated staff never asked him anything about the inhaler. Review of the EMR Doctor's Orders for R66 reflected an order for Ventolin HFA Inhalation Aerosol Solution 90 micrograms (mcg) (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for COPD/wheezing. May leave at bedside with a start date of 5/5/25. The policy provided by the facility titled 2.1 Self Administration of Medications last revised 6/1/24 was reviewed. The policy reflected, Procedure: 1. Facility should comply with the facility policy applicable law and the State Operations Manual with respect to resident self-administration of medications. The facility policy reflected in conjunction with the interdisciplinary care team, should assess and determine . whether self-administration is safe and clinically appropriate, based on the resident's functionality and health condition, The policy further reflected the facility must educate residents on possible side effects of the medication, ensure that the resident can correctly administer and address the storage of the medication. The facility policy also reflected 4. Facility should regularly observe the resident self-administering medications. And 8.the interdisciplinary care team should routinely assess the resident's cognitive, physical and visual ability to carry out this responsibility per facility policy. 10. Facility staff should document the self-administering of medications on the Medication Administration Record (MAR) . And 11. Facility should document the self-administration and self-storage of medications in the resident's care plan. Review of Progress Notes and the Assessment section of the EMR did not reveal any documentation the Resident had been assessed, educated, or monitored for proper and safe use of the inhaler. Review of MARs for R66 from 5/5/25 through 6/13/25 reflected documentation of one self-administration on 5/22/25 even though R66 reported using the inhaler sometimes a couple of times a day. On 6/13/25 at 9:54 AM the self-administration of medication by R66 was discussed with the Director of Nursing (DON). The DON was informed the EMR did not reveal the assessments and monitoring indicated by the facility policy had been conducted. The DON reported that if the information was not evident it likely was not there. As of survey exit no additional information had been provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respect the dignity of one (R224) of two residents reviewed for dignity. Findings include: Resident #224 (R224) Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. In an interview on 6/10/25 at 3:10 PM, R224 reported she has had to wait for long periods of time for the call lights to be answered so she can get assistance with toileting. The longest time she waited for the call light to be answered was about an hour and soiled her pants because she could not wait that long. A couple staff at night will tell her to just go in her brief if she cannot hold it and not to worry about it. If you have to go, just go they told her. R224 reported it makes her feel bad when she wets inside her brief even though the staff are very kind about it and will clean her up. In an interview on 6/13/25 at 10:41 AM, the Director of Nursing (DON) reported she had been addressing call light times in meetings and daily. The audits she had done so far were not problematic. A reasonable time for call lights to be answered is about 5-10 minutes. In an interview on 6/13/25 at 11:37 AM, the NHA reported she was aware of call light concerns in the facility and no ad hoc was done yet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately notify the physician/provider in a timely manner of a fall with injury for 1 of 2 residents (R15) reviewed for falls. Findings include: A review of R15's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident that was admitted to the facility on [DATE]. In addition, R15 had multiple diagnoses that included a traumatic subdural hemorrhage (brain bleed) with a loss of consciousness. A review of R15's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/21/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R15 was cognitively intact. During an interview on 06/10/25 at 12:30 PM, R15's spouse stated R15 had been in the hospital on and off five times since November 2024. Even though R15's MDS indicated he was cognitively intact, his spouse was interviewed because he had just returned to the facility after an 11-day hospital stay and was not alert and/or oriented at the time. A review of R15's progress notes, dated 11/13/24 to 6/11/25, revealed the following: - Incident Note, dated 11/18/24, revealed, CNA (certified nursing assistant) observed resident on the floor of bathroom at 0725 am. Resident was lying on his back with legs out in front of him and his head against the bathroom door . skin tear to L (left) elbow and swelling to back of head noted . change of condition place in dr. (doctor) book . - Nurse's Notes, dated 11/21/24, revealed, wife called from hospital to give update . resident is being admitted to hospital- elevated white count (high white blood cell count- potentially a reaction to an infection, tissue damage, or swelling)), small intercranial bleed (brain bleed) . A review of R15's Nursing/Physician Communication form, dated 11/18/24, revealed that on 11/18/24 at 7:25 AM, R15 had an unwitnessed fall and was found laying on the bathroom floor next to the door. It also revealed R15 had a skin tear to the left elbow and R15 was complaining of a headache. However, the form did not reveal that R15 also had swelling to the back of the head at the time they were found. In addition, R15's Nursing/Physician Communication form revealed Nurse Practitioner (NP) R was made aware of the incident on 11/20/24 (two days after the incident). A further review of R15's medical record failed to reveal that the physician/provider had been notified prior to 11/20/24 when NP R had noted the fall on the Nursing/Physician Communication form. During an interview on 06/13/25 at 4:57 PM, the Nursing Home Administrator stated she did not know if the physician was notified of R15's fall prior to 11/20/24. She stated the physician should have been notified at the time of the fall. In addition, the NHA stated if the surveyor could not find the documentation in R15's medical record that the physician/provider had been notified of R15's fall prior to 11/20/24, then they probably had not been notified. During an interview on 06/13/25 at 05:02 PM, Clinical Care Coordinator (CCC) E stated the nurse should have called the physician on 11/18/24 after R15 fell. She stated if it was after hours, the on-call physician/provider should have been notified. CCC E stated if that was the case (the fall occurred after hours, and the on-call physician/provider was notified) then the nurse would have also placed the notification in the Doctor's Book so the attending physician would know about the fall when he next came in for physician rounds. She stated the nurse should have documented the phone notification in the progress notes. CCC E stated she did not know personally if the physician/provider had been notified of R15's 11/18/24 fall prior to 11/20/24 because she was not an employee of the facility at that time. However, she did state that if the notification was not documented in R15's medical record, then it probably did not occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of neglect to the state survey agency for 1 of 19 sampled residents (R1). Findings include: A review of the facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy and procedure, revised February 2025, revealed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Serious Bodily Injury means an injury involving extreme physical pain . requiring medical intervention such as surgery, hospitalization, or physical rehabilitation . A review of the facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy and procedure, revised February 2025, further revealed, The Administrator or his/her designee will notify the State Agency and any other agencies (i.e., law enforcement, adult protective services) as appropriate of alleged violations involving abuse. neglect, misappropriation of resident property and injuries of unknown source. Serious bodily injury is reported immediately but not later than 2 hours after forming the suspicion if the allegation involves abuse or results in serious bodily injury . Resident #1 A review of R1's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed they had multiple diagnoses that included cerebral palsy, epilepsy, abnormal posture, torticollis (a rare condition in which the neck muscles contract causing the head to twist to one side), and scoliosis. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/14/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12 which revealed R1 was moderately cognitively intact. During an interview on 06/12/25 at 09:50 AM, R1 stated through short statements and yes/no answers that in February 2025 she rolled out of bed while staff were doing a bed bath. She stated staff rolled her to the side and she kept going until she was on the floor. R1 stated one staff member was present and giving her the bed bath. She stated usually only one staff member provides care to her, including bed baths. R1 denied the facility uses two staff members for her care. R1 stated after she fell out of bed onto the floor she had difficulty breathing and pain. She stated staff called an ambulance and staff stayed with her until the ambulance arrived. R1 stated she had several fractured ribs and a hip fracture. She stated she was in the hospital for several days, but did not have surgery. A review of R1's Fall Risk Assessment, dated 12/10/24, revealed R1 scored a 15 (Moderate Risk). A review of R1's Activities of Daily Living (ADL) Care Plan, dated 9/28/20 and revised on 12/27/23, revealed R1 required 2 staff participation for repositioning and turning in bed (date initiated: 4/6/23). However, R1 only needed total assistance of one person with brief changes and using the bed pan per the care plan. A review of R1's Nurse's Notes, dated 2/7/25, revealed, Resident observed laying on her left side on the floor next to the bed. Resident moaning with a snort like breathing. Resident complained of pain to back. Resident assessed, large forming bump noted on back of head. Hump in the middle of the bed observed Resident sent out to the emergency room for evaluation and treatment. Resident assessed . A review of the hospital's Internal Medicine Daily Inpatient Progress Note, dated 2/17/25, revealed on 2/7/25 R1 was admitted to the hospital due to rib fractures and a hip fracture after a fall. She presented to the ER (emergency room) after falling out of bed while receiving a bath at her facility. Workup revealed multiple rib fractures as well as a hip fracture. Additionally she was found to have a new LLL (left lower lobe) subsegmental PE (pulmonary embolism- a blood clot in the lung) and a very small left-sided pneumothorax (a condition that can be caused by a blunt or penetrating injury (e.g., from fractured ribs) where air leaks into the space between the lung and chest wall and causes the lung(s) to collapse) . A review of Certified Nursing Assistant (CNA) D's typed statement, undated, revealed she was cleaning R1 up because R1 had a bowel movement. She rolled R1 onto her right side to clean her up. CNA D stated she needed more washcloths, so she turned around to grab some more washcloths. She stated when she turned back around, she heard R1 make a grunting/growling noise and R1 was rolling off the bed. CNA D stated she could not catch her in time before she rolled off the bed completely. CNA D stated she had checked R1's kardex (a summary of a resident's care needs) before providing care and she noticed R1 was one assist for toileting and two assist for transfers. CNA D stated she did not remember if she checked R1's bed mobility assistance on the kardex. She then expressed guilt/remorse that the incident occurred. During an interview on 06/12/25 at 2:00 PM, the Nursing Home Administrator (NHA) stated she definitely had an investigation for this incident. She stated she did not report the incident to the state survey agency (SSA) because Regional Nurse Consultant (RNC) Q told her not to because the facility determined that the reason that R1 fell off the bed and onto the floor was a mattress issue from a hump in the mattress and not the result of anything that was reportable. During a second interview on 06/13/25 at 01:25 PM, the NHA stated CNA D had to complete training on safe resident handling because she rolled her (R1) away from her. The NHA stated if CNA D would have rolled her (R1) towards herself (CNA D), she would have caught her and R1 would not have rolled off the bed. The NHA further stated if there had been a hump/lump in the mattress staff should roll the resident over it and have another staff member on the other side of the mattress to make sure the resident did not roll off the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to appropriately transfer and/or discharge two residents (R69, R70) of two residents reviewed for discharges. Findings include: Resident #69 (R69) Review of the MDS dated [DATE] for R69 revealed in section A2105, R69's discharge status was 04. Short-Term General Hospital (acute hospitals, IPPS), indicating R69 was discharged to the hospital. Review of a Nursing Progress note dated [DATE] for R69 revealed he was discharged with his son to an Assisted Living Facility. Review of a document titled Discharge Instructions dated [DATE] for R69 revealed: admission (sic) In Progress, with no locked date. The document was not complete with the reason for the discharge and where the resident was discharged to, and no document signed by the resident indicating he or his representative acknowledged or received discharge information/instructions. No Home Care Agency information was documented. No other discharge form was in the electronic medical record (EMR). Review of the Progress Notes for R69 dated [DATE] revealed: Reviewed medications and discharge instructions with son. All nonreturnables (sic) sent with son. Reviewed upcoming doctor appointment and home care agency follow up. No questions asked after opportunity offered. Resident discharged with son via private vehicle to [Assisted Living]. Review of the EMR for R69 revealed no discharge summary or recap of stay. In an interview on [DATE] at 8:35 AM, RN Q reported R69 did go home and was not sure why R69 would be flagged for hospitalization. RN Q then verified the Social Worker documented R69 went back to the hospital, but he actually went home. Resident #70 (R70) Review of the MDS dated [DATE] for R70 revealed in section A2105, R70's discharge status was 13. deceased and indicated as a death in the facility. Review of the electronic medical records (EMR) for R70 revealed the resident had a change of condition and the Emergency Medical Services (EMS) was called. There was no documentation to show the resident left the facility and went to the hospital and no documentation to show he died in the facility. Review of a Bed Hold & Leaves of Absence document dated [DATE] revealed a request to hold a bed. Review of the Physician Orders for R70 revealed no orders for the resident to be discharged or sent to the hospital. In an interview on [DATE] at 8:35 AM, MDS Coordinator/Registered Nurse (RN) Q reported R70 did go to the hospital and died there. R70 should not have been documented as a death in the facility. R70 acknowledged there were no transfer forms in the EMR indicating R70 left the facility accompanied by EMS. A request for an admission, transfer and discharge policy was requested via email on [DATE] at 2:47 PM and was provided with a copy of an alleged power point slide provided to staff during training when hired according to the Clinical Nurse Consultant U with a date of 2017 that revealed: Transfers to Hospital: Complete Resident Transfer Form. -What do you send with the resident? - Transfer Form, Face sheet, Med List, Advance Directives, Bed Hold Policy. -Review checklist. Notify: DON (Director of Nursing), Physician, Responsible Party. Nursing Note: - Change in Condition. Another power point slide dated 2017 revealed: discharge: Interdisciplinary Discharge Summary. Post- Discharge Plan of Care- Review Post-Discharge POC (plan of care), - review medications/treatments with resident/family, - Provide list of medications/treatments, - instruct resident to sign form and provide a copy of the form to the resident. Nursing Discharge Note Discharge Resident in Vision (an electronic medical record not used by the facility), - Discontinue orders, resolve care plans. In an interview on [DATE] at 4:25 PM, Clinical Nurse Consultant (CNC) U reported they do not have formal policies for admissions, transfers and discharges and just follow the standards of practice. CNC U then reported the standards of practice should be followed for documentation and there should be an order for discharges.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for two Residents (R70 and R69) of three residents reviewed for closed records. Findings include: Resident #70 (R70) Review of the MDS dated [DATE] for R70 revealed in section A2105, R70's discharge status was 13. deceased and indicated as a death in the facility. Review of the Electronic Medical Records (EMR) for R70 revealed the resident had a change of condition and the Emergency Medical Services (EMS) was called. There was no documentation to show the resident left the facility and no documentation to show he died in the facility. In an interview on [DATE] at 8:35 AM, MDS Coordinator/Registered Nurse (RN) Q reported R70 did go to the hospital and died there. R70 should not have been documented as a death in the facility. R70 acknowledged there were no transfer forms in the EMR indicating R70 left the facility accompanied by EMS. Resident #69 (R69) Review of the MDS dated [DATE] for R69 revealed in section A2105, R69's discharge status was 04. Short-Term General Hospital (acute hospitals, IPPS), indicating R69 was discharged to the hospital. Review of a Nursing Progress note dated [DATE] for R69 revealed he was discharged with his son to [Name omitted] which is an Assisted Living Facility. In an interview on [DATE] at 8:35 AM, RN Q reported R69 did go home and was not sure why R69 would be flagged for hospitalization. RN Q then verified that the Social Worker documented R69 went back to the hospital, but he went home. A request for the facility's policy for MDS was requested and was provided with an MDS Completion Guideline dated [DATE] revealed it was not updated, reviewed, or revised since then.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an annual Preadmission Screening/Annual Resident Review (PASARR) Level I Screening and Level II Evaluation timely for 1 of 1 resident (R9) reviewed. Findings include: A review of R9's admission Record, dated 6/12/24, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R9 had multiple diagnoses that included dementia, depression, and narcissistic personality disorder. A review of R9's medical record, dated 5/1/24 to 6/11/25, revealed R9 last had a PASARR Level II Evaluation completed on 5/15/24. However, there was not any documentation in R9's medical record that a PASARR Level I Screening and/or Level II Evaluation had been completed since then (they should have been completed prior to 5/15/25). During an interview on 06/11/25 at 02:10 PM, Social Worker (SW) A stated per her tracking tool R9's PASARR Level I Screening was due on 5/1/25. She stated she knew it was late, but had not completed it yet. A review of SW A's PASARR tracking tool, dated 6/11/25, confirmed that R9's PASARR Level I Screening and Level II Evaluation were due on 5/1/25. During an interview on 06/11/25 at 2:40 PM, the Nursing Home Administrator (NHA) stated the facility was currently addressing late PASARR Screenings and Evaluations in their Quality Insurance and Performance Improvement (QAPI) Committee (a committee that self-identifies issues in the facility and works to correct them). She stated SW A identified this issue and notified the QAPI Committee last month (May 2025). The NHA stated SW A was aware that she was behind in getting her PASARR Level I Screenings and Level II Evaluations completed because she depends on the Medical Director (MD C) to do the Level II Evaluations. The surveyor requested a copy of anything that the NHA had to demonstrate that the facility had been addressing the timeliness of PASARR Screenings and Evaluations in QAPI, including the steps they had taken to correct the issue. During a second interview on 06/12/25 at 9:40 AM, the surveyor requested from the NHA a copy of anything that they may have demonstrating that the facility had been addressing the timeliness of PASARR Screenings and Evaluations in QAPI, including the steps they had been taking to correct the issue. A review of the facility's Performance Improvement Plan (PIP), dated 6/12/25, revealed the facility identified timely completion of PASARR's (Level I Screenings and Level II Evaluations) as a concern in QAPI on 5/14/25. However, the completion of all outstanding PASARR's was not started until 6/11/25 (during the annual survey) and audits will not be started until 6/16/25 (after the completion of the annual survey). During a third interview on 06/13/25 at 8:50 AM, the NHA verified that the facility had identified a concern in QAPI on 5/14/25 with the timeliness of the completion of the PASARR Level I Screenings and Level II Evaluations. She stated that the concern was not worked on for all residents until 6/12/25 (during the annual survey).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a person-centered Care Plan for one (R224) of two residents reviewed for Care Plans. Findings include: Resident #224 (R224) Review of a Face Sheet revealed R224 admitted to the facility on [DATE] with pertinent diagnoses of fusion lumbar spine, urinary tract infection (UTI), and fractured lumbosacral spine and pelvis. Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. Review of the Care Plan for R224 revealed: Focus: I have indwelling catheter, initiated on 5/30/25 and revised on 6/2/25 by the MDS Coordinator. The MDS reflects R224 is continent. Focus: At risk for infection related to indwelling catheter, initiated on 6/2/25. Focus: ADL (activities of Daily Living) Self Care Performance . Interventions/Tasks: TOILET USE: I require 1 staff participation to use toilet, initiated 5/30/25 and last revised 6/2/25. During an observation and an interview on 6/10/25 at 3:10 PM, R224 reported she has had to wait for long periods of time for the call lights to be answered so she can get assistance with toileting. The longest time she waited for the call light to be answered was about an hour and soiled her pants because she could not wait that long. A couple staff at night will tell her to just go in her brief if she cannot hold it and not to worry about it. If you have to go, just go they told her. R224 reported it makes her feel bad when she wets inside her brief even though the staff are very kind about it and will clean her up. R224 did not have an indwelling catheter.

Based on observation, interview, and record review, the facility failed to revise the Care Plan for two facility residents (R66 and R26) who had documented changes in care following admission to the facility. R66 Review of the Electronic Medical Record (EMR) reflected R66 was admitted to the facility 5/1/25 with pertinent diagnoses that included Acute Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD) On 6/11/25 at 9:43 AM and again on 6/12/25 at 2:34 PM, R66 was observed in a recliner chair with an Albuterol multidose inhaler on the over-the-bed table next to the Resident. R66 reported he used the inhaler sometimes a couple of times a day. R66 reported staff had not asked him if he had used it or how often. R66 indicated staff never asked him anything about the inhaler. Review of the EMR Doctor's Orders reflected an order for Ventolin HFA Inhalation Aerosol Solution 90 micrograms (mcg) (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for COPD/wheezing. May leave at bedside with a start date of 5/5/25. Review of the Care Plan for R66 did not reflect a plan of care for the assessment, monitoring of self-administration of medication, or the expectation of staff monitoring and documentation. R26 Review of the Electronic Medical Record (EMR) reflected R26 admitted to the facility 5/19/25 with diagnoses that included a fracture and a history of repeated falls. The medical record reflected a urinary catheter had been inserted during admission. Review of the EMR Progress Notes for R26 reflected an entry 6/2/25 at 5:42 PM of urine with increased cloudiness, sediment . and foul smelling. The entry reflected a lab specimen was obtained and transported to the lab for testing. Review of the laboratory urinalysis report dated 6/2/25 reflected an elevated white blood cell count (one of the signs of an infection). The EMR Progress Notes for R26 reflected an entry of 6/3/25 at 12:43 PM that the Lab had been called and the specimen was going to culture. Further documentation of 6/3/25 reflected antibiotic therapy had been initiated for a UTI. Review of the Care Plan for R26 did not reflect the Care Plan had been revised for a UTI with antibiotic administration. The policy provided by the facility titled Care plan preparation, long-term care dated May 19, 2025 was reviewed. The policy reflected A care plan is an individualized, written action plan for a resident's care, must be person-specific and guides a resident's care from admission to discharge. The policy reflected that the care planning is driven by a resident's conditions and issues as well as a resident's unique characteristics. The policy reflected that the interdisciplinary team collaborates with the resident and reviews and revises the care plan as necessary, to meet the resident's needs throughout the stay in the facility. The policy reflected Special Considerations If you must revise your plan as the resident's condition changes fill out a new care plan and add it to the medical record. The policy reflected sign and date the care plan whenever you make new entries to keep the plan current and to maintain accountability for planning the resident's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 19 sampled residents (R1). Findings include: R1 A review of R1's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed they had multiple diagnoses that included cerebral palsy, epilepsy, abnormal posture, torticollis (a rare condition in which the neck muscles contract causing the head to twist to one side), and scoliosis. During an interview on 06/12/25 at 09:50 AM, R1 stated through short statements and yes/no answers that in February 2025 she rolled out of bed while staff were doing a bed bath. She stated staff rolled her to the side and she kept going until she was on the floor. R1 stated one staff member was present and giving her the bed bath. She stated usually only one staff member provides care to her, including bed baths. R1 denied the facility uses two staff members for her care. R1 stated after she fell out of bed onto the floor she had difficulty breathing. She also stated she had pain. She stated staff called an ambulance and staff stayed with her until the ambulance arrived. R1 stated she had several fractured ribs and a hip fracture. She stated she was in the hospital for several days, but did not have surgery. A review of R1's Nurse's Notes, dated 2/7/25, revealed, Resident observed laying on her left side on the floor next to the bed. Resident moaning with a snort like breathing. Resident complained of pain to back. Resident assessed, large forming bump noted on back of head. Hump in the middle of the bed observed Resident sent out to the emergency room for evaluation and treatment. Resident assessed . A review of R1's medical record, dated 2/1/25 to 6/11/25, failed to reveal any additional documentation related to R1's fall on 2/7/25 (e.g., neurological checks (if performed), facility transfer forms to the hospital). A review of Certified Nursing Assistant (CNA) D's typed statement, undated, revealed she was cleaning R1 up because R1 had a bowel movement. She rolled R1 onto her right side to clean her up. CNA D stated she needed more washcloths, so she turned around to grab some more washcloths. She stated when she turned back around, she heard R1 make a grunting/growling noise and R1 was rolling off the bed. CNA D stated she could not catch her in time before she rolled off the bed completely. Based on this interview, the Nurse's Note, dated 2/7/25, was inaccurate since it was written to imply that R1 was found on the floor by staff (an unwitnessed fall) instead of accurately reflecting that R1 was allowed to roll out of bed in staff's presence. During an interview on 6/12/25 at 9:40 AM, the Nursing Home Administrator (NHA) was informed that documentation related to R1's fall on 2/7/25 (e.g., neurological checks (if performed), facility to hospital transfer form) could not be located in R1's medical record. The NHA stated the facility does complete a transfer form when they send someone to the hospital and it should be in the resident's medical record under the Miscellaneous tab. R1's hospital transfer form (the form the facility completes when they send a resident to the emergency room) and neurological checks (if performed), and any other documentation related to R1's fall and hospitalization on 2/7/25 that may be missing from R1's medical record were requested from the NHA. On 6/12/25 at 11:30 AM, the facility provided copies of R1's neurological checks, hospital physician notes, and hospital summary of stay notes. However, the facility failed to provide R1's 2/7/25 facility to hospital transfer form. During a second interview on 6/12/25 at 2:00 PM, R1's facility to hospital transfer form for 2/7/25 was requested from the NHA (2nd request). The NHA also verified that R1's neurological checks and some of the hospital physician notes had not been in R1's medical record. The NHA stated they were in medical records waiting to get scanned into R1's medical record or she had obtained copies from the hospital computer records system. As of the time of the completion of the survey and the survey team's exit from the facility, the facility failed to provide a copy of R1's facility to hospital transfer form for 2/7/25. During an interview on 6/13/25 at 4:38 PM, Regional Admissions Coordinator (RAC) S stated when a resident is sent to the ER, the transfer form would be uploaded under the Misc (miscellaneous) tab under the subheading admission Record and Consent Forms (older transfer forms were located under the Other subheading). She stated it will be labeled ST (State) of [name of State] Facility Initiated Transfer with the date of the transfer. She stated this file would contain the notification to the State of the transfer and the forms they send with the resident to the hospital. A second review of R1's medical record, dated 2/1/25 to 6/13/25, revealed R1's General Surgery hospital notes, dated 2/7/25, were uploaded to R1's medical record on 6/12/25 (4 months after R1's hospital stay) and R1's neurological assessment, dated 2/7/25 was uploaded into R1's medical record on 6/11/25 (4 months after her fall). However, R1's facility to hospital transfer form was not in R1's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to answer call lights in a timely manner for one Resident (R224) and those who attended the Resident Council meeting. This deficient practice affects all residents who reside at the facility. Findings include: Review of the Resident Council Minutes dated 4/24/25 revealed call light concerns especially on the 2nd and 3rd shift. Number of Residents who share concern: *leave light on until need is met! No number or specific residents listed. There were 13 residents who were documented as attending the meeting. The meeting minutes were signed by the Nursing Home Administrator (NHA). Review of an email correspondence provided dated 4/25/25 revealed the Activities Director notified the previous Director of Nursing (DON) of the call light concerns. However, the issue of Call Lights has come up again. They feel that they are not being answered in a timely manner. Typically, 2nd or 3rd shift but can be all over the place. Both residents from [NAME] and Yellow Units had the same complaint. They also said that staff will come in to answer the call light, say that they will let other staff know or that they will be right back, the need is never met. If staff could leave the call light on until the need is met, that would be best. Review of the Resident Council Minutes dated 5/29/25 revealed the Old business of call lights was not resolved to satisfaction. Seven residents were in attendance. The meeting minutes were signed by the NHA. Resident #224 (R224) Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. In an interview on 6/10/25 at 3:10 PM, R224 reported she has had to wait for long periods of time for the call lights to be answered so she can get assistance with toileting. The longest time she waited for the call light to be answered was about an hour and she soiled her pants because she could not wait that long. Review of the Call Light logs for R224 from 6/5/25 to 6/12/25 revealed the following call wait times: 6/5/25 at 6:28 AM, 27:14 minutes 6/5/25 at 7:48 AM, 40:31 minutes 6/5/25 at 12:23 PM, 24:22 minutes 6/5/25 at 8:01 PM, 20:40 minutes 6/6/25 at 7:58 AM, 40:37 minutes 6/6/25 at 9:30 AM, 22:33 minutes 6/6/25 at 1:48 PM, 30:01 minutes 6/8/25 at 9:10 PM, 36:17 minutes 6/9/25 at 7:31 PM, 23:06 minutes 6/10/25 at 11:14 AM, 41:46 minutes 6/11/25 at 5:16 AM, 35:17 minutes 6/11/25 at 7:55 AM, 45:49 minutes In an interview on 6/11/25 at 4:35 PM, Certified Nursing Assistant (CNA) S she is aware of R224's concerns about long call light wait times. CNA S reported she told the DON of R224's concerns, and the DON did meet with the resident. In an interview on 6/13/25 at 10:41 AM, the Director of Nursing (DON) reported she had been addressing call light times in daily meetings. The audits she had done so far were no problematic. A reasonable time for call lights to be answered is about 5-10 minutes. In an interview on 6/13/25 at 11:37 AM, the NHA reported she was aware of call light concerns in the facility and no ad hoc was done yet. The NHA gave the task to the Admissions Coordinator who did not make it to the Quality Assurance Meeting yet. The NHA reported she did not receive individual grievances resulting from the resident council meetings and only gets them once they are resolved to make sure they are complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit the Minimum Data Set (MDS) assessments timely for (R27, R35, R222 R224) of 4 residents reviewed for MDS transmissions. Findings include: Resident #27 (R27) Review of the MDS in the Electronic Medical Record (EMR) revealed R27 was due for her yearly annual assessment and had an ARD (assessment reference date)/Target date of 3/20/25. This assessment was completed on 6/5/25. Resident #35 (R35) Review of the MDS in the EMR revealed R35 was due to her yearly annual assessment and had an ARD (assessment reference date)/Target date of 5/4/25. This assessment was completed on 6/6/25. In an interview on 6/13/25 at 8:35 AM, MDS Coordinator/Registered Nurse (RN) Q confirmed R27 and R35's annual MDS assessments were over 120 days old. RN Q reported she was not sure what happened with R27's assessment but did find that R35's assessment was not flagged that it was due, or that it was late. RN Q reported R27 had an annual assessment that was missed and submitted an assessment based on the March data in the EMR. RN Q reported they need a new tracking system, so they do not miss any assessments. Resident #222 (R222) Review of the EMR for R222 on 6/11/25 revealed her ARD - 5-day assessment (5/29/25) was flagged as being 5 days overdue and her admission assessment dated [DATE] was flagged as 13 days overdue with a status of in progress. In an interview on 6/13/25 at 8:35 AM, RN Q reported R222's entry was not signed off until 6/6/25 and was one day late. The EMR showed it was 13 days overdue, and her entry was 5/29/25, which was submitted on 6/6/25. R222's Medicare started on 6/5/25 for a look back and was submitted on 6/11/25. Resident #224 (R224) Review of the EMR on 6/11/25 for R224 revealed she had a 5-day admission assessment due for a 5/30/25 entry to the facility and was flagged as being 5 days overdue. On 6/11/25 the status was showing it was in progress. In an interview on 6/13/25 at 8:35 AM, RN Q reported R224's MDS Entry submission was a day late but her Admission assessment was fine. When queried about the EMR flagging it was 5 days overdue, RN Q then clarified that it was in fact overdue. RN Q reported R224 entered the facility on 5/30/25 and the MDS was submitted on 6/6/25 and therefore it was submitted one day late. In an interview on 6/13/25 at 12:26 PM, the Nursing Home Administrator (NHA) reported she was told by RN Q that there were some late assessments, but they were working on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1) assess, monitor, and act upon abnormal findings, 2) have medications available timely after admission, 3) timely follow up to labs and/or diagnostics, and 4) document accurate skin assessments for three residents (R70, R224, and R6) of 4 residents reviewed for quality of care. Findings include: Resident #70 (R70) Review of the Electronic Medical Records (EMR) for R70 revealed he admitted to the facility on [DATE] and had diagnoses of chronic diastolic (congestive) heart failure (CHF), sepsis, pressure ulcer, and Alzheimer's disease. Review of the Minimum Data Set (MDS) dated [DATE] for R70 revealed in section A2105, R70's discharge status was 13. deceased and indicated R70 died in the facility. Review of the Nursing Progress notes for R70 dated [DATE] at 3:38 PM revealed R70 had a change of condition, and the Emergency Medical Services (EMS) was called. Resident observed unable to hold himself up in the chair and could not help during 2-person transfer. Resident was able to answer questions very slurred. Resident then began to cough up coffee ground color emesis. VS (vital signs) taken 66/44 (blood pressure), 80 (pulse), 97.9 (temperature), 18 (respirations), 87% (oxygen saturation). LS (lung sounds) clear. Abdominal pain noted in RUQ and LUQ (right and left upper quadrant). There was no documentation to show the resident left the facility and went to the hospital and/or no documentation to show he died in the facility. In an interview on [DATE] at 8:35 AM, MDS Coordinator/Registered Nurse (RN) Q reported R70 did go to the hospital and died there, not at the facility. R70 should not have been documented in the MDS as a death in the facility. R70 acknowledged there were no transfer forms in the EMR indicating R70 left the facility accompanied by EMS. Review of the Physician Orders for R70 revealed no orders for the resident to be discharged or sent to the hospital. Review of the Physician Orders for R70 revealed: 1. 2 Grams (GM) Cefazolin Sodium Dextrose Intravenous solution every 8 hours was ordered [DATE] at 7:51 PM. (For sepsis) 2. Blood pressure, temperature, pulse, respirations, and oxygen on admission and readmission, every shift obtain vital signs. No parameters ordered. 3. Coccyx wounds: Cleanse with normal saline, cut aquacel to fit wounds and cover with optifoam dressing. Change daily. Start date was [DATE], no treatment documented on [DATE]. 4. No orders for oxygen. 5. Braden Assessment Completed the Braden Assessment (tool used to assess risk for developing pressure ulcers) in Assessment tab (sic) ordered [DATE]. 6. Review of the Physician Orders revealed: 7. On [DATE], Weekly Skin Audit, every day shift, every Sat . (Saturday) was ordered and discontinued on [DATE]. 8. On [DATE], Weekly Skin Audit, every day shift every Tue . (Tuesday) was ordered and discontinued on [DATE]. Medication not available Review of a Nursing Progress note dated [DATE] at 8:15 AM for R70 revealed: Nurse called pharmacy regarding IV medication and pharmacy confirmed it will be drop shipped to facility in the next 4 hours and pump will be drop shipped to (sic). Patient to receive IV antibiotic dose as soon as its received. (12-16 hours post admission.) No documentation to show the physician was notified the prescribed antibiotic had not been received at the facility and administered as ordered. Vital signs Review of the [DATE] Medication Administration Record (MAR) for R70 revealed vital signs were checked as done twice a day but the Vital signs report is documented as either done once a day or every other day. No documentation to show R70 was a CO2 (carbon dioxide retainer as seen in patients with chronic obstructive pulmonary disease (COPD). Review of the vital sign for R70 were as follows and not completed most days as ordered (Normal: SpO2 ?95%): [DATE] 12:05 90.0% Room Air [DATE] 08:32 90.0% Room Air [DATE] 14:10 90.0% Room Air [DATE] 11:55 96.0% Room Air [DATE] 02:46 89.0% Room Air [DATE] 00:47 91.0% Room Air [DATE] 09:45 91.0% Room Air [DATE] 12:31 91.0% Room Air [DATE] 08:36 90.0% Room Air [DATE] 09:07 90.0% Room Air [DATE] 13:39 90.0% Room Air [DATE] 23:27 92.0% Room Air [DATE] 12:03 90.0% Room Air [DATE] 09:00 90.0% Room Air [DATE] 23:46 92.0%Room Air 3/ 26/2025 12:10 91.0% Room Air [DATE] 02:25 92.0% Room Air Blood Pressures for R70 were as follows and no follow up to the start of the abnormally low blood pressure (since admission) documented on [DATE] at 8:31 AM. [DATE] 12:05 98 / 54 mmHg Sitting l/arm [DATE] 08:32 93 / 53 mmHg [DATE] 08:31 93 / 53 mmHg [DATE] 06:21 112 / 67 mmHg [DATE] 14:10 107 / 68 mmHg Lying l/arm [DATE] 11:55 107 / 71 mmHg Sitting l/arm [DATE] 02:46 118 / 73 mmHg Sitting l/arm Review of a Physician Progress note dated [DATE] and electronically signed on [DATE] for R70 revealed no indication the practitioner was aware of R70's trend of low oxygen levels. Exam: Respiratory: auscultation: no rales, rhonchi, or wheezes. Problems: Acute hypoxemic respiratory failure, Status: Active, onset, noted (assessed) Community acquired pneumonia of left lower lobe of lung, Status, onset [DATE], . Plan does not address low oxygen levels. Review of the Order Summary for R70 revealed no orders or standing orders for oxygen. Review of the Care Plan for R70 revealed no focus or interventions for oxygen. In an interview on [DATE] at approximately 4:15 PM, the Clinical Care Coordinator (CCC) R reported R70 had CHF and therefore having an oxygen level at 89-90% was okay for him. CCC R reported the facility had standing orders for oxygen levels of 89% and below. Residents are to receive 2 liters of oxygen via nasal cannula across the board but was unable to provide the orders before the end of this survey. CCC R reported normal oxygen levels are 89% and above and are to notify the physician if it is below 89%. In an interview on [DATE] at 4:16 PM, the Director of Nursing (DON) reported oxygen levels should be individualized per residents and if they have CHF, it could be normal to have an oxygen level below 90%, but there should be an order for it and an evaluation. Vital Signs-Acceptable Ranges for Adults . Pulse oximetry (SpO2) Normal: SpO2 ?95% Respirations 12 to 20 breaths/min, deep and regular . [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 500). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Completing a health assessment and physical examination is an important step toward providing safe and competent nursing care. The nurse is in a unique position to determine each patient's current health status, distinguish variations from the norm, and recognize improvements or deterioration in the patient's condition. Nurses must be able to recognize and interpret each patient's behavioral and physical presentation . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 516-517). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, An alteration in vital signs signals a change in physiological function. Assessment of vital signs provides data to identify nursing diagnoses, implement planned interventions, and evaluate outcomes of care .Verify and communicate significant changes in vital signs. Baseline measurements provide a starting point for identifying and accurately interpreting possible changes. When VS appear abnormal, have another nurse or health care provider repeat the measurement to verify readings. Inform the charge nurse or health care provider immediately, document findings in your patient's record, and report changes to nurses during hand-off communication (TJC, 2020). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E Book (p. 467-468). Elsevier Health Sciences. Kindle Edition. Coccyx Wounds Review of a Nursing Progress note dated [DATE] at 8:15 PM for R70 revealed the resident arrived at the facility and had a small open area to his coccyx with mediplex applied and to be changed every 3 days. Review of a Nursing Management progress note dated [DATE] for R70 revealed: Red area on sacrum is not open at this time as reported on admission assessment, [Physician] observed area with this writer. Protective barrier cream to area for prevention. Review of the Clinical Assessment tab for R70 revealed no Braden Assessment was completed. Review of the Clinical Assessment tab for R70 revealed the first Skin Assessment documented was on [DATE]. Review of a Nursing Progress note dated [DATE] for R70 revealed: [Physician] in today. New orders for wound care to coccyx . No wound assessment documented. Review of the Physician Orders for R70 revealed on [DATE] an order for : Coccyx wounds: Cleanse with normal saline, cut aquacel (wound treatment) to fit wounds and cover with optifoam dressing. Change daily. Review of the April Treatment Administration Record (TAR) for R70 revealed his first coccyx wound dressing was done [DATE] (one day after the nurse documented there was a new order on [DATE].) No dressing change was documented on [DATE]. No documentation in the EMR that a clinical assessment, physician progress note and/or skin/wound note, or treatment order was in place to address the sacral wound that worsened in 12 days between [DATE] and [DATE] after admission. Review of a Late Entry Nursing Management Skin/Wound Note dated [DATE] for R70 revealed he had a left coccyx wound that measured 3 cm (centimeters) x 2 m (sic) x <0.1 cm, wound bed pink without s/s (signs and symptoms) of infection. The right coccyx measured 3.5 cm x 1.5 cm x <0.1 cm, wound bed pink without s/s of infection. Review of the Care Plan for R70 revealed on [DATE] a care plan for a pressure injury to the left and right coccyx was initiated. (18 days after admission.) In an interview on [DATE] at 4:16 PM, the Director of Nursing (DON) reported there should be more information in the EMR for R70 and reported the care plans should reflect the residents needs timely. Skin assessments should be done upon admission and weekly. They do not have policies for skin assessments, and it should be the standards of practice for documentation. It is also the standard of practice to have an order to be discharged . R224 Resident #224 (R224) Review of a Face Sheet revealed R224 admitted to the facility on [DATE] with pertinent diagnoses of fusion lumbar spine, urinary tract infection (UTI), and fractured lumbosacral spine and pelvis. Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. Review of the Care Plan for R224 revealed: Focus: I have indwelling catheter, initiated on [DATE] and revised on [DATE] by the MDS Coordinator. The MDS reflects R224 is continent. Focus: At risk for infection related to indwelling catheter, initiated on [DATE]. Focus: . ADL (activities of daily living) . Interventions: . TOILET USE: I require 1 staff participation to use toilet, initiated [DATE]. During an observation and interview on [DATE] at 1:14 PM, R224 reported she went to the bathroom the day before and her hips popped and it hurt like the dickens. R224 reported staff did not use a gait belt to assist with her transfer but staff did hold on to her post-surgical support brace that was observed wrapped around her back and her abdomen. R224 was sitting in her wheelchair with ice packs to both sides of her hips. R224 reported her biggest concern was the communication between the hospital and the facility regarding her medications she needed. At this time the nurse came in to tell R224 that the Physician ordered x-rays on her hips. No urinary catheter was observed. During an observation and an interview on [DATE] at 3:10 PM, R224 reported she was on antibiotics prior to admission for a urinary tract infection (UTI) and they were not available upon admission to the facility. R224 denied having a urinary catheter. Urine Culture Review of a urine culture collected [DATE] (day of admission) that last resulted on [DATE] for R224 revealed Citrobacter freundii bacteria and reported This is an edited result. Previous organism was Gram negative bacilli on [DATE]. R224 was to start Bactrim (antibiotic) for 7 days per undated signature. Review of a Nursing Progress note dated [DATE] at 12:38 PM for R224 revealed: Has complaints of needing an antibiotic for a UTI and states that she was on an antibiotic prior to leaving the hospital. Attempting to obtain a clean catch urine, though resident states that she is incontinent more times than not. Doctor made aware of situation and to address this during visit today. Review of a Nursing Progress note dated [DATE] for R224 at 7:17 PM revealed: Resident continues with occasional complaints of needing to be on an antibiotic for a UTI. Husband brought this nurse a specimen cup of urine which was warm, and clear red in color. No particulates or any debris was seen. Urine was brought for chemstrip (sic) testing. Chemstrip (sic) was dipped into the cup and every testing field was stained into an orange color, except for glucose which remained blue. Paper towel used also turned an orange color. Note left for doctor to follow up with resident during his visit. Review of the Nursing Progress notes dated [DATE] at 12:36 PM for R224 revealed: Urine culture results received . new orders received for . Bactrim DS (double strength) BID (twice a day) x 7 days. Review of the June Medication Administration Record (MAR) for R224 revealed Bactrim was ordered on [DATE] and at 7:00 PM and she received her first dose. (3 days after admission.) Review of the Care Plan for R224 initiated [DATE] revealed: Focus: At risk for infection related to indwelling urinary catheter. Resident did not have an indwelling catheter. Focus: I have Urinary Tract Infection, initiated [DATE]. Review of the Order Summary for R224 revealed she had no orders for a urinary catheter and no orders to discontinue a urinary catheter X-ray Review of R224's EMR on [DATE] revealed no x-ray results were documented or scanned into the computer. In an interview on [DATE] at 3:45 PM, Licensed Practical Nurse (LPN) H was questioned about the results of R224's x-ray and did not know what the status was. LPN H then looked into the facilities EMR and could not find any x-ray results. LPN H then looked into the hospital medical records system and found the x-ray results for R224 and provided a copy. There was no documentation or indication the results were followed up on and/or informed the medical provider of the results. In an interview on [DATE] at 4:08 PM, Physical Therapist (PT) T reported she was aware that x-rays were ordered for R224 but did not know the results at this time. PT T reported R224 is to be transferred with a gait belt and is a standby assist with contact guard (it would be helpful to indicate if PT T reported R224 should not be transferred by staff grabbing her orthotic). In an interview on [DATE] at 4:16 PM, the Director of Nursing (DON) reported the nurses, and the managers are to follow up on labs and diagnostics results for the residents. Resident #6 (R6) Review of a Face Sheet revealed R6 admitted to the facility on [DATE]. Review of the MDS dated [DATE] for R6 revealed she had a stage II pressure ulcer upon admission. Review of the Order Summary Report for R6 revealed orders for Right buttocks- cleanse with NS (normal saline), Pat dry, apply zinc, and cover with optifoam every day shift for treatment. During an observation and an interview on [DATE] at 11:43 AM, R6 was lying in bed with a wound vac connected to a surgical wound in her groin. She reported she was admitted to the facility from the hospital after a procedure that required a wound vac in her groin. She had a wound vac at the hospital but could not come to the facility with it because it belonged to the hospital. R6 reported it took a few days after admission to the facility for her to get a wound vac and now has an infection in the wound which requires antibiotics. Review of an admission Skin Assessment for R6 dated [DATE] revealed R6 had a surgical incision in her groin that measured 5.5 cm (centimeters) x 5cm x 4.5cm and a stage II pressure ulcer on her left buttock that measured 1cm x 1 cm. Review of a Physician Progress note for R6 dated [DATE] revealed: . Patient did not arrive with wound vac dressing in place. The wound is being treated with wet to dry dressings until wound vac is available. There are no pain issues. Plan: Wound right Groin secondary to hematoma evacuation 9x5c3 cm (sic) Continue with current dressings until wound Vac is available. (Measurements differ than admission nursing progress note.) No mention of a stage II pressure ulcer. Review of the May Medication Administration Record/Treatment Administration Record (MAR/TAR) for R6 revealed the following: 1. Right groin wound-Cleanse with NS (normal saline), pat dry and apply dry gauze and cover with foam dressing until wound vac supplies are available PER [Physician] (NO ISLAND DRESSING) every day shift for treatment, start [DATE] and discontinued [DATE]. 2. APPLY WOUND VAC- To right groin When supplies arrive (Supplies expected to arrive [DATE]) Order can be discontinued and New wound vac orders created when wound vac is applied. May also d/c (discontinue) dry dressing order, every shift for treatment, start [DATE] and discontinue [DATE]. Review of a Nursing Progress note dated [DATE] at 9:58 AM for R6 revealed: . Right groin wound with foam border dressing in place until wound VAC supplies arrive, these have not yet. Complaining of increased pain and Tylenol is not adequate. Review of a Nursing Skin/Wound Note dated [DATE] at 11:35 AM for R6 revealed: Wound bed pink with yellowish areas, foul odor noted. 6 cm wide x 4 cm length x 3.9 cm deep. Surrounding skin/tissue ecchymotic (sic), fissures extending laterally and medially along abdominal fold line. Wound VAC applied to area with bridging foam to open fissures. [Physician] here and updated of VAC placement. No indication the physician was aware of or notified of the abnormal wound assessment described above other than he was notified the wound vac was in place. No indication of where or what wound this is described. Review of a Late Entry Nursing Skin/Wound Note for R6 dated [DATE] revealed: Left medial buttock wound 2.1 x 1.1 cm x 0.2 cm. Wound bed pink. Surrounding area reddened, intact. Blanchable. Island dressing applied (no foam border dressing available at this time.) Will replace when restocked. Review of an IDT (interdisciplinary) Note for R6 dated [DATE] revealed: . has a wound vac for incision to groin and a stage II buttocks to wound (sic). Review of a Nursing Skin Assessment dated [DATE] for R6 revealed her skin was not intact and no assessment of her surgical wound in the groin was documented: Treatment continues to right buttock, area appears to be slowly improving. No other new areas of concern identified. This document did not reference a skin assessment was documented anywhere else. Review of a Nursing Progress note dated [DATE] for R6 revealed: Called to resident's room d/t possible wound VAC leaking. She states, I can smell it, and I haven't been able to. Assessed dressing. Drainage noted at bottom of dressing at fold next to groin. Foul odor noted coming from dressing. You can hear an air leak at the same site. Dressing changed and treatment resumed. No indication the physician was notified of foul odor or wound assessment. (5 days after the first documented abnormal assessment.) Review of a Nursing Progress note Skin/Wound Note dated [DATE] at 1:17 PM for R6 revealed: 5cm x 5 cm x 4 cm right groin wound with foul smelling odor. Beefy red wound base. Bleeding noted to wound rim and inferior left aspect when old foam removed. Fissures extending laterally from each side of wound along abdominal fold line. Pain with dressing changes described as burning. Also, resident indicates pain to lateral aspect near hip where bruising is noted from hematoma. Wound VAC dressing reapplied. Physician aware of ongoing treatment. No indication the physician is aware of the condition of the wound. Review of a Nursing Progress Note for R6 dated [DATE] revealed: Wound vac placed on hold per physician at this time d/t (due to) bedside debridement, wound care provided per updated order. See skin note for updated measurement per physician. Review of a Skin Assessment dated [DATE] for R6 revealed her skin was not intact. Groin- Wound vac reinforced today. Coccyx- Continued treatment orders. No new skin issued noted. Review of a Nursing Progress note dated [DATE] revealed: Wound VAC replaced today at bedside by physician per new order. Physician ordered IV Ancef 2 G every 8 hours x 7 days d/t (due to) the foul odor and necrotic tissue he debrided at the bedside. Review of a Physician Note dated [DATE] for R6 revealed: Seen for examination of wound and reapplication of Wound Vac dressing. The foul smell has now subsided. Currently on IV antibiotics. Exam: Inspection Right Hi wound- There (sic) is no / minimal necrotic tissue. Wound floor has healthy tissue. No mention of a stage II pressure ulcer. Review of an IDT (interdisciplinary) Note for R6 dated [DATE] revealed: . She has a wound vac for stage II pressure ulcer on buttocks and is receiving IV (intravenous) therapy for wound infection. This did not address the surgical wound in in her groin. Review of an Order Summary for R6 revealed on [DATE] an order for 2 Grams (GM) of cefazolin (antibiotic) is to be given every 8 hours intravenously for wound healing. No cultures documented in the EMR. On [DATE] Doxycline Hyclate (antibiotic) ordered twice a day for bacterial infection in the groin wound for 2 weeks. On [DATE] fluconazole (antifungal), 200 mg (milligrams) ordered for 13 days. On [DATE] Amoxicillin-Pot clavulanate (antibiotic) 875-125 mg ordered for bacterial infection/Groin wound for 2 weeks. No orders for labs or wound cultures. Review of a Skin Assessment dated [DATE] for R6 revealed her skin was intact and No new issues. Right thigh dermatitis almost resolved. Review of the Care Plan for R6 revealed the following: Focus: Alteration in skin integrity related to Pressure injury to left buttock, initiated [DATE], Interventions: Assess/evaluate impaired area weekly and document per protocol. During an observation and an interview on [DATE] at 2:31 PM, R6 was in bed and reported her brief was soaked. R6 reported she is on Lasix (diuretic) and cannot always tell when she urinates and will be wet for long periods of time. CNA V entered the room and provided incontinence care at this time. R6's buttocks were observed to have a darker purple area the size of a tennis ball in the cleft of her buttocks with some maceration and blanchable skin throughout. No dressing in place per orders for Treatment and no signs of a pressure ulcer observed. R6 said it is better than it used to be. CNA V then applied a barrier cream with a new brief. Review of the June Medication Administration Record/Treatment Administration Record (MAR/TAR) for R6 revealed on [DATE] she did not receive a dressing change on her left buttocks as ordered and is documented as receiving dressing changes on [DATE] and [DATE], even though there was no dressing in place during the observation on [DATE]. A request for a policy for skin assessments was made and the facility provided a document dated 2019 with the name of another entity at the bottom of the form titled Wound Assessment and Monitoring from the Wound Prevention and Management Guidebook revealed: . Assess the wound initially and re-assess at least weekly to monitor progress toward healing. In an interview on [DATE] at 4:16 PM, the Director of Nursing (DON) reported she was not working here when R6 admitted to the facility, but did help facilitate getting R6's wound vac after her admission to the facility. The DON reported it was an Admissions thing and did not have a back up of supplies at the facility. The DON confirmed there were no cultures in the EMR for R6's surgical wound and will look to see if any were done. No cultures were provided by the end of this survey. In an interview on [DATE] at 4:25 PM, Clinical Nurse Consultant (CNC) U reported they do not have formal policies for admissions, transfers and discharges and they just follow the standards of practice. The nurses perform weekly skin assessments here but do not have a policy for it. There are no policies for documenting or maintaining medical records. CNC U then reported the standards of practice should be followed for documentation and there should be an order for discharges.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that one resident (R224) of two residents reviewed for bowel and bladder, who admitted to the facility continent of bowel and bladder, received timely assistance to maintain continence. Findings include: Resident #224 (R224) Review of a Face Sheet revealed R224 admitted to the facility on [DATE] with pertinent diagnoses of fusion lumbar spine, urinary tract infection (UTI), and fractured lumbosacral spine and pelvis. Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. Review of the Care Plan for R224 revealed: Focus: I have indwelling catheter, initiated on 5/30/25 and revised on 6/2/25 by the MDS Coordinator. The MDS reflects R224 is continent. Focus: At risk for infection related to indwelling catheter, initiated on 6/2/25. Focus: . ADL (activities of daily living) . Interventions: . TOILET USE: I require 1 staff participation to use toilet, initiated 5/30/25. During an observation and an interview on 6/10/25 at 3:10 PM, R224 reported she was on antibiotics prior to admission for a urinary tract infection (UTI) and was on antibiotics that were not available upon admission to the facility. R224 reported she has had to wait for long periods of time for the call lights to be answered so she can get assistance with toileting. The longest time she waited for the call light to be answered was about an hour and soiled her pants because she could not wait that long. A couple staff at night will tell her to just go in her brief if she cannot hold it and not to worry about it. If you have to go, just go they told her. R224 reported it makes her feel bad when she urinates inside her brief even though the staff are very kind about it and will clean her up. R224 did not have an indwelling catheter. Review of the Call Light logs for R224 from 6/5/25 to 6/12/25 revealed the following call wait times: 6/5/25 at 6:28 AM, 27:14 minutes 6/5/25 at 7:48 AM, 40:31 minutes 6/5/25 at 12:23 PM, 24:22 minutes 6/5/25 at 8:01 PM, 20:40 minutes 6/6/25 at 7:58 AM, 40:37 minutes 6/6/25 at 9:30 AM, 22:33 minutes 6/6/25 at 1:48 PM, 30:01 minutes 6/8/25 at 9:10 PM, 36:17 minutes 6/9/25 at 7:31 PM, 23:06 minutes 6/10/25 at 11:14 AM, 41:46 minutes 6/11/25 at 5:16 AM, 35:17 minutes 6/11/25 at 6:06 AM, 2:19 minutes 6/11/25 at 7:55 AM, 45:49 minutes Review of the Nursing Progress notes dated 6/2/25 at 12:36 PM for R224 revealed: Urine culture results received . new orders received for . Bactrim DS (double strength) BID (twice a day) x 7 days. Review of the Urinary continence task list revealed R224 dated 6/1/25 to 6/10/25 revealed the resident had four incontinence episodes and on 5 days she was documented as toileted once a day. One example was on 6/7 when R224 was assisted toileting at 1:10 AM and again at 9:10 AM. There was no documentation to show R224 was toileted until 2:02 AM the next morning. In an interview on 6/11/25 at 4:35 PM, Certified Nursing Assistant (CNA) S reported staff are to document in the EMR each time a resident is toileted. CNA S reported she is aware of R224's concerns about long call light wait times. CNA S is aware of the 3rd shift staff not taking R224 to the bathroom and giving her a bed pan instead. CNA S reported she knows that is not how it is supposed to be. CNA S reported she told the DON of R224's concerns, and the DON did meet with the resident. A request for concern forms for R224 on 6/11/25 at 11:56 AM was made via email and the Nursing Home Administrator (NHA) responded that the resident did not have any concern forms. In an interview on 6/13/25 at 10:41 AM, the Director of Nursing (DON) reported she had been addressing call light times in daily meetings. The audits she had done so far were not problematic. The DON reported it is not the facility's practice to not assist a continent resident timely to the bathroom and advise residents to urinate in their brief. A reasonable time for call lights to be answered is about 5-10 minutes. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Urinary tract infections (UTIs) are the fifth most common type of health care-associated infection .Escherichia coli, a bacterium commonly found in the colon, is the most common causative pathogen ([NAME], 2020). The risk for a UTI increases in the presence of .urinary and fecal incontinence, and poor perineal hygiene practices. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1229). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that monthly pharmacy review irregularities and pharmacist recommendations were received and addressed by the physician for 2 of 5 residents (R1 and R17) reviewed for monthly pharmacy medication regimen reviews. Findings include: A review of the facility's Medication Regimen Review policy, last revised 6/1/24, revealed, 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR (Monthly Regimen Review) and the director of nursing to act upon the recommendations contained in the MRR. 9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained in the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected . 9.2 The attending physician should document in the residents' health (medical) record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 9.2.1 If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. A review of the facility's Medication Regimen Review policy, last revised 6/1/24, revealed, 11. When the consultant pharmacist identifies a time-sensitive medication related concern during MRR that requires immediate action, the consultant pharmacist will notify the nurse and request the facility contact the attending physician/prescriber to communicate the issue and obtain direction or new orders. 11.1 If the attending physician has not responded by the time the consultant pharmacist has completed his/her consultation for the day, the issue will be escalated to the medical director for immediate action by facility staff . 13. The attending physician/prescriber should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident . R1 A review of R1's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed they had multiple diagnoses that included cerebral palsy, epilepsy, abnormal posture, torticollis (a rare condition in which the neck muscles contract causing the head to twist to one side), and scoliosis. A review of R1's medical record, dated 6/27/24 to 6/12/25, revealed the pharmacist made recommendations on 8/27/24 (Labs), 1/31/25 (Vitamin D), and 4/30/25 (warfarin and feeds). However, the pharmacist's consultation reports for these dates that would detail what the actual recommendations were could not be located in R1's medical record. In addition, the pharmacist's review and/or consultation report for July 2024 was not in R1's medical record. During an interview on 06/12/25 at 12:55 PM, the Nursing Home Administrator (NHA) was notified R1's pharmacy review of July 2024 and consultation reports for 8/27/24, 1/31/25, and 4/30/25 could not be located in R1's medical record. The NHA stated she would try and locate them and would provide copies to the surveyor, if she can locate them. The NHA also stated that if she can locate the pharmacy consultation reports and the physician agreed with the recommendation, then she would provide supporting documentation that the recommendation was implemented. During a second interview on 06/13/25 at 8:50 AM, the NHA stated she could not locate R1's pharmacy recommendations that were signed by the physician (MD C). The NHA stated she contacted the pharmacy yesterday (6/12/25) and they sent copies of unsigned pharmacy consultation reports for 7/29/24, 8/27/24, 1/31/25, and 4/30/25. A review of R1's Consultation Report, dated 7/29/24 and unsigned, revealed the pharmacist recommended that the physician discontinue Vitamin D 3 2000 units daily and change it to Vitamin D 3 50,000 units twice monthly due to frequent dosing increased medication costs and it also placed R1 at increased risk for adverse events (negative side effects). However, the NHA failed to provide documentation that the physician had reviewed and/or addressed this report. A review of R1's Consultation Report, dated 8/27/24 and unsigned, revealed the pharmacist recommended lab monitoring (a CBC, BMP, and Phenobarbital trough concentration) starting on the next lab day and then every six months because R1 had Phenobarbital (a medication for seizures) prescribed. However, the NHA failed to provide documentation that the physician had reviewed and/or addressed this report. A review of R1's Consultation Report, dated 1/31/25 and unsigned, revealed the pharmacist recommended that the physician discontinue Vitamin D 3 2000 units daily and change it to Vitamin D 3 50,000 units twice monthly. This was the same recommendation that the pharmacist made on 7/29/24. However, the NHA failed to provide documentation that the physician had reviewed and/or addressed this report. A review of R1's Consultation Report, dated 4/30/25 and unsigned, revealed the pharmacist made a Clinical Priority Recommendation. Prompt Response Requested recommendation that warfarin (Coumadin- a blood thinner) not be administered with R1's tube feeding formula. The pharmacist recommended administering the warfarin one hour before or two hours after R1's received the formula because of a possible interaction between the formula and the medication (the formula can interfere with the effectiveness of the warfarin due to chemical incompatibilities). However, the NHA failed to provide documentation that the physician had reviewed and/or addressed this report. A second review of R1's medical record, dated 7/29/24 to 6/13/25, failed to reveal any evidence that the physician had reviewed and/or addressed R1's pharmacy recommendations for 7/29/24, 8/27/24, and 1/31/25. However, R1's medical record did reveal a Nurse's Note, dated 5/28/25 (29 days after the recommendation was made), that the nurse spoke to MD C about R1's Coumadin and he discontinued it and started R1 on a different blood thinner. During an interview on 6/13/25 at 9:30 AM, copies of any documentation that the physician had reviewed and/or addressed R1's pharmacy recommendations for 7/29/24, 8/27/24, and 1/31/25 were requested from the Director of Nursing (DON) (2nd request- 1st was to the NHA). In addition, any documentation that the physician had been notified prior to 5/28/25 of the pharmacist's 4/30/25 recommendation regarding R1's Coumadin was requested from the DON. During a second interview on 6/13/25 at 10:10 AM, the DON stated they could not locate any documentation that R1's pharmacy recommendations for 7/29/24, 8/27/24, and 1/31/25 were addressed by the physician. She also stated they could not find any documentation that the physician had been notified prior to 5/28/25 of the pharmacy recommendation on 4/30/25. During a third interview on 6/13/25 at 10:50 AM, the DON stated she found R1's physician signed pharmacy consultation report for 7/29/24. She stated she found it in a soft file binder (not in R1's medical record) in her office that the previous DON had left there. The DON also stated she would continue looking to see if she can locate R1's signed Consultation Reports for 8/27/24 and 1/31/25 and/or documentation that the pharmacist's recommendations were reviewed and/or address by the physician. However, at the time of the completion of the survey and the survey team's exit from the facility, the facility failed to provide documentation that the physician had reviewed and/or addressed R1's pharmacy recommendations for 8/27/24 and 1/31/25. A review of R1's Consultation Report, dated 7/29/24 and signed by the physician on 8/1/24, revealed the physician accepted the recommendation to change R1's Vitamin D 3 2000 units per day to Vitamin D 3 50000 units twice monthly. A review of R1's Medication Administration Records (MAR's), dated 8/1/24 to 6/13/25, revealed R1's Vitamin D 3 (cholecalciferol) was never changed per the pharmacy recommendation on 7/29/24 and provider approval on 8/1/24. Therefore, R1 had received Vitamin D 3 2000 units daily, instead of Vitamin D 3 50,000 units twice monthly, for over ten months after the physician agreed to change the dosing. R17 #1 of 2 Review of the admission Record reflected R17 originally admitted to the facility 1/18/17 with pertinent diagnoses that included Gastro-Esophageal Reflux Disease (GERD). Review of the EMR for R17 reflected a pharmacy Medication Regimen Review (MRR) was conducted 10/29/24 and a recommendation report had been submitted to the facility for physician review. The pharmacy recommendation reflected Please consider 1. Taper omeprazole to 20 milligrams (mg) (orally every other day) x (for) 7 days then Trial DC (discontinue). The EMR did not reveal the recommendation report had been reviewed and responded to by the physician. On 6/12/25 at 5:13 PM an email request was sent to the Nursing Home Administrator (NHA) requesting the Pharmacy recommendation response. On 6/13/25 at 2:56 PM the MRR recommendation of 10/29/24 reflected a response signed and dated 11/28/24 that I accept the recommendation above, please implement as written. Review of the EMR Doctor's Orders Summary for R17 reflected the accepted pharmacy recommendation had not been implemented and R17 had received the Omeprazole daily since the start date of 4/22/24. On 6/13/25 at 3:09 PM the NHA and the Director of Nursing (DON) were asked to review the MRR recommendation of 10/29/24. At 3:20 PM the DON reported that the facility did not implement as written as directed by the physician and acknowledged R17 continued to receive the medication. #2 of 2 Review of the EMR for R17 reflected a pharmacy Medication Regimen Review (MRR) was conducted 4/30/25 and a recommendation report had been submitted to the facility for physician review. The pharmacy recommendation reflected BMP (basic metabolic panel) on the next lab day . The EMR did not reveal the recommendation report had been reviewed and responded to by the physician. On 6/12/25 at 5:13 PM an email request was sent to the Nursing Home Administrator (NHA) which asked for the physician response to the pharmacy recommendation of 4/30/25. On 6/13/25 at 3:20 PM the facility provided the response to the pharmacy recommendation of 4/30/25 not found in the EMR. The response reflected it has been signed by a Unit Manager on 5/8/25 but six days later, on 5/14/25, the physician had signed as I accept the recommendation(s), please implement as written. At the bottom of the page was an unsigned and undated note that the lab had been completed on 2/5/25. No documentation was found in the EMR that indicated the physician had noted this lab result from 3 months prior or if it was acceptable to negate the instruction of 5/14/25 to implement as written. On 6/13/25 at 3:23 PM an interview was conducted with MDS RN U who reported she did not know if the Dr. was aware of the lab 2/5/25. As of survey exit no additional information was provided.

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled in 1 of 3 medication carts (Yellow Neighborhood Medication Cart) and 1 of 2 medication rooms (Yellow Neighborhood Medication Room) inspected, potentially affecting 25 of 74 facility residents. Findings Include: During an observation on 06/12/25 at 11:10 AM, the Yellow Neighborhood Medication Cart was inspected Licensed Practical Nurse (LPN) F. The following observation and interview were made: - A box of Ketotifen fumarate ophthalmic solution labeled [Resident # 52's last name] 2-10-25 [R52's room number] was observed in the medication cart. However, the solution bottle in the box was not labeled with any information that would identify the resident who the bottle belonged to should it become separated from the box. Other single user bottles/vials in other boxes in the medication cart were all labeled with resident names and/or room numbers. - LPN F stated she did not know if the vials and/or bottles in boxes that were for single resident user should be labeled with their names or other information to identify who the medications belonged to or if it was acceptable to just label the outside boxes. During an observation on 06/12/25 at 03:15 PM, the Yellow Neighborhood Medication Room was inspected with Clinical Care Coordinator (CCC) E. The following observation and interview were made: - A box of Tuberculin Purified Protein Derivative (TB PPD) solution 5 TU/0.1 ml (5 tuberculin units per 0.1 milliliters) was labeled 6-5-25 (open date). However, the vial inside the box was not labeled with an open date. - CCC E stated she was not sure if vials or bottles in boxes in the medication carts should be labeled with resident names if they are single user medications. She stated they are definitely labeled if they are inhalers in boxes because that goes into the resident's mouth. - CCC E also stated, I don't label the TB vials [with the open date]. That could cause confusion, especially if the date on the vial inside the box is different than the date on the box. I only label the TB vial box. The surveyor asked CCC E if there were two open TB vial boxes and the vials were not labeled, how would she know which box the vial goes to if they fall out of their individual boxes and the dates on the boxes are different. She stated, That's a good question. I'll have to find out and get back to you. During a second interview on 06/12/25 at 03:45 PM, CCC E stated, You learn something new every day. She stated she found out that the individual TB vials should be labeled with an open date in addition to the box being labeled. During an interview on 06/13/25 at 04:00 PM, Registered Nurse (RN) B stated the vials/bottles in boxes in the medication carts should be labeled with the residents' names in case they get separated from the boxes. She also stated that TB vials in the medication rooms should also be labeled with the open date in case they become separated from the boxes.

Based on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify and address issues and develop/implement appropriate plans of action in regard to 1) call light response time and care, 2) Grievances 3) MDS (minimum data set) late submissions and incorrect coding 4) antibiotic stewardship and infection control, 5) complete and accurate medical records, 6) available/updated policies and procedures annually reviewed, 7) and monitor nursing staff for compliance with nursing standards of practice. This deficient practice has the potential to affect all 74 residents who reside at the facility. Findings include: During an interview on 6/13/24 at 11:47 AM, The Nursing Home Administrator (NHA) was asked about her QAPI program and reported they have monthly QA meetings and are all learning together. The NHA reported she had access to the MDS (Minimum Data Set) Quality indicator report and will discuss them with the team. The NHA reported the report did not make sense when she first started a few months ago because it was not accurately reflecting the residents. The past Director of Nursing was not documenting things correctly and made the quality indicators look better than what they were. The NHA acknowledged the facility was just previously cited for infection control and complete and accurate medical records and aware we still had concerns about these issues and as follows: Call lights- When questioned about the concerns of call light response times and the needs of the residents being met per interviews of residents and review of call light timing data, and resident council minute concerns for 4/24/25 and 5/29/25 regarding call light timing and being turned off before the resident needs are met, the NHA reported this concern was identified and no ad hoc meeting was done yet. The NHA reported she gave this task to the Admissions person to have ownership, but they did not make it to the meeting and no follow up was done. Grievances- The NHA reported the Activities Director is supposed to bring resident grievances from the Resident Council Meetings to the IDT (interdisciplinary team) meetings. The NHA reported she reviewed the Resident Council Meeting minutes 6/12/25 (the day before this interview) and told the Activities Director she needed to add the resident grievances to the book and get them all onto forms. The NHA reported her Resident Council minutes were terrible, but she was a great activities person. The NHA reported once any grievance is addressed and completed by the designated department, she will get a copy of it to show it was completed. MDS (Minimum Data Set) late submissions- The NHA reported they were just starting a new admissions process and the MDS staff are involved but it is still in its planning stage. Did not address the late submissions. The NHA was informed of incorrect MDS coding at this time. Antibiotic Stewardship- The NHA reported the Infection Control Preventionist did not compare the Infection Control Pathway to the facility policy. The NHA reported she reached out to Corporate to help educate her more. Medical records- When queried about skin assessments not in an orderly manner, the NHA reported their current system is a definite improvement. They acknowledged a need for a Performance Improvement Plan (PIP) on 3/4/25 when the concern was identified and started the PIP in April. The NHA reported the Blue Unit is difficult to manage because of the rehab admissions and discharge turnover but they just got a new manager. The NHA reported they identified back in April about the Certified Nursing Assistants (CNA's) not having access to chart their tasks and corrected that by May. The NHA was informed that the CNA's were still not documenting appropriately in the EMR. Regarding the Pharmacy Medication Review, Consultation notes, Practitioner notes, laboratory/diagnostic records, and complete and accurate medical records to reflect the residents care lacking in the EMR, the NHA reported she talked to the staff and felt everyone was just focusing on the skin assessments. The NHA acknowledged some things would get uploaded to the EMR before the doctors and nurses could review them and nursing is now taking longer to get information into the medical records. There were several policies and procedures either not available, from the previous owners, not updated or annually reviewed by the facility as follows: Admissions, transfers and discharges. Infection Control Incontinence Care/Bowel and Bladder Care Skin/Wound Management Antibiotic Stewardship Water Management policy was from the previous owners and last reviewed 7/6/2020. Falls Management policy last reviewed/revised August 2021. Oxygen Administration policy last reviewed 1/2023. Care Plans- Form provided but does not indicate a policy and procedure. MDS policy dated 12/11/2015. The NHA did not have an answer to the lack of policies and procedures and reported they will sometimes use the same ones the hospital has. The QAPI Plan and Policy was requested during the entrance conference. The facility provided a blank plan and no additional details during the discussion of the concerns during the interview.

Based on interview and record review, the facility failed to have the required attendance of a Medical Director, or a designated physician at the facility's Quality Assessment/Improvement (QAPI) meetings at least quarterly resulting in the potential for lack of oversight of the quality assurance process and coordination of medical care that could impact 74 of 74 residents residing within the facility. Findings include: Review of the QAPI monthly sign in sheets from 6/2024 to 6/2025 revealed the Medical Director or designated physician was in attendance on 6/12/24, 8/5/24, and 4/9/25. This leaves 8 months with no physician representation for the QAPI meetings. In an interview on 6/13/25 at 3:25 PM, the Nursing Home Administrator (NHA) reported the facility has monthly QAPI meetings and has not had their meeting for June 2025 yet. The NHA did not have an answer to why there was no Medical Director present at least quarterly to the meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two Deficient Practice Statements (DPS) DPS #1 Based on interview and record review, the facility failed to ensure an annual review was completed of the Infection Control policy and procedures to verify adherence to current national standards of care. Findings: Review of the Infection Control Policy and program provided by the facility did not reflect if or when a review had been conducted to ensure the policy and program met current standards of care. On 6/11/25 at 1:04 PM. during the Infection Control task, an interview was conducted with Infection Preventionist (IP) L. IP L was asked to provide documentation the facility Infection Prevention policy and program was reviewed annually. IP L indicated this information would be provided. On 6/13/25 at 9:54 AM an interview was conducted with the Director of Nursing (DON). The DON was informed that the Infection Control policy provided by the facility did not indicate when the policy had been implemented or reviewed. The DON was informed IP L had yet to provide verification of an annual review. The DON indicated this data is usually documented on the first page of the policy but if this review verification was available, it would be provided by survey exit. As of survey exit no documentation was provided by the facility that verified an annual review of the Infection Control policy had been conducted. DPS #2 Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During an interview with Environmental Services Director (ESD) [NAME], at 12:54 PM on 06/11/25, it was found that an annual review of the Water Management Plan had not taken place. Further interview found that ESD was unsure of the current members of the interdisciplinary water management team or when the last review of the water management plan had taken place. A record review of the facility policy entitled Water Management Policy Version 7.0 last reviewed [DATE], was found to be developed and maintained by the previous owners with no updated policy for the facility currently owned and operated under [NAME] Health Senior Communities.

Based on interview and record review, the facility failed to formulate and implement an effective antibiotic stewardship program with written protocols for antibiotic use, documentation, and a monitoring system to provide feedback and ensure adherence to the antibiotic stewardship program. Findings: Review of the undated Infection Control policy provided by the facility contained a section titled Antibiotic Stewardship. This section included information on what components may be included as part of an antibiotic stewardship program. However, the description of the facility's program did not consist of written antibiotic use protocols, a protocol when a resident is admitted to the facility while on antibiotic therapy, necessary documentation surrounding antibiotic use, or include a description of a system to provide feedback to the prescribing medical practitioner. On 6/11/25 at 1:04 PM an interview and record review were conducted with Infection Preventionist (IP) L. IP L described a process identifying an infection through signs and symptoms, initial treatment measures and reporting to the medical provider. IP L reported obtaining labs, lab results and why and when antibiotic therapy would be initiated. IP L reported if antibiotic therapy was to be imitated prior to having laboratory results both nursing and the medical provider would document in the medical record. R26 Review of the Electronic Medical Record (EMR) reflected R26 admitted to the facility 5/19/25 with diagnoses that included a fracture and a history of repeated falls. The medical record reflected R26 had a urinary catheter that had been inserted during admission. Review of the EMR Progress Notes for R26 reflected a Nurses Note dated 6/2/25 at 5:42 PM of urine with increased cloudiness, sediment . and foul smelling. The entry reflected a lab specimen was obtained and transported to the lab for testing. Review of the laboratory urinalysis report dated 6/2/25 reflected an elevated white blood cell count (one of the signs of an infection). The EMR Progress Notes reflected a Nurses Note dated of 6/3/25 at 12:43 PM that the Lab had been called and the specimen was going to culture. The EMR Progress Note of 6/3/25 at 3:57 PM reflected The system has identified a possible drug allergy for the following order Cephalexin Capsule 500 mg (milligram) (an antibiotic) Give 1 capsule by mouth three times a day for UTI (urinary tract infection) for 7 days. This indicated an order to start an antibiotic had been received but the EMR did not reflect documentation the physician had been notified. The EMR did not reflect any documented justification for the initiation of antibiotic therapy pending culture results. Review of the EMR Progress Note entry on 6/3/25 at 4:50 PM reflected documentation that This order is outside of the recommended dose or frequency, Macrobid Oral Capsule 100 mg (an antibiotic) give 1 capsule by mouth every morning and at bedtime for UTI for 5 days . This drug's dose should be adjusted based on renal function. Manual screening is required. Review of the EMR did not reveal any documentation to explain the entries of two different antibiotics for UTI or that renal function was considered as part of the antibiotic therapy. Lab results for the urinalysis were identified but no culture results were found in the EMR as of 6/11/25. No documentation was found that indicated the medical provider had been contacted or that the medical provider had commented on the course of treatment. The: Miscellaneous (misc) section of the EMR reflected the last medical provider encounter occurred on 5/30/25 prior to the UTI. The EMR did not reflect a Care Plan for an active UTI or that antibiotic therapy had been initiated. Review of the EMR did not reflect another entry regarding antibiotic therapy from 6/3/25 until 6/6/25. However, on 6/6/25 at 4:45 PM there was a repeat entry that The system has identified a possible drug allergy . to the Cephalexin Oral tablet. Upon request the facility provided a timeline of R2's UTI identification and treatment to clarify information present and not identified in the EMR. IP L provided the following information: (R26) UTI Timeline 6/2/25 Resident voiced concern for UTI. Sediment noted in Foley Catheter with Urine foul odor 6/2/25 UA collected and sent to lab. 6/3/25 UA + (positive) Resident started on Macrobid 100 mg (twice daily) (times) 5 days pending culture results. 6/6/25 UA culture results sent to facility. Culture (positive) for . Physician notified and antibiotic changed to Keflex . End of timeline. On 6/12/25 at 11:35 AM the Nursing Home Administrator (NHA) and IP L were interviewed regarding the Antibiotic Stewardship Program and EMR documentation. The NHA reported the description of the facility Antibiotic Stewardship Program provided was the correct policy. The NHA reported that the physician does not document in the facility EMR. The NHA reported the physician uses a system that does not communicate with the facility EMR. IP L also acknowledged the physician does not document in the facility EMR and reported a request was submitted to the physician for the notes on R26. As of survey exit neither the NHA nor IP L provided any additional information that indicated the antibiotic therapy provided R26 was consistent with an antibiotic stewardship program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is related to MI00152071. Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 11 residents reviewed (R7). Findings include: A review of R7's admission Record, dated 4/18/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included an infection of the left knee prosthesis. A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/11/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R7 was cognitively intact. During an interview on 4/17/25 at 10:45 a.m., R7 stated they were sent to the hospital via ambulance the morning of 1/11/25 because the night nurse had left their PICC line (peripherally inserted central catheter- a line inserted into a peripheral site (usually the upper arm) and extends into a large vein that leads into the heart) uncapped (i.e., no cap on the end of the line to prevent bacteria and other contaminants from entering the line and contaminating it) all night long. R7 stated they had to have a new PICC line put in and they spent four days in the hospital receiving antibiotics. A review of R7's Nurse's Notes, a late entry dated 1/12/25 for 1/11/25, revealed, Patient (R7) transported to [name of hospital] at 12:00 pm via partner. Patient cleaned out room of patients belongings stating patient would never be returning to [initials of facility]. Patient not agreeable to filling out leaving AMA (against medical advice) paperwork. Patient not sent with medications due to being transferred out to hospital as status . A further review of R7's medical record failed to reveal the reason for R7's transfer to the hospital. In addition, R7's medical record failed to reveal whether they were transported via private vehicle (which could be inferred from R7's Nurse's Note where it indicated R7 transported to hospital via partner and Patient not agreeable to filling out leaving AMA paperwork) or via ambulance (which could be inferred from R7's Nurse's Note where it indicated R7 not sent with medications due to being transferred out to hospital as status and would suggest a facility to hospital transfer via ambulance). R7's medical record also failed to reveal whether any transfer paperwork was filled out and/or sent with R7 to the hospital. During an interview with the Nursing Home Administrator (NHA) on 4/17/25 at 2:00 p.m., the NHA was informed that the surveyor could not locate any information on the reason why R7 had been transferred to the hospital on 1/11/25. The NHA stated they would see if they could locate any additional documentation that would explain the reason why R7 went to the hospital on 1/11/25. The NHA stated they would provide copies of any documentation that they could locate to the surveyor. During a second interview with R7 on 4/18/25, they confirmed that the facility called an ambulance for them to go to the hospital on 1/11/25 and their partner did not drive them. R7 stated the facility sent a large envelope with papers inside (transfer paperwork?) with them to the hospital. A review of the Emergency Department Report, dated 1/12/25, revealed R7 arrived in the emergency department (ED) on 1/11/25 for a vascular access problem (a problem with their PICC line). R7 had been administered an antibiotic (cefepime) during the night through a right upper arm PICC line and when staff went to administer another antibiotic (vancomycin) that morning they noticed that the cap was missing. During a second interview on 4/18/25 at 4:00 p.m., the NHA stated R7 did go by ambulance to the hospital. The NHA also verified that the Nurse's Note, dated 1/12/25 for 1/11/25, did not indicate why R7 went to the hospital and was it confusing as to how they went. The NHA stated that they would expect to see a reason for R7 leaving, even if it was AMA. They stated since R7 arrived by ambulance to the hospital, they would have expected the nurse to fill out paperwork for a transfer and indicate the reason for the transfer. The NHA also verified that there was not any transfer paperwork in R7's medical record. They stated even if R7 had personally called the ambulance to go to the hospital they would still have expected the nurse to have documented the reason why R7 was leaving, what they did to try and convince R7 to wait or stay until they could notify the physician/provider, and that they called the physician provider to let them know R7 wanted to leave the facility. The NHA stated from the facility's end, it looked like R7 went to the hospital without a documented reason. The NHA stated because all they had was the Emergency Department Report (which they confirmed had not been in R7's medical record), they could only conclude that R7 went to the hospital because the PICC line was not capped for an extended period of time. The NHA stated they cannot prove otherwise.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is related to MI00152071. Based on interview and record review, the facility failed to maintain appropriate infection control practices for 1 of 11 residents reviewed (R7) and for 1 of 3 facility units (Blue Neighborhood), potentially affecting 18 of 70 residents. Findings include: R7 A review of R7's admission Record, dated 4/18/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included an infection of the left knee prosthesis. A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/11/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R7 was cognitively intact. During an interview on 4/17/25 at 10:45 a.m., R7 stated they were sent to the hospital via ambulance the morning of 1/11/25 because the night nurse had left their PICC line uncapped (i.e., no cap on the end of the line to prevent bacteria and other contaminants from entering the line and contaminating it) all night long. R7 stated they had to have a new PICC line put in and they spent four days in the hospital receiving antibiotics. A review of R7's Nurse's Notes, a late entry dated 1/12/25 for 1/11/25, revealed, Patient (R7) transported to [name of hospital] at 12:00 pm via partner . [Name of hospital] called at 6:00 pm with update, patient is being admitted to hospital for new PICC line (peripherally inserted central catheter- a line inserted into a peripheral site (usually the upper arm) and extends into a large vein that leads into the heart), new antibiotics and new treatment for knee. Manager on call and DON (Director of Nursing) notified . During an interview with the Nursing Home Administrator (NHA) on 4/17/25 at 2:00 p.m., the NHA was informed that the surveyor could not locate any information on the reason why R7 had been transferred to the hospital on 1/11/25. The NHA stated they would see if they could locate any additional documentation that would explain the reason why R7 went to the hospital on 1/11/25. The NHA stated they would provide copies of any documentation that they could locate to the surveyor. A review of the Emergency Department Report, dated 1/12/25, revealed R7 arrived in the emergency department (ED) on 1/11/25 for a vascular access problem (a problem with their PICC line). R7 had been administered an antibiotic (cefepime) during the night through a right upper arm PICC line and when staff went to administer another antibiotic (vancomycin) that morning they noticed that the cap was missing. R7 was unable to tell the ED staff how long the cap had been off the PICC line, but estimated it was around 10 hours. R7 did not have any systemic symptoms (e.g., fever, chills, sweats) or local symptoms (e.g., erythema streaking (red streaks on the skin) or swelling). The PICC line was removed and replaced with a new one in the emergency department. During a second interview on 4/18/25 at 4:00 p.m., the NHA stated R7's Nurse's Note, dated 1/12/25 for 1/11/25, did not indicate why R7 went to the hospital. The NHA stated that they would expect that the nurse would have documented the reason why R7 was transferred to the hospital. The NHA stated because they did not have any documentation in R7's medical record as to the reason for their transfer to the hospital and all they had was the Emergency Department Report (which they confirmed had not been in R7's medical record), they could only conclude that R7 went to the hospital because the PICC line was not capped for an extended period of time. A review of the Mayo Clinic's Peripherally inserted central catheter (PICC) line article, dated 6/6/23, revealed, A PICC line requires careful care and monitoring for complications, including infection and blood clots . PICC line complications can include: bleeding . blood clots, infection . A cap is placed over the end of the catheter to keep it free of germs and prevent infection Blue Neighborhood A review of a sign on the double doors leading onto the Blue Neighborhood unit revealed, As of 4/10/2025 Blue surgical masks are REQUIRED for staff. N95 masks are recommended when visiting residents with COVID+ Please assist with protecting the residents! During an observation on 4/23/25 at 1:25 p.m., Certified Nursing Assistant (CNA) V was observed at the nurse's station (which was centrally located on the unit) wearing a blue surgical mask that was positioned below their nose. CNA V spoke with the surveyor for approximately five minutes and continued to wear their mask below their nose. During an observation on 4/23/25 at 1:50 p.m., CNA V was observed walking down the hall on the Blue Neighborhood unit with Housekeeper (HSK) W. CNA V was observed wearing a blue surgical mask that was positioned below their nose. HSK W was observed not wearing a surgical mask or an N95 respirator (mask). During an interview on 4/23/25 at 3:35 p.m., the Director of Nursing (DON) stated the facility had one resident left in the facility with COVID on the Blue Neighborhood unit. The DON stated all staff are required to wear surgical masks on the Blue Neighborhood unit. A review of the Centers for Disease Control and Prevention (CDC) Transmission-Based Precautions information page, dated 4/3/24, revealed, Use Droplets Precautions for patients (residents) known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking . Use personal protective equipment (PPE) appropriately. [NAME] mask upon entry into the patient room or patient space . (https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html) A review of the CDC's Use of Personal Protective Equipment (PPE) When Caring for Patients with Conformed or Suspected COVID-19 education poster, dated 6/3/20, revealed, Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. (http://www.cdc.gov/coronavirus)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to accurately assess, monitor and treat wounds for 3 Residents (R1, R2 and R3) of 3 residents reviewed for wound care. Findings included: Review of R1's face sheet dated 2/12/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: encounter for other orthopedic aftercare, infection of amputation stump, osteomyelitis, muscle weakness, need of assistance with personal care and obesity. R1 was his own responsible party. Review of R1's Skin assessment dated [DATE] revealed that he and a left knee surgical incision. (no description). Review of R1's orders revealed, 1/4/25, reinforce dressing if staining, if saturation noted please contact ortho (orthopedic) PA (physician assistant). Do not remove dress for any reason unless discussed with ortho PA. Review of R1's surgical note dated 1/8/25 Revealed, He states that he is doing okay, patient says they are using a sit to stand at his nursing home, patient says the sit to stand pinched his amputation twice now and he says it causes a lot of pain. Impression infected left lower extremity BKA (below the knee amputation). I have recommended return to the hospital operative debridement and VAC placement probably doing that serially for some time until we get his joint stable wound stabilized again. Review of R1's orders revealed no wound care orders in place when he returned from the hospital on 1/22/25. Review of R1's orders revealed, 1/30/25 Wound Vac (vacuum) to be changed 3 times a week every Tuesday, Thursday and Saturday. Cleanse area with saline and change wound vac dressing. Review of R1's Treatment Administration Recorded (TAR) for January 2025 revealed. LBKA (left below the knee amputation) - wet to dry dressing, saline soaked gauze, covered with ABD (type of dressing) pad and secured with ACE wrap, xeroform to open areas on anterior shine, changed daily (D/C when wound vac applied). Every day shift for wound. Start date 1/23/25 at 7:15 D/C date 1/25/2025 at 10:31. The box for 1/23/25 was completed as done, the box for 1/26/25 was marked (6) for hospitalized and the box for 1/26/25 was blank indicating the treatment was not done. Review of R1's TAR for January 2025 revealed LBKA (left below the knee amputation) wet to dry dressing, saline soaked gauze, covered with ABD pad and secured with ACE wrap, xeroform to open areas on anterior shin, change daily (D/C (discontinued) when wound vac applied). At bedtime for Wound. Start date 1/25/25 at 19:00 and D/C (discontinued) on 1/31/2025 at 00:18. Treatments were documented as completed 1/25 to 1/29/25. 1/30/25 was marked as 5 for see nurses notes. Review of R1's medical record from 1/22/25 to 1/30/25 revealed no facility assessments of R1's surgical wound on his left below the knee amputation. Review of R1's nursing progress notes for 1/30/25 revealed no indication of any treatment of R1's wound (as indicated documented in notes on MAR for this date) on his left below the knee surgical incision. Review of R1's electronic medical record revealed no description of R1's surgical wounds were completed when dressing was changed. Review of a Report of consultation for R1 dated 1/29/25 revealed, Large wound hematoma that was closed over top with an ABD and 2-inch ACE wrap. Hematoma debridement and wound packed. Patient has not had ordered vac dressing for a week with no communication indicating such. Please investigate and apply ordered vac dressing. At least pack wound with wet to dry (unreadable word) 2 weeks. Review of R1's surgical services note dated 2/13/25 revealed, Significant improvement in wound over the last couple of weeks. Continue with his wound VAC. Recheck with him in about 4 weeks. R1 was observed in bed on 2/12/25 at 9:16 AM. R1 was not clear on the timeline of events since his admission to the facility on 1/4/25 but did recall getting his leg stump pinched in a stand-up lift prior to 1/8/25. R1 was readmitted to the hospital on [DATE] because the surgical wound on his left leg opened and was infected. R1 had a wound vacuum and dressing over the end of his stump (below the knee amputation) on his left leg. During an interview with the Director of Nursing (DON) on 2/12/25 at 9:27 AM the DON confirmed she was aware of problems with R1's wound care and the facility had started an investigation. A request for the full investigation and all documents relating to R1's wound care was requested. On 2/12/25 at 3:45 PM another request for all R1's wound care and investigation into wound care issues was requested. During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 2/13/25 at 3:15 PM. They reported they were ready to review wound documentation for R1. They did not have a timeline or all documentation of wound care available. They did not have an investigation into his wound care issues. They denied any knowledge or documentation of R1 having an injury involving his stump when standing in a stand-up lift. They did not have any description of the initial wound or assessments completed by facility staff. They did have documentation from the surgeon that documented the wound was open an infected on 1/8/25 (4 days after his admission to the facility) and suffering injury in a stand-up lift 2 times prior to that appointment, he was in the hospital from [DATE] to 1/22/25. No description of the surgical wound on 1/22/25 when R1 returned to the facility. R1 returned to the surgeon on 1/29/25 and the facility received documentation that they were not following wound care orders, and the physician wanted the lack of wound care investigated. The facility did not provide any documentation of any investigation. The facility received orders to start a wound vacuum on 1/30/25 and it was to be changed on the day shift on Tuesday, Thursday and Saturday. R1's Treatment Administration Record Revealed that the wound vacuum was not placed until 2/4/25 and was not changed as ordered on 2/8/25. The DON and NHA said they were in the process of investigating R1's lack of wound documentation and working on why orders were not sent from the hospital for wound care on 1/4/25 or on 1/22/25, treatment and addressing the wound care issues were still in the process of investigation. R1 did go to the surgeon's office on 2/13/25 and the facility provided documentation that the wound was healing, and they were to continue with the wound vacuum and changing the wound vacuum 3 x a week. Upon exit, the facility did not provide any investigation into R1's wound care not being treated as ordered by the surgeon or any wound measurements or assessments completed by facility staff. During an interview with the Director of Nursing DON, Nursing Home Administrator (NHA) and Corporate Nurse (CN) J on 2/13/ 24 at 3:45 PM, they said they did not have any policy or set expectations for nurses to document and assess wounds or surgical wounds. CN J said when they do not have a policy, they use [NAME] (name of nursing procedure book). CN J. Printed the Surgical wound dressing application of [NAME] and gave it to this Surveyor stating that it did not cover any assessment requirements or details on assessment of surgical wounds. Review of that document on, page 10 revealed: Documentation associated with surgical wound dressing applications includes: date and time of the procedure, type of wound dressing procedure, amount of soiled dressing, any packing removed, wound appearance (size, condition of margins, presence of necrotic tissue, wound odor, type color consistency and amount of drainage (for each wound) include drainage on intake and output record, presence and location of drains, additional procedures performed irrigation, packing application of topical medication, type and amount of new dressing or pouch applied, any allergic reactions, date and time of practitioner notification, name of practitioner notification, name of practitioner notified, prescribed interventions. Response to those interventions, tolerance to procedure, detailed wound care instructions, detailed pain management steps, teaching provided to the patient and family. R2 Review of R2's face sheet dated, 2/12/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Multiple Sclerosis, osteomyelitis of vertebra, sacral and sacrococcygeal region, muscle weakness, and muscle spasm. R2 was her own responsible party. R2 was observed to have a dressing change on her coccyx on 2/12/25 at 10:30 AM by Registered Nurse (RN) F. R2's dressing did not have a date or any information on it that indicated when it was last changed. RN F did not measure the wound. RN F reported that she had changed R2's dressing multiple times and it was healing. RN F did not know where to locate wound measurements or documentation that would indicate the wound was healing or declining. During an interview with R2 on 2/13/25 at 11:15 AM, R2 was asked if the facility always the dressings and medication had needed to treat her coccyx wound and she said she did. When questioned why the facility was documenting they were not always doing the treatments R2 said she wants the treatments done between 10:00 and 11:00 AM and 10:00 PM and midnight so that her muscle spasm medication would be working. R2 said because of staffing the facility can not always keep these times and she does refuse when they can not stay on the schedule. Review of R2's Treatment Administration Record (TAR) for February 2025 revealed, coccyx wound care: Pack wound with Dakins ¼ strength solution soaked kerlix, cove with ABD pad and tape. Every shift for wound care. Start date 12/6/24 and D/C (discontinue) 2/9/25. The number 2 was marked in the following boxes 2/1/25 day shift, 2/3/25 night shift, 2/4/25 night shift, 2/5/25 day shift, 2/7/25 night shift. Number 2 in a box indicated drug refused. Review of R2's medical record revealed no wound measurements being performed. During an interview with the DON and NHA on 2/13/25 at 3:15 PM the DON provided a timeline of R2's coccyx wound. The only wound measurement on the timeline was completed on 11/20/24 when the wound was noted to be a pressure ulcer it was 2 x 2 x 0.2. The timeline revealed R2 had surgery and returned from the hospital on [DATE] and the coccyx wound was now considered a surgical wound. The DON said pressure ulcers are followed weekly by a wound service, but they did not have any system in place to measure and monitor surgical wounds. The DON was not able to locate any facility assessments of R2's surgical wound since she returned from the hospital on [DATE]. The timeline revealed that R2 returned to the wound clinic on 2/3/25 and shows we are doing a great job of keeping the wound clean and dry. The timeline indicated the resident was refusing care. The DON said the #2 on the TAR's were due to the resident refusing care. The DON said she was not aware of R2's requested times for care and did not have any documentation to show why R2 had been refusing care. The DON said she would follow up with R2 for preferred treatment times. The DON said they are working on a process to document and assess wounds. R3 Review of R3's face sheet dated, 2/13/25 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Alzheimer's disease and urinary infection. She was not her own responsible party. R3 was observed to have a dressing on her right elbow on 2/12/25 at 8:55 AM. No date on the dressing. R3 was not aware of what happened to her elbow or when the dressing was placed. Review of R3's admission skin assessment dated [DATE] at 9:36 AM revealed, Abrasion to right elbow knees. Bruise to left hand. No size or description of any of these abnormal findings. Review of R3's comprehensive skin assessment dated [DATE] at 9:28 AM revealed, scattered bruising on RUE (right upper extremity), bilateral knees have open areas, open area on left elbow and bilateral heels soft. No description of size, color or drainage. On 2/13/25 at 2:36 PM, R3 was observed to have a dressing on her right elbow with no date and a dime size scab on her right knee and a quarter size scab on her left knee. Both scabbed areas were red on the boarder around the scabs. Certified Nurse Aide (CNA) K said she knew R3 was new to the facility. CNA K did not report the scabbed area's being red around the boarder and was not aware of when R3 would get the dressing changed on her right elbow. During an interview with Licensed Practical Nurse (LPN) L on 2/13/25 at 2:45 PM, LPN L did not know anything about R3's dressing on her right elbow or wounds on her knees. LPN L reviewed R3 orders and did not find any wound dressing orders. During an interview with Unit Manager (UM) M on 2/13/25 at 2:50 PM, UM M said R3 was admitted with the wound on her right elbow and both knees. UM M said the dressing was placed on R3's elbow after her shower yesterday and they have standing orders to do wound care. UM M said yesterday the scabbed areas on R3's knees were not red around the boarders, and she would need to review the standing orders to determine what treatment to use. UM M confirmed that the wound on the right elbow was open yesterday and removed the dressing on R3's right elbow at this time and the dressing was soiled showing it remained open it was approximately 1.5 inches long and ½ inch wide. UM M confirmed she did not implement any standing orders or treatment for R3's wound after she saw them on 2/12/25. UM M was not aware of any assessment process or record for recording the size or description of resident wounds. During an interview with the DON and NHA on 2/13/25 at 3:45 PM, they reviewed R3's medical record and confirmed that there was no description of R3's wounds on her right elbow or knees. They were able to locate an order that was placed on 2/13/25 at 15:03 (3:03 PM) for R3, Wound to right elbow: Cleanse with normal saline, pat dry. Apply xeroform gauze and bordered gauze. No wound measurements or description was located. No orders or description of the wounds on R3's knees were located.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00147647. Based on interview and record review, the facility failed to report an allegation of abuse timely for 1 resident (Resident #101), of 3 residents reviewed for abuse. Findings include: Review of an admission Record revealed Resident #101 (R101) admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety. Review of R101's Facility Reported Incident (FRI) Investigation Report, MI-FRI #00057977, revealed R101's allegation of abuse was discovered on 10/10/2024 at 12:30 PM, the Nursing Home Administrator (NHA) was notified of the allegation on 10/10/2024 at 3:41 PM, and the incident was reported to the State of Michigan on 10/10/2024 at 9:54 PM. In an interview on 10/28/2024 at 1:28 PM, Regional Nurse Consultant C reported she was assisting at the facility on 10/10/2024. Regional Nurse Consultant C reported R101 told the facility Nurse Practitioner at approximately 11:30 AM on 10/10/2024 that he had been assaulted by staff the previous day. Regional Nurse Consultant C reported the NHA was notified of this allegation of abuse in the afternoon. Regional Nurse Consultant C reported both the NHA and Director of Nursing (DON) were away from the facility on 10/10/2024. Review of R101's Nurse Practitioner note, dated 10/10/2024 at 2:48 PM, revealed R101 reported two staff members had assaulted him the previous day. In a telephone interview on 10/28/2024 at 3:15 PM, Former NHA A reported she was notified of R101's allegation of physical abuse the afternoon of 10/10/2024 but was unable to report this to the State of Michigan in the 2-hour required timeframe because of extenuating personal circumstances that required her to be away from the facility. In an interview on 10/28/2024 at 12:30 PM, the Interim NHA reported R101's allegation of abuse the afternoon of 10/10/2024 was not reported to the State of Michigan until almost 10:00 PM that evening, outside the required 2-hour time frame. Review of facility policy/procedure Abuse, Neglect, and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition, revised August of 2022, revealed .Reporting . Incidents and/or alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator/designee . table . When . All alleged violations-Immediately but not later than . 2 hours if the alleged violation involves abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely care for two residents (Resident #1 and Resident #53) of three residents reviewed, who are dependent on staff to meet their needs. Findings include: Resident #1(R1): Review of an admission Record revealed R1 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of quadriplegic cerebral palsy and difficulty speaking. Review of a Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 indicating R1 was cognitively intact despite not always being able to communicate her needs. R1 was completely dependent on staff for Activities of Daily Living (ADL) such as bathing, going to the bathroom, getting dressed, and eating. During an observation on 06/25/24 at 7:24 AM, the call light monitoring system showed that the call light in R1's room had been activated at 6:57 AM and remained on. During an interview on 06/25/24 at 7:28 AM, R1's call light remained on and she laid in bed and answered the following questions: yes she is waiting for help, yes she is wet, no she did not get changed during the night last night, yes it usually takes a long time for someone to answer her call light, no staff did not reposition her during the night last night, and yes this surveyor could wait with her until staff came to answer the call light. Staff entered R1's room to offer assistance at 8:00 AM, 1 hour and 3 minutes after R1 activated the call light system. Review of Care Plans for R1 revealed the following staff interventions that R1 required to meet her highest practicable physical and psychological well being: (1) Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance, (2) anticipate and meet my needs, (3) keep skin clean and dry, (4) I sometimes cannot fully form words, but I grunt when I want to make something known. I also can nod my head to yes and no questions, or say yes or no, (5) promote my comfort, and (6) I require 1 person for toileting needs including brief changes and using a bed pan. Review of a Braden Score for Predicting Pressure Sore Risk for R1 dated 06/24/24, revealed R1 was at High Risk for skin breakdown. Resident #53 (R53): Review of an admission Record revealed R53 was an [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of recent surgery to the right knee for an infected total knee replacement. During an observation on 06/26/24 at 7:10 AM, the call light monitoring system showed that the call light in R53's room had been activated at 6:41 AM and remained on. During an interview on 06/26/24 at 7:15 AM, R53's call light remained on and she laid in bed and stated the following: I am soaked, I need to be changed. When asked if she had been changed during the night she stated no. While waiting with this resident she stated I don't think there is anyone to help me. Staff entered the room to assist R53 at 7:44 AM. R53 stated the bed is soaked. While assisting R53, the aide placed a blanket over the large urine soaked spot on R53's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1.) Provide care following professional standards of practice and facility policy to prevent the development of an avoidable pressure injury and 2.) Promptly notify the family/emergency contact and provider of a newly-identified pressure injury for one resident (Resident #10) out of 6 residents reviewed for alterations in skin integrity/pressure injuries, resulting in the development of a pressure injury and a delay in treatment. Findings include: Resident #10 (R10): Review of an admission Record revealed R10 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Review of a Minimum Data Set (MDS) assessment for R10, with a reference date of 3/14/24 revealed in Section C-Cognitive Patterns that R10 was severely cognitively impaired. Review of Section M-Skin Conditions revealed R10 did not have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. R10 was identified as at risk of developing pressure ulcers/injuries. Review of R10's Functional Abilities and Goals dated 6/15/24 revealed that R10 was dependent on staff for bathing, dressing, toileting, and mobility. Review of R10's Braden Scale for Predicting Pressure Sore Risk dated 6/8/24 revealed a score of 12-high risk for the development of a pressure injury. Review of R10's Skin Care Plan last revised 4/22/20 revealed, The resident is at risk for alteration of skin integrity .Encourage &/or assist with repositioning as resident will allow Date Initiated: 04/15/2021. Review of R10's Care Plans did not include a repositioning schedule, pressure offloading devices, or any pressure injuries/skin breakdown remedies. During an observation on 06/24/24 at 09:34 AM, R10 was up in a Broda chair in front of the television in a communal area, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. During an observation on 06/24/24 at 11:50 AM, R10 was up in a Broda chair at the dining room table, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. During an observation on 06/24/24 at 01:47 PM, R10 was up in a Broda chair in her room, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. During an observation on 06/24/24 at 03:51 PM, R10 was up in a Broda chair in her room, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. During an observation on 06/25/24 at 07:24 AM, R10 was up in a Broda chair in the doorway of her room, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. During an observation on 06/25/24 at 08:02 AM, R10 was up in a Broda chair in the doorway of her room, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. During an observation on 06/25/24 at 08:56 AM, R10 was up in a Broda chair at the dining room table, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. During an observation on 06/25/24 at 09:31 AM, R10 was up in a Broda chair in front of the television in a communal area, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. During an observation on 06/25/24 at 11:00 AM, R10 was up in a Broda chair in front of the television in a communal area, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. During an observation on 06/25/24 at 12:19 PM, R10 was up in a Broda chair at the dining room table and staff were assisting her with eating, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. During an observation and interview on 06/25/24 at 03:14 PM, R10 was up in a Broda chair in her room, her head was tilted slightly towards the right, there were no offloading devices in place, and her feet/heels were resting directly on the footrest. Certified Nursing Assistant (CNA) R reported that R10 prefers to stay up in her Broda/geri chair most of the time. CNA R reported R10 was not care planned for scheduled repositioning (every 2 hours) or for limited time up in her chair. Review of R10's Skin Assessment, dated 6/10/24, revealed that R10's skin was intact. Review of R10's Skin Assessment, dated 6/17/24, revealed, Small open area on left buttocks 0.5 cm x 0.3 cm. Barrier cream applied and Optifoam dressing in place. Review of R10's Electronic Health Record revealed no documentation that R10's physician or family member/responsible party was notified of the newly identified pressure injury. Review of R10's Treatment Administration Record and Order Summary revealed no documentation that a treatment order was initiated on 6/17/24. Review of R10's Incident Report dated 6/20/24 revealed, Incident Description-Open area 1 cm x 1 cm noted on coccyx .(Intervention) Reposition resident every two hours as allowed .Family Member (notified) 6/21/24 at 7:01 (AM) . Indicating the worsening/increase in size of the pressure injury from the previous assessment. Review of R10's Nurse's Note dated 6/21/2024 revealed, Open area 1 cm x 1 cm noted on coccyx. Action: Cleansed with NS and Opti foam applied. Reposition resident every two hours as allowed. R10's Care Plan was not updated to reflect repositioning every 2 hours. Review of R10's Order Summary dated 6/21/24 revealed, Cleanse coccyx with NS (normal saline). Apply Opti foam dressing every night shift every Mon, Wed, Fri for Open area. (4 days after the identification of a pressure injury). Review of R10's Care Plan initiated on 6/25/24 revealed, Focus: Documented Pressure Ulcer Documented Pressure Ulcer (sic) to coccyx .Goal: Management of Pressure Ulcer .Interventions/Tasks: Monitor ulcer for signs of progression or declination-Notify provider if no signs of improvement on current wound regimen- Provide wound care per treatment order. During an interview on 06/25/24 at 03:53 PM, Family Member (FM) S reported he was notified that R10 had a pressure injury a couple days ago. FM S stated R10 can't move much anymore and required staff to assist with bed mobility and repositioning. During an interview via email at 06/26/24 at 1:47 PM, Nursing Home Administrator (NHA) stated that the Wound Care Nurse will look at her (R10) tomorrow (6/27/24) as Incident (pressure injury) found 6/20/(24). During an interview on 06/26/2024 at 12:53 PM, Wound Care Nurse (WCN) N (previous Director of Nursing) reported that she assessed residents with wounds weekly on Thursdays. WCN N had not been notified of a pressure injury on R10's coccyx on 6/17/24 or when she was completing wound rounds at the facility on 6/20/24. During an observation and interview on 06/27/24 at 11:55 AM, WCN N measured R10's coccyx wound with a 0.3 cm x 0.2 cm scab like center and reported it appeared as a healing open area. WCN N reported that surrounding the scab like center was superficial epithelial tissue loss and measured 2.5 cm x 2 cm and likely resulted from a mixture of MASD and positioning pressure but has now dried. No treatment changes were made at that time. Review of the facility policy Wound Care/Skin Integrity dated 2/1/21 revealed, Observation of all patient's skin is required every shift and must be reported to the oncoming shift RN and CENA with the Nursing Hand Off.MOBILITY DEFICIT *Patients that are Braden 14 or less are to be repositioned every 2 hours, unless contraindicated by primary diagnosis, complications, or co-morbidities .elevate lower extremities to keep heels off of the mattress . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention (EPUAP, NPIAP, PPPIA, 2019a). The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure (Maklebust and [NAME], 2016). Elevating the head of the bed to 30 degrees or less decreases the chance of pressure injury development from shearing forces (WOCN, 2016). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (EPUAP, NPIAP, PPPIA, 2019a). A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominences (WOCN, 2016). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1255). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident with limited mobility received appropriate/recommended equipment for one resident (Resident #10) out of 6 residents reviewed for range of motion, positioning, and mobility. Findings include: Resident #10 (R10): Review of an admission Record revealed R10 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Review of a Minimum Data Set (MDS) assessment for R10, with a reference date of 3/14/24 revealed in Section C-Cognitive Patterns that R10 was severely cognitively impaired. Review of R10's Functional Abilities and Goals dated 6/15/24 revealed that R10 was dependent on staff for bathing, dressing, toileting, and mobility. Review of R10's Screen Request for Potential Risk or Intervention and Therapy Orders dated 10/6/22 revealed the therapy department provided dumped (seat slope/recline), high back w/c (wheelchair)-10/7/22. The wall in R10's room held a picture of R10's high back wheelchair with the therapy recommended equipment in place. Written on the picture were instructions for the equipment R10 required. Legs: foot buddy on top of leg rests and secured with straps. Cushions: back/lateral supports on back rest. cushion on seat. bolster on (right) armrest. Review of R10's Care Plan did not reflect the type of chair R10 was to utilize (high back wheelchair or Broda chair) and did not indicate the type of equipment/cushions recommended by therapy. During an observation on 06/24/24 at 09:34 AM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/24/24 at 11:50 AM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/24/24 at 01:47 PM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/24/24 at 03:51 PM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/25/24 at 07:24 AM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/25/24 at 08:02 AM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/25/24 at 08:56 AM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/25/24 at 09:31 AM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/25/24 at 11:00 AM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/25/24 at 12:19 PM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/25/24 at 03:14 PM, R10 was sitting up in a Broda chair and did not have a foot buddy, cushions, or a bolster in place. During an observation on 06/26/24 at 12:47 PM, R10's high back wheelchair with foot buddy on top of leg rests, back/lateral support cushion on back rest, cushion on seat, and bolster on right armrest was in her bathroom in the shower area. During an observation on 06/27/24 at 08:57 AM, R10 was up in a Broda/geri chair at the dining room table. R10's high back wheelchair with foot buddy on top of leg rests, back/lateral support cushion on back rest, cushion on seat, and bolster on right armrest was in her bathroom in the shower area. During an interview on 06/27/24 at 08:59 AM, Certified Nursing Assistant (CNA) P reported that R10 had not used the high back wheelchair in her bathroom for at least a couple months and was in a Broda chair. CNA P reported that the chair she was utilizing suits her better. CNA P reported that she believed that R10 recently had a therapy evaluation/assessment and was changed to the Broda/geri chair. During an interview on 06/27/24 at 09:16 AM, Therapy Manager (TM ) O reported that R10 had not had a therapy evaluation/assessment since 9/21/23 when R10 had a decline in her functional abilities. TM O reported there had been no chair assessments since her therapy evaluation/assessment. During an observation and interview on 06/27/24 at 11:50 AM, R10's high back wheelchair with foot buddy on top of leg rests, back/lateral support cushion on back rest, cushion on seat, and bolster on right armrest was in her bathroom in the shower area. Previous Director of Nursing (PDON) N reported she was familiar with R10 but did not know why that chair was not being used and was unaware of an equipment/wheelchair order change and/or a recent therapy evaluation. (PDON N was the DON from 3/20/23-5/9/24 and continued to work at the facility as the wound nurse.) During an interview on 06/27/24 at 12:07 PM, Licensed Practical Nurse (LPN) Q reported that she was routinely R10's nurse. LPN Q reported that she had not worked the last few days and was unsure why R10 was not in her modified high back wheelchair. During an interview on 06/27/24 at 12:19 PM, TM O provided a therapy evaluation/assessment and confirmed that R10 was last seen by the therapy department in September of 2023 and was using a high back, recline, wheelchair. TM O reported that R10's transfer ability had declined, and it was recommended that she be transferred using a Hoyer lift instead of an EZ-stand but a change from her high back wheelchair to a Broda chair was not recommended. TM O reported that R10 should be using the high back wheelchair with the cushions, bolsters, and foot buddy based on the most recent therapy evaluation but was currently using a Broda chair. Review of R10's OT (Occupational Therapy) Therapist Progress & Discharge Summary revealed, Start of Care 9/21/23-End of Care 10/4/23. Occupational Therapist recommended the transfer change from an EZ-stand to a Hoyer lift. The records did not reflect a change from the high-back wheelchair to the Broda chair. During an interview on 06/27/24 at 01:27 PM, DON reported that she would be obtaining an order for a therapy evaluation for R10's Broda chair vs. high back wheelchair. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (In conjunction with an interprofessional health care team, develop an early intervention protocol using prescribed positioning, ROM exercises, and/or splints to reduce the risk of joint deformity and contracture formation ([NAME] and [NAME], 2018). o Health care agencies need to provide equipment (e.g., splints) and appropriate education for staff to reduce the risk of contractures .Use positioning and ROM and stretching exercises according to the individualized need of the patient and as ordered. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 879). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Sound clinical judgment involves using the resources needed to maintain a patient's function and independence. For example, it is important to collaborate with health care providers and physical and occupational therapists .Occupational therapists assist patients with adaptive devices and techniques to perform ADL's while improving mobility .In addition, always individualize a plan of care directed at meeting the actual or potential needs of the patient. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 841). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to discard expired medications for 1 of 3 medication carts reviewed, from a total 6 medication carts, resulting in the residents receiving medications that are expired and/or have reduced efficacy. Findings include: During an observation and interview on 6/26/24 at 8:00 AM, the 200 hall Medication cart had a bottle of eye drops with an opened date of 5/12/24, a bottle of nasal spray with a date opened of 5/2/24, a Lantus multi dose vial with an opened date of 5/10/24 and another Lantus multi dose vial with an open date of 5/8/24. Licensed Practical Nurse (LPN) D reported she was not sure of the expiration dates of the medications once they were opened but believed it was around 28 days. Review of an Insulin Storage Parameters document provided by the facility revealed Lantus is to be discarded 28 days after opening. Ophthalmic Solutions Storage Parameters: Eye medication bottles/tubes with accelerated expiration dates must be dated/initialed upon opening. Follow manufacturers instructions, or facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to 1.) Administer controlled medications following a physician's order and professional standards of practice and 2.) Ensure that medications were administered following the physician-ordered parameters for 4 residents (Resident #1, Resident #14, Resident #32, and Resident #57), reviewed for medication administration, resulting in medication errors and the withholding of medications without a physician's order. Findings include: Resident #1 (R1): Review of an admission Record revealed R1 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: spastic quadriplegic cerebral palsy. Review of R1's Order Summary revealed, Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth three times a day for pain -Start Date-11/28/2023. To be administered at 5:00 AM, 12:00 PM, and 8:00 PM. Review of R1's Controlled Substance Record revealed on 6/20/24 R1 received a dose of Norco at 6:10 am and 11:51 AM. R1 was not administered the 8:00 PM dose. Review of R1's Medication Administration Record revealed that the 8:00 PM dose of Norco was documented as administered. Review of R1's Controlled Substance Record revealed on 6/21/24 R1 received a dose of Norco at 5:15 AM, 8:00 PM, 11:50 AM, and 7:30 PM. Indicating an additional dose of Norco administered. Review of R1's Medication Administration Record revealed only that the 5:00 AM, 12:00 PM, and 8:00 PM doses of Norco were administered. Resident #14 (R14): Review of an admission Record revealed R14 was an [AGE] year-old male, admitted to the facility on [DATE]. Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 10 unit subcutaneously before meals for DM give with breakfast and lunch. Hold if BS (blood sugar) <120 -Start Date-05/03/2024 to be administered at 8:30 AM, 11:30 AM, and 5:30 PM. Review of R14's Medication Administration Record revealed: *On 06/08/2024 at 5:45 AM R14's blood sugar was 118 and the Lispro was administered. *On 06/09/2024 at 4:42 PM R14's blood sugar was 104 and the Lispro was administered. *On 06/13/2024 at 5:43 AM R14's blood sugar was 110 and the Lispro was administered. *On 06/13/2024 4:00 PM R14's blood sugar was 116 and the Lispro was administered. *On 06/17/2024 at 7:00 AM R14's blood sugar was 111 and the Lispro was administered. Resident #32 (R32): Review of an admission Record revealed R32 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R32's Order Summary revealed: Norco Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth in the morning for Pain -Start Date- 04/26/2024. Norco Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Pain -Start Date- 04/25/2024. Review of R32's Controlled Substance Record revealed on 6/14/24 R32 received a dose of Norco at 5:45 AM, 8:26 AM, 4:45 PM, and 10:45 PM. Review of R32's Medication Administration Record revealed the as needed dose of Norco administered at 10:45 PM was not documented. Review of R32's Controlled Substance Record revealed on 6/16/24 R32 received a dose of Norco at 1:00 AM, 8:30 AM, 3:10 PM, and 12:00 AM (6/17/24). Review of R32's Medication Administration Record revealed the as needed dose of Norco administered at 12:00 AM (6/17/24) was not documented. Review of R32's Controlled Substance Record revealed on 6/22/24 R32 received a dose of Norco at 5:45 AM, 7:32 AM, 1:30 PM, and 7:30 PM. Review of R32's Medication Administration Record revealed the as needed doses of Norco administered at 5:45 AM, 1:30 PM, and 7:30 PM were not documented. Review of R32's Order Summary revealed, amLODIPine Besylate Oral Tablet 10 MG (Amlodipine Besylate) Give 1 tablet by mouth in the morning for HTN (hypertension) HOLD FOR SBP <120 (systolic blood pressure less than 120)-Start Date- 05/15/2024 -D/C Date-06/20/2024 to be administered upon rising. Review of R32's Medication Administration Record revealed: *On 6/4/24 R32's blood pressure was 112/60 and the amlodipine was administered. *On 6/5/24 R32's blood pressure was 116/68 and the amlodipine was administered. *On 6/18/24 R32's blood pressure was 118/71 and the amlodipine was administered. Review of R32's Order Summary revealed, Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN with meals- HOLD for SBP <120 -Start Date- 05/14/2024 to be administered at 8:00 AM and 4:30 PM. *On 6/3/24 R32's blood pressure was 110/60 and the morning dose of carvedilol was administered. *On 6/3/24 R32's blood pressure was 116/62 and the afternoon dose of carvedilol was administered. *On 6/4/24 R32's blood pressure was 116/63 and the morning dose of carvedilol was administered. *On 6/4/24 R32's blood pressure was 114/66 and the afternoon dose of carvedilol was administered. Resident #57 (R57): Review of an admission Record revealed R57 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R57's Order Summary revealed, Lisinopril Tablet 5 MG Give 5 mg by mouth in the morning for hypertension Hold for SBP <100, pulse <60. -Start Date- 11/16/2023 to be administered upon rising. Review of R57's Medication Administration Record revealed that the Lisinopril was administered daily from 6/1/24 to 6/26/24. Review of R57's Blood Pressure Summary and Pulse Summary revealed that for the month of June 2024, R57's blood pressure and pulse were assessed one time on 6/10/24. There was no documentation that licensed nurses ensured R57's vital signs were within the ordered parameters prior to administering the medication. During an interview on 06/26/2024 at 1:16 PM, Previous Director of Nursing (PDON) N reported that physician ordered parameters should be reviewed prior to each medication administration and followed by the licensed nurses. PDON N reported that following physician ordered parameters was cited on the 2023 annual recertification survey and medication administration was monitored closely to ensure compliance. PDON N reported the Team Leads (Unit Managers) were responsible for reviewing orders and progress notes and that the expectation is for the licensed nurses to administer medication as it is ordered. (PDON N was the DON from 3/20/23-5/9/24). During an interview on 06/26/24 at 02:43 PM, Director of Nursing (DON) confirmed the narcotic medication errors for R1 and R14. DON reported that the licensed nurses were expected to follow the parameters ordered by the provider and education would begin immediately for all nurses. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, (Nurses) are responsible for documenting any preassessment data required of certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of Warfarin, before giving the medication. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 609). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Never document that you have given a medication until you have actually given it. Document the name of the medication, the dose, the time of administration, and the route on the MAR. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 610). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its established protocol to provide residents with clean oxygen delivery equipment and to monitor oxygen levels for one resident (Resident #11) of 3 residents reviewed. Findings include: Resident #11 (R11): Review of an admission Record reflected R11 was a [AGE] year-old female, last admitted to the facility on [DATE]. During an observation on 06/24/24 at 11:10 AM, R11 sat up in bed awake and alert. R11 reported using oxygen at night while sleeping. The oxygen tubing and bottle of water to humidify the oxygen were dated 06/05/24. During an observation on 06/25/24 at 7:09 AM R11 laid resting in bed with eyes closed and received oxygen via a nasal cannula. The oxygen tubing and bottle of water to humidify the oxygen were dated 06/05/24 and the bottle of water was empty. During an interview on 06/25/24 at 9:30 AM the Director of Nursing (DON) stated the all oxygen tubing and equipment are changed out weekly by third shift staff. During an observation on 06/26/24 at 9:36 AM R11 sat up on the side of the bed eating breakfast. R11 stated that she had used oxygen last night. The oxygen tubing and bottle of water to humidify the oxygen were dated 06/05/24 and the bottle of water was empty. During an observation on 06/27/24 at 11:45 AM R11 sat in a wheelchair watching TV. R11 reported that last night staff replaced the bottle of water used to humidify the oxygen. The bottle of water was dated 06/26/24. However, the oxygen tubing was still dated 06/05/24. Review of an 02 Sats (oxygen saturations) Summary for R11 showed the last time staff had monitored/documented R11's blood oxygen saturation occurred on 03/07/24. Review of a Physician Order Summary for R11 revealed no order for oxygen delivery, the rate of delivery, and the method of oxygen delivery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to operationalize policies and procedures and have a functional system in place for controlled substances to ensure that they were accounted for, dispensed, and disposed of in a sensical manner, resulting in the potential for drug diversion and the misappropriation of property. Findings include: Resident #65 (R65): During an observation and interview on [DATE] at 7:52 AM, the 200 Hall Registered Nurse (RN) A (night shift nurse) and Licensed Practical Nurse (LPN) D (oncoming nurse) were exchanging report and destroying a Schedule II narcotic (Norco (Hydrocodone/acetaminophen)). A blister pack of Norco 5/325 mg tablets had 23 tablets left from a 30-count blister pack for Resident #65 (R65). Both nurses entered the medication storage room and RN A popped the 23 tablets into his hand and discarded them into the drug buster bottle (a medication disposal system that quickly turns most non-hazardous medications into a non-toxic slurry that can be safely put in the trash). Neither nurse signed a document indicating that the 23 Norco tablets were counted and destroyed. The nurses reported they wanted to discard the 23 Norco tablets to not confuse anyone with the new increased dosage of Norco for R65. RN A and LPN D reported there was not a form to fill out for destroying the narcotic. Review of the Individual Resident's Controlled Substance Record dated [DATE]rd for R65 revealed handwritten information: [R65] Take 1-tab TID (three times a day) + 1 PRN (as needed) @ HS (at bedtime). No medication or dosage was identified on the sheet. The first entry on the page dated [DATE] at 1:15 PM shows amount on hand is 120, amount received is 120 with a circle around it and initials with a date of 6/5. One tablet was given and the amount remaining was 119. On [DATE] at 9:45 PM the count was at 83. On [DATE] at 7:00 AM, after the disposal of the 23 Norco's at 5/325 mg, one tablet was given at 7:00 AM and the count remaining was 59. At the top of these forms is a box that states Disposition of Remaining Doses- Per Facility Policy with space to sign, date, and document the quantity of medication disposed. During an observation and an interview on [DATE] at 8:00 AM, the 200-hall medication cart revealed R65 had 59 tablets of the Norco 7.5/325 mg remaining in the cart. LPN D verified that the Controlled Substance Record for R65 did not have the name of the Norco medication or the dosage on it. She clarified the document was a combination of both doses of Norco (5/325 mg and the 7.5/325 mg). The form was originally for the Norco 5/325 mg and new orders were obtained to increase the dosage of Norco to 7.5/325 mg. The document is unclear about what Norco dose was started, what dose was given, and when it was changed. LPN D thinks that whoever checked in or received the new prescription of Norco 7.5/325 mg combined the medication with the previous dose and logged them on the same sheet. The count of 83 tablets on [DATE] is the combination of both strengths, but since they wasted the 23 Norco 5/325 mg tablets this morning, the count is now at 59 tablets of the Norco 7.5/325 mg tablets. Review of the Individual Resident's Controlled Substance Record for R65 revealed on [DATE] 120 tablets of Norco 5/325 mg was delivered and signed by two nurses. On [DATE] at 6:20 AM the first dose was documented as given. On [DATE] at 7:10 PM 1 ½ pills were documented as given (equivalent to 7.5/325 mg). A total of 6 doses of 1 ½ tablets were given until [DATE] when 107 tablets were left. There is no account of where these 107 tablets are. There is no destruction log for these tablets. Review of the Individual Resident's Controlled Substance Record for R65 revealed on 6/3 a delivery of 120 tablets of Norco 7.5/325 mg were delivered signed by two nurses as receiving 120 tablets. The number 30 was handwritten under the printed label 120 EA. On [DATE] at 6:00 PM the AMOUNT ON HAND count is 120 and 1 tablet was given with 119 tablets remaining. The 119 has a line through it and the number 29 is handwritten next to it. The amount remaining was crossed off and changed a total of 7 times changing the original amount remaining of 119 tablets - 113 tablets between [DATE] to [DATE], to 29 tablets - 23 tablets remaining during that period. That leave 90 tablets of Norco unaccounted for. Review of the May and [DATE] Medication Administration Record (MAR)for R65 revealed several orders for Norco. The original order for Norco 5/325 mg started [DATE] and discontinued on [DATE]. On [DATE] was the first order for Norco 7.5/325 mg. In an interview on [DATE] at 9:20 AM, the Director of Nursing (DON) reviewed the 200 Hall medication cart and verified the Individual Resident's Controlled Substance Record for R65 was not accurately documented when received, accounted for, and disposed of. There should always be 2 nurses wasting medications and documenting what medication was wasted how much. The DON verified the record did not reflect the name of the medication or the dosage. The DON reported she had some education to do. In an interview on [DATE] at 11:30 AM, the DON reported the pharmacy was sending the medication narcotic delivery records to the facility and will give them to us as soon as they receive them. The DON reported the facility does not practice splitting medication tablets and does not have the capability to do so. When referencing R65's narcotic log, the DON agreed that is must have happened but not clear of the details yet. The DON reported the facility just switched pharmacy providers within the last 2-3 weeks and have a hybrid of both pharmacy medications in the facility at this time. The facility could not find any disposal logs of the Norco's for R65 by the time of the exit. Review of a Pharmacy delivery record revealed on [DATE] 120 tablets of Norco 5/325 mg were delivered and on [DATE] 120 tablets of Norco 7.5/325 mg was delivered. Resident #6 (R6): During an observation, interview, and record review on [DATE] at 8:00 AM, the Individual Resident's Controlled Substance Record for R6 revealed handwritten information: Amount Received: 30 ml (milliliters), take 0.5 mL by mouth 3 times daily. The document has 2 lines of white out on it and documented 30 mL on hand. LPN D reported she did not know why the report sheet was handwritten without a medication name on it or why it had white out on it. LPN D confirmed it was for the liquid Lorazepam ordered for R6. Review of an Individual Resident's Controlled Substance Record for R6 revealed Lorazepam with 22 mls left in a 30 ml bottle. This was verified in the medication refrigerator along with another 30 ml unopened bottle of Lorazepam. In an interview on [DATE] at 11:30 AM, the DON reported there should never be any white out on a Controlled Substance Record and will be looking into it. Review of a policy titled 6.0 General Dose Preparation and Medication Administration last revised [DATE] revealed: 2.9 Facility staff should not split tablets. 2.9.1 The pharmacy should be contacted to provide the correct dose. 5.5 Document the administration of controlled substances in accordance with applicable law. 6.2 Dispose of unused medication portions in accordance with facility policy. Review of a policy titled 8.2 Disposal/Destruction of Expired or Discontinued Medication last revised [DATE] revealed: Procedure: 1. Facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable environmental regulations. 2. Once an order to discontinue a medication is received, Facility staff should remove this medication from the resident's medication supply. 3. Facility should transmit or fax a copy of the discontinue order to Pharmacy to remove it from the resident's current medication list and from the Physicians order sheet and medication administration record. 6. Facility should enter the following information on a drug destruction form when medications are destroyed: 6.1 Resident's name, 6.2 name and strength of medication, 6.3 Prescription number, 6.4 Amount of medication (dosage units) destroyed, 6.5 Date of destruction 6.6 Signature of staff destroying medications, 6.7 Signature of witnesses; and 6.8 Method of disposition, including donation as permitted by Applicable Law. 9. Controlled substances may not be returned to Pharmacy, unless refused at the time of delivery. 10 Facility should record destruction of controlled substances on: 10.1 Medication Disposition/Destruction Form; 10.2 Controlled Substance Count Form; or 10.3 Medication Destruction Logbook. 11. Facility should destroy discontinued or outdated medications by one of three (3) methods: . 11.3 Facility-approved commercially available drug disposal kits. 12. Facility should destroy Schedule II-IV controlled substances as detailed above, with the following exceptions: 12.1 Facility should destroy controlled substances in the presence of a registered nurse and a licensed professional or in accordance with Facility policy or Applicable Law. 12.2 Destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and witnessing licensed professional who should record: 12.2.1 Quantity destroyed; 12.2.2 Date of destruction; and 12.2.3 Signature of registered nurse and licensed professional.

Based on interview and record review, the facility failed to 1) Implement Enhanced Barrier Precautions for residents with chronic wounds or indwelling medical devices to prevent, recognize, and control the onset and spread of infection among residents and 2) Investigate, document surveillance of, and implement preventative measures to address an outbreak of a respiratory illness among residents. Findings include: OUTBREAK INVESTIGATION Review of the Infection Prevention and Control Program revealed that in March 2024 there were 9 positive cases of Influenza A. On 06/24/2024 at 10:26 AM a request for a copy of any Line Lists and Outbreak Investigations was requested via email. There was no Line Lists or Outbreak Investigations received prior to the Infection Prevention and Control Program Review. During an interview on 06/27/2024 at 10:00 AM, the Infection Control Program was reviewed with Director of Nursing (DON) and Registered Nurse/Consultant (RNC) L. RNC L and DON were unable to locate/provide any additional outbreak investigation documentation related to the March 2024 Influenza A outbreak. DON and RNC L reported that a complete and thorough outbreak investigation should be started at the time the outbreak is identified. Review of the Infection Prevention and Control Program binders revealed a form completed on 4/1/24 titled LTC (Long Term Care) Outbreak Weekly Reporting Form The LTC Outbreak Weekly Reporting Form revealed that on 3/26/24 6 residents tested positive, on 3/27/24 2 residents tested positive, and on 3/28/24 1 resident tested positive. There was no documentation to identify: *9 residents that tested positive or contact tracing. *The date and time the Medical Director was notified of the outbreak. *The date and time the Health Department was notified of the outbreak. *The date and time the staff and residents were notified of the outbreak. *The date and time the family/emergency contacts/guardians were notified of the outbreak. *The interventions implemented to prevent the spread of Influenza-A in the facility (transmission-based precautions, increased cleaning, staff and resident education, restriction of movement between units, laboratory testing). *The daily active surveillance of all residents and staff for illness. ENHANCED BARRIER PRECAUTIONS Review of the Centers for Medicare & Medicaid Services Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Memorandum (Ref: QSO-24-08-NH) with an effective Date of April 1, 2024 revealed, Memorandum Summary o CMS is issuing new guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. o EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status . Review of the Electronic Health Record, the June 2024 Monthly Infection Surveillance Log, and the Facility Matrix (802) revealed the following: *5 residents with urinary catheters *1 resident with a Peripherally Inserted Central Catheter (PICC Line) *9 residents with a pressure injury/wound *1 resident with a feeding tube Throughout the survey process from 6/24/24-6/27/24, serial observations were made throughout the facility. Observations revealed that residents with chronic wounds or indwelling medical devices were not placed in Enhanced Barrier Precautions (no signage on door or PPE carts available in/near the rooms.) During an interview on 06/27/2024 at 10:00 AM, the Infection Control Program was reviewed with Director of Nursing (DON) and Registered Nurse/Consultant (RNC) L. RNC L reported she identified on Monday (6/24/24) that Enhanced Barrier Precautions had not been implemented for residents with chronic wounds or indwelling medical devices. RNC L confirmed that Enhanced Barrier Precautions were to be implemented by April 1, 2024 per CMS guidance (QSO-24-08-NH). RNC L reported an Action Plan was initiated to implement EBP. On 6/26/24 at 1:47 PM, an Enhanced Barrier Precautions Implementation Action Plan was received via email from Nursing Home Administrator (NHA). The Action Plan identified the lack of EBP, and the steps required to implement EBP in the facility. 1. Begin education with all staff 2. Define what residents qualify for EBP-master list 3. Inventory PPE (personal protective equipment), wheeled carts/PPE holders, trash receptacles (sic) with lids 4. Evaluate availability/placement of ABHR (alcohol based hand rub) and disinf. (disinfection) wipes 5. Estimate and order needed supplies 6. Start education with residents affected 7. Send education to families 8. Review EBP with resident council 9. Placement of defined residents on EBP and Care Plan 10. Plan for: *Education of all residents/families-letters, posters *How you will communicate to the staff- signs *Ordering and stocking of PPE (also off shifts) *Placement and removal of EBP-current and admissions *Communication of new wounds/devices/MDRO's *Consider placement of carts *Plan for more trash pick up 11. Monitoring plan and follow up education 12. Add review to IC (infection control) meeting agenda 13. Notify Med. (Medical) Director and discharge planners of new practice 14. Discuss non-healing wounds with weekly NAR 15. ICP's (Infection Control Preventionists) and DON's take 1 hour course on EBP 16. Consider information letter from CDC for admission packets During the survey exit conference the NHA and DON confirmed that no Enhanced Barrier Precautions Implementation Action Plan steps had been implemented as of 6/27/24 at approximately 4:00 PM. Review of the Centers for Medicare & Medicaid Services Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Memorandum (Ref: QSO-24-08-NH) with an effective Date of April 1, 2024 revealed, .The new guidance related to EBP is being incorporated into F-880 Infection Prevention and Control .GUIDANCE Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EBP are indicated for residents with any of the following: o Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or to Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid®) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. Facilities have discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC . For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: o Dressing o Bathing/showering o Transferring o Providing hygiene o Changing linens o Changing briefs or assisting with toileting o Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator o Wound care: any skin opening requiring a dressing . Facilities should ensure PPE and alcohol-based hand rub are readily accessible to staff. Discretion may be used in the placement of supplies which may include placement near or outside the resident's room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. For example, staff entering the resident's room to answer a call light, converse with a resident, or provide medications who do not engage in a high-contact resident care activity would likely not need to employ EBP while interacting with the resident .

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen, resulting in the potential to spread food borne illnesses to all residents that consume food from the kitchen. Findings include: During an initial tour of the walk-in cooler, at 9:44 AM on 6/24/24, it was observed that half empty box of nutritional shakes was found on the bottom storage rack. When asked if there was a date on the box of shakes, Certified Dietary Manager (CDM) J was unable to find one and stated that typically the box is dated for 14 days. A review of the items stated it was good for 14 days after thaw. When asked if the shakes are placed directly into the cooler upon receiving, CDM J stated they are first put in the freezer. During a tour of the Blue Pantry, starting at 10:23 AM on 6/24/24, it was observed that a container holding a dozen nutritional drinks were found in the refrigeration unit with no date to indicate discard. A review of the manufacturer's directions state the item is good 14 days from thaw. Further review found an open container of vanilla Med Pass 2.0 with no date to indicate discard. A review of the container stated it needed to be used within 4 days after opening. During a tour of the Yellow Pantry, at 10:34 AM on 6/24/24, two nutritional drinks were found with no date to indicate discard. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . During a tour of the cook line, at 9:57 AM on 6/24/24, it was observed that the top of the convection oven was found with heavy amounts of dust and crumb debris with one of the oven insert racks was being stored on top of the unit. During a tour of the kitchen, at 9:59 AM on 6/24/24, it was observed that clean utensils were stored in six bins by the ice machine. When asked how often the clean utensil bins get cleaned out, CDM J stated once a week. Observation inside of the bins found an accumulation of debris and crumbs on the bottom and inside backs of the bins. CDM J stated he would get them cleaned. During a tour of the Blue Pantry, at 10:23 AM on 6/24/24, it was observed that the underside of the juice machine was found with increased amounts of brown and orange sticky residue on the underside corners of the spouts. During a tour of the [NAME] Pantry, at 10:35 AM on 6/24/24, it was observed that the underside of the juice machine was found with increased amounts of brown and orange sticky residue on the underside corners of the spouts. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (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. During a tour of the kitchen, at 10:04 AM on 6/24/24, it was observed that three half pans were stacked and stored wet on the clean pots and pans storage rack. Further observation of the stacked pans found two quarter pans that were stacked and stored with water stuck in between. According to the 2017 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD . During the initial tour of the kitchen, at 10:08 AM on 6/24/24, observation of the dish machine found that the rinse pressure gauge only reached eight pounds per square inch (psi) after four times of cycling the machine. A review of the dish machines data plate states Flow Press. 20 +/- 5 PSI. A review of facilities dish machine log found that the rinse pressure is not something that is checked by staff and recorded. Observation of the inside of the unit found a loose screw in the top spray arm that was also impeding proper spray. According to the 2017 FDA Food Code section 4-501.113 Mechanical Warewashing Equipment, Sanitization Pressure. The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). According to the 2017 FDA Food Code section 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper storage of medication in 1 of 2 medication carts on the [NAME] Unit for 2 residents (Resident #28 and #36), resulting in the potential for diversion and/or misappropriation of medication. Findings: Resident #28 (R28) Review of an admission Record revealed R28 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: lung disease, heart disease, kidney disease, diabetes, and opioid dependence. Review of R28's Medication Administration Record (MAR) revealed R28 was to receive the following medications the morning of 6/27/23: *Norco Tablet 10-325 MG (milligram) (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every morning and at bedtime for pain (controlled drug/narcotic medication) *AmLODIPine Besylate Tablet Give 10 mg by mouth in the morning for high blood pressure. *Celecoxib Capsule 200 MG Give 200 mg by mouth in the morning for arthritis pain *Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth in the morning for Anemia *Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth in the morning for benign prostatic hyperplasia (enlarged prostate causing difficulty urinating). *hydrOXYzine HCl Tablet 25 MG Give 1 tablet by mouth in the morning for Itching *Levothyroxine Sodium Tablet 200 MCG Give 1 tablet by mouth in the morning for hypothyroidism *metOLazone Tablet 2.5 MG Give 2.5 mg by mouth in the morning for Edema (swelling) *DOK Plus Tablet 50-8.6 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth every morning and at bedtime for constipation Resident #36 (R36) Review of an admission Record revealed R36 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: heart disease, pain, pressure ulcers and acid reflux. Review of R36's MAR revealed R36 was to receive the following medications the morning of 6/27/23: *Norco Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every morning and at bedtime for pain *Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth in the morning for Supplement *Aspirin Tablet Chewable 81 MG Give 1 tablet by mouth in the morning for DVT (blood clot) prevention *Folic Acid Tablet 1 MG Give 1 tablet by mouth in the morning for Supplement *Iron (Ferrous Sulfate) Oral Tablet 325 (65 Fe) MG (Ferrous Sulfate) Give 1 tablet by mouth in the morning for Supplement *Lisinopril Oral Tablet 5 MG (Lisinopril) Give 1 tablet by mouth in the morning for Hypertension *Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1.5 tablet by mouth in the morning for HTN (hypertension) dose=37.5 mg *Multivitamin Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth in the morning for Wound *Potassium Chloride ER Tablet Extended Release 10 MEQ (milliequivalant) Give 1 tablet by mouth in the morning for Hypokalemia *Protonix Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth in the morning for GERD (acid reflux) *Zinc Sulfate Capsule 220 MG Give 1 capsule by mouth in the morning for zinc deficiency *Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every morning and at bedtime for blood clot prevention During an observation on 06/27/2023 at 5:50 AM, Licensed Practical Nurse (LPN) A opened the [NAME] Unit Medication Cart (the 313-324 medication cart) top drawer, removed a medication cup containing pills (preset medications) and entered R28's room to administer the medications. LPN A was not observed preparing the medications and the medications were not removed from the medication cart's locked narcotic box. Review of R28's MAR revealed the above listed medications were administered by LPN A. During an interview on 06/27/2023 at 5:55 AM, LPN A reported she did not preset R28's medications and reported that she had pulled his medications and found that he was sleeping and then placed the medications in the medication carts top drawer to administer when R28 woke up. LPN A was asked to open the drawers of the medication cart at that time. The [NAME] Unit Medication Cart (313-324 medication cart) top drawer contained a plastic cup of multiple medications mixed with applesauce, laying on its side with applesauce spilling from the cup. The plastic cup was labeled with R36's room number. LPN A reported that she had prepared R36's medications and found R36 sleeping and placed the medications in the top drawer of the medication cart to administer when R36 woke up. LPN A then entered R36's room to administer the medications. During an observation on 06/27/2023 at 6:01 AM, R36 refused her medications which required LPN A to have Registered Nurse (RN) X witness the waste of the controlled drug (Norco) contained in the medication cup. Confirming the controlled substance was stored in the top drawer of the medication cart and was not double locked. R36's MAR did not reflect that LPN A had administered the medication due to the medications being wasted at the time of the refusal. During an interview on 06/28/23 at 03:29 PM, Unit Manager (UM) F reported that medications should not be preset and stored in the medications carts and narcotic medications should be double locked in the medication cart to prevent the misappropriation of controlled substances. UM F reported that the expectation is for licensed nurses to ensure a resident is awake prior to preparing medications. Review of the facility policy Medication Storage and Security (no date) revealed, .Medication shall be stored under the proper conditions of light, temperature, moisture, ventilation, segregation, and security . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Controlled substances are not kept in an individual patient drawer. Instead they are kept in a larger locked drawer to keep them secure. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to 1.) ensure residents received consistent and comprehensive physician ordered care, 2.) notify the physician a change in condition, and 3.) ensure residents received care in accordance with professional standards for medication administration, in 3 residents (Resident #51, #55, and #6,) reviewed for quality of care, resulting in a delay in treatment and the potential for the worsening of a medical condition and residents not attaining or maintaining his or her highest practicable level of wellbeing. Findings: Resident #51 (R51) Review of an admission Record revealed R51 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: atrial fibrillation (abnormal beathing of the heart). Review of R51's Nurses Notes dated 5/2/2023 at 9:00 AM revealed, Resident came to nurse this morning and c/o (complained of) not feeling good. Resident pale and diaphoretic (excessive sweating due to an underlying health condition or a medication). BP (blood pressure) 97/33, HR (heart rate) 122. Resident taken to her room, assisted to bed, once lying down, color was better, BP 109/78, HR 67, O2 sat 94% on RA. Resident able to follow commands, left grip strong, push pull left foot to command. Resident tends to have a poor appetite, ate very little for supper last night, refused breakfast. Spoke to resident about the need to drink to stay hydrated and importance of eating. Drinks brought to resident and left by bedside, resident states she will sip on them. (symptomatic hypotension and tachycardia together can be indicative of impaired cardiac output requiring immediate provider notification.) Per [NAME] and [NAME] 10th edition, Tachycardia is an abnormally elevated heart rate, above 100 beats per/ min in adults and Hypotension (low blood pressure) is present when the systolic BP (top number of blood pressure) falls to 90 mm Hg or below. Review of R51's Blood Pressure Summary revealed: *12/13/22 a BP of 119/89 *1/6/23 a BP of 128/67 *2/6/23 a BP of 132/66 *4/2/23 a BP 134/66 *5/2/23 a BP of 90/52 Confirming R51 did not have a history of hypotension until 5/2/23 Review of R51's Pulse Summary revealed: *12/13/22 a HR of 76 *1/6/23 a HR of 68 *2/6/23 a HR of 72 *4/2/23 a HR 88 *5/2/23 a HR of 102 Confirming R51 did not have a history of tachycardia until 5/2/23 Review of R51's Provider Note dated 5/3/2023 at 11:15 AM revealed, .Nursing progress note reviewed from yesterday AM, patient reported not feeling well, she was observed to be pale and diaphoretic. Vitals taken, 97/33, HR 122 .Assessment: 1. Tachycardia .2. Paroxysmal atrial fibrillation 3. History of sick sinus syndrome 4. Malaise . Confirming R51's licensed nurse did not notify the provider at the time of the change of condition. During an interview on 06/28/23 at 03:29 PM, Unit Manager (UM) F reported that R51's nurse should have immediately notified the provider at the time R51 had a change in condition. UM F verified that the nursing progress note dated 5/2/23 did not indicate the provider had been notified at the time of the incident. Resident #55 (R55) Review of an admission Record revealed R55 was a 67year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R55's Physician Orders revealed: *dilTIAZem HCl ER Capsule Extended Release 24 Hour 120 MG Give 1 capsule by mouth in the morning for HTN (hypertension) Hold if SBP (systolic blood pressure/top number) is less than 100 or pulse is less than 60 *Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth in the morning for HTN Hold if SBP is less than 100 or pulse is less than 60 Review of R55's May Medication Administration Record revealed diltiazem and metoprolol were administered on the following dates (the administration of the medication is indicated by a check mark with licensed nurses identifier): *5/3/23 with a BP of 78/54 and a HR of 58. *5/9/23 with a HR of 55 *5/17/23 with a HR of 49 *5/18/23 with a HR of 56 *5/27/23 with a HR of 55 Review of R55's June Medication Administration Record revealed diltiazem and metoprolol were administered on the following dates: *6/6/23 with a HR of 49 *6/20/23 with a HR of 54 During an interview on 06/28/23 at 03:29 PM, UM F reported that if there are parameters ordered the licensed nurses are to ensure vital signs are obtained prior to the administration of the medication. UM F reported that if the vital signs are outside of the ordered parameters, the providers direction should be followed (hold medication, notify the provider, etc). UM F verified that R55's medications were not administered following the provider ordered parameters. Review of the facility policy Change in Resident's Condition last updated 11/1/19 revealed, .The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been .d) a significant change in condition: physical/emotional/mental .4. The nurse caregiver will record pertinent changes in the resident's medical record and whom was contacted related to these changes. Review of the facility policy Medication Administration Procedures dated 5/18/22 revealed, .11. Obtain and record any vital signs, and other assessments as appropriate prior to medication administration . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, An alteration in vital signs signals a change in physiological function. Assessment of vital signs provides data to identify nursing diagnoses, implement planned interventions, and evaluate outcomes of care .Use vital sign measurements to determine indications for medication administration. For example, give certain cardiac drugs only within a range of pulse or BP (blood pressure) values .Know the acceptable vital sign ranges for your patients before administering medications .Verify and communicate significant changes in vital signs. Baseline measurements provide a starting point for identifying and accurately interpreting possible changes. When VS appear abnormal, have another nurse or health care provider repeat the measurement to verify readings. Inform the charge nurse or health care provider immediately, document findings in your patient's record, and report changes to nurses during hand-off communication (TJC, 2020). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 467-468). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Responsibility and accountability are other critical thinking attitudes essential to safe medication administration. Accept full accountability and responsibility for all actions surrounding the administration of medications. Do not assume that a medication that is ordered for a patient is the correct medication or the correct dose. Be responsible for knowing that the medications and doses ordered are correct and appropriate. You are accountable if you give an ordered medication that is not appropriate for a patient. Therefore, be familiar with each medication, including its therapeutic effect, usual dosage, anticipated changes in laboratory data, and side effects. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 607). Elsevier Health Sciences. Kindle Edition. Resident #6 (R6) Review of an admission Record reflected R6 was a [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of Bipolar Disorder, Major Depressive Disorder, Congestive Heart Failure, and Diabetes Mellitus type 2. Not listed as diagnoses for R6 were migraines or seizure disorder. Review of a Physician Order Summary for R6 listed .Divalproex Sodium (ER) Extended Release 500 mg (milligrams) give one tablet by mouth twice daily for migraines. Review of a Physician Progress Note for R6, dated 03/23/23, did not list migraines or seizure disorder as a diagnoses. Review of a Physician Progress Note for R6, dated 04/06/23, revealed the following information regarding R6 .has a history of Bipolar Disorder in full remission is on Divalproex ER 500 mg twice daily and mood is stable this medication is monitored by the wellness committee on a regular basis. Review of a lab report, dated 07/27/22, reflected that the last Divalproex (Depakote) blood level drawn for R6, was 44. The therapeutic range (the range of drug doses which can treat a disease effectively without having toxic effects) for Depakote is 50 to 100. During an interview on 06/29/23, the Director of Nursing (DON) indicated that the Depakote prescribed to R6 was not used for mood stabilization, was used for migraines, and because R6 had not had any seizure activity, the Depakote level would be checked annually. Monitor Depakote levels, liver function, and complete blood count with differential every 3-6 months. Monitoring of Depakote levels is required to maintain the drug within the narrow recommended therapeutic range. https://emedicine.medscape.com > 2090462-overview Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Responsibility and accountability are other critical thinking attitudes essential to safe medication administration. Accept full accountability and responsibility for all actions surrounding the administration of medications. Do not assume that a medication that is ordered for a patient is the correct medication or the correct dose. Be responsible for knowing that the medications and doses ordered are correct and appropriate. You are accountable if you give an ordered medication that is not appropriate for a patient. Therefore, be familiar with each medication, including its therapeutic effect, usual dosage, anticipated changes in laboratory data, and side effects. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 607). Elsevier Health Sciences. Kindle Edition.