Based on observation, record review, facility policy review and interviews, the facility failed to ensure resident right to respectful, dignified care as evidenced by staff failed to position themselves at the resident's side while assisting the resident with eating for one (1) of four (4) sampled residents. Resident #2 Findings included:Record review of the facility policy, Tray Setup for Resident Who Will Dine Independently with Latest Review Date 01/24 (January 2024) PURPOSE To ensure that the resident obtains sufficient nourishment and fluids.7. Provide beverage from meal tray. 8. Be attentive to resident's needs during the meal: offer appropriate assistance as needed.Record review of the facility policy revealed, Feeding the Dependent Resident with latest review date 01/24 (January 2024) revealed the policy stated, PURPOSE To ensure adequate nutrition for resident who are unable to feed themselves.PROCEDURE.Ensure that resident is seated comfortable in upright position.Record review of the facility policy Resident's Rights Policy with latest review date 03/24 (March 2024) revealed Every resident in this facility has the right to. 12. Be treated courteously, fairly and with the fullest measure of dignity.On 9/25/25 at 12:45 PM, observation revealed Resident #2 in his bed with his lunch tray in front of him on the over-the-bed table and Licensed Practical Nurse (LPN) #1 standing at the bedside with a spoon assisting the resident to eat. On 9/25/25 at 12:48 PM, observation revealed the Staff Development Nurse provided correction to LPN #1 regarding resident's rights to include sitting at the resident's side to assist with eating/feeding the resident.On 9/25/25 at 1:00 PM, observation and interview with Resident #2 revealed he was usually able to feed himself, but he nonverbally indicated that he was not feeling well on 9/25/25. On 9/25/25 at 1:55 PM, interview with the Staff Development Nurse revealed she stated that the facility policy and current standards of practice for resident meal service included sitting beside the resident while assisting to eat or feeding them. She confirmed that she had observed LPN #1 attempting to assist Resident #2 to eat while standing at his bedside. On 9/25/25 at 2:30 PM, during an interview the Director of Nurses (DON) confirmed that the policy of the facility and current standards of practice included to sit beside the residents when assisting with meals/feeding residents. Record review of the admission Record for Resident #2 revealed the facility admitted the resident on 10/18/22 and the resident had diagnoses that included chronic kidney disease, diabetes and cerebral palsy. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 5/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. with documentation that the resident was unable to complete the interview. Long- and short-term memory was coded OK. Resident #2 had modified independence with cognitive skills for daily decision making. Section GG indicated the resident required set-up assistance for eating.

Based on observations, record review, facility policy review and interviews, the facility failed to promote dignity for a resident during dining as evidenced by a resident was observed unsafely positioned during a meal and the call light was out of reach for one (1) of four (4) sampled residents. Resident #1. Findings include: Record review of the facility policy Call Light/Bell with the latest review date 01/24 (January 2024) revealed PURPOSE To provide the resident a means of communication with staff members.PROCEDURE 1. Ensure resident has call light in reach when in resident room.7. Place the call light within the resident's reach before leaving the room .Record review of the facility policy, Tray Setup for Resident Who Will Dine Independently with Latest Review Date 01/24 (January 2024) PURPOSE To ensure that the resident obtains sufficient nourishment and fluids.7. Provide beverage from meal tray. 8. Be attentive to resident's needs during the meal: offer appropriate assistance as needed.Record review of the facility policy Feeding the Dependent Resident with the latest review date of 01/24 (January 2024) revealed PURPOSE To ensure adequate nutrition for resident who are unable to feed themselves.PROCEDURE.5. Ensure that resident is seated comfortable in upright position .On 9/24/25 at 4:00 PM, interview with Certified Nurse Aide (CNA) #1 revealed that the resident declined offers of assistance to transfer into her wheelchair for activities or to go to the dining room for meals.On 9/24/25 at 4:40 PM, a telephone interview with a family member of Resident #1 revealed the family member visited the resident weekly and had noticed upon entrance to her room that her call light was out of the resident's reach. He stated that he felt the staff should pay more attention upon exiting the residents' rooms. On 9/24/25 at 4:49 PM, a telephone interview with the Resident Representative (RR) of record for Resident #1 revealed she had concerns related to staff leaving the resident's room and leaving her call light out of reach of the resident. She said she was also concerned that the resident needed more assistance for meals, and that she didn't think the resident should be left alone while eating meals. She confirmed that the resident said she preferred to stay in bed.On 9/25/25 at 12:30 PM, the State Agency (SA) entered the room of Resident #1 and the resident's call light was hanging down below the mattress next to the floor out of the reach of the resident. The resident had slid down in the bed with her feet at the footboard and the head of the bed was elevated approximately forty-five (45) degrees. The resident had her lunch tray on the over-the-bed table in front of her and was feeding herself chicken. She could not reach her water or tea. CNA #1 entered the room and Resident #1 reached out for her water glass and asked CNA #1 to hand her her drink. CNA #1 stated that the resident was served meals in bed according to the resident's preference and set-up assistance was provided. She stated that the resident preferred not to be sat up in a seated position for meals. CNA #1 and another staff member repositioned Resident #1 in bed (pulled her up in bed) and raised the head of the bed so that the resident was in a slightly reclined but in a seated position and the resident was able to reach all lunch items. CNA #1 took a seat at the resident's bedside and provided verbal cues and encouragement for the resident to continue to eat.On 9/25/25 at 12:32 PM, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that Resident #1 did not have access to her call light as it was out of sight and out of reach, hanging down below the mattress. LPN #1 stated, She isn't going to reach it there. She confirmed that Resident #1 was routinely served meals while in a reclined position, not in an upright position, and was left alone to feed herself. On 9/25/25 at 1:55 PM, interview with the Staff Development Nurse she stated that the facility policy and current standards of practice for resident meal service included positioning the residents in an upright position for safety prior to meal service and while eating, ensuring that all items were within the residents' reach and sitting beside the resident while assisting to eat or feeding them. She stated that it was facility policy that all staff ensured each resident's call light was within their reach each time they exited a resident room to provide a means for residents to summon assistance as needed. On 9/25/25 at 2:30 PM, an interview with the Director of Nurses (DON) revealed she stated that the policy of the facility and current standards of practice included positioning residents properly in an upright position prior to serving meals. She confirmed that the reason for seating the resident upright was for safety while eating. She stated that she expected nursing staff to position residents appropriately prior to serving meals for the safety of the resident during eating and to sit beside the residents when assisting with meals/feeding residents. She stated that it was important for all staff to ensure the resident's call light was within the reach of the resident prior to exiting the residents' rooms as the residents relied on the call light to alert staff of their need for assistance. On 9/25/25 at 2:50 PM, during an interview CNA#2 revealed that she had been the CNA assigned to the care of Resident #1's care for 6:00 AM through 2:00 PM on 9/24/25. She stated that it was important for residents' call light to be kept within reach as a way for the residents to summon assistance as needed. She confirmed staff were responsible for making sure call lights were left within the resident's reach. She stated that she had not been aware that the resident's call light was not in reach at 12:30 PM and said, It must have fallen.Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 8/14/23 and the resident had diagnoses of diabetes, dementia and chronic kidney disease.Record review of the admission Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 8/08/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Section GG indicated that the resident required partial/moderate assistance for eating.

Based on interviews, record review, and facility policy review, the facility failed to ensure residents' rights for respect and dignity, as evidenced by staff entering resident rooms and providing care while using personal cell phones and wearing earbuds, which residents described as rude and disrespectful. This deficient practice affected two (2) of 18 sampled residents, Resident #4 and Resident #43. Findings Included: A review of the facility's policy, Resident's Rights, dated 3/24, revealed, Every resident in this facility has the right to .12. Be treated courteously, fairly and with the fullest measure of dignity . Resident #4 On 5/8/25 at 9:28 AM, during an interview with Resident #4, she confirmed her concerns shared during the Resident Council meeting and explained that staff often entered her room while on the phone or wearing earbuds. She stated that she felt this was disrespectful and rude. A record review of the admission Record revealed the facility admitted Resident #4 on 3/11/21 with diagnoses including Unspecified Atrial Fibrillation. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/10/25 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Resident #43 On 5/8/25 at 9:28 AM, during an interview with Resident #43, she explained that staff frequently entered her room while using phones or earbuds, which she found disrespectful. A record review of the admission Record revealed the facility admitted Resident #43 on 3/13/24 with diagnoses including an Unspecified Fracture of Sacrum. A record review of the Comprehensive MDS with an ARD of 2/21/25 revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 12, indicating her cognition was moderately impaired. On 5/8/25 at 11:50 AM, during an interview with the Director of Nursing (DON), she explained that she had provided multiple in-services on this issue. She stated that staff should not wear earbuds in resident rooms and acknowledged that it could be irritating to the residents. On 5/8/25 at 12:13 PM, during an interview with the Administrator, she explained that she had also in-serviced staff multiple times regarding not wearing earbuds. She stated that she was unaware the issue was still occurring and emphasized that residents should be given undivided attention because their rooms are their homes.

Based on interview, record review, and facility policy review, the facility failed to accurately code antipsychotic medications on the Minimum Data Set (MDS) for one (1) of eighteen (18) sampled residents, Resident #17. Findings included: A review of the facility's policy, Resident Assessment, revised 9/19, revealed, An assessment will be completed on each resident utilizing the MDS .The Registered Nurse is responsible for the completion of the assessment. The completed assessment guide the staffing in identifying key information about the resident and serves as a basis for identifying resident specific issues and objectives in order to develop a care plan. This process assists the resident in reaching the highest practical physical, mental and psychosocial well-being . A record review of the admission Record revealed the facility admitted Resident #17 on 4/23/21 and she had current diagnoses including Schizoaffective Disorder. A record review of the Comprehensive MDS with an Assessment Reference Date (ARD) of 2/10/25, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated her cognition was moderately impaired. Further review revealed Section N (Medications) indicated that she was not taking an antipsychotic medication. A record review of the Order Review History Report revealed Resident #17 had a Physician's Order, dated 11/21/24, for Abilify 2.5 milligrams (mg) at bedtime. A record review of the Medication Administration Record (MAR) for February 2025, revealed Resident #17 was administered Abilify 2.5 mg at bedtime during the MDS lookback period. A record review of the web page Drugs.com indicated the Drug Class of Abilify is Atypical antipsychotics. On 5/8/25 at 10:13 AM, during an interview with Licensed Practical Nurse (LPN) #1, who also served as the Minimum Data Set (MDS) nurse, she confirmed that completing the MDS for residents was part of her responsibilities. Upon reviewing the physician's order for Resident #17, she acknowledged that while an antipsychotic medication was ordered, it was not coded on the MDS. She stated this was an error. On 5/8/25 at 10:19 AM, during an interview with Registered Nurse (RN) #1, who also functioned as an MDS nurse, she explained that a Utilization Review of the MDS was conducted prior to submission to ensure accuracy. However, upon reviewing the physician's order from 11/21/24 for the antipsychotic medication for Resident #17, RN #1 acknowledged the current MDS did not reflect this order and confirmed that it was an error requiring correction.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure incontinent residents received appropriate care and services to prevent the possibility of urinary tract infection for two (2) of two (2) residents reviewed for perineal care, Resident #20 and Resident #38. This deficiency was also cited on the last Recertification Survey, therefore the scope/severity was increased to E representing a pattern. Findings included: A review of the facility's policy, Perineal Care, revised 1/24, revealed, Purpose to cleanse the perineum, eliminate odor, prevent irritation and to enhance the resident's dignity and self-esteem . Female-without catheter .5. Wash genital area, moving from front to back, while using a clean portion of the washcloth or pre-moistened wash wipe for each stroke . Male without catheter .5. Using the other hand gently cleanse from the tip to the base of the penis. Use a clean portion of the washcloth or pre-moisturized wash wipe after each stroke . Resident #20 A record review of Resident #20's admission Record revealed the facility admitted the resident on 1/11/21 with diagnoses including Hypertension. A record review of Resident #20's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/25 revealed she had a Brief Interview for Mental Status (BIMS) score of 5, which indicated her cognition was severely impaired. Further review revealed she was dependent upon staff for toileting hygiene. On 5/5/25 at 1:55 PM, during an observation of perineal care for Resident #20, Certified Nursing Assistant (CNA) #3 removed Resident #20's pants and brief and began care by wiping only the groin area on each side of the vagina. She did not wipe the vaginal area while providing the care. On 5/5/25 at 2:14 PM, during an interview with CNA #3, she acknowledged that she did not give proper perineal care and stated Resident #20 could get a urinary tract infection by not cleaning the perineal area appropriately. She explained she was supposed to clean both sides and the center of the vaginal area for Resident #20. Resident #38 A record review of Resident #38's admission Record revealed the facility admitted him on 4/5/24 and he had current diagnoses including Dementia. A record review of Resident #38's Quarterly MDS with an ARD of 4/18/25 revealed he required a staff assessment for Mental Status and his cognitive skills for daily decision making were severely impaired. Further review revealed he was dependent upon staff for toileting hygiene. On 5/7/25 at 1:20 PM, an observation revealed CNA #2 providing perineal care to Resident #38. CNA #2 removed the resident's brief and wiped the entire penis several times using the same wipe. She folded the wipe one time during perineal care. She did not clean the penis from the tip to the base, using a clean portion of the pre-moisturized wipe after each stroke. On 5/7/25 at 2:13 PM, during an interview with CNA #2, she acknowledged that she did not perform perineal care correctly because she did not clean the penis by starting at the tip and using a clean wipe for each stroke. On 5/7/25 at 3:50 PM, during an interview with the Licensed Practical Nurse (LPN)/Infection Preventionist (IP), she stated CNA #3 should have cleaned both sides and the center of the vagina for Resident #20 and CNA #2 should have cleaned the penis from the tip down using a clean wipe each time for Resident #38. She explained that Resident #20 and Resident #38 could develop a urinary tract infection (UTI) or other infection due to the improper care they received. On 5/7/25 at 4:00 PM, during an interview with the Director of Nursing (DON), she stated CNA #3 should have wiped the vaginal area down both sides and the center for Resident #20 and CNA #2 should have cleaned the penis from the tip downward, folding the wipe or using a clean one each time for Resident #38. She stated that improper care could result in skin breakdown and expressed that she expects staff to perform peri-care and all resident care correctly.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to ensure an incontinent resident received appropriate care and services to prevent the possibility of a urinary tract infection and failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection during an annual recertification survey on 11/2/2023. The facility was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for two (2) of five (5) deficiencies cited. F690 and F880 Findings included: A review of the facility's policy, Quality Assurance Performance Improvement Program (QAPI) with a revision date of 11/22 revealed, This facility shall develop, implement, and maintain an effective, comprehensive, data driven Quality Assurance Performance Improvement (QAPI) program that focuses on indicators of the outcome of care and quality of life. The facility shall have in place a system that continuously strives to improve the quality of care and services received by residents in this facility. This will be achieved through quality management. Quality management will be a systematic, pro-active process of accessing, controlling and improving outcomes. The system will focus on both health care outcomes and operational efficiency . Record review of the Provider History Profile revealed the facility received a citation for F690-Bowel/Bladder Incontinence, Catheter, UTI (Urinary Tract Infection) and F880-Infection Prevention & Control on the survey dated 11/2/2023. Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 11/02/2023, revealed the facility received a citation for F690, .Based on observation, interviews, record review, and facility policy review, the facility failed to ensure an incontinent resident received appropriate care and services to prevent the possibility of a urinary tract infection . and for F880, .Based on observation, interviews, record review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection . During the current recertification survey, the facility failed to ensure incontinent residents received appropriate care and services to prevent the possibility of urinary tract infection for two (2) of two (2) residents reviewed for perineal care and failed to follow infection control practices during the provision of perineal care for two (2) of two (2) residents observed for perineal care. On 5/8/25 at 11:47 AM, during an interview with the Director of Nursing (DON), she confirmed the facility was cited for the same deficient practices on the previous survey that was identified during the current survey. On 05/08/25 at 2:00PM, in an interview, the Nursing Home Administrator (NHA) explained that she is aware of the previous annual survey citations, and the facility has new staff, and part-time staff could have played a part in the repeat citations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to follow infection control practices during the provision of perineal care for two (2) of two (2) residents observed for perineal care, Resident #20 and Resident #38, as evidenced by not performing hand hygiene, using gloves inappropriately stored in pockets, continuing care with soiled gloves, and retrieving wipes from the packet with contaminated gloves, placing residents at risk for cross-contamination and infection. This deficiency was also cited on the last Recertification Survey, therefore the scope/severity was increased to E representing a pattern. Findings included: A review of the facility's policy, Infection Prevention and Control Program, revised 8/21, revealed, This facility has developed and maintains an infection prevention and control program that provides a safe, sanitary and comfortable environment to help prevent the development and transmission of infection . A review of the facility's policy, Hand Hygiene, revised 1/24, revealed, .Cleanse hands to prevent transmission of infection or other conditions . Indications for Hand Washing .2. Hand hygiene should be performed between all contact with residents or when entering and exiting a resident's room [ROOM NUMBER]. Before and after procedures. 4. Before and after applying gloves. 5. When hands are visibly soiled .Selecting Hand Washing Method .2. When to wash with soap and water .d. When hands are visibly contaminated with blood or bodily fluids . Resident #20 A record review of Resident #20's admission Record revealed the facility admitted the resident on 1/11/21 with diagnoses including Hypertension. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/25 revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident's cognition was severely impaired. On 5/5/25 at 1:55 PM, during an observation of perineal care for Resident #20, Certified Nursing Assistant (CNA) #3, assisted by CNA #1, was observed removing gloves from her pocket and applying them without first performing hand hygiene. CNA #3 also handed a pair of gloves to CNA #1, who applied them without washing her hands. CNA #3 then began providing care to Resident #20, who was visibly soiled with feces. During care, CNA #3 moved from dirty to clean areas without removing gloves or washing her hands. She verbalized awareness by stating she should have changed gloves and performed hand hygiene, but continued care without doing so. CNA #3 applied a clean brief while wearing soiled gloves and was observed removing perineal wipes from the package twice with contaminated gloves. On 5/5/25 at 2:14 PM, during an interview with CNA #3, she acknowledged she should not have stored gloves in her pocket or removed wipes from the pack with soiled gloves. She admitted she should have washed her hands before beginning care and during care. She acknowledged she had not provided proper perineal care and stated that the resident could develop a urinary tract infection as a result. On 5/6/25 at 1:18 PM, during an interview with CNA #1, she confirmed she applied gloves taken from CNA #3's pocket without washing her hands. She acknowledged this was an infection control issue and that gloves should not be stored in pockets, and hand hygiene should be performed prior to donning gloves. Resident #38 A record review of Resident #38's admission Record revealed the facility admitted the resident on 4/5/24 with diagnoses including Dementia. A record review of the Quarterly MDS with an ARD of 4/18/25 revealed the resident required a staff assessment for mental status and was documented as having severely impaired cognitive skills for daily decision making. On 5/7/25 at 1:20 PM, during an observation of perineal care for Resident #38, CNA #2 was observed touching the bed remote control with gloved hands prior to starting care. She continued care by cleaning feces from the resident and removed additional wipes from the package using soiled gloves. On 5/7/25 at 2:13 PM, during an interview with CNA #2, she acknowledged her actions during care were incorrect. She confirmed that retrieving wipes with soiled gloves could contribute to infection and skin breakdown. On 5/7/25 at 3:50 PM, during an interview with the Licensed Practical Nurse (LPN)/Infection Preventionist, she confirmed that hand hygiene should be performed before starting care and gloves should never be stored in pockets. She stated CNA #2 should not have touched the bed remote or pulled wipes from the package with soiled gloves. She acknowledged that both Resident #20 and Resident #38 were at risk of developing urinary tract infections or other complications from improper care. On 5/7/25 at 4:00 PM, during an interview with the Director of Nursing (DON), she confirmed CNAs are expected to wash hands prior to providing care and should not store gloves in pockets. She acknowledged that the improper perineal care observed placed residents at risk for infection and skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days for a resident with a physical and mental decline for one (1) of 21 sampled residents. Resident # 6 Findings include: A record review of the facility's policy Resident Assessment, with revision date 9/2019, revealed .The assessment will describe the resident's physical and mental deficits, strengths, and the requirements of assistance to meet their needs. The assessment will also identify risk factors associated with possible functional decline and describe the resident's objectives for maintaining or improving their functional abilities . During an interview on 11/1/23 at 11:28 AM, with Resident # 6 she revealed she was admitted to the facility for rehabilitation following a stroke. The resident explained that since admission, she had a fall and broke her hip. The resident commented that prior to the fall, she was able to get up and go to the restroom and dress herself without assistance. After the fall, she stated she was not able to do what she had been doing previously. A record review of the Departmental Notes for 8/27/23 reveals that at 9:32 PM, Resident #6 was found of the floor. The resident reported in an attempt to go to the bathroom, as she attempted to sit in her wheelchair, it rolled backwards, causing her to fall. The nurse documented that the resident reported severe pain in her right hip and knee. The physician was called and the resident was sent by ambulance to a local hospital. A record review of therapy notes titled Plan of Treatment for Rehabilitation, revealed in the Initial Assessment portion of the therapy notes, that Resident #6 was referred to therapy following hospitalization due to a right hip fracture with a potential for improvement in functional ADL (Activities of Daily Living) performance, dressing, positioning, functional mobility, and home safety. Therapy notes revealed that the resident's prior level of function regarding ADL was independent. Current evaluation revealed that following hospitalization for a fall resulting in a right hip fracture, the resident had a functional decline in transfers, gait, bed mobility, functional range of motion, safety awareness and skin health. An interview on 11/1/23 at 1:07 PM, with a COTA (Certified Occupational Therapy Assistant) revealed that Resident #6 had been admitted to the facility on [DATE] for rehabilitation following a stroke. The COTA stated that the resident had made significant progress and was working to return home prior to her fall. She explained that prior to her fall, the resident was able to get up and go to the restroom and dress herself without assistance. After the fall, there had been a significant change, as the resident was no longer able to do what she had been doing previously. Record review of Resident #6's medical record revealed a Significant Change MDS was not completed for the resident within 14 days after her significant change. An interview on 11/2/23 at 11:37 AM, with Licensed Practical Nurse (LPN ) #1/MDS Nurse revealed that she had not completed a Significant Change MDS for Resident #6 within 14 days for a resident with a physical and mental decline, as she didn't see that criteria was met with two changes. An interview on 11/2/23 at 12:53 PM, with the Administrator confirmed that the MDS Nurse did not complete a timely Significant Change MDS Assessment for Resident #6 and that it should have been completed within 14 days after her significant physical and mental decline began. The Administrator revealed the failure of proper transmittal was within the time of staffing changes and could have been missed. A record review of the Face Sheet for Resident # 6 revealed the facility admitted the resident on of 7/25/23, with diagnoses that included Hemiplegia following Cerebral Infarction Affecting Left Nondominant Side, Chronic Pain, and Chronic Obstructive Pulmonary disease.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure an incontinent resident received appropriate care and services to prevent the possibility of a urinary tract infection for one (1) of four (4) residents observed for incontinent care. Resident #27 Findings include: Record review of the facility's policy, Perineal Care, revised 10/18, revealed, .Female- Without Catheter . 5. Wash genital area moving from front to back, while using a clean portion of the washcloth or pre-moistened wash wipe for each stroke . 7. Dry genital area moving from front to back with towel . On 10/31/23 at 3:30 PM, an observation of perineal care on Resident #27, revealed Certified Nursing Aide (CNA) #2 did not thoroughly clean the genital area. The CNA used a pre-moistened wash wipe, but only wiped the exterior genital area front to back one time and did not dry the area with a towel. On 10/31/23 at 4:43 PM, in an interview with CNA #1, she stated she did not clean the perineal area properly. She stated she should have cleaned the genital area by wiping from front to back, using a clean portion of the wipe with each stroke. The CNA revealed she only wiped the external genital area one time and did not dry the area. She commented that the resident could get a urinary tract infection or have skin breakdown from the care she gave. On 11/1/23 at 4:17 PM, in an interview with Director of Nurses (DON), she stated CNA #1 should have used one peri wipe to wipe down one side of the perineum, used another clean wipe to wipe down the other side and used another clean wipe to wipe down the middle. She stated CNA #1 should clean the perineal area until it is clean. She stated the actions of the CNA could possibly cause the resident to get a urinary tract infection. Record review of the Face Sheet for Resident #27, revealed the facility admitted the resident on an 1/11/21, with diagnoses that included Unspecified Dementia and Malignant Neoplasm of Pharynx. Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/12/23, revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment.

Based on interview and facility policy review the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to ensure the program was sustained during transitions in leadership and failed to maintain implemented procedures and monitor the interventions the committee put into place in November 2021. This was for one (1) recited deficiency originally cited in November 2021, on an annual recertification survey. The deficiency was in the area of Infection Control for failure to perform hand hygiene during perineal care. The facility's continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee. Findings include: Record review of the facility's policy, QAPI (Quality Assurance and Performance Improvement) Introduction and Purpose, with a revision date of 08/15, revealed . The QAPI program has been developed to incorporate the Continuous Quality and Quality Assurance (QA) process consisting of ongoing analysis of clinical data and program results, identifying and prioritizing opportunities for improvement, implementing interventions and evaluating the effectiveness of those interventions on the quality of care and services . F 880: Cited in 11/2021 for failing to perform hand hygiene during peri care. On 11/2/23 at 3:50 PM, in an interview with Director of Nurses (DON) sated she was aware of the infection control issue from previous survey. She stated they have completed in-services and monitoring. She stated they will re-evaluate and identify additional interventions. On 11/2/23 at 04:00 PM, in an interview with Licensed Practical Nurse (LPN) #2/Infection Preventionist, she stated she was aware of the previous citations. She stated they are not in compliance based on previous survey results. She stated she was not aware of the issues with hand washing and peri care prior to the survey. She stated they met with QAPI after the previous survey and came up with solutions. She stated they did one-on-one training. She stated she plans to do more one-on-one observations and write ups. On 11/2/23 at 4:10 PM, in an interview the Administrator stated she was not the Administrator at the time of the previous survey in 11/2021. She stated she expects the staff to always follow policy and procedure while providing care. She stated she was not aware of the current handwashing issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection for two (2) of 17 sampled residents. Residents #26 and #33 Findings include: Record review of facility's policy, Hand Hygiene, with a revision date of 8/21, revealed, PURPOSE To cleanse hands to prevent transmission of infection or other conditions. To provide clean health environment for residents, staff, and visitor . INDICATIONS FOR HAND WASHING . 3. Before and after procedures 4. Before and after applying gloves . 9. Wearing gloves does not replace the need to perform hand hygiene . Resident #26 On 10/31/23 at 2:50 PM, an observation of Certified Nursing Aide (CNA) #2 performing perineal care for Resident #26 revealed she did not perform hand hygiene prior to applying gloves. After she applied gloves and before beginning care, the resident's call light fell on the floor and the CNA picked it up with her gloved hands and placed it on resident's bed. CNA #2 did not remove the soiled gloves, but instead, began cleaning the perineal area. During the procedure, CNA #2 removed her soiled gloves five (5) times, however, did not perform hand hygiene prior to applying clean gloves and continuing with care. On 10/31/23 at 4:33 PM, in an interview with CNA #2, she confirmed she should have performed hand hygiene before beginning care and should have removed her gloves, performed hand hygiene and applied clean gloves after picking up the call light. CNA #2 also confirmed she did not perform hand hygiene when she changed gloves during the procedure. She stated Resident #26 could get a urinary tract infection from her not washing her hands. CNA #2 revealed that she had attended recently attended an in-service on the importance of performing hand hygiene. On 11/1/23 at 4:13 PM, in an interview the Director of Nursing (DON) confirmed CNA #2 should have performed hand hygiene prior to beginning care and each time she removed her soiled gloves. The DON also confirmed CNA #2 should have removed her gloves and performed hand hygiene after picking up the call light from the floor. She stated the actions of CNA #2 could cause Resident #26 to develop a urinary tract infection. On 11/2/23 at 11:05 AM, in an interview with Licensed Practical Nurse (LPN) #2/ IP (Infection Preventionist) confirmed CNA #2 should have performed hand hygiene before beginning care and each time she removed her gloves. She also stated CNA #2 should have removed her gloves and performed hand hygiene after she picked up the call light from the floor. The IP commented that the actions of CNA #2 could cause Resident #26 to develop an infection. Record review of the sign-in sheets for an in-service on handwashing, dated 8/29/23, revealed CNA #2's signature. Record review of the Face Sheet for Resident #26 revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Alzheimer's Disease, Dysphagia, and Cognitive Communication Deficit. Record review of the admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) 9/29/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident was unable to complete the BIMS. Resident #33 On 10/31/23 at 3:55 PM, during an observation of Percutaneous Endoscopic Gastrostomy (PEG) tube care for Resident #33 with Registered Nurse (RN) #1 revealed RN #1 did not perform hand hygiene after removing the PEG site dressing and before applying new gloves to clean the PEG site, or prior to applying the clean dressing. RN #1 removed her gloves and exited the room without performing hand hygiene. She then returned to room after touching the doorknob and removing a pen from her pocket to date the dressing and again failed to perform hand hygiene prior to touching the dressing to add the date. On 10/31/23 at 4:20 PM, in an interview RN #1 confirmed that while she performed care, she should have performed hand hygiene each time she removed her soiled gloves and applied clean gloves. She stated there is a possibility Resident # 33 could get an infection from her care. She stated the resident's immune system is compromised due to health and age. RN #1 explained she knew she should have performed hand hygiene but forgot. She stated she has had attended in-services on PEG tube care and infection control. On 11/1/23 at 4:16 PM, in an interview the Director of Nurses (DON) she stated RN #1 should have performed hand hygiene each time she removed her gloves. She stated she also should have performed hygiene when she returned to the room to continue care and should not have used a pen in her pocket to date the dressing. The DON confirmed that the actions of RN #1 could cause the Resident #33 to develop an infection. On 11/2/23 at 11:11 AM, in an interview with LPN #2/IP confirmed RN #1 should have performed hand hygiene before leaving the room to get tape and when she returned to the room. She also confirmed that each time the nurse removed her soiled gloves, she should have performed hand hygiene. The IP stated the actions of RN #1 could cause Resident #33 to develop an infection. Record review of the Face Sheet for Resident #33 revealed the facility admitted the resident to the facility on 3/22/19, with diagnoses that included Chronic Diastolic Heart Failure, Cognitive Communication Deficit, and Dysphagia. Record review the MDS, with an ARD of 8/7/23 for Resident #33, revealed a BIMS score of 99, indicating the resident could not participate in the interview. A record review of the physician orders revealed there was an order, dated 8/16/22, for Resident #33's PEG site to be cleaned and dressed every shift, due to increased drainage. Record review of facility in-service sign-in sheets revealed RN #1 attended an in-service on PEG/wound care on 11/24/22.

Based on observation, staff interviews and facility policy review, the facility failed to ensure items in the kitchen refrigerators, freezers, and dry storage room were dated, labeled, and discarded by the expiration date for one (1) of three (3) dietary observations. This has a potential to affect all residents receiving meals prepared by the facility's dietary department. Findings include: A review of the facility's policy titled Food Storage Labeling, with a revision date of 05/18, revealed, Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures. Procedure: 1. Labeling a. All temperature-controlled foods and ready-to-eat foods prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the food, Date of storage . 3. Rotation .b. Food stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer's use-by date or expiration date. Suggested time frames: Dry storage - Weekly, Refrigerator storage- Weekly . During the initial tour of the kitchen with the Dietary Manager (DM) on 10/30/2023 at 9:46 AM, revealed expired food items in the pantry that included three (3) 128 oz. (ounce) plastic containers of Goldens Mustard with an expiration date of 8/06/23, two (2) 128 oz. plastic containers of Ken's Steakhouse Barbecue Dressing with an expiration date of 9/28/23 and (3) 128 oz. plastic containers of Kikkoman Sauce with an expiration date of 10/13/22. Observation of the items in the refrigerator revealed (2) 5 lb. (pound) containers of Wholesale Cottage Cheese, opened, with a green substance around the top. Both containers were unlabeled, with an expiration date of 7/15/23. There was (1) 5 lb. bag of shredded parmesan cheese unlabeled, with an expiration date of 6/14/23. On 10/30/23 at 10:46 AM, in an interview with the DM, regarding kitchen duties, she specified that all staff members of her dietary department are accountable for the proper dating, labeling, and removal of expired foods. Additionally, she disclosed that the Registered Dietitian conducts a monthly inspection to verify that expired foods are appropriately dated, labeled, and removed from the kitchen. Furthermore, the DM affirmed that expired foods must be removed from the kitchen to prevent being served to the residents. She acknowledged that it would be harmful to the residents' health to serve them expired foods. On 11/2/23 at 10:04 AM, during an interview with Dietary Aide (DA) #1, she stated that the DM typically labels and dates food as soon as it is unloaded from the morning truck. However, the assigned responsibility of inspecting expired foods is not established. She stated that instead, it is dependent upon the amount of available time during the shift. DA #1 did not recall attending an in-service that focused on the dating, labeling, and removal of expired foods a few weeks ago. On 11/02/23 at 10:10 AM, during an interview with DA #2, she shared that the DM had a responsibility to verify the food's expiration dates. She acknowledges being new to the job and is still learning. She admitted that failure to remove expired goods from the kitchen could result in them being served to the residents, causing them to become sick. On 11/2/23 at 11:50 AM, the Administrator verified in an interview that she is ultimately liable for ensuring that expired foods are removed from the kitchen. However, she mentioned that the Registered Dietician does monthly inspections to ensure the proper labeling, dating, and removal of expired foods from the kitchen. The Administrator acknowledged that residents could be harmed if expired foods are served.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident? interviews record review and facility policy review the facility failed to notify the physician that dialysis Residents were not receiving their morning medications as prescribed on dialysis days for two (2) of two (2) sampled residents reviewed. Resident #12 and Resident #51. Findings include: A record review of the facility's Change in Resident Medical Status policy revealed a revision date of 09/17 stated, facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with the resident representative when there is . 3. A need to alter treatment significantly .or change an existing treatment due to adverse consequences .). Resident #51 On 11/10/21 at 10:51 AM, in an interview with Licensed Practical Nurse #2 (LPN), stated Resident #51 does not get his 9 :00 AM medication on the days he goes to dialysis. She stated she did not notify the physician the resident's medication was not given. She stated the resident goes to dialysis on Monday, Wednesday, and Friday. She stated the resident is out of the building, so she charts in the Electronic Medication Administration Record (EMAR) for the resident being out of the building. She stated they have never sent medications with the resident. She stated she has not given the resident 9:00 AM medications after dialysis. She stated she did not follow physician orders and that could cause a significant medication error. She stated the resident leaves around 5:00-5:30 AM for dialysis and returns to the facility at 10:30 AM. She stated it is important that the resident gets all his medications. On 11/10/21 at 11:55 AM, in an interview with Physician #1 he explained he was not aware Resident #51 was not getting medication on dialysis days. He stated he makes rounds monthly at the facility and reviews the orders but does not review the EMAR. He stated he has not seen a change in Resident #51's behavior. He stated he has not been contacted to ask about dialysis resident medication and he assumed medications were given. He stated they could give Resident #51's medication at 10:30 AM when the resident returns from dialysis. He explained he expects medications to be given as ordered and it is very important for the resident to receive all medications daily. On 11/10/21 at 3:30 PM, interview with LPN #3, she explained she has worked with Resident #51 on the days the resident went to dialysis. When asked what N meant on the EMAR, she explained it means not given. When asked why she did not report that medications were not given on dialysis days, she explained when she started at the facility, she noticed meds not being given and she thought it was the normal way to do at the facility. She stated they have never sent medications with residents to dialysis and morning medications were not given to resident after dialysis. She stated she did not follow physician orders and missing medications could cause a significant medication error. She stated it is important that Resident #51 gets medications as ordered. Record review of the Face Sheet revealed Resident #51 was admitted to the facility on [DATE] with current diagnoses of Cerebral Infarction due to embolism of left post Cerebral Artery, Acute on Chronic systolic (Congestive Heart Failure (CHF), Chronic Pulmonary Disease (CPD), Type II Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Hypotension, Anxiety Disorder (AD), Recurrent Depression Disorder (RDD), Essential (primary) Hypertension, Gastro-esophageal reflux disease without esophagitis (GERD), Dependence on renal dialysis and Cardiomyopathy. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 10/11/21, revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 09 which indicated Resident # 51 had moderate cognitive impairment. Record review of Resident #51's Physician's Orders revealed an order dated 10/16/20 for Levemir 100 units/ML (milliliter) vial-give 18 units subcutaneous every morning related to DM. Record review of the Resident 51's EMAR revealed on, 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21 the facility failed to administer the 9:00 AM dose of Levemir 100 units/ML vial-give 18 units subcutaneous. Record review of Resident #51's Physician's Orders revealed an order dated 9/29/17 GERD Famotidine 20 MG (milligram) tablet give one tablet by mouth daily for GERD. Record review of the Resident 51's EMAR revealed on, 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21 the facility failed to administer the 9:00 AM dose of Famotidine 20 MG tablet gives one tablet by mouth. Record review of Resident #51's Physician's Orders revealed an order dated 1/20/21 for Lexapro 5 MG tablet one tablet by mouth daily related to depression (target behavior, tearful, anger, withdrawal). Record review of the Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Lexapro 5MG by mouth at 9:00 AM. Record review of Resident #51's Physician's Orders revealed an order dated 8/5/21 for Clopidogrel 75 MG tablet one tablet by mouth daily related to circulation. (Acute or chronic systolic CHF) Record review of the Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Clopidogrel 75 MG by mouth at 9:00 AM. Record review of Resident #51's Physician's Orders revealed an order dated 8/9/21 Aspirin 81 MG chewable tablet-give 4 tablets to equal 325 MG by mouth daily related to circulation. (Acute or chronic systolic CHF) Record review of the Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Aspirin 81 MG chewable tablet-give 4 tablets to equal 325 MG by mouth daily related to circulation. (Acute or chronic systolic CHF) 9:00 AM. Record review of Resident #51's Physician's Orders revealed an order dated 11/8/17 Ferrous Sulfate 325 MG tablet give one tablet by mouth twice daily related to Anemia iron supplement. Record review of the Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Ferrous Sulfate 325 MG tablet give one tablet by mouth twice daily related to Anemia iron supplement. Record review of Resident #51's Physician's Orders revealed an order dated 9/30/21, house liquid protein supplement 30 CC (cubic centimeters) by mouth twice daily related to End Stage Renal Disease (ESRD). Record review of the Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, and 11/8/21 the facility failed to give house liquid protein supplement 30 CC by mouth twice daily related to End Stage Renal Disease (ESRD). Record review of Resident #51's Physician's Orders revealed an order dated 8/5/21, Midodrine HCL 2.5 MG tablet one tablet by mouth three times a day. Record review of the Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, and 11/8/21 the facility failed to give 9 :00 AM dose of Midodrine HCL 2.5 MG tablet one tablet by mouth three times a day related to Hypotension. Record review of Resident #51's Care Plan revealed Resident #51 had the Problem/Need with onset date of 7/1/17, and a Goal and Target Date of 1/11/21 of Has a diagnosis of Hypo and Hypertension Heart Failure/CHF Goal will not have any complications through next review 1/11/22. Interventions included Administer Medications as ordered. Resident #12 A record review of Resident #12's Face Sheet revealed the facility admitted Resident #12 on 08/13/20 with diagnoses of Chronic Systolic Congestive Heart Failure, End Stage Renal Disease, Type 2 Diabetes Mellitus, Alzheimer's Disease, Dementia, Essential Hypertension, Generalized Anxiety, Major Depressive Disorder, and Dependence of renal dialysis. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Renvela 800 milligram (mg) one (1) tablet by mouth with meals three (3) times daily, Abilify 2 mg one (1) tablet by mouth every day, Aspirin 81 mg chewable tablet one (1) tablet by mouth every day, Metoprolol Succinate extended release (ER) 25 mg one (1) tablet by mouth every day, Memantine 10 mg one (1) tablet by mouth twice a day, Brilinta 90 mg one (1) tablet by mouth twice a day, Hydralazine 25 mg one (1) tablet by mouth three times a day, Klonopin 0.5 mg one (1) tablet by mouth every day, and Venlafaxine 75 mg one (1) tablet by mouth daily. Record review of Resident #12's yearly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/02/2021 section C revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #12 had severe cognitive impairment. Section N of the MDS revealed Resident #12 received four (4) days of antipsychotic, antianxiety, and antidepressant medications. Section O of the MDS revealed Resident #12 received dialysis while a resident at the facility. A record review of Resident #12's EMAR for November 2021 revealed on dialysis days (Monday, Wednesday, and Friday) 11/01/21, 11/03/21, 11/05/21, 11/08/21, and 11/10/21, Resident #12 did not receive the following morning medications as ordered: Klonopin 0.5 mg, Venlafaxine 75 mg, Renvela 800 mg, Abilify 2 mg, Aspirin 81 mg, Metoprolol Succinate ER 25 mg, Memantine 10mg, Brilinta 90 mg, and Hydralazine 25 mg. On 11/10/21 at 11:00 AM, during a phone interview with Registered Nurse (RN)#2 from the local dialysis treatment center, she explained Resident #12 does attend the dialysis clinic three (3) times a week. She explained the dialysis clinic only gives the resident the medications listed on the communication forms sent back to the facility and the facility is responsible for all other medications. On 11/10/21 at 10:45 AM during interview with LPN #2, she reviewed the current EMAR and explained the N represented medication not given. She explained none of the medications are given for the morning medication pass. When asked if meds are given when resident returns to the facility, she explained no, the morning medications are not given at all on the day the resident goes to dialysis. She further explained the nurse does not send any medications with the residents. She stated she did not notify the physician the resident's medication was not given. She stated if a resident refuses medication for three days, she contacts the physician. State Survey Agency (SSA) asked her if she should have notified the physician, since the resident did not get medication on dialysis days and missed medications three (3) times a week, she explained she never thought about it like that. She stated she has not given the resident's morning medications after dialysis. She stated she did not follow physician orders and it could cause a significant medication error. She stated it is important that the resident gets medications as ordered. At 11/10/21 at 11:05 AM, during a phone interview with the pharmacy consultant, she explained she has not had access to the resident's EMAR and therefor has not reviewed the resident's EMAR. She reported she was not aware of resident not receiving medications on dialysis days. She explained she was under the impression medications were given when the resident returned to facility from dialysis but has not looked at the EMARs. On 11/10/21 at 11:55 AM, in an interview with Physician #2 he explained he was not aware Resident #12 was not getting medication on dialysis days. He stated he makes rounds monthly at the facility and reviews the orders but does not review the EMARs. He stated he has not been contacted to ask about dialysis resident's medications and assumed medications were given as ordered. He stated they could give Resident #12's medication when resident returns from dialysis. He explained he expects medications to be given as ordered and it is very important for resident to receive all medications daily. On 11/10/21 at 3:30 PM, interview with LPN #3, when asked what N meant on the EMAR, she explained it means not given. When asked why she did not report to anyone medications not given on all of dialysis days, she explained when she started at the facility, she noticed meds not being given she explained she thought it was the normal way to do at the facility. She stated the nurses have never sent medications with resident and morning medications were not given to resident after dialysis. She stated she did not follow physician orders. She stated Resident #12 missing medications could cause a significant medication error. She stated it is important that Resident #12 gets medications as ordered. On 11/10/21 at 5:00 PM, interview with Resident #12, she explained the staff has not reported to her of missing any medication. On 11/10/21 at 11:30 AM, during an interview with interim Director of Nursing (DON), he explained he is not aware of medications not being given on dialysis days. He explained as a Corporate Nurse Consultant, he understood medications were to be given when residents returned to the facility from dialysis unless the physician had ordered something else. He explained the physician should be notified if a resident is not receiving their medications. On 11/10/21 at 4:00 PM, during an interview with RN #1 supervisor, she reported she was not aware that residents were not getting medication on dialysis days. She explained if residents are not getting medications as ordered, residents could have major effects of missing medications. She reported if the medication is for blood pressure the resident's blood pressure can go up, and if the medication is for diabetes, blood sugars can go up. If residents miss depression medication, the medication will not be as effective and can cause changes in behaviors and moods. Medications for depression would not be therapeutic. She explained if a resident is not receiving blood thinning medication such as Plavix or any anticoagulant, missing this kind of medications can cause shunt to clot off and resident can get a blood clot. At 5:10 PM on 11/10/21 interview with the DON, he explained the pharmacy consultant was at the facility on 11/04/21 and he is not sure if she looks at resident's MAR. He explained he seen her follow a nurse with medication pass and done a random cart check. When ask if the MAR was part of the medical records, he explained it is.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 Record review of Resident #12's Face Sheet revealed the facility admitted Resident #12 on 08/13/20 with the diagnoses of Chronic Systolic Congestive Heart Failure, End Stage Renal Disease, Type 2 Diabetes Mellitus, Dementia, Hypertension, Anxiety, Major Depressive Disorder, and Dependence of renal dialysis. Record review of Resident #12's yearly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/02/2021 section C revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #12 had severe cognitive impairment. Record review of Resident #12's Physician Orders for November 2021 revealed orders for Renvela 800 milligram (mg) one (1) tablet by mouth with meals three times daily, Abilify 2 mg one (1) tablet by mouth every day, Aspirin 81 mg chewable tablet one (1) tablet by mouth every day, Metoprolol Succinate extended release (ER) 25 mg one (1) tablet by mouth every day, Memantine 10 mg one (1) tablet by mouth twice a day, Brilinta 90 mg one (1) tablet by mouth twice a day, Hydralazine 25 mg one (1) tablet by mouth three times a day, Klonopin 0.5 mg one (1) tablet by mouth every day, and Venlafaxine 75 mg one (1) tablet by mouth daily. A record review of Resident #12's EMAR for November 2021 revealed on the Mondays, Wednesdays, and Friday dates: 11/01/21, 11/03/21, 11/05/21, 11/08/21, and 11/10/21 Resident #12 did not receive the following morning medications as orders: Klonopin 0.5 mg, Venlafaxine 75 mg, Renvela 800 mg, Abilify 2 mg, Aspirin 81 mg, Metoprolol Succinate ER 25 mg, Memantine 10mg, Brilinta 90 mg, and Hydralazine 25 mg. On 11/10/21 at 10:51 AM in an interview with LPN #2, reviewed the current EMAR and explained the N represented medication not given and further explained Resident #12 does not get her morning medications on the days she goes to dialysis. She stated she did not notify the physician the resident medication was not given. She stated the resident goes to dialysis on Monday, Wednesday, and Friday. State Survey Agency asked her if she should have notified the physician, since the resident did not get medication on dialysis days, she reported she never thought about it like that. She explained the nurses have never sent medications with the resident and she has not given the resident morning medications after dialysis. She stated she did not follow physician orders. She stated it could cause a significant medication error. She stated it is important that the resident gets medications as ordered. On 11/10/21 at 11:00 AM, during a phone interview RN #2 from local dialysis center, she explained Resident #12 does attend the dialysis clinic three (3) times a week. She explained the dialysis center only gives the resident the medications listed on the communication forms and the facility is responsible for all other medications. On 11/10/21 at 11:30 AM, during an interview with the interim Director of Nursing (DON), he explained he is not aware of medications not being given on dialysis days. He explained as a Corporate Nurse Consultant, he understood medications were to be given when residents returned to the facility from dialysis unless the physician had ordered something else. On 11/10/21 at 11:55 AM, in an interview with Physician #2 he explained he was not aware Resident #12 was not getting his medication on dialysis days. He stated he thought the facility set times for dialysis residents to get medications on dialysis days. He stated he has not been contacted to ask about dialysis residents medications. He stated he assumed medications were given as ordered. He stated they could give Resident #12's medication at 10:30 AM when the resident returns. He explained he expects medications to be given as ordered and it is very important for resident to receive all medications daily. On 11/10/21 at 3:30 PM interview with LPN #3, when ask what N meant on the EMAR, she explained it means no and the medication was not given. When asked why she medications were not given, she stated she has never sent medications with the resident and morning medications were not given to the resident after dialysis. She stated she did not follow physician orders. When asked if administering medications to residents was a service the facility provided to the resident, she stated Yes. She explained the resident did not receive medications due to the resident being gone to dialysis. On 11/10/21 at 4:17 PM, during an interview the Interim Administrator, she explained nobody bought it her attention that dialysis residents were not receiving their morning medications due to the residents were gone to dialysis. She explained administering resident medication is a care and service that should be provided to all residents. On 11/10/21 at 6:00 PM, interview with the MDS nurse, LPN #4, she explained once a care plan is in place, she expects the staff to follow the plan of care. She explained if a medication is ordered, she expects the medications to be given unless there is an order in place to hold medication for any reason. She explained if a resident refuses or misses three (3) doses or more of medications, the physician should be notified of the reason for the resident not receiving medications. She explained administering medications is part of the resident's care at the facility. Record review of LPN #3's Employee Corporate Compliance Code Of Conduct revealed her signature for training on Quality of Care and neglect, dated 11/2/21. Based on observation, staff and resident interview, record review and facility policy review the facility failed to ensure residents were free from neglect by failing to administer medications ordered by the physician on dialysis days for two (2) of two (2) residents reviewed for dialysis. Resident # 12 and Resident #51. Findings include: Record review of the facility's policy, Seven Components to Reduce, Detect, and Prevent Abuse and Neglect with an origination date of 06/19 revealed The facility has a comprehensive program to reduce, detect and prevent neglect of the residents Prevent-The facility has policies and procedures in place .to detect and prevent .neglect .IDENTIFY-The facility .maintains a proactive approach for identifying events .that may constitute .neglect .The objective .is to address .neglect at critical points . Record review of the Employee Corporate Compliance Code of Conduct date (05/18) revealed .4. Quality of Care: All .residents .are to be provided care in compliance with all federal and state laws, regulations and guidelines .No .neglect will be tolerated .relevant terms as defined .Neglect: A failure to provide goods and services necessary . Resident #51 On 11/10/21 at 10:51 AM, in an interview with Licensed Practical Nurse #2 (LPN), stated Resident #51 does not get his 9 :00 AM medication on the days he goes to dialysis. She stated she did not notify the physician the resident's medication was not being given. She stated the resident goes to dialysis on Monday, Wednesday, and Friday. She stated the resident is out of the building, so she charts in the Electronic Medication Administration Record (EMAR) that the resident is out of the building. She stated she did not follow physician orders and confirmed it is important that the resident gets all his medications. On 11/10/21 at 11:06 AM, in an interview with Interim Director of Nursing (DON), stated a nurse should get an order on the days the resident goes to dialysis to give medication when they return. He stated it is important that residents get their medications. On 11/10/21 at 11:41 AM, an phone interview with Physician #1 stated, he was not aware that Resident #51 was not getting his 9:00 AM medications on dialysis days. He stated the resident needs their medications. On 11/10/21 at 3:40 PM, in an interview with LPN #2 stated Resident #51 can have stomach and Acid Reflux issues if he does not get his Gastroesophageal Reflux Disease (GERD) medication. She stated resident missing Clopidogrel (Plavix) and Aspirin could cause the resident to have circulatory issues and Congestive Heart Failure. She stated Levemir not given can cause high blood sugar and affect his eyesight. She stated Lexapro can cause the resident to have behavioral issues. On 11/10/21 at 4:00 PM, in an interview with Registered Nurse #1 (RN) Nurse Supervisor/Wound Care Nurse, she stated she was not aware that Resident #51 did not get his 9:00 AM medication on dialysis days. She stated their policy is to notify the Physician. She stated the resident not getting medication can have major effects. She stated that by not receiving the medication for Hypertension and Diabetes could cause the resident's blood pressure and blood sugar to rise and depression medication would not be as effective. She stated it can cause change in behavior and mood and not getting blood thinner medications could cause the resident's dialysis shunt to clot. She stated it is very important that residents get their prescribed medication. On 11/10/21 at 4:17 PM, in an interview the Interim Administrator, she stated nobody bought it her attention, that the resident was not getting his 9:00 AM medications on dialysis days. She stated the resident's medications is a care or service that should be provided. She stated the nurse should have given the medication to the resident when they came back from dialysis. On 11/10/21 at 4:26 PM, in an interview with Resident #51 stated he go to dialysis on Monday, Wednesday, and Friday. He stated he takes one pill before he goes to dialysis. Record review of the Face Sheet revealed Resident #51 was admitted to the facility on [DATE] with current diagnoses of Cerebral Infarction due to embolism of left post Cerebral Artery, Acute on Chronic systolic Congestive Heart Failure (CHF), Chronic Pulmonary Disease (CPD), Type II Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Hypotension, Anxiety Disorder (AD), Recurrent Depression Disorder (RDD), Essential (primary) Hypertension, Gastroesophageal reflux disease without esophagitis (GERD), Dependence on renal dialysis and Cardiomyopathy. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/21, revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 09 which indicated Resident # 51 had moderate cognitive impairment. Record review of Resident #51's Physician's Orders revealed an order dated 10/16/20 for Levemir 100 units/ML vial-give 18 units subcutaneous every morning related to DM. Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on, 11/1/21, 11/3/21, 11/5/21, 11/8/21 and 11/10/21 the facility failed to administer the 9:00 AM dose of Levemir 100 units/ML vial-give 18 units subcutaneous. Record review of Resident #51's Physician's Orders revealed an order dated 9/29/17 for Famotidine 20 MG tablet give one tablet by mouth daily for GERD. Record review of the Resident 51's EMAR revealed on, 11/1/21, 11/3/21, 11/5/21, 11/8/21 and 11/10/21 the facility failed to administer the 9:00 AM dose of Famotidine 20 MG tablet gives one tablet by mouth. Record review of Resident #51's Physician's Orders revealed an order dated 1/20/21 for Lexapro 5 MG tablet one tablet by mouth daily related to depression (target behavior, tearful, anger, withdrawal). Record review of the Resident 51's EMAR revealed on 11/1/21, 11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Lexapro 5 MG. Record review of Resident #51's Physician's Orders revealed an order dated 8/5/21 for Clopidogrel 75 MG tablet one tablet by mouth daily related to circulation. (Acute or chronic systolic CHF). Record review of the Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Clopidogrel 75 MG. Record review of Resident #51's Physician's Orders revealed an order dated 8/9/21 for Aspirin 81 MG chewable tablet-give 4 tablets to equal 325 MG by mouth daily related to circulation. (Acute or chronic systolic CHF) Record review of the Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Aspirin 81 MG chewable tablet-give 4 tablets to equal 325 MG. Record review of Resident #51's Physician's Orders revealed an order dated 11/8/17 for Ferrous Sulfate 325 MG tablet give one tablet by mouth twice daily related to Anemia iron supplement. Record review of the Resident 51's EMAR revealed on 11/1/21, 11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Ferrous Sulfate 325 MG. Record review of Resident #51's Physician's Orders revealed an order dated 9/30/21 for house liquid protein supplement 30 CC by mouth twice daily related to End Stage Renal Disease (ESRD). Record review of the Resident 51's EMAR revealed on 11/1/21, 11/3/21, 11/5/21, and 11/8/21 the facility failed to give the 10:00 AM house liquid protein supplement 30 CC). Record review of Resident #51's Physician's Orders revealed an order dated 8/5/21, Midodrine HCL 2.5 MG tablet one tablet by mouth three times a day. Record review of the Resident 51's EMAR revealed on 11/1/21, 11/3/21, 11/5/21, and 11/8/21 the facility failed to give the 9 :00 AM dose of Midodrine HCL 2.5 MG. Record review of LPN #2's Employee Corporate Compliance Code Of Conduct revealed her signature for training on Quality of Care and neglect, dated 11/2/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #51 On 11/8/21 at 3:49 PM, in an interview with Resident #51 stated he was hospitalized in August. On 11/09/21 at 2:06 PM in an interview with Licensed Practical Nurse (LPN) #2 stated she sent Resident #51 to the emergency room(ER) due to a change in his level of consciousness. On 11/9/21 at 4:00 PM, in an interview with the Interim Director of Nursing (DON) stated Social Services (SS) did not notify the family in writing of the hospitalization. He stated that SS did not know she had to do it. On 11/09/21 at 4:13 PM, interview with the Business Office Manager (BOM) revealed she sends the hospital transfer letters to the Ombudsmen explaining why the resident was transferred to the hospital. The BOM said she did not know to send the letter to the family. The BOM said the nurses call the families explaining the reason for the hospital transfer. The families are also given bedhold letters upon admission. On 11/10/21 at 9:10 AM, in an interview with Social Services stated she does not send any of the paperwork for discharge to the Resident Representative. She stated she was never trained to do it. Record review of the discharge Minimum Data Ser (MDS) with an Assessment Reference Date of 8/2/21 revealed Resident # 51 was sent to the hospital 8/2/21. Based on staff and resident interviews, record review, and facility policy review, the facility failed to ensure two (2) of two (2) sampled residents received written notice of transfer following a transfer to the hospital. Resident # 51 and Resident # 57. Findings Include: Review of the facility's policy, Notice of Hospital Transfer/Therapeutic Leave, revised 8/21, revealed . 2. When a resident is transferred to the hospital, or goes out on therapeutic leave, a copy of the completed form (notice) is provided to the resident, specifying the duration of the bed-hold according to the state plan, and the facility's policy regarding bed-hold periods. In case of emergency transfer, notice at the time of transfer means that the family or resident representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying resident to the hospital. The staff member completing the transfer paperwork .should also be forwarded to the Accounts Manager. The Accounts Manager will contact the Resident representative and complete the verification of telephone notice within 24 hours. The Accounts Manager will also mail a copy of the Notice of Hospital Transfer/therapeutic leave form for signature by the Resident Representative if the Resident Representative is not available to sign on the day they are contacted. A copy of the completed form should be retained in the residents Administrative folder Resident #57 Review of the facility's, Departmental Notes, dated 8/13/21 at 2:14 PM, revealed Late entry for 415 PM 8/12/2021 .Resident received CXR (chest x-ray) .results for CXR received noting extensive pneumonia in both lungs. Resident with a Dx (diagnosis) of COVID .New order to transfer .to (name of local hospital) . During an interview on 11/09/21 at 03:44 PM, with License Practical Nurse (LPN) #1 revealed Resident #57 was at the facility short term. Resident #57 developed COVID-19 and was sent to the hospital. Record review of the Face Sheet revealed Resident #57 was admitted to the facility on [DATE]with diagnoses that included Dementia, Benign Prostatic Hyperplasia (BPH), and Hypertension. Record review of the discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/21 revealed Resident# 57 was discharged to the local hospital and had a Brief Interview for Mental Status (BIMS) score of 2 that indicted Resident # 57 had severe cognitive impairment.

Based on interviews, record review and facility policy review the facility failed to accurately code the Minimum Data Set (MDS) for three (3) of 16 resident MDS reviewed, Resident # 19, Resident #25, and Resident #50. Findings Include: A record review of a statement provided by the facility revealed the MDS assessment staff members of (Formal name of facility) uses the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual for researching and documenting information on the MDS 3.0 Assessment. Record review of the David Drug Guide for Rehabilitation Professionals revealed Aspirin .Classification Therapeutic: antipyretic, nonopioid analgesics . Pharmacologic: salicylates. Record review of the Resident Assessment Instrument (RAI) User's Manual for the MDS 3.0, dated October 2019, revealed Section P: Restraints and Alarms . Assessors will evaluate whether or not a device meets the definition of a physical restraint and code only the devices that meet the definitions in the appropriate categories .Definition Physical Restraints Any manual method or mechanical device, material or equipment attached to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Resident #25 Record review of Resident #25's Five (5) day Medicare admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 09/08/2021, revealed Section N was coded for anticoagulant given for seven (7) days in the last seven (7) days or since admission. Record review of Resident #25's Face Sheet revealed the facility admitted Resident #25 on 09/01/21 with the diagnoses of Pneumonia, Paroxysmal atrial fibrillation, Encounter for prophylactic measures, and other Seasonal Allergic Rhinitis. Record review of Resident #25's Physician Orders List revealed an order dated 9/1/21 for Aspirin Enteric Coated (EC) 81 milligram tablet one by mouth daily related to circulation. There were no anticoagulant medications listed on the Physician Orders List. Record review of Resident #25's Electronic Medication Administration Record (EMAR) for September 2021 revealed Aspirin EC 81 mg was administered daily and there were no anticoagulant medications administered. On 11/09/2021 at 1:30 PM, interview with the MDS nurse (LPN #4), explained she did not know aspirin was not considered an anticoagulant. She reviewed the MDS with an ARD of 09/09/21 and confirmed anticoagulant was selected and coded for the seven (7) days given. On 11/09/2021 at 1:50 PM, interview with the interim Director of Nursing (DON), when asked if aspirin was an anticoagulant, he replied no. He explained he expected all MDS assessments to be coded correctly. Resident #19 On 11/07/21 at 02:25 PM, the State Survey Agency (SSA) observed Resident #19 in the bed with half bedrail noted to the bed. In an interview with Resident #19 on 11/07/21 at 02:31 PM, she explained the bed rails help her move and turn over in bed. She denied having any restraints at any time. Record review of Resident #19's Face Sheet revealed facility admitted Resident #19 on 06/11/21 with diagnosis of Acute Kidney Failure. Record review of Resident #19's Physician Orders for August 2021 revealed no physician orders noted for restraints. Record review of Resident #19's Quarterly MDS with an ARD of 08/18/2021 revealed Section P restraints used in bed; bed rail used daily as physical restraints. On 11/09/2021 at 1:30 PM, during an interview with MDS nurse, LPN #4, she reviewed Resident #19's MDS with an ARD of 08/18/2021 and confirmed bed rail coded as used daily as physical restraints. She explained the MDS was coded in error. She explained prior to recent management changes the facility would do weekly meetings prior to submitting the MDS assessment but that has not been done regularly for months. Resident #50 On 11/07/21 at 04:06 PM, the SSA observed a one-fourth bedrail on Resident #50's bed. On 11/7/21 at 4:10 PM, Resident #50 explained she only has the two small bed rails on her bed and the rails help her with turning and moving in bed and getting up out of bed. Record review of Resident #50's Face Sheet revealed the facility admitted the resident on 04/09/2021 with the diagnoses of Major Depressive Disorder, and Chronic Obstructive Pulmonary Disease. Record review of Resident #50's Quarterly MDS with an ARD of 10/11/21, Section P revealed, bed rail used daily as physical restraints. On 11/09/2021 at 1:30 PM, during an interview with MDS nurse, LPN #4, she reviewed Resident #19's MDS with an ARD of 08/18/2021, and Resident #50's MDS with an ARD of 10/11/21, and confirmed bed rails were coded as used daily as physical restraints. She explained the MDS was coded in error. She explained prior to recent management changes the facility would do weekly meetings prior to submitting the MDS assessment but that has not been done regularly for months. On 11/09/2021 at 1:50 PM, interview with the interim DON, he reported the facility is a restraint free building and there are currently no restraints in use. He explained the facility uses the Long-term Facility Resident Assessment Instruction 3.0 User's Manual for researching and documenting information on the MDS 3.0 Assessment and expects the assessments to be completed accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #51 Record review of the Face Sheet revealed Resident #51 was admitted to the facility on [DATE], with current diagnoses of Cerebral Infarction due to embolism of left post Cerebral Artery, Acute on Chronic systolic Congestive Heart Failure (CHF), Chronic Pulmonary Disease (CPD), Type II Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Hypotension, Anxiety Disorder (AD), Recurrent Depression Disorder (RDD), Essential (primary) Hypertension, Gastro-esophageal reflux disease without esophagitis (GERD), Dependence on renal dialysis and Cardiomyopathy. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 10/11/21, revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated moderate cognitive impairment. Record review of Resident #51's Physician's Orders revealed an order dated 10/16/20 for Levemir 100 units/ML vial-give 18 units subcutaneous every morning related to DM. Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on, 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21 the facility failed to administer the 9:00 AM dose of Levemir 100 units/ML. Record review of Resident #51's Care Plan revealed Resident #51 had the Problem/Need with onset date of 7/01/2017, and a Goal and Target Date of 1/11/22 of Diabetes Mellitus 2 Goal of resident will have early detection of signs of hypo/hyperglycemia through next review date 1/11/22 . Interventions .Administer medications as ordered . Record review of Resident #51's Physician's Orders revealed an order dated 9/29/17 for Famotidine 20 MG tablet give one tablet by mouth daily for GERD. Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on, 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21 the facility failed to administer the 9:00 AM dose of Famotidine 20 MG. Record review of Resident #51's Care Plan revealed Resident #51 had the Problem/Need with onset date of 7/01/2017, and a Goal and Target Date of 1/11/22 of Diabetes Mellitus 2. Approaches included . Administer medications as ordered Record review of Resident #51's Physician's Orders revealed an order dated 1/20/21 for Lexapro 5 MG tablet one tablet by mouth daily related to depression (target behavior, tearful, anger, withdrawal). Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Lexapro 5MG by mouth at 9:00 AM. Record review of Resident #51's Care Plan revealed Resident #51 had the Problem/Need with onset date of 1/20/21, and a Goal and Target Date of 1/11/22 of Potential for altered mood state related to depression. Goal will maintain on lowest effective dose of antidepressant medication to help control mood and behavior with minimal or no side effects through next review date of 1/11/22. Approaches included . Administer Medications as ordered. Record review of Resident #51's Physician's Orders revealed an order dated 8/5/21 for Clopidogrel 75 MG tablet one tablet by mouth daily related to circulation. (Acute or chronic systolic CHF). Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Clopidogrel 75 MG by mouth at 9:00 AM. Record review of Resident #51's Care Plan revealed Resident #51 had the Problem/Need with onset date of 7/1/17, and a Goal and Target Date of 1/11/21 of Has a diagnosis of Hypo and Hypertension HF/CHF Goal will not have any complications through next review 1/11/22. Approaches included . Administer Medications as ordered . Record review of Resident #51's Physician's Orders revealed an order dated 8/9/21Aspirin 81 MG chewable tablet-give 4 tablets to equal 325 MG by mouth daily related to circulation. (Acute or chronic systolic CHF) Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Aspirin 81 MG chewable tablet-give 4 tablets to equal 325 MG by mouth daily related to circulation. (Acute or chronic systolic CHF) Record review of Resident #51's Care Plan revealed Resident #51 had the Problem/Need with onset date of 7/1/17, and a Goal and Target Date of 1/11/21 of Has a diagnosis of Hypo and Hypertension HF/CHF Goal will not have any complications through next review 1/11/22. Approaches included . Administer Medications as ordered . Record review of Resident #51's Physician's Orders revealed an order dated 11/8/17 Ferrous Sulfate 325 MG tablet give one tablet by mouth twice daily related to Anemia iron supplement. Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Ferrous Sulfate 325 MG tablet give, one tablet by mouth twice daily related to Anemia iron supplement. Record review of Resident #51's Care Plan revealed Resident #51 had the Problem/Need with onset date of 7/1/17, and a Goal and Target Date of 1/11/22Have no complications through next review. Approaches included . Administer Medications as ordered . Record review of Resident #51's Physician's Orders revealed an order dated 9/30/21, house liquid protein supplement 30 CC by mouth twice daily related to End Stage Renal Disease (ESRD). Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, and 11/8/21 the facility failed to give house liquid protein supplement 30 CC by mouth twice daily related to End Stage Renal Disease (ESRD). Record review of Resident #51's Care Plan revealed Resident #51 had the Problem/Need with onset date of 6/15/17, and a Goal and Target Date of 1/12/21 Therapeutic diet no added salt/low concentrated sweets double large portion of meat/eggs at each meal/1000 ML fluid restrictions. Will attempt for resident to receive adequate nutrition daily through staff . Approaches included .House liquid protein supplement 30 CC by mouth twice daily related to End Stage Renal Disease (ESRD). Record review of Resident #51's Physician's Orders revealed an order dated 8/5/21, Midodrine HCL 2.5 MG tablet one tablet by mouth three times a day. Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, and 11/8/21 the facility failed to give 9 :00 AM dose of Midodrine HCL 2.5 MG tablet one tablet by mouth three times a day. Related to Hypotension Record review of Resident #51's Care Plan revealed Resident #51 had the Problem/Need with onset date of 7/1/17, and a Goal and Target Date of 1/11/21 of Has a diagnosis of Hypo and Hypertension HF/CHF Goal will not have any complications through next review 1/11/22. Approaches included Administer Medications as ordered . Surveyor: [NAME], [NAME] Resident #12 Record review of Resident #12's Face Sheet revealed the facility admitted Resident #12 on 08/13/20 with the diagnoses of Chronic Systolic Congestive Heart Failure, End Stage Renal Disease, Type 2 Diabetes Mellitus, Dementia, Hypertension, Anxiety, Major Depressive Disorder, and Dependence of renal dialysis. Record review of Resident #12's yearly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/02/2021 section C revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #12 had severe cognitive impairment. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Renvela 800 milligram (mg) tablet, one (1) tablet by mouth with meals three times daily related to end stage renal disease. A record review of Resident #12's Electronic Medication Administration Record (EMAR) revealed on 11/01/21, 11/03/21, 11/05/21, 11/08/21 and 11/10/21 the facility failed to administer the 7:30 AM dose of Renvela 800 mg. Record review of Resident #12's Care Plan revealed Problem/Need with onset date of 08/13/2021 and a Goal and Target Date of 1/26/22 revealed Diagnosis of Renal Insufficiency/Renal Failure/End Stage Renal Disease and Receives Dialysis . with the Goal of resident will have no complications through next review 1/26/22, and Approaches included Administer medications as ordered . Resident is prescribed Renvela. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Abilify 2 mg tablet one (1) tablet by mouth every day related to Dementia. A record review of Resident #12's EMAR revealed on 11/01/21, 11/03/21, 11/05/21, 11/08/21, and 11/10/21 the facility failed to administer the 8:00 AM dose of Abilify 2 mg. Record review of Resident #12's Care Plan revealed Resident 12 had the Problem/Need with onset date of 10/19/2020 and a Goal and Target Date of 01/26/22 of Altered Thought Process related to Moderately Impaired Cognition related to Alzheimer's/Dementia with the Goal of resident will have needs met through next review 01/26/22, and Approaches include . Resident is prescribed Abilify. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Memantine HCL 10 mg tablet one (1) tablet by mouth twice a day related to Dementia. A record review of Resident #12's EMAR revealed on 11/01/21, 11/03/21, 11/05/21, 11/08/21, and 11/10/21 the facility failed to administer the 9:00 AM dose of Memantine HCL 10 mg. Record review of Resident #12's Care Plan revealed Resident 12 had the Problem/Need with onset date of 10/19/2020 and a Goal and Target Date of 01/26/22 of Altered Thought Process related to Moderately Impaired Cognition related to Alzheimer's/Dementia with the Goal of resident will have needs met through next review 01/26/22, and Approaches include . Resident is prescribed Memantine HCL. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Aspirin 81 mg chewable tablet one (1) tablet my mouth every day related to heart failure. A record review of Resident #12's EMAR revealed on 11/01/21, 11/03/21, 11/05/21, 11/08/21, and 11/10/21 the facility failed to administer the 8:00 AM dose of Aspirin 81 mg. Record review of Resident #12's Care Plan revealed Resident 12 had the Problem/Need with onset date of 10/19/2020 and a Goal and Target Date of 01/26/22 of Diagnosis of Heart Failure/Hypertension with the Goal of resident will be of any complications through next review 01/26/22, and Approaches include . Administer medications as ordered .Resident is prescribed Aspirin. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Metoprolol Succinate ER 25 mg tab take one (1) tablet by mouth every day related to hypertension. A record review of Resident #12's EMAR revealed on 11/01/21, 11/03/21, 11/05/21, 11/08/21, and 11/10/21 the facility failed to administer the 8:00 AM dose of Metoprolol Succinate ER 25 mg. Record review of Resident #12's Care Plan revealed Resident 12 had the Problem/Need with onset date of 10/19/2020 and a Goal and Target Date of 01/26/22 of Diagnosis of Heart Failure/Hypertension with the Goal of resident will be of any complications through next review 01/26/22, and Approaches include .Administer medications as ordered .Resident is prescribed Metoprolol Succinate. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Brilinta 90 mg tablet take one (1) tablet by mouth twice a day related to heart failure. A record review of Resident #12's EMAR revealed on 11/01/21, 11/03/21, 11/05/21, 11/08/21, and 11/10/21 the facility failed to administer the 9:00 AM dose of Brilinta 90 mg. A record review of Resident #12's Care Plan revealed Resident 12 had the Problem/Need with onset date of 10/19/2020 and a Goal and Target Date of 01/26/22 of Diagnosis of Heart Failure/Hypertension with the Goal of resident will be of any complications through next review 01/26/22, and Approaches include .Administer medications as ordered .Resident is prescribed Brilinta. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Hydralazine HCL 25 mg tablet take one (1) tablet by mouth three times a day related to hypertension (hold if systolic blood pressure is below 110). A record review of Resident #12's EMAR revealed on 11/01/21, 11/03/21, 11/05/21, 11/08/21, and 11/10/21 the facility failed to administer the 9:00 AM dose of Hydralazine HCL 25 mg. A record review of Resident #12's Care Plan revealed Resident 12 had the Problem/Need with onset date of 10/19/2020 and a Goal and Target Date of 01/26/22 of Diagnosis of Heart Failure/Hypertension with the Goal of resident will be of any complications through next review 01/26/22, and Approaches include . Administer medications as ordered .Resident is prescribed Hydralazine HCL. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Klonopin 0.5 mg generic Clonazepam tablet take one (1) tablet by mouth everyday related to anxiety. A record review of Resident #12's EMAR revealed on 11/01/21, 11/03/21, 11/05/21, 11/08/21, and 11/10/21 the facility failed to administer the 8:00 AM dose of Klonopin 0.5 mg. Record review of Resident #12's Care Plan revealed Resident 12 had the Problem/Need with onset date of 10/19/2020 and a Goal and Target Date of 01/26/22 of Risk for Depression/Anxiety with the Goal of resident will have no complications through next review and resident will not show an increase in depression mood through next review 01/26/22 and Approaches include . Administer medications as ordered .Resident is prescribed Clonazepam. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Venlafaxine HCL 75 mg tablet take one (1) tablet by mouth daily related to depression. A record review of Resident #12's EMAR revealed on 11/01/21, 11/03/21, 11/05/21, 11/08/21, and 11/10/21 the facility failed to administer the 9:00 AM dose of Venlafaxine HCL. Record review of Resident #12's Care Plan revealed Resident 12 had the Problem/Need with onset date of 10/19/2020 and a Goal and Target Date of 01/26/22 of Risk for Depression/Anxiety with the Goal of resident will have no complications through next review and resident will not show an increase in depression mood through next review 01/26/22, and Approaches include . Administer medications as ordered . Resident is prescribed Venlafaxine HCL. On 11/10/21 at 10:45 AM, during interview with LPN #2 reviewed the current EMAR and explained the N represented medication not given and further explained none of the medications are given for the morning medication pass. When asked if meds are given when resident returns to the facility, she explained no, the morning medications are not given at all on the day resident goes to the dialysis. She further explained the nurse does not send any medications with the residents. She stated she did not notify the physician the resident's medication was not given. She explained the nurses have never sent medications with Resident #12 to dialysis and she has not given Resident #12 any morning medications after dialysis. She stated she did not follow physician orders and that could cause a significant medication error. She stated it is important that the resident get medications as ordered. On 11/10/21 at 11:00 AM, during a phone interview with RN#2 from the local dialysis treatment center, she explained the dialysis clinic only gives the resident the medications listed on the communication forms sent back to the facility and the facility is responsible for all other medications. On 11/10/21 at 11:30 AM, during an interview with the interim Director of Nursing (DON), he explained he is not aware of medications not being given on dialysis days. He explained as a Corporate Nurse Consultant, he understood medications were to be given when residents returned to the facility from dialysis unless the physician had ordered something else. On 11/10/21 at 11:55 AM, in an interview with Physician #2 he explained he was not aware Resident #12 was not getting medication on dialysis days. He stated he thought the facility set times for dialysis resident to get medications on dialysis days. He stated he has not been contacted to ask about dialysis residents medications. He stated he assumed medications were given as ordered. He stated they could give Resident #12's medication when resident returns. He explained he expects medications to be given as ordered and it is very important for resident to receive all medications daily. On 11/10/21 at 3:30 PM interview with LPN #3, when asked what N meant on the EMAR, she explained it means no and the medication was not given. She explained she has never sent medications with Resident #12 and morning medications were not given to resident after dialysis. She explained she did not follow physician orders and Resident #12 missing medications could cause a significant medication error. She stated it is important that Resident #12 gets medications. On 11/10/21 at 6:00 PM, interview with the MDS nurse, LPN #4, she explained once a care plan is in place, she expects the staff to follow the plan of care. She explained if a medication is ordered, she expects the medications to be given unless there is an order in place to hold medication for any reason. She explained if a resident refuses or misses three (3) doses or more of medications, the physician should be notified of the reason for the resident not receiving medications. She explained administering medications is part of the resident's care at the facility. Based on observation, interviews and facility policy review the facility failed to follow the comprehensive care plan for three (3) of (16) care plans reviewed. Resident #12, Resident #39 and Resident #51. Findings include: Record review of the facility's policy, Care Plan Process with a revision date of 08/17 revealed, The care plan format includes the Problem Statement, the Goal, the Interventions, the staff responsible to carry out the interventions . Resident #39 Record review of Resident #39's care plan with a Problem onset date of 2/4/2020 revealed .Is at high risk for skin break down and is frequently incontinent of bowel and bladder .Approaches .Incontinent care every two (2) hours and PRN(as needed) .Provide peri care following each incontinence episode. During an incontinent care observation, on 11/09/21 at 10:00 AM, CNA # 3 failed to follow Resident #39's care plan by failure to provide care in a manner to prevent the possible spread of infection when she cleansed the residents peri area in a circular motion. CNA #3 wiped the peri area several times with the same side of the towel, then wiped down the middle of the vaginal area. CNA #3 turned the Resident over and cleansed the Resident's buttocks wiping from back to front with soap and water. CNA #3 also wiped the Resident from back to front with the rinse water. In an interview on 11/9/21 at 10:30 AM, interview with CNA #3 confirmed she failed to change the position of the towel while providing incontinent care. CNA #3 also confirmed she wiped the Resident from back to front while cleansing her buttocks. CNA #3 confirmed this could cause the Resident to get infections by not wiping from front to back. During an interview on 11/10/21 at 6:00 PM, with License Practical Nurse (LPN) #4, explained once a care plan is in place, she expects the staff to follow the plan of care. LPN #4 said CNA #3 should change positions with each wipe. LPN #4 said this could cause the resident to get Urinary Tract Infections if the CNA does not change the area of the towel when providing incontinent care. Record review of the Face Sheet revealed the facility admitted Resident #39 on 2/04/20 with the diagnosis that included Hemiplegia, Convulsions, and Hypertension. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 09/30/21, revealed Resident# 39 had a Brief Interview for Mental Status (BIMS) score of 14 that indicted Resident #39 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 A record review of Resident #12's Face Sheet revealed the facility admitted Resident #12 on 08/13/20 with diagnoses of Chronic Systolic Congestive Heart Failure, End Stage Renal Disease, Type 2 Diabetes Mellitus, Alzheimer's Disease, Dementia, Essential Hypertension, Generalized Anxiety, Major Depressive Disorder, and Dependence of renal dialysis. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Renvela 800 milligram (mg) one (1) tablet by mouth with meals three times daily, Abilify 2 mg one (1) tablet by mouth every day, Aspirin 81 mg chewable tablet one (1) tablet by mouth every day, Metoprolol Succinate extended release (ER) 25 mg one (1) tablet by mouth every day, Memantine 10 mg one (1) tablet by mouth twice a day, Brilinta 90 mg one (1) tablet by mouth twice a day, Hydralazine 25 mg one (1) tablet by mouth three times a day, Klonopin 0.5 mg one (1) tablet by mouth every day, and Venlafaxine 75 mg one (1) tablet by mouth daily. A record review of Resident #12's Electronic Medication Administration Record (EMAR) for November 2021 revealed on the Monday, Wednesday, and Friday dialysis days of 11/01/21, 11/04/21, 11/05/21, 11/08/21 and 11/10/21, Resident #12 did not receive the following morning medications as orders: Klonopin 0.5 mg, Venlafaxine 75 mg, Renvela 800 mg, Abilify 2 mg, Aspirin 81 mg, Metoprolol Succinate ER 25 mg, Memantine 10 mg, Brilinta 90 mg, and Hydralazine 25 mg. On 11/10/21 at 10:45 AM, during interview with LPN #2, she explained none of Resident #12's morning medications are given for the morning medication pass on the days Resident #12 goes to dialysis due to Resident #12 is not in the building. When asked if meds are given when resident returns to the facility, she explained no, the medications are not given at all on days Resident #12 goes to dialysis because Resident #12 is gone to dialysis. She further explained the nurse does not send any medications to dialysis with the residents. When asked if administering medications was part of the care and services the facility must provide for the residents, she explained yes. On 11/10/21 at 11:00 AM, during a phone interview RN #2 from local dialysis center, she explained Resident #12 does attend the dialysis clinic three (3) times a week. She explained the dialysis only gives the resident the medications listed on the communication forms and the facility is responsible for all other medications. On 11/10/21 at 11:30 AM, during an interview with interim Director of Nursing (DON), he explained he is not aware of medications not being given on dialysis days. He explained as a Corporate Nurse Consultant, he understood medications were to be given when residents returned to the facility from dialysis unless the physician had ordered something else. On 11/10/21 at 11:55 AM, in an interview with Physician #2 he explained he was not aware Resident #12 was not getting medication on dialysis days. He stated he thought the facility set times for dialysis resident to get medications on dialysis days. He stated he has not been contacted to ask about dialysis resident medication. He stated he assumed medications were given as ordered. He stated they could give Resident #12's medication when resident returns from dialysis. He explained he expects medications to be given as ordered and it is very important for resident to receive all medications daily. On 11/10/21 at 3:30 PM interview with LPN #3, when ask what N meant on the MAR, she explained it means no and the medication was not given. When ask why she medications were not given, she explained thought it was the normal way to do at the facility, residents do not receive morning medication of dialysis days. She stated she has never sent medications with Resident #12 and morning medications were not given to the resident after dialysis because resident was not in the building. She stated she did not follow physician orders. When asked if administering medications to residents was a service the facility provided to the resident and if the resident did not receive medications due to the resident being gone to dialysis, she explained yes. A record review of Resident #12's Yearly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/02/2021 section C revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #12 had severe cognitive impairment. On 11/10/21 at 11:00 AM, during a phone interview RN #2 from local dialysis center, she explained Resident #51 and Resident #12 do attend the dialysis clinic three (3) times a week. She explained the dialysis only gives the resident the medications listed on the communication forms and the facility is responsible for all other medications. On 11/10/21 at 4:17 PM, during an interview the Interim Administrator, she explained nobody bought it her attention that dialysis residents were not receiving their morning medications due to the residents were gone to dialysis. She explained administering resident medication is a care and service that should be provided to all residents. Based on staff interviews, records review, and facility policy review the facility failed to provide care and services for residents receiving dialysis for two (2) of two (2) sampled residents. Resident #12 and Resident #51. Finding include: A record review of the facility's policy Hemodialysis-Care of Resident latest revision date 12/20, revealed Goal: . Dialysis center shall provide to the facility information on all aspects of the management of the resident's care related to the provision of dialysis services . Evaluation: 3. Notify physician immediately of problems . follow physician orders . Resident #51 On 11/10/21 at 10:45 AM, during interview with LPN #2, she explained none of Resident #51's morning medications are given for the morning medication pass on the days Resident #51 goes to dialysis due to Resident #51 is not in the building. When asked if meds are given when the resident returns to the facility, she explained no, the medications are not given at all on days Resident #51 goes to dialysis because Resident #51 is gone to dialysis. She further explained the nurse does not send any medications with the resident. When asked if administering medications was part of care for the residents, she explained yes. On 11/10/21 at 11:30 AM, during an interview with the interim Director of Nursing (DON), he explained he is not aware of medications not being given on dialysis days. He explained as a Corporate Nurse Consultant, he understood medications were to be given when residents returned to the facility from dialysis unless the physician had ordered something else. On 11/10/21 at 11:55 AM, in an interview with Physician #2 he explained he was not aware Resident #51 was not getting medication on dialysis days. He stated he thought the facility set times for dialysis residents to get medications on dialysis days. He stated he has not been contacted to ask about dialysis resident medication. He stated he assumed medications were given as ordered. He stated they could give Resident #12's medication at 10:30 AM when the resident returns. He explained he expects medications to be given as ordered and it is very important for resident to receive all medications daily. On 11/10/21 at 3:30 PM, in an interview with LPN #3, she explained she had worked with Resident #51 on the days the resident went to dialysis. When asked what N meant on the Electronic Medication Administration Record (EMAR), she explained it means no and the medication was not given. When asked why the medications were not given, she explained she thought it was the normal way to do at the facility, residents do not get morning medication on dialysis days. She stated she has never sent medications with the resident and morning medications were not given to the resident after dialysis because the resident was not in the building. She stated she did not follow physician orders. When asked if administering medications to residents was a care and service the facility provided to the resident, she explained yes. Record review of the Face Sheet revealed Resident #51 was admitted to the facility on [DATE] with current diagnoses of Cerebral Infarction due to embolism of left post Cerebral Artery, Acute on Chronic systolic Congestive Heart Failure (CHF), Chronic Pulmonary Disease (CPD), Type II Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Hypotension, Anxiety Disorder (AD), Recurrent Depression Disorder (RDD), Essential (primary) Hypertension, Gastro-esophageal reflux disease without esophagitis (GERD), Dependence on renal dialysis and Cardiomyopathy. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 10/11/21, revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated moderate cognitive impairment. Record review of Resident #51's Physician's Orders revealed an order dated 10/16/20 for Levemir 100 units/ML(milliliter) vial-give 18 units subcutaneous every morning related to DM. Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21, 11/3/21, 11/5/21, 11/8/21 and 11/10/21 the facility failed to administer the 9:00 AM dose of Levemir 100 units/ML vial-give 18 units subcutaneous. Record review of Resident #51's Physician's Orders revealed an order dated 9/29/17 for Famotidine 20 MG tablet give one tablet by mouth daily for GERD. Record review of the Resident 51's EMAR revealed on, 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21 the facility failed to administer the 9:00 AM dose of Famotidine 20 MG (milligram) tablet gives one tablet by mouth. Record review of Resident #51's Physician's Orders revealed an order dated 1/20/21 for Lexapro 5 MG tablet one tablet by mouth daily related to depression (target behavior, tearful, anger, withdrawal). Record review of the Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Lexapro 5MG by mouth at 9:00 AM. Record review of Resident #51's Physician's Orders revealed an order dated 8/5/21 for Clopidogrel 75 MG tablet one tablet by mouth daily related to circulation. (Acute or chronic systolic CHF). Record review of Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Clopidogrel 75 MG by mouth at 9:00 AM. Record review of Resident #51's Physician's Orders revealed an order dated 8/9/21 for Aspirin 81 MG chewable tablet-give 4 tablets to equal 325 MG by mouth daily related to circulation. (Acute or chronic systolic CHF). Record review of the Resident 51's EMAR revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Aspirin 81 MG chewable tablet-give 4 tablets to equal 325 MG. Record review of Resident #51's Physician's Orders revealed an order dated 11/8/17 for Ferrous Sulfate 325 MG tablet give one tablet by mouth twice daily related to Anemia iron supplement. Record review of the Resident 51's EMAR revealed on 11/1/21, 11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Ferrous Sulfate 325 MG. Record review of Resident #51's Physician's Orders revealed an order dated 9/30/21, house liquid protein supplement 30 CC (cubic centimeters) by mouth twice daily related to End Stage Renal Disease (ESRD). Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, and 11/8/21 the facility failed to give house liquid protein supplement 30 CC twice a day. Record review of Resident #51's Physician's Orders revealed an order dated 8/5/21 for Midodrine HCL 2.5 MG tablet one tablet by mouth three times a day. Record review of the Resident 51's EMAR revealed on 11/1/21, 11/3/21, 11/5/21, and 11/8/21 the facility failed to give the 9 :00 AM dose of Midodrine HCL 2.5 MG. Record review of the Employee Corporate Compliance Code Of Conduct revealed LPN #2 and LPN #3's signatures for training on Quality of Care and neglect, dated 11/2/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 A record review of Resident #12's Face Sheet revealed the facility admitted Resident #12 on 08/13/20 with the diagnoses of Chronic Systolic Congestive Heart Failure, End Stage Renal Disease, Type 2 Diabetes Mellitus, Dementia, Alzheimer's Disease, Essential Hypertension, Generalized Anxiety, Major Depressive Disorder, and Dependence of renal dialysis. A record review of Resident #12's Yearly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/02/2021, Section C revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #12 had severe cognitive impairment. Section O of the MDS revealed Resident #12 received dialysis treatment while a resident at the facility. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Renvela 800 milligram (mg) one (1) tablet by mouth with meals three times daily, Abilify 2 mg one (1) tablet by mouth every day, Aspirin 81 mg chewable tablet one (1) tablet by mouth every day, Metoprolol Succinate extended release (ER) 25 mg one (1) tablet by mouth every day, Memantine 10 mg one (1) tablet by mouth twice a day, Brilinta 90 mg one (1) tablet by mouth twice a day, Hydralazine 25 mg one (1) tablet by mouth three times a day, Klonopin 0.5 mg one (1) tablet by mouth every day, and Venlafaxine 75 mg one (1) tablet by mouth daily. A record review of Resident #12's Electronic Medication Administration Record (EMAR) for November 2021 revealed the Monday, Wednesday, and Friday dialysis days of November 1st, 3rd, 5th, 8th, and 10th Resident #12 did not receive the following morning medications as ordered as indicated by an N for each dose: Klonopin 0.5 mg, Venlafaxine 75 mg, Renvela 800 mg, Abilify 2 mg, Aspirin 81 mg, Metoprolol Succinate ER 25 mg, Memantine 10mg, Brilinta 90 mg, and Hydralazine 25 mg. Based on staff interviews, record reviews, and facility policy review, the facility's pharmacy consultant failed to review Electronic Medication Administration Records (EMAR) to ensure the correct medication process was completed for two (2) of two (2) dialysis residents reviewed. Resident #51 and Resident #12. Findings include: A record review of the facility's Pharmacist Services Policy with latest revision date of 11/17 revealed The facility shall have a written agreement for the provision of pharmaceutical services in order to meet the needs of the residents . B) Consultant: The facility will provide Pharmacy Consultation on all aspects of the provision of Pharmacy Services in the facility; i.e., there will be a monthly audit of medication processes in the facility to ensure the correct procedures are being followed. The Consultant Pharmacist shall .inspect medication processes . ensure proper administration of medications . On 11/10/21 at 11:05 AM, during a phone interview with the Pharmacy Consultant, she explained she has been working from home and reviewing the resident's physician orders from home and has not been having access to the residents' EMAR. She was not aware of residents not receiving medications on dialysis days. She reported she was under the impression medications were given when resident returned to facility from dialysis. She explained she has not reviewed Resident #51's or Resident #12's EMARs. On 11/10/21 at 5:10 PM, interview with the Interim Director of Nursing (DON), he explained the Pharmacy Consultant was at the facility on 11/04/21. He explained he is not sure if she looks at resident's EMAR. He explained he saw her follow a nurse with medication pass and do a random cart check. When asked if the EMAR was part of the medical records, he explained it is and he has not been informed by the facility Pharmacy Consultant of any irregularities in administering medications or the medication processes for residents. On 11/10/21 at 11:30 AM interview with Interim DON, he explained he is not aware of medications not being given on dialysis days. He explained as a Corporate Nurse Consultant, he has not been informed from the Pharmacy Consultant of any irregularities in the medications. Resident #51 Record review of Resident 51's EMAR for November 2021 revealed an N for the following medications on 11/1/21, 11/3/21, 11/5/21, 11/8/21 and 11/10/21, which indicated the facility failed to administer the 9:00 AM doses of Levemir 100 units/ML(milliliters) 18 units, Famotidine 20 MG (milligram) tablet, Lexapro 5 MG tablet, Clopidogrel 75 MG tablet, Aspirin 81 mg 4 tablets to equal 325 MG, Ferrous Sulfate 325 MG tablet, Midodrine HCL 2.5 MG tablet, Multivitamins tablet, and the 10:00 AM house liquid protein supplement 30 CC (cubic centimeters). On 11/10/21 at 3:30 PM, interview with LPN #3, when ask what N meant on the MAR, she explained it means no and the medication was not given. When asked when why she did not report to anyone regarding medications not given on all of dialysis days, she explained when she started at the facility, she noticed medications not being given on dialysis days and thought it was the normal way to medications for dialysis residents at the facility. Record review of Resident #51's Physician's Orders dated November 2021 revealed orders for Levemir 100 units/ML (milliliter) vial-give 18 units subcutaneous every morning related to Diabetes Mellitus (DM). Famotidine 20 MG (milligram) tablet give one tablet by mouth daily, Lexapro 5 MG tablet one tablet by mouth daily related to depression, Clopidogrel 75 mg tablet 1 tablet by mouth daily related to circulation, Aspirin 81 MG chewable tablet-give 4 tablets to equal 325 MG by mouth daily related to circulation, Ferrous Sulfate 325 MG tablet give one tablet by mouth twice daily related to Anemia/ iron supplement, house liquid protein supplement 30 CC (cubic centimeters) by mouth twice daily related to End Stage Renal Disease (ESRD), Midodrine HCL 2.5 MG tablet one tablet by mouth three times daily related to hypotension and Multivitamins tablet one by mouth. Record review of the Face Sheet revealed Resident #51 was admitted to the facility on [DATE] with current diagnoses of Cerebral Infarction due to embolism of left post Cerebral Artery, Acute on Chronic systolic (Congestive Heart Failure (CHF), Chronic Pulmonary Disease (CPD), Type II Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Hypotension, Anxiety Disorder (AD), Recurrent Depression Disorder (RDD), Essential (primary) Hypertension, Gastro-esophageal reflux disease without esophagitis (GERD), Dependence on renal dialysis and Cardiomyopathy. Record review of the discharge Minimum Data Set (MDS) with an Assessment Reference Date of 10/11/21, revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated moderate impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 A record review of Resident #12's Face Sheet revealed the facility admitted Resident #12 on 08/13/20 with the diagnoses of Chronic Systolic Congestive Heart Failure, End Stage Renal Disease, Type 2 Diabetes Mellitus, Dementia, Hypertension, Anxiety, Major Depressive Disorder, and Dependence of renal dialysis. A record review of Resident #12's Physician Orders for November 2021 revealed orders for Renvela 800 milli gram (mg) one (1) tablet by mouth with meals three times daily, Abilify 2 mg one (1) tablet by mouth every day, Aspirin 81 mg chewable tablet one (1) tablet by mouth every day, Metoprolol Succinate extended release (ER) 25 mg one (1) tablet by mouth every day, Memantine 10 mg one (1) tablet by mouth twice a day, Brilinta 90 mg one (1) tablet by mouth twice a day, Hydralazine 25 mg one (1) tablet by mouth three times a day, Klonopin 0.5 mg one (1) tablet by mouth every day, and Venlafaxine 75 mg one (1) tablet by mouth daily. A record review of Resident #12's Yearly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/02/2021 section C revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #12 had severe cognitive impairment. Section N of the MDS revealed Resident #12 received four (4) days of antipsychotic, antianxiety, and antidepressant medications. A record review of Resident #12's EMAR for November 2021 revealed on the Mondays, Wednesdays, and Friday dialysis days of November 1st, 3rd, 5th, 8th, and 10th, Resident #12 did not receive the following morning medications as ordered: Klonopin 0.5 mg, Venlafaxine 75 mg, Renvela 800 mg, Abilify 2 mg, Aspirin 81 mg, Metoprolol Succinate ER 25 mg, Memantine 10mg, Brilinta 90 mg, and Hydralazine 25 mg. On 11/10/21 at 10:45 AM, during interview and record review of the current Electronic Medication Administration Record (EMAR) with LPN #2 for Resident #12, she explained the N represented medication not given. She explained none of Resident #12's medications are given for the morning medication pass. When asked if medications are given when Resident #12 returns to the facility, she explained no, the morning medications are not given at all on the day Resident #12 goes to the dialysis. She further explained the nurse does not send any medications with the resident. She stated Resident #12 is out of the building, so she charts as resident not being in the facility at medication pass time. She stated the nurses have never sent medications with Resident #12. She stated she has not given Resident #12's morning medications after dialysis. She stated she did not follow physician orders. She stated it could cause a significant medication error. She stated it is important that resident get medications. On 11/10/21 at 11:00 AM during a phone interview with RN#2 from local dialysis treatment center, she explained Resident #12 and Resident #51 attend the dialysis clinic three (3) times a week. She explained the dialysis clinic only gives the resident the medications listed on the communication forms sent back to the facility and the facility is responsible for all other medications. On 11/10/21 at 11:30 AM during an interview with interim Director of Nursing (DON), he explained he is not aware of medications not being given on dialysis days. He explained as a Corporate Nurse Consultant, he understood medications were to be given when residents returned to the facility rom dialysis unless the physician had ordered something else. He explained the physician should be notified if a resident is not receiving their medications. On 11/10/21 at 11:55 AM in an interview with Physician #2 he explained he was not aware Resident #12 was not getting medication on dialysis days. He stated he makes rounds monthly at the facility and reviews the orders but does not review the EMARs. He stated he does not think it will make a difference if the resident takes medication when they return or take medications with her to dialysis. He stated he thought the facility set times for dialysis residents to get medications on dialysis days. He stated he has not seen a change in Resident #12's behavior. He stated he has not been contacted to ask about dialysis resident medication. He stated he assumed medications were given. He stated they could give Resident #12's medication at 10:30 AM when the resident returns. He explained he expects medications to be given as ordered and it is very important for resident to receive all medications daily. On 11/10/21 at 3:30 PM, interview with LPN #3, when ask what N meant on the EMAR, she explained it means not administered and the medication was not given. She stated the nurses have never sent medications with the resident and morning medications were not given to the resident after dialysis. She stated she did not follow physician orders. She stated Resident #12 missing medications could cause a significant medication error. She stated it is important that Resident #12 gets medications. When ask what missing medications could cause for the resident, she explained missing Abilify and Memantine could cause increase in Dementia episodes, missing Aspirin and Brilinta could increase chance of resident getting blood clots and cause the shunt to become clotted, missing Metoprolol and Hydralazine could cause increased blood pressure, missing Klonopin 0.5 mg could cause increased anxiety, and missing Venlafaxine could cause increased depression. On 11/10/21 at 4:00 PM, during an interview with RN #1 supervisor, she reported she was not aware that residents were not getting medication on dialysis days. She stated no nurses ever came and told her. She explained if the nurses had told her so she would have been aware, and she could have figured something out. She stated if there is a pattern the nurse should have noticed. She explained if residents are not getting medications as ordered, residents could have major effects of missing medications. She reported if the medication is for blood pressure the resident's blood pressure can go up, and if the medication is for diabetes, blood sugars can go up. If residents miss depression medication, the medication will not be as effective and can cause changes in behaviors and moods. Medications for depression would not be therapeutic. She explained if a resident is not receiving blood thinning medication such as Plavix or any anticoagulant, missing this kind of medication can cause the shunt to clot off and the resident can get a blood clot. She reported she thought all medications were given to residents after returning from dialysis. Record review of LPN #3 Employee Corporate Compliance Code Of Conduct reveals signature for training on Quality of Care and neglect, dated 11/2/21. Based on observations, staff and resident interview, record review, and facility policy review the facility failed to administer significant medications as ordered for two (2) of two (2) dialysis residents. Resident #12 and Resident #51. Findings include: Record review of the facility's policy, Drug Administration and Documentation, revision date 4/021, revealed .If a dose of regularly scheduled medication is refused, held or for some reason not given for more than two (2) doses in a row, notify the attending physician. Record review of the facility's policy, Medication Errors, revision date 03/2015, revealed .Note: a significant medication error is one that cause resident discomfort and or jeopardizes his/her health and or safety . Resident #51 On 11/10/21 at 10:51 AM, in an interview with Licensed Practical Nurse #2 (LPN), she stated Resident #51 does not get his 9:00 AM medication on the days he goes to dialysis. She stated she did not notify the physician the resident's medication was not given. She stated the resident goes to dialysis on Monday, Wednesday, and Friday and is out of the building, so she charts in the Electronic Medication Administration Record (EMAR) for the resident being out of the building. She stated they have never sent medications with the resident. She stated she has not given Resident #51's 9:00 AM medications after dialysis. She stated she did not follow physician orders and it could cause a significant medication error. She stated the resident leaves around 5:00-5:30 AM for dialysis and returns to the facility at 10:30 AM. She stated it is important that the resident gets all medications. On 11/10/21 at 11:06 AM, in an interview with the Interim Director of Nursing (DON), stated we are supposed to get an order to give medication when the resident is out of the building. He stated the resident is back by 10:30 AM so the nurse should get an order to give medication upon return to the facility. As a nurse we should obtain an order on the days the resident goes to dialysis to give medication when they return. He stated it is important that residents get their medication. On11/10/21 at 11:41 AM, a phone interview with Physician #1 revealed he was not aware that Resident #51 was not getting his 9:00 AM medications on dialysis days. He stated he has not been contacted about the resident not getting his medications. He stated he would have told them to give the resident his medication after he returns from dialysis. He stated he assumed that the facility gave the medication before or after dialysis. He stated the resident needs their medication. On 11/10/21 at 3:40 PM, in an interview with LPN #2, she stated that Resident #51 can have stomach and acid reflux issues if does not get his medication for Gastro-esophageal reflux disease (GERD). She stated the resident missing Plavix and aspirin could cause the resident to have circulatory issues and congestive heart failure. She stated Levemir not given can cause high blood sugar and affect his eyesight. She stated missing Lexapro can cause the resident to have behavioral issues. On 11/10/21 at 4;00 PM, in an interview with Registered Nurse #1 (RN) Nurse Supervisor/Wound Care Nurse, she stated she was not aware that Resident #51 did not get his 9:00 AM medication. She stated their policy is to notify the Physician. She stated the resident not getting medication can have major effects. She stated missing hypertension and diabetes medication can cause resident blood pressure and blood sugar to rise. She stated a resident that misses his medication for depression could cause the medication to not be as effective. She stated it can cause changes in behavior and mood. Medication for depression would not be therapeutic. She stated it is very important that residents get their prescribed medication. She stated not getting blood thinner medications can cause the shunt to clot. On 11/10/21 at 4;17 PM, in an interview with the Interim Administrator she stated nobody bought it her attention that Resident #51 was not getting his 9:00 AM medication. She stated the resident medication is a service that should be provided. She stated the nurse should gave the mediation to resident when they come back from dialysis. On 11/10/21 at 4:26 PM in an interview with Resident #51, he stated he goes to dialysis on Monday, Wednesday and Friday. He stated he takes one pill before he goes to dialysis. Record review of the Face Sheet revealed Resident #51 was admitted to the facility on [DATE] with current diagnoses of Cerebral Infarction due to embolism of left post Cerebral Artery, Acute on Chronic systolic (Congestive Heart Failure (CHF), Chronic Pulmonary Disease (CPD), Type II Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Hypotension, Anxiety Disorder (AD), Recurrent Depression Disorder (RDD), Essential (primary) Hypertension, GERD, Dependence on renal dialysis and Cardiomyopathy. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 10/11/21, revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated moderate cognitive impairment. Record review of Resident #51's Physician's Orders revealed an order dated 10/16/20 for Levemir 100 units/ML vial-give 18 units subcutaneous every morning related to DM. Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on, 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21 the facility failed to administer the 9:00 AM dose of Levemir 100 units/ML. Record review of Resident #51's Physician's Orders revealed an order dated 9/29/17 for Famotidine 20 MG tablet give one tablet by mouth daily for GERD. Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on, 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21 the facility failed to administer the 9:00 AM dose of Famotidine 20 MG. Record review of Resident #51's Physician's Orders revealed an order dated 1/20/21 for Lexapro 5 MG tablet one tablet by mouth daily related to depression (target behavior, tearful, anger, withdrawal). Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21, 11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Lexapro 5MG. Record review of Resident #51's Physician's Orders revealed an order dated 8/5/21 for Clopidogrel 75 MG tablet one tablet by mouth daily related to circulation. (Acute or chronic systolic CHF). Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Clopidogrel 75 MG. Record review of Resident #51's Physician's Orders revealed an order dated 8/9/21 for Aspirin 81 MG chewable tablet-give 4 tablets to equal 325 MG by mouth daily related to circulation. (Acute or chronic systolic CHF) Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Aspirin 81 MG. Record review of Resident #51's Physician's Orders revealed an order dated 11/8/17 for Ferrous Sulfate 325 MG tablet give one tablet by mouth twice daily related to Anemia iron supplement. Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, 11/8/21 and 11/10/21, the facility failed to administer the 9:00 AM dose of Ferrous Sulfate 325 MG. Record review of Resident #51's Physician's Orders revealed an order dated 9/30/21 for house liquid protein supplement 30 CC by mouth twice daily related to End Stage Renal Disease (ESRD). Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, and 11/8/21 the facility failed to give house liquid protein supplement 30 CC. Record review of Resident #51's Physician's Orders revealed an order dated 8/5/21, Midodrine HCL 2.5 MG tablet one tablet by mouth three times a day. Record review of the Resident 51's Electronic Medication Administration Record (EMAR) revealed on 11/1/21,11/3/21, 11/5/21, and 11/8/21 the facility failed to give 9 :00 AM dose of Midodrine HCL 2.5 MG tablet one tablet by mouth three times a day. Related to Hypotension Record review of Resident #51's Care Plan revealed Resident #51 had the Problem/Need with onset date of 7/1/17, and a Goal and Target Date of 1/11/21 of Has a diagnosis of Hypo and Hypertension HF/CHF Goal will not have any complications through next review 1/11/22. Interventions Administer Medications as ordered. Record review of LPN #2 competency evaluation revealed her signature on the page dated 9/17/18. The Annual Licensed Skills Competency Evaluation form revealed training on administering medication. Record review of LPN #2 Employee Corporate Compliance Code Of Conduct reveals signature for training on Quality of Care and neglect, dated 11/2/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review the facility failed to prevent the possible spread of infection for two (2) of five (5) resident care observations (peri care and wound care). Resident #5 and Resident #39. Findings include: Record review of the facility's policy, Infection Prevention and Control Surveillance Policy, revision date 8/2021, it is policy of this facility to prevent infections whenever possible . Record review of the facility's policy, Hand Hygiene, with a revision date of 10/2017, revealed, Purpose . To cleanse hands to prevent transmission of infection or other conditions . Procedure .4. Before and after applying gloves . After contact with inanimate objects (including medical equipment). Review of the facility's, Perineal Care, policy revised 10/18 revealed . Female without a catheter . 5. Wash genital area, moving from front to back, while using a clean portion of the washcloth or pre-moistened wash wipe for each stroke. 6. When soap is used, rinse genital area moving front to back using a clean portion of the washcloth or pre-moistened wash wipe for each stroke. 7. Dry genital area moving front to back with a towel. Resident #5 On 11/9/21 at 9:15 AM, an observation of incontinent care by Certified Nursing Assistant #1 (CNA) and assisted by Lead CNA #2 revealed before CNA#1 began peri care she applied clean gloves and raised the bed by turning the bed crank at the foot of the bed. CNA #1 did not remove gloves and sanitize hands. She began peri care with the same gloves on. CNA #1 provided peri care to the front of the resident's vaginal area and stated to the State Agency that she was going to remove gloves and sanitize hands and apply clean gloves. CNA #1 did not sanitize hands or wash hands. She changed gloves and continued care. CNA #1 did not sanitize hands or wash hands throughout peri-care. On 11/9/21 at 1:35 PM, in an interview with CNA #1, she stated she did not wash her hands. She stated her actions could cause cross contamination and make the resident sick. She stated she should have washed hands before applying clean gloves. She stated she should have changed gloves after using the bed crank to adjust the resident's bed. On 11/9/21 at 1:40 PM, in an interview with CNA #2, she stated that CNA #1 should have washed her hands and changed gloves when she raised the bed and sanitized hands before putting on clean gloves during care. On 11/10/21 at 9:21 AM, in an interview with Licensed Practical Nurse (LPN)/ Infection Control Nurse stated that CNA #1 should have removed gloves after using the bed crank. CNA#1 should have removed gloves, sanitized her hands and applied clean gloves. She stated CNA #1's actions could cause the resident to get Urinary Tract Infection, vaginal infection or wound infection. On 11/10/21 at 12:34 PM, in an interview with Interim Director of Nursing (DON) stated CNA #1 should have changed gloves and sanitized hands after touching the bed crank. He stated she should have done this before starting care. He stated that is an infection control issue. He stated it could introduce infection to the resident. He stated the resident could get a urinary tract infection. Record review of CNA #1's Performance and Skill Evaluation dated 10/4/21 for infection control revealed her signature. On 11/9/21 at 10 :25 AM, an observation of wound care provided by Registered Nurse #1(RN) revealed she used her gloved hands to lower resident bed rail and then begin wound care. She did not change gloves, sanitize hands, or apply clean gloves after touching the bed rail. On 11/9/21 at 10:55 AM, in an interview with RN #1 stated she should have taken the gloves off, sanitize her hands and put on clean gloves before beginning wound care. On 11/10/21 at 9:25 AM, in an interview with LPN #1/ Infection Control Nurse stated RN #1 should have removed gloves when she touches anything. She stated RN #1 should have stopped and washed her hands and put on fresh gloves. She stated RN #1 spread germs by not changing gloves and she could spread germs to the wound. Whatever she touched she carried it to the wound. She stated this can lead to infection of the wound. On 11/10/21 at 12:30 PM, in an interview with the Interim DON, he stated RN #1 should have removed gloves and sanitized hands after touching the bed rail and before beginning care. He stated that is an infection control issue. He stated it can cause the wound to get infected. Record review of the Physician Orders dated 11/3/21, revealed clean sacral wound with normal saline and pack with kerlix moistened with Dakin's solution. Cover with ABD pad and secure with tape two times a day till healed. Record review of Resident #5's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses of unspecified lack of coordination, pressure ulcer of sacral region, stage three (3), Dementia in other diseases classified elsewhere with behavioral disturbance, and muscle weakness. Record review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/18/21 revealed a Brief Interview of Mental Status (BIMS) score of 03, which indicated the resident had severely impaired cognition. Section G is coded total dependence for toileting and personal hygiene two-person physical assist. Section H is coded always incontinent of bowel and bladder. Section M is coded for stage 3 pressure wounds. Record review of a In-service Sign In Sheet on Hand Hygiene dated 10/6/21, revealed signature of RN #1. Record review of RN #1 Orientation Checklist revealed hand hygiene was checked off on 8/18/21. `Resident #39 During an observation on 11/9/2021 at 10:00 AM, revealed Certified Nursing Assistant (CNA) #3 provide incontinent care to Resident #39. CNA #3 cleansed the residents peri area in a circular motion. CNA #3 wiped the peri area several times with the same side of the towel, then wiped down the middle of the vaginal area. CNA #3 turned Resident #39 over and cleansed the Resident's buttocks wiping from back to front with soap and water. CNA #39 also wiped the Resident from back to front with the rinse water. During an interview on 11/9/21 at 10:30 AM, CNA #3 confirmed she failed to change the position of the towel while providing incontinent care. CNA #3 also confirmed she wiped Resident # 39 from back to front while cleansing her buttocks. CNA #3 confirmed this could cause Resident #39 to get infections by not wiping from front to back. During an interview on 11/9/20 at 11:00 AM, with License Practical Nurse (LPN) #1 said CNA #3 should have changed the position on the towel after each swipe. LPN #1 also said CNA #3 was trained to wipe from front to back because this could cause the resident to get infections. LPN #1 said the staff watch incontinent care videos upon hire and quarterly. The staff is also checked off periodically during the year. Record review of CNA #3's CNA Performance and Skills Evaluation with a date of employment of 8/24/2021 revealed, Section A: Skills Evaluation for Perineal Care male/female was dated 9/8 (21) and checked S for satisfactory and was initialed by CNA #3. An Inservice Training dated 10/6/21 on Resident Care revealed CNA #3's signature was on the sign in sheet as having attended the inservice. Record review of the Face Sheet revealed Resident #39 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia, Convulsions, and Hypertension. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/21 revealed Resident# 39 had a Brief Interview for Mental Status (BIMS) score of 14 that indicted Resident #39 is cognitively intact.