Based on observations, staff interviews and record reviews the facility failed to promote dignity as evidenced by a resident not being assisted with his meal immediately after nursing staff delivered the meal tray to his room for one (1) of eight (8) residents reviewed for dining. Resident #16 Findings Included: Record review of the facility policy titled, Residents' Rights with no revision date revealed Residents Rights Under Federal Law. The facility shall protect and promote the rights of each resident, including each of the following rights: 1. The resident has a right to a dignified existence, self-determination, communication with access to people and services inside and outside the facility . On 11/3/24 at 5:28 PM, during a continuous observation, Resident #16 was observed in bed as Certified Nursing Assistant (CNA) #8 delivered a meal tray to his room, placing it on the overbed table positioned against the wall and out of the resident's reach. The tray remained covered as CNA #8 exited the room without assisting Resident #16. She then delivered the meal tray to Resident #16's roommate, setting it up for the roommate to eat before leaving the room. Upon exiting, she informed Resident #16 that someone would be in shortly to assist him. Nursing staff were observed walking past the room but did not enter to assist Resident #16. At 5:34 PM on 11/3/24, Registered Nurse (RN) #1 entered the room and began assisting Resident #16 with his meal. She confirmed that Resident #16 could not feed himself and required assistance from the staff. She agreed that CNA #8 should have assisted Resident #16 when she brought the meal tray into the room, rather than leaving it and setting up the roommate's meal. She acknowledged that this could make the resident feel that his needs were not being prioritized. In an interview with CNA #8 on 11/3/24 at 5:40 PM, she explained that as long as the food remains covered, they usually leave the tray in the room and wait for someone to assist the resident. She mentioned that she was assigned to the room but was not specifically tasked with assisting Resident #16 with eating assistance, stating that no one is assigned specifically to assist residents; instead, staff members assist residents as they see the need. She confirmed she was aware that Resident #16 required assistance with eating. An interview on 11/4/24 at 2:00 PM, with Licensed Practical Nurse (LPN) #2 indicated that the facility has a list of residents who require assistance with eating to inform staff. She stated that while no staff member is specifically assigned to assist residents with eating, all nursing staff are responsible for passing trays and assisting residents requiring help when delivering the tray. In a follow-up interview on 11/4/24 at 2:05 PM, the Director of Nursing (DON) verified that all nursing staff are responsible for passing trays and, when bringing a tray into the room of a resident who requires assistance, they are expected to assist the resident at that time rather than leaving the tray unattended. She agreed that CNA #8 should not have set up the roommate's meal while leaving Resident #16's tray without assistance, acknowledging this as a dignity concern. Record review of the admission Record revealed that the facility admitted Resident #16 on 6/6/14 with diagnoses including Multiple Sclerosis. Record review of the Quarterly Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 9/25/24 revealed, under Section GG Functional Abilities and Goals, Resident # 16 is dependent for eating.

Based on resident and staff interview, record review, and facility policy review, the facility failed to honor a resident's right to make health care decisions for one (1) of 25 residents reviewed for advanced directives. Resident #58 Findings Include: Record review of the facility policy titled Advanced Directives with a revision date of 8/11 revealed under, Policy Interpretation and Implementation: 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. Record review of the Advanced Directive Form for Resident #58 revealed a family member signed the form dated 4/23/24, with no signature from the resident. An interview with Resident #58 on 11/4/24 at 1:20 PM, revealed when he admitted to the facility, he did not sign his advanced directives form and explained that no one had spoken to him regarding his code status. He revealed he felt it was important that he make his own decisions because he might not feel the same way as his family members. An interview with Social Services (SS) #1 on 11/4/24 at 1:40 PM, confirmed Resident #58 did not sign his own advanced directive form. She revealed if a resident was cognitive and able to sign it, they should because the residents have a right to self-determination. An interview with the Director of Nursing (DON) on 11/5/24 at 7:59 AM, revealed Resident #58 was cognitive and could make his own health care decisions. She confirmed he should have been allowed to sign his own advanced directive form, ensuring his wishes were honored. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/24 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #58 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #58 on 4/23/24 with a medical diagnosis that included Nontraumatic Intracranial Hemorrhage.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to provide a safe, clean, and comfortable environment, as evidenced by an over-bed table with exposed jagged edging (Resident #4) and a sagging mattress (Resident #58) for two (2) of 61 residents. Findings include: Review of the facility policy titled Maintenance Service with a revision date of December 2009 revealed, Maintenance service shall be provided to all areas of the building, grounds, and equipment. J. Ensuring equipment is maintained in good, operational working order. Resident #4 An observation on 11/03/24 at 4:25 PM, revealed Resident #4 lying in bed with her overbed table pulled up to her. The overbed table edging was missing around the table, exposing chipped and jagged wood. An observation on 11/04/24 at 8:25 AM, revealed the overbed table remained in the same condition as the prior day. During an interview and observation on 11/04/24 at 1:30 PM, Certified Nurse Aide (CNA) #4 confirmed that Resident #4's overbed table was tattered and torn and revealed she had not reported the condition of the overbed table to anyone. She revealed that when they see equipment or anything that needs repair in a resident's room, they are supposed to notify the nurse or maintenance. In an interview and observation on 11/04/24 at 1:48 PM, the Director of Nurses (DON) confirmed that Resident #4's overbed table needed to be replaced and revealed that the resident could get hurt by the exposed wood around the edge of the table. She revealed that all department heads make rounds each morning and look at each room to ensure there are no issues. Record review of the admission Record revealed the facility admitted Resident #4 on 06/22/2020 with medical diagnoses that included Parkinson's Disease with Dyskinesia. Resident # 58 An observation and interview with Resident #58 on 11/03/24 at 3:11 PM, revealed him lying in bed. He explained that his mattress was uncomfortable and had a sag in the middle. The resident revealed he had told all of the staff that entered his room that his mattress was uncomfortable. An observation and interview on 11/4/24 at 8:20 AM, with Resident #58 revealed, the resident lying on a raised perimeter mattress which the resident explained made it difficult for him to turn side to side in the bed. An observation and interview with Licensed Practical Nurse (LPN) # 1 on 11/4/24 at 1:00 PM, revealed she was not aware of Resident #58's complaints regarding the mattress. She revealed the nursing staff were responsible for changing out the mattresses. LPN #1 confirmed the resident should be comfortable, and the equipment should be in good repair. An interview with the DON on 11/5/24 at 7:58 AM, revealed Resident #58 should have a regular mattress, but had a raised perimeter mattress because the facility did not have any regular mattresses on hand. She confirmed the resident should have a comfortable mattress. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/24 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #58 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #58 on 4/23/24 with a medical diagnosis that included Nontraumatic Intracranial Hemorrhage.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure residents were free from physical restraints as evidenced by a resident with full side rails to both sides of the resident's bed for one (1) of two (2) residents reviewed for restraints. Resident #44. Findings Include: A review of the facility policy titled Residents' Rights with no revision date revealed The facility shall protect and promote the rights of each resident, including each of the following rights: . The resident has a right to be free from any physical restraints imposed or psychoactive drugs administered for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. During an observation on 11/03/24 at 3:35 PM, Resident #44 was observed in bed with side rails extending the length of the bed on both sides. In an interview on 1/4/24 at 1:12 PM, Certified Nursing Assistant (CNA) #3 stated that she did not know why Resident #44 had full side rails on his bed. During an interview on 1/4/24 at 1:17 PM, with a Licensed Practical Nurse (LPN) #1, she stated that Resident #44 has had full side rails for approximately two weeks. She noted that the full side rails were implemented to prevent the resident from getting out of bed, as he had previously used half (1/2) side rails but was climbing out. She mentioned that she contacted hospice to request full side rails, which have been in place since then. In an interview on 1/4/24 at 2:12 PM, the Director of Nursing (DON) verified that Resident #44's bed had full side rails extending the length of the bed on both sides and confirmed that the resident has a history of attempting to get out of bed. She acknowledged that the side rails act as a restraint, preventing the resident from getting out of bed. A record review of Resident #44's Order Summary revealed an order for Bilateral 1/2 Side Rails to Assist with Turning and Positioning with an onset date of 6/10/24. A record review of the Assessments for Resident #44 revealed no documentation of a side rail or restraint assessment. A record review of Resident #44's medical record indicated no consent for the use of the full side rails on the resident's bed. In a follow-up interview with the DON on 11/5/24 at 8:05 AM, she confirmed that Resident #44 did not have a side rail or restraint assessment, consent, or physician orders for full side rails on both sides of the bed. She stated that consent should have been obtained from the resident's representative and that education regarding side rail use should have been provided. Additionally, she acknowledged that an assessment should have been conducted to ensure the full side rails were safe for the resident. Record review of the admission Record revealed that the facility admitted Resident #44 on 7/12/22 with diagnoses including Dementia.

Based on staff interview, record review, and facility policy review the facility failed to ensure that the Minimum Data Set Assessment (MDS) was coded accurately for one (1) of 22 sampled residents. Resident #19. Findings Included: Record review of the facility policy, titled Resident assessment Instrument revealed Policy Statement: A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. Policy Interpretation and Implementation .4. Information derived from comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. 7. All persons who have completed any portion of the MDS Resident Assessment Form must sign such a document attesting to the accuracy of such information. Record review of Resident #19's Annual MDS with Assessment Reference Date (ARD) of 7/2/24, revealed in Section A 1500 coded as No, Is the resident currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have serious mental illness and/or intellectual disability or a related condition? Record review of Resident #19's Summary of Findings Report, from the PASRR Office, dated 1/29/2019, under Mental Health revealed the individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Interview with MDS Nurse on 11/5/24 at 1:15 PM, she verified that the Annual MDS with an ARD of 7/2/24, for Resident # 19 was coded incorrectly, because the resident does have a mental illness. She agreed that the MDS should be coded correctly to ensure that the resident is receiving the correct level of care. A record review of the admission Record revealed Resident #19 was admitted by the facility on 1/14/19 with a diagnoses including Schizophrenia.

Based on resident and staff interviews, record review, and facility policy review the facility failed to complete a baseline care plan timely and provide a summary of the baseline care plan to the resident and their representative for two (2) of three (3) baseline care plans reviewed. Resident 59 and 166 Findings include: A review of the facility policy titled, Care Plans-Baseline, with a revision date of 12/2016 revealed Policy Interpretation and Implementation: 1.) To ensure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 4.) The residents and their representatives will be provided with a summary of the baseline care plan . Resident #59 A record review of the Baseline Care Plan for Resident #59 revealed the care plan was completed on 8/22/24 with no signature of the resident or representative acknowledgement of receipt of the care plan summary findings. In an interview with Resident # 59 on 11/4/24 at 3:00 PM, she revealed that there were no staff that discussed her plan of care with her on admission. Record review of the admission Record revealed the facility admitted Resident #59 on 8/22/24. Record review of Resident #59's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Resident #166 A review of the Baseline Care Plan for Resident #166 revealed the care plan was initiated on 11/1/24, the day of admission by staff but was not completed within 48 hours. Further review of the baseline care plan revealed there was no signature of family, resident or representative notification of the baseline care plan summary findings. In an interview with Resident #166 on 11/3/24 at 2:00 PM, he revealed that no one explained his plan of care to him when he was admitted . In an interview with the MDS nurse on 11/04/24 at 12:00 PM, she revealed she was unaware that the Baseline Care Plan needed to be completed within 48 hours or that the findings needed to be discussed with the resident or the representative. She then confirmed that they have not been discussing the Baseline Care Plan findings with the new admission residents or the representatives. The MDS nurse revealed the purpose of the Baseline Care Plan is to identify resident needs and direct staff resident required care. In an interview with the Care Plan Nurse on 11/04/24 at 12:15 PM, she revealed that she was unaware of a timeframe for the Baseline Care Plan to be completed. She also revealed she was not aware that the facility was supposed to discuss the care plan findings with the resident/resident representative and confirmed she has not been discussing the baseline plan of care with any of the new admissions. In an interview with the Director of Nursing on 11/04/24 at 12:22 PM, she revealed she was unaware that the baseline care plan findings needed to be discussed with the resident/resident representative within 48 hours of admission. Review of the admission Record revealed the facility admitted Resident #166 on 11/01/24. Record review of Resident #166's BIM Evaluation dated 11/01/24 revealed a BIMS score of 13, indicating the resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) care to maintain hygiene as evidenced by: Resident # 9, # 17, #58 were observed with long jagged fingernails and Resident #12 was observed with unkept and greasy hair and an unkept beard for four (4) of 61 residents reviewed for ADL care. Residents #9, #12, #17 and #58. Findings Included: Record review of a statement on facility letterhead, undated, and signed by the Administrator revealed We do not have a direct policy ADLs. Resident #9 An observation on 11/03/24 at 2:30 PM revealed, Resident #9 lying in bed with long jagged nails on both hands, measuring approximately three-eighths (3/8) inch in length past the tips of the fingers with a brown substance underneath. An observation and interview with the Director of Nursing (DON) on 11/4/24 at 1:10 PM, confirmed Resident #9's nails were long and had a brown substance underneath. She revealed the treatment nurse was responsible for cutting and cleaning the residents' nails. She explained the facility did not have a task set up for the residents to get nail care on a routine basis. The DON revealed the long nails, and the brown substance underneath could cause an infection if the resident scratched herself. Record review of the admission Record revealed the facility admitted Resident #9 on 12/13/13 with medical diagnoses that included Dementia, unspecified. Resident #12 An observation on 11/03/24 at 3:15 PM, revealed Resident #12's hair was unkept and greasy in appearance and his beard/facial hair was unkept and disheveled. An observation on 11/04/24 at 8:00 AM, revealed Resident #12's appearance was the same as the previous observation on 11/3/24 at 3:15 PM. In an observation of Resident #12 with Licensed Practical Nurse (LPN) #1 on 11/04/24 at 12:55 PM, she revealed that Resident # 12's hair appeared very oily and unkept, his face appeared oily, and his facial hair appeared unkept, and he needed to be shaved. She also revealed that Resident #12 had a strong body odor that was related to the need for a bath and good personal hygiene care. She stated that concerns from not bathing/shaving the resident could lead to dandruff build-up and skin concerns. In an interview with the DON on 11/05/24 at 7:15 AM, she revealed that staff failing to provide needed ADL care like bathing and grooming could lead to skin issues. Review of the admission Record revealed the facility admitted Resident #12 on 12/15/21 with diagnoses that included Epilepsy. Record review of Resident #12's Section GG: Self-Care of the MDS with an ARD of 9/25/24 was coded as dependent for personal hygiene. Resident #17 An observation on 11/03/24 at 2:44 PM, revealed Resident #17 fingernails were untrimmed and approximately (one) 1 inch in length past the tips of the fingers and jagged in appearance. In an observation of Resident #17 with LPN #1 on 11/04/24 at 12:50 PM, she confirmed Resident #17's fingernails on both hands were long and jagged. She stated that the nails being long and jagged could cause skin concerns such as breakdown. In an interview with the DON on 11/05/24 at 3:20 PM, she revealed staff not cutting the resident's nails could lead to skin concerns. Review of the admission Record revealed the facility admitted Resident #17 on 9/11/15 with diagnoses that included Contractures to right and left hands. Record review of Resident #17's Section GG: Self-Care of the MDS with an ARD of 8/22/24 was coded as dependent for personal hygiene. Resident #58 An observation and interview on 11/03/24 at 3:11 PM, with Resident #58 revealed, long nails on both hands that measured approximately one-half (1/2) inch in length. The resident stated he was a diabetic and would like to have his nails cut because he does not like them long. An observation and interview with LPN #1 on 11/4/24 at 1:04 PM, confirmed Resident #58 had long fingernails. She revealed the resident was a diabetic and his nails must be cut by a nurse. LPN #1 revealed the nail care task was not set up to prompt staff to cut nails, and explained the facility did not have anyone who went around regularly to do nail care. She confirmed the resident could scratch himself or the staff. Record review of the admission Record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus. Record review of the Quarterly MDS with an ARD of 10/14/24 revealed, under section C, a Brief Interview for Mental for Status (BIMS) summary score of 15, which indicated Resident #58 was cognitively intact.

Based on observation, staff interview, record review and facility policy review, the facility failed to provide the services needed for a resident to maintain and/or improve their level of range of motion (ROM) and mobility for four (4) of 32 residents reviewed for positioning and mobility. (Resident #17, # 19, #22, and #39). Findings include: Record review of facility policy titled Resident Mobility and Range of Motion with a revision date of 7/2017 revealed Policy Statement, 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited will receive appropriate services, equipment and assistance to maintain or improve mobility unless a reduction in mobility is unavoidable. Resident #17 An observation on 11/03/24 at 2:44 PM revealed Resident #17 to have a right and left-hand contracture with no device in place. In an observation of Resident #17 with Licensed Practical Nurse (LPN) #1 on 11/04/24 at 12:50 PM, she confirmed that Resident #17's left and right hands were contracted. A record review of the Order Summary Report for Resident # 17 revealed there were no orders for services for the right- and left-hand contractures. A record review of the Task Report for November 2024 for Resident # 17 revealed there was no documentation of services to be provided to the right and left-hand contractures. In an interview with the Occupational Therapist (OT) on 11/4/24 at 3:04 PM, he verified Resident #17 had contractures to bilateral hands. He stated that Resident #17 would benefit from ROM exercises to possibly prevent worsening of the contractures. In an interview with Certified Nurse Assistant (CNA) #1 on 11/04/24 at 3:13 PM, she revealed she was assigned to Resident #17, and confirmed she did not do any exercises or range of motion to his contracted hands. An interview with the Director of Nursing (DON) on 11/05/24 at 3:30 PM, revealed that staff not providing ROM to the contracted hands could lead to worsening of the contractures. In an interview with CNA #2 on 11/05/24 at 8:15 AM, she revealed she was assigned to Resident #17, and confirmed she did not do any exercise or ROM to his hands. She revealed they used to have a restorative program, but no longer have it right now. Record review of the admission Record revealed the facility admitted Resident #17 on 9/11/15 with a diagnosis of Contracture to Right and Left Hand. Record review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/22/24 Section GG: 0115 functional limitation in range of motion was coded impairment on both sides of the upper and lower extremities Resident #19 On 11/3/24 at 4:00 PM, an observation and interview with Resident # 19 revealed that the resident had limited ROM to first through fourth fingers of the left hand at the first finger joints. Resident #19 stated he did not receive ROM exercises or braces. Record review of Resident #19's Electronic Medical Record (EMAR) revealed no documentation of that Resident #19 received ROM exercises or bracing. On 11/4/24 at 3:00 PM, an interview with OT verified Resident #19 had contractures at first finger joints of 1st through 4th fingers of left hand. He stated that the resident would benefit from ROM exercises and could have possibly prevented the contractures. During an interview with CNA #10 on 11/4/23 at 3:23 PM, she stated that Resident #19 is dependent for all care and cannot help at all. She stated that Resident #19 has contractures to his fingers and his legs, but she does not perform any type of ROM on the resident. Record review of the admission Record revealed the facility admitted Resident #19 on 1/14/19 with a diagnosis of Multifocal Motor Neuropathy. Record review of the Quarterly MDS with an ARD of 9/24/24, section GG, Functional Limitation in ROM revealed Resident # 19 had impairments to upper and lower extremities on one side. Resident #39 On 11/03/24 at 4:07 PM, an observation of Resident # 39, revealed Resident #39 had limited ROM of both arms with no braces or splints in use. Record review of OT Plan of Care, dated 11/4/24 for Resident #39 revealed Exacerbation of BUE (bilateral upper extremity) AROM (Active Range of Motion). During an interview on 11/4/24 at 8:51AM, Resident #39's Representative stated the resident did not have contractures on admission and he had never received therapy and/or bracing. In an interview on 11/4/24 at 3:02 PM, the OT verified Resident #39 had contractures of his bilateral elbows. He stated that the resident would benefit from ROM exercises and bracing elbows and that ROM could have possibly prevented the contractures. On 11/4/23 at 3:24 PM, during interview CNA #10 stated that Resident # 39 is dependent for all care and cannot help at all. She stated that Resident #39 had contractures to his arms and his legs, but she does not perform any type of ROM on the resident. Record of the admission Record revealed the facility admitted Resident #39 on 3/18/22 with a diagnosis of Disorders of Bone Density and Structure. Record review of the Annual MDS with an ARD of 8/22/24, section GG, Functional Limitation in ROM revealed Resident # 39 had impairment to upper and lower extremities on both sides. Resident #22 An observation of Resident #22 on 11/03/24 at 3:15 PM, revealed the resident lying in bed with his left arm drawn toward his chest. The resident was observed to be unable to move it on command. An interview with the OT on 11/4/24 at 2:50 PM, revealed Resident #22 was not receiving any therapy services related to the contracture and explained that he knew it had been a year since he had. He revealed the resident would benefit from passive range of motion (PROM) to prevent worsening of the contracture. An interview with the DON on 11/4/24 at 3:10 PM, revealed that the facility did not have a restorative nursing program. An interview with CNA #9 on 11/4/24 at 3:25 PM, revealed Resident #22 was able to move his arms by himself, so she did not do any exercises with him. She revealed the resident kept one of his legs bent and would holler out when it was moved. An interview with the DON on 11/05/24 at 3:20 PM, revealed that not providing PROM to Resident #22 could lead to worsening contractures. An interview with CNA #7 on 11/6/24 at 9:25 AM, revealed that she did not perform exercises with Resident #22 during daily care and confirmed it was not set up on the task for them to do. Record review of the Resident Care Kardex for Resident #22 revealed there was not a task set up for PROM. Record review of the MDS with an ARD of 8/30/24 revealed under, section GG, Resident #22 had upper and lower extremity impairment on one side. Record review of the admission Record revealed the facility admitted Resident #22 on 6/29/23 with a medical diagnosis that included Hemiplegia and hemiparesis following Cerebral Infarction affecting the left non-dominant side. .

Based on staff interviews, record review, and facility policy review, the facility failed to ensure sufficient weekend nursing staffing for the 3rd quarter payroll-based journal (PBJ) for one (1) of three (3) quarters reviewed. Findings include: Record review of the facility policy titled Staffing with a revised date of April 2007 revealed, . 1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 3 2024 (April 1-June 30), revealed Excessively Low Weekend Staffing-Triggered. Triggered=Submitted Weekend Staffing data is excessively low. An interview on 11/04/24 at 10:00 AM, the Assistant Director of Nurses (ADON) revealed she is responsible for staff development and scheduling. She revealed she was not employed as the ADON during the 3rd quarter dates of April-June 2024 but worked part-time for the facility. She revealed that the facility had an issue maintaining enough staff for the weekends during that time and confirmed that after she reviewed the weekend staffing for the third (3rd) quarter, it was due to low staffing. She revealed that they now have agency staffing to help ensure they are adequately staffed. During an interview on 11/05/24 at 1:45 PM, Human Resources (HR) confirmed the PBJ for the third quarter of 2024 was entered accurately. She revealed we were running low on staffing due to excessive call-ins and staff either clocking in late or out early. She stated that she is responsible for inputting the direct care hours into the dashboard and then submits to the corporate office. In an interview on 11/06/24 at 9:25 AM, the Administrator revealed she became the Administrator at the end of May 2024, and started working on ensuring they were adequately staffed to care for their residents. She revealed that they now have agency staff on board while actively trying to hire staff and feels like the staffing issue has improved with the help of the agency staff.

Based on staff interview, record reviews and facility policy review, the facility failed to monitor a resident receiving anticoagulant medication for side effects for one (1) of (10) residents on anticoagulant medications. Resident #4 Findings include: Record review of the facility policy titled Anticoagulation-Clinical Protocol with a revision date of September 2012 revealed . Monitoring and Follow-Up . 4. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in the urine), hemoptysis (vomiting blood), or other evidence of bleeding, the nurse will discuss the situation with the physician . Record review of the Order Summary Report with active orders as of 11/5/24 revealed an order with a start date of 6/10/24 for Xarelto Oral Tablet 10 mg (Rivaroxaban) Give 1 tablet by mouth one time a day. Record review of the Order Summary Report and the Medication Administration Record (MAR) for November 2024 revealed there was not a monitoring tool for staff to monitor for signs of bruising and bleeding with the anticoagulant (blood thinner) medication Xarelto. On 11/05/24 at 10:46 AM, an interview with the Director of Nurses (DON) confirmed that Resident #4 was on an anticoagulant and did not have adequate monitoring for the medication. She revealed that monitoring for side effects of bleeding and/or bruising is supposed to be under supplementary documentation in the actual physician orders and confirmed that it was not. She revealed inadequate monitoring of the anticoagulant medication places the resident at risk for bleeding. Record review of the admission Record revealed the facility admitted Resident #4 on 06/22/2020 with medical diagnoses that included Parkinson's disease with Dyskinesia, History of Pulmonary Embolism, History of Transient Ischemic Attack (TIA), and Cerebral Infarction.

Based on observation, resident and staff interview, and facility policy review, the facility failed to accommodate a resident's food preference during one (1) of three (3) meal services observed. (Resident # 55) Findings Include: A review of the facility policy titled, Resident Nutrition Services, with a revision date of 11/2015 revealed, Policy Statement: Each resident shall receive meals, with preferences accommodated . A dining observation on 11/3/24 at 5:45 PM, revealed the admission Nurse set the meal tray up for Resident #55. The meal tray was observed to have a ham and cheese sandwich with no observation of the admission Nurse offering the resident condiments for the sandwich, and there were no condiments observed on the meal tray. An interview with the admission Nurse on 11/3/24 at 5:48 PM, confirmed Resident # 55 did not have any condiments on her meal tray and that the residents were provided with condiments if they asked for them. In an interview with Resident #55 on 11/3/24 at 5:50 PM, she revealed she prefers both mayonnaise and mustard on her sandwiches. A continued dining observation on 11/3/24 at 6:00 PM revealed no observations of staff offering any condiments to Resident #55 for her ham and cheese sandwich. In an interview with the Dietary Manager (DM) on 11/4/24 at 8:50 AM, she confirmed that the condiments for Resident #55 's sandwich should have come out on her meal tray from the dietary department. She then stated that the staff passing the tray should have asked the resident what her preference of condiments was for her sandwich and asked the dietary staff for the condiments. An observation of a drawer in the dining room on 11/4/24 at 8:57 AM with the DM revealed a drawer full of condiments. She stated the staff working in the dining room always have access to this drawer and could have gotten the condiments needed. In an interview with the admission Nurse on 11/04/24 at 1:13 PM, she confirmed she should have asked Resident #55 what type of condiment she would like on her sandwich during the evening meal on 11/3/24, but she just did not even think about it. In an interview with the Director of Nursing (DON) on 11/04/24 at 1:20 PM, she revealed that staff assisting Resident #55 with her evening meal tray on 11/3/24 should have asked the resident what she would like on her sandwich. She then revealed that by not doing so, it could cause the resident to not eat the food provided and lead to weight loss. Review of the admission Record revealed the facility admitted Resident #55 on 3/01/24 with diagnoses that included Unspecified dementia. Record review of Section C of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident/staff interviews, and facility policy review, the facility failed to ensure snacks/nourishments were offered to residents for two (2) of four (4) survey days. Resident #10. Findings include: Review of the facility policy, Resident Nutrition Services, with a revised date of November 2015, revealed, . Policy Interpretation and Implementation .8 . Snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns . During an interview on 11/03/24 at 03:45 PM, Resident #10 revealed that she often gets hungry, especially at bedtime. She revealed they put the snacks out at the nurse's station, but you must go up there if you want anything. They don't come around to your room and offer any snacks. She revealed that one night, I specifically asked my Certified Nursing Assistant (CNA) for cheese and crackers, but she didn't get anything for me. She may have forgotten about it. In an interview on 11/04/24 at 1:20 PM, Resident #10 revealed that she was not offered a snack last night, nor has she been offered one today. She revealed that she kept her cookie, soup and four packs of crackers from her supper last night, so she ate those before going to bed. In an interview on 11/04/24 at 1:35 PM, CNA #4 revealed that she was assigned to the resident today. She revealed that she passed out hydration but didn't ask the resident about a snack because CNA #5 usually passes out the snacks. During an interview and observation on 11/04/24 at 2:25 PM, CNA #6 revealed that usually CNA #5 passes out the daytime snacks, and the nurses or aides on the other shifts pass out the snacks. She revealed the aides typically pass out the bedtime snacks. An observation of a tray of snacks, consisting of marshmallows, graham crackers, and [NAME] buddy bars, was sitting on a tray at the nurse's station. An interview on 11/04/24 at 3:13 PM, CNA #5 revealed that she was passing out the snacks at one time and would get a tray for each hall and go down the hall and make sure everyone who was able to have a snack was getting one because if you didn't, the snack tray would sit at the nurse's station. The residents sitting around the desk would get several snacks, but the others didn't. She revealed that several months ago, a dietary aide told me she couldn't give me the tray, but it had to be put at the nurse's station, so now I think everyone is just supposed to be passing them out to their residents. In an interview on 11/04/24 at 3:25 PM, the Dietary Manager (DM) revealed snacks are passed out at 10 AM, 2 PM, and 7 PM, and the dietary aide takes them out to the nurse's station and leaves the tray and the CNA pass them out. She revealed that snacks should be offered three times a day in addition to their meals. During an interview on 11/04/24 at 3:35 PM, the Assistant Director of Nurses (ADON) revealed that the residents should receive hydration and snacks three times daily. She revealed CNA #6 was passing out the snacks, but she heard that a dietary aide had told her that they needed to be set up at the nurse's station, so honestly, the only ones who were getting the snacks would be those sitting around the nurse's station or if someone asked for one. She revealed to my understanding, they had stopped going around to each room and offering a snack. Record review of the admission Record revealed Resident #10 was admitted to the facility on [DATE] with medical diagnoses that included anxiety disorder. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/24 revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.

Based on observation, record review, staff interview and facility policy review the facility failed to prevent the possibility of the spread of infection during wound care for one (1) of two (2) treatments observed. Resident # 11. Findings Included: Record review of facility policy titled, Enhanced Barrier Precautions Checklist revised January 2012 revealed .Policy Interpretation and Implementation 1. Staff shall apply Enhanced Barrier Precautions to the care of all residents in high contact care activities regardless of suspected or confirmed presence of infectious disease . Record review of facility policy titled Pressure Ulcer Treatment revised September 2013, revealed . Steps in the Procedure 1. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the clean field .7. Put on clean gloves. Loosen tape and remove soiled dressing. 8. Pull glove over dressing and discard into plastic or biohazard bag. 9. Wash and dry your hands thoroughly .14. Put on clean gloves 16. Cleanse the wound with the ordered cleanser. Use a syringe to irrigate the wound, if ordered. If using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward) . Record review of November 2024 Electronic Treatment Record (ETAR) revealed Resident # 11 had a Stage four (4) pressure ulcer to the right heel with a treatment to clean with wound cleanser, pat dry, apply Collagen with non-boarded super absorbent dressing and wrap with Kerlix and secure with tape daily. Observation of wound care for Resident #11 on 11/5/24 at 10:15 AM, performed by the Treatment Nurse (TN) revealed she failed to perform hand hygiene before gathering wound care supplies after propelling another resident down the hall in a wheelchair. The TN placed the wound care supplies (gloves, dermal wound cleanser bottle, scissors, collagen powder, abdominal pad and gauze packages) on top of the treatment cart without a barrier or cleaning the top of the cart. After entering the resident's room, the TN placed the wound care supplies and open gloves on an overbed table noted to be soiled with a clear substance without cleaning the table or placing a barrier on the table. The TN washed her hands and applied the gloves that had been sitting on the soiled overbed table. She then removed the old dressing and discarded it and began cleaning the wound without performing hand hygiene or changing gloves. She cleaned the wound by wiping over the wound bed with the same four by fours (4x4) four (4) times in a circular motion. Next, she discarded the soiled 4x4's and used a clean 4x4 to pat wound dry and began applying collagen to wound bed using a clean 4x4 , applied a clean 4x4, abdominal pad , gauze and secured the dressing with tape without removing soiled gloves or perform hand hygiene. The TN also failed to follow Enhanced Barrier Precautions (EBP) during wound care. Upon exiting the resident's room, the TN placed the contaminated dermal wound cleanser bottle and scissors on top of the treatment cart then placed them inside cart without sanitizing them. During an interview on 11/5/24 at 10:20 AM, the TN agreed that she contaminated wound care supplies by placing them on top of treatment cart and on the soiled overbed table without cleaning them or providing a barrier. She agreed that she used gloves that had been contaminated by the soiled overbed table, cleaned wound by wiping over the wound bed with the same 4x4 four (4) times, failed to remove soiled gloves and perform hand hygiene after removing the old dressing and before applying collagen & dressing, placed the dermal wound cleanser and scissors on top of the treatment cart then placed them inside cart without sanitizing them and did not follow EBP while performing wound care. She verified that this failure placed the resident at risk for infection. An interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) on 11/5/24 at 10:25 AM, she verified that the treatment nurse's failure to follow infection control practices during wound care placed the resident at risk for infection. Record review of the admission Record revealed that the facility admitted Resident # 11 on 3/19/14 with a diagnoses that included Pressure ulcer of right heel, Stage 4 and Hemiplegia and Hemiparesis following Cerebral Infarction affecting the right dominant side.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #9 Record review of Resident #9's care plans revealed under, Focus: ADLS (activities of daily living): Alterations in ADL's R/T (related to) impaired mobility .Interventions/Tasks . Trim fingernails and toenails PRN (as needed). Date initiated 12/13/13. On 11/03/24 at 2:30 PM, observation revealed, Resident #9 lying in bed with long jagged nails on both hands, measuring approximately three-eighths (3/8) inch in length past the tips of the resident's fingers. An observation and interview with the DON on 11/4/24 at 1:10 PM, confirmed Resident #9's nails were long. An interview with the Care Plan Nurse on 11/6/24 at 10:02 AM revealed the purpose of the care plan was to ensure the resident's needs were taken care of. She confirmed the care plan was not followed for Resident #9's nail care. Record review of the admission Record revealed the facility admitted Resident #9 on 12/13/13 with a medical diagnosis that included Dementia, unspecified. Resident #58 Record review of Resident #58's ADL Care Plan revealed a care plan was not developed for nail care. On 11/03/24 at 3:11 PM, observation and interview with Resident #58 revealed, long nails on both hands that measured approximately one-half (1/2) inch in length. The resident stated he was a diabetic and would like to have his nails cut because he does not like them long. An observation and interview with Licensed Practical Nurse (LPN) #1 on 11/4/24 at 1:04 PM, confirmed Resident #58 had long nails. An interview with the Care Plan Nurse on 11/6/24 at 10:02 AM, confirmed a nail care plan was not developed for Resident #58. Record review of the Quarterly MDS with an ARD of 10/14/24 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #58 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #58 on 4/23/24 with a medical diagnosis that included Nontraumatic Intracranial Hemorrhage. Resident # 17 On 11/04/24 at 12:50 PM, an observation of Resident #17 with Licensed Practical Nurse (LPN) #1 , she confirmed that Resident #17's right and left hands were contracted. A review of a care plan for Resident #17 titled, Risk for new contractures related to Cerebral Palsy, has contractures of left and right hand, revised 9/10/24 revealed no routine services to prevent worsening of the contractures. On 11/05/24 at 3:20 Pm, in an interview with the DON , she revealed after review of Resident #17's care plan related to the resident 's contracted hands, the care plan was not developed appropriately when range of motion was not added as an intervention. Record review of the admission Record revealed the facility admitted Resident #17 on 9/11/15 with diagnoses of Cerebral Palsy and contracture to right and left hand. Record review of Resident #17's MDS with an ARD of 8/22/24 Section GG: 0115 functional limitation in range of motion was coded impairment on both sides of the upper and lower extremities. Resident #18 A review of the Order Summary Report for Resident # 18 revealed orders for Aripiprazole 30 mg (milligram) one tablet at bedtime related to schizoaffective disorder . Ativan (Lorazepam) one (1) mg tablet 0.5 mg in the morning for generalized anxiety for (4) four days . Ativan one (1) mg tablet 0.5 mg at bedtime for generalized anxiety for (4) four days . Olanzapine 10 mg one tablet at bedtime for schizoaffective disorder . Venlafaxine HCL (hydrochloride) extended one tablet by mouth one time a day related to Major Depressive disorder . A review of the Order Summary Report for Resident # 18 revealed no order to monitor for side effects of the multiple psychotropic medications ordered. Record review of a care plan for Resident #18 titled, Psychotropic medication use Antianxiety, Antidepressant, Antipsychotic, , revised 9/14/24 revealed Interventions: Monitor for effects and side effects of medication every shift Observe for signs of complications such as cognitive behavior problems, sedation, hypotension, gait disturbance, and tremors In an interview with the DON on 11/04/24 at 2:45 PM, she confirmed after review of the psychotropic care plans for Resident #18 that staff were not following the care plan intervention for monitoring for side effects of the psychotropic medications. She stated that the purpose of the comprehensive care plan is to identify residents' specific needs and direct the individual care each resident needs. Review of the admission Record revealed the facility admitted Resident #18 on 9/05/24 with diagnoses including Schizophrenia, Bipolar Disorder, and Anxiety Disorder. Record review of Resident #18's Section N: Medications of the admission MDS with an ARD 9/12/24 revealed, N: 04115 : High-Risk Drug Classes: antipsychotic, antianxiety, and antidepressant coded yes for receiving the medications. Resident #51 A record review of the Order Summary Report for Resident # 51 revealed orders for Lorazepam oral concentrate two (2) mg/ml (milligram/milliliter): give .25 mg by mouth every four hours as needed anxiety with an order date of 8/27/24 with no stop date, Ativan 0.5 mg by mouth three times daily, related to anxiety, and Zoloft 50 mg tablet one tablet by mouth at bedtime related to Anxiety. A continued review of the Order Summary Report for Resident # 51 revealed no order to monitor for side effects of the multiple psychotropic medications ordered. A record review of a care plan for Resident #51 titled, Anxiety as exhibited by paranoia, revealed Interventions: Monitor effects and side effects of medication (sedation, drowsiness, agitation, headache) . In an interview with the DON on 11/05/24 at 7:35 AM, she revealed after review of Resident #51 ' s psychotropic care plan that staff were not following the intervention for monitoring for side effects. Review of the admission Record revealed the facility admitted Resident # 51 on 11/30/23 with diagnoses of Mood disorder, and Anxiety. Record review of Resident #51's Section N: Medications of the Quarterly MDS with an ARD/Target Date of 11/18/24 revealed N: 04115 : High-Risk Drug Classes: antianxiety and antidepressant coded yes for receiving the medications. Resident #55 A record review of the Order Summary Report for Resident # 55 revealed orders for buspirone (5) five mg tablet twice daily for Anxiety, Risperdal (2) two mg at bedtime for bipolar disorder, and Risperdal 0.5 mg daily for bipolar disorder. A continued review of the Order Summary Report for Resident # 55 revealed no orders to monitor the side effects of the psychotropic medications. A record review of a care plan for Resident #55, date initiated 5/17/24 titled, Bipolar: impaired thought process, revealed, Interventions: Monitor for side effects such as feeling sleepy in the day or difficulty falling asleep at night, problems with movement, difficulty moving, stiff muscles with movements which are difficult to control, a slow shuffling walk, shakes and drooling, headaches, and putting on weight or changes in appetite. A record review of a care plan for Resident #55 date initiated 8/14/24 titled, Anxiety: risk for episodes of anxiety, revealed, Interventions: Monitor effects and side effects of medication (sedation, drowsiness, agitation, headache). In an interview with the DON on 11/04/24 at 2:40 PM, she revealed after reviewing the psychotropic drug care plans for Resident #55, staff were not implementing the care plan when there was no side effect monitoring. Record review of the admission Record revealed the facility admitted Resident #55 on 3/01/24 with diagnoses of Bipolar Disorder, Anxiety Disorder, Borderline Personality Disorder, and Psychotic Disorder with Delusions. Record review of Resident #51's Section N: Medications of the Quarterly MDS with an ARD 8/23/24 revealed N: 04115 : High-Risk Drug Classes: antipsychotic and antianxiety coded yes for receiving the medications Resident #19 An observation on 11/03/24 at 4:00 PM revealed Resident #19 had limited range of motion (ROM) to first through fourth fingers of the left hand at the first finger joints. During an interview on 11/4/23 at 3:23 PM, with Certified Nursing Assistant (CNA) #10 she stated he is dependent for all care and cannot help at all. She stated that Resident #19 has contractures to his fingers and his legs. Record review of Resident #19's care plan revised 7/8/24 revealed Risk for contracture r/t (related to) limited mobility. Residents will not have new development of contractures in the next 90 days through participation with ADLS allow for rest periods. Interventions included: allow for rest periods as needed, bilateral half transfer bars to aid in turning and positioning , encourage and assist resident to turn and reposition at least q (every) 2 (two) hours ., encourage resident to attempt task during ADLs (Activities of Daily Living) which he can safely perform, praise resident for all efforts, wheelchair with built in cushion for mobility/locomotion. Record review and interview with Care Plan Nurse on 11/5/24 at 1:22 PM, of Resident # 19's care plan she verified that the care plan had no interventions developed, like ROM, that would help to prevent contractures for Resident #19. Record of the admission Record revealed the facility admitted Resident #19 on 1/14/19 with diagnoses including Contracture, left hand. Record review of the Quarterly MDS with an ARD of 9/24/24, section GG, Functional Limitation in ROM revealed Resident # 19 had impairments to upper and lower extremities on one side. Resident #39 An observation of Resident # 39 on 11/03/24 at 4:07 PM, revealed Resident #39 had limited ROM of both arms with no braces or splints in use. During an interview on 11/4/23 at 3:24 PM, with CNA #10 she stated Resident #39 is dependent for all care and cannot help at all. She stated that Resident #39 has contractures to his arms and his legs. Record review of Resident # 39's care plan revealed there was no care plan developed related to the prevention of contractures. Record review and interview with Care Plan Nurse on 11/5/24 at 1:23 PM, of Resident #39's care plan she verified that a care plan had not been developed related to the prevention of contractures for Resident # 39. Record of the admission Record revealed the facility admitted Resident #39 on 3/18/22 with a diagnosis of Disorders of Bone Density and Structure. Record review of the Annual MDS with an ARD of 8/22/24, section GG, Functional Limitation in ROM revealed Resident # 39 had impairment to upper and lower extremities on both sides. Resident #44 Record review of Resident #44's care plan revealed Focus: Restless/Agitation/Mood Disorder .Interventions included: Lexapro Oral tablet 5 mg (milligrams) .Monitor for SE (side effects) such as: Anxiety, irritability, or high or low mood · Feeling restless · Dizziness · Confusion · Headache Date Initiated: 06/10/2024. Lorazepam 2 mg/ml (milligrams per milliliter) .Monitor for SE such as: Drowsiness, dizziness, loss of coordination, headache, nausea, blurred vision, change in sexual interest/ability, constipation, heartburn, or change in appetite Date Initiated: 04/17/2024. Risperidone 0.25 mg .Monitor for SE such as: Drooling, nausea, weight gain. Date Initiated: 08/19/2023. Trazadone 50 mg .Monitor for SE such as N/V (nausea/vomiting), diarrhea, nervousness Date initiated 2/19/23 Record review of Resident #44's Electronic Medication Administrator Record (EMAR) revealed no documentation of monitoring for side effects of psychotropic medications prior to 11/4/24. Interview with the DON on 11/5/24 at 8:05 AM, she verified that Resident #44 had no documentation that he was being monitored for side effects of psychoactive medications. She stated she thought that the monitoring for side effects did not pull over when they changed computer systems. She stated failure to monitor for side effects could lead to over sedation, increased risk for falls. Interview with the Care Plan Nurse on 11/5/24 at 1:10 PM she agreed that Resident #44's care plan was not followed with regard to monitoring for side effects of psychotropic medications. Record review of the admission Record revealed that the facility admitted Resident #44 on 7/12/22 with diagnoses including Dementia and Anxiety. Based on observation, resident and staff interview, record review and facility policy review, the facility failed to develop and/or implement a person-centered care plan for monitoring side effects of medications, range of motion (ROM) and providing nail care for 11 of 24 resident care plans reviewed. Resident #4, #9, #10, #17, #18, #19, #39, #44, #51, #55 and #58. Findings Include: Record review of the facility policy titled Comprehensive Assessments and the Care Delivery Process with a revision date of 12/16 revealed under, Policy Statement: Comprehensive assessments will be conducted to assist in developing person-centered care plans. Resident # 4 Record review of Resident #4's care plan revealed under focus, Closed fracture of right tibia and fibula, date initiated 05/01/2024. Interventions included Xarelto 10 milligram tablet, monitor for side effects such as abdominal pain, back pain, itching, dizziness, muscle spasms, trouble sleeping, and anxiety. Date initiated 5/6/2024. In an interview on 11/05/24 at 10:46 AM, the Director of Nurses (DON) confirmed that Resident #4 was on an anticoagulant medication and confirmed that Resident #4's care plan was not developed for anticoagulation medication, which should also include monitoring for bleeding and bruising. An interview on 11/06/24 at 9:50 AM, the Care Plan Nurse confirmed that Resident #4 did not have a care plan developed that addressed the potential outcomes associated with the use of an anticoagulant medication, which is bleeding and bruising and revealed it is so important to ensure that adequate monitoring of a blood thinner is being done. Record review of the admission Record revealed the facility admitted Resident #4 on 06/22/2020 with medical diagnoses that included Parkinson's Disease with Dyskinesia. Resident #10 A review of the care plan titled Psychotropic medication use with a start date of 10/04/2024, revealed Interventions: Monitor and document side effects of medication every shift. During an interview on 11/06/24 at 08:57 AM, the DON confirmed they were not monitoring for the side effects of psychotropic medications, and they should have been. She revealed Resident #10's care plan was not being followed since the psychotropic medications were not being monitored or documented. An interview on 11/06/24 at 10:42 AM, the Care Plan nurse revealed the purpose of the care plan is to inform staff on how to take care of each resident individually. She confirmed that according to Resident #10's care plan, she was on psychotropic medications. Since the nurses were not monitoring and documenting the side effects of the medication, the plan of care was not being followed. Record review of the admission Record revealed Resident #10 was admitted to the facility on [DATE] with medical diagnoses that included Anxiety Disorder. A record review of the MDS with an ARD of 10/11/2024 revealed that Resident #10 had a BIMS score of 14, which indicated that the resident was cognitively intact.

Based on staff interview, record review, and facility policy review the facility failed to monitor for side effects and obtain a stop date for a psychotropic medication for five (5) of 40 residents receiving psychotropic medications reviewed. Resident #10, #18, #44, #51 and #55 Findings include: A review of the policy titled, Behavioral Assessment, Intervention and Monitoring, revised December 2016 revealed . Management: 10.) When medications are prescribed for behavioral symptoms, documentation will include a.) Rationale for use . h.) Monitoring for efficacy and adverse consequences . Resident #10 Record review of Resident #10's Order Summary Report with active orders as of 11/3/24 revealed an order dated 10/18/24 Buspirone HCI oral tablet 10 mg (milligrams) Give 2 tablets by mouth two times a day related to anxiety disorder. An additional order dated 10/7/24 revealed Venlafaxine HCI oral tablet 75 mg Give 1 tablet by mouth two times a day related to anxiety disorder. The order summary revealed there was not an order to monitor for side effects of the multiple psychotropic medications ordered. A record review of the Medication Administration Record (MAR) for the month of October 2024 revealed Resident #10 received Buspirone 10 mg and Venlafaxine 75 mg. There was no documentation on the MAR regarding monitoring for side effects of the psychotropic medications. On 11/06/24 at 8:57 AM, an interview the Director of Nurses (DON) confirmed they were not monitoring for side effects of psychotropic medications, and they should have been. She revealed it should have been on the physician's orders, which would then pull over to the MAR to ensure the nurses were adequately monitoring for side effects and documented accordingly. Record review of the admission Record revealed the facility admitted Resident #10 on 10/04/2024 with medical diagnoses that included Anxiety Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/24 revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident is cognitively intact. Resident #18 A review of the Order Summary Report with active orders as of 11/3/24 revealed an order dated 9/5/24 for Aripiprazole 30 mg Give one tablet at bedtime related to schizoaffective disorder. An order dated 10/31/24 for Ativan (Lorazepam) one (1) mg tablet give 0.5 mg in the morning for generalized anxiety for (4) four days. An order dated 10/31/24 for Ativan (1) mg tablet give 0.5 mg at bedtime for generalized anxiety for (4) days . An order dated 10/23/24 for Olanzapine 10 mg Give one tablet at bedtime for Schizoaffective disorder . An order dated 9/5/24 for Venlafaxine HCL (hydrochloride) extended Give one tablet by mouth one time a day related to Major Depressive disorder . The order summary revealed there was not an order to monitor for side effects of the multiple psychotropic medications ordered. In an interview with the DON on 11/04/24 at 2:45 PM, she confirmed that Resident #18 did not have any monitoring in place for the side effects of the psychotropic medications. Review of the admission Record revealed the facility admitted Resident #18 on 9/05/24 with diagnoses of Schizophrenia, Bipolar Disorder, and Anxiety Disorder. Record review of Resident #18's MDS, Section N, with an ARD of 9/12/24 revealed, N: 04115 : High-Risk Drug Classes: antipsychotic, antianxiety, and antidepressant coded yes for receiving the medications. Resident #51 A review of the Order Summary Report with active orders as of 10/3/24 revealed an order dated 8/27/24 for Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth three times a day related to Anxiety disorder due to know physiological condition. An additional order dated 8/27/24 revealed Lorazepam oral concentrate two (2) mg/ml (milligram/milliliter): Give 0.25 mg by mouth every four hours as needed Anxiety disorder. The orders did not include a stop date. An order dated 9/19/24 revealed Zoloft 50 mg tablet give one tablet by mouth at bedtime related to Anxiety. The order summary revealed there was not an order to monitor for side effects of the multiple psychotropic medications ordered. In an interview with the DON on 11/04/24 at 2:00 PM, she revealed there were no monitoring tools in place to monitor for side effects of psychotropic medications for Resident #51. She revealed concerns from not monitoring the psychotropic medications is to watch for adverse reactions like sedation, tremors, and tardive dyskinesia. She also revealed she was unaware that prn (as needed) Ativan (Lorazepam) needed to have a stop date after 14 days to evaluate the residents' need for further use because the resident was on Hospice services. In an interview with Licensed Practical Nurse (LPN) #1 on 11/05/24 at 8:05 AM, she revealed all residents on psychotropic medications should be monitored for side effects and notify the provider of changes. She stated the monitoring used to be on the medication record but was no longer on it after the facility switched electronic medical record companies. Review of the admission Record revealed the facility admitted Resident # 51 on 11/30/23 with diagnoses of Mood disorder and Anxiety. Record review of Resident #51's Quarterly MDS with an ARD 11/18/24,Section N, revealed in N: 04115 : High-Risk Drug Classes: antianxiety and antidepressant coded yes for receiving the medications. Resident #55 A review of the Order Summary Report with active orders as of 11/3/24 revealed an order dated 8/22/24 for buspirone oral tablet five (5) mg Give 1.5 tablet by mouth two times a day related to Anxiety Disorder. An additional order dated 6/19/24 revealed Risperdal Tab 0.5 mg Give 1 tablet by mouth at bedtime related to bipolar disorder. An additional order dated 5/16/24 revealed Risperidone Tab 0.5 mg Give (2) two mg at bedtime for bipolar disorder. The order summary revealed there was not an order to monitor for side effects of the multiple psychotropic medications ordered. On 11/04/24 at 2:40 PM, an interview with the DON revealed there were no monitoring tools in place to monitor for the psychotropic drugs for Resident #55. In an interview with LPN#2 on 11/5/24 at 3:00 PM, she confirmed that all residents on psychotropic medications should be monitored for side effects to identify adverse reactions from the medications. She revealed she was unsure why there was no monitoring in place. Review of the admission Record revealed the facility admitted Resident #55 on 3/01/24 with diagnoses of Bipolar disorder, Anxiety Disorder, Borderline Personality Disorder, and Psychotic Disorder with Delusions. Record review of the Quarterly MDS with an ARD of 8/23/24, Section N, revealed in N:04115: High-Risk Drug Classes: antipsychotic and antianxiety coded yes for receiving the medications. Resident #44 Record review of Order Summary Report with active orders as of 10/31/24 revealed an order dated 8/18/23 for Risperidone Tab 0.25 MG (milligrams), Give 1 tablet orally one time a day related to Psychotic disorder with delusions. An additional order dated 11/17/22 for Risperidone Tab 1 MG, give 1 tablet orally one time a day related to Psychotic disorder with delusions. An order dated 2/3/23 for Trazodone HCl Tab 50 MG, give 1 tablet orally one time a day for related to Insomnia. An order dated 6/7/24 for Lexapro Oral Tablet 5 MG (Escitalopram Oxalate), Give 1 tablet by mouth one time a day for anxiety. An order dated 4/17/24 for Lorazepam Concentrate 2 MG/ML (milligrams per milliliter), Give 0.5 milliliter orally every four (4) hours as needed for restlessness and agitation with no stop date. The order summary revealed there was not an order to monitor for side effects of the multiple psychotropic medications ordered. During an interview with the DON on 11/5/24 at 8:05 AM, she verified that Resident #44 had an PRN order for Lorazepam with no stop date. She stated that she was not aware that residents on hospice had to have a 14-day stop date for Lorazepam. She also verified that Resident #44 had no documentation that he was being monitored for side effects of psychoactive medications. She stated she thought that the monitoring for side effects did not pull over when they changed computer systems. She agreed failure to have a stop date for lorazepam and to monitor for side effects could lead to over sedation and increased risk for falls. Record review of the admission Record revealed that the facility admitted Resident #44 on 7/12/22 with diagnoses which included Dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility policy/procedure review, and record review, the facility failed to implement the interventions of a care plan for a resident related to medication administration for one (1) of six (6) residents care plans reviewed. Resident #1 Findings include: Review of the facility's policy/procedure Using the Care Plan last revised August 2006 revealed the Policy Statement: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Record review of Resident #1's care plan revealed, Pain risk r/t (related to) diagnosis Breast Cancer and impaired mobility .Start date 10/06/2023 .Roxicodone 30 mg (milligrams) tablet: take one tablet by mouth Q (every) 4 (four) hours 12A/4A .Dilaudid 4 mg tablet: take three tables (12 mg) by mouth q 4 hours PRN (as needed) . Record review of Resident #1's Physician Orders List revealed orders dated 10/6/23 for Roxicodone 30 MG (milligrams) 1 tablet every (q) four (4) hours (hr) and Dilaudid 4 MG tablet three (3) tablets q 4 hrs PRN. All medications are taken by mouth (PO). Record review of the Report of Investigation signed by the Administrator and Director of Nursing (DON) on 11/10/23 revealed, Date of occurrence: 10-18-23 Time of occurrence 7:00 AM .9. Unusual occurrence .Medication Error .Injury: NO .Details of investigation .On 10/18/2023 at approximately 6:25am while conducting a medication count with the oncoming nurse, (Proper Name Licensed Practical Nurse (LPN)#1) noticed she performed a medication error on resident (Proper Name Resident #1). Resident #1's order was for 3 (three) dilaudid and 1 (one) roxicodone to be administered and (LPN#1) administered 1 dilaudid and 3 roxicodone. The medication error occurred two times, once at 12:00am and again at 4:00am on 10/18/2023. (LPN#1) then notified the on-call nurse who in turned notified the Director of Nursing. The facility MD (Medical Doctor) was notified and gave the order to hold (Resident #1's) 8:00am narcotics and monitor for 24 hours for any adverse reactions. The Director of Nursing notified the Pharmacy of the medication error and conducted a narcotic count on all carts with no discrepancies noted with the exception of the medication error. Based on resident interview by the Assistant Director of Nursing, (Resident #1) stated she did not notice the difference in appearance of the medication given but consumed them anyway . Interview with the facility Care Plan Nurse, on 11/9/23 at 1:15 PM revealed, pain medications are listed on the pain care plan interventions. The pain care plan also has why the resident is taking the pain medication. Resident #1's care plan was not followed. Interview with the facility's DON on 11/8/23 at 1:20 PM, revealed that nurses are supposed to follow the care plans and that care plans have the medications listed. A post survey interview with LPN #1 on 11/17/23 at 12:10 PM, revealed that she gave Resident #1 the wrong pain medication twice in 1 night. She confirmed that nurses are trained on following the care plan and MD orders and med pass administration. She stated that the care plans do include the medications and that staff is supposed to follow the interventions and Resident # 1's care plan was not followed. Record review on 11/8/23 of Resident #1's Face Sheet revealed she was admitted into the facility on [DATE] with diagnoses including Intraductal carcinoma in situ of right breast, Anxiety and Secondary malignant neoplasm of bone. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #1 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, facility policy/procedure review, and record review, the facility failed to ensure that one (1) of six (6) residents sampled received care and services that would meet the professional standards of quality as evidenced by Resident #1 not receiving medications as ordered. Findings include: Review of the facility's policy for Administering Medications last revised December 2012 revealed Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Review of the facility's policy for Adverse Consequences and Medication Errors last revised April 2014 revealed the .Policy Interpretation and Implementation . 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medication errors include: c. Wrong dose . Record review of the facility's Charge Nurse-LPN (Licensed Practical Nurse) job description dated 2003 revealed the Duties and Responsibilities and the section Drug Administration Functions are for the LPN (Licensed Practical Nurse) to Prepare and administer medications as ordered by the physician. Record review of Resident #1's Physician Orders List revealed orders dated 10/6/23 for Roxicodone 30 MG (milligrams) 1 tablet every (q) four (4) hours (hr) and Dilaudid 4 MG tablet three (3) tablets q 4 hrs PRN. All medications are taken by mouth (PO). Record review of the Report of Investigation signed by the Administrator and Director of Nursing (DON) on 11/10/23 revealed, Date of occurrence: 10-18-23 Time of occurrence 7:00 AM .9. Unusual occurrence .Medication Error .Injury: NO .Details of investigation .On 10/18/2023 at approximately 6:25am while conducting a medication count with the oncoming nurse, (Proper Name Licensed Practical Nurse (LPN) #1 noticed she performed a medication error on resident (Proper Name Resident #1). Resident #1's order was for 3 (three) dilaudid and 1 (one) roxicodone to be administered and (LPN#1) administered 1 dilaudid and 3 roxicodone. The medication error occurred two times, once at 12:00am and again at 4:00am on 10/18/2023. (LPN#1) then notified the on-call nurse who in turned notified the Director of Nursing. The facility MD (Medical Doctor) was notified and gave the order to hold (Resident #1's) 8:00am narcotics and monitor for 24 hours for any adverse reactions. The Director of Nursing notified the Pharmacy of the medication error and conducted a narcotic count on all carts with no discrepancies noted with the exception of the medication error. Based on resident interview by the Assistant Director of Nursing, (Resident #1) stated she did not notice the difference in appearance of the medication given but consumed them anyway . In an interview with the facility Administrator at 11:20 AM revealed there was a medication error with Resident #1. In an interview with the facility's DON on 11/8/23 at 1:20 PM, revealed that nurses are supposed to follow the care plans and that care plans have the medications listed. The care plans are updated when there are changes in the resident's care. She stated that LPN #1 was counseled and re-inserviced on medication administration. She stated she did not in-service the other nurses on medication administration when this incident occurred. Nurses are observed during medication pass by her, the Assistant Director of Nursing (ADON) and pharmacy consultant frequently. She stated the pharmacy consultant will watch medication pass during most visits. In an interview with the ADON on 11/8/23 at 12:40 PM, she revealed, on 10/18/23 12:00 AM and 4:00 AM (Resident #1) received 3 Roxicodone tablets and 1 Dilaudid tablet at each of those medication passes. She was supposed to get 1 Roxicodone tablet and 3 dilaudid tablets. When I explained to her there was a medication error, she stated she did notice there were 3 blue pills instead of 3 white pills. She never said anything to anyone. This nurse did it twice that shift. The nurse discovered the error at the end of the shift narcotic count. She was counseled and in-serviced on medication errors. The resident's vital signs were monitored for 24 hours. There was no increase in pain and no harm. She said she didn't want the nurse fired. We held all the narcotic pain medication until the 12:00 PM doses. Interview with Resident #1 on 11/8/23 at 2:25 PM, revealed, What I got was 3, 30 MG Roxicodone and 1, 4 MG Dilaudid. I got it at 12 midnight and again at 4:00 AM on October 18th. I do not know the nurse's name. I did not need any emergency care. The nursing home staff told me about the medication error. They held my other pain meds until 11:00 AM. They wake me up for my pills and it is in the middle of the night. So, I felt 4 pills in my mouth, I didn't see them. On 11/17/23 at 12:10 PM, a post survey interview with LPN #1 confirmed that she gave Resident #1 the wrong pain medication twice in 1 night. She was unable to recall the date. She said that Resident #1 always sleeps with the television on and she always turns the light on when she goes into the room to give Resident #1 her medications. She stated that Resident #1 will always ask where her Dilaudid is when you take her the Roxicodone. This was found at shift change when I was counting narcotics with the on-coming nurse. The medication count was off. I notified the ADON. Someone else told Resident #1. She confirmed she was counseled and re-inserviced on medication administration. She confirmed that nurses are trained on abuse, neglect, following the care plan and MD orders and med pass administration. She stated that the care plans do include the medications and that staff is supposed to follow the interventions. She stated No, Ms. (Resident #1) did not act any differently that shift. There were no noted side effects of the medications being given wrong. Record review on 11/8/23 of Resident #1's Face Sheet revealed she was admitted into the facility on [DATE] with diagnoses including Intraductal carcinoma in situ of right breast, Anxiety and Secondary malignant neoplasm of bone. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #1 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, facility policy/procedure review, and record review the facility failed to ensure that one (1) of six (6) residents sampled were free from any significant medication errors. Resident #1. Findings include: Review of the facility's policy for Administering Medications last revised December 2012 revealed Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed . Record review of the facility's policy for Adverse Consequences and Medication Errors last revised April 2014 revealed, .Policy Interpretation and Implementation .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medication errors include: .c. Wrong dose . Record review of the facility's Charge Nurse-LPN(Licensed Practical Nurse) job description dated 2003 revealed the Duties and Responsibilities and the section Drug Administration Functions are for the LPN to Prepare and administer medications as ordered by the physician. Record review of the Report of Investigation signed by the Administrator and Director of Nursing on 11/10/23 revealed, Date of occurrence: 10-18-23 Time of occurrence 7:00 AM .9. Unusual occurrence .Medication Error .Injury: NO .Details of investigation .On 10/18/2023 at approximately 6:25am while conducting a medication count with the oncoming nurse, (Proper Name LPN#1) noticed she performed a medication error on resident (Proper Name Resident #1). Resident #1's order was for 3 (three) dilaudid and 1 (one) roxicodone to be administered and (LPN#1) administered 1 dilaudid and 3 roxicodone. The medication error occurred two times, once at 12:00am and again at 4:00am on 10/18/2023. (LPN#1) then notified the on-call nurse who in turned notified the Director of Nursing. The facility MD (Medical Doctor) was notified and gave the order to hold (Resident #1's) 8:00am narcotics and monitor for 24 hours for any adverse reactions. The Director of Nursing notified the Pharmacy of the medication error and conducted a narcotic count on all carts with no discrepancies noted with the exception of the medication error. Based on resident interview by the Assistant Director of Nursing (ADON), (Resident #1) stated she did not notice the difference in appearance of the medication given but consumed them anyway .Notification of State Health Department .11-09-23 . Record review of Resident #1's Physician Orders List revealed orders dated 10/6/23 for Roxicodone 30 MG (milligrams) 1 tablet every (q) four (4) hours (hr) and Dilaudid 4 MG tablet three (3) tablets q 4 hrs PRN. All medications are taken by mouth (PO). Interview with the facility Administrator at 11:20 AM, revealed there was a medication error with Resident #1. He stated there was no harm to the resident. Interview with the ADON on 11/8/23 at 12:40 PM revealed that on 10/18/23 at 12:00AM and 4:00 AM Resident #1 received 3 Roxicodone tablets and 1 Dilaudid tablet at each of those medication passes. She was supposed to get 1 roxicodone tablet and 3 dilaudid tablets. When I explained to to her (Resident #1) there was a medication error, she stated she did notice there were 3 blue pills instead of 3 white pills. She never said anything to anyone. This nurse did it twice that shift. The nurse discovered the error at the end of the shift narcotic count. She was counseled and in-serviced on medication errors. The resident's vital signs were monitored for 24 hours. There was no increase in pain and no harm. She said she didn't want the nurse fired. We held all the narcotic pain medication until the 12:00 PM doses. In an interview with Resident #1 on 11/8/23 at 2:25 PM, revealed she is her own Responsible Party. She stated, What I got was 3, 30 MG (milligram) Roxicodone and 1, 4 MG Dilaudid. I got it at 12 midnight and again at 4 AM on October 18th. I do not know the nurse's name. I did not need any emergency care. The nursing home staff told me about the medication error. They held my other pain meds until 11:00 AM. They wake me up for my pills and it is in the middle of the night. So, I felt 4 pills in my mouth, I didn't see them. During a post survey interview with LPN #1 on 11/17/23 at 12:10 PM confirmed she gave Resident #1 the wrong pain medication twice in 1 night. She was unable to recall the date. She said that Resident #1 always sleeps with the television on and she always turns the light on when she goes into the room to give Resident #1 her medications. She stated that Resident #1 will always ask where her Dilaudid is when you take her the Roxicodone. This was found at shift change when I was counting narcotics with the on-coming nurse. The medication count was off. I notified the ADON. Someone else told Resident #1. She confirmed she was counseled and re-inserviced on medication administration. She confirmed that nurses are trained on abuse, neglect, following the care plan and MD orders and med pass administration. She stated that the care plans do include the medications and that staff is supposed to follow the interventions. She stated No, (Resident #1) did not act any differently that shift. There were no noted side effects of the medications being given wrong. Record review on 11/8/23 of Resident #1's Face Sheet revealed she was admitted into the facility on [DATE] with diagnoses including Intraductal carcinoma in situ of right breast, Anxiety and Secondary malignant neoplasm of bone. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #1 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, facility policy review and record review, the facility failed to label an enteral feeding with nurse's initials, and date and time the formula was hung/administered for one (1) of five (5) residents with enteral feeding. Resident #17 Findings include: A record review of the facility policy titled, Enteral Tube Feeding via Continuous Pump with a revision date of March 2015, revealed, . Initiate Feeding . 5. On the formula label, document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . An observation on 03/13/23 at 10:20 AM, revealed Resident #17's enteral feeding of Jevity 1.2 was infusing. There was no date, time initiated, or nurse initials noted on the bottle. An observation on 03/13/23 at 01:34 PM, revealed Resident #17's enteral feeding of Jevity 1.2 was infusing. The Jevity 1.2 bottle had no date, time initiated or nurse initials on the bottle. An interview on 03/13/23 at 02:05 PM, the Director of Nurses (DON) revealed any resident on enteral feeding, the tubing and milk is supposed to be changed out at least every twenty-four hours. She revealed the nurse that changes out the feeding is supposed to fill out the label on the bottle which includes the date and time it is hung, the flow rate and their initials. An observation and interview on 03/13/23 at 2:15 PM, the DON confirmed that Resident #17 had Jevity 1.2 infusing, and the bottle was not labeled with the date, time initiated, flow rate and the nurses initials. She confirmed that the nurses are always supposed to label the bottles. She revealed she was not sure how long the bottle had been hanging and she was going to find out. She revealed this could cause the resident to get sick if the feeding was hanging past twenty-four hours. An interview on 03/13/23 at 2:34 PM, the DON revealed there was no way to tell on the electronic medication record of what time the feeding was hung, she revealed it gets changed out when the bottle is empty or at least every twenty-four hours per protocol but the nurse is always supposed to label the bottle so the next nurse will know when it was last changed. A record review of Resident #17's Face Sheet revealed the Resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, Gastrostomy status and Dysphagia, oropharyngeal phase. Record review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/2023 revealed Resident #17 is severely impaired-never/rarely made decisions.

Based on observation, staff interview and facility policy review, the facility failed to provide privacy for Resident #2 during the administration of medications through a Percutaneous Endoscopic Gastrostomy (PEG) Tube, for one (1) of nine (9) residents observed for medication administration. Findings include: Record review of the facility's Quality of Life - Dignity policy, revised August 2009, revealed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation and Implementation: 1. Residents shall be treated with dignity and respect at all times; 2. Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth; 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. On 1/12/2020, at 3:17 PM, during an observation of Percutaneous Endoscopic Gastrostomy (PEG) tube medication administration, Licensed Practical Nurse (LPN) #4, did not pull the privacy curtain between Resident #2 and her roommate. Resident #2's roommate was sitting up in her wheelchair facing Resident #2's bed. Resident #2's abdomen and PEG tube medication administration was exposed to her roommate during the procedure. On 1/13/2020, at 4:32 PM, an interview with the Interim Director of Nursing (IDON), revealed she stated that would be a privacy issue and a dignity issue for sure and that staff should always pull the curtain when performing care. On 1/15/2020, at 1:29 PM, during an interview with LPN #4 she stated she should have pulled the curtain between the residents to ensure Resident #2's privacy. Record review of Resident #2's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 9/26/19, revealed in Section C, Item C1000, Cognitive Skills for Daily Decision Making was coded a 3, which indicated severe cognitive impairment-never/rarely made decisions.

**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 develop a care plan to address Resident #27's hospital return with a new medication and diagnosis; to implement Resident #45's care plan for Passive Range of Motion (PROM) exercises, to implement Resident #40's use of an alarm only while in bed, and to store and change Residents #24 and #50's oxygen (O2) tubing. This concern was identified for five (5) of 19 residents reviewed. Findings include: Review of the facility's Care Plan - Comprehensive policy, dated September 2010, revealed: Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. 6. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes. 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Each resident's comprehensive care plan is designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. Resident #27 Record review revealed upon Resident #27's return to the facility, on 1/2/2020, from the hospital, the Comprehensive Care Plan did not develop a care plan for the new medication Eliquis or its possible side effects and the new diagnosis of a Pulmonary Emboli. On 01/14/2020, at 11:41 AM, an interview with Licensed Practical Nurse (LPN) #5 revealed she was responsible for revising and developing care plans for residents when they return from the hospital. LPN #5 revealed the nurses on the floor do not revise or develop care plans when they write new orders or readmit a resident to the facility. LPN #5 confirmed she did review the new readmit orders on Resident #27 when he returned to the facility on 1/2/20. LPN #5 confirmed she did not update the comprehensive care plan for Resident #27 to include the new medication Eliquis or the diagnosis from the hospital of Pulmonary Emboli. LPN #5 revealed she had no idea why she did not include the Eliquis or the diagnosis of Pulmonary Emboli. LPN #5 revealed it is important to update the care plan with blood thinners and history of a Pulmonary Embolus because the resident could have complications. Record review of the admission Orders, dated 1/2/2020, revealed Resident #27 returned to the facility from the hospital with a new order for Eliquis 5 milligrams (mg) tablet two (2) times a day. Record review of the Hospital Discharge summary, dated [DATE], revealed a chest x-ray impression of a right pulmonary emboli filling defects in the branches of the descending right pulmonary arteries. Resident #45 Record review of the Care Plan, dated 11/11/2019, revealed the Problem/Need for Restorative Nursing for contracture management/right upper extremity (RUE) functional strength training. The Goal stated to maintain current level of function for dressing using the right extremity. Next Resident will maintain level of function assisting with dressing using the right extremity times (x) 12 weeks, 2/11/20. The Approaches included: Perform Right Upper Extremity (RUE) shoulder flexion exercises four (4) sets of 15 reps (repetitions) pain free. Perform Passive Range of Motion (PROM) to the Left Upper Extremity (LUE) shoulder flexion/abduction four (4) sets with 15 second holds pain free. Perform Restorative six (6) days weekly. Notify Occupational Therapy (OT) of changes or decline in function. The Restorative Certified Nursing Assistant (RCNA) was the staff assigned to these approaches. Record review of the January 2020 Physician's Orders, revealed an order, dated 11/14/19, to admit Resident #45 to Restorative Nursing Program: 1) AROM (Active Range of Motion) to the right shoulder flexion exercises, four (4) sets of 15 reps (repetitions) 2) PROM to the left shoulder Flexion/Abduction four (4) sets 15 second holds six (6) days weekly. On 1/12/2020, at 3:40 PM, in an interview with Resident #45, he stated he is supposed to have Restorative Nursing for exercises for his shoulders, but they don't do it. On 01/14/2020, at 10:46 AM, during an interview with Certified Nursing Assistant (CNA) #2, she stated she had been doing Resident #45's restorative exercises because sometimes the Restorative CNA (RCNA) would have a section to work. She stated she performed Range of Motion (ROM) with his shoulders and arms and that the left arm is PROM. She stated she did PROM 15 times to the left shoulder and arm which included one set of 15 or sometimes 10. This Surveyor asked CNA #2 to read the order for PROM to the left shoulder. CNA #2 read it from the Kiosk and she stated, I do it 10 sometimes 15 times, I thought it means hold it a couple of seconds and let it go rest on the bed. In an interview, on 01/14/2020, at 11:00 AM, the Occupational Therapist (OT) stated the order for PROM to the left shoulder for four (4) sets of 15 second holds was for contracture management and pain management. The OT stated he goes over the exercises with the Restorative Aide, have them return a demonstration and sign the competency sheet. The OT stated it should be the four (4) sets of 15 second holds with the PROM, the key word is pain free with the hold. He stated the CNA should be holding the extremity in the pain free position for 15 seconds four (4) times. He stated the important part was the hold for 15 seconds and that reps and holds get a little confusing. On 1/15/2020 at 3:00 PM, an interview with the Director of Nursing (DON), confirmed the Restorative Care Plan for Resident #45 was not followed due to the PROM exercises were not performed correctly. Resident #24 Review of Resident #24's Comprehensive Care Plan revealed the Problem/Need, dated 1/31/2019, for the diagnosis Chronic Obstructive Pulmonary Disease (COPD) and at risk for Shortness of Breath (SOB). The Approaches included: Change the nebulizer and O2 tubing weekly, on Wednesdays. An observation in Resident #24's room, on 1/12/2020 at 5:01 PM, revealed the resident's O2 tubing was on the floor beside the bed, with the bed wheel on the tubing. The O2 tubing was dated 1/8/2020. Further observation revealed there was no storage bag or container for the O2 tubing. An observation of Resident #24's room, on 1/13/2020 at 10:30 AM and 4:20 PM, revealed the O2 tubing was still on the floor beside the bed, and there was no storage bag/container in the room. On 1/14/2020 at 9:15 AM and 3:45 PM, observations of Resident #24's room revealed the O2 tubing was on the floor beside the bed, and there was no storage bag/container in the room. On 1/15/2020 at 9:15 AM, an observation of Resident #24's room revealed the O2 tubing was on the floor beside the bed, and these still was no storage bag/container in the room. An interview with Resident #24, on 1/12/2020 at 5:05 PM, revealed she doesn't remember ever having a bag to put the O2 tubing. Resident #24 stated just throws it wherever. Review of the Physician's Order List revealed an order, dated 10/3/19, for Oxygen at 2L/min (liters per minute) via nasal cannula as needed for shortness of breath, change oxygen tubing out weekly on Wednesday, Check O2 sat (saturation) every shift. Notify MD (Medical Doctor) if <90% for Shortness of Breath. An interview with Director of Nursing (DON), on 1/15/2020 at 9:30 AM, revealed the floor nurses on the day shift was responsible for changing the O2 tubing on Wednesdays and should be ensuring there is a bag in there to store the tubing. Record review of the Face Sheet revealed Resident #24 was admitted by the facility, on 1/31/2019, with the included diagnoses of Rhabdomyolysis, Heart Failure, Insomnia, Shortness of Breath, Chronic Obstructive Pulmonary Disease, Essential Hypertension. Resident #40 Record review of Resident #40's Comprehensive Care Plan revealed the Problem/Need, dated 3/16/19, for risk for fall related to (R/T) history of fall, impaired mobility. The Approaches included a body alarm to be worn when in bed. Further review of the care plan revealed the Problem/Need, dated 3/23/18, for resident wanders daily and exhibits repetitive verbalizations in the form of questions. She has a history of sleep disturbance, agitation, restlessness including repetitive attempts to get out of bed or chair without assistance. The Approaches included the use a body alarm as ordered. Review of Resident #40's January 2020 Physician's Orders revealed an order, dated 11/21/18, for a body alarm on when in bed R/T resident unaware of safety. On 1/12/2020 at 5:00 PM, an observation revealed Resident #40 was observed to wheel herself into the dining room with a body alarm on and attached to her wheelchair. On 1/12-2020 at 5:10 PM, an observation revealed an alarm was heard from the hallway. Upon entering the dining room, a staff member was observed reattaching Resident #40's body alarm to her wheelchair to stop the alarm noise. Review of Resident #40's Resident Incident Report, dated 12/09/19 at 2:30 PM, revealed: While sitting at desk this nurse was alerted by chair alarm was lead to room [ROOM NUMBER] where resident had entered another resident room threw covers back and attempted to crawl in bed. During an interview with the Director of Nursing (DON), she was informed about Resident #40's body alarm being on in the dining room on 1/12/2020 at 5:00 PM, the alarm sounding at 5:10 PM, with a CNA intervening to reattach the alarm to Resident #40's wheelchair, and the documented statement on the Resident's Incident Report, dated 12/09/19 at 2:30 PM, when Resident #40's body alarm sounded when she attempted to climb into another resident's bed, where the nurse documented she was alerted by chair alarm, and was lead to room [ROOM NUMBER]. When the DON was asked if the body alarm should have been present on Resident #40's wheelchair on those dates and times, if the care plan stated the body alarm was to be on when in bed. The DON the alarm should not have been on her during the day, the staff probably saw it on her bed and thought she was supposed to have it all the time.` Resident #50 Review of Resident #50's Comprehensive Care Plan revealed a Problem/Need, dated 9/29/19, for Congestive Heart Failure (CHF) and risk for dehydration and SOB. The Approaches included: Check O2 SAT PRN (as needed) and notify the physician if < 90%, change O2 tubing Q (every) Wednesday, and O2 at 2L/M per nasal cannula PRN. The care plan was last reviewed/ updated on 1/02/2020. Observations in Resident #50's room, on/12/2020 at 4:40 PM, 1/13/2020 at 8:45 AM, and on 1/13/2020 at 2:10 PM, revealed the O2 tubing and nasal cannula was hanging over the O2 concentrator, uncovered and undated. Review of Resident #50's Electronic Treatment Administration Record (eTAR), revealed an order was noted to change O2 tubing weekly every Wednesday, however, there were no signatures on the eTAR for the entire months of October 2019, November 2019, December 2019, or on Wednesday, the 1st of January, 2020, nor Wednesday, the 8th of January, 2020. On 1/13/2020 at 2:47 PM, an interview with the Director of Nursing (DON), revealed when she was asked about no signatures being present on the eTAR for the months of October 2019 through January 2020, she pulled up the eTARs on her computer, and verified there were no signatures for the months of October 2019 through January 13, 2020. On 1/13/2020 at 2:55 PM, an interview with the DON revealed, the nurse that put in the admission order marked it as a PRN medication and should have assigned a day and time to the oxygen tubing change order for it to fire for the nurses to sign. The nurse that put in the order did not do the special requirements section correctly. When asked if there was any way she could verify the tubing was being changed according to the physicians order and care plan, from October 2019, through 1/13/2020, and she stated no.

Based on staff interview, resident interview, facility policy review and record review, the facility failed to provide Resident #45's Passive Range of Motion (PROM) exercises correctly to prevent the potential decline in range of motion for one of three (1 of 3) residents reviewed receiving restorative services. Findings include: Review of the facility's policy titled, Restorative Nursing Services, revised July 2017, revealed, Policy Statement: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. On 1/12/19, at 3:40 PM, during an interview with Resident #45, he stated he was supposed to have Restorative Nursing for exercises to his shoulders but they don't do it. Record review of the January 2020 Physician's Orders revealed an order, dated 11/14/19, to admit Resident #45 to the Restorative Nursing Program for 1) Active Range of Motion (AROM) right shoulder flexion exercises four (4) sets 15 repetitions (reps) 2) Passive Range of Motion (PROM) left (L) Shoulder Flexion/Abduction 4 sets 15 second holds six (6) days weekly. On 1/14/2020 at 10:25 AM, an interview revealed Restorative Certified Nursing Assistant (CNA) #1, stated, the CNA who gets him up does it for me and they just tell me. Other than that, he gets done. He has AROM to the left and PROM to the right shoulder. CNA #1 stated CNA #2 has him four (4) days and she usually does it for me. CNA #1 said normally by the time I get down there she will have already done his exercises, dressed him and got him up. This morning he got up at 8:15 because he had to be at the dentist at 9:00. CNA #2 did it this morning. CNA #1 stated therapy explains and tells her about new orders for each individual. CNA #1 said she did not know if the CNAs on the floor got the instructions when she got them or when they are discharged to the floor CNAs. CNA #1 states a man from therapy did go over a lot of things with all the CNAs recently. Record review of the Therapy to Restorative Form for Resident #45 revealed the resident was discharged from Occupational Therapy on 11/11/19 with Goals for Restorative Program: 1. Resident will perform RUE shoulder flexion exercises 4 sets of 15 reps pain free range. 2. Perform PROM to LUE in shoulder flexion and shoulder abduction 4 sets of 15 second holds. Pain free range. Restorative CNA #1 signed the form on 11/14/19. On 1/14/2020, at 10:46 AM, an interview with CNA #2 revealed she stated, she does Resident #45's exercises because sometimes CNA #1 has a section and I don't know if she has a section or not. CNA #2 said Resident #45 does look for CNA #1 because he knows she's the restorative aide. CNA #2 said she did ROM with his shoulders and arms. Just a little exercise up and down with his shoulders, the left is passive. CNA #2 said she did PROM 15 times to the left shoulder and arm, and one set of 15 or sometimes 10. CNA #2 said they had an in-service a good while ago where they took us in there (therapy room) and showed us dressing, ROM and stuff. No one goes over exercises for individual residents with us when they are discharged to restorative from therapy. We are responsible for making sure Restorative exercises get done if Restorative CNA #1 is assigned to a section. CNA #2 stated that CNA #1 has a lot of different assignments from working on the floor to transportation. CNA #2 stated she does have access to Restorative Nursing Program (RNP) Care Task in the Kiosk as she demonstrated by opening it in the Kiosk and this surveyor observed that the exercises for Resident #45 were documented as completed for January 2020. CNA #2 stated sometimes she charts it's done and sometimes she just tells CNA #1 that it's done and she charts it. CNA #2 reviewed the order at this time for PROM to the left shoulder from the Kiosk and she stated she does it 10 sometimes 15 times, and she thought it meant to hold it a couple of seconds and let it go rest on the bed. On 1/14/2020, at 11:00 AM, an interview with the Occupational Therapist (OT), revealed PROM to the left shoulder for 4 sets of 15 second holds, that's for contracture management. and pain management. The PT stated he goes over the exercises with the Restorative Aide, have them return demonstrations and sign the competency sheet. The OT stated we try to word it so that if another aide comes in he/she will know what to do as well. If they have any questions about it they can consult with us. It should be the 4 sets of 15 second hold with the passive, key word is pain free with the hold. The CNA should be holding the extremity in the pain free position for 15 seconds 4 times. I think sometimes it gets confusing with the wording. Active ROM should be 4 sets of 15. Probably there are communication issues with that. The important part is the hold for 15 seconds. Reps and holds get a little confusing. We have in-serviced the CNAs on different exercises, AROM, PROM, a list of things that they would be doing actually in the restorative program. On 1/14/20, at 2:26 PM, an interview with the OT revealed he stated he just evaluated Resident #45 and there were no changes found with ROM of bilateral shoulders since discharge from therapy. An interview with Licensed Practical Nurse (LPN) #3/Restorative Nurse, on 1/15/2020, at 9:06 AM, revealed LPN #3 stated all Certified Nursing Assistants (CNA) staff are aware of how to do the restorative. They were in-serviced by a therapist because when CNA #1 is not here, the floor CNA picks it up, We do six (6) days a week, Monday- Saturday. CNA #1 wears many hats, she drives the van, works a section and when she works a section the CNAs are required to do their people. LPN #3 stated she was not aware that CAN #2 was not aware of how to interpret the PROM order of 4 sets of 15 second holds. On 1/15/2020 at 9:40 AM, an interview with the Interim Director of Nursing (IDON), revealed a consequence of not getting the correct restorative exercises could be a regression of the resident's ability to move instead of a progression toward his goals. The IDON stated she believed that CNA #2 truly did not understand the order. She said she felt that the RCNA should be the one to do the restorative exercises because she is the one who was trained to do them. The IDON stated she did not know that the floor CNAs were doing the exercises on a regular basis. She stated there were three (3) residents on the Restorative Nursing Program at this time and even though the RCNA has other duties, she should be able to cover those residents She stated the facility just hired a new RCNA and that she felt like having a backup RCNA would be a good idea. Record review of the Face Sheet for Resident #45 revealed the resident was admitted by the facility, on 8/28/19, with diagnoses including but not limited to Other Seizures, Muscle Wasting and Atrophy, not elsewhere classified (NEC), left upper arm, Hemiplegia following Cerebral Infarction Affecting Left Non-dominant Side. Record review of the Quarterly Minimum Date Set, with an Assessment Reference Date of 12/2/19, revealed in Section C, Resident #45 had a Brief Interview for Mental Status score of 15, indicating intact cognition. Record review of the Occupational Therapy Plan of Care (Evaluation Only) performed by the Occupational Therapist, on 1/14/2020, revealed no decline in function since discharge from OT on 11/11/19.

Based on observation, staff interview, and record review, the facility failed to address Resident #40's care plan after a fall with an intervention to prevent the potential for another fall. Resident #40 was assessed a high risk for falls by the facility, on 11/15/2019, and experienced another fall on 12/9/2019. This concern was identified for one (1) of two (2) residents reviewed for falls. Findings include: Review of Resident #40's Resident Incident Report, dated 12/09/2019 at 2:30 PM, revealed Resident #40 had a fall, in which she entered another resident's room, threw the covers back on the bed and attempted to crawl in bed. She was found laying on the floor next to the bed with her knees bent and asking for a pillow so she could put it under her head. Review of Resident #40's care plan, with the reviewed/update of 11/20/19, revealed the Problem/Need for risk for fall related to (r/t) a history (HX) of falls, and impaired mobility. The Approaches included: call light within reach, bed in lowest position and wheels are locked, non-skid footwear, fall assessment quarterly and as needed (PRN), Physical Therapy (PT) to evaluate after each fall, body alarm when in bed, bilateral safety transfer bars on bed for turning and positioning. Resident # 40's care plan did not address fall interventions dated after the fall on 12/9/19. During an interview with the Director of Nursing (DON), on 1/13/2020 at 4:30 PM, she revealed the staff had attempted another intervention after Resident #40's recent fall, she stated therapy had screened the resident, according to the care plan, and they recommended no therapy due to her cognitive impairment. When asked if any of the interventions currently listed on Resident #40's care plan would have helped to prevent the fall on 12/09/2019, in which resident #40 had wandered into another resident's room to try to get in their bed, the DON stated no. When asked why the staff didn't attempt an additional intervention to address the cause of the fall, which was wandering into another resident's room in search of a place to lay down, the DON We didn't put another intervention in place, when therapy didn't pick her up because she doesn't usually get up and move around a lot out of her chair. She is always on the move up and down the halls in her wheelchair, and she is hard to keep track of. When asked if another intervention to address the cause of the fall should have been put into place for Resident #40, she stated yes. Review of Resident #45's Fall Risk Evaluation revealed a score of 12. The assessment indicated A score of 10 or GREATER indicates a potential FALL RISK. Review of Resident #45's Assessment of Risk for Falls revealed a score of 8 on 11/15/19. This assessment indicated a score of 07-18 Resident is high risk. Review of the Face Sheet revealed Resident #40 was admitted by the facility, on 3/16/18, with the included diagnoses of Unspecified Dementia without behavioral disturbance, Personal HX of TIA (Trans Ischemic Attack) and Cerebral Infarction without residual deficits and Major Depressive Disorder, single episode, unspecified. Review of Resident #40's Quarterly Minimum Data Assessment, dated 11/15/19, revealed the resident's BIM score was 99 due to the resident was not interviewable.

Based on observation, staff interview, resident interview, record review and facility policy review, the facility failed to store and change oxygen (O2) tubing to prevent the possibility of infection/cross contamination, for two (2) of 17 residents reviewed on oxygen therapy. Resident #50 and Resident #24 Findings include: Review of the facility's policy titled, Changing of Oxygen Supplies, dated September 2019, revealed: Policy Statement: Riverview Nursing and Rehabilitation Center incorporates procedures to maintain an environment as free of infection as possible for our residents. Policy Interpretation and Implementation: 1. Designated nursing staff will change oxygen tubing, mask, and cannulas at least every (7) days and PRN (as needed), 2. Designated nursing staff will label oxygen tubing, cannulas and oxygen humidifier water containers with date of change in a visible site. 3. Designated nursing staff will place opened oxygen tubing, mask and cannulas in labeled/dated container/covering while not in use. An observation, on 1/12/2020 at 5:01 PM, in Resident #24's room, revealed the resident's O2 tubing was on the floor beside the bed, with the bed wheel on the tubing. The O2 tubing was dated 1/8/2020, and there was no storage bag or container for the O2 tubing. On 1/13/2020 at 10:30 AM and 4:20 PM, an observation of Resident #24's room revealed the O2 tubing was still on the floor beside the bed, and there was no storage bag/container in the room. Observations, on 1/14/2020 at 9:15 AM and 3:45 PM, of Resident #24's room, revealed the O2 tubing was on the floor beside the bed, and there was no storage bag/container in the room. On 1/15/2020 at 9:15 AM, an observation of Resident #24's room revealed the O2 tubing was on the floor beside the bed, and these still was no storage bag/container in the room. On 1/12/2020 at 5:05 PM, an interview with Resident #24, on revealed she doesn't remember ever having a bag to put the O2 tubing, so she just throws it wherever. Review of the Physician's Order List revealed an order, dated 10/3/19, for Oxygen at 2L/min (liters per minute) via nasal cannula as needed for shortness of breath, change oxygen tubing out weekly on Wednesday, Check O2 sat (saturation) every shift. Notify MD (Medical Doctor) if <90% for Shortness of Breath. On 1/15/2020, at 9:30 AM, an interview with the Director of Nursing (DON), revealed the floor nurses on the day shift was responsible for changing the O2 tubing on Wednesdays and should be ensuring there is a bag in there to store the tubing. Record review of the Face Sheet revealed Resident #24 was admitted by the facility, on 1/31/2019, with the included diagnoses of Rhabdomyolysis, Heart Failure, Insomnia, Shortness of Breath, Chronic Obstructive Pulmonary Disease, Essential Hypertension. Resident #50 On 1/12/2020 at 4:40 PM, 1/13/2020 at 8:45 AM, 1/13/2020 at 10:42 AM and on 1/13/2020 at 2:10 PM, observations of Resident #50's room revealed the O2 tubing and nasal cannula was hanging over the O2 concentrator, uncovered and undated. On 1/13/2020, at 2:15 PM, the Director of Nursing (DON) verified Resident #50's O2 tubing was not dated, and there was no container visible or in the resident's night stand to place the nasal cannula in when it was not in use. The DON stated, there should be a bag in each resident's nightstand drawer that is dated, with the resident's name on it to put the cannula in when it is not being used, and I don't see one in here anywhere. Review of Resident #50's Electronic Treatment Administration Record (eTAR), revealed an order was noted to change O2 tubing weekly every Wednesday, however, there were no signatures on the eTAR for the entire months of October 2019, November 2019, December 2019, or on Wednesday, the 1st of January, 2020, nor Wednesday, the 8th of January, 2020. An interview, on 1/13/2020 at 2:47 PM, revealed the Director of Nursing (DON), revealed when she was asked about no signatures being present on the eTAR for the months of October 2019 through January 2020, she pulled up the eTARs on her computer, and verified there were no signatures to document the resident's O2 tubing was changed weekly for the months of October 2019 through January 13th, 2020. An interview, on 1/13/2020 at 2:55 PM, with the DON revealed, the nurse that put in the admission order marked it as a PRN medication and should have assigned a day and time to the oxygen tubing change order for it to fire for the nurses to sign. The nurse that put in the order did not do the special requirements section correctly. When asked if there was any way she could verify the tubing was being changed according to the physician's order and care plan, from October 2019, through 1/13/2020, and she stated no. Review of the Face Sheet revealed Resident #50 was admitted by the facility, on 9/25/19, with the included diagnoses Congestive Heart Failure (CHF), Diabetes Type II, Shortness of Breath (SOB), Cough and Wheezing. `

Based on observation, staff interview and facility policy review, the facility failed to properly label medications for two of four (2 of 4) medication carts and one (1) of two (2) medication storage rooms. Findings include: Review of the facility's policy titled, Labeling of Medication Containers, revised April 2007, revealed the Policy Statement: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Under a section titled Policy Interpretation and Implementation it stated: 2. Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. 3. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; d. The name, strength, and quantity of the drug; e. The prescription number (if applicable); f. The date that the medication was dispensed; g. Appropriate accessory and cautionary statements; h. The expiration date when applicable; and i. Directions for use. Review of the facility's Storage of Medications policy, revised April 2007, revealed under the section Policy Interpretation and Implementation: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. On 01/14/2020 at 4:00 PM, an observation of Registered Nurse (RN) #1's medication cart, revealed: The medication cart was unlocked and the following items observed: One bottle of Artificial Tears, opened, no open date on the bottle or box, and without a designated resident name. Two bottles of Opsumit, ( a medication used to treat pulmonary arterial hypertension), without a pharmacy prescription label of any kind. Four tablets of Imodium (an over the counter (OTC) medication), loose in the cart without a container, prescription label, or expiration date. An interview with RN #1 at this time revealed she did not know who these medications belonged to because there was no names on the bottles. On 01/14/2020, at 4:30 PM, an observation of Licensed Practical Nurse (LPN) #2's medication cart revealed one bottle of Dorzolomide HCL 2% eye drops, opened, partially used, with no open date on the bottle or box it was stored in. An interview at this time with LPN #2 revealed there was a lot of new nurses working at the facility now, and he keeps telling them they need to date the medications when they open them. An observation, on 1/14/2020 at 4:45 PM, with the Director of Nurses (DON), revealed one vial of multi-dose Tubersol 5T units/0.1 milliliter (ml), opened, with flip top removed, and no date opened on the vial or the box it was stored in. An interview at this time with the DON revealed the findings from the two medication cart checks and the medication storage room. The DON stated, That the Tubersol vial is 100 percent my fault, I opened it and didn't mark the date I opened it. That one is 100 percent on me. When asked about the storage and labeling of medications in the facility, the DON indicated they should all be labeled appropriately from the pharmacy, and the date opened should be written on the label or box it is stored in for eye drops, insulin and multiple use vials.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure a medication error rate of less than five percent (5%), out of 27 medication administrations observed. The medication error rate was 14.81%. Findings include: Review of the facility's policy titled, Administering Medications through an Enteral Tube, revised March 2015, revealed, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Steps in the Procedure: 21. When correct tube placement and acceptable GRV have been verified, flush tubing with 15-30 ml warm sterile water (or prescribed amount). 23. Dilute the crushed or split medication with 15-30 ml room temperature purified water (or prescribed amount). 26. If administering more than one medication, flush with 5 ml (or prescribed amount) room temperature purified water between medications. 27. When the last of the medication begins to drain from the tubing, flush the tubing with 5 ml of room temperature purified water (or prescribed amount). An observation, on 1/12/2020 a 3:17 PM, revealed Licensed Practical Nurse (LPN) #4 administered Resident #2's medications via his Percutaneous Endoscopic Gastric (PEG) tube. LPN #4 turned on the water faucet in the resident's room and allowed 5 cubic centimeters (CC) of water to pour into two (2) medicine cups. LPN #4 added the crushed Keppra 1,000 milligram (mg) tablet to one of the medicine cups, and she added the crushed Coreg 6.25 mg tablet to the second medicine cup. LPN #4 poured up 30 cc of Pro-Stat into a third medicine cup. LPN #4 administered the medications via Resident #2's PEG tube without flushing with the prescribed 5 ml of water between the medications. LPN #4 also did not add the 15 to 30 ml of water to dissolve the crushed/split medications. Review of Resident #2's Physician Orders List, printed 1/13/2020 at 4:38 PM, revealed the following orders: (1) 3/13/19, flush the PEG tube with 60 milliliters (ml) of water before and after (AC/PC) medications and with 5 ml between meds. (2) 2/15/17 Keppra 1000 mg tablet, give one tablet via the PEG tube twice a day. (3) 12/19/17 Pro-Stat Sugar Free Liquid 30 cc per the PEG tube twice a day. (3) 4/24/18 Coreg 6.25 mg tablet via the PEG tube twice a day. On 1/15/2020, at 1:21 PM, an interview with LPN #4, revealed she stated she knew the order said 5 ml between meds, but she thought the 5 ml that she mixed the medication with was the 5 ml ordered. LPN #4 stated it was just a misunderstanding. LPN#4 confirmed she had mixed the Coreg and Keppra with 5 ml of water, and she did not know the amount of water that should be used to dissolve the medications. An interview with the Director of Nursing (DON), on 1/13/20, at 4:40 PM, revealed LPN #4 should have flushed Resident #2's PEG tube with 5 ml of water between the medications, and dissolved the medications with 15-30 ml of water per agency policy. Record review of the Face Sheet revealed Resident # 2 was admitted by the facility, on 10/25/16, with diagnoses including Essential (primary) Hypertension, Alzheimer's Disease, and Dysphagia. Resident #52 On 1/13/2020 at 8:10 AM, Licensed Practical Nurse (LPN) #1, was observed administering a medication via a PEG tube for Resident #52. LPN #1 pulled the medication, Klonopin 0.5 mg tablet, from the cart, crushed the medication and placed it in a medicine cup. LPN #1 obtained 120 cc of water from an unopened water bottle. LPN #1 stated at this time, I give 60 cc of water before and after the medication. LPN #1 mixed 5 cc of water with the medication and stirred it to dissolve it. LPN #1 disconnected the syringe, removed the plunger and reconnected the syringe to the enteral tube and poured the medication dissolved in 5 cc of water into the syringe. Once it went through, she administered a 120 cc water flush into the syringe and waited for it to all run in. LPN #1 then removed the syringe, clamped the PEG tube and reattached the enteral feeding, secured it, and started the feeding pump. Review of Resident #52's January 2020 Physician's Orders, revealed an order, dated 3/13/19, to flush the PEG tube with 60 cc of water AC and PC medications, and with 5 ml of water between the medications. Further review of the Physician's Orders revealed an order, dated 5/29/17, to administer Klonopin 0.5 mg tablet per the PEG tube daily.

Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure measures to prevent the possible spread of infection and/or cross contamination for five (5) of nine (9) residents observed during the medication administration observations, Residents #2, #13, #15, #29, and #52. Findings include: Review of the facility's Infection Prevention and Control Program policy, revised October 2018, revealed the Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation: The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. The program is based on national infection prevention and control standards. The infection control prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program includes prevention of infection. Policies and Procedures included: (2) Assessment of staff compliance with existing policies and regulations. Prevention of Infection included: (3) Educating staff and ensuring they adhere to proper techniques and procedures. (4) Communicating the importance of standard precautions. (8) Following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). Review of the facility's policy titled, Administering Medication Through an Enteral Tube, revised March 2015, revealed the Steps in the Procedure included wash your hands before the procedure begins and when the procedure is completed. Resident # 29 On 1/12/2020, at 3:06 PM, an observation of Resident #29's finger stick blood glucose testing performed by Licensed Practical Nurse (LPN) #4, revealed LPN #4 placed a white tray which contained the blood glucose testing supplies on the resident's over bed table without a barrier. LPN #4 then returned to her cart at the resident's door to obtain the bottle of blood glucose test strips which she then placed on top of the resident's over bed table without a barrier. After completing the test, LPN #4 placed the bottle of test strips into the top drawer of the medication cart and placed the tray into the bottom right drawer of medication (med) cart. LPN #4 did not disinfect the tray or bottle prior to returning them to the cart. In an interview with LPN #4, on 1/13/2020, at 1:17 PM, LPN # 4 confirmed she had contaminated the medication cart and it was an infection control issue. During an interview with the Director of Nursing (DON), on 01/13/2020, at 4:36 PM, the DON confirmed this was an infection control issue and agreed the medication cart was contaminated by the tray and bottle. Resident # 2 On 1/12/2020, at 3:17 PM, during an observation of medication administration for Resident #2, Licensed Practical Nurse (LPN) # 4 took a white tray from the medication (med) cart, placed it on top of the med cart and prepared Resident #2's mediations. This was the same tray which was used for Resident # 29. LPN # 4 then placed the white tray on Resident #2's bedside table. LPN # 4 placed gloves in her uniform pocket which she used during the administration of medications. After administering medications, LPN # 4 took the white tray and set it on the sink in Resident # 2's room while she washed her hands. She then took the tray and placed it on top of the med cart. On 01/13/2020, at 4:40 PM, an interview with the Director of Nurses (DON) revealed this was an infection control issue. On 01/15/2020, at 1:21 PM, in an interview with LPN #4, she confirmed she did put the gloves in her pocket and that they were contaminated because the pocket is considered a dirty area. LPN #4 confirmed that by placing the tray on the sink it contaminated the tray and the top of the medication cart. Resident #13 On 1/15/2020 at 11:25 AM, an observation revealed Licensed Practical Nurse (LPN) #6 prepared medications for Resident #13. LPN #6 obtained a Sani Cloth Plus wipe from the container to clean the resident's inhaler when she dropped the red plastic top to the wipes on the floor. The red plastic top hit the floor and rolled under the medication cart. LPN #6 picked up the plastic top, placed it on top of the med cart, then placed it on top of the wipe container, and then placed the wipe container with the contaminated plastic top in the medication cart drawer. The plastic top was not wiped off or cleaned before placing it back on the medication cart, on top of the wipe container or in the medication cart drawer. On 1/15/2020 at 11:45 AM, an interview with LPN #6 confirmed she did not clean the red plastic top to the Sani Cloth Plus container before placing it on the medication cart, on the container or in the drawer of the medication cart. LPN #6 confirmed the top was contaminated and could cause the spread of infection. On 1/15/20 at 2:15 PM, an interview with the DON confirmed the plastic top to the wipe container was contaminated after falling on the floor and should have been cleaned before it was placed on the medication cart or in the drawer in the medication cart. Resident # 15 On 1/12/20, at 3:49 PM, an observation revealed LPN #4 as she prepared medications for Resident #15. LPN #4 placed a bottle of Lantanoprost 0.005% eye drops on the over bed table without a barrier. LPN #4 administered the medications and eye drops and walked over to the sink to wash her hands. LPN #4 then placed the eye drop bottle on the sink and then back into the eye drop box in the cart. During an interview with LPN #4, on 01/15/20, at 1:25 PM, LPN #4 stated the eye drop bottle was contaminated when she sat it on the over bed table and the sink. LPN #4 stated it could be a risk of taking germs from one resident to another. In an interview, on 01/13/2020, at 4:52 PM, the DON confirmed that it was an infection control issue. Resident #52 On 01/13/20 at 8:10 AM, Licensed Practical Nurse (LPN) #1 was observed administering medication per Resident #52's Percutaneous Endoscopic Gastrostomy (PEG) tube. LPN #1 did not wash her hands prior to beginning the medication administration. LPN # 1 placed a paper towel barrier on the bedside table and sat all her supplies on the barrier except for the medication cup with the crushed medication, which she sat on the bedside table, off of the barrier. LPN #1 obtained an unopened bottle of water, and poured out 120 cc to use for the PEG tube water flushes. LPN #1 mixed five cubic centimeters (5cc) of water with the medication and stirred it to dissolve it. LPN #1 put her gloves on and cleaned the stethoscope that was on the bedside table. LPN #1 checked the PEG tube placement by auscultation with the stethoscope. LPN #1 completed the medication administration via the PEG tube, and resumed the PEG tube feeding via the feeding pump. LPN #1 discarded all of her used supplies, removed her gloves and threw them in the trash. LPN #1 walked over and obtained the plunger and syringe she used to administer Resident #52's medication and washed them off with water, in the sink, with her bare hands. She dried them and placed them in a newly dated bag and hung them on the enteral feeding pole. LPN #1 then cleaned the stethoscope and placed it on her medication cart, came back in to wash her hands and left Resident #52's room.