Based on record review and interviews, the facility failed to ensure staff provided care per standards of practice when staff failed to follow physician orders regarding elevated blood glucose levels and failed to document insulin administration amounts due to elevated blood glucose levels for one resident (Resident #1) of four residents sampled. The facility census was 61. Review of the facility policy entitled Blood Glucose Monitoring, revised 01/13/23, showed the following: -Purpose of the policy was to ensure the effective and accurate monitoring of blood glucose levels for individuals with diabetes or at risk for blood glucose abnormalities; to prevent low or high blood sugar; to guide healthcare professionals, caregivers, and patients in proper blood glucose monitoring practices to ensure safe and effective management of diabetes; -Doctors and nurses are responsible for ordering and interpreting blood glucose tests, providing guidance on target glucose levels, and adjusting medications accordingly; -Caregivers are responsible for regularly checking blood glucose, following prescribed testing schedules, recording results, and seeking medical advice when necessary; -Caregivers are required to document blood glucose readings, especially for those with insulin-dependent diabetes or undergoing intensive management; -Regular review of blood glucose logs should be done by healthcare professionals to ensure that the patient is staying within the target range and making necessary adjustments to their management plan; -A comprehensive blood glucose monitoring policy ensures that patients and healthcare professionals follow standardized, evidence-based practices for managing blood glucose. It aims to reduce complications associated with diabetes, improve patient outcomes, and enhance the overall quality of care. Review of the medical director's hyperglycemic (high blood sugar levels) protocol showed to leave a message on the physician's office line if the resident's blood glucose reading was greater than 500 milligrams/deciliter (mg/dL). 1. Review of Resident #1's face sheet (gives basic profile information) showed the following information: -admission date of 06/02/23; -Diagnoses included type 2 diabetes mellitus with hyperglycemia, long term use of insulin, and thyroid disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 09/13/24, showed the following; -Moderately impaired cognition; -Received insulin on 7 of the last 7 days. Review of the resident's care plan, last updated 09/13/24, showed the following: -Resident had a diagnosis of diabetes; -Administer diabetes medication as ordered by doctor; -Monitor/document for side effects and effectiveness diabetes medication; -Monitor/document/report any signs/symptoms of low or high blood sugar; -Perform blood sugar checks as ordered by doctor. Review of the resident's October 2024 Physician Order Sheets (POS) showed the following: -An order, dated 08/01/24, for insulin regular human injection solution (used to treat diabetes) 100 units/milligram (u/mg). Staff to inject per sliding scale before meals and at bedtime for diabetes: -If blood glucose reading was 131 mg/dL to 180 mg/dL, administer 4 units of insulin; -If blood glucose reading was 181 mg/dL to 240 mg/dL, administer 8 units of insulin; -If blood glucose reading was 241 mg/dL to 300 mg/dL, administer 10 units of insulin; -If blood glucose reading was 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood glucose reading was 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood glucose reading was 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If blood glucose reading was 451 mg/dL to 500 mg/dL, administer 30 units of insulin; -Call physician for blood sugar reading over 500 mg/dL; before meals and at bedtime for diabetes. Review of the resident's October 2024 Medication Administration Records (MAR) showed on 10/11/24, the resident's blood sugar reading at 7:07 A.M. was 505 mg/dL. Staff documented option 9 - Other/See Nurse Notes. Review of resident's nurse's note, dated 10/11/24, showed staff did not document information pertaining to notification to physician regarding the resident's blood sugar reading greater than 500 mg/dL, any orders/direction received, or amount of insulin administered. Review of the resident's October 2024 MAR showed on 10/15/24, the resident's blood sugar reading at 7:01 A.M. was 501 mg/dL. Staff documented option 9 - Other/See Nurse Notes. Review of the resident's nurse's notes, dated 10/15/24, showed staff did not document information pertaining to notification to physician regarding the resident's blood sugar reading greater than 500 mg/dL, any orders/direction received, or amount of insulin administered. Review of the resident's October 2024 POS showed the order, dated 08/01/24, for insulin regular human injection solution per sliding scale was discontinued on 10/22/24. Review of the resident's October 2024 and November 2024 POS showed the following: -An order, dated 10/25/24, for NovoLog FlexPen Injection Solution (rapid acting insulin) 100 u/ml. Inject subcutaneously (below the skin) before meals and at bedtime for diabetes per sliding scale: -If blood glucose reading was 70 mg/dL to 130 mg/dL, administer no insulin; -If blood glucose reading was 131 mg/dL to 180 mg/dL, administer 2 units of insulin; -If blood glucose reading was 181 mg/dL to 240 mg/dL, administer 4 units of insulin; -If blood glucose reading was 241 mg/dL to 300 mg/dL, administer 6 units of insulin; -If blood glucose reading was 301 mg/dL to 350 mg/dL, administer 8 units of insulin; -If blood glucose reading was 351 mg/dL to 400 mg/dL, administer 10 units of insulin; -If blood glucose reading was 401 mg/dL to 450 mg/dL, administer 15 units of insulin; -If blood glucose reading was 451 mg/dL to 500 mg/dL, administer 18 units of insulin; -If blood glucose reading was over 500 mg/dL, call physician. Review of the resident's October 2024 MAR showed on 10/27/24, the resident's blood sugar reading at 7:14 A.M. was 590 mg/dL. Staff documented option 9 - Other/See Nurse Notes. Review of the resident's nurse's note, dated 10/27/24, showed staff did not document information pertaining to notification to physician regarding a blood sugar reading greater than 500 mg/dL, any orders/direction received, or amount of insulin administered. Review of the resident's November 2024 MAR showed on 11/15/24, the resident's blood sugar reading at 11:00 A.M. was 517 mg/dL. Staff documented option 5 - Hold/See Nurse Notes. Review of the resident's nurse's note, dated 11/15/24, showed staff did not document information pertaining to notification to physician regarding a blood sugar reading greater than 500 mg/dL, any orders/direction received, or amount of insulin administered. During an interview on 11/21/24, at 2:50 P.M., Registered Nurse (RN) A said if a resident's blood glucose reading was greater than 500 mg/dL. he/she would give the highest level of insulin for the specific sliding scale orders, recheck the blood glucose in an hour, and call the physician if the result was not in acceptable range. The resident's blood sugar test result was often high in the morning because the resident had refused insulin at bedtime the night before. The nurse should document the test result and the amount of insulin given. During an interview on 11/21/24, at 3:00 P.M., Licensed Practical Nurse (LPN) B said if the resident's sliding scale insulin order showed to call physician if the reading was greater than 500 mg/dL, he/she would wait to give insulin until contacting the physician for orders. He/she would document the orders and the amount of insulin given. During an interview on 11/21/24, at 3:05 P.M., RN C said he/she would contact the physician if a resident's blood glucose reading was greater than 500 mg/dL, which is the facility's protocol. They can either call the physician's office or put a message through on the secure electronic system and then they obtain orders regarding the amount of insulin to give. The physician can then re-address any medication changes when they are in the facility, usually weekly. During an interview on 11/21/24, at 3:20 P.M., the Director of Nursing (DON) said the nurses should follow the physician orders for administering insulin. If the order states to contact the physician if a resident's blood glucose reading is greater than 500 mg/dL, the nurse can use the secure electronic communication application to notify the physician. The nurse could give the highest level of insulin listed for the ordered sliding scale, but should go ahead and call/notify the physician. The physicians are good about getting back to them with orders, and there is always a physician on-call. The nurse should document the blood glucose reading, any physician orders, the amount of insulin given, and any re-check results. The DON reviewed the resident's nurses' notes and the electronic communications from the facility to the physician for 10/11/24, 10/15/24, 10/27/24, and 11/15/24. The DON was unable to locate documentation or evidence pertaining to physician notification of blood sugar readings above 500 mg/dL, subsequent physician orders, or amount of insulin given. During an interview on 11/21/24, at 5:02 P.M., the Administrator said he/she would expect staff to follow physician orders regarding blood sugar checks, contacting the physician if the test result was above a specified range, and insulin administration. The nurse should document all information, including the physician notification, orders, and amount of insulin given. MO00243846

Based on observation, interview, and record review, facility staff failed to notify the physician of a change in condition for one resident (Resident #30) when the resident complained to a nurse of pain, and stinging and burning in his/her legs, and expressed concerns about the possibility of urinary sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to it's own tissues and organs). A sample of 22 residents were reviewed in a facility with a census of 59. Review of the facility policy titled, Resident Change in Condition, dated 01/01/24, showed the following: -The facility will keep the physician, who is in charge of the resident's medical care, informed of the resident's medical condition so they may direct the plan of care as needed; -Notification of the physician should occur promptly when there is a change in the resident's condition; -Examples of change in condition may include new pain; -Staff should document the symptoms and the observations associated with the change in condition and the date and time of contact with the physician. 1. Review of Resident #30's face sheet showed: -admission date of 09/26/22 with readmission date of 11/26/23; -Diagnoses included Type 2 diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), history of sepsis, history of urinary tract infections, dysuria (painful or uncomfortable urination), and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff,) dated 01/10/24, showed the following: -Resident cognitively intact; -Dependent on staff for personal and toileting hygiene, showers, and upper and lower body dressing; -Always incontinent of urine; -Resident on antidepressant, opioid (narcotic pain medication), and hypoglycemic (a medication used to reduce the amount of sugar in the blood) medications. Review of the resident's January 2024 physician orders showed the following: -An order, dated 01/03/24, for staff to administer Augmentin (an antibiotic) 875/125 milligram (mg) orally two times a day for urinary tract infection for seven days (medication to be administered 01/03/24 to 01/10/24). Review of the resident's current comprehensive care plan the resident had no plan of care related to his/her history of urinary tract infections. Review of the resident's progress note dated 01/14/24, at 4:03 A.M., showed a nurse documented the following: -The nurse took the resident his/her 4:00 A.M. pain medication and the resident said he/she was in a lot of pain and his/her legs were stinging and burning. The resident told the nurse he/she was afraid the antibiotics for the urinary tract infection (UTI) did not work and was worried about going septic. The nurse documented he/she would report this information to the day shift nurses and request a follow up urinalysis for the resident. Review of the resident's progress notes showed staff did not document follow-up physician notification or request for urinalysis regarding the resident's concerns on 01/14/24. During an interview on 02/28/24, at 11:53 A.M., the resident said he/she felt the staff could do a better job on how quickly they respond when the resident is not feeling well. Sometimes, he/she tells the staff, but the concerns do not get reported to the nurse or physician. During an interview on 03/01/24, at 10:44 A.M., Licensed Practical Nurse (LPN) T said the following: -When the night nurse documented the resident was concerned about the possibility of re-development of a urinary tract infection and complained of his/her legs stinging/burning, the night nurse should have assessed the resident and documented the assessment; -The night nurse should have passed on in report to the day nurse to call the resident's physician and ask for an order for a urinalysis; -The night nurse also could have faxed the physician; -LPN T checked the resident's record and the physician communication book, but said he/she could not find documentation that the night nurse notified the resident's physician on 01/14/24 of the resident's concerns. During an interview on 02/29/24 at 5:16 P.M., the director of nursing (DON) said the following: -On 1/14/24, the nurse should have assessed the resident for signs and symptoms of a urinary tract infection and documented that assessment, but he/she did not; -The nurse should have faxed the resident's physician to notify of the resident's signs/symptoms and request for a urinalysis, but the director of nursing could not locate a fax or notification of the physician; -If the nurse sent a fax to the physician, the physician would have seen the fax at 8:00 A.M. on the morning of 01/14/24, and responded; -The night nurse should have also reported the resident's symptoms to the day shift nurse, but the DON said he/she had no proof/documentation that the information was passed on in report.

Based on interview and record review, the facility failed to provide a bed-hold policy to one resident (Residents #39), out of a sample of four residents, who transferred to the hospital. The facility census was 59. Review of the facility's policy titled Bed Hold Policy, undated, showed before and at the time the facility transfers a resident for hospitalization or therapeutic leave, the facility will provide resident or resident's representative with written notice explaining the duration of the bed-hold policy. 1. Review of Resident #39's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 01/28/21; -The resident was his/her own responsible party; -Diagnoses included diabetes (a metabolic disease, involving inappropriately elevated blood glucose levels), reduced mobility, and fracture of right lower leg. Review of the resident's nurse's progress note dated 01/11/24, at 4:39 P.M., showed the following: -Certified nursing assistant (CNA) called him/her to the resident's room to look at the resident's foot. The resident had been scheduled for surgery tomorrow morning. When talking with the resident, the resident informed him/her that the surgery had been canceled due to weather. Upon assessment of the resident's foot, noted edema (swelling) and redness to the bottom of the foot, significantly worse than yesterday. He/she notified the Director of Nursing (DON) and placed a call to the physician's office with orders to send to hospital via ambulance for a direct admit through the emergency room (ER). Staff placed call to emergency medical services (EMS). The resident left the facility via ambulance at 4:38 P.M.; -Staff did not document regarding a bed hold transfer form/policy sent with the resident. Review of the resident's transfer documents, dated 01/11/24, showed no bed hold policy. During an interview on 02/28/24, at 3:29 P.M., the Social Services Designee (SSD) said the he/she talked to the resident about the bed hold policy, but did not provide one to the resident. He/she did not document his/her discussion with the resident about the bed hold policy. During an interview on 03/01/24, at 1:31 P.M., the Administrator said staff should have given the bed hold policy to the resident. During an interview on 02/28/24, at 2:41 P.M., Licensed Practical Nurse (LPN) A said the following: -When he/she sent a resident to the hospital, he/she sent the resident's face sheet, orders, advanced directives and guardianship information; -He/she did not know what the bed hold policy was; -Residents were allowed to come back to their room in the facility when they readmitted . During an interview on 02/28/24, at 2:34 P.M., Registered Nurse (RN) B said the following: -When he/she sent a resident to the hospital, he/she sent their medication list, code status, and personal belongings they needed; -The facility had a bed hold policy, but he/she did not send that with the resident; -The Director of Nursing (DON) was responsible for the bed hold policy; -When a resident returned from the hospital, they admitted back to their room unless they had a roommate and required transmission based precautions. During an interview on 02/28/24, at 3:29 P.M., the Social Services Designee (SSD) said the following: -When the facility sent a resident to the hospital, nursing staff sent their face sheet, guardianship information, medication list, medication administration record (MAR), and advanced directives; -He/she sent a letter and bed hold policy to the resident's responsible party or gave it to the resident if they were their own responsible party; -If the resident was their own responsible party, he/she gave the letter, and bed hold policy to them when they returned to the facility; -He/she was responsible for ensuring residents or their representatives received the bed hold policy when transferred to the hospital. During an interview on 03/01/24, at 8:34 A.M., the DON said the following: -When a resident was transferred to the hospital, nursing staff sent the bed hold policy to the resident's responsible party in the mail; -Nursing staff should send the bed hold policy with the resident to the hospital and the resident should sign the policy if they were capable. If the resident was not capable of signing the bed hold policy, nursing staff should call the resident's emergency contact and document that on the bed hold policy; -Nursing staff was not sending the bed hold policy with residents when they transferred to the hospital; -The SSD was sending the bed hold policy and was responsible for ensuring it was completed. During an interview on 03/01/24, at 1:31 P.M., the Administrator said staff should send the bed hold policy with the resident when they transferred to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Minimum Data Sets (MDS - a federally mandated assessment instrument completed by facility staff) were accurate for all residents when staff failed address one resident's (Resident #55) anti-anxiety medication on the resident's MDS. The facility census was 59. Review of the facility's policy titled Resident Assessment Instrument, dated 01/01/24, showed the following: -It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's MDS to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services (CMS). This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development; 1. Review of Resident #55's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 05/08/23; -Diagnoses included right sided hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), depression, and anxiety. Review of the resident's February Physician's Order Sheet (POS) showed the following: -An order, dated 12/01/23, for buspirone (an anti-anxiety medication) oral tablet 10 milligrams (mg), give 20 mg by mouth three times a day for anxiety. Review of the resident's February 2024 Medication Administration Record (MAR) showed staff administered busprirone as ordered. Review of the resident's care plan, revised 02/14/24, showed the following: -He/she used anti-anxiety medication and anti-depressant medication related to anxiety disorder and depression; -Administer antianxiety and antidepressant medications as ordered by the physician; -Monitor for side effects and effectiveness and notify his/her physician if any issues were noted. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 02/14/24, showed the following: -The resident had no behaviors; -The resident did not take an antianxiety medication. During an interview on 03/01/24, at 11:17 A.M., the MDS/Care Plan Coordinator said the following: -She entered residents' medications into the MDS; -She clicked the category on the physician orders in the computer to to see what a resident was prescribed such as a narcotic or antianxiety medication; -She looked at how many days in the look back period they were on a medicine; -She entered the resident's medications into the quarterly MDS dated [DATE]; -She overlooked the anti-anxiety medication on the resident's quarterly MDS; -She is responsible for the MDS completion; -MDS assessments include admission, quarterly, annual and significant change, entry and medicare; -She reviews residents' initial data from hospital records, home, physician history and physical, previous facility information and interviews with resident and/or family; -Staff who attend the morning nurse meeting include MDS Coordinator, Director of Nursing (DON), charge nurse and the Restorative Nurse Aide (RNA); -Staff discussed weight loss, appetite, falls, behaviors, etc in the morning nurse meeting. During an interview on 03/01/24, at 8:34 A.M., the DON said the following: -If a resident received antianxiety medication, it should be reflected on their MDS assessment; -The resident received antianxiety medication since his/her admission to the facility on [DATE]; -The resident MDS assessment, dated 02/14/24, showed the resident did not receive antianxiety medications, but it should be marked he/she did; -The MDS Coordinator was responsible for ensuring accuracy of the MDS assessments and he/she was responsible for ensuring the MDS Coordinator completed the MDS accurately. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the following: -The resident's MDS assessment should include his/her antianxiety medication; -He/she expected the MDS assessments be completed accurately; -The MDS completed the MDS assessments and the DON was responsible or signing off to ensure the MDS was completed accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all dependent residents received services necessary to maintain good grooming and personal hygiene when the staff failed to provide assistance with bathing to two dependent residents (Resident #55 and Resident #31) and failed to provide assistance with shaving to one resident (Resident #55) in out of a sample of two residents. The facility's census was 59. Review of the facility's policy titled Know Your Rights, undated, showed the following: -Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination. Many states also include residents' rights in state law or regulation; -Right to self-determination: choice of activities, schedules, health care, and providers, including attending physician; reasonable accommodation of needs and preferences; participate in developing and implementing a person-centered plan of care that incorporates personal and cultural preferences; choice about designating a representative to exercise his or her rights; organize and participate in resident and family groups; and request, refuse, and/or discontinue treatment. Review of the facility's policy titled Hair Care, dated 01/01/24, showed the following: - Ensure the resident's hair/beard is clean, combed, and in good condition in order to promote quality of life and positive self-image; -Hair/beard must be combed at least daily and more often as needed. Review of the facility's policy titled Bathing, dated 01/01/24, showed the following: -It is the policy of the facility to provide the residents with the environment and assistance as needed for bathing to promote cleanliness, hygiene and comfort; -Residents may be placed on a schedule to ensure that each resident is offered a shower two to three times weekly. Upon admission and as needed, residents shall be interviewed by nursing personnel to determine what days or time of day they prefer to shower. As much accommodation as possible should be made to offer showers at the resident's preferred time and day; -For each shower completed, the nursing personnel shall fill out a shower sheet and turn into the Director of Nursing (DON) daily; -In the event that a resident declines a shower, no less than three offers should be made before a refusal is documented. Any refusal must be signed off on by a nurse. If shower declinations are noted frequently, a new interview should be done to determine and resolve the reason; -A resident may choose to receive a bed bath in place of a shower for any reason. 1. Review of Resident #55's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 05/08/23; -Diagnoses included right sided hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), depression, and anxiety. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 02/14/24, showed the following: -The resident required supervision for oral hygiene, moderate assistance from staff for toilet hygiene and personal hygiene, and maximum assistance from one staff for bathing; -The resident used a cane or crutch for mobility. Review of the resident's care plan, revised 02/14/24, showed the following: -He/she had limited physical mobility related to a stroke. Staff should assist him/her with shaving with his/her showers and as needed. He/she was dependent for this task. Review of the facility's weekly shower schedule showed the resident scheduled for a shower on day shift, Monday and Friday, to be completed by the E Hall aide. Review of the resident's bathing documentation in electronic medical record for February 2024 showed the resident received a shower on 02/05/24. Review of the resident's Shower-Skin Monitoring Sheets showed the resident received a shower on the following dates: -On 02/05/24; -On 02/09/24; -On 02/12/24; -Staff did not document any showers after 02/12/24. Observations and interviews on 02/27/24, at 10:07 A.M., on 02/28/24, at 12:32 P.M., and on 02/29/24, at 11:01 A.M., showed the following: -The resident required help with showers and had not received a shower for two weeks; -He/she liked to be clean shaven; -The resident's hair was unkempt and he/she had a beard and mustache approximately ¼ to ½ inches long. Observation on 03/01/24, at 8:18 A.M., showed the resident continued to be unshaved. During an interview on 02/28/24, at 4:05 P.M., Certified Nursing Assistant (CNA) D said the following: -The resident required assistance with showers; -He/she believed the resident was scheduled twice a week; -The resident did not refuse showers unless he/she did not feel well or was agitated. During an interview on 02/29/24, at 9:43 A.M., Restorative Nursing Aide (RNA) F said the following: -The resident was scheduled for showers twice weekly; -The CNAs shaved the resident on his/her shower days and as needed; -The resident did not refuse showers. During an interview on 02/29/24, at 10:46 A.M., Registered Nurse (RN) B said the following: -The resident was scheduled on Mondays and Fridays for showers; -The resident should have received a shower on Monday, 02/26/24, and should have been shaved that day too; -The resident did not refuse showers or to be shaved. During an interview on 03/01/24, at 8:34 A.M., the DON said the following: -The resident was scheduled for showers on Mondays and Fridays and should receive them; -The resident liked to be shaved and he/she should be shaved on his/her shower days. If he/she wanted shaved more often, he/she should be shaved as often as he/she chose; -The resident did not refuse showers; -The resident's last documented shower was on 02/12/24. The resident should have received five more showers since then; -He/she had not paid enough attention to see if the resident had been shaved since 02/12/24; -The resident should receive his/her showers as scheduled; -He/she and the charge nurse were responsible for ensuring the resident received his/her showers and was shaved. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the following: -He/she expected staff to shower the resident per the shower schedule unless the resident refused; -The resident should be clean shaven if that was his/her choice. 2. Review of Resident #31's face sheet showed the following information: -admission date of 04/11/23; -Diagnoses included congestive heart failure (a long-term condition in which the heart can't pump blood well enough to meet the body's needs), left leg above knee amputation, and obesity. Review of the resident's baseline care plan, dated 10/03/23, showed the resident was able to make own decisions and needed assistance with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting). Staff did not address showers/baths on the care plan. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Used wheelchair for mobility; -Dependent for transfers; -Partial to moderate assistance with showering and lower body dressing; -Set up and clean up assistance for oral hygiene, upper body dressing, and personal hygiene. Review of the facility's electronic medical record) shower record for January 2024 showed the resident had one shower on 1/24/24. Staff did not document refusals or additional showers. Review of the resident's shower sheets, dated January 2024, showed resident received a shower on the following dates: -On 01/07/24 (at least seven days after the resident's last shower); -On 01/24/24 (17 days after the resident's last shower); -On 01/28/24. Review of the resident's electronic medical record shower record for February 2024 showed the resident had no refusals or showers recorded. Review of the resident's shower sheets, dated February 2024, showed the resident received a shower on the following dates: -On 02/04/24 (seven days after the resident's last shower); -On 02/19/24 (15 days after the resident's last shower). Observation on 02/26/24, at 10:30 A.M. showed the resident sitting in bed with hair that appeared greasy at roots. During an Interview on 02/27/24, at 3:31 P.M., the resident said they would like to have two showers a week, but are only getting one. He/she reported showers usually occur on Sunday nights. The resident had asked staff for additional showers and staff said they do not have time. There is not a shower aide at the facility and aides are responsible for showers. Observation on 02/28/24, at 12:17 P.M., showed the resident returned from outside appointment and appeared to have unkempt, greasy hair. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the resident should receive his/her showers as scheduled unless he/she refused. 3. During an interview on 02/28/24, at 11:37 A.M., CNA H said the following: -Staff gave the residents two showers a week; -CNAs completed the shower sheet, give them to the DON, and entered the information into the computer system; -Staff may not get the showers completed at times if staff are redirecting, calming, or providing one-on-one with a resident. 4. During an interview on 02/28/24, at 12:35 P.M., CMT I said the following: -Staff had a shower schedule with the list of residents due each day; -The aides completed showers assigned to them on the floor they work; -The DON assigned the showers; -Aides should complete the shower sheet, sign it, and give to the charge nurse; -Aides documented the completed shower in the computer; -Staff may need an extra staff person to do the shower if they are busy, staff make up the shower the next day if not given. 5. During an interview on 02/28/24, at 4:05 P.M., CNA D said the following: -Residents received showers twice a week or more if needed; -He/she documented showers on a shower sheet and in electronic medical system; -Residents were shaved on their shower days or by request; -The facility did not have a shower aide, but had a shower schedule located at the nurses' station. Each hall had shower assignments for each day of the week; -If a resident refused a shower twice in a day, the CNA told the charge nurse and the charge nurse attempted to get the resident to shower. If a resident continued to refuse, they signed the shower sheet. 6. During an interview on 02/29/24, at 9:43 A.M., RNA F said the following: -Residents received showers twice weekly or per their preference; -The facility did not have a shower aide; -Showers were split between the CNAs working on the halls; -If a resident was scheduled for a shower, they should receive a shower; -If a resident refused a shower, the CNA tried again and if the resident continued to refuse, the CNA told the nurse. If a resident continued to refuse, the nurse documented this on a shower sheet; -The charge nurses and DON monitored if showers were given; -Residents were shaved on their shower days or as needed. 7. During an interview on 02/29/24, at 10:46 A.M., RN B said the following: -Residents received showers twice weekly or as needed or requested; -If a resident was scheduled for a shower, they should receive a shower; -The charge nurses ensured the CNAs completed their scheduled showers and assisted on the floor so the CNAs could get their scheduled showers done; -The DON had a spreadsheet to monitor if showers were completed and Medical Records audited the showers as well; -Residents were shaved on their shower days. 8. During an interview on 03/01/24, at 8:21 A.M., Medical Records said the following: -Residents received showers twice weekly and were shaved on shower days and as needed. If a resident needed a shave daily, the staff should shave the resident daily; -The facility had a shower schedule; -When staff completed a shower, they filled out a shower sheet and documented under their ADLs in the electronic medical record; -If a resident was on the schedule for a shower, staff should give them a shower; -The charge nurses should monitor that the CNAs completed their scheduled showers and pass the information on the DON; -He/she was auditing showers and then the facility hired an Assistant Director of Nursing (ADON) the they took over the audits; -After the ADON left, he/she assumed the DON took over the shower audits; -He/she had not audited the showers since 01/2024. 9. During an interview on 03/01/24, at 8:34 A.M., the DON said the following: -Residents received showers two to three times a week; -Residents were shaved on their shower days or when the beautician came; -If a resident wanted to remain clean shaven, they should be shaved daily; -The facility had a shower schedule and if a resident was scheduled for a shower, they should receive it unless they refused; -If a resident refused, the CNAs attempted three times and then the charge nurse had to sign off on the shower sheet; -The CNAs documented showers on a shower sheet and in electronic medical record when given and refused; -The charge nurse was responsible for ensuring residents received showers on their shifts. He/she (the DON) audited showers daily. 10. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the following: -Residents should be offered a shower twice weekly and as needed; -Residents could choose to shower more than twice weekly; -The facility had a shower schedule and she expected staff to follow the schedule; -The DON was responsible for shower audits; -Residents should be shaved daily or as needed; -Staff should document showers given or refused on a shower sheet and electronic medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the physician signed the Outside the Hospital Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) order for two residents (Resident #35 and Resident #57) out of a sample of four residents. The facility census was 59. Review of the facility's policy titled Code Status, (the level of medical interventions a resident wishes to have if their heart or breathing stops), dated [DATE], showed the following: -It is the policy of the facility to honor code status of the resident in accordance to State and Federal Regulations; -During the admission process the Social Services Designee (SSD) or charge nurse will discuss with each resident and/or the person accompanying the resident the following: -Whether they have a preference regarding code status in the event the resident is found without a pulse or respirations; -All DNR forms shall be submitted to the medical director or primary care physician for approval and signature; -The absence of an order not to resuscitate executed pursuant does not preclude a physician from withholding or withdrawing CPR as otherwise permitted by law. Therefore, a properly completed physician's order in the chart should be honored. Review of the Outside the Hospital Do Not Resuscitate (OHDNR) form showed the following: -Area for patient's name and patient's signature or patient representative's signature; -Area for attending physician's signature with date, physician' license number, telephone number, physician printed or typed name and address, and facility or agency name. 1. Review of Resident #35's face sheet (admission data) showed the following: -admission date of [DATE] ; -Diagnoses included chronic obstructive pulmonary disease (COPD - lung disease that blocks airflow and makes it difficult to breathe) and major depressive disorder. Review of the resident's OHDNR form showed the following: -The resident signed the form on [DATE]; -The physician did not sign the DNR form. Review of the resident's current Physician's Order Sheet (POS) showed an order, dated [DATE], for the resident's code status as DNR . Review of the resident's care plan, dated [DATE], showed a code status of DNR. During an interview on [DATE], at 2:28 P.M., Licensed Practical Nurse (LPN) A said the physician should have signed the resident's DNR form. During an interview on [DATE], at 2:38 P.M., the Director of Nursing (DON) said the physician should have signed the resident's DNR form. 2. Review of Resident #57's face sheet showed the following: -admission date of [DATE]; -Diagnoses included unspecified dementia and hypertension (HTN - high blood pressure); -Code Status as a DNR. Review of the resident's OHDNR forms showed the following: -An OHDNR form signed by the resident's representative for DNR on [DATE]. The physician did not sign the form; -An OHDNR form signed by the physician for DNR form on [DATE]. The resident's representative did not sign the form. Review of the resident's February 2023 POS showed a code status of DNR. Review of the resident's care plan, dated [DATE], showed a code status of DNR. During an interview on [DATE], at 02:38 P.M., the DON said the resident's DNR form should be signed by the resident's representative and the physician. 3. During an interview on [DATE], at 12:35 P.M., Certified Medication Technician (CMT) I said the following: -The SSD and nurses complete the code status upon admission; -Nurses enter the code status in the chart. 4. During an interview on [DATE], at 2:28 P.M., Licensed Practical Nurse (LPN) A said the following: -Staff find a resident's code status in the physical chart and on the computer; -Nursing enters the code status; -The admitting nurse completes the code status with new admissions; -He/she did not complete a lot of new admissions; -The physician signs the DNR forms when he comes to the facility; -The DNR form should be signed by a physician. 5. During an interview on [DATE], at 02:50 P.M., Medical Records Staff said the following: -SSD completes the resident's code status; -He/she looks at charts each morning to ensure the code status form is in the chart; -He/she looks in the chart to ensure the code status form is in the front part of the chart when the physician emails the signed DNR back to the SSD. 6. During an interview on [DATE], at 2:54 P.M., the SSD said the following: -She asks the resident on admission of their code status; -The nurse reviews the code status with the resident if she is not at the facility at the time of the admission; -She emails the physician DNR form to sign; -She puts the signed DNR form on purple paper and places it in the chart when the physician sends back the signed DNR form; -She did not know why both of the residents' DNR forms were not signed. 7. During an interview on [DATE], at 2:38 P.M., the DON said the following: -Staff should ask a resident's code status on admission; -The SSD completes the code status upon admission and if not at the facility, nursing staff complete the code status with the resident and/or the representative; -Staff email the DNR form to the physician for approval and signature which he/she signs and returns to the facility; -The physician signs the DNR form which is considered an order; -Medical record staff or SSD received the signed DNR form; -Staff should upload a copy in the computer and a copy for the physical chart; -Nurses enter the code status order into the computer. 8. During an interview on [DATE], at 03:02 P.M., the Administrator said she expects the physician to sign a DNR form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to consistently track and monitor the dry, scaly skin with multiple nodules to bilateral lower extremities skin condition for one resident (Resident #24) and failed to follow, physician ordered blood pressure parameters for determining administration of an antihypertensives (blood pressure) medication for one resident (Resident #54) out of 22 sampled residents in a facility with a census of 59. 1. Review of facility policy titled Skin Assessments, dated 01/01/24, showed the following: -Facility should accurately record any chronic or acute abnormalities of resident's skin; -Skin assessment should be performed and documented weekly; -Nursing assessment should include lesions, redness or rash, edema (swelling), skin tears, abrasions, bruises, pressure injuries, cyanosis (blue color), and surgical wounds. Review of Resident #24's face sheet (a general information sheet) showed the following: -admission date of 05/11/23; -Diagnoses included diabetes mellitus, non-pressure chronic ulcer of lower leg, and lymphedema (swelling caused by lymphatic system blockage). Review of resident's care plan, revised 11/14/23, showed the following: -Skin is at risk for pressure ulcers; -Staff will follow facility policies and protocols for the prevention and treatment of skin breakdown. Review of resident's readmission Assessment, dated 12/26/23, showed the front of the right and left lower legs had discoloration. (Staff did not document any nodules or dry, scaly skin.) Review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/10/24, showed the following: -Cognitively intact; -Had a stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer); -Had no other ulcer, wound, or skin problems; -Dependent on staff for toileting, showering, dressing, and transfers. Review of the resident's weekly skin assessment, dated 01/29/24, showed discoloration to bilateral lower extremities. (Staff did not document regarding multiple nodules or dry, scaly skin.) Review of the resident's March 2024 Physician's Order Sheet (POS) showed the following: -A current order to elevate bilateral lower extremities as tolerated two times a day for dependent edema; -A current order to apply Eucerin cream to bilateral lower extremities two times a day for dry skin. Review of the resident's nurses' notes, dated 12/2023 to 02/2024, showed staff did not document regarding the resident's bilateral lower extremities. During interviews and observations on 02/29/24, at 04:35 P.M., and 03/01/24, at 12:37 P.M., the resident said he/she had lower leg blisters for a long time, but they do not hurt. He/she has not seen a specialist for lymphedema. Staff are putting Eucerin cream on his/her legs. Observation showed front of the lower legs had brown scaly discoloration with multiple pea sized nodules scattered throughout with redness noted to inner thigh area with a garbanzo bean sized fluid filled blister located below his/her left inner knee. No nodules or discoloration observed to back of lower legs. During an interview on 02/29/24, at 5:00 P.M., the resident's physician said the following: -The skin condition is due to chronic lymphedema; -The resident was mostly bedbound and it is making the condition worse; -Blisters on legs can be hard to compress and feel firm and hard; -Skin was scaly during visit one week ago, but Eucerin cream helps; -Staff should monitor legs for open blisters. During an interview on 03/01/24, at 10:23 A.M., Certified Nurse Assistant (CNA) R said the resident's lower legs were brown colored and had blisters on top of the feet. During an interview on 03/01/24, at 10:28 A.M., Registered Nurse (RN) N said the following: -Nurses conduct weekly skin assessments; -CNA's reported skin issues to the nurse; -He/She notified the wound care nurse if a skin issue was found; -The resident had discoloration and edema to lower legs; -Current orders for resident were elevation of extremities and application of Eucerin cream; -He/she believed the doctor is aware of nodules on legs. During an interview on 03/01/24, at 11:45 A.M., Licensed Practical Nurse (LPN) T said the following: -The nurse report book contains skin assessment schedule; -Skin assessments should include documentation on bruising and scaly skin, surgical sites, or any abnormal findings; -Resident's legs are bumpy and used to be really dry, but they are improved; -Physician had seen resident every week and was aware of nodules; -He/She would not document nodules on skin assessment as they are not abnormal for resident; -Resident has had nodules on lower legs since admission. During interview on 03/01/24, at 1:33 P.M., the Director of Nursing (DON) said the following: -Nurses should conduct skin assessments weekly; -All skin issues should be documented on assessment; -Physician should be notified for new issues or worsening of current conditions; -The resident's legs are dry with plaque and nodules, which should be noted in skin assessment. During an interview on 03/01/24, at 3:18 P.M., the Administrator said nurses should be more descriptive in skin assessments. 2. Review of Resident #54's face sheet showed an admission date of 03/29/23. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnoses included compression fracture of spine, coronary artery disease (CAD - caused by plaque buildup in the wall of the arteries that supply blood to the heart), hypertension (high blood pressure), type 2 diabetes mellitus, and depression. Review of the resident's February 2024 Medication Administration Record (MAR) showed the following: -A current order for staff to administer metoprolol tartrate (medication used to treat high blood pressure (BP)) oral tablet 25 milligram (mg), administer 0.5 (one-half) tablet by mouth two times a day related to hypertension; -The order directed staff to hold (not give) the medication, if the systolic (upper number) BP was less than 100 millimeters of Mercury (mm/Hg) or if the diastolic (lower number) BP was less than 60 mm/Hg, or if heart rate (per minute) was less than 60, and to notify the physician; -On 02/19/24, the resident's BP measured 114/56 mm/Hg. Staff administered the resident's metoprolol tartrate. The order stated to hold and notify physician; -On 02/20/24, the resident's BP measured 115/51 mm/Hg. Staff administered the resident's metoprolol tartrate. The order stated to hold and notify physician; -On 02/21/24, the resident's BP measured 115/56 mm/Hg. Staff administered the resident's metoprolol tartrate. The order stated to hold and notify physician;; -on 02/26/24, the resident's BP measured 114/55 mm/Hg. Staff administered the resident's metoprolol tartrate. The order stated to hold and notify physician; -On 02/27/24, the resident's BP measured 111/53 mm/Hg. Staff administered the resident's metoprolol tartrate. The order stated to hold and notify physician; -On 02/28/24, the resident's BP measured 116/54 mm/Hg. Staff administered the resident's metoprolol tartrate. The order stated to hold and notify physician. During an interview on 02/28/24, at 1:16 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she expected certified medication technicians (CMTs) to notify him/her if a resident's blood pressure was outside of the parameters and they should also hold the medication as directed; -He/she would then re-check the resident's blood pressure and pass the information on in report to the next shift nurse; -Additionally, if the resident's blood pressure remained low, he/she would encourage fluids and notify the resident's physician. During an interview on 02/29/24, at 4:04 P.M., CMT W said f a resident's blood pressure was out of parameters, he/she would hold the medication and notify the nurse. During an interview on 03/01/24, at 11:29 A.M., CMT I said the following: -He/she gave the resident his/her blood pressure medication when the diastolic was below of 60 mm/Hg, because the systolic BP was over 120 mm/Hg. During an interview on 02/29/24, at 5:21 P.M., the Director of Nursing (DON) said the following: -When ordered, the CMT should check the resident's blood pressure (BP) and pulse rate and record the results on the resident's MAR on the computer; -If the BP or pulse rate falls above or below the parameters set forth in the order, then the CMT should report those results immediately to the nurse on duty and hold the medication as directed; -The nurse should then recheck the BP and pulse rate and if either were out of parameters, the nurse should report those results to the resident's physician; -After reviewing the resident's BP results, it looked like the resident's BP did fall below the parameters and the CMT should have held the resident's medication and notified the nurse, but instead the CMT administered the medication. During an interview on 03/01/24, at 3:50 P.M., the Administrator said she expected staff to not administer the medication and notify the charge nurse and the physician, if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed ensure residents did not experience a reduction in range of motion unless unavoidable when staff failed to evaluate the need for restorative therapy for one resident (Resident #11) who expressed concerns with his/her decreased hand/finger range of motion (ROM) and expressed a desire for restorative therapy. A sample of 22 residents was reviewed in a facility with a census of 59. 1. Review of Resident #11's face sheet showed an admission date of 01/18/19 and readmission date of 01/07/24. Review of the resident's February 2024 physician orders showed: -Dependence on wheelchair, weakness, acquired absence of right and left legs below the knees, chronic pain, type 2 diabetes mellitus with diabetic neuropathy (nerve damage), end-stage kidney disease, and dependent on dialysis (a treatment for people whose kidneys are failing); -An order, dated 01/18/19, for activity as desired or as health permits; -An order, dated 01/28/19, may be seen and evaluated for treatment by licensed therapist. Review of the resident's current care plan showed the following: -Activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) self care deficit related to weakness and disease process; -Resident to maintain current level of functioning. Review of the resident's occupational Discharge summary, dated [DATE], resident will remain in the facility with restorative nursing assistant program established. Review of the resident's last restorative nursing progress note, dated 04/12/22, resident had completed restorative nursing program at this time. Staff will re-evaluate quarterly or/and with a change in status of the resident. Review of the resident's quarterly minimum data set (MDS - a federally-mandated assessment tool completed by facility staff), dated 1/29/24, showed the following: -Cognitively intact; -Required set-up or clean up assistance with eating and oral hygiene; -Dependent on staff for toileting hygiene, showering, and lower body dressing; -Required substantial of maximum assistance with upper body dressing and personal hygiene; -Utilized a motorized wheelchair for mobility. Observation and interview on 02/26/24, at 4:04 P.M., showed the following: -The resident said due to the neuropathy of his/her hands, he/she has limited ROM; -The resident demonstrated by holding out his/her right hand and attempting to bend and straighten the fingers on his/her right hand; -The resident had some difficulty straightening his/her right fingers completely out and was unable to make a fist with his/her right hand; -The resident said the inability to completely bend his/her right fingers, makes it difficult to hold small objects, such as pens/pencils; -The resident said sometimes small items slip out of his/her hands; -The resident said his/her right hand is worse and he/she is right-hand dominant; -The resident said the inability to bend his/her fingers has gotten worse over time. Observation and interview on 02/28/24, at 12:22 P.M., showed the following: -The resident said it had been a while since he/she received any physical or occupational therapy; -The resident said his/her insurance quit paying for therapy and he/she was discharged from services; -The resident said he/she received restorative therapy for a while, but the facility quit doing that and was unsure why they quit; -He/she would like to have some type of therapy due to limited use of hands and poor ability to grasp small objects; -The resident demonstrated attempting to pick up and hold a pencil and had difficulty picking up the pencil and was unable to hold the pencil in a normal pinch type grasp; The resident said, he/she was no longer able to sign papers; -The resident said he/she has neuropathy and his/her hands are always painful and have a tingling sensation; -The resident said every day, he/she tried to stretch out his/her own fingers and lift his/her arms; -The resident said his/her left arm was very stiff due to dialysis and having to hold the arm still for several hours three times per week for dialysis; -The resident demonstrated how he/she was unable to straighten his/her left arm all the way out at the elbow and stated due to pain and stiffness in the elbow; -The resident states he is used to the pain at this point. Observation and interview on 03/01/24, at 10:38 A.M., showed the following: -The resident attempted to make a tight fist with his/her right hand. The resident's right index finger was approximately two inches from touching his/her palm and his/her third, fourth, and fifth digits were approximately one inch from touching his/her palm; --The resident again said he/she would like to have some type of therapy or restorative exercises to help with this issue and keep his/her mobility from getting worse. During an interview on 02/29/24, at 9:43 A.M., Restorative Nursing Assistant (RNA) F said the following: -The resident received therapy in the past; -The resident participated for the first week or two and then started refusing therapy; -When staff referred the resident for therapy, therapy picked him/her up; -The resident was given the option for RNA, but he/she declined; -If a certified nurse aide (CNA), nurse, Director of Nursing (DON), or Social Services Director (SSD) saw a resident had a decline, they told therapy and therapy filled out a form and gave the form to the Business Office Manager (BOM). The BOM checked the resident's insurance to determine if the resident's insurance would approve therapy; -If the resident's insurance would not pay for therapy, the resident was referred for RNA; -Therapy staff did not complete screens of residents for therapy on a regular basis. Therapy only screened residents when a resident had a fall or a decline in function. During an interview on 02/29/24, at 8:11 A.M., Certified Occupational Therapy Assistant (COTA) E said the following: -Therapy staff screened residents for therapy when they saw a need or if nursing staff informed them of a fall; -Therapy staff did not complete screens for therapy on a regular basis. Therapy did not have a Therapy Director and all therapy staff performed screens. During an interview on 02/28/24, at 4:05 P.M., CNA D said if a resident requested therapy, he/she told the therapy department or the RNA. During an interview on 02/29/24, at 10:46 A.M., Registered Nurse (RN) B said the following: -A certified medication technician (CMT) told him/her that the resident had increased difficulty with holding their medication cup and believed the resident's hands were getting contracted and required increased assistance; -He/she did not tell therapy about the reported decline in function, but he/she should have; -If he/she noticed a decline in a resident's function, he/she notified therapy; -If a CNA or CMT noticed a decline in a resident's function they reported this to the charge nurse. During an interview on 02/29/24, at 11:23 A.M., the MDS Coordinator said the following: -The resident was not currently on therapy or a RNA program; -He/she had not been informed of a decline in the resident; -If a CMT reported this to a charge nurse, the charge nurse should have notified the Director of Nursing (DON). -If nursing staff saw a decline in function in a resident or a resident fell, they referred the resident to therapy; -The therapy department did not screen residents on a regular basis to see if a resident would benefit from therapy services; -If a CNA or CMT saw a decline in a resident's function, they told the charge nurse and the charge nurse told the DON. The department heads then discussed this in morning meeting. During an interview of 03/01/24, at 8:05 A.M., the SSD said the following: -The resident was declined by his/her insurance to therapy; -He/she did not know if the resident had a decline in function. -If staff noticed a resident had a decline in function, they told the nurse and the department heads including therapy talked about it in the morning meeting; -Therapy filled out a form and gave the form to him/her and he/she checked the resident's insurance. During an interview on 03/01/24, at 8:34 A.M., the DON said the following: -He/she had not noticed a decline in the resident's function and had not been informed of any decline; -If a CMT noticed a decline in a resident's function, they told the nurse and the nurse passed that information on to him/her; -Therapy performed screens upon admission and if a resident had a decline; -He/she considered not being able to hold a cup and possible contractures a decline in function. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the following: -If a CNA or CMT notice a resident had a decline in function they should tell the charge nurse. The charge nurse notified the DON or therapy; -Therapy screened residents when facility staff requested it, but did not have a formal screening process; -If the resident had increased difficulty with grip and possible contractures, he/she considered that a decline in function and the charge nurse should have reported this.

Based on observation, interview, and record review, the facility failed to ensure residents only had catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) when necessary when staff obtained an order for a catheter for one resident (Resident #24) without a documented clinical condition that demonstrated necessity. The facility census was 59. Review of the facility policy titled, Indwelling Urinary Catheters, dated 01/01/24, showed it was the policy of the facility that indwelling urinary catheters should be used only when a medical condition exists requiring the use of the catheter. 1. Review of Resident #24's face sheet (document that gives a resident's information at a quick glance) showed the following: -admission date of 05/11/23; -Diagnoses included diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), congestive heart failure (CHF - a long-term condition in which the heart can't pump blood well enough to meet the body's needs), and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 11/01/23, showed the following: -Cognitively intact; -Dependent on staff for toileting, showering, dressing, and transfers. Review of resident's care plan, revised 11/14/23, showed the resident had an indwelling catheter. Review of resident's chart showed an order, dated 12/26/23, for Foley catheter (includes a tube, drainage port, and bag) 16 French (fr) (size) 10 cubic centimeters (cc). Staff did not document on the order or the chart the indication or diagnosis for the catheter usage. Review of resident's admit/readmit assessment, dated 12/27/23, showed the resident incontinent of urine for longer than a year, incontinent once or more times per shift, and had large amounts of urine when incontinent. Review of resident's February Order Summary Report showed the following orders: -An order, dated 01/02/24, to change Foley catheter and Foley bag, size 16 fr 10 cc bulb as needed; -An order, dated 01/02/24, to change Foley catheter and Foley bag, size 16 fr 10 cc bulb every day shift every thirty days, -An order, dated 12/30/23, for Foley catheter care every shift. Observation and interview on 02/27/24, at 10:21 A.M., with the resident showed a Foley catheter in which the drainage bag was below waist level and placed in a dignity bag. The resident reported he/she used the catheter due to the inability to hold urine. Staff changed the catheter every two weeks to monthly. During an interview on 02/28/24, at 2:30 P.M., Registered nurse (RN) B said the resident initially admitted to the facility with a catheter due to urinary retention. During interviews on 02/29/24, 8:30 A.M., and on 03/01/24, at 1:33 P.M., the Director of Nursing (DON) said the following: -Resident admitted to facility with a catheter, but returned from a hospital stay in December 2023 without one; -Resident had issue with urine retention upon return from hospital and nurse obtained order for indwelling catheter; -Indication for catheter use was not in the chart; -Nurses should contact physician to obtain an indication for catheter use if not provided with initial order.

Based on interview and record review, the facility failed to ensure all residents maintained acceptable parameters of nutrition, unless unavoidable, when staff failed complete physician ordered weekly weights and failed to care plan weekly weights and new interventions for weight loss for one resident (Resident #36) with weight loss out of two sampled residents. The facility's census was 59. Review of the facility's policy titled Resident Weights and Weight Management, dated 01/01/24, showed the following: -It is the policy of the facility to accurately measure and record residents' weights to provide a baseline and track weights as an indicator of nutritional status and medical condition of the resident. Residents should be weighed on admission and monthly, unless otherwise indicated; -The physician should be informed of a significant change in weight and may order nutritional interventions. Significant weight changes may be described as, but not limited to, greater than or equal to 5% loss in 30 days, greater than or equal to 10% loss in 180 days, gain of three pounds in one day or gain of five pounds in one week; -The Dietary Manager or Registered Dietician should review weights monthly and assist with interventions. Actions are recorded in the dietary progress notes; -Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate; -The Director of Nursing (DON) shall review monthly resident's weights for those who meet the following criteria: hospice, have an active pressure injury, weigh less than 100 pounds, dialysis, have a noted significant change in weight, or ordered by physician for weekly weights. 1. Review of Resident #36's face sheet showed the following: -admission date of 02/12/20; -Diagnoses included high blood pressure, osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D), and gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints). Review of the resident's current Physicians Order Sheet (POS) showed the following: -An order, dated 06/07/21, to weigh weekly; -An order, dated 01/24/22, for regular diet mechanical soft texture and thin consistency for nutrition. Review of the resident's weight summary, dated from 08/02/23 through 09/30/23 showed the following: -On 08/02/24, the resident weighed 122.2 lbs; -On 08/08/23, the resident weighed 125.6 lbs; -On 08/16/23, the resident weighed 124.9 lbs.; -On 09/04/23, the resident weighed 125.8 lbs (a three week gap on weights). (Staff did complete any additional weights in September 2023.) Review of the facility's Consultant Dietitian Report, dated 09/20/23, showed the resident's annual assessment was reviewed. The RD assessed the resident and no changes were recommended. Review of the resident's Nutrition Assessment, dated 09/30/23, showed the following: -Most recent weight on 09/04/23 was 125.8 pounds (lbs); -No weight gain or loss greater than 5%; -The resident's current diet order was regular, mechanical soft, thin with thin liquids; -Supplements included 60 cubic centimeters (cc) Hi-Cal three times a day; -Current appetite was regular; -Change in appetite was decreased; -He/she preferred meals in the dining room; -Snacks offered three times a day; -Average intake of 26% to 75%; -Ate independently with set-up assistance; -Registered Dietician's (RD) recommended continue on Hi-Cal. Review of the residents weight summary, dated 10/01/23 to 10/31/24, showed on 10/05/23 the resident weighed 113.4 lbs. (a loss of 12.4 lbs since the resident's last weight. Staff did not document any additional weights for the month of October 2024. Review of the resident's current POS showed the following: -An order, dated 10/18/23, for Hi-Cal liquid (nutritional supplements), give 2 ounces by mouth three times a day for supplement. Review of the residents weight summary, dated 11/01/23 to 02/28/24, showed the following: -On 11/01/23, the resident weighed 108.6 lbs. (a loss of 4.8 pounds since the resident's last weight); -On 12/04/23, the resident weighed 109.6 lbs.; -On 01/05/24, the resident weighed 107.9 lbs. (Staff did not document additional weekly weights for 11/2023 to 01/2024.) Review of the facility's Consultant Dietitian Report, dated 01/20/24, showed the resident was not assessed by the RD. Review of the residents weight summary, dated 02/2024, showed the following: -On 02/05/24, the resident weighed 105.8 lbs (a loss of 2.1 pounds since the resident's last weight and a total weight loss of 16.4 pounds (7.3%) since 08/02/24.) (Staff did not document any additional weight for 02/2024.) Review of the facility's Consultant Dietitian Report, dated 02/07/24, showed the resident's quarterly assessment was reviewed. The resident had a weight loss trend and the RD recommended ice cream with lunch and dinner for increased calories. Review of the resident's Medication Administration Record (MAR), dated January 2024 and February 2024, showed no weekly weights documented or a reminder to obtain weekly weights. Review of the resident's care plan, revised 02/21/24, showed the following: -He/she may be a risk for nutritional problems due to chronic kidney disease; -He/she would maintain his/her nutritional status; -He/she was on a regular diet with mechanical soft texture (a diet designed for people who have trouble chewing and swallowing. Chopped, ground and pureed foods are included in this diet, as well as foods that break apart without a knife); -He/she enjoyed coffee in the dining room and would have several cups with each meal. He/she also liked orange juice a lot. Dr. Pepper was also a favorite of his/hers; -He/she received 2 ounces Hi-Cal three times a day between meals for weight gain; -He/she enjoyed eggs. He/she would want extra scrambled eggs in the morning and boiled eggs when the facility had them. His/her family would also bring him/her deviled eggs sometimes' -Please encourage him/her to eat the daily meal provided. He/she would often ask for a peanut butter and jelly sandwich several times a day. Hard boiled eggs was one of his/her favorite foods; -The Registered Dietician (RD) would evaluate and make diet change recommendations as needed; -He/she had an activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) self-care performance deficit related to fatigue and impaired balance. He/she would maintain his/her current level of function in ADL's. He/she fed him/herself after staff provided set-up assistance. (Staff did not care plan the ordered weekly weights or RD recommendation for ice cream with lunch and dinner.) Review of the resident's quarterly MDS assessment, dated 02/24/24, showed the following: -Required set-up assistance from staff for eating; -Resident weighed 106 pounds; -The resident did not have a weight loss of 5% or more in the last month or 10% or more in the last six months. During an interview on 02/28/24, at 4:05 P.M., Certified Nursing Assistant (CNA) D said the the following: -The resident had a weight loss since he/she admitted ; -The restorative nurse assistant (RNA) obtained residents' weights; -Weight loss interventions included providing snacks and increase a resident's calories. During an interview on 02/29/24, at 9:43 A.M., RNA F said the following: -The resident maintained his/her weight for the most part, but had a loss a while back and staff found food the resident would eat such as eggs, cottage cheese, ice cream, and Dr. Pepper; -If the resident had an order for weekly weights, the resident should be weighed weekly; -Interventions for weight loss included encourage the resident to eat, house or protein shakes, offer snacks, refer to speech therapy, and refer to the physician for medical management; -He/she weighed residents monthly unless a resident had a decline, swelling, weighed less than 100 lbs., or had a weight loss or gain. If a resident had one of these, they were weighed weekly or daily per the physician's orders; -The charge nurses or CNAs completed the weekly and daily weights. During an interview on 02/29/24, at 10:46 A.M., Registered Nurse (RN) B said the following: -The resident had a weight loss, but he/she did not know if it was a significant weight loss; -The resident's interventions included offer snacks and peanut butter and jelly sandwiches when the resident would not eat the regular meal; -The resident had an order for weekly weights, but it did not show on his/her MAR because the frequency was not specified in the order to show on the MAR, but it should be; -The resident was weighed weekly until the middle of August 2023; -Staff should have weighed the resident weekly per the physician's orders; -Weight loss interventions included getting a resident up for meals, offering snacks, and assisting residents to eat; -If he/she noticed a weight loss, he/she reported this to therapy and the physician. Therapy could evaluate a resident's ability to chew; -The RNA completed monthly weights; -If a resident had an order for weekly weights, it showed in the MAR. During an interview on 03/01/24, at 1:00 P.M., the Dietary Manager (DM) said the following: -The resident had a weight loss, but he/she could not recall if it was significant; -The RD recommended ice cream for the resident; -Staff offered peanut butter and jelly sandwiches, eggs or cottage cheese when the resident would not eat the regular meal, offered the resident snacks and foods he/she liked to eat; -The RD came to the facility monthly and was available by telephone or e-mail in between visits. During an interview on 03/04/24, at 12:40 P.M., the RD said the following: -The resident had a significant weight loss and the facility told him/her; -The resident received HiCal, but he/she did not know about any other interventions; -He/she did not know what the resident's orders were for obtaining the resident's weight; -He/she knew a resident had a weight loss by the weights the facility gave him/her; -If staff had a concern about a resident they contacted him/her by e-mail; -Significant weight loss was 5% in 30 days, 7.5% in 90 days and 10% in 180 days; -He/she monitored residents' weights on their quarterly and annual assessments; -He/she was required to document of weights if a resident triggered for significant weight loss on their MDS assessment. During an interview on 02/28/24, at 4:44 P.M., and on 03/01/24, at 8:34 A.M., the Director of Nursing (DON) said the following: -The resident had an order for weekly weights; -The order did not trigger on the MAR because the physician wanted all of the residents weighed weekly and those orders were not set to trigger on the MAR. He/she believed staff forgot to remove the resident's order for weekly weights.; -The resident was not weighed weekly, but should have been since he/she had an order; -The resident had a weight loss and was covered in the last two Quality Assurance Performance Improvement (QAPI) meeting so the resident's weight loss was significant; -The resident's weight loss interventions included HiCal, extra snacks, and liked food/drinks such as peanut butter and jelly sandwich, eggs, orange juice, coffee and Dr. Pepper; -He/she was responsible for auditing resident weights and orders. -The RD came to the facility monthly; -The RD assessed resident's quarterly unless a resident had a pressure ulcer, was on dialysis or hospice or if a resident weighed less than 100 lbs., then the RD assessed monthly; -The RD made recommendations on residents with significant weight loss such as fortified foods, increased protein, ensure and med pass and the DON sent those recommendations to the physician; -The RD knew a resident had a weight loss by a report in the electronic documentation program. The report showed if a resident had a weight loss of 5% in 30 days or 10% in 120 or 180 days; -If a resident had an order for weekly weights, the weights should be completed. This order showed on the MAR for the nurse to complete or for the nurse to have a CNA complete; -He/she had issues getting the RD's notes, but addressed it and the RD started putting some notes in electronic record and started giving their summaries to him/her; -Significant weight loss should be on the care plan and the MDS assessment; -Medical Records audited residents' weights until 02/16/24 and then he/she took over the audits During an interview on 03/01/24, at 1:31 P.M., the Administrator said staff should have weighed the resident weekly. If a resident had an order for weekly weights, staff should complete the weight weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide respiratory care per standards of practice when staff failed to administer oxygen as ordered for two residents (Residents #31 and #49). The facility census was 59. Review of facility policy titled Supplemental Oxygen, dated 01/01/24, showed the facility shall provide oxygen to any resident with a doctor's order for treatment of certain diseases or conditions. 1. Review of Resident #31's face sheet (a general information sheet) showed the following: -admission date of 04/11/23; -Diagnoses included sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), respiratory failure with hypoxia (low levels of oxygen) and hypercapnia (high levels of carbon dioxide in blood), congestive heart failure (CHF - a long-term condition in which the heart can't pump blood well enough to meet the body's needs), and chronic kidney disease. Review of resident's Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/21/24, showed the following: -Moderate cognitive impairment; -Used wheelchair for mobility; -Resident is on oxygen; -Requires partial to moderate assist with showering, dressing and dependent with transfers. Review of the resident's March 2024 Physician Order Sheet (POS) showed a physician order, dated 04/11/23, for oxygen at 4 liters via nasal cannula (nc), continuous every shift. Review of the resident's care plan, last updated 10/03/23, showed the following: -Staff to monitor the resident for signs and symptoms of respiratory distress and report to physician as needed; -Oxygen via nasal cannula when awake and titrate to keep blood oxygen levels at 90% and above as needed; -Monitor oxygen saturations at least once a shift and when short of breath. Observation on 02/27/24, at 3:31 P.M., showed resident sitting in bed with oxygen in place via nc and concentrator set at 2 liters. Observation on 02/29/24, at 03:33 P.M., showed resident sitting in wheelchair with oxygen in place via nc and set at 2 liters on a portable tank. Observation on 03/01/24, at 10:21 A.M., showed resident sitting in bed with oxygen in place via nc and concentrator set at 2 liters. Observation on 03/01/24, at 12:37 P.M., showed resident resting in bed with oxygen in place via nc and concentrator set at 2 liters. 2. Review of Resident #49's face sheet showed the following: -admission date of 10/19/23; -Diagnoses included respiratory failure with hypoxia, dyspnea (difficult breathing), and hypoxemia (low oxygen concentration in blood). Review of the resident's MDS, dated [DATE], showed the following: -Cognitively intact; -Resident used oxygen -Requires partial to moderate assist with shower but set up or supervision with all other activities; -Used walker for mobility. Review of the resident's care plan, last updated 10/18/22, showed the following: -Resident on oxygen therapy related to ineffective gas exchange; -Oxygen via nasal prongs at 2 to 4 liters as needed, titrate to keep saturation above 90%; -Monitor for signs and symptoms of respiratory distress and report to physician as needed; -Give medications as ordered by physician. Monitor and document side effects and effectiveness. Review of the resident's March 2024 POS showed a physician order, dated 12/21/23, for oxygen at 2 liters as needed to keep oxygen saturation above 90%, every shift. Observation on 02/26/24, at 4:00 P.M., showed resident in bed with eyes closed, nasal cannula in place and oxygen concentrator set at 3.5 liters. Observation on 02/28/24, at 11:15 A.M., showed resident resting in bed with oxygen in place via nasal cannula and concentrator set at 3.5 liters. Observation and interview on 02/29/24, at 10:19 A.M., showed resident with via nasal cannula in place with oxygen set at 3.5 liters. The resident said his/her oxygen is to be set at 3 liters and the nurse adjusts the flow rate and fills the humidifier when empty. Observation on 03/01/24, at 10:42 A.M., showed the resident walked in hallway with walker and no oxygen in place. Resident entered room and turned oxygen concentrator on and put on nasal cannula. The oxygen flow rate was set at 3.5 liters. During an interview on 02/29/24, at 10:41 A.M., Certified Nurse Aide (CNA) R said the resident's was oxygen should be at three liters. 3. During an interview on 02/29/24, at 10:23 A.M., CNA C said he/she has not received training on oxygen in last six months. Flow rate of oxygen is shown on the concentrator, or he/she would ask the nurse. CNA's set up portable oxygen tank and nurses are responsible for the concentrators in resident rooms. 4. During an interview on 02/29/24, at 10:41 A.M., CNA R said facility trained staff on oxygen once a long time ago. Nurses are responsible for concentrators, but aides fill empty humidifiers at times. CNA's set up portable oxygen tanks, he/she set one up that morning. He/she asked the nurse about resident's flow rate, but knows most of the rates. 5. During an interview on 02/29/24, at 12:43 P.M., Registered Nurse (RN) B said there have been no specific in-service on oxygen. Nurses were responsible for concentrators and portable oxygen tank set up. Oxygen flow rate and oxygen saturation are checked every shift. CNA's never set up portable oxygen tanks as it is a medication. 6. During an interview on 3/01/24, at 1:33 P.M., the Director of Nursing (DON) said nurses are responsible for every aspect of oxygen concentrators and portable tanks. Nurses should check oxygen flow rate every shift, but there is not a place to document in the chart. CNA's are allowed to transport portable tanks, but should never adjust flow rate, set tanks up, or fill humidifiers. 7. During an interview on 3/01/24, at 3:18 P.M., the Administrator said nurses should follow physician orders related to oxygen and CNAs should not adjust oxygen concentrators or tanks.

Based on observation, interview, and record review, the facility failed to provide dialysis (the cleaning of the blood with a machine due to the kidneys not working) services per professional standards of practice when the facility failed to have a contract with the dialysis provider, failed to document routine assessment and monitoring of the dialysis site, and failed to document ongoing communication with the dialysis center for one resident (Resident #31) who received dialysis. The facility census was 59. Review of the facility's policy Dialysis Service, dated 02/18/24, showed the following information: -The facility must ensure that residents that require dialysis service receive services consistent with the professional standards of practice, comprehensive person-centered care plan, and residents' goals and preferences; -Facility shall ensure transportation to and from dialysis 1. Review of Resident #31's face sheet (a general information sheet) showed the following: -admission date of 04/11/23; -Diagnoses included diabetes with diabetic neuropathy (nerve damage), congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), and chronic kidney disease. Review of the resident's baseline care plan, dated 10/03/23, showed the following information: -Received hemodialysis (a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately) related to end stage renal disease on Tuesday, Thursday, Saturday and additional days as needed; -Had potential fluid volume overload related to kidney failure and dialysis; -Required staff to monitor fluid intake and output every shift. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/21/24, showed the following information: -Moderate cognitive impairment; -Used wheelchair for mobility; -Resident receives dialysis; -No skin conditions or treatments. Review of the resident's February 2024 Physician Order Sheet (POS) showed the following information: -Diagnosis of chronic kidney disease; -Dialysis three times per week on Tuesday, Thursday, and Saturday; -Resident had a central double lumen dialysis catheter (a flexible tube inserted through a narrow opening into a body cavity for removing fluid); -Fluid intake limited to 40 ounces daily, every shift for stage four kidney disease. (There was no order for routine assessment of dialysis catheter.) Review of the resident's medical record showed staff had no copy of an agreement or contract between dialysis provider and facility. Review of the resident's medical record showed staff had no dialysis communication forms between the facility and the dialysis center. Review of the resident's nurses' notes showed staff did not document related to dialysis or assessment of dialysis catheter site. During an observation and interview on 02/27/24, at 3:31 P.M., the resident said the following: -He/She had been going to dialysis since March 2023; -The dialysis catheter had been replaced three times, once due to an infection and twice due to not functioning properly; -Observation of dialysis catheter on upper right chest showed the bandage was intact with no drainage or redness noted to area. During an interview on 02/28/24, at 4:16 PM., Licensed Practical Nurse (LPN) A said the following: -Communication with the dialysis center occurs via telephone; -The dialysis center does not send paper communication after appointments; -The dialysis center contacted facility via telephone for additional appointments or changes; -He/she notified of additional dialysis appointments in morning meeting. During interviews on 02/29/24, at 9:28 A.M. and 12:37 P.M., Registered Nurse (RN) B said the following: -The dialysis provider organized transport with transportation service; -The resident had a dialysis catheter; -The resident had an upcoming appointment for fistula (a connection) placement due to becoming septic (a serious condition in which the body responds improperly to an infection) at port site previously; -Nursing staff would reinforce loose dressings and change with sterile procedure if needed, but dialysis provider changed dressing during visit; -The dialysis catheter assessment consisted of assessing for drainage or discoloration; -Nurses do not document dialysis catheter assessment in the chart, but it should be documented; -There is no order for dialysis site assessment; -Nurses would notify physician for any complications or problems with catheter site; -The dialysis center updates facility via telephone after appointments, but nurses do not enter a note in chart; -The dialysis provider sends lab results and orders which are placed in resident's paper chart; -He/she gives morning medications prior to dialysis appointments, but blood pressure medications are held until the resident returns. During an interview on 02/29/24, at 9:41 A.M., Certified Nurse Assistant (CNA) C said the following: -The resident had dialysis on Tuesday, Thursday, and Saturday; -Nurses notified aides if thee was an extra dialysis day; -He/she would notify the nurse for any issues with dressing on catheter. During an interview on 03/01/24, at 1:33 P.M., the Director of Nursing (DON) said the following: -The dialysis provider and facility communicated via telephone for acute changes prior to and after appointments; -Nurses should document information obtained during phone calls from dialysis; -Nurses should assess dialysis catheter every shift and document findings; -There should be an order from physician for dialysis site assessment; -The dialysis provider notified facility by telephone regarding additional appointments; -The dialysis provider sent labs and new orders on paper. During interviews on 02/28/24, at 1:26 P.M. and 2:00 P.M., and on 03/0/1/24, at 3:18 P.M., the Administrator said the following: -Facility does not they have a contract with the dialysis company; -Transportation company transports residents to and from dialysis appointments; -Nurses should document dialysis information in the chart.

Based on interview and record review, the facility failed to provide trauma-informed care in accordance with standards of practice when staff failed to identify, assess, care plan, and provide supportive interventions for one resident (Resident #41) with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of one sampled resident. The facility's census was 59. Review showed the facility did not provide a policy related to Trauma Informed Care. 1. Review of Resident #41's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 09/12/23; -Diagnoses included PTSD, depression, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/21/23, showed the following: -The resident was cognitively intact; -The resident had no behaviors; -The resident's Patient Health Questionnaire (PHQ-9 - a depressive symptom scale and diagnostic tool introduced in 2001 to screen adult patients in primary care settings. The instrument assesses for the presence and severity of depressive symptoms and a possible depressive disorder) showed no depressive symptoms. Review of the resident's care plan, revised 01/24/24, showed staff did not are plan related to the resident's PTSD diagnosis and any triggers or interventions related to PTSD. Review of the resident's medical record showed staff did not document completion of a Trauma Informed Care Assessment since admission. During an interview on 03/01/24, at 10:51 A.M., Registered Nurse (RN) N said the following: -He/she did not know the resident had PTSD or the triggers for the resident; -Staff should document in the nurses' notes if a resident has behaviors; -Interventions for behaviors include redirection or take the resident to a quieter place; -He/she did not know of the assessment for trauma informed care for a new admission; -Diagnosis of PTSD should be in the care plan; -Staff should know of a resident's triggers for PTSD to provide care needed and not to upset the resident; -Nursing staff should pass on to the nurse aides triggers for PTSD to not upset the resident. During an interview on 03/01/23, at 8:05 A.M., the Social Services Designee (SSD) said he/she did not complete Trauma Informed Care Assessments and did not know if staff completed one on the resident. He/she did not know what assessments staff completed for residents with a PTSD diagnosis. During an interview on 03/01/24, at 11:17 A.M., the MDS/Care Plan Coordinator said the following: -She had not discussed PTSD in the care plan meetings with the resident and family; -She enters MDS data from review of a resident's initial data from outside sources, hospital records, physician history and physical, other facility information and talking with the resident and/or family; -She did not know of the trauma informed care assessment; -Social services completes an assessment with residents; -PTSD diagnosis should be on the care plan; -PTSD interventions should address triggers or what upsets the resident. During an interview on 03/01/24, at 8:34 A.M., the Director of Nursing (DON) said the following: -The resident did not have a Trauma Informed Care Assessment and the resident's care plan did not address his/her PTSD; -The charge nurse should have assessed the resident upon admission and the MDS Coordinator should have included PTSD in the resident's care plan to ensure the resident received the most appropriate care and services needed and staff would know the resident's triggers. -If a resident had a diagnosis of PTSD, the MDS Coordinator should put this on their care plan; -The care plan included interventions for resident's triggers; -The MDS Coordinator knew the resident's triggers through an interview when the resident admitted to the facility; -If the MDS Coordinator could not obtain the resident's triggers through an interview, staff then observed the resident for possible triggers and updated the care plan and trained staff; -The facility did not have a formal Trauma Informed Care assessment; -The MDS Coordinator was responsible for ensuring PTSD was addressed on the resident's care plan and the DON was responsible for ensuring the MDS Coordinator addressed the resident's PTSD. During an interview on 03/01/24, at 1:31 P.M., the Administrator said staff should have assessed the resident's PTSD and the MDS Coordinator should have included the resident's PTSD with interventions on the resident's care plan.

Based on interview and record review, the facility failed to ensure the physician responded timely to a pharmacist's request to discontinue a medication during the monthly drug regimen review for one resident (Resident #54) out of 22 sampled residents in a facility with a census of 59. 1. Review of Resident #54's face sheet showed an admission date of 03/29/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally-mandated assessment tool completed by facility staff), dated 01/05/24, showed the following: -Moderate cognitive impairment; -No symptoms of depression and no problem behaviors; -Diagnoses of compression fracture of spine, coronary artery disease (CAD - caused by plaque buildup in the wall of the arteries that supply blood to the heart), hypertension (high blood pressure), type 2 diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), and depression. Review of the pharmacist's recommendations to prescriber (ordering physician), dated 09/11/23, showed: -The pharmacist sent a medication discontinuation request for oxy (a medication used to treat overactive bladder) tablet 5 milligrams (mg) by mouth at bedtime for urinary incontinence. The pharmacist noted that per nursing documentation in the MDS from 07/11/23, the resident is frequently incontinent of bladder. Elderly patients have a higher potential for anticholinergic side effects (some potential side effects include dry mouth, headache, impaired memory, reduced cognitive function, behavioral disturbances, anxiety, and insomnia); -The prescriber's recommendation and comments sections at the bottom of the page were left blank, indicating no response from the physician. Review showed the facility provided no further documentation to show any physician communication regarding the recommended discontinuation of oxy after 09/11/23 until 12/13/23. Review of the pharmacist's recommendations to prescriber (ordering physician), dated 12/13/23, showed: -The pharmacist sent a medication discontinuation request for oxy 5 mg tablet by mouth at bedtime for urinary incontinence. The pharmacist noted that per nursing documentation in the MDS from 10/20/23, the resident is frequently incontinent of bladder. Elderly patients have a higher potential for anticholinergic side effects; -The prescriber's recommendation section showed an X beside discontinue oxy tab 5 mg and the form was signed by the physician and dated 12/17/23. (This occurred three months after the pharmacist's recommendation to the physician's.) During an interview on 02/29/24, at 5:21 P.M., the Director of Nursing (DON) said the following: -The facility's consulting pharmacist reviewed resident medications monthly and made recommendations for changes/reductions in medications; -These pharmacy recommendations and gradual dosage reductions were sent to the physician for review; -The facility had a chronic issue with one of the physician's not addressing pharmacy recommendations, including gradual dosage reductions; -The DON realized the issue in September 2023. If he/she does not hear back from the physician in two days, he/she re-faxes the physician; -The DON notified the facility medical director of the issue and he/she said it was the DON's responsibility and to keep reaching out to the physician and documenting the attempts to contact the physician; -When the pharmacist's recommendations did not get addressed, the DON spoke with the pharmacist and the pharmacist re-issued some of the requests/recommendations; -This inability to get the physician to respond caused potential delays in needed medication changes/discontinuations and gradual dosage reductions for some of the residents. During an interview on 03/01/24, at 3:50 P.M., the Administrator said the following: -She expected the DON to monitor the pharmacy recommendations and gradual dosage reduction requests and if the physician did not respond, the DON should notify the Medical Director and the Administrator of the issue; -If the pharmacist's recommendations were not addressed by the physician, that could cause a potential problem to that resident, if they continued to receive a medication that needed to be discontinued or reduced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #30) did not receive unnecessary drugs when staff administered two different antibiotics simultaneously, despite physician directions to the contrary, out of 22 sampled residents in a facility with a census of 59. 1. Review of Resident #30's face sheet showed: -admission date of 09/26/22 and re-admitted on [DATE]; -Diagnoses of type 2 diabetes mellitus, hypertension (high blood pressure), dysuria (painful or uncomfortable urination), muscle weakness, history of sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to it's own tissues and organs), and history of urinary tract infections. Review of the resident's current physician orders showed: -An order, dated 10/18/23, for Hiprex (an antibiotic - used to prevent and control urinary tract infections) tablet 1 gram, give one tablet by mouth two times a day for urinary tract infection (UTI). Resident not to take simultaneously with other antibiotic. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/10/24, showed the following: -Resident cognitively intact; -Dependent on staff for personal and toileting hygiene, showers, and upper and lower body dressing; -Always incontinent of urine. Review of the resident's current physician orders showed: -An order, dated 01/26/24, for a Foley (urinary) catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Staff to change monthly. Catheter related to the resident's diagnosis of acute renal failure. Review of the resident's February 2024 medication technician (med tech) Medication Administration Record (MAR) showed the following: -A current order for Hiprex 1 gram, give one tablet by mouth two times a day for UTI prevention. Directions on order showed: Resident not to take simultaneously with other antibiotics. Staff initialed administration of Hiprex two times per day every day from 02/01/24 to 02/29/24; -A previous order for Macrobid (an antibiotic used to treat UTIs) 100 mg capsule, give one capsule by mouth two time a day for seven days, beginning on 02/07/24 and ending on 02/13/24 for treatment of UTI. Staff initialed administration of Macrobid two times per day from 02/07/24 to 02/13/24; -Staff continued administration of Hiprex while administering Macrobid. Observation of the resident on 02/26/24, at 11:35 A.M., showed: -The resident had a urinary catheter tube running out the bottom of his/her pant leg with yellow urine present in the tubing; -The catheter tubing ran to a gravity drainage bag located on the side of the resident's wheelchair (the drainage bag was inside of a cloth dignity bag). Review of the resident's current physician orders showed an order, dated 02/27/24, for Macrobid 100 mg, give one capsule by mouth two times a day for UTI for seven days. Review of the resident's February 2024 med tech MAR showed the following: -A current order for Macrobid 100 mg capsule, give one capsule by mouth two time a day for seven days, beginning on 02/27/24. Staff initialed administration of Macrobid two times per day from 02/27/24 to 02/29/24; -Staff continued administration of Hiprex while administering Macrobid. During an interview on 03/01/24 at 10:44 A.M., Licensed Practical Nurse (LPN) T said the following: -Staff should stop the Hiprex while the resident is on another antibiotic, and then restart the Hiprex once the antibiotic administration is complete; -When the nurse obtained the Macrobid order, the nurse should have entered an order to hold the Hiprex; -Both the nurse and the certified medication technician (CMT) have been watching for that. During an interview on 03/01/24, at 11:29 A.M., CMT I said the following: -He/she was aware the resident was taking Hiprex and Macrobid, and he/she gave the resident the two medication together; -He/she did not see the note to not give the Hiprex simultaneously with another antibiotic. During an interview on 03/01/24, at 12:04 P.M., the Director of Nursing (DON) said the following: -When the physician placed the resident on Macrobid, the nurse should have placed the resident's Hiprex on hold, but this was not done; -This would be considered a medication error since they were both given and nursing should notify the resident's physician and responsible party of the error. During an interview on 03/01/24, at 3:50 P.M., the Administrator said she expects staff to administer the medication as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure a medication regimen was free from unnecessary psychotropic medications when the facility failed to document target behaviors for administration of antipsychotic medications and reevaluate a gradual dose reduction (GDR-a step wise tapering of a dose to determine if symptoms, conditions, or risk can be managed by a lower dose or if the dose or medication can be discontinued) for one resident (Resident #16) and failed to document use of other non-pharmacological interventions, target behaviors, and adverse reactions for one resident (Resident #57) out of a sample of 22 residents. The facility's census was 59. Review of the facility's policy titled Behavioral Health Services, dated 01/01/24, showed the following: -The behavior management team will meet monthly (for each resident) to review those residents receiving antipsychotic medications; -The goals of the GDR are to achieve the lowest effective dose, to discontinue the medications that no longer benefit the resident, and to minimize exposure to increased risk of adverse consequences; -GDR is indicated when the resident's clinical condition has improved or stabilized, or the underlying causes of symptoms have resolved, and the type of medication requires gradual reduction of the dosage in order to avoid adverse consequences that cold occur if the medication is stopped abruptly; -The resident's response to medication is not only evaluated by the behavior management team. Evaluation and consideration of the resident's medication to continue, reduce or discontinue must also take place during monthly medication regimen review by the consulting pharmacist, review of care plan and monthly renewal of orders, quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) review, daily behavior monitoring every shift. and resident and family staff meetings; -During the first year if receiving an antipsychotic or other psychopharmacologic medication, at least one attempt at GDR or dose tapering and a second attempt, in a subsequent quarter the same year (12 month period) unless the first attempt demonstrated that GDR or tapering was clinically contraindicated. The attempts should be at least one month apart; after the first year, GDR or tapering should be attempted once a year. -GDR or tapering may be considered clinically contraindicated if the resident's targeted symptoms worsened or returned during the reduction. If this occurs the physician must document the clinical rationale why further GDR attempts should not be done (further attempts may cause impairment of resident function, increase distressed behavior(s), cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder); -Based on the regulatory mandates of Centers of Medicare and Medicaid Services (CMS) related to unnecessary drugs an anti-psychotic, antidepressant, antianxiety, and a hypnotic medication will not be initiated unless the behavior management committee has determined the medication is necessary to treat a specific condition. The targeted behaviors causing the resident distress must be clearly identified; -Non-pharmacological interventions previously attempted without success must be documented. The condition must be comprehensively assessed in the rationale clearly documented in the resident's medical record. A comprehensive care plan must be in place with the problems/condition identified, measurable goals determined, and interventions in place to manage/decrease/eliminate the behaviors; -The behavior management committee will ensure the following has been completed before a psychoactive medication is administered: monitoring for the anticipated response to the medication, consideration of administering the lowest possible dose for the shortest, yet effective duration; contributing factors and triggers for the symptom/behavior have been assessed/identified and approaches put in place to reduce/eliminate the impediments, triggers, and causes; and appropriate non-pharmacological interventions have been identified and implemented based on an individual resident assessment. 1. Review of Resident #16's face sheet (resident's information at a quick glance) showed the following: -admission date of 06/30/14 with a readmission date of 09/8/21; -Diagnoses include psychophysical visual disturbances (mental state characterized by a loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes) and personal history of traumatic brain injury (TBI - caused by a forceful bump, blow, or jolt to the head or body, or from an object that pierces the skull and enters the brain). Review of the note to the resident's attending physician/prescriber regarding the resident's GDR review, dated 02/15/22, showed the following: -Psychotropic medications due for a routine GDR consideration: -Fluoxetine (Prozac - antidepressant) 60 milligrams (mg), every day, treating major depression disorder (MDD), initiated 02/2019; -Quetiapine (Seroquel - antipsychotic) 100 mg, twice a day and 250 mg at bedtime, treating dementia with behaviors initiated 08/2014; -Relevant Diagnosis: History of TBI -MDS/Clinical Data: refusing showers; -Physician/Prescriber Response: Decrease Seroquel, 50 mg, every morning, 100 mg, at noon and 250 mg, at bedtime. -Signed by the physician, dated 02/15/22. (The physician did not address the recommendation for reducing the resident's fluoxetine.) Review of the note to the resident's attending physician/prescriber regarding the resident's GDR review, dated 02/15/23, showed the following: -Psychotropic medication due for a routine GDR consideration: -Fluoxetine 60 mg, every day, treating MDD initiated 02/2019; -Quetiapine 50 mg, every morning, 100 mg, at noon and 250 mg, at bedtime, treating dementia with behaviors initiated 08/2014; -Relevant Diagnosis: History of TBI; -MDS/Clinical Data: negative for behaviors per most recent interdisciplinary team (IDT) notes; -Recommendation: Other: Will eval for GDR. -Signed by the physician, dated 02/16/2023. Review of the resident's medical record showed staff did not document a GDR evaluation for use of antipsychotic medication in 2023. Staff did not have documentation of physician reasoning a GDR would be contraindicated. Review of resident's care plan, updated 01/18/24, showed the following: -The resident had impaired cognitive skills; -Report significant change in cognitive status, mood, and behavioral status to physician; -The resident is at risk for mood state issues as evidenced by diagnoses of depression and history of traumatic brain injury; -The resident is at risk for behavior disturbances related to diagnoses of dementia with behavioral disturbance and traumatic brain injury; -The resident uses psychotropic medication related to psychovisual disturbances, dementia, depression, and behavior disturbances; -Give the resident medications ordered by physician. Monitor for side effects and effectiveness; -Assess the resident for physical/psychological causes for mood indicators, address as needed; -Monitor and record changes in mood state pattern; -Intervene during behavioral outburst to protect the safety of the resident and to others; -Observe and record changes in behavioral symptoms; -Report any exacerbation of behaviors to the Medical Director; -Monitor/document/report PRN any adverse reactions of psychotropic medications; -The residents' behaviors are monitored and the physician will adjust my medications as my condition warrants; -The resident's physician has determined that the resident's medications can not be reduced in dosage it is contraindicated. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -No behaviors; -Received antipsychotic medications on a routine basis only; -GDR last attempted 02/15/23, documented by physician as clinically contraindicated. Review of resident's February 2024 Physician Order Sheet (POS) showed the following: -An order, dated 09/8/2021, for Abilify (an antipsychotic medication) tablet, 20 mg, give one tablet by mouth (PO) one time a day related to unspecified psychosis not due to a substance or known physiological condition; -An order, dated 09/15/23, for Seroquel tablet, give 250 mg PO at bedtime related to unspecified psychosis not due to a substance or known physiological condition; - An order, dated 10/13/23, for Seroquel tablet 50 mg, give one tablet PO one time a day bedtime related to unspecified psychosis not due to a substance or known physiological condition; - An order, dated 10/17/23, for Seroquel tablet 100 mg, give one tablet PO one time a day bedtime related to unspecified psychosis not due to a substance or known physiological condition. Review of the resident's progress notes, dated 01/01/21 to 02/29/24, showed staff did not document any resident behaviors. Review of the resident's medical record showed staff did not document target behaviors for the use of the antipsychotic medications. Review of the resident's February 2024 Behavior Monitoring & Interventions Tasks showed staff did not document any behaviors observed. Review of the note to attending physician/prescriber regarding the resident's GDR review, dated 02/05/24, showed the following: -Psychotropic medications due for a routine GDR consideration: -Fluoxetine 60 mg, every day, since 02/2019; -Quetiapine 50 mg, every morning, 100 mg, at noon and 250 mg, at bedtime, since 9/9/2021 when the dose was increased from 100 mg twice a day; -Relevant Diagnosis: History of TBI, MDD, and psychosis/psychovisual disturbances; -MDS/Clinical Data: per nursing notes, no negative behaviors. However, refusing some breathing treatments; -Recommendation: No change to current therapy. Therapy is consistent with current standards of practice. Benefits out way risk. Attempted GDR at this time would be likely to impair the resident's function and/or exacerbate underlying medical or psychiatric disorder. -Prescriber's comments: Previously failed GDR; -Signed by the physician, dated 02/09/24. During an interview on 02/29/24, at 1:13 P.M., Certified Medication Technician (CMT) I said the resident has not exhibited any behaviors. The resident has not had any recent changes in behavior medications. During an interview on 02/29/24, at 1:31 P.M., Certified Nurse Aide (CNA) O said the resident had not had recent behaviors. The communication notebook had no documented notes regarding the resident in it. During an interview on 02/29/24, at 1:58 P.M., CNA P said the resident had not had any behaviors. During an interview on 02/29/24, at 4:38 P.M., the resident's physician said the following: -He has not conducted a GDR of the resident's medication in the last year or two; -The last time he attempted a GDR with the resident it failed drastically, he/she broke his/her hip and assaulted a staff member; -He has attempted a GDR twice in the past and both times were unsuccessful; -The resident stays in his/her room and is awake and alert when the physician sees him/her; -The resident's moods are stable, the resident shows no aggression. During an interview on 03/01/24, at 12:16 P.M., the Director of Nursing (DON) said the following: -The physician has attempted a GDR several times in the past for the resident; -The GDR for the resident has been ineffective in the past; -The resident's behaviors included punching, striking out, kicking, and decline in care; -The resident had significant behaviors, including physical assault after a GDR attempt, between August 2014 and October 2015; -The DON would expect staff to document what they are doing to redirect the resident in the resident's chart; -The DON would expect to find documentation for GDR, dated 02/13/23, noted will evaluate for GDR in the resident's chart. During an interview on 02/29/24, at 4:38 P.M., the resident's physician said the following: -If the GDR is not clinically indicated, the pharmacy will contact him when a GDR is due; -The physician reviews the GDR online, completes and sends back to the DON; -The physician will call the DON if he has any question or will wait till he rounds at the facility; -The physician looks in nurses' notes for documented behaviors and also talks to staff when making rounds; -The physician rounds with the nurse to get current information. 2. Review of Resident #57's face sheet showed the following: -admission date of 02/02/24; -Diagnoses included unspecified dementia, hypertension (HTN-high blood pressure), and disorientation. Review of the resident's baseline care plan dated 02/02/24 showed the following: -Zyprexa (an antipsychotic medication) for delusions and agitation; -Staff to monitor every shift behavior tracking and monitoring. Review of the resident's February 2024 Medication Administration Record (MAR) showed the following: -An order, dated of 02/02/24 and discontinued on 02/05/24, for lorazepam (an antianxiety medication) 0.5 mg, give one tablet PO as needed (PRN) for anxiety twice a day. Staff administered the medication on 02/02/24 at 9:00 P.M., on 02/03/24, at 10:00 A.M., on 02/03/24 at 6:25 P.M., and on 02/04/24 at 8:30 P.M. with effective results noted; -An order, dated 02/05/24 and discontinued on 02/09/24, for lorazepam 0.5 mg, give one tablet PO every 12 hours as needed for anxiety. Staff did not administer the medication; -An order, dated 02/09/24, for lorazepam 0.5 mg give one tablet PO every 12 hours PRN for anxiety for 30 days. Review of the resident's medical record, dated 02/02/24 to 02/15/24, showed staff did not document the target behaviors for use of the lorazepam or if there were any adverse reactions. Review of the resident's skilled nurses' notes showed the following: -On 02/13/24, at 10:38 A.M., a nurse documented the resident's mood and behavior pleasant and cooperative with no distress noted at this time; -On 02/14/24, at 4:07 P.M., a nurse documented the resident was calm and pleasant during the assessment; -On 02/15/24, at 4:39 P.M., a nurse documented the resident is calm and pleasant during assessment. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognitive skills; -No behaviors; -Received antianxiety medications. Review of the resident's care plan, revised on 02/15/24, showed the following: -The resident takes antianxiety medication related to anxiety disorder; -Administer antianxiety medications as ordered; -Staff to monitor for side effects and effectiveness every shift; -Staff to monitor, document, and report as needed any adverse reactions to antianxiety therapy; -Staff to monitor and record occurrence for target behavior symptoms; pacing, wandering, disrobing, inappropriate response to verbal communication toward staff and others and document per facility protocol. Review of the resident's February 2024 MAR showed the following: -Staff administered the resident's as needed lorazepam on 02/17/24, at 9:24 P.M., and on 02/18/24, at 12:58 P.M., with effective results note; -The lorazepam order was discontinued on 02/22/24. Review of the resident's records showed staff did not document what targeted behaviors the lorazepam was administered for on 02/17/24 and 02/18/24. Review of the resident's nurses' note dated 02/20/24, at 2:16 P.M., showed Registered Nurse (RN) B documented a certified nurse aide (CNA) reported that he/she tried to redirect the resident and the resident struck the CNA with a closed fist. RN B assessed the resident who showed no signs of distress and no injury from striking the staff. Review of the resident's POS, dated 02/22/24, showed the following: -An order, dated 02/22/24, for buspirone (an anti-anxiety medication) 5 mg, three times a day PO for anxiety; -An order, dated 02/22/24, for Ativan (an antianxiety medication) 0.5 mg give one tablet PO every four hours as needed for anxiety for 30 days with an end date of 03/23/24. Review of the resident's February 2024 MAR showed, on 02/22/24, a nurse documented see nurses notes regarding buspirone/Ativan administration/orders. Review of the resident's nurses' notes, dated 02/22/24, showed staff did not document regarding the resident's buspirone or Ativan. Review of the resident's February 2024 MAR , dated 02/23/24 through 02/29/24, showed staff documented the medication administered as ordered. Review of the resident's records showed staff did not document target behaviors or non pharmological interventions attempted before the medication orders for busipirone and Ativan. Observation on 02/28/24, at 11:59 A.M., showed the resident sitting at a dining room table in the special care with no signs of distress. During an interview on 02/28/24, at 4:06 P.M., CNA H said the resident goes into other residents' rooms and takes things out of their rooms and takes the items to his/her room. The resident hits, punches, and scratches the staff during cares. The resident has shown this behavior since his/her admission. The resident has better days and his/her family visits the resident everyday. During an interview on 02/29/24, at 05:20 P.M., CNA O said the resident did not sleep well, was combative with cares, and wanders. Staff attempt to redirect the resident. During an interview on 02/29/24, at 2:50 P.M., the Social Services Director (SSD) did not know of any behaviors for the resident. During an interview on 02/29/24, at 2:56 P.M., Registered Nurse (RN) B said the resident sometimes gets anxious and upset. The resident cusses at staff. During an interview on 02/29/24, at 3:05 P.M., LPN A said the following: -The resident was put on buspirone on 02/22/24; -The resident seems good now and not as anxious; -The resident would get anxious after his/her family left from a visit and appeared distressed. During an interview on 03/01/24, at 12:15 P.M., the Director of Nursing (DON) said the following: -Staff did not document every shift on the resident. Staff did attempt nonpharmological interventions, but did not document the interventions; -She expects nursing staff to document adverse reactions, target behaviors, and non pharmological interventions on the resident's newly prescribed medication. During an interview on 02/29/24, at 04:30 P.M., the resident's physician said the following: -The resident was at another facility previously and the resident appeared oriented to self and did not seem combative, but the prior facility staff reported the resident beating everyone up at night and the staff could not take care of the resident; -He did not observe any aggressiveness with the resident at the other facility. The resident required sitters all night per the prior facility staff; -The resident had a urinary tract infection and was a little combative and did not remember if redirection helped; -He prescribes buspirone if a resident swings aimlessly; -He expects staff to document the adverse reactions and the targeted behaviors for the buspirone. 3. During an interview on 02/28/24. at 4:06 P.M., CNA H said the following: -Interventions for behaviors include playing a game and redirection with a resident; -Report any behavior changes to the charge nurse; -Resident behaviors should be in the resident care plan. 4. During an interview on 02/29/24, at 1:13 P.M., CMT I said the following: -Staff will verbally relay to new employees if the resident has any behaviors; -The staff will tell the nurse if a resident has any behavior changes; -The physician makes his rounds weekly and will ask if any residents have exhibited any behaviors; -The nurse keeps a log book of concerns for the physician. 5. During an interview on 02/29/24, at 1:31 P.M., CNA O said the following: -The staff document resident behaviors in a communication notebook; -The staff report behaviors to the charge nurse; -The charge nurse will put residents name on a list for the doctor to see; -The nurse documents resident's behaviors in their chart. 6. During an interview on 02/29/24, at 1:58 P.M., CNA P said the following: -He/She reports resident's behavior to the nurse; -He/She will text the nurse if resident has behaviors; -Staff use a teachable moments notebook to communicate resident's behaviors. 7. During an interview on 02/29/24, at 2:50 P.M., the SSD said the following: -The facility staff have a behavior meeting every week; -Staff discuss the residents who are listed for behaviors to monitor for yelling, screaming and hitting; -Examples of non-pharmological interventions, depending on what type of behavior, include one on one and sitting with the resident; -The DON documents on a resident behaviors in the computer; -She did not attend the behavior meeting anymore. 8. During an interview on 02/29/24, at 2:56 P.M., RN B said the following: -Staff know residents with behaviors due to the tab in the computer which flags who to document on; -Staff should document behaviors on the treatment administration record in the computer; -Facility staff have a behavior meeting once per week and discuss residents' past behaviors and prescribed medications; -Signs of behavior for staff to monitor include anxiousiousness, yelling out at other people, socially inappropriate, physical and/or verbal altercations with staff; -Non-pharmological interventions include staff to reapproach the resident, have different staff approach the resident, take the resident to a calmer environment,; -Staff should attempt non-pharmological interventions before notifying the physician; -Staff should review the nurses notes to see if any behaviors; -Most residents are easily redirected; -The pharmacist comes to the facility monthly to review residents' medications; -Staff send pharmacy recommendations to the physician who reviews and does not change the medication or discontinues -Staff should document any adverse effects of a medication or if a medication is gradually reduced; -Staff report to the physician on Thursday of any behaviors of residents for rounds; -He/she did not know how the physician decides what medication to prescribe. 9. During an interview on 02/29/24, at 3:05 P.M., LPN A said staff should document on a new prescribed medication with follow up on the TAR of a resident behaviors. 10. During an interview on 03/01/24, at 10:51 A.M. , RN N said the following: -Staff should document in the nurses' notes of residents with behaviors; -Interventions for behaviors include, redirection, quiet place; -Staff should attempt non pharmological interventions and then notify the physician. 11. During an interview on 03/01/24, at 12:15 P.M., the DON said the following: -Staff should contact the physician after staff have exhausted all non-pharmacological interventions, if the resident is at risk for hurting themselves or other, and the behaviors are distressing to the resident to discuss pharmacological interventions; -The staff should be charting behaviors every shift in nurses' notes; -Pharmacy recommends GDR monthly, the physician documents recommendations, signs the document and returns it to the DON; -The physician determines an appropriate time frame to attempt a GDR again; -Nursing staff should document behavior charting every shift for residents on an antipsychotic; -Nursing staff should document every shift for behavior monitoring for residents with behaviors; -Staff should review new admission in the referral of any behaviors and document every shift; -Nursing staff did not document on every resident every shift currently if no behaviors noted for 60 to 90 days; -Staff monitor for behaviors such as yelling at staff, inappropriate behavior with staff, hitting, striking out, paranoia, and hallucinations; -Examples of non pharmological interventions to attempt before prescribed a new psychotropic medication include redirection, quiet environment, provide reassurance, offer a snack, drink, get to know the resident and the best way to assist, assess toileting needs and make sure the resident is safe; -Staff discuss types of medications residents are on in the monthly quality assurance meeting; -The physician explains to staff of reason on certain medication and if anti anxiety medication more appropriate than anti depressant; -Staff should monitor residents closely if on Seroquel to make sure most appropriate and least restrictive; -Staff should monitor for medication effectiveness improvement and staff discuss in the weekly behavior meeting; -Staff discuss in the weekly behavior meeting of medications started for residents and behavior charting every shift which is in the nurses' notes; -Staff who attend the weekly behavior meeting include the DON, MDS coordinator, and pharmacist. Medical records pulls the GDR recommendations, medications and behaviors; -Staff email the medical director the pharmacy recommendations; -The pharmacist brings the recommendations with her and discusses with the physician and DON to make an informed decisions. The physician decides, signs the recommendations as discontinue or not appropriate; -The physician should document the resident on the pharmacy recommendation of decision to not perform a GDR; -The physician decides if the resident has a history that was ineffective for the resident, unsuccessful GDR and it is up to the physician of if he agrees to a GDR. 12. During an interview on 03/01/24, at 2:20 P.M., the Administrator said the following: -The Administrator expects staff to attempt non-pharmological interventions before prescribing psychotropic medications; -The Administrator expects the GDR to be reevaluated if the physician says he/she will reevaluate.

Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made two errors out of 25 opportunities resulting in an 8% error rate. Staff administered medication when the blood pressure was out of the parameter for medication to be given for one resident (Resident #31) and failed to assess resident's pulse rate prior to administration for one resident (Resident #46) during random medication pass observations. The facility had a census of 59. Review of the facility's Medication Administration Policy, dated 01/01/24, included the following information: -It is the policy of the facility to safely and accurately administer physician ordered medication to each resident. -Record vital signs as ordered before administering medications; -Follow physician orders regarding holding medications based on a vital sign parameter; -Record any vital sign included in the physician's order for the medication. 1. Review of the Resident #31's February 2024 Physician Order Sheet (POS) showed the following: -An order, dated 10/22/23, for midodrine (used to treat low blood pressure) 5 milligram (mg), administer one tablet by mouth three times a day related to congestive heart failure (CHF - a long-term condition in which the heart can't pump blood well enough to meet the body's needs). Staff to obtain manual blood pressure and administer medication if systolic blood pressure is less the 100 millimeters of mercury (mmHg) . Review of the resident's February 2024 Medication Administration Record (MAR) showed an order, dated 10/22/23, for midodrine 5 mg, scheduled for morning, noon, and evening, with an area to record resident blood pressure. Observation on 02/28/24, at 12:10 P.M., showed Certified Medication Technician (CMT) G sanitized his/her hands and then obtained ordered medications from bottle, including midodrine). The medications were crushed and placed in a cup with applesauce. CMT G checked resident's blood pressure and reported it as 127/56 mmHg (systolic blood pressure 127 mmHg) and then administered medication including midodrine. 2. Review of Resident #46's March 2024 POS showed the following: -An order, dated 10/19/23, for metoprolol tartrate tablet (medication used to treat high blood pressure) 50 mg, give by mouth two times a day for high blood pressure. Hold medication for blood pressure less than 110/60 mmHg or pulse less than 60 beats per minute. Review of the resident's February 2024 MAR showed an order, dated 10/19/23, for metoprolol tartrate tablet 50 mg, give 50 mg by mouth two times a day for high blood pressure. Staff to hold for blood pressure less than 110/60 mmHg or pulse less than 60 beats per minute. The MAR had an area to record resident blood pressure. Observation of on 02/28/24, at 9:18 A.M., showed CMT I prepared the resident's medications, including metroprolol tartrate, and entered the resident's room. He/she checked resident's blood pressure with a manual blood pressure cuff and reported a result of 116/64 mmHg. He/she then administered the medications, including metoprolol tartrate, without checking the resident's pulse rate. During interviews on 03/01/24, at 10:36 A.M., and on 03/01/24, at 11:11 A.M., CMT I said the following: -Metoprolol is a blood pressure medication that can lower heart rate and blood pressure and pulse should be checked prior to giving the medication; -The resident had vital signs parameters to hold medication for systolic blood pressure below 100 mmHg; -He/she reviewed the resident's order for metoprolol which showed blood pressure and pulse should be checked, but reported there is not an area to record pulse on the MAR. 3. During interviews on 03/01/24, at 10:36 A.M., and on 03/01/24, at 11:11 A.M., CMT I said the following: -There are vital sign parameters to hold blood pressure medications if needed; -He/she can find parameter information on the MAR and will check vital signs prior to administration; -If vital signs are below the parameters, medication would not be given and he/she would report it to charge nurse. 4. During an interview on 03/01/19, at 1:33 P.M., the Director of Nursing (DON) said medications for blood pressure and pulse need vital sign parameters. CMTs should be checking vital signs before administering medications and then document in electronic health record. 5. During an interview on 03/01/24, at 3:18 P.M., the Administrator said staff should be checking parameters for medications and administer based upon findings.

Based on interview and record review, the facility failed to implement policies to prevent possible abuse, neglect, or misappropriation of residents when the facility failed to complete a Family Care Safety Registry (FSCR - a state registry that provides multiple checks on staff including a Criminal Background Check) or a Criminal Background Check (CBC) prior to hire to ensure two staff (Certified Nursing Assistant (CNA) J and Certified Medication Technician (CMT) K), did not have a disqualifying criminal background that would prevent the staff member from working in a certified long-term care facility; failed to perform an Employee Disqualification List (EDL) check on three staff (CNA J, CNA M, and CMT K); and failed to perform a Nurse Aide (NA) Registry (registry which shows if someone has a Federal Indicator (indicates individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility)) check on two staff (CNA J and Licensed Practical Nurse (LPN) L) out of a sample of ten staff members. The facility census was 59. Review of the facility's policy titled Abuse, Neglect, and Exploitation, dated 01/01/24, showed the following: -The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences; -Screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries; -The facility must not employ or otherwise engage individuals who: have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. 1. Review of CNA J's personnel file showed the following: -Hire date of 05/23/22; -Staff did not have a documented FCSR or CBC check prior to or upon hire; -Staff did not have an EDL check prior to or upon hire; -Staff did not have a NA Registry check prior to or upon hire. During an interview on 03/01/24, at 12:16 P.M., the Social Services Designee (SSD) said the following: -CNA J did not have any recent FCSR, CBC, EDL, or NA Registry checks on his/her most recent hire date. He/she had these completed back in 2013 and 2016; -He/she should have completed these for the most recent hire date. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the SSD should have completed the CNA's FCSR, CBC, EDL and NA Registry checks prior to the CNA's hire date. 2. Review of CMT K's personnel file showed the following: -Hire date of 03/04/22; -Staff did not have a documented FCSR or CBC check prior to or upon hire; -Staff did not have an EDL check prior to or upon hire. During an interview on 03/01/24, at 12:16 P.M., the SSD said he/she could not find the CMT's FCSR, CBC or EDL checks. The checks should have been completed prior to the CMT's hire date. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the SSD should have completed the CMT's FCSR, CBC and EDL checks prior to the CMT's hire date. 3. Review of LPN L's personnel file showed the following: -Hire date of 09/01/23; -Staff did not have a NA Registry check prior to or upon hire. During an interview on 03/01/24, at 12:16 P.M., the SSD said he/she could not find the LPN's NA Registry check. The check should have been completed prior to the LPN's hire date. During an interview on 03/01/24, at 1:31 P.M., the Administrator the SSD should have completed the LPN's NA Registry check prior to the LPN's hire date. 4. Review of CNA M's personnel file showed the following: -Hire date of 02/01/22; -Staff did not have an EDL check prior to or upon hire. During an interview on 03/01/24, at 12:16 P.M., the SSD said he/she could not find the CNA's EDL check. The check should have been completed prior to the CNA's hire date. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the SSD should have completed the CNA's EDL check prior to the CNA's hire date. 5. During an interview on 03/01/24, at 12:16 P.M., the SSD said the following: -Prior to hiring a new employee, he/she completed a CBC, FCSR, EDL and NA Registry check and new employees were not allowed to work prior to the checks being completed; -He/she was responsible for completing these checks and the Administrator was responsible for ensuring he/she completed them. 6. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the following: -The SSD completed FCSR, CBC, EDL and NA Registry checks on all new employees prior to their hire date; -These checks were important to ensure the facility did not hire a staff member that had the potential to harm the facility's residents; -The SSD was responsible for completing these checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed implement a comprehensive person-centered care for each resident when staff failed to complete a comprehensive and individualized care plan, including interventions, to address the specific needs of four residents (Resident #24, #30, #31, and #38) out of a sample of 22 residents. The facility had a census of 59. Review of the facility's policy, titled Care Plans, dated 01/01/24, showed the following: -It is the policy of the facility to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's medical, physical, mental, and psychosocial needs; -This facility will help develop and implement a comprehensive person-centered care plan for each resident that includes: measurable objectives and timeframes to meet the resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment utilizing the resident assessment instrument (RAI) process; resident's goals, preferences, needs, strengths, and weaknesses; and services are furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; -The comprehensive care plan will be reviewed and revised based on changing goals, preferences, and needs of the resident and in response to current interventions, by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 1. Review of Resident #24's face sheet (a general information sheet) showed the following: -admission date of 05/11/23; -Diagnoses included congestive heart failure (CHF - a long-term condition in which the heart can't pump blood well enough to meet the body's needs), edema (fluid retention), non-pressure chronic ulcer of lower leg, and lymphedema (swelling caused by lymphatic system blockage). Review of resident's March 2024 Physician Order Summary (POS) showed the following orders: -An order, dated 10/23/23, for staff to administer Bumex (to treat fluid retention and high blood pressure) one tablet by mouth (PO) two times a day (BID) for bilateral lower extremities (BLE) edema. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 01/10/24, showed the following: -Cognitively intact; -Used a diuretic (used to help remove excess fluids. Review of resident's March 2024 physician order summary sheet (POS) showed the following orders: -An order, dated 01/25/24, to elevate BLE as tolerated BID for dependent edema; -An order, dated 01/25/24, for tubigrips (bandage that provides continuous support for the management of swelling) to bilateral lower extremities. Place on in the morning and take off at bedtime BID for dependent edema. Review of the resident's current care plan. last revised on 01/17/24, showed staff did not address the use of Bumex, tubigrips, or to elevate BLE for edema. During an interview on 03/01/24, at 10:28 A.M., Registered Nurse (RN) N said the resident's legs are discolored and edematous and staff elevate as tolerated. During an interview on 03/01/24, at 10:23 A.M., Certified Nurse Assistant (CNA) R said the facility had a binder at the nurses' station that lists all residents who need tubigrips. Tubigrips are applied in the morning and removed when residents' go to bed. Sometimes residents refuse to wear them. During an interview on 03/01/24, at 10:28 A.M., RN N said the tubigrips are kept in the resident's room. A reminder of the order appears on the computer daily and that information is shared with the aides. 2. Review of Resident #30's face sheet showed the following: -admission date of 09/26/22 with readmission date of 11/26/23; -Diagnoses included Type 2 diabetes mellitus, history of sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to it's own tissues and organs), history of urinary tract infections, dysuria (painful or uncomfortable urination), and muscle weakness. Review of the resident's January 2024 POS for January 2024 an order, dated 01/03/24, for staff to administer Augmentin (an antibiotic) 875/125 milligram (mg) orally two times a day for urinary tract infection for 7 days (starting on 01/03/24 and ending on 01/10/24). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident cognitively intact; -Dependent on staff for personal and toileting hygiene, showers, and upper and lower body dressing; -Always incontinent of urine; -Resident on antidepressant, opioid (narcotic pain medication), and hypoglycemic (a medication used to reduce the amount of sugar in the blood) medications. Review of the resident's January 2024 POS showed an order, dated 01/26/24, for staff to change the resident's Foley catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) monthly related to the resident's diagnosis of acute renal failure. Review of the resident's February 2024 POS showed an order, dated 02/07/24, for staff to administer Macrobid (an antibiotic) 100 mg orally two times a day for urinary tract infection for 7 days (starting on 02/07/24 and ending on 02/14/24). Observation of the resident on 02/26/24, at 11:35 A.M., showed the following: -The resident had a urinary catheter tube running out the bottom of his/her pant leg with yellow urine present in the tubing; -The catheter tubing ran to a gravity drainage bag located on the side of the resident's wheelchair (the drainage bag was inside of a cloth dignity bag). Review of the resident's February 2024 POS showed an order, dated 02/27/24, for staff to administer Macrobid 100 mg orally two times a day for urinary tract infection for 7 days (starting on 02/27/24 and ending on 03/05/24). Review of the resident's current comprehensive care plan showed the following: -Staff did not care plan related to his/her history of frequent urinary tract infections; -Staff did not care plan related to his/her presence of a urinary catheter. During an interview on 03/01/24 at 10:44 A.M., Licensed Practical Nurse (LPN) T said if a resident had a catheter, the MDS Coordinator should update the care plan to reflect that. During an interview on 03/01/24, at 11:28 A.M., Certified Nurse Aide (CNA) Q said the following: -He/she referred to the resident care plan to see what a resident's care needs were; -He/she said it is important to know if a resident had a catheter. During an interview on 03/01/24, at 10:51 A.M., RN N said the resident gets confused and starts shaking and will say his/her urine burns. The resident's catheter and UTI's should be on the care plan. During an interview on 03/01/24, at 11:17 A.M., the MDS/Care Plan Coordinator said the resident's care plan did not address the catheter. The care plan should state for staff to monitor intake and output of urine, provide proper catheter care, change the catheter monthly, and to maintain the catheter bag below the resident's bladder. 3. Review of Resident #31's face sheet showed the following information: -admission date of 04/11/23; -Diagnoses included congestive heart failure, left leg above knee amputation, and chronic kidney disease. Review of the resident's March 2024 POS showed an order, dated 10/30/23, to apply a tubigrip to the resident's right lower extremity upon rising and remove at bedtime for edema. Review of the resident's quarterly , dated 01/21/24, showed the following information: -Moderate cognitive impairment; -Used a diuretic. Review of the resident's current care plan, last updated 10/03/23, showed staff did not address the use of tubigrips. During an interview on 03/01/24, at 10:23 A.M., CNA R said the resident reminded staff to put on his/her tubigrip. 4. Review of Resident #38's face sheet showed the following information: -admission date of 08/21/23 with readmission date of 10/12/23; -Diagnoses included Alzheimer's disease and vascular dementia. Review of the resident's February 2024 POS showed an order, dated 11/09/23, for staff to apply tubigrips to bilateral lower extremities and elevate as tolerated two times a day for dependent edema. Review of the resident's quarterly MDS, dated [DATE] , showed the following information: -Cognitive skills severely impaired; -Diuretic not marked; -Supervision or touching assistance with lower body dressing. Review of the resident's February 2024 POS showed an order, dated 12/21/23, for staff to administer furosemide (Lasix - a diuretic), 20 mg PO one time a day for edema. Observation on 02/28/24, at 12:35 P.M., showed the resident sat at the dining room table with tubigrips on both of his/her legs. Review of the resident's current care plan, last revised on 10/17/23, showed staff did not address the use of Lasix, tubigrips and the diagnosis of edema on the care plan. During an interview on 03/01/24, at 11:17 A.M., the MDS/Care Plan Coordinator said she did not put edema, Lasix and tubigrips on the resident's care plan. 5. During an interview on 02/28/24, at 11:37 A.M., CNA H said care plans show staff how to care for residents. 6. During an interview on 03/01/24, at 10:51 A.M., RN N said the following: -The MDS/Care Plan Coordinator develops the care plans; -He/she did not know the process of updating care plans; -Care plans show staff how to care for a resident; -Staff should monitor residents with edema for daily weights, medications, elevate legs, and communicate with the physician if needed; -Staff should assist a resident with tubi-grips if has an order; -Foley catheter should be on a care plan, staff should monitor every shift and as needed, measure input output, change monthly; -A resident's UTI should be on care plan, staff should monitor for pain, discomfort, confusion, altered mental status, odor appearance, and encourage the resident to drink enough water; -Staff should monitor resident's who take Lasix for lab results, potassium and edema. A resident's edema should be on the care plan. 7. During an interview on 03/01/24, at 11:17 A.M., the MDS/Care Plan Coordinator said the following: -Staff have a nurse meeting every morning; -The morning nursing meeting includes the MDS/Care Plan Coordinator, charge nurse, and RNA; -Staff discuss weight concerns, falls, behaviors and concerns that need addressed; -She updates the care plans; -Nursing staff have access to the care plans in the computer; -Care plans should include the residents assistance needed with activities of daily living, pain issues, fall risks, skin concerns, smoking, smoking, if the resident wears glasses or hearing aids; -The care plan is road map or directions with information of how to care for the resident; -Staff review the care plans quarterly with the resident and/or family and address all care areas; -Staff should monitor for swelling and elevate a resident's legs if they have edema; -Staff should monitor residents on Lasix for edema, weight gain and if wear tubigrips. 8. During interviews on 03/01/24, at 8:34 A.M. and 12:15 P.M., the DON said the following: -Staff meet daily in the morning meeting and have weekly meetings regarding residents; -Care plans should include edema, catheters, frequent UTI's anticoagulants, diabetes and Lasix. 9. During an interviewed on 03/01/24, at 1:31 P.M. and 2:20 P.M., the Administrator said she expects resident care plans to have the individualized areas for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store food in a manner to protect it from potential contamination when staff failed to store cleaning supplies in a separate area from food; failed to date stored food in refrigerator; failed to keep non-food contact surfaces clean and free of debris; failed to dispose of expired food items; failed to rinse dishes prior to placing them into the sanitizer in the three vat sink and sanitize at the minimum manufacturer's requirements; and failed to control flies in the kitchen. The facility's census was 59. 1. Review of the facility's policy titled, Non-Food Storage, undated, showed chemical and toxic products must be stored in a separate closet, closed cabinet, or outside of the kitchen area. Observation on 02/26/24, at 9:54 A.M., on 02/27/24, at 9:00 A.M., and on 02/28/24, at 8:02 A.M., of the dry food storage area showed cleaning supplies sitting on milk crates with the next table containing fresh bananas and a gold wire rack in the corner containing graham crackers, oatmeal cream pies, dry cornbread mix, french fried onions, boxes of baking soda and corn starch, rotel, and marshmallows. During an interview on 02/29/24, 9:23 A.M., Dietary Aide (DA) S, said cleaning supplies are kept in the locked metal cage in the dry food storage room away from food. During an interview on 02/29/24, at 9:33 A.M., [NAME] U said the cleaning supplies are stored in the chemical cage, in the janitor closet, and soaps are stored under the sinks. Chemicals should not be stored next to food. During an interview on 02/29/24, at 9:47 A.M., the Dietary Manger (DM) said staff are responsible for putting cleaning supplies in the proper storage area. Cleaning supplies are to be stored in the metal cage in the dry food storage room, away from food. During an interview on 02/29/24, at 3:27 P.M., the Administrator said staff should not be storing cleaning supplies or chemicals next to food. 2. Review of the facility's policy titled, Food Storage, undated, showed the following: -All containers must be labeled with the contents and date food item was placed in storage; -Food items that remain sealed from the supplier may be held until the expiration date if unopened. Observations on 2/26/24, at 9:54 A.M., on 2/27/24, at 9:00 A.M., and on 2/28/24, at 8:02 A.M., of the dry food storage area showed 15 boxes of baking soda with expiration date of 02/24/23 on all 15 boxes. Observation on 02/26/24, at 10:07 A.M., of the walk in refrigerator showed the following: -Four styrofoam to go boxes containing lettuce salad and one boiled egg cut in half, not dated, on the top shelf; -One styrofoam to go box containing lettuce salad and one boiled egg cut in half, dated 2/21, on the top shelf. Observation on 02/27/24, at 9:05 A.M., of the walk in refrigerator showed five styrofoam to go boxes containing brown wilted lettuce salad and one boiled egg cut in half, dated 2/26, on the top shelf. During an interview on 02/29/24, 9:23 A.M., DA S said kitchen staff are responsible for dating food prior to it being put in refrigerator. Kitchen staff are responsible for checking expiration dates on food and disposing of expired items. During an interview on 02/29/24, at 9:33 A.M., [NAME] U said the following: -Kitchen staff are responsible for making sure food is dated before putting in the refrigerator; -Kitchen staff are responsible for checking expiration dates of food already on shelf when putting up new products; -Staff should throw out items that are past the expiration date or not dated. During an interview on 02/29/24, at 9:47 A.M., the DM said the following: -Staff putting away food are responsible for dating the food prior to putting in refrigerator; -Staff should be looking at food prior to using to determine if the item has expired; -The Dietitian completes a walk-through of the kitchen monthly. During an interview on 02/29/24, at 3:27 P.M., the Administrator said staff should date food when stored in refrigerator and freezer. Staff should check food weekly for expiration dates. 3. Review of the facility's policy titled, Dietary Cleaning, undated, showed walk-in refrigerators and freezers must be cleaned quarterly or more often if needed. Review of the facility's Daily Cleaning Schedule showed it did not address the walk in refrigerator vents/fans. Observations on 02/26/24, at 10:07 A.M., on 02/27/24, at 9:05 A.M., and on 02/28/24, at 8:15 A.M., of the walk-in refrigerator showed dust build up on the cooler fans and on the left side of the cooler fan box. (The dust could fall and potentially contaminate food.) During an interview on 02/29/24, 9:23 A.M., DA S said kitchen staff have a weekly cleaning schedule that show the staff which areas of the kitchen he/she is responsible for cleaning. During an interview on 02/29/24, at 9:33 A.M., [NAME] U said staff have a weekly cleaning schedule showing the responsibilities of each shift. During an interview on 02/29/24, at 9:47 A.M., the DM said staff are responsible for cleaning the vents, walls, and floors. The kitchen staff use a weekly cleaning schedule to make sure all areas of the kitchen are cleaned. During an interview on 02/29/24, at 3:27 P.M., the Administrator said all kitchen staff are responsible for making sure everything in the kitchen is clean. The staff use a weekly cleaning schedule. 4. Review of the facility's policy titled, Ecolab Scout Pot & Pan Procedure, dated 2011, showed the following: -Fill the rinse sink with hot water; -Submerge washed item in hot water rinse and allow excess water to run back into rinse sink; -Submerge in sanitizer sink for one minute or as specified by product label and or local guidelines. Observation on 02/28/24, at 10:54 A.M., showed cook U used the electric handheld [NAME] Mixer Pro to puree food items for lunch. [NAME] U removed the shaft and blade of the mixer after use to wash them. [NAME] U used the three vat sink and submerged the shaft and blade in the wash sink, washed it, skipped the rinse sink, then dipped the shaft and blade in the sanitizer sink, pulled them out with suds still on them and put on clean surface to dry. [NAME] U then used the mixer, shaft, and blade again to puree the next item. During an interview 02/29/24, at 9:23 A.M., DA S said the following: -Cooks use the three vat sink to wash pots and pans; -The procedure for washing pots and pans in the three vat sink is to wash, rinse, put in sanitizer water and let sit for a minute, and put out to dry; -The rinse sink had not been used lately because there is no plug for the rinse sink. During an interview on 02/29/24, at 9:33 A.M., [NAME] U, said the following: -Cooks use the three vat sink to wash, rinse, and sanitize pots and pans; -Staff should rinse items, let sit in sanitizer for one minute, and sit out to dry with no suds on it; -Staff are not rinsing items currently because the sink does not have a plug; -The DM and Maintenance Supervisor are responsible for making sure the sink has a plug. During an interview, at 9:47 A.M., the DM said the following: -The cooks use the three vat sink for washing pots and pans; -The cooks should be washing items in hot soapy water, dipping in the rinse sink, making sure the item is fully rinsed, and let the item sit in the sanitizer sink for one minute; -The cook puts clean items to dry and does not put the items away till dry; -The rinse sink is currently being used as it should be. During an interview conducted on 02/29/24, at 3:27 P.M., the Administrator said staff should be using the three vat sink according to manufactures recommendation. 5. Review showed the facility did not provide policy regarding wall maintenance. Observations on 02/26/24, at 10:26 A.M., on 02/27/24, at 9:15 A.M., and on 02/28/24, at 8:07 A.M., showed a six foot line of peeling paint on the wall two feet above a food prep table located on the northwest wall of the kitchen. (The peeling paint could fall and contaminate food or food contact surfaces.) During an interview on 02/29/24, 9:23 A.M., DA S said staff tell the DM when staff notice paint peeling from ceiling or wall. During an interview on 02/29/24, at 9:33 A.M., [NAME] U said the staff are responsible for telling the dietary manager if they notice paint peeling on the walls. During an interview on 02/29/24, at 9:47 A.M., the DM said the dietitian will point out peeling paint and maintenance issues and the DM will report those issues to the Administrator. During an interview on 02/29/24, at 3:27 P.M., the Administrator said staff should report maintenance issues to the maintenance supervisor by word of mouth or through the maintenance notebook kept at the nurses' desk. The DM is responsible for the oversight of the kitchen. 6. Observation on 02/28/24, at 11:45 A.M., showed two flies buzzed around in the kitchen while staff served the lunch meal. A DA waved flies off of the drinks and desserts. A fly sat on clean serving spoon hanging from the ceiling over the meal preparation table. During an interview on 02/29/23, at 9:23 A.M., DA S said the pest control company comes to the facility. He/she reports to main supervisor if he/she notices pests. There are some flies. The kitchen has two bug zappers by the dishwashing door and exit door. Observation on 02/29/24, at 9:23 A.M. showed a bug zapper plugged in at the door located near the dishwashing area. During an interview on 02/29/24 at 09:33 A.M., [NAME] U said the facility unfortunately has flies. The flies are hard to get rid of, but staff report to the maintenance and the facility administration takes care of it. During an interview on 02/29/24, at 9:47 A.M., the DM said she did not think there was a problem with flies. Staff should report any pest issues to the Maintenance Supervisor or the Administrator During an interview on 02/29/24, at 3:27 P.M., the Administrator said the facility should not have flies in kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an effective infection control program for all residents when the facility failed to have a program in place for the prevention of the growth of Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems) in the facility water supply or where moist conditions existed. The facility had a census of 59. Review of the Centers for Disease Control and Prevention (CDC) Toolkit for Legionella (also titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings), dated [DATE], showed healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assess how much risk the hazardous conditions in those water systems pose; -Apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread; -Make sure the program is running as designed and is effective. Review of the facility policy titled, Water Management Program, dated [DATE], showed the following: -To inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -The purpose of this standard is to establish minimum Legionellosis risk management requirements for building water systems; -To meet the requirement of 42 Code of Federal Regulations (CFR) 483.80 to help prevent the development and transmission of communicable diseases and infections as it relates to Legionellosis; -The program team shall include the Administrator, Maintenance Director, Infection Preventionist, and Environmental Service Director. The program team shall have knowledge of the building water system design and water management as it relates to Legionellosis; -Determine the locations in the system where control measures (heating, adding disinfectant, cleaning, etc) are required; -For each control measure at each control measure location the facility will determine the limits including but not limited to a maximum value, a minimum value, or a range of values within which a chemical or physical parameter must be monitored and maintained in order to reduce hazardous conditions to an acceptable level; -Annual cleaning (when needed) of the shower heads, quarterly monitoring of the control limits (PH and Chlorine levels); -The Water Management Team is to review and confirm that all the program elements are being implemented as designed. Review of the facility's form, titled 'Baseline and Quarter, not dated, showed the following: -Location, Sediment and Biofilm, temperature, water age, disinfectant for the ice machine, showers, tubs, hot water heaters, sinks and fire suppression system; -The document was not completed for the baseline and quarter form. 1. Review of facility records showed the following: -The facility did not document a risk assessment to identify at risk areas for Legionella growth; -The facility did not document water testing for at risk areas for Legionella; -The facility did not document facility specific measures taken to prevent the growth and/or spread of Legionella bacteria. During an interview on [DATE], at 2:56 P.M., the Infection Preventionist said she did not have anything to do with the Legionella monitoring and the Maintenance Supervisor is responsible. During an interview on [DATE], at 3:10 P.M., the Housekeeping Supervisor said the following: -He/she did not have any training on Legionella; -He/she did not know housekeeping's responsibilities regarding Legionella. During an interview on [DATE], at 3:47 P.M., Certified Nurse Aide (CNA) R said the following: -He/she did not have any training on Legionella; -He/she did not have any training regarding the importance of draining shower hoses after each use. During an interview on [DATE], at 3:50 P.M., CNA Q said the following: -He/she did not have any training on Legionella; -He/she did not have training regarding the importance of draining shower hoses after each use. During an interview on [DATE], at 3:55 P.M., the Maintenance Director said the following: -He did not test water for PH and chlorine to make sure no Legionella growth; -He did not know how often to test the water for Legionella growth; -He did not meet with the water management team to discuss Legionella; -The Administrator has studied on the Legionella program and will implement a new water plan soon. During an interview on [DATE], at 3:50 P.M., the Administrator said the following: -The facility did not do any routine Legionella testing yet; -The baseline form was not conducted yet for Legionella risks; -She started in [DATE] and revised the water management policy [DATE]; -No water management team and they have not met yet.

Based on interview and record review, the facility failed implement an antibiotic stewardship program when staff failed to adequately track eight residents currently on antibiotics for various infections in the facility by not completing a current and ongoing antibiotic log of residents with active infections, this failure could potentially place all residents at risk of infection. The facility census was 59. Review of the facility policy titled, Infection Control, General, revised on 02/18/24, showed: -It is the policy of the facility to ensure that the infection control program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, provide a safe, sanitary, and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with state and federal regulation, and national guidelines; -The facility will establish and maintain an infection prevention and control program under which it: prevents, identifies, reports, investigates, and controls the spread of infection and communicable disease in the facility; conducts surveillance for early detection of infections, clusters/outbreaks, and reportable diseases and to track and trend surveillance data; and decides when and how isolation should be applied to an individual resident; -The facility is to maintain a surveillance system with the capacity to identify possible communicable disease and infections before they can spread to other persons in the facility; -To identify infections the following information regarding residents is reviewed on an ongoing basis and information is to be communicated by staff in meetings (morning meetings) to the person responsible for infection prevention and control: signs and symptoms; laboratory and other diagnostic testing orders/results; new antibiotics starts; and new admission orders; -The local health department will be notified of all reportable diseases identified and of any clusters or outbreaks of any disease in accordance with state law. All clusters and or outbreaks will be investigated to identify breaches in infection control and or opportunities to improve current practices. 1. Review showed the facility did not provide an antibiotic log. During an interview on 03/01/24, at 2:56 P.M., the Infection Preventionist (IP) said the following: -He/she reviewed the physician orders to see which residents were on antibiotics about two times per week; -He/she did not track or document culture and sensitivity results or chest x-ray results; -He/she did not follow-up with residents during antibiotic administration or after completion to determine if the antibiotic was working; -He/she logged the infections from the previous month for the quality assurance and performance (QAPI - a data-driven, meeting to improve the quality of care, life, and services for the residents) meeting with facility department heads to discuss any trends of infections in the past month; -The Director of Nursing (DON) had the antibiotic log book which contained the monthly infection log. During an interview on 03/01/24, at 3:33 P.M., the DON said the following: -Staff had not completed the antibiotic log for February 2024. The IP and DON generally completed the log at the end of each month, but they had not had time to complete the February 2024 log; -At the end of each month, the IP or DON added the resident name, antibiotic information, and type of infection to the antibiotic log at the end of each month and highlighted different types of infections on a facility room map; -The log did not include information about resident culture/sensitivities. During an interview on 03/01/24, at 3:50 P.M., the Administrator said the following: -He/she expected the the IP or DON to track resident infections in real time and record on the antibiotic log as they are happening, so the staff can monitor for infection trends in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population when multiple flies were present in and around eight residents (Residents #54, #52, #41, #35, #2, #6, #46 and #57) and in resident common areas. The facility census was 59. Review showed the facility did not provide a pest control policy. 1 Review of Resident #54's face sheet (admission data) showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly minimum data sheet (MDS - a federally-mandated assessment form completed by facility staff), dated 01/05/24, showed the following: -Moderately impaired cognitive ability; -Required supervision of staff while eating; -Dependent on staff for toileting hygiene and showers; -Substantial/maximum assistance of staff with personal hygiene and dressing. Observation and and interview on 02/26/24, at 11:15 A.M., showed the following: -Resident flat on his/her back in bed in his/her room located on the A-hall; -Multiple flies buzzed around the resident and one fly crawled on the resident's arm; -The resident said, Yes, we have flies here. My family member put a fly strip up in my other room and it had a lot of flies on it, but staff said I couldn't have it. Observation and interview on 02/27/24, at 2:20 P.M., showed the following: -The resident sat in a recliner in his/her room with his/her feet elevated. Two flies buzzed about the resident with one fly crawling on the resident's left hand and another crawling on his/her face; -The resident said the flies were bad and bothered him/her; -The resident said, Flies get on my food and who wants to eat that. 2. Review of Resident #52's face sheet showed an admission date of 12/05/22. Review of the resident's annual MDS, dated [DATE], showed severe impaired cognitive skills. Observation and interview on 02/26/24, at 11:59 A.M., showed the following: -The resident sat on the side of his/her bed; -A fly buzzed around the room; -The resident said oh yeah when asked if the facility had flies. Observation and interview on 02/28/24, at 12:32 P.M., showed the following: -The resident ate lunch in his/her room; -The resident said a fly just got on his/her plate and he/she just wants the flies to find another home; -The resident said he/she did not have a fly swatter in the room due to someone took it to kill the flies. 3. Review of Resident #41's face sheet showed an admission date of 09/12/23. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident had no behaviors. Observation and interview in the main dining room on 02/27/24, at 9:45 A.M., during the resident council interview a fly buzzed around. The resident said he/she had been at the facility since September 2023 and there had only been a week or two that he/she has not seen flies. 4. Review of Resident #35's face sheet showed the admission date of 10/10/22. Review of the resident's quarterly MDS, dated [DATE], showed resident was cognitively intact. Observation and interview on 02/27/24, at 12:50 P.M., showed the following: -Resident lying on his/her bed in his/her room located on the A-hall; -Two to three flies buzzed around the resident; -The resident said that flies are a problem in his/her room and they bother him/her. During an interview on 02/29/24, at 4:10 P.M., Certified Medication Technician (CMT) V said the following: -He/she saw flies in a few of the resident rooms recently; -He/she saw a couple flies in the resident's room earlier today, on 02/29/24, but the resident refused showers/personal cares and that attracted the flies to his/her room. 5. Observation on 02/26/24, at 11:38 A.M. showed three flies on the window in Resident #2 and Resident #6's room. 6. Observation on 02/26/24, at 11:54 A.M., showed three flies on the exit door at end of the B hall (special care unit). 7. Observations on 02/26/24, at 12:00 P.M., showed the following: -A fly on the floor by the first dining room table in the (B Hall) special care unit dining room; -Resident #46 sat on the side of his/her bed eating lunch. A fly buzzed around the resident. 8. Observation on 02/27/24, at 12:19 P.M., showed Resident #57 sitting at the dining room table in the (B Hall) special care unit. A fly landed on his/her dining room table. The resident waved the fly away after it landed on his/her left hand. 9. Observation on 02/27/24, at 1:36 P.M., showed multiple flies buzzed around the dining room in the (B Hall) special care unit. 10. Observation on 02/28/24, at 12:47 P.M., in the hall beside the main dining room showed a 'bug' zapper not plugged in. 11. During an interview on 02/28/24, at 11:37 A.M., Certified Nurse Aide (CNA) H said the following: -The facility has a lot of flies; -The flies come in the entrance to the special care unit and the back door of the special care unit; -Flies are around the utility room located outside the entrance to the special care unit; -The facility has fly swatters in the dining room; -He/she did not know how the facility monitors the flies. 12. During an interview on 02/28/24, at 1:16 PM, Licensed Practical Nurse (LPN) A said the following: -The facility had an issue with flies; -He/she saw more flies due to the warmer weather; -The facility had some fly swatters and he/she tried kill some of the flies, when he/she could; -He/she reported the flies to the maintenance supervisor in the past, but was unsure what he/she did to fix the issue; -He/she encouraged staff to pick up food trays and trash timely and keep the rooms clean to help reduce the number of flies in the rooms and that helped. 13. During an interview on 02/29/24, at 2:56 P.M., Registered Nurse (RN) B said the following: -He/she notices flies some days more than others; -Staff should make sure trash is taken out and food trays are picked up to control the flies; -Staff should inform the housekeeping supervisor or maintenance staff know if staff notice flies. 14. During an interview on 03/01/24, at 12:15 P.M., the Director of Nursing (DON) said the following: -Flies come in the smokers door if it is open for a long period of time; -Flies gravitate toward odors; -The facility has pest control come out regularly to the facility; -She expects the flies to be controlled in the facility. 15. During an interview on 02/29/24, at 2:58 P.M., the Maintenance Supervisor said the following: -Staff report by word of mouth regarding pest issues. He did not know of any fly issues lately; -Staff should notify him if any pests or flies; -The pest control company comes to the facility monthly to treat; -There is a bug zapper on the D hall which is not plugged in. The zapper works, but a resident unplugs it. It is not effective to kill flies; -No staff or residents have informed him about fly issues; -He did not notice a fly problem in the facility; -He reports to the Administrator about calling pest control. 16. During an interview on 03/01/24, at 10:30 A.M., the Environmental Service Manager said the following: -She has seen some flies; -Staff and residents did not mention the flies as a problem; -She is not aware of preventions to keep flies from getting in the building. 16. During an interview on 02/29/24, at 3:27 P.M., the Administrator said the following: -She did not really notice a lot of flies; -Staff need to find a way to try and prevent the flies from coming in the building doors.

Based on interview and record review, the facility failed to provide all residents reasonable access to the use of a phone when the facility did not have a phone the one resident (Resident #56) could use to talk with family while on isolation precautions due to coronavirus disease 2019 (COVID-19- an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)). The facility census was 61. Record review showed the facility did not provide a policy related to providing forms of communication with privacy to every resident. 1. Record review of Resident #56's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 07/28/21; -Resident had a guardian; -No medical diagnoses listed. Record review of the resident's care plan, dated 9/15/21, showed the following: -Interventions related to cognitive function, dementia, or impaired thought process included keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion; -No medical diagnoses listed. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 11/6/21, showed the following: -Cognitively intact; -Independent with dressing, grooming, eating, and toileting. -Required supervision with bathing; -Diagnoses included alcohol induced persisting dementia (a deterioration of mental function resulting from the persisting effects of alcohol abuse), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), depression, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of the resident's nurse progress note dated 12/4/21, at 1:47 P.M., showed the resident tested positive for COVID-19. The nurse notified the resident's spouse. The nurse explained to the resident that his/her door needed to remain closed and he/she had to stay in his/her room. The nurse notified the Director of Nursing (DON). During an interview on 12/07/21, at 10:29 A.M., the resident said he/she tried to get staff to let him/her call his/her family member for two days, but no one would bring him/her a phone. He/she did not have a personal cell phone. During an interview on 12/08/21, at 1:52 P.M., the resident said he/she still had not been able to call his/her family member. During an interview on 12/09/21, at 3:50 P.M., the resident said he/she had asked facility staff several times and still had not been able to call his/her family member. During an interview on 12/10/21, at 11:15 A.M., the Activity Director (AD) said the following: -If a resident who resided in the special care unit (SCU) needed to make a phone call, staff assisted him/her to the nurses' station or at the phone on C Hall; -Before the resident contracted COVID-19, the resident called his/her spouse every night around 6:00 P.M. A staff member brought him/her out of the SCU and he/she used the phone on the C Hall; -The facility did not have a portable phone for the resident to use while he/she was on isolation precautions; -He/she obtained permission the other day to take his/her personal cell phone for the resident make a phone call. He/she took it down to him/her one day this week. The resident's family member said he/she would text the AD today when he/she would be available and the AD would take his/her personal cell phone down for the resident to use. During an interview on 12/10/21, at 1:00 P.M., Certified Nurse Aide (CNA) D said the following: -The resident had not asked him/her to use the phone. If he/she did, he/she would tell the resident he/she could not use his/her phone; -The facility had a phone outside of the SCU for residents to use, but they did not have a phone available in the SCU. During an interview on 12/10/21, at 1:52 P.M., Nursing Assistant (NA) E said no residents had asked him/her by to use the phone while working the SCU and he/she did not know if there was a phone for the resident's to use in the SCU. During an interview on 12/10/21, at 4:12 P.M., the Assistant Director of Nursing (ADON) said the following: -Staff assisted residents who resided in the SCU to the nurses' station (located outside of the unit's locked doors) to make a phone call; -In the past, residents used a phone in the SCU's TV area, but the residents kept calling 911 and staff had to remove the phone; -Before the resident contracted COVID-19, the resident called his/her spouse every day around 6:00 P.M. The ADON had not thought about the resident calling his/her spouse since they placed the resident on isolation; -The resident should be offered a staff member's personal cell phone to make the call because they can be sanitized; -The facility should have a phone that residents who are on isolation could access. During an interview on 12/10/21, at 6:22 P.M., the Administrator said the resident could use the AD's personal cell phone because they were related. During an interview on 12/10/21, at 7:04 P.M., the Administrator said he/she could not find a facility policy regarding forms of communication with privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to a hospital, including the reasons for the transfer, and failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification or monthly log showing transfers, for two residents (Residents #4 and #13). The facility census was 61. Record review showed the facility did not provide a policy regarding notifications upon transfer to a hospital. 1. Record review of the facility monthly Transfer/Discharge Log, dated March 2021, showed the following: -Resident #4 was transferred to the hospital on 3/12/2021 for an unplanned evaluation, admitted to the hospital, and returned to the facility on 4/1/2021; -The column marked Resident/Representative Notified in Writing was left blank. Record review of the resident's nurses' progress notes showed the following information: -On 3/12/2021, the resident experienced rapid temperature spike, increased pulse and respiration rate. Staff did not document information pertaining to a transfer out to the hospital; -On 3/23/2021, staff did not document information pertaining to a transfer to the hospital; -On 4/1/2021, staff documented resident returned to the facility post hospital stay since 3/23/2021, related to urinary tract infection and wound care. Record review of the resident's electronic medical record (EMR) and paper medical chart showed no copy of any written notice provided to the resident or resident representative regarding a transfer on 3/12/2021 or on 3/23/2021. 2. Record review of the facility's Transfer/Discharge Log, dated June 2021, showed the following: -Resident #13 was transferred to the hospital on 6/21/2021 for an unplanned evaluation, admitted to the hospital, and returned to the facility on 6/29/2021; -The column marked Resident/Representative Notified in Writing was left blank. Record review of the resident's nurses' notes showed the following information: -On 6/21/2021, staff documented the resident was transferred to the hospital for evaluation. Staff did not document regarding written notification provide to resident or representative; -On 6/29/2021, staff documented the resident returned to the facility. Record review of the resident's EMR and paper medical chart showed no copy of any written notice provided to the resident or resident representative regarding the transfer on 6/21/2021. Record review of the facility's Transfer/Discharge Log, dated September 2021, showed the following: -The resident was transferred to the hospital on 9/30/21 for an unplanned evaluation, admitted to the hospital, and returned to the facility on [DATE]; -The column marked Resident/Representative Notified in Writing was left blank. Record review of the resident's nurses' progress notes showed the following information: -On 9/30/2021, at 7:10 P.M., resident sent to the hospital related to rapid heart rate and elevated temperature. Staff did not document regarding written notification provide to resident or representative.; -On 10/8/2021, at 1:45 P.M., resident returned to the facility. Record review of the resident's EMR and paper medical chart showed no copy of any written notice provided to the resident or resident representative regarding the transfer on 9/30/2021. 3. During an interview on 12/09/2021, at 2:30 P.M., Licensed Practical Nurse (LPN) P and LPN A said they would call the physician for orders to transfer a resident to the hospital. They would call the responsible party, guardian, or emergency contact to notify them the resident was being transferred out to hospital. They were unaware of the requirement to issue a written notification to the resident and/or responsible party and the ombudsman. 4. During an interview on 12/9/2021, at 10:32 A.M., the Social Services Director (SSD) said the nurse would call the resident's responsible party to tell them if the resident was going to be sent out to the hospital, but said the facility did not send a written letter out. The SSD was not aware of a regulatory requirement to issue a written notification to the resident and/or responsible party and the ombudsman. He/she referred to a monthly log of residents transferred out and said the ombudsman used to call occasionally to ask for a list of residents transferred out, but they hadn't done that for awhile. He/she did not routinely fax the log to the ombudsman. 5. During an interview on 12/10/2021, at 3:06 P.M., the Administrator said when a resident is being sent out to the hospital, the nurse calls the resident's responsible party to advise them. A written notice is not issued. The administrator did not know if anyone was responsible for sending the monthly transfer log to the ombudsman.

Based on observation, interview, and record review the facility failed to identify, document on, and treat new non pressure wounds on the feet of one resident (Resident #45) in a timely manner. The facility's census was 61. Record review of the facility's Wound Prevention Program policy, undated, showed the following: -The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds; -Weekly skin checks will be conducted by the licensed nurse. This will be documented in the resident's Electronic Medical Record (EMR); -Daily, during routine care, the Certified Nursing Assistant (CNA) will observe the resident's skin. When abnormalities are noted this will be communicated to the licensed nurse and the licensed nurse will proceed as mentioned in step 2 and complete a Wound Event; -The facility complies with State and Federal guidelines as it relates to wound prevention and definitions. Adherence to these program is under the direction of the Director of Nursing (DON). 1. Record review of Resident #45's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 07/16/21; -No diagnoses listed. Record review of the resident's December 2021 physician order sheets showed the following: -An order, dated 7/20/21, to perform skin audit monthly on day shift on the 16th day of each month; -An order, dated 9/11/21, for a nurse to assess feet for new and/or acute skin issues daily at bed time. Record review of the resident's care plan, dated 9/22/21, showed the following: -The resident had an activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) self-care performance deficit related to a diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). The resident required physical assistance by one staff with showering twice weekly and as necessary; -On 09/11/21, the resident has a diabetic ulcer of the left dorsal (the area facing upwards while standing) foot. Avoid mechanical trauma such as tight socks or shoes, no cutting on feet with clippers, cutting and trimming corns and calluses, adhesive tapes, improper shaving or vigorous massage. Carefully dry between toes but do not apply lotion between toes. Determine and treat the cause such as poorly fitting shoes, poor blood sugar control, pressure area or infection. Ensure appropriate protective devices are applied to affected areas. Monitor blood sugars. Monitor pressure areas for color, sensation and temperature. Refer to foot care nurse or podiatrist. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 10/25/21, showed the following: -Cognitively intact; -Required assist of one person for bathing and supervision for all other ADLs; -The resident had no other ulcers, wound and skin problems and no foot problems such as infections of the foot, diabetic foot ulcers or other open lesions on the foot; -Diagnoses included Alzheimer's disease, dementia, high blood pressure, anxiety and diabetes. Record review of the resident's December 2021 physician order sheet showed the following: -An order, dated 11/30/21, to cleanse the ball of the right foot with wound cleanser, pat dry, and apply a thin layer of triple antibiotic ointment. Staff to cover with an island dressing. Observation and interview on 12/7/21, at 9:32 A.M., showed the following: -The resident said he/she had a wound on his/her right foot. He/she removed his/her sock and showed a gauze dressing, dated 12/6/21, loosely attached with tape, on the ball of his/her foot beneath the first toe. The resident lifted up the dressing and showed a nickel-sized wound covered with black/brown eschar (a dry, dark scab of dead skin); -The resident said he/she had another wound on his/her right foot. He/she gently separated his/her 4th and 5th toes and showed a small pea-sized opened wound with a pink wound bed and reddened skin surrounding the area. The resident said he/she tried to tell staff about this wound, but staff ignored it; -The resident removed the sock covering his/her left foot and showed a small, open, reddened wound near the toenail of his/her first toe and a small opened area on the first joint of his/her second toe. The resident said about a month ago, someone came to the facility and trimmed his/her toe nails causing the two small toe wounds; -The skin on both of his/her feet was dry and flaky. Observation and interview on 12/07/21, at 1:16 P.M., showed the following: -Licensed Practical Nurse (LPN) A entered the resident's room to provide wound care to the ball of the resident's right foot. -LPN A performed dressing change on the ball of the resident's right foot; The resident lifted his/her foot attempting to show LPN A the opened area between his/her fourth and fifth toe. LPN A told the resident she needed to complete the treatment that she prepared for and did not look at the opened wound between the resident's toes. The LPN completed the treatment, as ordered, to the bottom of the resident's left foot; -LPN A said she completed weekly wound assessments unless a wound care consultant treated the resident's wounds in which they would conduct the assessments; -The nurses did not complete general weekly skin assessments, but completed monthly skin audits (assessments). Record review of the resident's nurse progress notes, dated 12/01/21 to 12/10/21, showed staff did not document regarding the condition or wound on the resident's feet. During an interview on 12/10/21, at 9:19 A.M., Certified Nurse Aide (CNA) G said the following: -When he/she completed a resident's shower, he/she checked the residents body for bruises, scratches and any marks, and documented it on a shower sheet, he/she gave the completed shower sheets to the charge nurse; -The resident had a wound on the ball of his/her left foot. The CNA had not noticed any other areas on the resident's feet; -If he/she found a new wound, he/she would tell the charge nurse. During an interview on 12/10/21, at 9:45 A.M., CNA F said the following: -He/she documented bruises and other marks on the shower sheet and give the sheet to the charge nurse; -If the resident had a new area, he/she would tell the charge nurse and they assess the resident. Observation and interview on 12/10/21, at 10:33 A.M., showed the following: -LPN A and the Assistant Director of Nursing (ADON) entered the resident's room to assess the resident's feet; -LPN A described the wound on the ball of the resident's right foot as dry, scabbed and peeling. The resident clipped dry skin off his/her foot causing the wound; -LPN A assessed the wound on the resident's right foot, between his/her fourth and fifth toe, and described it as soft and open. LPN A said this was the first time he/she observed this wound; -The LPN assessed the resident's left foot and described the wound on his/her first toe, near the toe as pea-sized, scabbed with no drainage and the wound on his/her second toe as a pin-prick sized little scab. The resident said those areas were caused by the someone who clipped his/her toenails, about a month ago. LPN A said a podiatrist routinely visited the facility and clipped the resident's toenails; -The LPN said she would notify the physician of the new areas on the resident's feet. During an interview on 12/10/21, at 12:19 P.M., Registered Nurse (RN) B said the following: -If a CNA found a new area on a resident, he/she should tell the charge nurse or the wound nurse (LPN A); -The facility had a nurse assigned to wound care every day and night shift did wound treatments as well; -He/she did not know how often skin assessments were completed, but he/she had completed them at times upon admission of a resident to the facility. Whoever the facility assigned to the wound treatments was who completed the skin assessments. He/she believed he/she saw them come up on the TAR monthly; -He/she checked the resident's whole body when he/she completed a skin assessment; -If he/she found a new area on a resident, he/she tried to find out if it was a new issue. He/she asked the CNA's and the resident how the area happened. He/she had a bruise and skin tear investigation he/she filled out and told ADON and LPN A; -If the area was open, he/she would measure it, document it in the resident's chart and tell the ADON and LPN A. -He/she documented measurement, what the area looked like, any odors and if the wound had any drainage. He/she also notified the physician and the resident's family or responsible party; -He/she did not know what the ADON did with the bruise and tear investigations; -He/she looked at the resident's feet last weekend because the resident had an order for a treatment and to check the resident's feet daily for any new issues. He/she did not see any new areas on the resident's feet at that time; -If he/she found a new wound on a weekend, he/she contacted the physician, resident's family and tell LPN A on Monday. During an interview on 12/10/21, at 3:25 P.M., the resident said the following: -The area between his/her fourth and fifth toes had been there since he/she admitted . He/she had it at home and worked hard with his/her physician to get it healed. He/she had it healed before he/she admitted to the facility; -The areas on his/her left foot started around a month and a half ago after the podiatrist came to the facility and ground on his/her toes. During an interview on 12/10/21, at 4:00 P.M., LPN A said the following: -Skin assessments are scheduled in the electronic medical records program monthly and wound assessments weekly; -If anything the nurse completing the skin assessment found anything new when he/she completed the skin assessment, he/she should measure and assess the wound, call the physician for treatment orders and document in the nurse's notes. They should document measurement, general integrity, appearance of surrounding tissue, appearance of peri-wound, redness and if there is drainage and color of drainage; -The nurse on shift that finds the wound documented and notified the physician for orders and left the information in report; -He/she found out about new wounds if a new treatment showed in the TAR or through report; -He/she generally did a follow up assessment and documented in the treatment book; -He/she rounded with Wound Care Plus and document that in the resident's chart; -He/she asked the MDS Coordinator and ADON to create an assessment in PCC to be able to document weekly in one place and better track new wounds; -He/she did not know their policy instructed them (the nurses) to complete and document weekly skin assessments. -He/she asked for the facility's wound policies so he/she could review them further. During an interview on 12/10/21, at 4:12 P.M., the ADON said the following: -Nurses should complete skin assessments weekly but they currently completed monthly; -Nurses add an order for monthly skin assessments when a resident admitted . He/she did not know the facility's policy stated they were to complete skin assessments weekly; -If the treatment nurse found a new area when he/she completed a skin assessment, he/she should fill out an interdisciplinary team report. They have them available for bruise, pressure and skin tear but can just change the pressure to diabetic if it is. Anytime the nurse found an open or non-blanchable area, they are to fill out one of the forms and give a copy to the ADON or LPN A. If he/she was not at the facility, the nurse should slide the form under his/her door. If the wound is severe the nurse should phone the physician, if not, they wrote it in the physician book; -If the wound is pressure related the nurse puts it on the wound tracking but if non-pressure, the ADON and LPN A track it to ensure it is healing; -The nurse that found the wound should document size, color, odor, drainage and cause. If they cannot find a cause then they should report to Department of Health and Senior Services; -The treatment nurse was treating the area between the resident's fourth and fifth toes when they found the spot on his/her right metatarsal. The treatment on the wound between the right fourth and fifth toes started on 08/18/21 and they healed it on 10/09/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep one resident (Resident #56) free from possible harm by not supervising the resident while smoking as care planned and by not providing a receptacle to put used cigarette butts. The facility also failed to keep residents who reside in the special care unit (SCU) free from possible harm by not securing hazardous chemicals, cigarettes, and a lighter in a small storage room in the dining room. Fifteen residents resided on the SCU and the facility census was 61. 1. Record review of the facility's undated policy titled Smoking Policy showed the following: -It is the policy of Roaring River Rehab and Health to allow residents to smoke in designated areas; -Smokers will dispose cigarette butts in the appropriate available receptacles; -Residents who choose to smoke will be assessed upon admission, and quarterly thereafter, to determine if they are able to manage their smoking program independently; -If it is determined by the Smoking Assessment that the resident poses a danger to him/herself or others, the facility staff will confiscate any and all smoking items and paraphernalia from there resident and make it available for use by the resident only at specific times and/or under the supervision of the facility staff. Record review of Resident #56's face sheet (a document that gives a patient's information at a quick glance) showed the following: -The facility admitted him/her on 07/28/21; -He/she had a guardian; -No medical diagnoses listed. Record review of the resident's Smoking Assessment's, dated 7/28/21, showed the following: -The resident required one-on-one assistance with smoking due to being a flight risk and the resident required the facility to store his/her cigarettes and lighter. (The facility did not provide any other smoking assessments for this resident.) Record review of the resident's current care plan, dated 09/15/21, showed the following: -He/she was an elopement risk related to impaired safety awareness; -He/she had impaired cognitive function, dementia or impaired thought processes related to impaired decision making. The resident needed supervision with all decision making; -No medical diagnoses listed; -No mention of interventions related to smoking. Record review of the resident's Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 11/06/21, showed the following: -He/she was cognitively intact; -He/she required no assistance with his/her activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -His/her diagnoses included alcohol induced persisting dementia (a deterioration of mental function resulting from the persisting effects of alcohol abuse), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), depression and schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly). Record review of the resident's nurses' progress notes showed the following: -On 12/04/21, and 1:47 P.M., the resident tested positive for coronavirus (COVID-19- an infectious disease caused by the SARS-CoV-2 virus) this date on the rapid test twice. The nurse notified the resident's wife. The nurse explained to the resident that his/her door needed to remain closed and he/she had to stay in his/her room. He/she cannot go out to smoke at this time. The nurse offered the resident a nicotine patch and something for anxiety if needed. The resident stated That's just not going to work. The nurse notified the Director of Nursing (DON). During an interview on 12/07/21, at 10:39 A.M., the resident said the following: -He/she smoked out in the fenced in area; -Facility staff did not stay with him/her when he/she smoked; -Facility staff still took him/her out to smoke. Observation on 12/07/21, at 1:35 P.M. showed the following: -Certified Nursing Assistant (CNA) C escorted the resident from his/her room to the courtyard of the SCU (The fenced courtyard had a gate the resident could access to leave the area. No way to dispose of cigarette butts in the courtyard were observed.) and gave the resident his/her cigarettes and lighter and opened the door to let the resident outside to smoke; -CNA C stood inside and watched the resident who stood outside. The resident walked out of sight and did so. CNA C stated that the resident did that on purpose and moved to the other side of the door to try to see where the resident went. The CNA could not see the resident from that angle and did not attempt to go outside to observe the resident; -The resident came back into view and CNA C let him/her back into the facility and escorted him/her back to his/her room. During an interview on 12/07/21, at 1:45 P.M. CNA D said the following: -The resident puts his/her cigarette out and placed it on the edge of the concrete because there is not an ash tray for him/her to put them in. Observation on 12/07/21, at 1:50 P.M., showed no cigarette butts placed on the concrete outside the door in the SCU courtyard. Observation on 12/08/21, at 1:32 P.M., showed the following: -CNA D escorted the resident from his/her room to the SCU courtyard to smoke. The CNA gave the resident his/her cigarettes and lighter and opened the door for the resident to go outside. He/she left the resident outside and did not supervise the resident from inside the door; -At 1:34 P.M., CNA C saw the resident outside unsupervised and went to the door to watch the resident; -When the resident finished his/her cigarette, he/she extinguished it using his/her fingers and carried the cigarette butt inside into his/her room. During an interview on 12/08/21, at 1:40 P.M., CNA C said the following: -The resident placed his/her cigarette butts in the trash can in his/her room. Before the resident had COVID-19, he/she placed them in the trash can in the dining room. An observation and interview on 12/08/21, at 1:46 P.M., showed the following: -The resident said he/she brought his/her cigarette butts in and either flushed them or placed them in the trash can. Today, he/she flushed the cigarette butts because he/she did not want his/her room to smell like stale cigarettes; -He/she asked facility staff to get him/her an ashtray for outside but they had not provided one; -The staff in the SCU did not always supervise him/her when he/she smoked outside and he/she usually had to knock on the door a couple times to get the staff to let him/her in; -No cigarette butts observed in the trash can at this time. Observation on 12/09/21, at 3:33 P.M., showed the following: -CNA H escorted the resident to the special care unit (SCU) courtyard to smoke. The CNA had difficulty getting the door alarm to turn off and the resident had to show the CNA how to do this; -CNA H gave the resident his/her cigarettes and lighter and after the CNA left the resident unattended outside and left the SCU to go out to the main facility; -The resident stood within view outside and smoked his/her cigarette; -When the resident completed his/her cigarette, he/she put his/her cigarette out using his/her fingers and the concrete and attempted to get the attention of staff to let him/her back into the facility. CNA H came back onto the SCU and saw the resident wanted back inside and let him/her back into the facility. During an interview on 12/09/21, at 3:50 P.M., the resident said the following: -He/she placed his/her used cigarette butt in his/her pants pocket; -Facility staff are supposed to either go outside with him/her or watch him/her from inside while he/she smoked so he/she did not escape. During an interview on 12/09/21, at 4:03 P.M., CNA H said the following: -SCU staff let the resident outside to smoke and when he/she finished, he/she stood in front of the door so staff would know to let him/her in; -SCU staff are not required to supervise the resident while he/she was out smoking. During an interview on 12/10/21, at 9:19 A.M., CNA G said the following: -He/she usually went outside with the resident when he/she smoked but since the resident tested positive for COVID-19, the CNA watched the resident from inside the door; -The resident required supervision while he/she was out smoking because the resident could try to escape. The resident had talked about it; -There is not an ashtray available for the resident to put his cigarette butts in. The CNA took the cigarette butt from the resident and placed it in the red biohazard bag. Before the resident tested positive for COVID-19, he/she put the cigarette butts in the trash can in the dining room. The resident placed them there since he/she had been at the facility; -The resident should place the cigarette butt in an ashtray but they did not have one; -It is not safe for the resident to put the cigarette butts in the trash, but the resident did crumble the tobacco on the ends before he/she placed them in the trash. During an interview on 12/10/21, at 9:45 A.M., CNA F said the following: -He/she did not go outside with the resident to smoke, but watched the resident from inside; -If the resident wandered out of the CNA's view, the CNA would go outside to check on the resident; -He/she supervised the resident because the resident could escape. The resident had not tried to but sometimes the resident threatened to; -The resident placed his/her cigarette butts in the trash can and had since he/she admitted to the facility. There was not an ashtray in the courtyard for the resident and the CNA had not asked the facility administration for one. If the CNA asked for an ashtray, he/she would ask the charge nurse; -He/she made sure the resident extinguished the cigarette butt before the resident threw it in the trash by looking at the end of it; -Putting a cigarette butt in the trash was not safe because it could start a fire. During an interview on 12/10/21, at 12:19 P.M., Registered Nurse (RN) B said the following: -The CNA's on the SCU should walk the resident to the door, give him/her the cigarettes and lighter and watch the resident from inside the door; -If the resident walked out of view, the RN expected the CNA's to call for help or come and get him/her; -Before the resident had COVID-19, he/she expected the CNA's to follow the resident outside, but did not expect that since the resident had COVID-19; -He/she expected the CNA's to watch the resident because the resident did not want to be here and they are afraid he/she will run away. The resident had not tried to run away. During an interview on 12/10/21, at 1:00 P.M., CNA D said the following: -When he/she took the resident down to smoke, he/she gave the resident cigarettes and lighter and let the resident outside. They are required to watch the resident because the resident was on lock down and had to make sure the resident did not run down the road. The resident had not tried to escape; -The resident put his/her cigarette out and depending on the day, he/she either left it on the corner of the concrete or sometimes he/she handed the butt to the CNAs and they threw it in the trash. The resident did not take his/her cigarette butts back to his/her room; -The resident did not have access to an ashtray outside and the CNA had not asked facility administration for one because the resident said he could just put the cigarette out on the concrete; -If the resident put the cigarette completely out, it would be okay for him/her to throw in the trash. If it is not completely out it could start a fire; -The resident should not put the cigarette but in his/her pants pocket because if it is not completely out, it could burn him/her. During an interview on 12/10/21, at 1:21 P.M., the MDS Coordinator said the following: -He/she completed smoking assessments on the residents who smoke quarterly; -If a resident smoked it should be included in their care plan; -He/she had fallen behind on the assessments and had told the old administrator; -The resident should have his/her smoking care planned; -He/she should have completed another smoking assessment on the resident at the end of October, but had not completed it yet. During an interview on 12/10/21, at 2:01 P.M., Housekeeper (HK) I said the following: -He/she had not cleaned up any cigarette butts in the courtyard of the SCU and he/she had not seen any cigarette butts in the trash cans. During an interview on 12/10/21, at 4:12 P.M., the Assistant Director of Nursing (ADON) said the following: -Residents in the SCU smoked outside the back door in the courtyard; -He/she placed a metal coffee can outside for their cigarette butts; -When residents completed smoking, they should not place the cigarette butt in a trash can inside or outside the facility and should not place in their pocket. The trash can or the resident could catch on fire or the cigarette could burn the resident through the pocket; -He/she personally placed the metal coffee can back there and told the resident he/she would get the resident an ashtray. The resident told the ADON there was no place to put his/her cigarette butts when he/she admitted to the facility. The ADON planned to purchase an ashtray him/herself for the resident to use; -The CNAs should supervise the resident while he/she smoked due to him/her being an elopement risk; -If the resident walked out of view, he/she expected the staff to go out the door and follow the resident; -The only reason the CNAs are supervising the resident from inside right now is because the resident had COVID-19. The staff usually go outside with the resident. 2. Record review of the facility's undated policy titled Roaring River Health & Rehab Hazardous materials Policy showed the following: -The purpose of the policy is to inform the employees of the facility about possible hazards connected with materials in their workplace and about proper handling of materials used in the facility operations; -All staff is expected to follow these guidelines to ensure a safe working environment; conduct yourself in a safe and responsible manner when working with chemicals and hazardous materials; and keep hazardous material and chemicals locked in a storage cabinet to prevent contamination of resident areas. Record review of the Safety Data Sheet (SDS-a document that lists information relating to occupational safety and health for the use of various substances and products) for Neutral Disinfectant Cleaner, dated 08/24/20, showed the following: -Harmful if swallowed, in contact with skin, or if inhaled. Causes severe skin burns and eye damage. Record review of the SDS for Comet Deodorizing Cleanser with Chlorinol, revised 04/07/15, showed causes eye irritation. Record review of the SDS for Zep Concentrated Glass Cleaner, dated 05/20/99, showed the following: -Acute effects of overexposure: eye irritant. Eye contact may produce stinging, burning, inflammation, and in extreme cases injury to eye tissue may occur. Prolonged exposure to mists or vapors may be irritating to skin and upper respiratory tract. Over exposure can result in mild narcotic effects, including flushing, headache, dizziness and nausea. Record review of the SDS for Zep Shower, Tub & Tile Cleaner, revised 02/05/18, showed the following: -GHS H code (GHS hazard statement means a standard phrase assigned to a hazard class and category to describe the nature and severity of a chemical hazard. Each hazard statement is designated a code, starting with the letter H and followed by 3 digits) H314 causes severe skin burns and eye damage. Record review of the SDS for [NAME] Brands nail polish dryer, dated 01/19/18, showed the following: -Acute health effects: Prolonged or repeated skin contact may cause minimal irritation; direct eye contact may cause irritation; and ingestion may cause irritation. Record review of the SDS for Delta Brands Nail Polish Remover, dated 09/22/15, showed the following: -This chemical is considered hazardous by the 2012 Occupational Safety and Health Administration Hazard Communication Standard (29 CFR 1910.1200); -Hazard statements: causes eye irritation; may cause drowsiness or dizziness; and highly flammable liquid and vapor. Record review of the SDS for Turbo Kill, dated 08/03/15, showed the following: -Hazard statements: may cause skin and eye irritation. Observations of the storage room located in the SCU dining room, on 12/07/21 to 12/10/21, showed the following: -The storage room had two doors, both which opened on different sides of the U-shaped dining room. The door on the left had a key hanging above the door, the door on the right remained unlocked. The supply room contained a bottle of Comet deodorizing cleanser, an almost empty can of [NAME] Nail Polish Dryer and one bottle of Zep shower, tile, tub cleaner sat on a shelf above the sink. A mop and bucket partially obstructed the path to the sink. Immediately inside the door a small refrigerator and microwave sat on a two compartment shelving unit. Nail clippers, nail polish remover and nail polish sat in a caddy on a shelf below the refrigerator and microwave and a gray wash basin filled with various body sprays sat on the bottom shelf. A cigarette pack and a lighter belonging to Resident #56 sat on top of the refrigerator within easy reach. Hanging on the right side of the refrigerator was a bottle of streak-free glass cleaner, hanging on the left side of the refrigerator was a bottle of Neutral Disinfectant Cleaner and Turbo Kill disinfectant; -On 12/07/21, at 1:34 P.M., the right door was open. Staff were nearby in the hall, but not where they could visualize the door. Staff walked down the hall with a resident leaving the door opened and unattended; -On 12/8/21, at 11:15 A.M., the right door was opened and unsupervised. Staff were nearby in the hall attending to residents, the door was not in their direct line of sight. At 11:19 A.M.,CNA C walked by the opened door and saw the surveyor inside the storage room. The surveyor stepped out of the room and the CNA closed the door. The door remained unlocked. CNA D opened the left locked door, using the key hanging above the door. When he/she exited the room, he/she left the door ajar. At 11:21 A.M., CNA C entered the storage room and shut the left door, locking it. The right door remained unlocked. Staff were nearby in the hall but not where they could visualize the door. No residents were in the dining room or near the opened door; -On 12/09/21, at 12:00 P.M., the right door was ajar and the left door was locked and unsupervised by staff. Residents sat in the dining room waiting for their meal, staff served meals to residents eating in their rooms before serving residents in the dining room; -On 12/10/21, at 9:10 A.M., the left the door was unlocked and unsupervised. One resident sat in the dining room eating breakfast and another resident wandered around the dining room and into the hall immediately outside of the dining room. Staff attended to residents in their rooms or in the hallway, not in direct sight of the opened door. During an interview on 12/10/21, at 9:91 A.M., CNA G said the following: -He/she used the key hanging on the wall next to the door to the small storage room in the SCU dining room to unlock the door; -Residents sometimes attempt to wander into the closet to get juice or snacks; -He/she kept personal items in the closet; -SCU staff do not store cleaning supplies in that room. They store these items over in the housekeeping area; -Fingernail polish and fingernail polish remover should be stored in the television room. Staff should not leave them out on a table with residents present and staff not; -Staff should not leave the doors to the small storage room unlocked or open with residents present in the dining room, but staff not. During an interview on 12/10/21, at 9:45 A.M., CNA F said the following: -He/she used the key on the wall by the small storage room in the dining room to unlock that door. Staff should lock the doors to that room; -Residents sometimes wander in that room to get things; -Staff did not store any hazardous chemicals in that room. The spray he/she used to clean the tables was stored in that room, but the spray was not a hazardous chemical; -Staff stored Resident #56's cigarettes and lighter in that room on the top of a shelf where residents cannot see them; -Staff stored fingernail polish and finger nail polish remover in that room and they are hazardous chemicals. Staff should not leave them on a table with residents present and staff not; -Staff should keep both doors to the small storage closet locked and staff should not leave them open or unlocked with residents present and staff not. During an interview on 12/10/21, at 12:19 P.M., Registered Nurse (RN) B said the following: -Staff should keep the doors to the small storage room in the SCU dining room locked at all times; -Residents try to wander into that room; -Staff store a residents cigarettes and lighter in that room and residents did not need access to them; -He/she did not know if any hazardous chemicals were stored in that room; -Staff should not leave the doors unlocked or open when residents are present and staff are not; -Staff should not leave fingernail polish and fingernail polish remover unattended on a table with residents present. They are hazardous chemicals and residents on the SCU could not know what they are and attempt to drink them. During an interview on 12/10/21, at 1:00 P.M., CNA D said the following: -Staff locked Resident #56's cigarettes in the small storage room in the dining room in the SCU; -Staff kept disinfectants in that room along with clean linens; -If he/she found the room unlocked or open, he/she locked and closed the door; -Staff should not leave the doors to that room unlocked or open when residents are present and staff are not. During an interview on 12/10/21, at 3:07 P.M. Maintenance said the following: -He/she kept Safety Data Sheets in the kitchen and housekeeping; -He/she considered Zep streak free glass cleaner, Turbo, Comet, [NAME] professional nail dryer, Neutral disinfectant and Zep shower, tub and tile cleaner hazardous chemicals and should not be left in an unlocked or open room with residents present and staff not. During an interview on 12/10/21, at 4:12 P.M., the ADON said the following: -Staff should not leave the small storage room in the SCU dining room unlocked or open when residents are present and staff are not because hazardous cleaning chemicals, a microwave and mop bucket are kept in there; -He/she believed residents attempted to go into that room out of curiosity; -Staff should no leave fingernail polish and fingernail polish remover unattended on a table when residents are present because they are hazardous chemicals; -Staff should lock Resident #56's cigarettes and lighter in that room.

Based on observation and interview, the facility failed to ensure a clean homelike environment when staff failed to clean one cloth recliner and one cloth couch in the special care unit (SCU). The facility census was 61. 1. Observations of the SCU television room showed the following: -On 12/7/21, at 10:47 A.M., Resident #38 sat on a cloth recliner in the SCU television room. Several dried white spots, some crusted with white debris, stained the arms of the cloth recliner. -On 12/8/21, at 11:37 A.M., and 12/9/21, at 12:17 P.M., the cloth recliner had several dried white spots, some with crusty debris, on the arms and seat of the cloth recliner. The cloth couch had a dark liquid-type substance pooled on the seat of the couch that dripped down the front of the couch. Observation and interview on 12/9/21, at 3:40 P.M., showed the following the cloth recliner in the SCU television room, had several dried white spots, some with crusty debris, on the arms and seat of the recliner. The cloth couch in the SCU television room had a dark stain on the seat of the couch that extended down the front of the couch. Housekeeper (HK) R said when housekeeping staff started their shift, they obtained a housekeeping report sheet that listed cleaning duties for each specific hall. When the housekeeping staff completed a listed item, he/she marked it off the list. At the end of their shift, staff turned in the housekeeping report to the housekeeping supervisor. Housekeeping staff cleaned the SCU's television room every day. Cleaning consisted of wiping frequently touched surfaces and sweeping and moping the floor. Staff should also check the chairs and couch for cleanliness and clean as needed. During interviews on 12/9/21, at 3:45 P.M., and on 12/10/21, at 1:34 P.M., the Environmental Services Supervisor said a previous supervisor handwrote the specific cleaning expectations for each area of the facility on a piece of paper. She copied the paper for staff to use as guide. Most of the staff marked off each listed item when they completed the task. Staff gave her their completed reports. Staff should clean the chairs and couch in the SCU's television room daily. It was included on the housekeeper report sheet, but apparently staff did not always clean it. She ensured staff thoroughly cleaned a specific area by walking down the facility halls checking for cleanliness. During an interview on 12/10/21, at 1:00 P.M., Certified Nursing Assistant (CNA) D said the following: -If he/she assisted a resident to sit in the recliner or on the couch in the day room of the SCU, he/she tried to put a pad under them and night shift sanitizes the furniture; -The spots on the recliner and couch had been there since someone donated the furniture; -He/she had tried to clean the spots using washcloths. During an interview on 12/10/21, at 2:01 P.M., HK I said the following: -When he/she cleaned the day room in the SCU, he/she dumped the trash, swept crumbs off chairs, picked up items off the floor, swept, mopped, and wiped surfaces down; -He/she had not tried to clean the recliner and couch; -If he/she noticed spots on the couch and recliner, he/she would try to wipe them off. He/she saw crumbs on the recliner and couch and no spots; -Cleaning the couch and recliner was not part of his/her duties unless listed on the deep cleaning page. During an interview on 12/10/21, at 4:12 P.M., the Assistant Director of Nursing (ADON) said the following: -Housekeeping was responsible for cleaning the cloth couch and recliner in the SCU television room; -Plastic furniture should be wiped down with Sani-Cloth's (disinfectant cloth) by the CNA's and should be done every shift and after every resident; -He/she did not expect the furniture to be dirty; -If there is bodily fluids, such as bowel movement on the furniture, nursing staff was required to clean that up. If anything else, CNA's should call housekeeping; -Cleaning is housekeeping's role so he/she expected them to look at all the surface to see if needed cleaned.

Based on interview and record review, the facility failed to fully implement the facility's abuse prevention policies when staff did not check the Nurse Aide (NA) Registry prior to hiring four out of ten sampled staff (Registered Nurse (RN) N, [NAME] M, Business Office Manager (BOM) L, and Laundry Services O) to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility's census was 61. Record review of the facility's policy entitled Abuse Prevention, dated 2/18/2015, showed the following: -All applicable licenses or registries shall be called and verification of license obtained; -Written verification of the call shall be placed in the employee's permanent record; -In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), the Human Resources Department will conduct a background investigation that includes a criminal record check as well as personal reference checks on all employees making application for employment with this facility; -Should the reference check disclose any misrepresentation on the application form or information indicating that the individual is not suited for hire, the applicant will not be employed, or if already employed, will be terminated. 1. Record review of RN N's personnel record showed the following: -Hire date of 8/23/2021; -The facility staff did not check the CNA Registry to determine if RN N had a federal marker that would prohibit his/her employment at the facility. 2. Record review of [NAME] M's personnel record showed the following: -Hire date of 10/11/2021; -The facility staff did not check the CNA Registry to determine if [NAME] M had a federal marker that would prohibit his/her employment at the facility. 3. Record review of BOM L's personnel record showed the following: -Hire date of 11/19/2021; -The facility staff did not check the CNA Registry to determine if BOM L had a federal marker that would prohibit his/her employment at the facility. 4. Record review of Laundry Services O's personnel record showed the following: -Hire date of 12/2/2021; -The facility staff did not check the CNA Registry to determine if Laundry Services O had a federal marker that would prohibit his/her employment at the facility. 5. During an interview on 12/10/2021, at 8:20 A.M., the Human Resource Coordinator said she did not know she was supposed to check all employees for a federal indicator on the CNA registry. She had been checking only CNA's. 6. During an interview on 12/10/2021, at 8:45 A.M., the facility administrator said she was unaware the Nurse Aide registry was to be checked for all staff. She thought they only needed to check that registry for nurses and CNAs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have a system in place to provide consistent showers for two residents (Residents #48, and #56) who resided on the special care unit and one resident (Resident #4) who resided in the main facility. The facility census was 61. Record review showed the facility did not provide a bathing/showering policy. 1. Record review of Resident #48's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted to the facility on [DATE] and readmitted on [DATE]; -The resident had a responsible party; -Diagnoses included depression, cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain), and need for assistance with personal care. Record review of the resident's care plan, dated 8/4/21, showed the following: -The resident required assistance with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) related to weakness, disease process, and altered mental status. He/she would be clean, well-groomed, and appropriately dressed daily through the next ninety days. Staff to assist him/her with showers twice weekly and as needed. If he/she refused care, staff to approach at a later time and offer care; -The resident had an ADL self-care performance deficit related to dementia. The resident required limited assistance of one staff with showering twice weekly and as necessary. Staff to provide a sponge bath when a full bath or shower was not tolerated. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 10/28/21, showed the following: -Moderate cognitive impairment; -Required set-up assistance with bathing. Record review of the facility's undated B Hall shower schedule showed the following: -The resident scheduled for showers on Tuesdays and Fridays on the 6:00 A.M. to 2:00 P.M. shift. Record review of a calendar that certified nursing assistants (CNA) in the special care unit (SCU) documented completed showers on, dated November 2021 and December 2021, showed no showers completed for the resident. Record review of the resident's nurse progress notes, dated 11/01/21-12/10/21, showed staff did not document refusal of showers. Record review showed the facility did not provide any completed shower sheets or signed refusals of showers. During an interview on 12/10/21, at 9:19 A.M., CNA G said the following: -He/she always asked the resident if he/she wanted to take a shower, but the resident always said no and he/she could not force the resident to take one; -The resident would shower sometimes, but sometimes required two aides; -He/she did not have the resident on his/her shower schedule. Observation on 12/10/21, at 10:11 A.M. showed the following: -The resident entered the dining room with what appeared to be dried food particles around his/her mouth and in his/her facial hair; -The resident's hair was unkempt. During an interview on 12/10/21, at 1:00 P.M., CNA D said the following: -The resident refused to shower for him/her usually, but CNA G could get the resident to shower. During an interview on 12/10/21, at 4:10 P.M., the Assistant Director of Nursing (ADON) said the following: -The resident was hard to give showers to; -The resident used to have a physician's order for Ativan (a medicine used to treat anxiety) to be given as needed prior to showers. When the resident went to the hospital in September, they discontinued the order. The ADON spoke to the physician about the order; -The resident had a specific CNA that he/she liked, but the CNA was off due to illness. The ADON did not think the resident had showered since that CNA had been off. The CNA had been off for a month. 2. Record review of Resident #56's face sheet showed the following: -admitted to the facility on [DATE]; -He/she had a guardian; -No medical diagnoses listed. Record review of the resident's care plan, dated 09/15/21, showed the following: -The resident had an ADL self-care performance deficit. Staff to provide sponge bath when a full bath or shower would not be tolerated. The resident is able to shower with supervision for safety; -He/she had impaired cognitive function, dementia, or impaired thought processes related to impaired decision making. The resident needed supervision with all decision making; -No medical diagnoses listed. Record review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Required supervision for bathing; -His/her diagnoses included alcohol induced persisting dementia (a deterioration of mental function resulting from the persisting effects of alcohol abuse), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), depression, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of the facility's undated B Hall shower schedule showed the following: -The resident scheduled for showers on Mondays and Thursdays on the 2:00 P.M. to 10:00 P.M. shift. Record review of a calendar that CNAs in the SCU documented completed showers on for November 2021 and December 2021 showed staff did not document any showers completed the resident. Record review of the resident's nurses' progress notes, dated 11/01/21 to 12/10/21, showed staff did not document refusal of showers. Record review showed staff did not provide any completed shower sheets for the resident. Staff provided one undated refusal of a shower signed by the resident and CNA. The refusal was not signed by the charge nurse. During interviews on 12/07/21, at 10:34 A.M. and 12:00 P.M., the resident said staff did not offer showers regularly. He/she did not receive regular showers. He/she performed his/her own sink baths, at times, when staff did not take him/her to the shower. During an interview on 12/10/21, at 9:19 A.M., CNA G said he/she did not have the resident on his/her shower schedule. During an interview on 12/10/21, at 1:00 P.M., CNA D said the resident is on the evening shower schedule. He/she did not require any assistance, just supervision. During an interview on 12/10/21, at 4:10 P.M., the ADON said the following: -If the resident wanted a shower while he/she was isolated, he/she had to wear a N95 mask when going to the shower; -The resident refused showers often; -The CNAs should ask the resident what time he/she wanted a shower and offer the shower three times; -If the resident refused, the CNA should fill out a refusal form and sign and date it, attempt to get the resident to sign it, and have the charge nurse sign it. 3. Record review of Resident #4's annual MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Cognitively intact. Record review of the resident's electronic medical record (EMR) showed the resident's diagnoses included paraplegia (paralysis of the lower body, particularly the legs), right and left hand contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching), diabetes, anxiety, and depression. Record review of the resident's care plan, last updated 12/6/21, showed the following: -ADL self-care performance deficit and required extensive assistance of one staff for bathing. During an interview on 12/7/2021, at 2:08 P.M., the resident said he/she had only been getting one shower a week at the most. The resident said he/she felt dirty and would like at least two showers per week. Record review of the resident's shower sheets for November and December 2021, showed the following: -On 11/1/2021, the resident received a shower; -On 11/3/2021, the resident refused a shower, saying he/she was too sore that day; -The facility did not have provide any other shower sheets for that time period. During an interview on 12/10/2021, at 12:08 P.M., CNA D said the resident was generally cooperative with offered care, and sometimes he/she gave the resident a bed bath if requested. 4. During an interview conducted on 12/9/21, at 9:40 A.M., the ADON said in mid-November 2021, after the shower aide quit, she conducted shower audits. The CNAs who worked in the SCU assisted residents with showers. The aides should complete a shower sheet for each resident each time they assisted a resident with a shower. However, the aides documented when they assisted residents with showers on a calendar located in a binder in the SCU. 5. During an interview on 12/10/21, at 9:19 A.M., CNA G said the following: -The CNAs who worked on the SCU assisted the residents with showers. They did not have a shower aide; -They scheduled two residents for a shower in the morning and two residents in the evening; -When he/she completed a shower, he/she documented it on a shower sheet and gave the sheet to the charge nurse. If the resident refused, he/she just wrote refused on the shower sheet; -If a resident refused a shower, he/she told the oncoming shift so they can attempt again. If they refuse that shift they should tell the charge nurse. If a resident refused the CNA's tried another day; -They had a shower schedule posted in the small storage room in the SCU that told them which residents shower to complete on a certain day; -The aides took the resident's off the SCU for their shower and he/she did not know if they were allowed to take residents off the SCU right now due to positive cases of COVID-19 in the facility. 6. During an interview on 12/10/21, at 9:45 A.M., CNA F said the following: -CNAs who worked on the SCU were responsible for showers of residents in the SCU. They did not have a separate bath aide; -The aides on the SCU had a calendar on the inside of the door of the small storage room to tell them the scheduled residents for a specific day; -He/she completed a shower sheet when he/she completed a shower and gave the shower sheet to the charge nurse; -If a resident refused a shower, he/she told the charge nurse and tried again. If the resident refused again, he she told the charge nurse and documented the refusal on a shower sheet. 7. During an interview on 12/10/21, at 12:08 P.M., CNA Q and CNA D said since they no longer had a full-time bath aide, the evening/night shift staff gave most of the showers. The nurse would tell them if they needed to give showers on the day shift. They would tell the nurse if the shower was not completed, but did not document the information anywhere. 8. During an interview on 12/10/21, at 12:19 P.M., Registered Nurse (RN) B said the following: -The CNA's working in the SCU complete the showers for the SCU; -He/she expected the CNAs to get the resident's signature when they refused a shower even in the SCU and bring the shower sheet to the charge nurse; -He/she would try to get the resident to take a shower and if the resident still refused then he/she gave the shower sheet to the ADON; -The CNAs should fill out a shower sheet when they completed a shower and they are located in the shower book. 9. During an interview on 12/10/21, at 4:10 P.M., the ADON said the following: -CNAs who worked on the SCU were responsible for the showers on the SCU; -The CNAs had a shower schedule on the door of the small storage room in the SCU; -Residents should receive showers at least twice a week. If a resident wanted a shower every other day, they should get a shower every other day; -CNAs should document completed showers on a shower sheet and give the sheet to the ADON. He/she did not have the documentation that showed the residents in the SCU received showers. The CNAs did not document consistently; -CNAs on the SCU documented showers given on a calendar; -If a resident refused a shower, the CNA should document on a refusal form and tell the charge nurse; -The CNA should offer the shower three times and if the resident continued to refuse the CNA filled out a shower refusal sheet and signed and dated it, attempted to get the residents signature and the charge nurse signed it. The sheet should be given to the ADON and the nurse should document the refusal of a shower in the nurse's progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to routinely provide individualized and meaningful activities to the residents of the Special Care Unit (including Resident #38, Resident #45, Resident #48 and Resident #56) Fifteen residents resided on the SCU and the facility census was 61. Record review of the facility's undated policy titled Activities Meet Interest/Needs of Each Resident, undated, showed the following: -It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs; -The facility will provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. 1. Record review of the facility's activity calendars dated November 2021 and December 2021, showed the following: -The Activity Director (AD) scheduled three activities Monday through Friday and two to three activities Saturday and Sunday in 11/21 and 12/21; -On 12/06/21, scheduled activities included activity packets at 10:30 A.M., room visits at 2:00 P.M. and dietary discussion at 3:30 P.M.; -On 12/07/21, scheduled activities included national cotton candy day at 10:30 A.M., activity discussion at 2:30 P.M., and room visits at 3:30 P.M.; -On 12/08/21, scheduled activities included room visits at 10:30 A.M., activity packets at 2:30 P.M. and crafts at 3:30 P.M.; -On 12/09/21, scheduled activities included paper and donuts at 10:00 A.M., nails at 11:00 A.M. and shopping at 1:00 P.M.; -On 12/10/21, scheduled activities included Christmas crafts, room visits and paper bingo. The calendar did not have specified times for activities this date. Record review showed there was no separate activity schedule for the SCU. Observations in the SCU, on 12/6/21 to 12/10/21, showed there was no unit specific activities or a calendar of activities available to residents. A television was on in the resident sitting area. In the dining area in a small storage room, fingernail polish and remover were available for staff to perform nail care. In a closet in the resident sitting area, coloring pages, games, and puzzles were available to the residents. There was not a calendar of staff initiated activities. Observations on 12/7/21 showed the following: -At approximately 9:00 A.M., Resident #48 laid in bed, eyes closed. The room was dark, the curtains were pulled with no light;. -At 10:00 A.M., Residents #14, #25, #38, and #52 sat in the television room in the SCU. Resident #14 watched the television program playing on the television, the other three residents either dozed or looked around; -At 10:04 A.M., Certified Nurse Aide (CNA) D placed Resident #52's hands in his/her hands looking at his/her (the resident's) nails then placed the resident's hands back into his/her lap. CNA D said, all done. CNA E asked CNA D what he/she was doing and CNA D said he/she was doing nails. CNA E asked CNA D if he/she was going to paint the residents' nails and CNA D said no, he/she just filed them, they were long; -At 10:12 A.M., CNA E and CNA D wheeled Resident #38 from the television room to his/her room. After the resident finished toileting, staff wheeled him/her to the television room and assisted him/her into the recliner; -At 10:37 A.M., staff assisted Resident #52 from the television room to the bathroom. When finished, staff assisted him/her to the television room. He/she sat on the couch. Resident #38 sat in his/her recliner with his/her eyes closed. Resident #14 wheeled himself/herself out of the TV room and positioned himself/herself in front of the SCU's locked glass door. Resident #48, using his/her walked into the hall from his/her room, and asked for something to eat. Staff offered the health shake. The resident refused the shake, returned to his/her room and laid in bed; -At 10:44 A.M., Resident #48 walked into the hall, from his/her room, and asked staff if it was lunch time. Staff said no, but soon. The resident returned to his/her room and laid in bed; -At 1:52 P.M., Resident #38, #52, #25 and #32 sat in television room. Resident #52 and #25 sat on the couch, both with their eyes closed. Resident #32 and #38 sat in the recliners dozing, occasionally opening their eyes, then closing them. Observation on 12/7/21, at 2:25 P.M., showed the AD brought bags of cotton candy to the residents in the SCU. The activity consisted of asking each resident if they wanted cotton candy. Observations and interview on 12/8/21, at 1:50 P.M., showed the following: -CNA C sat at a table in the dining room with Resident #25 working a word search puzzle. Resident #43 wheeled into the dining room. CNA C asked Resident #43 if he/she wanted to do a word search. The resident looked at CNA C then wheeled away without answering; -Resident #48 sat at one of the tables in the dining room with an opened coloring book placed in front of him/her. The crayons, in a plastic box, was positioned on the table just out of reach. Resident #48 got up, walked to his/her room and laid down; -CNA C said the activity director just brought the word searches to the SCU. The SCU did not have a specific activity calendar. For activities, many of the residents like baby dolls and the CNAs also did the residents' nails. Observations and interviews on 12/9/21 showed the following: -At 3:40 P.M., CNA G took the plastic caddy that contained fingernail polish remover and various fingernail polish out of the supply closet and placed it on one of the dining room tables. CNA G said he/she was going to do the residents' nails. The CNA left the dining room to assist residents; -At 3:55 P.M., the plastic caddy remained on the dining room table untouched as CNA G continued to attend to residents' needs; -At 4:00 P.M., a CNA took the plastic caddy off the dining room table and returned it to the supply closet. Observations on 12/10/21 showed the following: -At 9:10 A.M., Resident #52 sat in the dining room, at a table by himself/herself, eating breakfast. Resident #48 laid in bed turned towards the wall. Resident #260 wandered the dining room and area near the locked SCU door; -At 9:18 A.M., Resident #52 finished eating. Staff removed his/her meal tray. The resident remained in the dining room -At 10:00 A.M., Resident #52 remained at the dining room table, in the dining room, with his/her eyes closed. Resident #45 walked up and down the hall. Resident #48 left his/her room and walked up and down the hall. 2. Record review of Resident #38's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 10/5/20; -Diagnoses included anorexia (lack or loss of appetite for food (as a medical condition)) and oral phase dysphagia (problems with using the mouth, lips and tongue to control food or liquid). Record review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 10/14/21, showed the following: -Severe cognitive impairment; -Required extensive assistance for dressing, grooming, toileting and locomotion on the unit; -Required limited assistance with eating; -The resident required a wheelchair for mobility. Record review of the resident's current care plan, dated 11/19/20, showed the following: -He/she had impaired cognitive function/dementia or impaired thought processes; -Engage him/her in simple, structured activities that avoid overly demanding tasks; -Provide a program of activities that accommodates his/her abilities; -He/she enjoyed listening to music and liked coloring and watching older movies. He/she liked the Walton's and Little House on the Prairie; -He/she enjoyed reading the Bible and listening to gospel music; -He/she liked to watch the birds and squirrels in the fenced in outside area and enjoyed being outside when the weather was nice. He/she really liked to see the flowers and he/she used to have a flower garden every year; -He/she really liked to watch family shows on television. The Golden Girls is one of his/her favorite shows. He/she did not like shows that have foul language; -He/she liked to hold stuffed toys and would often hold and rock a baby doll when given one; -He/she liked to help out and if he/she was restless, offer to her him/her help by asking him/her to fold laundry. He/she liked to fold towels and wash cloths and also enjoyed helping to clean things up. Staff to offer to let him/her wipe down his/her table after meals. He/she always prided him/herself on having a clean home so he/she liked to help clean. Staff to ask him/her to dust the hand rails in the hallway; -He/she often told stories about his/her life. Ask him/her about his/her children or his/her opinion on what to make for dinner. He/she loved children and cooking. He/she liked to share things he/she cooked; -Reminisce with the resident using photos of family and friends. Record review of the resident's Resident Interest Inventory, dated 10/10/21, showed the resident liked television, game shows, movies (comedy, romantic and western), talking books, newspapers, magazines, music (bluegrass and religious), bible reading, and small and large group activities. The resident needed reading materials read to him/her and enjoyed listening to books on tape. He/she liked to do crafts. Record review of the resident's daily activity attendance log, dated 11/10/21 to 12/09/21, showed the following: -The resident participated in seventeen out of eighty-one scheduled group and one-on-one activities from 11/10/21 to 12/9/21; -There were no documented refusals to participate in scheduled activities. Record review showed no activity progress notes in the resident's electronic medical record. During an interview on 12/10/21, at 9:45 A.M., CNA F said the resident liked to color and play with his/her doll. He/she also watched television. During an interview on 12/10/21, at 10:12 A.M., CNA G said the resident liked to play with baby dolls and the CNA also offered the resident coloring pages. The resident got bored with coloring and throws the crayons away. The resident enjoyed talking about family. During an interview on 12/10/21, at 11:15 A.M., the Activity Director (AD) said the resident liked the AD to read to him/her. He/she liked to visit about his/her family and to tell you what to make for dinner. He/she attended some social activities like a craft or ball toss, but the AD positioned the resident by the door and checked on him/her when there was a crowd. The resident liked to listen to books on tape. During an interview on 12/10/21, at 1:00 P.M., CNA D said the resident liked to be involved in activities some days and some days she did not. Sometimes he/she gave the resident a broom because the resident liked to sweep it around. 3. Record review of Resident #45's face sheet showed the following: -admission date of 07/16/21; -No diagnoses listed. Record review of the resident's current care plan, dated 9/22/21, showed the staff did not care plan related to the resident activity needs. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required staff supervision for dressing, grooming and toileting and total dependence for bathing; -Diagnoses included Alzheimer's disease dementia (a group of thinking and social symptoms that interferes with daily functioning) and anxiety. -Required limited assistance from staff for locomotion on the unit; -Required a walker for mobility. Record review of the resident's Resident Interest Inventory, dated 7/17/21, showed the resident liked television, variety shows, game shows and the news. He/she liked romantic movies and westerns. He/she liked to read the newspaper, Bible, westerns and magazines. He/she liked to write letters and had the AD mail them for him/her. He/she liked playing cards, guessing games and working puzzles such as cross words and word searches. He she liked bluegrass, religious and classical music. He/she liked to attend small group, large group and one-on-one activities. Record review of the resident's daily activity attendance, dated 11/10/21 to 12/10/21, showed the following: -The resident participated in seventeen out of eighty-four scheduled activities; -The resident declined activities on 11/23/21, but had no other documented refusals. Record review showed no activity progress notes in the resident's electronic medical record. Observations and interviews on 12/07/21 showed the following: -At 9:04 A.M., the resident sat on his/her bed, in his/her room playing solitaire. The resident said the SCU did not have any activities. -At 1:16 P.M., the resident sat on his/her bed playing solitaire. -At 2:25 P.M., the resident walked from his/her room towards the dining room. The AD brought bags of cotton candy to the SCU. The AD asked the resident if he/she wanted a bag of cotton candy and the resident said no, he/she was diabetic. The resident then walked to his/her room. Observations and interview on 12/8/21 showed the following: -At 11:20 A.M., the resident stood in the doorway of his/her room. The resident said right now, he/she did not leave his/her room very much due to the sickness. He/she liked to walk up and down the hall and outside for exercise; -At 11:37 A.M., the resident walked up and down the hall two times before returning to his/her room. During an interview on 12/10/21, at 9:45 A.M., CNA F said the resident liked to play cards and color. He/she participated in activities regularly. During an interview on 12/10/21, at 10:12 A.M., CNA G said the resident liked to color and play cards. The CNA offered the resident other activities at times. The resident liked to go outside sometimes. During an interview on 12/10/21, at 11:15 A.M., the AD said the resident would seek the AD out for activities. He/she liked to keep him/herself busy with crossword, word searches and coloring. He/she had a folder filled with activity pages that he/she liked to do. He/she would do anything the AD asked him/her to do. He/she liked to participate and loved the attention. During an interview on 12/10/21, at 1:00 P.M., CNA D said the resident was independent and told staff what he/she liked and did not like. He/she liked crosswords, coloring, walking and visiting in the television room. During an interview on 12/10/21, at 2:48 P.M., the AD said if the resident had mail, he/she told the CNA's and they let the AD know so he/she could mail it for him/her. On national cotton candy day, he/she discussed when it was invented and different ways to make it with the resident. During an interview on 12/10/21, at 3:25 P.M., the resident said the AD did not do a Christmas tree activity with him/her today. 4. Record review of Resident #48's face sheet showed the following: -admitted to the facility on [DATE] and readmitted on [DATE]; -Diagnoses included depression, cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain) and need for assistance with personal care. Record review of the resident's current care plan, dated 8/4/21, showed the following: -The resident had a short attention span during activities as evidenced by he/she came and left an activity while in progress. He/she forgets what activity is being performed and will verbally repeat to him/herself. Avoid overly demanding and long activities with the resident. He/she needed to attend brief, cognitively appropriate activities; -He/she enjoyed watching westerns and sports shows on television as well as enjoyed looking at car and truck magazines. He/she enjoyed talking about an amusement place he/she ran with his/her family where they had go carts; -He/she liked to sit in his/her room with the AD and talk about different things he/she did at the amusement place as well as different things they added as the business grew; -He/she liked to play cards as well as checkers and dominoes and liked to work on puzzles. He/she did better in small group activities due to him/her getting overstimulated. He/she liked one-on-one time with staff. He/she really enjoyed playing black jack, twenty-one, spades and other card games. He/she was very knowledgeable and would teach others to play with him/her. He/she knew the rules of the games and would remind others of them; -Place him/her close to the exit of an activity to allow him/her to come and go; -Staff should give verbal cues to him/her to help keep him/her on task during an activity; -If he/she refused activities or one-on-one, do not attempt to persuade him/her to participate due to his/her tendency to become aggressive. Record review of the resident's annual MDS, dated [DATE], showed the following: -The resident had moderate cognitive impairment. -Required no assistance from staff for transfers and toileting, supervision from staff for dressing, eating and personal hygiene and set-up assistance from staff for bathing; -Required supervision for walking and did not require a device such as a wheelchair or walker for mobility. Record review of the resident's Resident Interest Inventory, dated 4/4/17, showed the following: -He/she liked television, game shows, sports and car shows and western movies. He/she liked car magazines and the newspaper. He/she liked cards, checkers, dominoes, horseshoes and working puzzles. He/she liked bluegrass, religious, country and rock and roll music. He/she participated in small and large groups and one-on-one activities. He she liked woodworking, painting and drawing. Record review of the resident's daily activity attendance, dated 11/20/21 to 12/09/21, showed the following: -The AD provided two attendance lists for the resident. Both lists matched with the exception of 12/08/21 and 12/09/21. One showed on 12/08/21 the resident declined to participate and the other showed the resident participated in coffee and donuts. On 12/09/21, one showed the resident participated in coffee, newspaper and donuts and the other had no information for that date; -The resident participated in twenty-one out of eighty-one scheduled activities; -The resident declined to participate on 11/18/21 and possibly 12/08/21. No other refusals documented. Record review showed no activity progress notes in the resident's electronic medical record. During an interview on 12/10/21, at 9:45 A.M., CNA F said the resident liked to stay in bed and sometimes watched television in the day room. The CNA did not offer the resident activities because the resident liked for his/her lights to be out in his/her room. The CNA attempted to offer the resident a coloring sheet once but the resident walked away so the CNA had not offered any other activities to the resident. During an interview on 12/10/21, at 10:12 A.M., CNA G said the resident did not like to do activities. The resident refused, but the CNA continued to offer. During an interview on 12/10/21, at 11:15 A.M., the AD said the resident liked to look at cars and trucks. The AD took his/her laptop back and they looked up old cars on the computer. The resident liked to play cards and knew multiple games. The resident could teach staff how to play card games. During an interview on 12/10/21, at 1:00 P.M., CNA D said the resident did not like to stay in one spot and did not enjoy any activity besides sleeping. 5. Record review of Resident #56's face sheet showed the following: -admission date of 7/28/21; -No medical diagnoses listed. Record review of the resident's current care plan, dated 9/15/21, showed the following: -The resident had depression. Staff to assist the resident in developing a program of activities that is meaningful and of interest. staff to encourage him/her and provide opportunities for exercise and physical activity. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required no assistance from staff for dressing, transfers, toileting and personal hygiene and supervision from staff for bathing; -The resident was independent with walking and required no device such as a wheelchair or walker for mobility; -Diagnoses included alcohol-induced persisting dementia (a deterioration of mental function resulting from the persisting effects of alcohol abuse), dementia, depression and schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly). Record review of the resident's Resident Interest Inventory, dated 08/2/21, showed the following: -He/she watched a variety of television shows and movies. He/she liked police shows. He/she loved to read mystery and suspense novels. He/she liked playing cards, horseshoes and going to sporting events. He/she liked country music. He/she read the Bible and liked to keep a time log in a notebook. He/she participated in small and large group activities but preferred to do self-directed activities. He/she liked painting and drawing. Record review of the resident's daily activity attendance, dated 11/20/21 to 12/09/21, showed the following: -The resident participated in fifteen out of eighty-one scheduled activities; -He/she declined to participate on 11/27/21, 12/01/21, and 12/08/21, but no other documented refusals. Record review of activities progress notes in the resident's electronic medical record showed the following: -On 11/26/21, at 2:25 P.M., the resident went out of the facility with family for lunch. The resident had fun and returned to the facility without incident; -On 11/26/21, at 2:23 P.M., the resident went home with family for Thanksgiving. His/her temperature was taken and the resident signed in and out. During an interview on 12/07/21, at 10:29 A.M., the resident said the following: -He/she heard staff announce activities for the residents not on the SCU, but did not offer the same activities to the residents in the SCU; -He/she would participated in activities if staff offered them to him/her. During an interview on 12/09/21, at 3:50 P.M., the resident said staff had not offered any activities to him/her. During an interview on 12/10/21, at 9:45 A.M., CNA F said the resident never participated in activities. He/she liked to watch television or listen to music. The CNA offered the resident activities, but the resident refused. The resident liked to write in his/her book. During an interview on 12/10/21, at 10:12 A.M., CNA G said the resident did not want to do activities, he/she only wanted to smoke. Sometimes, he/she asked the resident if they wanted to go outside or to the greenhouse but the resident declined. During an interview on 12/10/21, at 11:15 A.M., the AD said the resident did not like to come out of his/her room for crafts, but liked to write in his/her notebook. The CNA's should ask the resident if he wanted to participate in activities and ask the resident if he/she needed a new notebook. The AD checked to see if the resident needed a new notebook as well. The resident liked to read. He/she refused activities at times. During an interview on 12/10/21, at 1:00 P.M., CNA D said the resident liked hanging out in his/her room and going outside to smoke. He/she felt trapped and had a negative attitude. The CNA did not offer him/her activities. He/she liked to walk in the hall before he/she had COVID-19. 6. During an interview conducted on 12/8/21, 1:55 P.M., CNA D said they did not have a specific SCU activity calendar. Activities on the SCU depended on the season. For example, the residents recently decorated the tree and hall with Christmas decorations. Residents also could work word searches and color in coloring books. Sometimes we (CNAs) sit in the television room and play ball with the residents but the activities depended on the residents' moods. The CNAs could assist with more activities on Tuesdays because they only had a few residents scheduled for showers. Staff did not usually document the activities. 7. During an interview on 12/10/21, at 9:19 A.M., CNA G said the following: -The SCU did not have a calendar of scheduled activities; -The CNAs who worked in the SCU were responsible for providing activities for the residents. -Some of the activities included puzzles, coloring, cards, and playing ball. Some participated and some did not while the residents watched television. The residents liked to color too; -Sometimes the AD came to the SCU to give the CNAs more supplies and sometimes the AD colored and played ball with the residents; -The CNA did not know where to find activity interests for each individual resident. 8. During an interview on 12/10/21, at 9:45 A.M., CNA F said the following: -When he/she started working in the SCU, the residents had activity calendars on their doors but activities stopped because of COVID-19; -The CNAs who worked in the SCU assisted residents with activities and the AD assisted at times too; -He/she saw the AD once a week, but he/she only worked two days a week; -He/she knew what the residents liked by if they enjoyed the activity he/she gave them to do. If they did not like that activity, he/she would try another. He/she did not know where to find specific likes and dislikes of the residents; -The CNA did not document activities because he/she had nowhere to document them. 9. During an interview on 12/10/21, at 11:15 A.M., the AD said the following: -He/she became the AD in 2017; -He/she completed a resident interest inventory within seven days of admission and then did his/her section on the MDS. He/she kept the resident interest inventory form in a binder in his/her office; -He/she tried to do a variation of the scheduled activity in the main facility with the residents in the SCU. He/she did not have a separate activity calendar for the SCU; -He/she did an activity daily in the SCU and jotted it down; -He/she made ornaments with the residents in the SCU this date; -He/she made activity packets for the SCU and in between activities the CNA's did puzzles and activities with the residents; -If he/she did an activity in the main area of the facility, he/she did an activity in the SCU as well; -He/she scheduled activity times in the main area of the facility, but he/she did not schedule times in the SCU; -He/she documented who participated in an activity in a notebook in his/her office and sometimes documented in a progress note in the resident's chart. He/she liked to document at least once a week either in the notebook in his/her office or in the resident's chart. He/she typically charted a one-on-one visit or special activity; -The care plan tells what activities the resident enjoys. He/she documented this in their care plan and the CNA's had access to the residents care plans; -The AD attempted to complete one-on-one activities with the residents in the SCU three times a week. 10. During an interview on 12/10/21, at 12:19 P.M., Registered Nurse (RN) B said the following: -The AD and the CNAs did activities in the SCU; -They set the residents up with coloring books or something to do; -The AD found out the residents likes and dislikes upon admission and passed that information along to staff; -The CNAs can look at the residents care plan that included activities or look at the AD's progress notes. 11. During an interview on 12/10/21, at 1:00 P.M., CNA D said the following: -CNAs usually do activities in the SCU. The AD gave the CNAs sheets to do with them; -The AD passed donuts and newspapers to the residents and asked the residents if they needed anything from the store. The CNAs completed most of the activities in the SCU and the AD helped by providing the supplies; -On 12/07/21, the AD colored with the residents in the SCU and did a crossword with a few of the residents; -Usually the residents who sat in the television room were okay with an activity going on. The residents that wander or stayed in their room did not like to participate in group activities; -He/she did not know how to find the residents likes and dislikes when it came to activities. He/she just took a trial and error approach; -He/she did not document who participated in an activity; 12. During an interview on 12/10/21, at 1:21 P.M., the MDS Coordinator said the following: -He/she, social services, activities, nursing, and dietary all completed the residents care plan; -The care plan included ADLs, discharge plans, if the resident had a guardian or not, activities the resident did, therapy, restorative nursing, resident likes and dislikes and behaviors. 13. During an interview on 12/10/21, at 2:48 P.M., the AD said the following: -Self activity included the resident writing letters, word searched and crosswords; -On National Cotton [NAME] Day, he/she made cotton candy and bagged it up into single servings. He/she discussed with the residents when it was invented and different ways to make it. He/she asked the residents on the SCU what their favorite flavor was. 14. During an interview on 12/10/21, at 3:24 P.M., CNA F said today, the AD came back to the SCU that day and made Christmas trees with the residents. 15. During an interview on 12/10/21, at 4:12 P.M., the ADON said the following: -The AD posted a calendar of activities in the SCU. The AD goes to the SCU at different times; -The CNAs in the SCU can generally get the residents to participate in activities; -The residents do a lot of coloring, puzzles, get their nails painted and occasionally paint. They decorate for every holiday; -The CNAs did not document when they complete an activity. The CNAs do not have a place to document activities; -The AD completed the admission assessment of the resident's likes and dislikes. The CNAs can also ask the resident's family what the resident liked. He/she tried to keep the CNAs consistent back in the SCU and they know the residents likes and dislikes; -He/she expected the same amount of activities in the SCU as the main area of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a a risk/benefit review and document alternatives attempted prior to bed rail use, failed to obtain informed consent for the use of bed rails, and failed to complete a bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for three residents (Residents #4, #10, and #34). The facility failed to care plan the use of the bed rail for one resident (Resident #4). The facility census was 61. Record review of a facility document entitled Procedure: Bedrails, date blank, showed the following information: -The facility shall provide adequate management of bedrails to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being; -The facility will attempt to use appropriate alternatives prior to installing a side or bed rail; -If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bed rails, including, but not limited to, the following elements: assess the resident for risk of entrapment from bed rails prior to installation; review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation; ensure that the bed's dimensions are appropriate for the resident's size and weight; and follow the manufacturer's recommendations and specifications for installing and maintaining bed rails; -When bed/side rails are requested by the resident/resident representative, the nurse will complete the Side Rail Evaluation; -When bed/side rails are deemed to be appropriate for the resident, upon completion of the Side Rail Evaluation, the nurse will review risks and benefits and obtain informed consent. Record review of a the facility document entitled Recommendations for Health care Providers about Bed Rails, undated, showed the following information was included: -Use the recommendations in the FDA (Food and Drug Administration) Guidance Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment; -Be aware that not all bed rails, mattresses, and bed frames are interchangeable and not all bed rails fit all beds. Check with the manufacturer to make sure the bed rails, mattress, and bed frame are compatible; -Avoid the routine use of adult bed rails without first conducting an individual resident assessment; -Follow the health care facility's procedure and/or manufacturer's recommendation/specifications for installing and maintaining bed rails; -Inspect and regularly check the mattress and bed rails to make sure they are still installed correctly and for areas of possible entrapment and falls. The bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body; -Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement or bed position, or by using a specialty mattress, such as an air mattress or mattress pad; -Attached nonbinding recommendations listed specific instructions for assessing each zone of the bed and bed rails. 1. Record review of Resident #4's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 8/19/21, showed the following: -admitted to the facility on [DATE]; -Cognitively intact. Record review of the resident's current care plan, last updated 12/6/2021, showed the following: -Activities of Daily Living (ADL) self-care performance deficit with extensive assistance of one to two staff to turn and reposition in bed every two hours. (Staff did not care plan the use of bed rails.) Observation and interview on 12/7/2021, at 2:05 P.M., showed the resident had half side rails in use on each side of his/her bed. The resident said the rails help keep him/her from rolling off of the bed, and he/she could use the side rails to help turn him/herself in the bed. Record review of the resident's electronic medical record (EMR) showed the following information: -Diagnoses included paraplegia (paralysis of the lower body, particularly the legs), right and left hand contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching), diabetes, anxiety, and depression; -Staff documented completion of a quarterly Side Rail Assessment on 8/30/2021; -Staff did not document risk education with informed consent or a bed rail safety gap check at the initial time of use. 2. Record review of Resident #34's quarterly MDS, dated [DATE], showed the following: -admission date of 12/31/19; -Cognitively intact. Record review of the resident's current care plan, last updated 12/6/21, showed the following: -ADL self-performance deficit related to musculoskeletal impairment; -Assistance of one to two staff to turn and reposition every two hours and when requested by resident; -Uses hand rails to maximize independence with turning and repositioning in bed. Observation on 12/7/2021, at 12:17 P.M., showed the resident had u-shaped grab bars (u-bars) in use on each side of his/her bed. Observation made on 12/8/2021, at 11:15 A.M., showed the resident used his/her u-bars for help in positioning him/herself during personal care. Record review of the resident's EMR showed the following information: -Diagnoses included post-polio syndrome (late reaction to polio virus: progressive muscle and joint weakness), paraplegia, and supra-pubic catheter (tubing placed directly into the bladder for draining into a collection bag); -Staff documented completion of a quarterly Side Rail Assessment on 10/25/2021; -Staff did not document risk education with informed consent or a bed rail safety gap check at the initial time of use. 3. Record review of Resident #10's quarterly MDS, dated [DATE], showed the following: -admission date of 11/19/19; -Cognitively intact. Record review of the resident's current care plan, last updated 9/16/2021, showed the following: -ADL self-performance deficit related to spina bifada (birth defect to the spinal cord that impairs mobility); -Used hand rails to maximize independence with turning and repositioning in bed. Observation on 12/7/21, at 12:25 P.M., showed the resident had u-bars in use on each side of his/her bed. During an observation and interview on 12/7/2021, at 1:32 P.M., the resident said he/she used the u-bars to reposition in bed. The resident demonstrated appropriate movement and gripping strength in both arms and hands. Record review of the resident's EMR showed the following information: -Diagnoses included Arnold Chiari Syndrome with spina bifida, paraplegia, and seizure disorder; -Staff documented completion of a quarterly Side Rail Assessment on 8/6/2021; -Staff did not document risk education with informed consent or a bed rail safety gap check at the initial time of use. 4. During an interview on 12/8/2021, at 4:34 P.M., the Maintenance Director said the following: -He/she went through every room monthly and checked every bed for side rails. He/she checked to see if the side rails were secure or if they needed repaired; -The former Administrator gave him/her paperwork they were supposed to start a couple of months ago, but did not provide instruction on how to complete the paperwork; -He/she did not do safety gap assessments; -He/she thought housekeeping or nursing installed the side rails, and then he/she checked them monthly; -He/she was not involved in a risk/benefit review or obtaining informed consent for the use of bed rails. 5. During an interview on 12/10/21, at 11:55 A.M., the Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) P said nursing staff places rails on a bed and the nurse notifies maintenance. He/she should complete an assessment to include gap measurements based on different zones of the bed. The ADON did not know if anyone had been provided with education regarding safety gap measurements and entrapment risk assessment. He/she said the nurse completed a Side Rail Assessment, but he/she was not aware of risk education given to residents/resident representatives or informed consents being completed. 6. During an interview on 12/10/2021, at 3:06 P.M., the facility Administrator said staff should be doing a risk assessment and educating the resident/resident representative on risks prior to installation of bed rails. Designated staff should complete and document safety gap measurements for all bed rails. The Administrator was not aware that the safety gap measurements were not currently being done and was not sure if staff obtained a signed consent for the use of bed rails.

Based on record review and interview, the facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility census was 61. Record review of a facility document entitled Director of Nursing (undated) , showed the following information: -Objective to maintain effective and efficient operations of the facility, to ensure resident provision of appropriate care, safety and optimal level of functioning; -Daily Tasks included be available at least, within the facility between the hours of 8:00 A.M. and 5:00 P.M., except for prearranged situations; on call for medical issues; review of physician orders against telephone and written orders; hall rounds to monitor resident care (at least twice daily); and monitoring of change of condition charting; -Weekly Tasks included weekly skin audit sheet completed and distributed to members by 3:00 P.M. on Wednesday; standard of care meeting facilitation and documentation; weekly lab tracking; Certified Nurse Aide (CNA) assignment sheets completed, copied and distributed for the next week; monitoring of weekly weights; and scheduling of all nursing personnel; -Monthly Tasks included monthly change out of medications checked against resident's medical record; pharmacy consultation follow up completed timely; dietary consultation follow up; monitoring of emergency drug box; monitoring of crash cart and emergency supplies; infection control education, documentation, tracking logs; and oversight of nursing supplies, inventory, and ordering; -Ongoing Tasks included in-service education training; recording of education events; employee evaluations; TB, flu, pneumonia provision and documentation; drug destruction log current; monitoring incontinence care, visual inspection, educational training, and compliance; monitoring of evening snacks, consumption totals, hydration pass, restorative program, psychotropic drug use, restrain reduction program, bowel and bladder program; and physician's requirement for documentation (annual Health & Physical, quarterly entry, etc.). (The document did not include qualifications required for the position.) 1. During an entrance conference on 12/6/2021, at 9:45 A.M., the facility administrator said the Assistant Director of Nursing (ADON), a licensed practical nurse (LPN), was currently acting as the DON. Record review of the Missouri State Board of Nursing license verification system showed the ADON held an unencumbered license as a practical nurse (expiration date 5/31/2022). The ADON did not hold a license as a registered nurse. During an interview on 12/7/2021, at 10:22 A.M., RN N said he/she thought the ADON was currently acting as a DON. RN N said the ADON, an LPN, was in nursing school and was scheduled to graduate in December and take his/her RN board testing in January. The ADON would then become the DON. During an interview on 12/10/2021, at 11:55 A.M., the ADON said he/she was aware of the regulatory requirement that the designated DON hold the license of RN. When he/she took on duties of the previous DON, approximately the end of September 2021, he/she thought it was understood (by the previous facility administrator) that the ADON was not allowed by regulation to act as the DON. The ADON said he/she was an LPN and would take board testing in January to transition to an RN. During an interview on 12/10/2021, at 3:06 P.M., the facility administrator said he/she was aware that the regulations require the DON to be a registered nurse. The administrator began the position on 11/8/2021. As allowed by the previous administrator, the ADON was currently performing duties usually assigned to the DON, would finish nursing school and take the RN board testing in January, and then become the DON.

2. Record review of the Interim Infection Prevention and Control (IPC) Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic on the CDC website, updated 09/10/21, showed the following: -Source control refers to use of respirators or well-fitting face masks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing; -Source control options for HCP include a National Institute of Occupational Safety and Health (NIOSH)-approved N95 or equivalent or higher-level respirator; or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering face piece respirators; or a well-fitting facemask. When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned. Record review of the facility's policy titled Coronavirus COVID-19 (Skilled Nursing Facility,) revised 10/29/20, showed the following: -To provide infection control guidelines to help protect and prevent the spread of Coronavirus COVID 19 within the facility by minimizing disease transmission among patients, visitors, and healthcare personnel. Prompt detection, triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel (HCP) and visitors; -COVID-19 is spread from person-to person with close contact (6 ft). COVID-19 is mostly transmitted via respiratory droplets when an infected person coughs or sneezes. These droplets land in the mouths or noses of people who are nearby or inhaled into the lungs; -Respiratory Protection-Put on a clean surgical mask prior to entering patient room. Change the mask if becomes wet or soiled; -For the duration of the state of emergency, all facility should wear a facemask while they are in the facility; -Residents confirmed or suspected with COVID-19 infection should wear a surgical face mask when being evaluated by health care personnel; -Ensure staff using N95 respirators are medically cleared and fit tested to confirm the N95 fits properly and the staff can safely wear it; -If N95 fit testing is unavailable, document all attempts to access fit test; -Employees will wear a surgical mask or homemade mask in the facility while on duty as recommended by CDC; -If facility outbreak occurs, all staff will be required to wear a surgical mask and/or KN95 if available. Homemade masks will not be allowed at this time. Observation on 12/08/21, at 12:12 P.M., showed the following: -Certified Nurse Aide (CNA) C wore an N95 mask that appeared altered. The two straps of the N95 that fit around the head, appeared cut and tied and worn behind his/her ears. (This caused the mask to not seal properly on the CNA's face.) He/she sat down with Resident #27, who was unmasked, to assist the resident with eating, realized the resident did not have a drink and got up to retrieve a drink for the resident; -The Activity Director (AD) wore an N95 mask that appeared altered. The two straps that should fit around the head appeared cut, tied and worn behind the ear (causing the mask to not seal properly on the AD's face.). He/she sat down within three feet of Resident #27, who was unmasked. The AD then stood up and hugged a resident, who was unmasked; -CNA D wore an N95 mask that appeared altered. The two straps that go around the head were cut, tied and worn behind his/her ears. The metal nose piece appeared pinched tight together, not around the nose, and the mask rested on the nose. The CNA walked through the dining room to check on the unmasked residents; -At 12:18 P.M., CNA C sat down within two to three feet of Resident #52 to assist the resident with eating. The CNA wore the altered mask and the CNA had a cough and, as reported by the CNA, a runny nose. CNA C asked the AD to assist with covering in the SCU while he/she took his/her COVID-19 test; -At 12:30 P.M., CNA C stopped assisting Resident #52 and left the SCU to take a COVID-19 test; -The AD sat down within two to three feet of unmasked Resident #52 to assist the resident with eating. The AD's N95 mask continued to not fit/seal properly; -CNA C returned from receiving his/her COVID-19 test at 12:34 P.M. and sat down next to unmasked Resident #27 to assist the resident with eating. CNA C sat within two to three feet and his/her altered mask; -CNA C's altered N95 mask did not fit appropriately. During an interview on 12/10/21, at 9:19 A.M., Certified Nurse Aide (CNA) G said the CNA's mask kept falling below his/her nose and was ill-fitting. Both straps of the N95 were around his/her head, but sat crossed and below his/her ears allowing the mask to ride down. During an interview and observation on 12/10/21, at 9:45 A.M., CNA F said the following: -He/she received his/her mask from the facility; -He/she had no training on how to put the mask on; -He/she cut the straps on the mask and tied the straps behind his/her ears, because he/she did not like the straps on his/her hair; -He/she learned how to cut the straps on his/her mask from other staff members and he/she saw other staff members doing this; -Facility administration had not told him/her to not cut the straps on his/her mask, but he/she did not think they could see that he/she altered the mask; -He/she should not alter the mask because the facility had positive COVID-19 cases; -The CNA's modified N95 mask did not sit and seal properly on the CNA's face. Observations and interviews on 12/10/21, at 9:19 A.M. and 10:12 A.M., showed the following: -CNA G's mask kept falling below his/her nose and was ill-fitting. Both straps of the N95 were around his/her head, but sat crossed and below his/her ears allowing the mask to slide down; -CNA G said he/she received his/her mask from the facility and got a new one daily. The facility trained him/her how to put the N95 mask on and take off at the start of COVID-19 in 2020. The mask should cover his/her nose and mouth and one strap should go around above the ears and one strap around the bottom towards the neck. The mask will not slide down as much if he/she wore his/her straps like that, but the mask felt itchy, so he/she had moved it around a lot. During an interview on 12/10/21, at 11:15 A.M., the AD said the following: -He/she received his/her mask from the facility and gets a new mask every day; -He/she received training from the facility on how to put N95 on at the beginning of COVID-19 back in 2020; -He/she should wear both straps of N95 mask around his/her head; -He/she had cut the straps on other masks that he/she has had; -Earlier this week, his/her mask on the one side broke and he/she tied it. If his/her mask broke, he/she tried to go get a new mask; -He/she had worn masks that he/she purchased and ran out of those masks earlier this week; -Facility staff should not cut the straps and tie behind their ears on the N95 masks because they won't get a tight fit. During an interview on 12/10/21, at 12:19 P.M., Registered Nurse (RN) B said the following: -He/she received his/her N95 mask at the front door of the facility; -Staff should wear N95 mask covering both their nose and mouth and both straps should go around their head; -Staff should not cut the straps of the N95 and tie them around their head, cut the bottom strap off or wear them with the bottom strap hanging below their chin; -He/she has seen some staff cutting their straps and when he/she does, he/she tells the staff to put a new mask on and wear it the right way; -He/she had not received training at this facility on how to put on the N95 mask. There is a teachable moments book at the nurses station that he/she had to review every day and sign, but did not know if there was education of how to put masks on in there. During an interview on 12/10/21, at 1:00 P.M., CNA D said the following: -He/she received his/her N95 mask at the front door of the facility and got a new mask daily; -The mask should cover the nose, mouth and under the chin and the straps should go over the head; -He/she should not cut the straps and tie behind his/her ears because the mask does not fit snugly that way; -He/she saw other staff doing this and asked them if it was okay to do and the other staff told him/her no, but altering the mask made it easier to breathe so he/she started doing it too; -He/she received education on how to wear a N95 mask during his/her orientation when he/she started working at the facility. There is a book for teachable moments at the nurse's station. When there is a new training, facility administration taped it to the desk and he/she read and signed it. There had not been a teachable moment on masks recently. During an interview on 12/10/21, at 1:52 P.M., Nursing Assistant (NA) E said the following: -He/she received his/her N95 mask from the facility's front lobby; -He/she should wear a N95 masks tight over nose and mouth at all times with no open areas and the straps should go around your head; -He/she sometimes cut the straps of his/her N95 mask and tied them behind his/her ears, because the mask pulled his/her hair down and fogged up his/her glasses; -He/she did not know if he/she should alter the N95 mask and no facility staff had told him/her not to do it; -He/she did not receive training on how to wear a N95 mask at this facility and there had not been a paper in-service on mask wearing. During an interview and observation on 12/10/21, at 2:01 P.M., Housekeeper (HK) showed the following: -HK I wore a N95 mask with the top strap around his/her head, the bottom strap hanging below his/her chin and a significant gap between the mask and neck area. -He/she received his/her N95 mask from the facility; -Another housekeeping employee that no longer worked at the facility told him/her that he/she could wear the N95 mask with the bottom strap hanging below his/her chin. He/she did not have to wear the lower strap around his/her head. He/she did not like to wear the bottom strap, because he/she can't breathe with it on. No facility staff had told him/her not to wear his/her mask with only one strap around his/her head; -He/she wore the N95 mask because the facility had residents positive with COVID-19 in the building; -If the mask had gaps, it still protected him/her, but did not protect the residents; -He/she received training from the facility on how to wear a mask back in 2020 when COVID-19 started. During an interview on 12/10/21. at 4:12 P.M., the ADON said the following: -The facility provided N95 masks at the front door and he/she expected the staff to get a new N95 mask every day; -Staff should wear both straps around their head and the fit should be snug and covering both their nose and mouth; -Staff should not modify the N95 masks. They should not cut the straps and tie them behind their ears. Staff should not cut the bottom strap off their N95 or leave the bottom strap dangling below their chin. He/she saw staff doing this at one time but had not seen it recently. When he/she saw it, he/she educated the staff member and had them put a new mask on; -He/she expected the charge nurse and supervisors to correct staff if they are wearing the N95 wrong and have the staff change their mask; -The last training he/she did on masking was a year ago. He/she educated on putting the mask on and off, checking for a tight fit and if the mask got wet to change it. This deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies dated . Based on observation, interview, and record review, the facility failed to provide an effective, thorough program for the prevention of the growth of the Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems.) in the facility water supply or where moist conditions existed. Additionally, the facility failed to maintain an effective infection control program when staff failed to wear N95 masks appropriately. The facility census was 61. 1. Record review of the Centers for Disease Control and Prevention (CDC) Toolkit for Legionella (officially titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings) showed that healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assess how much risk the hazardous conditions in those water systems pose; -Apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread; -Make sure the program is running as designed and is effective. Record review of the facility's policy titled Water Management Program, effective date of 12/11/17, showed the following: -Conduct a systematic risk analysis of hazardous conditions in the building water systems; -Determine the locations in the water system where control measures (such as using disinfectants like chlorine) are required; -Determine a range of acceptable levels for the control measures; -Monitor and log results of control measures for the identified areas at risk for contributing to Legionella; -Actions are to be taken include annual cleaning (when needed) of the shower heads and quarterly monitoring of the control limits (pH and chlorine levels). Corrective actions may need to be taken to bring measures back into the required established control limits; -The maintenance department shall conduct preventative maintenance which includes cleaning (visible buildup of dirt, organic matter, or other debris) and maintaining pumps and filters as recommended by the manufacturer. During an interview on 12/8/21, at 2:00 P.M., the Administrator said she had not reviewed the facility's Water Management Program. She also said she had not completed any steps related to the program to prevent the growth or spread of Legionella in the building. She was unaware of any staff taking any action to look for potential problem areas or taking other action to prevent the growth or spread of Legionella in the building. During an interview on 12/8/21, at 2:10 P.M., the Maintenance Director said he has not been involved, in any manner with the facility water management program. He said he has not been checking the building's water system in any way. He said the previous administrator told him she had the water management program taken care of herself and he didn't need to do anything. Since that time (precise date unknown), he has not had anything to do with the program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff developed, reviewed, and revised one resident's (Resident #58) comprehensive care plan to include an indwelling catheter (a sterile tube inserted into the bladder to drain urine) and catheter care. Staff failed to to revise a care plan for one resident (Resident #22) to remove precautions and care of a Jackson Pratt (JP -used to collect body fluids after a surgery) drain after removal. The facility census was 59. Record review of the facility's policy titled Care Plan, dated 2019, showed the following: -Documentation is a crucial aspect care, to plan and structure the highest standard of care and ensure there is a continuity of care; -On admission the initial care plan will be further developed to include more information and detail to produce a holistic person centered care plan; -Care plan will be reviewed regularly to make sure it continues to be necessary and relevant, and takes into account any improvements, changes, or deterioration in the condition of the resident; -The care plan must be reviewed more frequently when the resident condition changes or the resident changes there mind about anything on the care plan. 1. Record review of Resident #22's face sheet (a document that gives a resident's information at a quick glance) showed the following: -readmit date d 2/23/18; -Diagnoses included colitis (inflammatory bowel disease) with abscess, muscle weakness, peptic (stomach) ulcer, dementia (decline in memory or thinking and social symptoms that interferes with daily functioning), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder. Record review of the resident's care plan, dated 7/18/18 with revision date of 7/18/19, showed the direction to staff for the following; -Temporarily has a JP drain; -Avoid activities that involve bending or lifting; -Monitor the JP drain for excess drainage, odor, redness, swelling, and color around drain site; -The resident had methicillin-resistant staphylococcus aureus (MRSA - a difficult to treat cause of staph infection because of resistance to some antibiotics) at the JP drain site; -Thoroughly clean the drain site using disinfectants, and use give antibiotic therapy as ordered. Record review of the residents nurse's progress note dated 8/14/18 showed staff documented the residents JP drain was discontinued. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/19, showed the following information: -Cognitively intact; -Supervision required with transfers and self-care. During an interview on 6/5/19, at 9:25 A.M., Registered Nurse (RN) D said Resident #22 does not have a JP drain anymore and it should have been removed from the resident's care plan. During an interview on 6/5/19, at 11:30 A.M., the Director of Nursing (DON) said the following: -Staff should have updated Resident #22's care plan when the JP drain was discontinued; 2. Record review of Resident #58's face sheet showed the following: -admit date d 8/21/15; -Diagnoses included chronic interstitial cystitis (ongoing painful bladder condition), and history of urinary tract infections (UTI's). Record review of the resident's physician order sheets (POS) showed the following: -An order dated 3/18/19, the physician instructed staff to insert a Foley catheter (also know as an indwelling catheter); -An order dated 3/20/19, the physician instructed staff to provide catheter care every shift for the catheter. Record review of the resident's care plan, dated 7/23/18, showed direction for the following: -Dependent on staff for toileting needs; -Incontinence of bladder with a history of UTI's; -Sit the resident on the toilet and remind him/her to empty his/her bladder> (The care plan did not address the catheter or catheter care.) Record review of the resident's quarterly MDS dated [DATE], showed the following: -Severely impaired cognition; -Required extensive staff assistance for toilet use; -Required total staff assistance for personal hygiene; -Indwelling catheter. Observations on 5/30/19, at 10:12 A.M., showed the resident sat in a wheel chair and watched television. A catheter bag hung on the side of the wheelchair covered with a dignity bag. Observations on 5/31/19, at 12:32 P.M., showed staff assisted the resident from the dining room. A catheter bag hung on the lower edge of the wheelchair, covered with a dignity bag. During an interview on 6/5/19, at 8:30 A.M., RN D said the following: -The residents care plans should be updated when a residents has a catheter inserted; -Resident #58's care plan should show he/she has an indwelling catheter and should instruct staff to provide catheter care and monitor the resident's output. During an interview on 6/5/19, at 10:40 A.M., the MDS Coordinator said the following: -Care plans should be revised when a resident gets a catheter and should include catheter care, monitoring and the type of catheter. During an interview on 6/5/19, at 11:30 A.M., the DON said the resident's catheter care should be included on the resident's care plan. 3. During an interview on 6/5/19, at 9:20 A.M., CNA C said he/she looks at the care plans to find out how much care a resident needs when he/she is not sure. 4. During an interview on 6/5/19, at 10:40 A.M., the MDS Coordinator said the following: -He/She is responsible for creating and updating the residents' care plans; -Care plans are reviewed by the facility staff quarterly and are revised as needed when a resident has a change of condition. 5. During an interview on 6/5/19, at 11:30 A.M., the DON said residents' care plans should be updated whenever the resident has a change in status and should be reviewed quarterly.

Based on observation, interview, and record review, the facility failed to ensure staff administered two residents (Resident #24 and #36) rapid-acting insulin injections (medication to treat high blood glucose, usually taken before a meal to cover the blood glucose elevation from eating) timely. Twenty-nine medication opportunities were observed, resulting in an error rate of 6.9%. The facility census was 59. Record review of the Novolog (brand name of a rapid-acting insulin) insulin manufacturer's insert showed the following: -Novolog starts acting fast; -A meal should be eaten within five to ten minutes of taking a dose of Novolog; -Dosage adjustments may be needed in regards to timing of food intake. Record review of Medscape website (medical reference website for clinicians) showed the following: -This medication can cause hypoglycemia (low blood sugar). This may occur when enough calories are not consumed after taking the insulin within the time frame; -Older adults may be more sensitive to the side effects of low blood sugar from Novolog insulin. Record review of the facility's undated policy titled Medication Administration-Specific Insulin, showed rapid-acting insulin had an onset (when the insulin starts to work) of 15 minutes. 1. Record review of Resident #24's face sheet (a document that gives a resident's basic information at a quick glance) showed the following information: -admission date of 12/16/16; -Diagnosis of insulin dependent diabetes mellitus (IDDM - a chronic condition in which the body does not produce enough insulin). Record review of the resident's physician order sheet (POS) showed the following: -An order, dated 12/16/16, to administer Novolog insulin according to sliding scale (a progressive increase in the pre-meal insulin dose, based on pre-defined blood glucose ranges): -If blood glucose level is 70-130 milligrams/deciliter (mg/dL), administer no insulin; -If blood glucose level is 131-180 mg/dL, administer 4 units of insulin; -If blood glucose level is 181-240 mg/dL, administer 8 units of insulin; -If blood glucose level is 241-300 mg/dL, administer 10 units of insulin; -If blood glucose level is 301-350 mg/dL, administer 12 units of insulin; -If blood glucose level is 351-400 mg/dL, administer 16 units of insulin; -If blood glucose level is 401 mg/dL or greater, administer 20 units of insulin and notify the physician. Observations on 6/3/19 showed the following: -At 11:08 A.M., Licensed Practical Nurse (LPN) A administered four units of Novolog insulin according to the sliding scale (based on a blood glucose level of 174 mg/dL). The resident remained in his/her room; -At 12:24 P.M., staff served the resident lunch in his /her room (86 minutes after staff administered the Novolog insulin). 2. Record review of Resident #36's face sheet showed the following information: -admission date of 12/29/18: -A diagnosis of IDDM. Record review of the resident's POS showed the following: -An order, dated 2/3/19, to administer Novolog insulin according to sliding scale, based on pre-defined blood glucose ranges: -If blood glucose level is 70-130 mg/dL, administer no insulin; -If blood glucose level is 131-180 mg/dL, administer 2 units of insulin; -If blood glucose level is 181-240 mg/dL, administer 4 units of insulin; -If blood glucose level is 241-300 mg/dL, administer 6 units of insulin; -If blood glucose level is 301-350 mg/dL, administer 8 units of insulin; -If blood glucose level is 351-400 mg/dL, administer 10 units of insulin; -If blood glucose is 401-450 mg/dL, administer 15 units of insulin; -If blood glucose level is 451-500 mg/dL, administer 18 units of insulin. Observations on 6/3/19 showed the following: -At 11:16 A.M., LPN A administered the residents 4 units of Novolog insulin according to the sliding scale (based on a blood glucose level of 231 mg/dL). Staff assisted the resident to the dining room; -At 12:05 P.M., staff served the resident lunch. The resident began eating (49 minutes after staff administered the Novolog insulin). 3. During an interview on 6/3/19, at 10:55 A.M. LPN A said he/she starts administering the residents' insulin injections at 11:00 A.M. and staff start serving lunch at 12:00 P.M. 4. During an interview on 6/3/19, at 12:05 P.M., the Director of Nursing (DON) said the following: -She expects staff to provide rapid-acting insulin no longer than 30 minutes before the resident receives their meal; -Residents should receive food within 30 minutes after receiving a rapid-acting insulin injection; -She expects the nurses to monitor to assure the residents eat within 30 minutes of the injection; -Residents receiving insulin are not served their meals first; -The goal of the facility is to follow manufacturer's directions when administering insulin; -She had not reviewed the manufacturer's guidelines for rapid-acting insulin and was not aware of the recommendation of food within 15 minutes; -When a resident does not receive food within the manufactures guidelines after receiving a rapid-action insulin, they are at risk of their blood glucose level dropping. 5. During an interview on 6/5/19, at 8:35 A.M., Registered Nurse (RN) D said the residents should have food within 30 minutes of receiving a rapid-acting insulin. Insulin injections should be administered at 11:30 A.M. because lunch is served at 12:00 P.M. Residents who eat meals in their room should not receive insulin injections until the room trays are being prepared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a bed rail safety check and regular inspections of the bed frame and bed rails for risk of entrapment for two residents (Resident #1 and #29). The facility census was 59. Record review of the facility's policy titled, Restraints and Side Rails, dated 6/5/19, showed the following: -Side rails may be used as an enabler or positioning, bed control, or at a resident's request, but may not be used as a restraint. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 10/19/18; -Diagnoses included dementia (memory and judgment problems) with behavioral disturbance, schizoaffective disorder (mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms (mood swings ranging from depressive lows to manic highs)) and history of falls. Record review of the resident's nursing admit/readmit assessment, dated 10/19/18, showed the following: -Bed rails used on both sides of the bed; -Bed rails indicated for safety and to promote independence with bed mobility. Record review of the resident's quarterly Minimum Date Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/19, showed the following: -Severely impaired cognition; -Total staff assistance required for transfers; -Extensive staff assistance required for bed mobility; -Bed rails not used. Observations on 5/30/19, at 10:23 A.M., showed the resident in bed with the back of the bed against the wall and a half bed rail in the up position on the front of the bed. The bed rail was very loose with approximately six to eight inch gap of space between the mattress and the bottom of the bed rail. Record review of the residents' June 2019 physician's order sheet (POS) showed no physician order for bed rails. Observations on 6/3/19, at 9:50 A.M., showed the resident in bed with a half bed rail in the up position on the front of the bed. The bed rail moved loosely approximately six inches side to side and back and forth from the edge of the bed. Record review of the resident's medical record showed staff failed to document ongoing assessments or inspections of the bed frame and rails to ensure the bed rails were appropriate for use. During an interview on 6/4/19, at 3:14 P.M., Certified Nurse Assistant (CNA) G said the following: -Resident #1's bed rail should not move from side to side; -The side rail is too lose and could be a danger to the resident; -If a bed rail is not working or the rail is broken staff should report it to the charge nurse and fill out a maintenance ticket to be repaired. Record review of the resident's care plan, last revision dated 6/5/19 showed the resident used bed rails for positioning him/her self in bed. 2. Record review of Resident #29's face sheet showed the following: -admission date of 3/21/19; -Diagnoses included kidney failure, heart disease, high blood pressure and weakness. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Extensive staff assistance required with transfers and bed mobility; -Wheelchair used; -Bed rails not used. Record review of the resident's admit/readmit assessment, dated 3/21/19, showed the following; -Half bed rails on both sides of the bed; -Bed rails indicated for safety and to promote independence with bed mobility. Record review of the resident's May 2019 physician order sheet (POS) showed no physician's order for bed rails. Record review of the resident's current care plan showed bed rails was not care planned. Record review of the resident's medical record, on 6/4/19, showed staff failed to document the following: -A bed rail safety check form; -Regular inspections of the bed rails or bed frame. Observations on 5/31/19, at 9:15 A.M., showed the resident in bed on an air mattress with half rails in the up position on both sides of the bed. The right bed rail was loose and leaning on the air mattress towards the resident. Observations on 6/3/19 showed the following: -At 11:05 A.M., the resident in bed on an air mattress with both half bed rails in the up position. The right bed rail remained loose and leaning more inward towards the resident; -At 1:40 P.M., CNA B leaned over the loose bed rail to complete catheter care and the resident grabbed the loose bed rail to assist in rolling from side to side. During an interview on 6/4/19, at 3:25 P.M., Licensed Practical Nurse (LPN) A said the following: -Resident #29 uses the bed rail to roll side to side in the bed; -He/She was not aware Resident #29's bed rail was loose; -The bed rail was lose and needed to be repaired; -He/She notifies the charge nurse and maintenance staff know whenever a resident's bed rail needs to be repaired. 3. During an interview on 6/4/19, at 2:42 P.M., Registered Nurse (RN) E said the following: -He/She notifies the Directors of Maintenance or Housekeeping when there is a bed rail needing repairs or tightened; -He/She had not recently reported broken or loose bed rails; -The facility staff should assess bed rails for safety. 4. During an interview on 6/4/19, at 3:47 P.M., the Maintenance Director said the following: -The housekeeping supervisor installs bed rails when requested by nursing; -He/She does not complete bed rail assessments or measurements when installing new bed rails to the resident's beds; -He/She does not complete reassessments or maintenance logs for bed rails; -He/She was not aware of loose bed rails needing repair until today. 5. During an interview on 6/4/19, at 3:47 P.M., the Director of Nursing (DON) said the following: -The Maintenance director or housekeeping staff install the bed rails; -Staff should notify the Maintenance director when a bed rail needs repaired. 6. During an interview on 6/5/19, at 10:32 A.M., the housekeeping supervisor said the following: -Nursing lets him/her know when a resident needs a bed rail; -The bed rail is supposed to be no more than four inches from the mattress to prevent injury to the residents; -The facility staff look at the distance between the bed rail and mattress and estimate the distance but have not been measuring the distance; -He/She is aware of the possible entrapment risk for residents; -There is not a system in place to complete assessments, measurements, or regular maintenance checks for the resident's bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a side rail assessment, to include a risk/benefit review and alternatives attempted prior to use, to document ongoing side rail assessments, and/or failed to obtain informed consent for side rails for five residents (Resident #1, #15, #29, #48 and #57). The facility census was 59. Record review of the facility's policy titled, Policy for Restraints and Side Rails, dated 6/5/19, showed the following: -Side rails may be used as an enabler or positioning, bed control, or at a resident's request. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 10/19/18; -Diagnoses included dementia (memory and judgment problems) with behavioral disturbance, schizoaffective disorder (mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms (mood swings ranging from depressive lows to manic highs)), and history of falls. Record review of the nursing admit/readmit assessment, dated 10/19/18, showed the following: -Bed rails used on both sides of the bed; -Bed rails indicated for safety and to promote independence with bed mobility. Record review of the resident's quarterly Minimum Date Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/19, showed the following: -Severely impaired cognition; -Total staff assistance required for transfers; -Extensive staff assistance required for bed mobility; -Side rails not used. Observations on 5/30/19, at 10:23 A.M., showed the resident in bed with the back of the bed against the wall and a half bed rail in the up position on the front of the bed. The bed rail was very loose with approximately six to eight inch gap of space between the mattress and the bottom of the bed rail. Record review of the residents' June 2019 physician's order sheet (POS) showed no physician order for bed rails. Observations on 6/3/19, at 9:50 A.M., showed the resident in bed with a half bed rail in the up position on the front of the bed. The bed rail moved loosely approximately six inches side to side and back and forth from the edge of the bed. Record review of the resident's medical record showed staff failed to document the following: -An assessment for the use of possible alternatives prior to the use of bed rails; -An assessment for the risk versus benefits of bed rail use; -An informed consent for the use of bed rails prior to installation; -Ongoing assessments or inspections of the bed frame and rails to ensure the bed rails were appropriate for use. During an interview on 6/4/19, at 3:14 P.M., Certified Nurse Aide (CNA) G said staff should check the residents' care plan for instructions for side rail use. Resident #1 uses a side rail on the front of his/her bed. Record review of the resident's care plan, last revision dated 6/5/19, showed the resident used bed rails for positioning him/her self in bed. 2. Record review of Resident #48's face sheet showed the following: -admission date of 11/21/16; -Diagnoses included history of falls, dementia with behavioral disturbance, anxiety disorder, and expressive language disorder. Record review of the nursing admit/readmit assessment, dated 1/5/19, showed staff documented side rails were not indicated. Record review of the resident's significant change MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required limited staff assistance for transfers and bed mobility; -Side rails not used. Observations on 5/30/19, at 10:32 A.M., showed the resident in bed on an air mattress. The back of bed against the wall. A half side rail in the up position on the front of the bed. A fall mat was on the floor at the bed side. Record review of the resident's June 2019 POS showed no physician order for side rails. On 5/8/19, the physician instructed staff to apply an air mattress to the residents bed and to monitor for under or over inflation. Observation on 6/3/19, at 12:49 P.M., showed the resident in bed with a half side rail in the up position on the front side of the bed. Observations on 6/3/19, at 9:50 A.M., showed the resident in bed with a half side rail in the up position on the front of the bed. The loose side rail moved from side to side. Record review of the resident's medical record showed staff failed to document the following: -An assessment for the use of possible alternatives prior to the use of bed rails; -An assessment for the risk versus benefits of bed rail use; -An informed consent for the use of bed rails prior to installation; -Ongoing assessments or inspections of the bed frame and rails to ensure the bed rails were appropriate for use. During an interview on 6/4/19 at 3:14 P.M., CNA G said he/she is unsure if Resident #48 uses side rails. Record review of the resident's care plan, revision dated 6/5/19, showed the resident required half side rails for positioning in bed. 3. Record review of Resident #15's face sheet showed the following: -readmitted date of 11/27/18; -Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (paralysis or partial paralysis of one side of the body), convulsions, aphasia following a stroke (loss of ability to understand or express speech), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Extensive staff assistance required for transfers and bed mobility; -Wheelchair used; -Side rails not used. Record review of the resident's nursing admit/readmit assessment, dated 5/7/19, showed the following: -Side rails on both sides of the bed; -Side rails indicated for safety and to promote independence with bed mobility. Record review of the resident's May 2019 POS showed no physician's order for side rails. Record review of the resident's medical record showed staff failed to document the following: -An assessment for the use of possible alternatives prior to the use of bed rails; -An assessment for the risk versus benefits of bed rail use; -An informed consent for the use of bed rails prior to installation; -Ongoing assessments or inspections of the bed frame and rails to ensure the bed rails were appropriate for use. Observations on 6/03/19, at 12:15 P.M., showed the resident in bed with half rails on both sides of the bed in the up position. The resident used the side rails to move in the bed using his/her right hand. During an interview on 6/4/19, at 3:25 P.M., CNA B said Resident #15 uses the bed rails to move around in the bed. Record review of the resident's care plan, review dated 6/4/19, did not show the use of side rails. 4. Record review of Resident #29's face sheet showed the following: -admission date of 3/21/19; -Diagnoses included kidney failure, heart disease, high blood pressure, and weakness. Record review of the resident's nursing admit/readmit assessment, dated 3/21/19, showed the following; -Half bed rails on both sides of the bed; -Bed rails indicated for safety and to promote independence with bed mobility. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Extensive staff assistance required with transfers and bed mobility; -Wheelchair used; -Bed rails not used. Record review of the resident's May 2019 POS showed no physician order for bed rails. Record review of the resident's current care plan showed use of bed rails was not care planned. Record review of the resident's medical record showed staff failed to document the following: -An assessment for the use of possible alternatives prior to the use of bed rails; -An assessment for the risk versus benefits of bed rail use; -An informed consent for the use of bed rails prior to installation; -Ongoing assessments or inspections of the bed frame and rails to ensure the bed rails were appropriate for use. Observation on 6/03/19, at 11:05 P.M., showed the resident in bed on an air mattress with half side rails on both sides of the bed in the up position. During an interview on 6/4/19 at 3:25 P.M., Licensed Practical Nurse (LPN) A said Resident #29 uses side rails to assist in rolling from side to side. 5. Record review of Resident #57's face sheet showed the following: -admit date d 4/23/19; -Diagnoses included knee level amputation of the left leg. Record review of the resident's care plan, dated 4/23/19, showed the following: -Activities of daily living (ADL) self-care deficit due to weakness and disease process; -The resident used positioning rails and trapeze to maximize independence with turning and repositioning in bed. Record review of the resident's annual MDS, dated [DATE], showed the following: -No cognitive impairment; -Independent in eating and bed mobility; -Limited staff assist required for dressing and hygiene; -Extensive staff assist required for transfer and bathing; -Side rails not used. Record review of the resident's June 2019 POS showed no physician's order for a side rail. Record review of the resident's medical record showed staff failed to document the following: -An assessment for the use of possible alternatives prior to the use of bed rails; -An assessment for the risk versus benefits of bed rail use; -An informed consent for the use of bed rails prior to installation; -Ongoing assessments or inspections of the bed frame and rails to ensure the bed rails were appropriate for use. Observations and interview on 05/31/19, at 11:22 A.M., and on 6/3/19, at 12:00 P.M., showed side rails on both sides of the resident's bed. The resident said he/she uses them for shifting in bed. 6. During an interview on 6/4/19, at 2:42 P.M., Registered Nurse (RN) E said the following: -He/She has not processed any assessments for side rails in a while; -The Director of Nursing (DON) has a list of residents using side rails; -The bed rail assessment is included in the initial nursing assessment, but does not evaluate the use of side rails for safety; -Facility staff should complete an assessment for half and quarter side rails; -Staff should include side rails in the resident's care plans; -He/She was not sure if it was necessary to have a physician's order for side rail use. 7. During an interview on 6/4/19, at 3:30 P.M., the DON said the following: -Facility staff should complete an assessment for all side rails except for the grab bars (bed handle); -The only type of assessment being completed is on the initial assessment; -The initial side assessment addresses the purpose of the side rails, but does not assess the resident's safety with side rail use; -The residents should have their side rails assessed to ensure safety; -Staff should include the use of side rails in the resident's care plan. 8. During an interview on 6/4/19, at 3:47 P.M., the Maintenance Director said he/she does not complete an assessment when installing new side rails onto the residents beds. 9. During an interview on 6/5/19, at 2:30 P.M., the administrator said the following: -He/She was made aware of the issues concerning the resident that used side rails without a completed assessment; -The facility staff completed side rail assessments for residents with side rails starting on 6/4/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a rationale to continue an as needed (PRN) psychotropic medication (drugs that alter chemical levels in the brain which impact mood and behavior, used to treat mental illnesses) past 14 days for four residents (Resident #1, #9, #25, and #41). The facility census was 59. Record review of the facility's undated policy titled Medication Management showed direction for the following: -An order for anti-anxiety medication may be extended beyond 14 days if the physician believes it is appropriate to extend the order; -The physician should document the rationale for the extended time period in the medical record and indicate a specific duration. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admit date d 10/19/18; -Diagnoses included dementia (decline in memory or thinking and social symptoms that interferes with daily functioning) with behavioral disturbance, schizoaffective disorder (mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms (mood swings ranging from depressive lows to manic highs)), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of the residents' physician's order, dated 10/25/18, showed the resident's physician directed staff to administer Lorazepam (an anti-anxiety medication) 0.5 milligrams (mg) every four hours as needed (PRN) for anxiety and agitation. The PRN order did not show a stop date. Record review of the resident's November 2018 medication administration record (MAR) showed the following: -On 11/15/18, staff administered the resident's PRN Lorazepam; -On 11/16/18, staff administered the resident's PRN Lorazepam; -On 11/18/18, staff administered the resident's PRN Lorazepam; -On 11/19/18, staff administered the resident's PRN Lorazepam; -On 11/21/18, staff administered the resident's PRN Lorazepam; -On 11/23/18, staff administered the resident's PRN Lorazepam; -On 11/24/18, staff administered the resident's PRN Lorazepam; -On 11/25/18, staff administered the resident's PRN Lorazepam; -On 11/26/18, staff administered the resident's PRN Lorazepam; -On 11/27/18, staff administered the resident's PRN Lorazepam; -On 11/29/18, staff administered the resident's PRN Lorazepam; -On 11/30/18, staff administered the resident's PRN Lorazepam. Record review of the resident's December 2018 MAR showed the following: -On 12/1/18, staff administered the resident's PRN Lorazepam; -On 12/2/18, staff administered the resident's PRN Lorazepam; -On 12/6/18, staff administered the resident's PRN Lorazepam; -On 12/7/18, staff administered the resident's PRN Lorazepam; -On 12/9/18, staff administered the resident's PRN Lorazepam; -On 12/10/18, staff administered the resident's PRN Lorazepam; -On 12/11/18, staff administered the resident's PRN Lorazepam; -On 12/15/18, staff administered the resident's PRN Lorazepam; -On 12/16/18, staff administered the resident's PRN Lorazepam; -On 12/19/18, staff administered the resident's PRN Lorazepam; -On 12/27/18, staff administered the resident's PRN Lorazepam; -On 12/30/18, staff administered the resident's PRN Lorazepam. Record review of the resident's January 2019 MAR showed the following: -On 1/3/19, staff administered the resident's PRN Lorazepam; -On 1/6/19, staff administered the resident's PRN Lorazepam; -On 1/7/19, staff administered the resident's PRN Lorazepam; -On 1/15/19, staff administered the resident's PRN Lorazepam; -On 1/17/19, staff administered the resident's PRN Lorazepam; -On 1/20/19, staff administered the resident's PRN Lorazepam; -On 1/21/19, staff administered the resident's PRN Lorazepam; -On 1/23/19, staff administered the resident's PRN Lorazepam; -On 1/24/19, staff administered the resident's PRN Lorazepam. Record review of the resident's February 2019 MAR showed the following: -On 2/12/19, staff administered the resident's PRN Lorazepam; -On 2/21/19, staff administered the resident's PRN Lorazepam; -On 2/23/19, staff administered the resident's PRN Lorazepam. Record review of the resident's March 2019 MAR showed the following: -On 3/3/19, staff administered the resident's PRN Lorazepam; -On 3/5/19, staff administered the resident's PRN Lorazepam; -On 3/9/19, staff administered the resident's PRN Lorazepam; -On 3/10/19, staff administered the resident's PRN Lorazepam; -On 3/11/19, staff administered the resident's PRN Lorazepam; -On 3/12/19, staff administered the resident's PRN Lorazepam; -On 3/17/19, staff administered the resident's PRN Lorazepam; -On 3/25/19, staff administered the resident's PRN Lorazepam; -On 3/26/19, staff administered the resident's PRN Lorazepam; -On 3/29/19, staff administered the resident's PRN Lorazepam. Record review of the resident's April 2019 MAR showed the following: -On 4/9/19, staff administered the resident's PRN Lorazepam; -On 4/13/19, staff administered the resident's PRN Lorazepam. Record review of a pharmacist note, dated 4/18/19, to the residents attending physician, showed the following: -The resident received Lorazepam 0.5 mg every four hours PRN; -PRN anti-anxiety medications cannot exceed 14 days with the exception the prescriber documents a rationale in the residents' medical record and specifies the duration on the PRN order; -The physician documented to continue the same dose of Lorazepam. The PRN order did not show a stop date. Record review of the resident's quarterly Minimum Date Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/19 showed the following: -Severely impaired cognition; -An anti-anxiety medication received seven out of the previous seven days. Record review of the resident's May 2019 MAR showed the following: -On 5/2/19, staff administered the resident's PRN Lorazepam; -On 5/7/19, staff administered the resident's PRN Lorazepam; -On 5/10/19, staff administered the resident's PRN Lorazepam; -On 5/11/19, staff administered the resident's PRN Lorazepam; -On 5/14/19, staff administered the resident's PRN Lorazepam; -On 5/15/19, staff administered the resident's PRN Lorazepam; -On 5/16/19, staff administered the resident's PRN Lorazepam; -On 5/20/19, staff administered the resident's PRN Lorazepam; -On 5/21/19, staff administered the resident's PRN Lorazepam; -On 5/22/19, staff administered the resident's PRN Lorazepam; -On 5/23/19, staff administered the resident's PRN Lorazepam; -On 5/25/19, staff administered the resident's PRN Lorazepam; -On 5/30/19, staff administered the resident's PRN Lorazepam; -On 5/31/19, staff administered the resident's PRN Lorazepam. Record review of the resident's June 2019 MAR showed the following: -On 6/2/19, staff administered the resident's PRN Lorazepam; -On 6/4/19, staff administered the resident's PRN Lorazepam. Record review of the resident's care plan, dated 6/5/19, showed direction for staff to administer the anti-anxiety medication as needed. 2. Record review of Resident #41's face sheet showed the following: -admit date d 5/28/15; -Diagnoses included dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. Record review of the residents' physician's order, dated 3/1/19, showed the resident's physician directed staff to administer Ativan (an anti-anxiety medication) 0.5 mg every six hours PRN for anxiety. The PRN order did not show a stop date. Record review of a pharmacist note, dated 3/1/19, to the residents physician, showed the following: -The resident received Ativan 0.5 mg every 4 hours PRN since 7/30/18; -The physician directed staff to administer Ativan 0.5 mg every six hours PRN: -The physician did not document a rationale to continue the Ativan. The PRN order did not show a stop date. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -An anti-anxiety medication received seven out of the previous seven days. Record review of the resident's April 2019 MAR showed the following: -On 4/11/19, staff administered the resident's PRN Ativan. Record review of the resident's care plan, dated 5/01/19, showed direction for staff to administer the resident's anti-anxiety mediation as ordered. Record review of the resident's June 2019 MAR showed the following: -On 6/3/19, staff administered the resident's PRN Ativan. 3. Record review of Resident #9's face sheet showed the following: -admit date d 8/6/18; -Diagnoses included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of the residents' physician's order, dated 2/7/19, showed the physician directed staff to administer Lorazepam 0.5 mg every 4 hours as needed (PRN) for anxiety. The order did not have a stop date. Record review of the resident's care plan, dated 2/19/19, showed direction for staff for the following: -Psychotropic medication due to behavior management, neuropathic pain, depression and anxiety; -Discuss with the resident's physician and family the ongoing need for medication; -Review behaviors/interventions and alternate therapies attempted and their effectiveness; -Monitor and document any adverse reactions of psychotropic medications. Record review of the resident's February 2019 MAR showed the following: -On 2/21/19, staff administered the resident's PRN Lorazepam four times; -On 2/22/19, staff administered the resident's PRN Lorazepam four times; -On 2/23/19, staff administered the resident's PRN Lorazepam three times; -On 2/24/19, staff administered the resident's PRN Lorazepam three times; -On 2/25/19, staff administered the resident's PRN Lorazepam four times; -On 2/26/19, staff administered the resident's PRN Lorazepam two times; -On 2/27/19, staff administered the resident's PRN Lorazepam three times; -On 2/28/19, staff administered the resident's PRN Lorazepam one time. Record review of the resident's March 2019 MAR showed the following: -On 3/1/19, staff administered the resident's PRN Lorazepam two times; -On 3/2/19, staff administered the resident's PRN Lorazepam three times; -On 3/3/19, staff administered the resident's PRN Lorazepam three times; -On 3/4/19, staff administered the resident's PRN Lorazepam two times; -On 3/5/19, staff administered the resident's PRN Lorazepam three times; -On 3/6/19, staff administered the resident's PRN Lorazepam three times; -On 3/7/19, staff administered the resident's PRN Lorazepam two times; -On 3/8/19, staff administered the resident's PRN Lorazepam three times; -On 3/9/19, staff administered the resident's PRN Lorazepam three times; -On 3/10/19, staff administered the resident's PRN Lorazepam two times; -On 3/11/19, staff administered the resident's PRN Lorazepam four times; -On 3/12/19, staff administered the resident's PRN Lorazepam three times; -On 3/13/19, staff administered the resident's PRN Lorazepam two times; -On 3/14/19, staff administered the resident's PRN Lorazepam two times; -On 3/15/19, staff administered the resident's PRN Lorazepam two times; -On 3/16/19, staff administered the resident's PRN Lorazepam four times; -On 3/17/19, staff administered the resident's PRN Lorazepam three times; -On 3/18/19, staff administered the resident's PRN Lorazepam three times; -On 3/19/19, staff administered the resident's PRN Lorazepam three times; -On 3/20/19, staff administered the resident's PRN Lorazepam two times; -On 3/21/19, staff administered the resident's PRN Lorazepam three times; -On 3/22/19, staff administered the resident's PRN Lorazepam two times; -On 3/23/19, staff administered the resident's PRN Lorazepam two times; -On 3/24/19, staff administered the resident's PRN Lorazepam three times; -On 3/25/19, staff administered the resident's PRN Lorazepam two times; -On 3/26/19, staff administered the resident's PRN Lorazepam three times; -On 3/27/19, staff administered the resident's PRN Lorazepam three times; -On 3/28/19, staff administered the resident's PRN Lorazepam three times; -On 3/29/19, staff administered the resident's PRN Lorazepam three times; -On 3/30/19, staff administered the resident's PRN Lorazepam three times; -On 3/31/19, staff administered the resident's PRN Lorazepam three times. Record review of the resident's April 2019 MAR showed the following: -On 4/1/19, staff administered the resident's PRN Lorazepam three times; -On 4/2/19, staff administered the resident's PRN Lorazepam three times; -On 4/3/19, staff administered the resident's PRN Lorazepam four times; -On 4/4/19, staff administered the resident's PRN Lorazepam three times; -On 4/5/19, staff administered the resident's PRN Lorazepam three times; -On 4/6/19, staff administered the resident's PRN Lorazepam two times; -On 4/7/19, staff administered the resident's PRN Lorazepam three times; -On 4/8/19, staff administered the resident's PRN Lorazepam four times; -On 4/9/19, staff administered the resident's PRN Lorazepam three times; -On 4/10/19, staff administered the resident's PRN Lorazepam four times; -On 4/11/19, staff administered the resident's PRN Lorazepam four times; -On 4/12/19, staff administered the resident's PRN Lorazepam three times; -On 4/13/19, staff administered the resident's PRN Lorazepam four times; -On 4/14/19, staff administered the resident's PRN Lorazepam three times; -On 4/15/19, staff administered the resident's PRN Lorazepam three times; -On 4/16/19, staff administered the resident's PRN Lorazepam four times; -On 4/17/19, staff administered the resident's PRN Lorazepam four times; -On 4/18/19, staff administered the resident's PRN Lorazepam four times; -On 4/19/19, staff administered the resident's PRN Lorazepam four times; -On 4/20/19, staff administered the resident's PRN Lorazepam three times; -On 4/21/19, staff administered the resident's PRN Lorazepam three times; -On 4/22/19, staff administered the resident's PRN Lorazepam four times; -On 4/23/19, staff administered the resident's PRN Lorazepam two times; -On 4/24/19, staff administered the resident's PRN Lorazepam four times; -On 4/25/19, staff administered the resident's PRN Lorazepam four times; -On 4/26/19, staff administered the resident's PRN Lorazepam four times; -On 4/27/19, staff administered the resident's PRN Lorazepam four times; -On 4/28/19, staff administered the resident's PRN Lorazepam two times; -On 4/29/19, staff administered the resident's PRN Lorazepam four times; -On 4/30/19, staff administered the resident's PRN Lorazepam three times. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No mood or behaviors noted; -Independent with ADL's (routine activities people do every day without assistance, such as eating, using the bathroom). Record review of the resident's May 2019 MAR showed the following: -On 5/1/19, staff administered the resident's PRN Lorazepam three times; -On 5/2/19, staff administered the resident's PRN Lorazepam four times; -On 5/3/19, staff administered the resident's PRN Lorazepam four times; -On 4/4/19, staff administered the resident's PRN Lorazepam three times; -On 5/5/19, staff administered the resident's PRN Lorazepam three times; -On 5/6/19, staff administered the resident's PRN Lorazepam four times; -On 5/7/19, staff administered the resident's PRN Lorazepam three times; -On 5/8/19, staff administered the resident's PRN Lorazepam four times; -On 5/9/19, staff administered the resident's PRN Lorazepam four times; -On 5/10/19, staff administered the resident's PRN Lorazepam four times; -On 5/11/19, staff administered the resident's PRN Lorazepam three times; -On 5/12/19, staff administered the resident's PRN Lorazepam four times; -On 5/13/19, staff administered the resident's PRN Lorazepam four times; -On 5/14/19, staff administered the resident's PRN Lorazepam three times; -On 5/15/19, staff administered the resident's PRN Lorazepam four times; -On 5/16/19, staff administered the resident's PRN Lorazepam two times; -On 5/17/19, staff administered the resident's PRN Lorazepam four times; -On 5/18/19, staff administered the resident's PRN Lorazepam three times; -On 5/19/19, staff administered the resident's PRN Lorazepam three times; -On 5/20/19, staff administered the resident's PRN Lorazepam three times; -On 5/21/19, staff administered the resident's PRN Lorazepam four times; -On 5/22/19, staff administered the resident's PRN Lorazepam three times; -On 5/23/19, staff administered the resident's PRN Lorazepam three times; -On 5/24/19, staff administered the resident's PRN Lorazepam four times; -On 5/25/19, staff administered the resident's PRN Lorazepam three times; -On 5/26/19, staff administered the resident's PRN Lorazepam three times; -On 5/27/19, staff administered the resident's PRN Lorazepam three times; -On 5/28/19, staff administered the resident's PRN Lorazepam two times; -On 5/29/19, staff administered the resident's PRN Lorazepam four times; -On 5/30/19, staff administered the resident's PRN Lorazepam three times; -On 5/31/19, staff administered the resident's PRN Lorazepam three times. Record review of the resident's June 2019 MAR showed the following: -On 6/1/19, staff administered the resident's PRN Lorazepam three times; -On 6/2/19, staff administered the resident's PRN Lorazepam three times; -On 6/3/19, staff administered the resident's PRN Lorazepam three times; -On 6/4/19, staff administered the resident's PRN Lorazepam three times; -On 6/5/19, staff administered the resident's PRN Lorazepam two times. During an interview on 6/5/19, at 11:15 A.M., the resident said he/she takes a small dose of Lorazepam for his/her nerves. He/she cannot tell if it helps, but he/she can have it every four hours. During an interview on 06/05/19, at 11:22 A.M., Registered Nurse (RN) D said the resident shows signs of high anxiety and gets upset about things, mostly involving the residents spouse's care. The resident watches closely for the time he/she can have the anxiety medication. 4. Record review of Resident #25's face sheet showed the following: -readmit date d 12/10/2018; -Diagnoses included heart failure, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Record review of the residents' physician's order, dated 12/10/18, showed the resident's physician directed staff to administer Xanax (an anti-anxiety medication) 0.25 mg every four hours as needed (PRN) for shortness of breath, anxiety, and agitation. The PRN order did not show a stop date. Record review of the resident's December MAR showed the following: -On 11/15/18, staff administered one dose of the resident's PRN Xanax. Record review of the resident's January 2019 MAR showed the following: -On 1/15/19, staff administered one dose of the resident's PRN Xanax. Record review of a pharmacist note, dated 1/24/19, to the resident's attending physician, showed the following: -The resident received Xanax 0.25 mg every four hours PRN; -The pharmacist requested the physician evaluate the resident's current diagnosis, behaviors, and usage patterns to determine the continued need or the PRN Xanax; -PRN anti-anxiety medications cannot exceed 14 days with the exception the prescriber documents a rationale in the residents' medical record and specifies the duration on the PRN order; -The physician responded to continue the same dose of Xanax due to continued PRN anxiety. The PRN order did not show a stop date. Record review of the resident's February 2019 MAR showed the following: -On 2/25/19, staff administered one dose of the resident's PRN Xanax. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No mood or behavior concerns; -An anti-anxiety medication received seven out of the previous seven days. Record review of the resident's care plan, revision date 3/22/19, showed staff direction to staff for the following: -The resident has extreme anxiety and at times needs the PRN Xanax; -Administer PRN Xanax as prescribed when needed. Record review of the resident's April 2019 MAR showed the following: -On 4/1/19, staff administered one dose of the resident's PRN Xanax: -On 4/2/19, staff administered one dose of the resident's PRN Xanax; -On 4/30/19, staff administered one dose of the resident's PRN Xanax; Record review of the resident's May 2019 MAR showed the following: -On 5/8/19, staff administered one dose of the resident's PRN Xanax; -On 5/14/19, staff administered one dose of the resident's PRN Xanax; -On 5/28/19, staff administered three doses of the resident's PRN Xanax; -On 5/30/19, staff administered one dose of the resident's PRN Xanax. 5. During an interview on 6/5/19, at 8:13 A.M., Certified Medication Technician (CMT) F said the PRN anti-anxiety medications are generally on-going without stop dates. If there was a stop date it would show on the electronic MAR. 6. During an interview on 6/5/19, at 8:35 A.M., Registered Nurse (RN) D said the following: -The pharmacist makes a recommendation to the physician; -The physician should document a rationale in the resident's medical record if the medication is continued; -PRN anti-anxiety medication generally do not include a stop date. 7. During an interview on 6/6/19, at 12:05 P.M., the Director of Nursing (DON) said the pharmacist reviews the resident's medication regime monthly. The physician decides the duration for a PRN anti-anxiety medication. The physician generally does not order a stop date on PRN anti-anxiety medication. She is aware anti-anxiety should only be given for 14 days, unless the physician re-evaluates and writes a rationale for why the mediation is needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer the pneumococcal vaccine (vaccines used to prevent some cases of pneumonia, meningitis (swelling of brain and spinal cord membranes, typically caused by an infection), and sepsis (potentially life-threatening complication of an infection)) to four residents (Resident #30, #41, #44, and #62) following the residents' admission to the facility. The facility census was 59. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines are recommended for adults; -CDC recommends vaccinations with the pneumococcal conjugate vaccine (PCV13 or Prevnar13) for all adults 65 years or older and people 19 through 64 years with certain medical conditions, including chronic (ongoing) conditions; -CDC recommends vaccination with the pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax23) for all adults 65 years or older regardless of previous history of vaccinations with pneumococcal vaccines, and people 19 to [AGE] years old with certain medical conditions including chronic medical condition. Record review of the facility's policy titled Pneumonia Vaccinations, dated June 2019, showed the following: -Residents will be educated on the benefits and potential side effects of the vaccination; -Residents will be offered the vaccination, unless medically contraindicated or has received previously; -Residents have the right to decline the vaccination; -A physician order will be obtained for the pneumonia vaccine. 1. Record review of Resident #30's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 9/18/18; -Diagnoses included, dementia (mental decline that interferes with daily functioning), atrial fibrillation (an irregular heart beat), and atherosclerotic heart disease (a buildup of plaque in the arteries). Record review of the residents' physician order sheet (POS) showed and order dated 9/18/18 to administer the pneumonia vaccine per the facility policy if not contraindicated. Record review of the resident's immunization record showed the following: -Staff did not document the resident received a PCV13 or PPSV23 vaccine since admission; -Did not include documentation the resident received the PCV13 or PPSV23 prior to admission; -Staff did not document education of risks and benefits provided to the resident or responsible party; -Staff did not document a refusal for the vaccines. 2. Record review of Resident #41's face sheet showed the following: -admission date of 5/28/15; -Diagnoses included dementia with behavioral disturbances, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder. Record review of the resident's physician's order, dated 5/28/15, showed to administer the pneumonia vaccine per facility policy if not contraindicated . Record review of the resident's immunization record showed the following: -Staff did not document the resident received a PCV13 or PPSV23 vaccine since admission; -Did not include documentation the resident received the PCV13 or PPSV23 vaccine prior to admission; -Staff did not document education of risks and benefits provided to the resident or responsible party; -Staff did not document a refusal for the vaccines. 3. Record review of Resident #44's face sheet showed the following: -admission date of 7/2/16; -Diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe), heart disease, and diabetes mellitus II (DM II - chronic condition that affects the way the body processes blood sugar (glucose)). Record review of the resident's physician's order, dated 07/02/16, showed to administer the pneumonia vaccine per the facility policy if not contraindicated. Record review of the resident's immunization record showed the following: -Staff did not document the resident received a PPSV23 vaccine since admission; -Did not include documentation the resident received the PPSV23 vaccine prior to admission; -Staff did not document education of risks and benefits provided to the resident or responsible party; -Staff did not document a refusal for the vaccine. 4. Record review of Resident #62's face sheet showed the following: -admission date of 10/6/16; -Diagnoses included acute kidney failure, idiopathic pulmonary fibrosis (hardening of the lung tissue), peripheral vascular disease (PVD - poor blood circulation in the extremities), and DM II. Record review of the residents' physician order, dated 10/6/16, showed the physician directed staff to administer the pneumonia vaccine per the facility policy if not contraindicated. Record review of the resident's immunization record showed the following: -Staff did not document the resident received a PCV13 or PPSV23 vaccine since admission; -Did not include documentation the resident received the PCV13 or PPSV23 vaccine prior to admission; -Staff did not document education of risks and benefits provided to the resident or responsible party; -Staff did not document a refusal for the vaccines. 5. During an interview on 6/5/19, at 8:35 A.M., Registered Nurse (RN) D said the following: -Residents should be offered the pneumonia vaccine on admission; -Residents will be educated on the risks and benefits of receiving the pneumonia vaccine; -The resident or the responsible party sign a consent or refusal for the vaccines; -The vaccines will be given at the time the consent is signed when the resident consents to the vaccine; -The vaccines administered should be documented on the resident's immunizations record; -The facility offers one pneumonia vaccine, he/she is unsure which type is offered. 6. During an interview on 6/5/19 at 12:05 P.M., the Director of Nursing (DON) said the facility follows the CDC guidelines for pneumonia vaccinations. The facility policy reflects the CDC guidelines. She expects staff to offer the pneumonia vaccines to all residents on admission to include education on the risks and benefits of receiving the vaccine. The resident or responsible party should sign a consent or a refusal for the vaccines and it will be a part of the resident's medical record. She expects the nurse giving the immunization vaccine to document the vaccine on the resident's immunization record. She tracks the immunization vaccines given in a log book. If the immunization record is blank, then the resident did not receive the vaccine.

Based on interview and record review, the facility failed to provide an effective, thorough program for the prevention of the growth of the Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems.) in the facility water supply or where moist conditions existed. The facility had a census of 59. According to the CDC Toolkit for Legionella (which is officially titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings) showed that healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assess how much risk the hazardous conditions in those water systems pose; -Apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread; -Make sure the program is running as designed and is effective. 1. Record review of the facility's undated policy titled Water Management Program, showed the following: -Conduct a systematic risk analysis of hazardous conditions in the building water systems; -Determine the locations in the water system where control measures (such as using disinfectants like chlorine) are required; -Determine a range of acceptable levels for the control measures; -Monitor and log results of control measures for the identified areas at risk for contributing to Legionella; -Actions are to be taken include annual cleaning (when needed) of the shower heads and quarterly monitoring of the control limits (pH and chlorine levels). Corrective actions may need to be taken to bring measures back into the required established control limits. -The maintenance department shall conduct preventative maintenance which includes cleaning (visible buildup of dirt, organic matter, or other debris) and maintaining pumps and filters as recommended by the manufacturer. During an interview on 6/5/19, at 5:15 P.M., the administrator said the following: -The facility identified risk areas in the building to monitor for Legionella risks as: shower 1 (between Aspen and Birch halls), the break room, the beauty shop, and the greenhouse fountain; -She tests areas around the facility with test strips. Every week she tests about four locations (rooms) in the building - these include all rooms, not just those identified as risk areas. The test strips test for total bromine, free chlorine, alkalinity, pH level, total hardness of water; -She uses the test strips because it is what the prior administration used. Although the bottle had guidance for recommended levels, she was unsure what corrective actions to take if the test strips indicated water was outside the recommended levels; -She was not aware of appropriate levels (pH and chlorine) to prevent Legionella growth; -She identified the primary risk areas in the building, and was unaware of other areas of high risk.