**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a discharge summary was completed, including a recapitulation of the resident's stay and final summary of the resident's status at the time of discharge (Resident #7). The sample was 14. The census was 168. Review of the discharge or transfer policy, dated January 2021, showed: -Purpose: -To provide prompt and safe discharge/transfer of a resident from the facility and to ensure continuity of care through provisions of pertinent resident information; -To provide orientation for a resident being discharged /transferred to ensure a safe and orderly transition home or to a new living environment; -Procedure: -A discharge summary observation will be completed for all residents who: -Discharge to a private residence/home or independent retirement community; -Transferred to another facility; -The nurse will obtain an order from the physician for transfer/discharge or a resident as well as release of medications; -discharged to residence/home or independent retirement community: -Discharge summary; -Any prescriptions; -Follow up physician appointments or labs; -If home care is ordered, fax, scan or email the following to the home care of choice: -Discharge summary observation, Physician Order Sheet (POS), face sheet, advance directives/living will, nurse notes, therapy notes, lab/x-ray reports, most recent Minimum Data Set and Care Plan, physician progress notes, list of medications and copy of the Medication Administration Record (MAR), skin testing; -Reconcile the pre-admission and post discharge medications and review the medication regimen with the resident and/or representative. Call the resident's pharmacy of choice if medications need to be ordered; -If being discharged home or to an independent retirement community and the meds are bubble packaged, refer to the discharge plan for med set-up policy; -If transportation is being provided by an emergency transportation complaint, the notification to Emergency Medical Services (EMS) personnel if the resident is an at risk behavioral health patient; -Prepare the resident for transfer/discharge. Pack all personal items and document on the inventory form; -The nurse will complete a progress note in the medical record, that includes: -Physician; -Physician discharge order, including time and date the order was obtained; -List of medications sent with the resident/family member; -Disposal/returned medications; -Location resident was discharged /transferred to; -Who transported the resident (ambulance, family etc); -Diagnoses of resident and reason for discharge/transfer; -Signature of nurse completing the summary; -Resident and/or resident representative must sign the discharge summary observation and the POS; -Copy of signed discharge summary and POS will be scanned into the electronic health record (EHR). Review of Resident #7's medical record, showed: -admitted to the facility: 11/14/24; -discharged : 3/18/25; -Diagnoses included vascular disease, heart failure, left shoulder cuff tear, long term use of diuretics and anticoagulants and stroke. Review of the POS, showed: -An order dated 3/18/25: discharge home with medications, home health, and therapy; -Atorvastatin (used for heart disease) 20 milligram (mg). Take one tablet daily; -Bumetanide (used for edema) take one tablet daily; -Cyclobenzaprine (used for muscle relaxant) 5 mg. Take one tablet three times a day; -Dilitazem (used for blood pressure) 30 mg. Take one tablet every six hours; -Eliquis (used to thin the blood) 5 mg. Take one tablet twice a day; -Furosemide (used for edema) 40 mg. Take one tablet once a day; -Levofloxacin (antibiotic) 500 mg. Take once tablet twice a day; -Lidocaine patch (used to treat pain) 4 percent (%). Apply once patch twice a day to left shoulder; -Mirtazapine (used for depression) 7.5 mg. Take once daily at bedtime; -Simbrinza (used to treat eye dryness) 0.2%. Apply one drop in both eyes twice daily; -Vancomycin (antibiotic) powder 900 micrograms (mcg)/mg. Apply daily to clean right toe, cover with dry dressing; -Warfarin (blood thinner) 4 mg. Take one tablet daily at bedtime. Review of the resident's care plan, dated 11/18/24, showed: -Problem: discharge plans: the resident has a goal of returning to prior living arrangements at home with family support; -Goal: the resident will transition into the community; -Approach: referrals as needed, nursing to provide teaching and evaluations, provide frequent feedback to resident/family on progress. Review of the progress notes, showed: -On 11/18/24 at 2:41 P.M., a social worker (SW) note: care conference held today with family, therapy and nursing. The resident had been living independently prior to the hospital. The resident may not be able to return home due to several health concerns at present time. He/She has some current skin conditions the facility is managing. SW will follow for discharge planning; -On 11/27/24 at 12:22 P.M., a social service note: care plan meeting held with resident, family and therapy. The resident and family agreed to remain at the facility while a space at an assisted living (AL) level II is pursued. The family was notified the resident will not be able to return home alone, as he/she needs a level of supervision. Referrals sent to agreeable facilities; -On 12/16/25 at 11:03 A.M., a social service note: the resident's family continued to be referred to an assisted living facility. However, most decline due to wound care needs, and AL facilities are recommending resident remain in house until the wounds resolve; -On 3/7/25 at 3:17 P.M., a nurse note: the resident's prothrombin ratio and international normalized ratio (PT/INR, measures how long it takes blood to clot) reported to the physician. New order received to continue 4 mg daily; -No further progress notes in the resident's medical record. Review of the physician's Discharge summary, dated [DATE], showed: -admission date: 11/14/24; -discharge date : [DATE]; -Diagnoses: peripheral vascular disease, heart failure, atrial fibrillation (a-fib, is an irregular heart rhythm), malnutrition; -discharged home with home health, therapy, nursing, meds and belongings; -Signed: 3/21/25. During an interview on 4/10/25 at 11:04 A.M., the Director of Nursing said when a resident discharges home or to another care facility, the electronic medical record should have a discharge summary from all departments. The summary should include the medications, recapitulation of stay, if home health is ordered and what company, list of medications and how many were sent with the resident, and any follow up appointments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policy to provide the necessary care to prevent pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one resident who was at high risk for pressure ulcers and developed a new pressure ulcer (Resident #10) and for a resident who was at risk for pressure ulcers and had an existing pressure ulcer (Resident #11). The sample size was three. The census was 168. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling. Review of the facility's Wound Care Protocol, dated 7/23, showed: -Prevention and early interventions goals: To identify residents at risk for pressure ulcers and to create an environment to promote the prevention of pressure ulcers; -Prevention: Turn and reposition; Manage moisture and shear (a horizontal force that causes the bony prominence to move across skin causing it to tear); Charge nurse responsible for reviewing each risk factor and potential causes individually and provide interventions written on the care plan; -Treatment: Offer routine toileting; -For residents with Stage I or Stage IV pressure ulcers: adjust turning schedule to eliminate turning to compromised area; reduce shearing forces; use positioning devices to avoid placing resident on an ulcer; turn and reposition, offer routine toileting. 1. Review of Resident #10's care plan, dated 1/30/25, showed: -Problem: Incontinent of bowel and bladder related to history of incontinence, reduced cognition, mobility deficits and need for assistance with all transfers and lower body clothing management and hygiene. Interventions included: check for incontinence frequently and provide prompt perineal care (peri-care, washing the front and back of the hips, genitals, anal area and buttocks) to prevent skin damage; -Problem: Deficit in activities of daily living (ADLs) functioning and mobility and required assistance. Interventions included: Assist with repositioning in bed and in wheelchair frequently; -Problem; At risk for pressure ulcers. Interventions included: history of Stage II pressure ulcer to coccyx (tailbone); Monitor skin for any redness, bruises or open areas. Review of the resident's Braden scale assessment (for predicting pressure ulcer risk) dated 2/8/25, showed the resident was at high risk. Review of the resident's Continuity of Care Document, dated 4/8/25, showed: -Diagnoses included atrial fibrillation (irregular heart rhythm), dementia, chronic kidney disease (CKD, impaired kidney function) and stroke; -Received hospice (end of life care) services. Review of the resident's Medication Administration Record (MAR), dated 3/9/25 through 4/8/25, showed: -An order dated 2/6/24, complete weekly skin assessment once a day on Tuesday, was completed as ordered. On 4/1/25, there was no skin issues reported; -An order, dated 1/30/25, for Calmoseptine ointment (a skin barrier treatment containing zinc oxide), apply to left and right buttock after each incontinence episode, every shift. Documentation showed the treatment was completed as ordered. Observation on 4/8/25 at 7:27 A.M., showed: -The resident lay on his/her bed on top of an alternating pressure mattress (APM, specialty mattress used to reduce, eliminate and help treat pressure ulcers); -Licensed Practical Nurse (LPN) A and Certified Nursing Assistant (CNA) B performed perineal care on the resident, removing a urine soaked brief; -The resident had an area of red skin located on his/her lower right gluteal (buttock) which had an open area located within the boundaries of the red skin; -LPN A applied Calmoseptine on the resident's right and left buttocks; -LPN A and CNA B finished dressing the resident and transferred the resident to his/her wheelchair; -The wheelchair had a special pressure relieving cushion in the seat of the chair. During an interview on 4/8/25 at 7:39 A./M., LPN A said: -The area on the resident's right lower gluteal measured 4.9 centimeters (cm) by 2.6 cm with a small area measuring 1.1 cm by 0.6 cm which had the first layer of skin gone, exposing a red wound bed; -He/She was not allowed to stage pressure ulcers per facility directions but per his/her nursing knowledge, the wound on the resident's right lower gluteal was a Stage II pressure ulcer; -It was a new wound; -The Wound Nurse was responsible for completing wound treatments every Monday, Wednesday and Friday, and the nurses were responsible for completing wound treatments on Tuesday, Thursday, the weekends and any time the Wound Nurse was not able to complete treatments; -The Wound Nurse was responsible for completing wound assessments on all residents every Tuesday; -Nurses were responsible for completing all skin assessments; -He/She expected CNAs to alert any new skin issues to the nurses so they could get assess, inform the Primary Care Physician (PCP) and family, as well as get new orders. Observation on 4/8/25 at 8:55 A.M., showed the resident sat flat on his/her buttocks in his/her wheelchair, in the dining room eating breakfast. Review of the Hospice Visit Documentation, dated 4/8/25, showed: -Hospice CNA arrived at 9:24 A.M. and left at 10:47 A.M.; -There was no other documentation of the visit found. Observation on 4/8/25 at 11:37 A.M., at 12:05 P.M., at 12:20 P.M., at 12:57 P.M. and at 1:13 P.M., showed the resident in the dining room, sitting flat on his/her buttocks in his/her wheelchair. The resident was eating lunch. Observation on 4/8/25 at 1:19 P.M., showed the resident was in his/her bedroom, sitting flat on his/her buttocks in his/her wheelchair with a visitor. During an interview on 4/8/25 at 1:34 P.M., CNA B said: -The CNA from Hospice came to give the resident a bed bath that morning around 9:00 A.M. and finished at roughly 10:45 A.M.; -The resident had been sitting flat on his/her buttocks in his/her wheelchair since the Hospice Aide left that morning; -He/She had not provided any incontinence care or repositioned the resident since 7:27 A.M.; -He/She should have asked the visitor if it was okay to perform incontinence care after the resident finished with lunch; -The resident was at greater risk of skin breakdown if not repositioned or checked for incontinent episodes at least every two hours. During an interview on 4/8/25 at 1:47 P.M., LPN A said: -He/She expected CNAs to reposition and check residents for incontinent episodes at least every two hours to prevent skin breakdown; -Residents needed to be kept clean and dry to decrease the risk of skin breakdown, prevent pressure ulcers and prevent the risk infection of existing pressure ulcers; -He/She expected CNAs to alert him/her if the resident had not received incontinent care before a visitor arrived as he/she would have intervened and asked the resident and their visitor if they could perform care first; -The Hospice CNA came and gave the resident a bed bath that morning at approximately 10:30 A.M. During an interview on 4/8/25 at 2:05 P.M., the Hospice Registered Nurse (RN) said: -The resident refused the Surveyor's request to watch the Hospice RN and CNA B provide incontinent care to the resident; -They laid the resident down in the bed from his/her wheelchair and removed a moderately to heavily urine soaked brief before perineal care; -The resident had a Stage II pressure ulcer located on his/her right buttock which measured 0.5 cm by 0.5 cm.; -The Hospice RN saw the resident earlier that day but wanted to come back to assess the resident's buttocks as she was informed by a nurse there was an area of concern. Review of the resident's progress notes, showed: -On 4/8/25 at 2:05 P.M., a nurse wrote he/she assessed the resident and noted an area was found on the resident's right buttock, non-blanchable, with the first layer of skin gone. It measured 2.6 centimeters by 0.6 centimeters. The nurse reported the new skin alteration to the Hospice Nurse, the Wound Nurse, the PCP and family; -On 4/8/25 at 5:26 P.M., the Hospice RN wrote she assessed the resident's right buttock and noted a small opened Stage II pressure ulcer was present on the inner part of the buttock measuring 0.5 cm by 0.5 cm with no depth. The PCP was informed with orders to apply ointment with zinc oxide on the open area every brief change until healed. Observation on 4/9/25 at 7:15 A.M. and at 8:12 A.M., showed the resident sat in his/her wheelchair, on a pressure relieving pad, in front of the nurses station. Observation on 4/9/25 at 9:06 A.M., showed the resident in the dining room, eating breakfast. The resident's position was unchanged; He/She sat in his/her wheelchair. There were no positioning pillows or wedges present. At 9:24 A.M., 9:36 A.M., 9:55 A.M., 10:10 A.M., 10:17 A.M., 10:32 A.M., 10:40 A.M., 10:45 A.M., 10:55 A.M., 11:05 A.M., and at 11:14 A.M., the resident sat in his/her wheelchair in his/her bedroom. There were no positioning pillows or wedges present. During an interview on 4/9/25 at 11:28 A.M., the Hospice RN said: -She expected nursing staff to reposition the resident while he/she was in his/her wheelchair with pillows or offer to lay the resident down at least every two hours to prevent pressure ulcers; -She expected nursing staff to check the resident at least every two hours for incontinence episodes and provide perineal care to prevent pressure ulcers; -Hospice services were extra care for the resident and the facility staff were still responsible for providing care to the resident as per their policies and per nursing professional standards; -The lack of repositioning and lack of incontinence care could have contributed to the resident's new Stage II pressure ulcer found on his/her right buttock on 4/8/25. Review of the Wound Management note, dated 4/11/25, showed: -Seen for evaluation of an ulcer on his/her buttock discovered on 4/8/25. The ulcer is being treated topically with barrier cream. Healing complicated by incontinence and immobility; -Right buttock: Type: Pressure Ulcer/Injury: Stage 1 Intact (Skin Reddened with no Blanch) (no open ulcers). Measurements: 5.5 x 6.5 cm; -Left buttock: Type: Pressure Ulcer/Injury: Stage 1 Intact (Skin Reddened with no Blanch) (no open ulcers). Measurements: 5.5 x 4.0 cm; -Goal: Adequate offloading to alleviate pressure for optimal wound healing and Comfort Care to maintain quality of life and dignity; -Plan: Will continue to treat his/her buttocks topically with Remedy Protect Zinc Oxide Paste every shift and as needed (PRN). Staff is going to be sure to lie him/her down in bed periodically throughout the day and provide incontinent care as needed. Caregivers educated on skin care, positioning and wound care. 2. Review of Resident #11's Braden Score, dated 10/9/24, showed the resident was at high risk for pressure ulcers. Review of the resident's care plan, dated 11/29/24, showed: -Problem: Pressure Ulcer; The resident had an alteration in skin integrity and required wound monitoring. Interventions included: The resident preferred to be on his/her back and was educated on the importance of repositioning for better wound healing; Apply treatments per physician orders; Keep clean and dry as possible, minimize skin exposure to moisture; Offer and assist resident to turn and reposition frequently. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors present; -Dependent on assistance from staff for toileting, dressing, personal hygiene, bed mobility and transfers; -At risk for pressure ulcers; -One unhealed Stage IV pressure ulcer present; -Diagnoses included kidney disease, chronic obstructive pulmonary disease (COPD, lung disease), heart disease and respiratory failure. Review of the resident's progress notes, showed: -On 3/31/25 at 12:25 P.M., the resident was seen by outside wound company and no new orders were given; -On 4/7/25 at 2:42 P.M., the resident was seen by an outside wound company and new orders were given; -There was no documentation the resident was offered repositioning or educated on increased risk of pressure ulcers without repositioning. Review of the resident's outside wound company wound report, dated 4/7/25, showed a Stage IV pressure ulcer was located at the resident's sacrum (triangular bone located above the coccyx (tailbone)), 100% pink granulation tissue (new tissue) present in wound bed, measuring proximal area (located closer to trunk of body) 0.6 cm by 0.7 cm by 0.1 cm deep and distal area (away from trunk of body) measuring 1.0 cm by 1.0 cm by 0.2 cm with moderate amount of sero-sanguinous (composed of serum and blood) exudate (drainage) present. Review of the resident's MAR, dated 3/9/25 through 4/8/25, showed: -An order, dated 7/21/23, to complete weekly skin assessments once a day on Tuesdays, was completed as ordered; -An order, dated 2/24/25 through 4/7/25, to cleanse sacral ulcer with normal saline, apply Sorbagon silver (AG, a calcium alginate dressing used to manage moderately to heavily exudating (drainage) wounds) to proximal ulcer, apply Triad (ointment for wound care) to ulcer at the six o'clock position and cover with foam dressing twice a day and as needed. Documentation showed the treatment was administered as ordered; -An order, dated 4/7/25, to cleanse sacral ulcer with normal saline, apply Sorbagon AG, cover with bandage twice a day and as needed. Documentation showed the treatment was administered as ordered. Observation on 4/8/25 at 8:05 A.M., showed the resident asleep, flat on his/her back, on top of an APM. Observation on 4/8/25 at 8:26 A.M., showed: -The Wound Nurse and CNA B gave perineal care to the resident after removing a visibly heavily soaked with urine brief; -The Wound Nurse and CNA B turned the resident to his/her left side, exposing a bandage located on the resident's sacrum, dated 4/7/25; -The resident had bowel movement located on his/her anus and right and left buttocks; -The Wound Nurse instructed the CNA to remove the bandage from the resident's sacrum; -The bandage had dried brown matter on the outside edges of the dressing; -CNA B used a wet cleansing cloth and wiped the bowel movement from the resident's anus up towards the open wound; -The Wound Nurse administered the wound treatment to the sacral wound after CNA B completed perineal care; -They put a clean brief on the resident and covered him/her with a blanket, leaving the resident lying on his/her bed, flat on his/her back. During an interview on 4/8/25 at 8:35 A.M., the Wound Nurse said: -He was not allowed to stage pressure ulcers until he completed his Wound Nurse certification per facility directions but per his nursing knowledge, the resident had a Stage IV pressure ulcer located at his/her sacrum; -The outside wound company evaluated and treated the resident's Stage IV pressure ulcer every Monday; -He described the resident's Stage IV pressure ulcer as having a 100% pink wound bed, with one area of depth, with a scant amount of sero-sanguineous exudate; -The resident was admitted with the Stage IV pressure ulcer located on his/her sacrum and it had improved greatly since admittance. Observation on 4/8/25 at 1136 A.M., at 11:56 A.M., showed the resident asleep in his/her bed, flat on his/her back. Observation on 4/8/25 at 12:20 P.M. through 12:40 P.M., showed CNA B in the dining room assisting residents with lunch. Observation on 4/8/25 at 12:43 P.M., showed the resident sat up in his/her bed, with the head of the bed elevated approximately 45 degrees, listening to his/her phone. The resident did not have any wedges or positioning pillows underneath him/her and sat flat on his/her buttocks. Observation on 4/8/25 at 1:15 P.M., showed the resident sat up in his/her bed, flat on his/her buttocks, with the head of the bed elevated approximately 90 degrees. The resident's bed tray was positioned over him/her and the resident was eating lunch. During an interview on 4/8/25 at 1:16 P.M., the resident said: -He/She did not think staff had changed his/her brief since the morning when the Wound Nurse was present and changed his/her treatment; -He/She did not have any pillows or wedges underneath him/her to reposition him/her off of his/her buttocks; -He/She could change his/her position in the bed by using the bed remote; -He/She required assistance to move/roll in the bed. Observation on 4/8/25 at 1:40 P.M., showed the resident lying in bed, flat on his/her back. CNA B removed the resident's blankets and pulled back his/her gown to expose the resident's brief. The brief was visibly soaked with urine, with the material bunching up in clumps underneath the outermost layer of the brief. There was a strong odor of urine present. During an interview on 4/8/25 at 1:42. P.M., CNA B said he/she had not provided incontinence care since 8:00 A.M. that morning and had not repositioned the resident during his/her shift. He/She should have checked the resident frequently for incontinence and repositioned the resident every two hours to prevent further skin breakdown and deterioration of the resident's existing pressure ulcer. He/She would get help from another CNA and provide incontinence care to the resident. Review of a documented interview, dated 4/16/25, submitted by the facility and with CNA B, showed he/she assisted Resident #11 with peri care, brief change and repositioning before lunch and after lunch. At 2-2:30 the resident was given a full bed bath with the assistance of a fellow CNA and CNA B. CNA B states the resident does not use the call light when he/she is incontinent, but has full control over the bed remote and often repositions the head and foot of the bed. CNA B states although resident prefers his/her back, the resident allows CNA B to place pillows under hips to reposition. Observation on 4/9/25 at 7:14 A.M., showed the resident asleep, lying on his/her APM, positioned flat on his/her back. Observation on 4/9/25 at 8:13 A.M., showed: -The resident sat up in his/her bed, positioned flat on his/her buttocks; -LPN C administered medications to the resident; -There was a strong odor of urine emitting from the resident. Observation on 4/9/25 at 8:22 A.M., showed: -The resident lay flat on his/her back in his/her bed; -LPN C removed the covers from the resident and pulled back the resident's gown, exposing his/her brief; -The resident's brief was visibly soaked with urine, bulging between the resident's thighs; -There was a strong odor of urine emitting from the resident; -LPN C covered the resident back up with his/her gown and covers. During an interview on 4/9/25 at 8:24 A.M., LPN C said: -The resident's brief was wet with urine; -LPN C could not say he/she smelled any urine from the resident but he/she smelled pee all day long. During an interview on 4/9/25 at 8:39 A.M., the resident said: -He/She could feel the brief was wet, and could feel the wetness against his/her skin; -He/She was not sure if the wetness was bothering him/her but preferred to get changed. Observation on 4/9/25 at 8:42 A.M., showed: -The resident received incontinence care from LPN C and CNA D; -The nursing staff removed the resident's visibly urine soaked brief from the resident and performed perineal care; -The resident was then rolled to his/her left side with assistance from the nursing staff, exposing his/her buttocks which had dried brown matter stuck to them; -The resident was laying on an absorbent pad which was visibly dirty with brown matter; -The resident's sacral Stage IV pressure ulcer had a treatment on it, dated 4/8/25; -The bottom and left sides of the treatment were not secured to the resident's skin and were yellow in color with brown matter visible at the edges; -LPN C confirmed the brown matter on the edges of the treatment and on the resident's buttocks was bowel movement; -LPN C removed the treatment from the sacral Stage IV pressure ulcer and showed there was fecal matter on the inside of the treatment as well; -LPN C performed perineal care on the resident, cleaning him/her of the bowel movement; -LPN C cleaned the sacral Stage IV pressure ulcer wound and applied the treatment as ordered; -LPN C failed to adhere the bottom edge of treatment to the resident's skin, leaving the bandage open; -The LPN and CNA put a new, clean brief on the resident and positioned the resident on his/her back; -LPN C and CNA D failed to remove the absorbent pad from underneath the resident, which was visibly dirty with brown matter; -LPN C and CNA D left the room. Observations on 4/9/25 at 9:04 A.M., 9:25 A.M., 9:36 A.M., 9:55 A.M., 10:10 A.M., 10:17 A.M., 10:32 A.M., 10:40 A.M., 10:45 A.M., 10:55 A.M., 11:05 A.M., and at 11:24 A.M., showed the resident lay in his/her bed, flat on his/her back. Review of a documented interview, dated 4/16/25, submitted by the facility and with CNA E, showed he/she was the assigned CNA for Resident #11 on 4/9/2025. CNA E was pulled from Division 700 at approximately 0730. He/She received report and began preparing for breakfast. CNA E stated he/she changed and performed peri care after breakfast, before lunch and after lunch. CNA E's shift ends at 1:30 P.M. CNA E stated the resident verbalized preferring to lay on his/her back. CNA E encouraged resident to offload and allowed a pillow to be placed under resident's hip, alternating each hip with each ADL care. During an interview on 4/10/25 at 9:56 A.M., the Wound Nurse said: -He expected nurses to ensure treatments were sealed/adhered to the resident's skin to prevent the risk of bowel movement or urine, or any other bacteria, from entering into the pressure ulcer, which could lead to infection and risk delay of the healing process; -He expected nursing staff to wipe bowel movement away from the resident's sacral Stage IV pressure ulcer to avoid getting bowel movement into the pressure ulcer; -He expected nursing staff to lay the resident on clean absorbent pads which were free from urine or bowel movement to prevent the risk of infection or delay the healing process of the resident's pressure ulcer. 3. During an interview on 4/8/25 at 1:34 P.M., CNA B said: -He/She was assigned to both Residents #10's and #11's care today from 7:00 A.M. through 3:00 P.M.; -Residents who were dependent on staff for care needed to get repositioned and checked for incontinent episodes every two hours in order to prevent pressure ulcers. During an interview on 4/8/25 at 1:47 P.M., LPN A said: -He/She expected CNAs to reposition and check residents for incontinent episodes at least every two hours to prevent skin breakdown; -Residents needed to be kept clean and dry to decrease the risk of skin breakdown, prevent pressure ulcers and prevent the risk infection of existing pressure ulcers. During an interview on 4/9/25 at 11:07 A.M., and on 4/10/25 at 9:56 A.M., the Wound Nurse said: -He expected nursing staff to check residents for incontinent episodes at least every two hours to ensure they were kept clean and dry, and more often if the residents had heavy urine incontinence; -It was important to keep residents clean and dry to prevent skin breakdown and to decrease the risk of deterioration and infection of existing pressure ulcers; -He expected nursing staff to reposition residents off of bony prominences at least every two hours to prevent skin breakdown and to improve blood flow throughout residents' tissues; -He expected nursing staff to get residents up and out of their wheelchairs to prevent pressure ulcers and to help heal existing pressure ulcers, even if the resident was on hospice, as the goal was to prevent any harm to the resident; -He expected nursing staff to continue to offer repositioning to residents, even if they refuse and if their refusals were care planned; -Nursing staff had a responsibility to continue to educate residents on the importance of repositioning to prevent pressure ulcers and to try to figure out why the resident was refusing repositioning in order to put appropriate interventions in place; -He expected nursing staff to write progress notes showing they continued to offer repositioning and educated the residents on importance of repositioning so nursing staff could see the pattern of refusals and what interventions were tried. During an interview on 4/9/25 at 11:52 A.M. and at 1:20 P.M., the Director of Nursing (DON) said: -She expected staff to have knowledge of and to follow facility policies; -She expected staff to prevent pressure ulcers and promote healing of existing pressure ulcers by repositioning residents, checking them for incontinence episodes and performing perineal care if needed at least every two hours; -She expected nursing staff to offer to lay residents down or reposition them while they were in a wheelchair at least every two hours to help prevent pressure ulcers and promote healing of existing pressure ulcers; -She expected staff to offer residents repositioning and continued education on the importance of repositioning for pressure ulcer prevention and healing throughout their shift and to include their refusal in a care plan with appropriate interventions; -She expected nursing staff to keep residents' treatments free of any bowel movement to prevent the risk of infection and delayed healing of existing pressure ulcers. MO00243017 MO00243255 MO00248943

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure the advance health care directive of one (Resident (R) 147) of six residents reviewed for advance directives was honored. This failure had the potential to result in unwanted provision of cardio-pulmonary resuscitation (CPR) resulting in possible pain, injuries such as broken ribs, and altered mental status. Findings include: Review of the undated Advance Directives Policy revealed, Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive . Resident wishes will be communicated to the staff via the care plan and (identify facility protocol for communication of advance directives either in written or oral format) and to the resident physician. Review of R147's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with anxiety, depression, and repeated falls. Review of R147's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed he/she was unable to answer the Brief Interview for Mental Status (BIMS) and staff assessed him/her with short- and long-term memory problems and severely impaired cognition. R147 was rarely/never able to make himself/herself understood. Review of R147's Health Care Directive, dated [DATE] and located in the Documents tab of the EMR, revealed, I make this Health Care Directive (Directive) to exercise my right to determine the course of my health care and to provide clear and convincing proof of my wishes and instructions about my treatment. If I am persistently unconscious or there is no reasonable expectation of my recovery from a seriously incapacitating or terminal illness or condition, I direct that all of the life-prolonging procedures that I have initialed [sic] below be withheld or withdrawn . heart-lung resuscitation (CPR). The form designated family member (F) 2 as R147's durable power of attorney (POA). Review of R147's Orders tab of the EMR revealed a physician's order, dated [DATE], for full code status, meaning CPR would be provided. Review of R147's Care Plan, dated [DATE] and located in the RAI tab of the EMR, revealed, I or my responsible party for Health Care decisions has selected the following directive for Code Status: Administer CPR. The goal was, My wishes for my code status will be honored during my stay in this facility. The approaches included: In the event that I have no pulse or respirations, CPR will be administered with the notification of 911 . My code status will be discussed and updated quarterly with my care plan review . [and] My physician and family will be notified following notification of 911 emergency response. Review of R147's Care Conference Information summary, dated [DATE] and located in the RAI tab of the EMR, revealed, admission care plan done over phone with [F2] and SW . [F2] stated Resident has had dx [diagnosis] of dementia for approximately 8 years. [F2] confirmed residents code status is to remain Full Code. Resident is unable to make needs known due to confusion. During an interview on [DATE] at 11:18 A.M., Licensed Practical Nurse (LPN) 5 stated typically, a report of each residents' code status was printed by the night shift each night and kept at the nurses' station for reference; however, he/she was unable to find the code status reference list at the 500 Division nurses' station. He/She stated in this instance, he/she would refer to the physician's orders in the Orders tab of the EMR. LPN5 reviewed R147's orders and stated he/she had a full code status and CPR would be provided. During an interview on [DATE] at 11:29 A.M., the Social Worker (SW) stated the admissions staff were responsible for uploading the POA document and the Health Care Directive into R147's medical record and she was not aware that R147 had a Health Care Directive electing a 'do not resuscitate (DNR)' status. The SW stated she reviewed the code status with F2 during the initial Care Conference, and stated F2 requested a Full Code status at that time. The SW stated since she was not aware of R147's Healthcare Directive, she did not address the discrepancy with F2. The SW stated she was not aware how to proceed in a situation where the POA's wishes went against the resident's advance directive. The SW stated she would contact F2 to discuss the situation. During an interview on [DATE] at 2:10 P.M., the SW stated she discussed R147's Healthcare Directive with F2; however, F2 wished for the resident to remain with full code status. She stated this situation needed to be escalated for further discussion related to honoring R147's wishes. During an interview on [DATE] at 4:20 P.M., the Admissions Coordinator (AC) stated he would typically upload an advance directive to the Documents tab of the EMR upon a resident's admission, and all staff would be able to access the directive in the EMR. He stated since F2 was the POA, the POA's wishes for full code status would be honored and added that if the POA wishes did not align with the Health Care Directive, the SW should discuss the issue with the POA. The AC stated the admitting nurse would enter the code status order in the EMR and the SW reviewed the code status during the initial Care Conference. During an interview on [DATE] at 2:21 P.M., with F2, he/she stated he/she was now aware R147 had elected DNR status in her Health Care Directive and stated this had not been discussed with him/her prior to today. F2 stated he/she would like R147 to remain with a full code status and did not believe R147 was able to understand the Health Care Directive he/she formulated in 2018 due to dementia. During an interview on [DATE] at 6:40 P.M., with the Administrator and Director of Nursing (DON), the Administrator stated if a POA's wishes did not align with a resident's advance directive, she would expect the SW to have a conversation with the POA and involve the Ombudsman or other agencies as needed. She stated there was no clear direction on how to proceed in this instance so other agencies could help navigate the issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to conduct a comprehensive assessment including assessment of mood and daily activity preference for two (Resident (R) 100 and R147) of 40 sample residents. These failures created a potential for specific resident needs related to mood and/or daily and activity preference to go unidentified. Findings include: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, accessed at https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf, revealed, Mood: Intent: The items in this section address mood distress and social isolation. Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. Social isolation refers to an actual or perceived lack of contact with other people and tends to increase with age. It is a risk factor for physical and mental illness, is a predictor of mortality, and is important to assess in order to identify engagement strategies . If a resident cannot communicate, then Staff Mood Interview (D0500 A-J) should be conducted . Preferences for Customary Routine and Activities: Intent: The intent of items in this section is to obtain information regarding the resident's preferences for their daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences . If a resident cannot communicate, then family or significant other who knows the resident well may be able to provide useful information about preferences . If the resident is unable to complete the resident interview, attempt to conduct the interview with a family member or significant other. If neither a family member nor significant other is available, skip to item F0800, Staff Assessment of Daily and Activity Preferences. 1. Review of R100's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including: dementia, hemiplegia, and hemiparesis following a stroke, and dependence on wheelchair. Review of R100's Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/21/23 and located in the RAI [Resident Assessment Instrument] tab of the EMR, revealed he/she was unable to answer to the Brief Interview for Mental Status (BIMS) and staff assessed him/her with short- and long-term memory problems and severely impaired cognition. R100 was rarely/never able to make himself/herself understood and did not exhibit behavioral symptoms. The MDS areas to assess mood symptoms and daily activity preferences were not completed. The assessment documented the resident interviews for mood and for daily activity preferences should not be completed as the resident was rarely/never able to make himself/herself understood; however, the alternative staff assessments for mood and for daily activity preferences also were not completed. Additionally, the assessment did not indicate R100 used a wheelchair. During an interview with the MDS Coordinator (MDSC) on 02/09/24 at 4:06 PM, she stated the social services staff was responsible for completion of the mood section and the activities director was responsible for the daily and activity preferences section. She stated she provided a calendar of assessment due dates and expected staff to complete their assigned sections based off the calendar. She stated she was then responsible to sign off on completion of the MDS. The MDSC stated there was an interim staff person who had completed some nursing sections of the MDS assessments remotely from home and was reliant solely on documentation in the record for completion of the assessment, and this person would have assessed the resident's wheelchair use. During an interview on 02/09/24 at 4:40 P.M., the MDSC stated she could not find any evidence of an assessment of R100's mood or daily activity preferences and she did not know why the assessments had not been done. She stated the resident's record reflected use of a wheelchair in multiple areas and the use of a wheelchair should have been included on the MDS. 2. Review of R147's Resident Face Sheet under the Resident tab in the EMR revealed he/she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with anxiety, depression, and repeated falls. Review of R147's admission MDS assessment, with an ARD of 12/13/23 and located in the RAI tab of the EMR, revealed he/she was unable to answer the BIMS and staff assessed her with short- and long-term memory problems and severely impaired cognition. R147 was rarely/never able to make himself/herself understood. R147's daily and activity preferences had not been assessed as required. The MDS documented yes, the resident interview for daily and activity preferences should be completed; however, the questions were unanswered. During an interview on 02/09/24 at 5:09 P.M., the MDSC stated she could not find any evidence of an assessment of R147's daily and activity preferences and she did not know why the assessment had not been done. The MDSC added there was no facility policy on MDS completion; they followed guidance in the RAI Manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to conduct a quarterly assessment including assessment of cognitive patterns and mood for one (Resident (R) 118) of 40 sampled residents. These failures created a potential for specific resident needs related to cognition and mood to go unidentified. Findings include: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, accessed at https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf, revealed, Cognitive Patterns: Intent: The items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions . Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) . Mood: Intent: The items in this section address mood distress and social isolation. Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. Social isolation refers to an actual or perceived lack of contact with other people and tends to increase with age. It is a risk factor for physical and mental illness, is a predictor of mortality, and is important to assess in order to identify engagement strategies . If a resident cannot communicate, then Staff Mood Interview (D0500 A-J) should be conducted. Review of R118's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, anxiety, hearing loss, and altered mental status. Review of R118's Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/31/23 and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed R118 was usually able to make himself/herself understood and understand others. His/Her cognitive patterns and mood symptoms were not assessed. Though the assessment documented both the Brief Interview for Mental Status (BIMS) and the resident interview for mood should be completed; the questions were unanswered. During an interview with the MDS Coordinator (MDSC) on 02/09/24 at 4:06 P.M., she stated the social services staff was responsible for completion of the cognitive patterns and mood sections. She stated she provided a calendar of assessment due dates and expected staff to complete their assigned sections based off the calendar. She stated she was then responsible to sign off on completion of the MDS. During an interview on 02/09/24 at 4:40 P.M., the MDSC stated she could not find any evidence of an assessment of R118's cognitive patterns or mood and she did not know why the assessments had not been done. During an interview on 02/09/24 at 5:09 P.M., the MDSC stated there was no facility policy on MDS completion; they followed guidance in the RAI Manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate Level 1 pre-screening of a resident for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility was completed for one of one resident (Resident (R) 23) reviewed for Level 1 (one) Pre-admission Screening and Resident Review (PASARR). Findings include: Review of R23's ''Face Sheet'' located in the electronic medical record (EMR) under the ''Profile'' tab, revealed an admission date of 12/15/17 and included the following diagnoses: anxiety disorder, major depressive disorder, and bipolar disorder. Review of R23's annual ''Minimum Data Set (MDS),'' located in the EMR under the ''MDS'' tab, with an Assessment Reference Date (ARD) of 11/06/23 revealed R23 had a ''Brief Interview for Mental Status (BIMS)'' score of eight out of 15, which indicated he was moderately cognitively impaired. The MDS indicated R23 had anxiety disorder and manic depression. Review of R23's EMR did not include a Level 1 PASARR. Review of R23's ''Care Plan'' located in the EMR under the ''Care Plan'' tab, dated 01/21/24, included R23 was at risk for adverse medication reactions related to taking psychotropic medication to assisting in managing his/her diagnosis of anxiety. R23 had behavioral symptoms as evidenced by refusing care and becoming agitated/combative with staff. R23 had cognitive decline and difficulties with memory/recall due to his/her disease progression. During an interview on 02/08/24 at 1:12 P.M., the Social Worker (SW) confirmed R23 was admitted to the facility on [DATE] and should have a PASARR level one on file. The SW stated the facility went electronic in 2017 and maybe the paper copy did not get scanned. Additionally, the SW stated R23 transferred from another facility on Medicaid and the facility would not have admitted him/her without having PASARR Level 1. Prior to the admission they would have had to do the paperwork to receive funding for his/her care. The SW deferred this matter to the Admissions Department who may have additional information. During an interview on 02/08/24 at 4:41 P.M., the Administrator confirmed R23 did not have a PASARR level one on file and that they follow Centers for Medicare and Medicaid Services (CMS) guidelines. The facility did not have a separate policy related to PASARR. During an interview on 02/09/24 at 4:32 P.M., the Admissions Coordinator (AC) stated R23 was approved for Medicaid prior to his/her admission to the facility in 2017. AC confirmed that the facility should have a PASARR on file, but were unable to locate it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure two (Resident (R) 100 and R147) of four residents reviewed for activities of daily living (ADLs) received assistance with incontinence care and/or using the toilet as needed. These failures created a potential for skin problems, urinary tract infections, or increased incontinence for these two residents. Findings include: Review of the Urinary Incontinence Management policy, dated June 2021, revealed, AII residents will receive perineal care, as needed, in the morning before breakfast. every evening with evening care at bedtime, as needed after bowel movement or urination, and each time the resident is incontinent. The policy failed to address the expectation for rounding to check for incontinence and change if needed at least every two hours. 1. Review of R100's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including: dementia, hemiplegia and hemiparesis following a stroke, dependence on wheelchair, and urinary incontinence. Review of R100's Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/21/23 and located in the RAI [Resident Assessment Instrument] tab of the EMR, revealed he/she was unable to answer to the Brief Interview for Mental Status (BIMS) and staff assessed him/her with short- and long-term memory problems and severely impaired cognition. R100 was rarely/never able to make himself understood and did not exhibit behavioral symptoms. He/she had impaired range of motion in the upper and lower extremities on one side and was dependent on staff with toileting hygiene. He/she had not used the toilet during the review period. R100 was always incontinent of bladder and bowel and was not on a toileting program. Review of R100's Care Plan, dated 08/05/22 and located in the RAI tab of the EMR, revealed, [R100] has a deficit in ADL functioning and impaired mobility related to weakness caused by cerebral infarction affecting his/her right side and cognitive impairments. The approaches included, Toileting: Assist x2 [by two staff] and Transfer status: Mechanical lift assist x2. The Care Plan also documented, [R100] was incontinent of bowel and bladder related to his/her cognitive impairments caused by dementia, history of [stroke]. The goal was, Will be dry/free of odors and attain highest level of continence. The approaches included, Cleanse peri area after each incontinence episode. Apply protective barrier ointment/cream as ordered and Offer fluids frequently to prevent UTIs [urinary tract infections]. Review of R100's Incontinence Assessment Quarterly, dated 12/21/23 and located in the Observations tab of the EMR, revealed he/she was always incontinent, was cognitively impaired, had impaired mobility, and had an inability to recognize the need to void. The assessment documented, Continue current plan of care. During an interview with family member (F) 1 on 02/05/24 12:20 PM, he/she stated R100 was not provided with incontinence care often enough. He/She stated, He/She goes too long without being changed. He/She is wet most of the time. He/She drinks a lot of fluids in the morning. The family member stated the staff woke R100 up early and changed his/her incontinence brief at that time, but then he/her stayed up in his/her wheelchair until about 2:00 PM without being changed again, and R100 could not tell the staff when he/she was wet. The family member stated he/she brought these concerns to staff, but nothing had been done to improve the situation. At this time, R100 sat in a wheelchair in the area around the nurses' station. He/she was unable to answer screening questions verbally. During continuous observations of R100 on the 500 Division on 02/06/24 from 9:33 AM to 1:15 PM, there were no observations of incontinence checks or brief changes: -At 9:33 A.M., R100 sat in his/her wheelchair in the dining room finishing his/her breakfast. -At 10:09 A.M., R100 was taken in his/her wheelchair from the dining room to the area in front of the nurses' station. He/She remained seated in this spot, in the same position, until 12:02 P.M., without any interaction or checks from staff. -At 12:02 P.M., R100 was taken in his/her wheelchair from the nurses' station to the dining room. -From 12:03 P.M. to 1:15 P.M., R100 sat in his/her wheelchair in the dining room eating lunch. During continuous observations of R100 on the 500 Division on 02/07/24 from 10:16 A.M. to 1:39 P.M., there were no observations of incontinence checks or brief changes: -At 10:16 A.M., R100 sat in his/her wheelchair in the area in front of the nurses' station. -At 10:50 A.M., R100 propelled his wheelchair from the nurses' station to his/her room, where he/she sat in his/her wheelchair without any checks by staff until 11:39 AM. -At 11:39 AM, R100's family member arrived and propelled him/her in his/her wheelchair to the dining room, where he/she remained, seated in his/her wheelchair, until 1:21 PM. -At 1:21 PM, R100's family member propelled him/her in his/her wheelchair to his/her room and alerted Certified Nursing Assistant (CNA)11 he/she was ready for assistance. -At 1:39 PM, CNA11 and CNA14 began preparing to assist R100 to bed using a mechanical lift. During an interview on 02/07/24 at 1:45 P.M., R100's family member stated he/she had not been changed all morning and was wet. He/She stated the staff were changing his/her incontinence brief now, but it had not been done all morning. During an interview on 02/07/24 at 1:56 P.M., CNA11 stated he/she had just assisted R100 to bed and changed his/her brief. She stated his/her brief was very wet with urine, and added the resident would drink a lot of coffee in the morning. The CNA confirmed R100 had not been changed between breakfast and lunch. During an interview on 02/09/24 at 2:21 P.M., CNA11 stated R100 was always incontinent and did not use the toilet. She stated she was aware the resident's family member was concerned he did not get changed frequently enough. CNA11 stated R100 should be checked and changed if needed during the morning between breakfast and lunch, and then again after lunch, but that was not always done, because he/she required two staff members for assistance, and it was difficult to find a second CNA who could assist. 2. Review of R147's Resident Face Sheet under the Resident tab in the EMR revealed he/she was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease with anxiety, repeated falls, and traumatic subarachnoid hemorrhage. Review of R147's admission MDS with an ARD of 12/13/23 and located in the RAI tab of the EMR, revealed he/she was unable to answer the BIMS and staff assessed his/her with short- and long-term memory problems and severely impaired cognition. R147 was rarely/never able to make herself understood. He/She had severely impaired vision and did not exhibit any behavioral symptoms. R147 was totally dependent on staff for toileting hygiene and required partial/moderate assistance with toilet transfers. He/She was occasionally incontinent of bowel and bladder and was not on a toileting program. Review of R147's Care Plan, dated 12/05/23 and located in the RAI tab of the EMR, revealed, [R147] is at risk for incontinence of bowel and bladder related to his/her decreased ability to alert others of toileting urgency and his/her need for assistance with lower body dressing/hygiene. The goals were, [R147] will remain clean, dry, and free from odors and Resident will attain or maintain highest level or current level of continence through next review. The approaches included, Assist with toileting and hygiene per resident routine and as needed/requested and Check me for incontinence frequently and provide prompt peri care to prevent skin damage. Cleanse peri care and apply protective barrier as indicated. The Care Plan also documented, [R147] has a deficit in ADL functioning/mobility and requires assistance related to his/her repeated falls, subarachnoid hemorrhage, Alzheimer's dementia, visual deficits, and decreased mobility. The approaches included, Assist with repositioning in bed and in wheelchair frequently and Encourage ADL participation and allow resident sufficient time to perform ADLs without being rushed. Provide assistance, as needed or requested. During continuous observations of R147 on the 500 Division on 02/06/24 from 9:33 A.M. to 1:15 P.M., there were no observations of incontinence checks or brief changes: -From 9:33 A.M. to 10:13 A.M., R147 was seated in the dining room in his/her wheelchair. -At 10:13 A.M., R147 was taken in her wheelchair from the dining room to the area in front of the nurses' station. He/She remained seated in this spot without any interaction or checks from staff. -At 10:42 A.M., no staff were present near the nurses' station. R147 began reaching his/her arms out in front of his/her and sitting forward in his/her chair. CNA10 was walking through the area, approached R147 at 10:43 A.M., and told him/her to sit back in his/her chair. CNA10 then walked away, and no additional staff were in the area. -At 10:59 A.M., R147 began reaching out in front of him/her and mumbling to himself/herself. There were no staff present in the area. -At 11:17 A.M., R147 stood up from his/her wheelchair. CNA14 assisted R147 to sit back down in his/her wheelchair. -From 11:17 A.M. to 12:03 P.M., R147 remained seated in this spot, in the same position, until 12:03 P.M., without any interaction or checks from staff. -At 12:03 P.M., R147 was taken in his/her wheelchair from the nurses' station to the dining room. -From 12:03 P.M. to 1:15 P.M., R147 was seated in his/her wheelchair in the dining room eating lunch. During continuous observations of R147 on the 500 Division on 02/07/24 from 10:16 A.M. to 1:57 P.M., there were no observations of incontinence checks or brief changes: -At 10:16 A.M., R147 was seated in the area in front of the nurses' station in his/her wheelchair. He/She remained seated in this spot without any checks or interaction until 10:50 A.M. -At 10:50 A.M., R147 stood up from his/her wheelchair and walked approximately 6 feet before CNA10 and Licensed Practical Nurse (LPN) 5 assisted him/her back to her wheelchair and told her to sit back down. He/She remained seated in this spot without any checks or interaction until 11:34 A.M. -At 11:34 A.M., R147 was taken in his/her wheelchair from the nurses' station to the dining room, where he/she remained until 1:17 PM. -At 1:17 P.M., R147 was taken in his/her wheelchair from the dining room to the nurses' station, where he/she remained seated in the spot without any checks or interaction until 1:57 P.M. -At 1:57 P.M., R147 stood up from his/her wheelchair. CNA11 walked with R147 to the bathroom in the shower room near the nurses' station. During an interview on 02/07/24 at 2:10 P.M., CNA11 stated R147 used the toilet in the shower room and his/her brief was a little wet at that time. He/She stated R147 was not always able to use the toilet and was frequently incontinent. The CNA stated R147 could not tell the staff when he/she was wet or when he/she needed to use the toilet. CNA11 stated R147 received a shower in the morning and used the toilet at that time and confirmed he/she had not used the toilet or been changed again until after lunch. During an interview on 02/07/24 at 2:21 P.M. with F2, he/she stated R147 was blind and had dementia, so he/she was not able to speak for his/her self. He/She stated before R147 was admitted to the facility, he/she was taken to the bathroom every two hours and was able to use the toilet and remain continent. The family member stated a sign that R147 needed to be changed or use the bathroom was frequent standing from his/her wheelchair. During an interview on 02/09/24 at 2:21 P.M., CNA11 stated R147 was frequently incontinent and should be checked and changed if needed every two hours. He/She stated R147 should be checked sometime between breakfast and lunch and then again after lunch; however, this did not always get done because of other duties pulling the CNA's away from resident care, like dining room setup and cleanup and serving meals. During an interview on 02/09/24 at 10:31 A.M., CNA13 stated every resident with incontinence should be checked and changed if needed at least every two hours, and those who were unable to communicate their needs should be checked on more frequently. CNA13 stated every two hours was the standard, but there were some residents who were unable to wait that long. During an interview on 02/09/24 at 11:22 A.M., CNA8 stated residents with incontinence should be checked and changed if needed at least every two hours. During an interview on 02/09/24 at 11:38 A.M., CNA6 stated residents with incontinence should be checked and changed if needed at least every two hours. During an interview on 02/09/24 11:53 A.M., CNA12 stated residents with incontinence should be checked and changed if needed at least every two hours and sometimes it was hard to get that done plus complete meal service and dining assistance at times. 3. During an interview on 02/09/24 at 2:21 P.M., CNA11 stated, We do our best . but we need extra staff to help with toileting. During an interview on 02/09/24 at 2:55 P.M., Licensed Practical Nurse (LPN)5 stated the expectation was that staff would make rounds to check for incontinence and change if needed every two hours: in the morning, after breakfast but before lunch, and after lunch. LPN5 stated CNAs did not document their rounding or episodes of incontinence. During an interview on 02/09/24 at 6:40 P.M., with the Administrator and Director of Nursing (DON), the Administrator stated staff were expected to check and change each resident with incontinence every two hours at the minimum. The DON stated staff had been educated frequently regarding the requirement to check and change at least every two hours. He/She stated he/she had not conducted recent monitoring of staff rounding or incontinence management and care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure two (Resident (R) 147 and R151) of five residents reviewed for activities were assessed for activity interests and needs and received a program of activities to meet their needs. These failures placed R147 and R151 at risk for increased feelings of depression, helplessness, and boredom. Findings include: A policy on provision of activities was requested from the facility; however, was not provided prior to survey exit. 1. Review of R147's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease with anxiety, depression, and repeated falls. Review of R147's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/13/23 and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed he/she was unable to answer the Brief Interview for Mental Status (BIMS) and staff assessed his/her with short- and long-term memory problems and severely impaired cognition. R147 was rarely/never able to make herself understood. He/She had severely impaired vision and did not exhibit any behavioral symptoms. R147's activity preferences had not been assessed as required (cross-reference F636: Comprehensive Assessment). Review of R147's EMR revealed there was no assessment of his/her activity interests or participation or activities progress notes. Review of R147's Care Plan, dated 12/05/23 and located in the RAI tab of the EMR, revealed it did not address his/her activity preferences or participation needs. His/Her Care Plan documented, [R147] is at risk for falls related to his/her poor safety awareness, history of repeated falls, Alzheimer's dementia, daily psychotropic medication use, and visual deficits and included the approach, dated 01/09/24: Staff encouraged to monitor in high-view areas. Activities to be involved in promoting participation in cognitive/physically stimulating activities. During continuous observations of R147 on the 500 Division on 02/06/24 from 9:33 A.M. to 12:03 P.M., there were no observations of provision of activities: -From 9:33 A.M. to 10:13 A.M., R147 was seated in the dining room in his/her wheelchair. There was nothing on the table in front of her. -At 10:13 A.M., R147 was taken in his/her wheelchair from the dining room to the area in front of the nurses' station. He/She remained seated in this spot without any interaction or activity. There was no TV or music in the area and he/she was not wearing his/her headphones. -At 10:42 A.M., no staff were present near the nurses' station. R147 began reaching his/her arms out in front of his/her and sitting forward in his/her chair. Certified Nursing Assistant (CNA)10 was walking through the area, approached R147 at 10:43 AM, and told his/her sit back in his/her chair. CNA10 then walked away, and no additional staff were in the area. -At 10:59 A.M., R147 began reaching out in front of his/her and mumbling to his/her self. There were no staff present in the area. -At 11:17 A.M., R147 stood up from his/her wheelchair. CNA14 was walking through the area and assisted R147 to sit back down in his/her wheelchair. No physically or cognitively stimulating activities were provided. CNA14 then left the area, and no additional staff were present. -At 11:17 A.M., R147 stood up from his/her wheelchair. CNA14 assisted R147 to sit back down in his/her wheelchair. No physically or cognitively stimulating activities were provided. -From 11:17 A.M. to 12:03 P.M., R147 remained seated in this spot, in the same position, until 12:03 P.M., without any interaction or activity. There was no TV or music in the area and he/she was not wearing his/her headphones. -At 12:03 P.M., R147 was taken in his/her wheelchair from the nurses' station to the dining room. During continuous observations of R147 on the 500 Division on 02/07/24 from 10:16 A.M. to 1:57 P.M., there were no observations of provision of activities: -At 10:16 A.M., R147 was seated in the area in front of the nurses' station in his/her wheelchair. He/She remained seated in this spot until 10:50 A.M. without any interaction activity. There was no TV or music in the area, and he/she was not wearing his/her headphones. -At 10:50 A.M., R147 stood up from his/her wheelchair and walked approximately 6 feet before CNA10 and LPN5 assisted his/her back to his/her wheelchair and told her to sit back down. He/She remained seated in this spot until 11:34 A.M. There was no TV or music in the area and he/she was not wearing his/her headphones. -At 11:34 A.M., R147 was taken in his/her wheelchair from the nurses' station to the dining room, where he/she remained until 1:17 P.M. -At 1:17 P.M., R147 was taken in his/her wheelchair from the dining room to the nurses' station, where he/she remained seated in the spot until 1:57 P.M. There was no TV or music in the area and he/she was not wearing his/her headphones. -At 1:57 P.M., R147 stood up from his/her wheelchair and CNA11 walked with R147 to the bathroom in the shower room near the nurses' station. During continuous observations of R147 on the 500 Division on 02/08/24 from 11:08 A.M. to 11:58 A.M., there were no observations of provision of activities: -At 11:08 A.M., R147 sat in his/her wheelchair in the area in front of the nurses' station. He/She was leaning forward and reaching out in front of him/her. There was no TV or music in the area and he/she was not wearing his/her headphones. -At 11:12 A.M., R147 was attempting to scoot his/her wheelchair forward, but was unable to move it. He/She then began leaning forward and reaching in front of him/her. -At 11:41 A.M., R147 scooted forward in his/her chair, bent forward, and reached his/her arms out in front of his/her. The Director of Nursing (DON) entered the area and stated, He/She needs his/her headphones on for some music, approached R147, and asked if he/she would like his/her headphones. The DON then left the area, but did not return with the headphones or any type of music for R147. -At 11:58 A.M., R147 was taken in his/her wheelchair to the dining room. During an interview on 02/07/24 at 2:21 P.M. with family member (F) 2, he/she stated R147 was blind and had dementia, and he/she loved music. F2 stated R147 had headphones to play the music he/she likes while out at the nurses' station; however, the staff did not put the music on for his/her. During an interview on 02/09/24 at 2:21 P.M., CNA11 stated R147 liked to listen to music and wore headphones tuned to his/her favorite music. CNA11 stated activities department staff did not work with R147 or provide him/her with any type of engagement or stimulation. The CNA stated, He/She loves the headphones . sometimes he/she sings along with it. CNA11 stated R147 never refused to wear the headphones when offered. During an interview on 02/09/24 at 4:51 P.M., with the Assistant Administrator and Activity Director (AD), the AD stated he/she had only been working in the facility for three days and the Assistant Administrator was more knowledgeable about the current activity programming and residents. During an interview on 02/09/24 at 5:19 P.M., the Assistant Administrator stated he/she was unable to find any activity participation records for February 2024 for R147, did not locate an activity assessment or Care Plan for R147 and was unable to describe the activity program for R147. During an interview on 02/09/24 at 6:40 P.M., with Administrator and DON, the DON stated he/she did not provide R147 with headphones on 02/08/24, because the headphones were not working and needed to be fixed. He/She stated music was soothing to R147 and should be provided to him/her for sensory stimulation and engagement. The Administrator stated he/she expected the staff to provide activities to cognitively impaired residents to meet their needs according to their likes and dislikes. 2. Review of the EMR Diagnosis tab for R151 revealed he/she was admitted to the facility on [DATE] with diagnoses to include dementia with other behavioral disturbances, generalized anxiety disorder, unspecified hearing loss, legal blindness with corrective glasses, and major depressive disorder. Review of R151's admission MDS with an ARD of 05/22/23 and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed her BIMS score was 12 out of 15 which indicated moderately impaired cognition. Per the MDS staff had indicated the daily and activity preferences interview should be conducted, however the daily and activity preferences questions were not completed. Review of the EMR Care Plan tab for R151's care plan, dated 11/28/23, documented that R151 required monitoring for activities of daily living (ADLs) for all transfers and mobility. The care plan documented R151 had behavioral symptoms as evidenced by standing up without staff assistance, and frequent yelling out for help that was disturbing to other residents. The documentation for activities listed in the care plan documented that R151 has an activity deficit related to his/her cognitive impairment. Documentation in the care plan for R151 regarding customary routine or activity preferences or interventions was not identified. During observation in the common area near the nurses' station on 02/05/24 at 10:24 A.M., R151 was seated in a recliner positioned in recline. R151 was calling out for help and did not open her eyes. CNA5 responded to R151 and asked him/her how he/she could help him/her. R151 said he/she needed a hug, and CNA5 gave the resident a hug. R151 stopped calling out for help and continued to sit with his/her eyes closed. During an observation of R151 on 02/05/24 at 2:57 P.M. through 3:45 P.M., R151 was observed seated in his/her wheelchair at the nurses' station calling out for help and standing up from him/her wheelchair. Registered Nurse (RN) 4 was seated beside R151 and consistently tried to redirect the resident to sit down. During continued observation of R151 on 02/05/24 at 4:10 P.M., the resident was seated in his/her wheelchair at the nurses' station beside RN4. R151 was calling out for help standing up from his/her wheelchair. The RN4 tried to consistently redirect the resident to sit down in his/her wheelchair so he/she would not fall. During an interview on 02/08/24 at 2:20 P.M., the Activity Assistant (AA) stated he/she had been employed as the activity assistant for a few weeks and could not locate or identify progress notes to indicate activity interventions had been documented for R151. The AA stated the activity progress notes were not documented on paper, but could be viewed in the EMR under the tab for activity progress notes. On 02/08/24 at 10:30 AM, all documentation regarding an activity program assessment or care plan interventions for R151 was requested from the Administrator. The Administrator provided one activity calendar dated November 2023 with seven activity events highlighted to indicate attendance to the activity by R151. The highlighted calendars did not contain a signature of the staff member that highlighted the activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to ensure the physician acted upon the notification of irregularities in the medication regimen for one (Resident (R) 53) of five residents reviewed for unnecessary medications. This failure created the potential for unnecessary antipsychotic medication use, which could lead to adverse consequences such as over-sedation, mental status changes, or involuntary movements. Findings include: Review of the Behaviors Using Person -Centered Care, Accommodating policy, dated February 2021, revealed, Psychopharmacological therapy Charting requirements [for] Antipsychotics and/or any psychotherapeutic agents (other than antipsychotics, sedative/hypnotics: Targeted harmful behaviors must be defined and the occurrence of such documented quantitatively every shift on flow sheet. A policy addressing the Pharmacist's drug regimen review and physician response was requested but not provided prior to survey exit. Review of R53's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance and depression. Review of R53's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/24 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed he scored 10 out of 15 on the Brief Interview for Mental Status, which indicated moderately impaired cognition. The resident did not exhibit any mood or behavioral symptoms. R53 had diagnoses of depression, Parkinson's Disease, and dementia and received antipsychotic and antidepressant medications. R53 had not been provided a gradual dose reduction (GDR) of the antipsychotic medication and the physician had not documented clinical rationale for declination of a GDR. Review of R53's Care Plan, dated 06/29/23 and located in the RAI tab of the EMR, revealed, [R53] is at risk for adverse medication reactions related to taking psychotropic medication to assist in managing his/her diagnosis of Parkinson's disease and depression. The goal was, Resident will not exhibit signs of drug related side effects or adverse drug reaction. Will promote/maintain optimal physical, mental, and psychosocial well-being through next review. The approaches included: Administer medication as ordered . Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms . Attempt a gradual dose reduction (if not contraindicated) . Monitor for effectiveness of the medication. Increase dosage gradually if ineffective . Monitor resident's behavior/mood and response to medication . Pharmacy consultant review per protocol. Evaluate drug reductions, as recommended . Review for continued need at least quarterly. Attempt to give the lowest dose possible . [and] Try non-pharmacological interventions. The Care Plan failed to address the specific mood and behavioral symptoms targeted for treatment by the medications, how to monitor for effectiveness of the medication, and which non-pharmacological approaches were effective to address the identified mood or behavioral symptoms. Review of R53's Orders tab of the EMR revealed a physician's order, dated 06/28/23, for quetiapine (an anti-psychotic medication), 100 milligrams (mg) daily for a diagnosis of dementia with behavioral disturbance The Orders tab also included a physician's order, dated 07/29/23, which documented, Anti-Psychotic Medication Use - Observe resident closely for significant side effects: Common - Sedation, Drowsiness, Dry Mouth, Constipation, Blurred Vision, Extra Pyramidal Reaction, Weight Gain, Edema, Postural Hypotension, Sweating, Loss of Appetite, Urinary Retention. Every Shift Special Attention For: Tardive Dyskinesia, Seizure Disorder, Chronic Constipation, Glaucoma, Diabetes, Skin Pigmentation, Jaundice. There was no order to monitor target behaviors in order to assess effectiveness of the medication. Review of R53's Pharmacist's Drug Regimen Review, dated 10/31/23 and located in the Documents tab of the EMR, revealed: Resident receives the following antipsychotic: quetiapine 100mg tablet. Regulations associated with psychoactive medication use require that all patients receiving psychoactive drugs have supporting behavior patterns identified and charted on. Please select behaviors on the list below to justify antipsychotic use in this resident, and document the occurrence of these behaviors every shift: Hitting Banging Hoarding Aggressive/combative Constant need to go to bathroom Cursing Crying Disrobing in public areas Hallucination Inappropriate sexual behaviors Increased confusion Paranoia Refusing medications Resisting ADLs Screaming/yelling Other: ____________________________ Please add behavior flow sheets to Matrix with the checked behaviors above. Note: I already added antipsychotic side effect monitoring to Matrix. No behaviors were checked and there was no physician response documented on the form. Review of R53's Pharmacist's Drug Regimen Review, dated 01/31/24 and located in the Documents tab of the EMR, again revealed, Resident receives the following antipsychotic: quetiapine 100mg tablet. Regulations associated with psychoactive medication use require that all patients receiving psychoactive drugs have supporting behavior patterns identified and charted on. Please select behaviors on the list below to justify antipsychotic use in this resident, and document the occurrence of these behaviors every shift: Hitting Banging Hoarding Aggressive/combative Constant need to go to bathroom Cursing Crying Disrobing in public areas Hallucination Inappropriate sexual behaviors Increased confusion Paranoia Refusing medications Resisting ADLs Screaming/yelling Other: ____________________________ Please add behavior flow sheets to Matrix with the checked behaviors above. There were no behaviors checked and no physician response documented on the form. Review of R53's November 2023, December 2023, January 2024, and February 2024 Medication Administration Summary records, located in the Reports tab of the EMR, revealed no targeted behaviors were documented and no behavior monitoring was included. Review of R53's November 2023, December 2023, January 2024, and February 2024 Progress Notes, located in the Progress Notes tab of the EMR, revealed no documentation of any behavioral or mood symptoms. Review of R53's Documents tab of the EMR revealed no physician documentation addressing R53's behavior or the pharmacist's recommendations from 10/31/23 and 01/31/24. During an interview on 02/09/24 at 12:30 P.M., with the Administrator, she stated the physician typically did not document their response to a pharmacist's recommendations, but would document an order change if the recommendation was accepted. She stated if a recommendation was declined, the physician did not document the rationale for declination. The Administrator stated she had not provided education to the physicians or involved the Medical Director to ensure the physicians responded to the pharmacist's recommendations and provided a rationale when required. The Administrator did not know why the recommendation to identify and monitor target behaviors had not been addressed by the physician or nursing staff on 10/31/23 and again on 01/31/24. During an interview on 02/09/24 at 3:33 P.M., the Medical Director stated he was provided with the pharmacist's monthly drug regimen review recommendations, and he would respond by ordering a medication change if he agreed with the recommendation. He stated if he disagreed with a recommendation, he would mark the appropriate check box on the form and a reasoning for disagreeing. During an interview on 02/09/24 at 6:40 P.M., with the Director of Nursing (DON) and Administrator, the DON stated there was no reason why the pharmacist's recommendation for monitoring of targeted behaviors for the use of quetiapine on 10/31/23 should not have been implemented or why the recommendation had to be made a second time on 01/31/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to ensure the drug regimen of one (Resident (R) 53) out of five residents reviewed for unnecessary medications contained adequate indication for use of an anti-psychotic medication. This failure placed R53 for potentially avoidable adverse effects of the drug, including over-sedation, mental status changes, or involuntary movements. Findings include: Review of the Behaviors Using Person -Centered Care, Accommodating policy, dated February 2021, revealed, Criteria for identifying a problem behavior: A danger or safety risk to self/others . The potential risks of Antipsychotic Drugs are: Movement disorders, e.g., tardive dyskinesia, EPS symptoms; Hypotension; Sedation; Weight gain; Blurred vision; Dry mouth; Constipation; Urinary retention; Tachycardia; Increase risk for falling and fractures; Stroke; [and] Associated hospitalizations/death . Inappropriate use for antipsychotic medications: Wandering; Poor self-care; Restlessness; Impaired memory; Anxiety; Depression without psychotic features; Insomnia; Unsociability; Indifference to surroundings; Fidgeting; Uncooperativeness; [and] Agitated behavior which does not present a danger to resident or others . Psychopharmacological therapy Charting requirements [for] Antipsychotics and/or any psychotherapeutic agents (other than antipsychotics, sedative/hypnotics): Targeted harmful behaviors must be defined and the occurrence of such documented quantitatively every shift on flow sheet . GDR Gradual Dose Reduction . First year (after admitted or/started on antipsychotic), must attempt reduction in 2 separate quarters, at least 1 month between. Review of R53's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance and depression. Review of R53's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/24 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed he/she scored 10 out of 15 on the Brief Interview for Mental Status, which indicated moderately impaired cognition. The resident did not exhibit any mood or behavioral symptoms. R53 had diagnoses of depression, Parkinson's Disease, and dementia and received antipsychotic and antidepressant medications. R53 had not been provided a gradual dose reduction (GDR) of the antipsychotic medication and the physician had not documented clinical rationale for declination of a GDR. Review of R53's Care Plan, dated 06/29/23 and located in the RAI tab of the EMR, revealed, [R53] is at risk for adverse medication reactions related to taking psychotropic medication to assist in managing his diagnosis of Parkinson's disease and depression. The goal was, Resident will not exhibit signs of drug related side effects or adverse drug reaction. Will promote/maintain optimal physical, mental, and psychosocial well-being through next review. The approaches included: Administer medication as ordered . Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms . Attempt a gradual dose reduction (if not contraindicated) . Monitor for effectiveness of the medication. Increase dosage gradually if ineffective . Monitor resident's behavior/mood and response to medication . Pharmacy consultant review per protocol. Evaluate drug reductions, as recommended . Review for continued need at least quarterly. Attempt to give the lowest dose possible . [and] Try non-pharmacological interventions. The Care Plan failed to address the specific mood and behavioral symptoms targeted for treatment by the medications, how to monitor for effectiveness of the medication, and which non-pharmacological approaches were effective to address the identified mood or behavioral symptoms. Review of R53's Orders tab of the EMR revealed a physician's order, dated 06/28/23, for quetiapine (an anti-psychotic medication), 100 milligrams (mg) daily for a diagnosis of dementia with behavioral disturbance The Orders tab also included a physician's order, dated 07/29/23, which documented, Anti-Psychotic Medication Use - Observe resident closely for significant side effects: Common - Sedation, Drowsiness, Dry Mouth, Constipation, Blurred Vision, Extra Pyramidal Reaction, Weight Gain, Edema, Postural Hypotension, Sweating, Loss of Appetite, Urinary Retention. Every Shift Special Attention For: Tardive Dyskinesia, Seizure Disorder, Chronic Constipation, Glaucoma, Diabetes, Skin Pigmentation, Jaundice. There was no order to monitor target behaviors in order to assess effectiveness of the medication. Review of R53's Pharmacist's Drug Regimen Review, dated 10/31/23 and located in the Documents tab of the EMR, revealed: Resident receives the following antipsychotic: quetiapine 100mg tablet. Regulations associated with psychoactive medication use require that all patients receiving psychoactive drugs have supporting behavior patterns identified and charted on. Please select behaviors on the list below to justify antipsychotic use in this resident, and document the occurrence of these behaviors every shift: Hitting Banging Hoarding Aggressive/combative Constant need to go to bathroom Cursing Crying Disrobing in public areas Hallucination Inappropriate sexual behaviors Increased confusion Paranoia Refusing medications Resisting ADLs [activities of daily living] Screaming/yelling Other: ____________________________ Please add behavior flow sheets to Matrix with the checked behaviors above. Note: I already added antipsychotic side effect monitoring to Matrix. No behaviors were checked and there was no physician response documented on the form. Review of R53's Pharmacist's Drug Regimen Review, dated 01/31/24 and located in the Documents tab of the EMR, again revealed, Resident receives the following antipsychotic: quetiapine 100mg tablet. Regulations associated with psychoactive medication use require that all patients receiving psychoactive drugs have supporting behavior patterns identified and charted on. Please select behaviors on the list below to justify antipsychotic use in this resident, and document the occurrence of these behaviors every shift: Hitting Banging Hoarding Aggressive/combative Constant need to go to bathroom Cursing Crying Disrobing in public areas Hallucination Inappropriate sexual behaviors Increased confusion Paranoia Refusing medications Resisting ADLs Screaming/yelling Other: ____________________________ Please add behavior flow sheets to Matrix with the checked behaviors above. There were no behaviors checked and no physician response documented on the form. Review of R53's November 2023, December 2023, January 2024, and February 2024 Medication Administration Summary records, located in the Reports tab of the EMR, revealed no targeted behaviors were documented and no behavior monitoring was included. Review of R53's November 2023, December 2023, January 2024, and February 2024 Progress Notes, located in the Progress Notes tab of the EMR, revealed no documentation of any behavioral or mood symptoms. During an interview on 02/06/24 at 11:41 A.M., R53 appropriately answered all questions. He/She reported he/she got along well with the staff and his/her roommate and rarely interacted with residents outside his/her room. R53 was calm and cooperative and smiled and made eye contact throughout the interview. He/She did not report any behavioral or psychiatric concerns. During an interview on 02/09/24 at 2:21 P.M., Certified Nursing Assistant (CNA) 11 stated he/she had not witnessed R53 exhibit any behavioral symptoms or mood symptoms. He/She stated R53 was real down to earth and pleasant. CNA11 added R53 liked to stay in his/her room and socialize with his/her roommate and did not come out into the milieu very often. CNA11 stated only nurses were responsible for documenting any behavioral symptoms observed and CNAs did not monitor behaviors; however, R53 did not exhibit any behaviors and he/she was always pleasant. During an interview on 02/09/24 at 2:55 P.M., Licensed Practical Nurse (LPN)5 stated he/she was not aware of behavioral or mood symptoms for R53. LPN5 stated nurses documented any behaviors in the Progress Notes and residents who used antipsychotic medication should have behavior monitoring in the Medication Administration Summary and should be monitored daily. LPN5 stated a physician's order was required for behavior monitoring to be included in the Medication Administration Summary. LPN5 added there was no behavior monitoring for R53. During an interview on 02/09/24 at 3:33 P.M.,, the Medical Director stated a GDR should be attempted for a resident using an antipsychotic medication if it had not yet been tried during the first year, unless it was contraindicated based on the resident's behavioral symptoms. During an interview on 02/09/24 at 6:40 P.M. with the Director of Clinical Services, Director of Nursing (DON), and Administrator, the DON stated the facility had identified a need to address the use of psychotropic medications and behavior monitoring and implemented a behavior committee to review the issues. He/She stated the committee determined R53 exhibited increased confusion as an indication for use of the anti-psychotic medication; however, stated the confusion did not place the resident or other at risk of harm or distress. The DON stated R53 did not exhibit any behavioral symptoms. The Director of Clinical Services stated only behaviors that had negative effects on the resident or others indicated use of anti-psychotic medication. He/She stated in the event the indication for use was not present, a GDR should be conducted. The DON stated monitoring of targeted behaviors should have been conducted by the nurses on the Medication Administration Summary to evaluate the effectiveness of the medication. The Administrator provided a Behavior Management Committee Recommendations form, dated 01/25/24 and provided on paper, which documented, Your resident has been receiving the psychotropic medication quetiapine 100 mg since 6/28/23 without the benefit of a dose reduction. The behavior management committee met on 1/25/25 and has made the following recommendations based upon a comprehensive behavioral and psychosocial assessment: Decrease dose of quetiapine. There was no physician response documented on the form and R53's dose of quetiapine had not been reduced.

Based on observation, interview, and review of the United States (US) Food and Drug Administration (FDA) Food Code, the facility failed to ensure dishware stored at the ice machine was covered or inverted for storage in a clean, dry location not exposed to dust or other potential contamination. Findings include: Review of the 2022 US FDA Food Code under Storing: Equipment, Utensils, Linens, and Single-Service and Single-Use Articles revealed cleaned equipment and utensils shall be stored in a clean, dry location; where they are not exposed to splash, dust, or other contaminants; and shall be stored covered or inverted. During an interview with Resident (R) 103's family member (F3) on 02/06/24 at 12:21 P.M., he/she stated his/her family member did not like to drink from the hydration mugs, because he/she did not think they were clean. F3 stated he/she brought R103 drinks from home. During on observation on 02/09/24 at 2:05 P.M. of the room containing the facility ice machine and the employee time clock, revealed a large plastic shelving unit in the corner of the room. The shelving unit had three levels of shelves that contained approximately 75 hydration mugs. Some of the mugs were inverted on the open shelving and some were not inverted. Above the shelving unit was a missing ceiling panel that allowed open access to the attic space. The bottom shelf of the shelving unit contained an open bin of lids and straws for the hydration mugs. During an interview on 02/09/24 at 3:09 P.M., the Dietary Manager (DM) stated he/she did not monitor the sanitation of the hydration mugs. The DM verified the plastic shelving unit in the room containing the ice machine and the employee time clock, were not in a sanitary environment. The DM stated the mugs were brought to the kitchen from the resident rooms and were properly cleaned and sanitized before the mugs were placed on the shelving units. He/She confirmed some of the mugs were inverted, and some were not inverted, and all were open to contamination from the room environment. The DM confirmed the open bin of lids and straws was not sanitary and was also open to the room contaminates and the attic contaminates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and policy review, the facility failed to ensure one resident's room (room [ROOM NUMBER]-1) was clean and in good repair for one room observed on the 200 Hall. Findings include: Review of the Environmental Cleaning and Infection Control Policy effective date March 2020 under Housekeeping Resident Room, under Procedures item 5 revealed Staff should promote a homelike living environment for all residents. Under Bathroom Cleaning Clean the toilet with disinfectant (including the tank, outside and inside the bowl) .Clean the sink, tub/shower, including all tile inside and around the shower walls and floor . During an observation of room [ROOM NUMBER]-1 on 02/08/24 at 10:15 A.M., the resident who resided in the room said his/her room, bathroom, and shower had not been cleaned for several weeks. In addition, the resident complained that the floor in her room and bathroom had a sticky film. During an observation on 02/09/24 at 10:20 A.M., the floor in room [ROOM NUMBER]-1 and in the bathroom were observed to have a non-visible sticky substance on the floor when walking on the floor. The bathroom sink and toilet basin had a brown substance inside. The toilet bowl also had two missing bolt covers. The shower floor had a dark black substance throughout the shower floor. During an interview with the resident of room [ROOM NUMBER]-1 on 02/09/24 at 10:20 A.M., the resident stated that he/she could not remember exactly when her room and bathroom was last cleaned, but it had been several weeks. The resident further stated, if I could clean my room and bathroom, I would clean it myself. The resident also stated that housekeeping staff come in spray and leave. During an interview with the Director of Nursing (DON) and the Housekeeping Supervisor on 02/09/24 at 10:40 A.M., confirmed that the floor in the resident's room (209) and bathroom had a sticky film when stepping and walking on the floor. The both also confirmed that the bathroom sink basin, toilet bowl and shower needed to be cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected 15 residents who expired and had money in their accounts (Residents #509, #505, #502, #503, #511, #504, #501, #508, #510, #506, #512, #517, #513, #516, #515). The sample size was 17. The census was 179. 1. Review of Resident #509's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $927.44; -No documentation of a TPL. 2. Review of Resident #505's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $150.07; -TPL completed on [DATE]. 3. Review of Resident #502's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $4238.47; -TPL completed on [DATE]. 4. Review of Resident #503's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $3768.40; -TPL completed on [DATE]. 5. Review of Resident #511's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $4499.59; -TPL completed on [DATE]. 6. Review of Resident #504's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $55.98; -TPL completed on [DATE]; -Ending balance of $15.00; -TPL completed on [DATE]. 7. Review of Resident #501's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $1228.00 -TPL completed on [DATE]. 8. Review of Resident #508's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $22.31; -TPL completed on [DATE]. 9. Review of Resident #510's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $5667.29; -No documentation of a TPL. 10. Review of Resident #506's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $382.15; -TPL completed on [DATE]. 11. Review of Resident #512's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $2622.19; -TPL completed on [DATE]. 12. Review of Resident #517's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $1666.41; -TPL completed on [DATE]. 13. Review of Resident #513's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $626.74; -TPL completed on [DATE]. 14. Review of Resident #516's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $1594.13; -TPL completed on [DATE]. 15. Review of Resident #515's medical record showed the following; -Effective/Expired on [DATE]; -Ending balance of $76.00; -TPL completed on [DATE]. During an interview on [DATE] at 1:05 P.M., the Business Office Manager (BOM) said she was aware the TPL was behind and thought the required time frame was 60 days and not 30 days. The BOM said she had fallen behind in the process. During an interview on [DATE] at 1:30 P.M., the Assistant Administrator said she was not aware the TPL was not completed in the required timeframe. The Assistant Administrator said she did not know why.

Based on observations, staff and resident interviews, record reviews, and review of monthly Resident Council meeting minutes, the facility failed to ensure sufficient staffing to meet the needs of the 180 residents in the facility. Several residents and staff members voiced concerns regarding sufficient staffing, and the facility exhibited failures related to a lack of sufficient staffing throughout the survey. Findings include: A policy on staffing was requested but was not provided prior to survey exit. Review of the monthly Resident Council meeting minutes, provided on paper, revealed concerns of call lights taking too long to be answered were brought up in January 2024, November 2023, October 2023, and June 2023. During Initial Pool interviews and observations, four residents voiced concerns related to a lack of sufficient staffing: -During an interview with a resident who wished to remain anonymous on 02/05/24 at 11:28 A.M., the resident stated there was not enough staff available to answer call lights, especially at night. -During an interview on 02/05/24 at 11:57 A.M., Resident (R)79 stated he/she waited up to an hour at times for his/her call light to be answered and felt like it was related to insufficient staffing. -During an interview on 02/06/24 at 11:41 A.M., R53 stated it could take a long time for call lights to be answered, especially at night. He/She felt there were insufficient staff available to answer call lights in a timely manner. -During an interview on 02/06/24 at 5:04 P.M., R69 stated the facility used a lot of agency staff who did not know the needs of the residents and did not always get the job done. During observations of the night shift on 02/08/24 at 4:45 A.M., Certified Nursing Assistant (CNA) 7 was observed at the 300 Division nurses' station seated in a chair with his/her head on the desk. He/She had a hood over his/her head and a blanket and appeared asleep. At 4:50 A.M., CNA7 awoke when spoken to. He/She stated he/she had just laid down to rest, but was not asleep and stated he/she was resting before he/she had to start getting residents up around 5:00 A.M. CNA7 stated he/she was tired, because he/she had worked two eight-hour shifts in a row. During observations of the night shift on 02/08/24 at 4:55 A.M., CNA16 was observed in a chair in the area around the nurses' station at the 500 Division. His/Her eyes were closed, his/her feet were up on another chair, and he/she was covered in a blanket. At 5:00 A.M., CNA16 awoke when spoken to. He/She stated he/she was resting before starting to make rounds and get residents out of bed. CNA16 stated he/she was tired because he/she had been working for 12 hours. Additional concerns related to short staffing were voiced by the staff during the survey: -During an interview on 02/09/24 at 11:53 A.M., CNA12 stated he/she felt like there was not enough staff to meet the residents' needs and the facility administration did not provide enough help. CNA12 stated agency staff were used to fill in for open shifts; however, the agency staff did not know the needs of the residents and often required help to complete their daily tasks. CNA12 stated when staff called in sick, sometimes the shifts went unfilled. He/She stated it was unfair to the residents and felt like a punishment to all the staff. CNA12 stated sometimes residents did not get their showers because of being short-staffed. He/She also stated the staff were required to check for incontinence at least every two hours for residents with incontinence, and it was difficult to complete those checks timely plus complete all other assigned duties, such as setting up the dining room, serving meals, and cleaning up the dining room. CNA12 stated he/she loved the residents he/she worked with and did not want to leave his/her job, but was considering leaving because of the staffing levels. CNA12 stated he/she had witnessed staff sleeping on the job, especially when arriving in the morning and relieving the night shift staff. He/She stated, I see call lights on not being answered. Last week on 300 [Division], . I walked in and the [night shift staff] was asleep and three call lights were on. The smell hit me before anything. You could tell no one had been changed . There is a resident who digs and eats his/her feces. He/She was supposed to be up, but wasn't, so we had to take care of all that. There were people covered in urine head to toe . I was devastated. During an interview on 02/09/24 at 2:21 P.M., CNA11 stated he/she felt like there were not enough staff and not enough hours in the day to meet the needs of the residents. He/She stated residents and family members were upset, because they did not see the care they were paying for. He/She stated there were not enough staff to provide incontinence checks every two hours. CNA12 added, We do our best . but we need extra staff to help with toileting. He/She stated it was especially hard to find another staff member to help with transfers via mechanical lift when two staff were required. CNA12 stated there were times when staff did not show up for their shift and the shift was not able to be filled. He/She stated this created an additional hardship to get everything done. CNA12 added it was difficult to complete all tasks during mealtime, as CNAs were also responsible for dining room setup and tear down, plating the food, serving the food, and assisting the residents. During an interview on 02/09/24 at 2:55 P.M., Licensed Practical Nurse (LPN) 5 stated he/she did not feel there was enough staff to meet the needs of the residents. He/She stated the nurses had to pick up extra duties, such as assistance with toileting, feeding, or answering call lights, when CNAs were short. He/She stated the nursing staff also had to complete extra dietary and housekeeping duties, as those departments were short-staffed as well. LPN5 stated the CNAs were responsible for setting up and serving food at all meals, and this took away from their resident care duties. He/She stated residents who used a mechanical lift suffered because two staff were required to assist with a transfer. LPN5 stated he/she brought up concerns about staffing to administration several times, but nothing had changed. During an interview on 02/09/24 at 3:21 P.M., CNA9 stated there were not enough staff on the floor to meet residents' needs. He/She stated one of the problems was having the nurse aide students working on the floor who had not yet been trained in all the care the residents required, so the CNAs had to fill in. He/She also stated there was not enough staff during mealtimes to assist the residents to eat, and he/she ended up having to feed two residents at the same time, then stop after a few bites and go to another table, so none of the residents were able to finish their whole meal. CNA9 stated he/she had witnessed night shift staff sleeping on the job upon arrival in the morning, and he/she had brought his/her concerns up to administration, but nothing was done. During the survey, the following deficient practices related to insufficient nurse staffing were identified: -The facility failed to provide checks for incontinence in a timely manner. Cross-reference F677: Activities of Daily Living. -The facility failed to implement interventions to aid in the prevention of falls. Cross-reference F689: Free of Accident Hazards/Supervision/Devices. -The facility failed to implement components of an effective infection control program. Cross-reference F880: Infection Prevention and Control. During an interview on 02/09/24 at 3:33 P.M., the Medical Director stated staffing had been a challenge since the COVID-19 pandemic; however, he had not been directly involved with staffing in building. During an interview on 02/09/24 at 6:40 P.M. with the Administrator, Director of Clinical Services, and Director of Nursing (DON), the Administrator stated he/she was aware of incidents in the last few months of staff sleeping on the job during the night shift. He/She stated staff were never supposed to be sleeping while at the nurses' station; they could sleep during their break in the break room. The Administrator stated he/she had not come in during the night shift to monitor the staff. He/She stated the Nurse Manager used to come in on night shift, but had not been doing that in the last few months. The DON stated he/she had not come in during the night shift at least for the last four months. The Administrator stated, I think our nursing staff ratio is really good. We have good staffing in building. The Administrator stated the facility experienced post-pandemic challenges with staffing in all departments, so all staff worked together to get the work done. The Administrator stated she understood the concerns the nursing staff has voiced regarding serving the meals in addition to other CNA duties; however, That's the way it has always been done. The Director of Clinical Services stated the facility was actively recruiting staff and implementing things like job fairs, wage increases, recruiting at nursing schools, and hiring bonuses. The Administrator added they had advertised positions on websites held job fairs every quarter.

Based on observation, interview, review of Resident Council Meeting notes, and policy review, the facility failed to serve hot foods at palatable temperatures for seven of 40 sampled residents (Resident (R) 6, R64, R57, R75, R123, R143, and R146). This failure had the potential to contribute to decreased intake by residents. Findings include: A review of the facility policy titled Enhancing the Dining Experience, from the Dining Services policy and procedures manual, dated 2014, number 11 of 12 listed tasks stated that the meals were to be served in an attractive manner; served at the appropriate temperature; served according to safe food handling practices, and meets the residents' individualized needs. Review of the Resident Council Meeting notes, provided by the facility, revealed two previous food temperature group complaints were recorded on 07/24/23 and 11/27/23. During observation of the lunch meal service on 02/06/24 at 12:30 P.M., R64 was served lunch and ate less than 25 percent of his/her meal. R64 stated his/her food did not look appetizing or taste good. Observation on 02/08/24 11:59 A.M., revealed resident meals being delivered to resident rooms were covered with clear thin plastic wrap. During the group Resident Council interview on 02/08/24 at 1:46 P.M., R6, R57, R75, R123, R143, and R146 stated the food was sometimes served cold. During observation of meals served to residents in their room on 02/09/24 at 2:22 P.M., a test tray was provided to the surveyor. The meal cart transported eight food trays that revealed a thin plastic wrap covering the plates of food, no heated base or other insulation, and a clear thin plastic film was draped over the cart. The measured temperature of food served on the test tray revealed the protein meat (polish sausage on a bun) measured at 115 degrees Fahrenheit (F) and the vegetable (sauerkraut) was served at a temperature measured at 116 degrees (F). The Dietary Manager (DM) was present and confirmed the temperature of the food on the test tray. The DM stated she was aware of the low temperature of the food served to residents in their room, but did not have serving equipment that would contain the heat of the food until received by the resident.

Based on observations, resident and staff interviews, record reviews, and review of the Administrator's Job Description, the facility failed to ensure good faith attempts were made to correct quality deficiencies through their Quality Assurance and Performance Improvement (QAPI) process. The Administration had not implemented any QAPI programs to address the ongoing COVID-19 and respiratory syncytial virus (RSV) outbreaks. Additionally, the administration failed to identify sufficient staffing as a possible quality deficiency. These failures placed all facility residents at risk for transmission of COVID-19 and RSV and accidents, unmet needs, and lack of incontinence care related to insufficient staffing. Findings include: Review of the undated Job Description - Administrator revealed, Assist with all aspects of Quality Assurance . [and] Ensure that each resident receives the necessary nursing, medical, and psychosocial services to attain and maintain the highest possible mental and physical functional status possible. Throughout the survey, the following deficient practices were identified: 1. The facility failed to ensure sufficient staffing to meet the needs of the 180 residents in the facility. Several residents and staff members voiced concerns regarding sufficient staffing, and the facility exhibited failures related to a lack of sufficient staffing throughout the survey. Observations on the night shift revealed staff asleep at the nurses' stations. Several staff members stated they had voiced concerns to administration related to the current staffing levels and extra duties, such as serving meals; however, no changes had been made. Cross-reference F725: Sufficient Nurse Staffing. During an interview with the Administrator, Director of Nursing (DON), and Director of Clinical Services on 02/09/24 at 6:40 PM, the Administrator confirmed she was aware of instances of staff sleeping during the night shift. However, the Administrator and DON both stated they did not visit the facility on the night shift to monitor the staff. The Administrator stated, I think our nursing staff ratio is really good . We have good staffing in building but also explained there were post-pandemic challenges with all departments and there were efforts to hire more staff and use less agency staff. The Administrator stated she had heard complaints from the nursing staff, especially about serving food at meals, but stated, This is the way it has always been done. During an interview with the Administrator, DON, and Director of Clinical Services on 02/09/24 at 7:42 PM, the Administrator stated the QAPI committee interviewed and listened to the concerns of the Certified Nursing Assistants (CNAs) and nurses and incorporated their concerns into the QAPI program. However, the Administrator stated the facility had not brought any of the staffing concerns to the QAPI committee for improvement activities, such as increased monitoring of night shift staff or auditing of resident care to determine appropriate staffing levels to meet the residents' needs. The Administrator stated, Personally, I don't think staffing is a problem. The Director of Clinical Services added the facility had implemented plans to decrease reliance on agency staffing to improve the continuity and quality of care; however, this was not included in the QAPI program. 2. The facility staff failed to wear appropriate personal protective equipment (PPE) when providing care to residents on transmission-based precautions, doff (take off) soiled PPE prior to exiting the room, complete resident testing upon new positive cases of COVID-19 in the building, complete contact tracing for staff that were in close contact with COVID-19 or exposed to RSV, ensure appropriate staff testing during an outbreak of COVID-19, and ensure appropriate cohorting of residents within close contact to COVID-19 and RSV. Cross-reference F880: Infection Control. During an interview with the Administrator, DON, and Director of Clinical Services on 02/09/24 at 7:42 PM, the Administrator stated the QAPI committee discussed the type of infections in the facility and antibiotic use; however, the committee had not identified the outbreak that began on 11/09/23 and affected 46 residents as an area for potential performance improvement. The Administrator stated the RSV outbreak was too recent to be discussed in the QAPI committee, and the recent COVID-19 outbreak was not too severe. The Director of Clinical Services stated the facility had an interdisciplinary team meeting when they started to see their numbers increasing; however, this was not documented or incorporated into the QAPI program. 3. The facility failed to ensure two (Resident (R) 100 and R147) of four residents reviewed for activities of daily living received assistance with incontinence care and/or using the toilet as needed. These failures created a potential for skin problems, urinary tract infections, or increased incontinence for these two residents. Cross-reference F677: Activities of Daily Living. During an interview on 02/09/24 at 6:40 PM with the Administrator and DON, the Administrator confirmed her expectation was that staff provided incontinence checks/care at least every two hours. The DON stated this was a problem and the staff had received frequent education to provided care every two hours. She stated, however, that she had not conducted audits to monitor staff compliance. During an interview with the Administrator, DON, and Director of Clinical Services on 02/09/24 at 7:42 PM, the Administrator stated there was no QAPI monitoring of toileting/incontinence care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, review of the Centers for Disease Control (CDC) guidelines, and facility policy review, the facility failed to: 1. Wear appropriate personal protective equipment (PPE) when providing care to residents on transmission-based precautions. 2. Doff (take off) soiled PPE prior to exiting the resident's room. 3. Complete resident testing upon new positive cases of COVID-19 in the building. 4. Complete contact tracing for staff that were in close contact with COVID-19 positive residents or exposed to Respiratory Syncytial Virus (RSV) positive residents 5. Provide evidence of staff testing done during an outbreak of COVID-19. 6. Ensure appropriate cohorting of residents within close contact to other COVID-19 and RSV positive residents. This affected 49 (Residents (R) 116, R46, R121, R65, R81, R72, R13, R157, R14, R96, R67, R172, R88, R92, R134, R221, R111, R173, R156, R174, R83, R130, R175, R158, R114, R176, R4, R177, R159, R131, R273, R272, R178, R28, R179, R108, R102, R87, R171, R155, R118, R55, R62, R13, R64, R139, R108, R106, R85, and had the potential to affect all 180 residents of the facility. Findings include: Review of the facility policy titled, Infection Control Policy and Procedure Manual revised 06/2020 revealed, It is the policy of this community to, when necessary; prevent the transmission of infections within the community through the use of Isolation Precautions. The 2007 Centers for Disease Control and Prevention (CDC) Guidelines for Isolation Precautions will be utilized in this community with some modifications .Droplet Precautions: In addition to Standard Precautions, use Droplet Precautions for a resident known or suspected to be infected with microorganisms transmitted by droplets .Contact Precautions: In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact .All personal protective equipment (disposable isolation gowns, mask, gloves, etc.) should be used once and discarded in either the trash or used linen receptacle before you leave the room .Contact tracing will be completed for any staff who have had prolonged contact with a person with confirmed COVID-19 . Close contact is defined as being within six feet for a cumulative total of 15 minutes or for over a 24-hour period with someone with COVID-19 infection . test is recommended on day 1 (not earlier than 24 hours after the exposure, if known. If negative, test again on day three and day five. If additional positives are identified, repeat testing with antigen testing every three days until there are no new cases for 14 days on the affected unit(s). Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 06/08/23 and accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed, A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP [health care professionals] identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Review of the CDC Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 12/05/23 and accessed at https://www.cdc.gov/longtermcare/prevention/viral-respiratory-toolkit.html, revealed, Prepare for respiratory viruses (e.g., SARS-CoV-2, influenza, RSV) . Roommates of symptomatic residents - who have already been potentially exposed - should not be placed with new roommates, if possible. They should be considered exposed and wear a facemask for source control around others. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 06/08/23 and accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed, Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 06/08/23 and accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed, HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 [COVID-19] infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the CDC Transmission Based Precautions, dated 01/07/16 and accessed at https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html revealed, Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Review of the CDC's Respiratory Virus Toolkit (cdc.gov), revealed Residents: Apply appropriate Transmission-Based Precautions for symptomatic residents based on the suspected cause of their infection. Roommates of symptomatic residents - who have already been potentially exposed - should not be placed with new roommates, if possible. They should be considered exposed and wear a facemask for source control around others. 1. Review of the facility's ongoing Line Listing provided on paper revealed an outbreak of COVID-19 began in the facility on 11/09/23 with R116 and spread to 15 additional residents (R46, R121, R65, R81, R72, R13, R157, R14, R96, R67, R172, R88, R92, R134, and R221) during November 2023 through Divisions 100, 300, 400, and 600. In December 2023, an additional 22 residents (R111, R173, R156, R174, R83, R130, R175, R158, R114, R176, R4, R177, R159, R131, R273, R272, R178, R28, R179, R108, R102, and R87) tested positive for COVID-19 throughout all Divisions (100, 200, 300, 400, 500, and 600). In January 2024, an additional five residents (R171, R155, R118, R55, and R62) tested positive for COVID-19 in Divisions 200, 300, 400, and 700. From 02/01/24 to 02/05/24, three additional residents (R13, R108, R72) tested positive for COVID-19 in Divisions 200, 300, and 400. The facility did not provide any records of staff testing for November 2023 and did not provide tracking of staff COVID-19 infections from 11/09/23 to 02/05/24. There was no documentation of contact tracing for all positive cases to ensure testing of any residents or staff within close contact were tested as needed. 2. Review of the facility's ongoing Line Listing and resident testing records, provided on paper, revealed: -R273 was diagnosed with COVID-19 on 12/24/23. R273 resided on Division 200, but there was no record of any Division 200 resident testing until 12/27/23. -On 12/24/23, R272 was diagnosed with COVID-19. R272 resided on Division 300, but division 300 residents were not tested until 12/31/23. -On 01/19/24, R62 was diagnosed with COVID-19. There were no records of resident testing in January 2024. -On 01/23/24, R171 was diagnosed with COVID-19. There were no records of resident testing in January 2024. -On 01/30/24, R155 was diagnosed with COVID-19. There were no records of resident testing in January 2024. 3. Review of the facility's ongoing Line Listing and Roommate Tracking Record, provided on paper revealed: -R28 was diagnosed with COVID-19 on 12/27/23. His/Her roommate, R113, was moved to a room with R112, who was not exposed or positive, on 12/28/23. -R83 was diagnosed with RSV on 01/16/24. His/Her roommate, R75, was moved to a room with R92, who was not exposed or positive, on 01/17/24. -R85 was diagnosed with RSV on 01/19/24. His/Her roommate, R110, was moved to a room with R54, who was not exposed or positive, on 01/22/24. 4. Review of R118's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE]. Review of the facility's ongoing Line Listing, provided on paper, revealed R118 was diagnosed with COVID-19 on 01/31/24. During an observation and interview on 02/06/24 at 10:30 A.M., R118's room door had signage and PPE for contact and droplet precautions and the bin to dispose the PPE was outside the door in the hallway; there was no hand sanitizer available in the room or on the door. Certified Nursing Assistant (CNA) 3 exited the room while wearing his/her gloves, gown, face shield, and mask and carrying a dirty meal tray in one hand. He/She doffed his/her gloves, gown, mask, and shield in the hallway, put the tray on the cart, and walked down the hall to the hand sanitizer dispenser at least 20 feet away across from the soiled utility room. All other residents who resided on the hall where the CNA walked through were negative, and often passed by the room and the dirty PPE container in the hallway. 5. Review of R106's Significant Change of Status Minimum Data Set (MDS) assessment, dated 12/28/23 and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed he/she was admitted to the facility on [DATE]. Review of the facility's ongoing Line Listing, provided on paper, revealed R106 was diagnosed with RSV on 02/03/24. During an observation and interview on 02/06/24 at 2:06 PM, R106's room door had signage and PPE for contact and droplet precautions and the bin to dispose the PPE was outside the door in the hallway; there was no hand sanitizer available in the room or on the door. CNA2 entered R106's room wearing a gown, mask, and gloves; CNA2 did not wear any eye protection. CNA2 confirmed that eye protection was available, but did not think about putting it on. No trash bin was available inside the room to dispose of soiled PPE and CNA2 exited the room without doffing the PPE. 6. Review of R13's Significant Change of Status MDS assessment, dated 12/31/23 and located in the RAI tab of the EMR, revealed he/she was admitted to the facility on [DATE]. Review of the facility's ongoing Line Listing, provided on paper, revealed R13 was diagnosed with COVID-19 on 02/01/24. During observation on 02/06/24 from 2:45 PM to 3:30 PM, R13's room door had signage and PPE for contact and droplet precautions and the bin to dispose the PPE was outside the door in the hallway. The bin was overflowing with used PPE and uncovered; there was no hand sanitizer available in the room or on the door. There was a large bin in the room for linen that was empty. 7. Review of R72's Quarterly MDS assessment, dated 11/02/23 and located in the RAI tab of the EMR, revealed he/she was admitted to the facility on [DATE]. Review of the facility's ongoing Line Listing, provided on paper, revealed R72 was diagnosed with COVID-19 on 02/02/24. During observation on 02/06/24 at 3:45 PM, R72's room door had signage and PPE for contact and droplet precautions and the bin to dispose the PPE outside the door in the hallway; the bin was overflowing with used PPE and was uncovered. 8. Review of R64's Face Sheet located in the Electronic Medical Record (EMR) under the Resident tab revealed he/she was admitted to the facility on [DATE]. Review of the facility provided document titled, Line Listing R64 was diagnosed with RSV on 01/31/24. Review of R139's Minimum Data Set (MDS) located in the EMR under the RAI (Resident Assessment Instrument) tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of non-traumatic brain dysfunction. Review of the facility provided document titled, Line Listing R139 was diagnosed with RSV on 01/28/24. During an observation and interview on 02/06/24 at 12:34 PM CNA1 entered R64 and R139's room who were both on droplet and contact precautions for RSV. Signs were posted on the door that all staff entering the room should wear full PPE for contact and droplet precautions, including gown, gloves, mask, and eye protection. CNA1 donned a gown and mask only and entered the room to deliver meal trays. CNA1 delivered R64's meal tray, moved R64's over-bed side table, raised the head of the bed, and emptied a beverage cup in the sink. He/She did not sanitize or wash his/her hands prior to serving R139. CNA1 confirmed that he/she should have worn eye protection and gloves. At 12:45 PM CNA1 exited the room while wearing his/her soiled PPE and proceeded to remove his/her PPE outside the R64's room and disposed of the PPE in a bin outside of the room in the hallway. At 1:00 PM the Director of Nursing (DON) entered the room wearing a mask, gown, and gloves. The DON confirmed that she and CNA1 should have been wearing full PPE including eye protection. There was a trash bin observed outside the residents' rooms with soiled PPE. There was no hand sanitizer in the room for staff to use prior to exiting. There was no bin for soiled linens inside the room. 9. During an interview on 02/06/24 at 2:04 PM, the Infection Preventionist (IP) stated the facility did not document tracing of staff who came in close contact with positive residents and employees were responsible for testing themselves and did not report their results to her. She did not document who needed a test, when they tested, or the results and expected the staff to report a positive test. The IP stated, we just believe our employees and expect them to be truthful. The IP stated she did not have a way of ensuring all employees with close contact were tested and did not have a way to trace whether additional facility staff assigned to other areas worked with the positive resident. Additionally, the IP revealed she was told by the DON that staff should doff soiled PPE outside of the infected resident's room and place the PPE in the trash bin just outside the door, and soiled linen should go in a trash can inside the room. The IP revealed she was not aware that staff were not wearing all necessary PPE for residents on transmission-based precautions. Her expectation was for the staff member to wear a mask, gloves, eye protection, and a gown when in the rooms of residents on contact and droplet precautions. The IP stated when a resident tested positive for COVID-19, their roommate would be moved to another room. Ideally, they would be moved to a private room; however, if none were available, they would be moved to a room with another resident who was not positive and had not been exposed, and there was no additional testing of the new roommate. During an interview on 02/06/24 at 3:30 PM with Licensed Practical Nurse (LPN) 2, he/she stated he/she did not know who was responsible to maintain and/or empty the bins with used PPE outside the rooms so they did not overflow. During an interview on 02/09/24 at 3:33 PM, the Medical Director stated the Administrator and DON had not reached out for guidance in handling the ongoing outbreak and he had not been involved in surveillance, contact tracing, outbreak testing, or cohorting decisions. The Medical Director stated he did not know what the current CDC recommendations were related to a COVID-19 outbreak.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three residents did not run out of their medications and the resident, resident's physician and/or family were notified when their medications were unavailable for administration (Residents #4, #6 and #2). In addition, the facility failed to ensure one resident with an admission order to use an incentive spirometer had and used an incentive spirometer (a medical device used to exercise the lungs after an illness or a surgery) (Resident #1). The census was 191. Review of the facility Medication Administration policy, revised on 1/2021, included the following: General: -Only licensed Registered Nurses (RN's), Licensed Practical Nurses (LPN's) or Certified Medication Technicians (CMTs) are assigned responsibility for preparing, administering and recording of medications, or permitted access to drug storage areas on each nursing unit; -Medication and treatment errors and undesirable effects are to be immediately reported to the Director of Nursing (DON) or nursing designee and the attending physician, charted in detail on the progress notes, and described in a full incident report; -Personnel administering drugs are to refer to the PDR (physician's desk reference - a drug reference), or its equivalent, when unfamiliar with the pharmacology of the drug, its potential toxic effects or contraindications; -If a medication is not available from the pharmacy, the attending physician is to be notified for an alternative. Review of the Pharmacy Policy/Procedures, Emergency Drug Supply, undated, included the following: Pharmacy Responsibility: -Emergency drug supply refers to medication kept at the facility for stat (immediate) medication doses. These medications will be kept in the StatSafe. An emergency drug kit is supplied by the pharmacy if appropriate for the facility; Facility Responsibility: - An emergency drug kit is available at the facility. A list of contents of this kit is kept with the kit; -When a resident has an order for a medication that needs to be started prior to the next delivery from pharmacy, the medication can be pulled from the emergency kit to get them started; -Ensure that the correct medication/dose is taken from the emergency kit to match the resident's order. Review of the facility Charge Nurse job description, undated, included the following: Reports To: -DON/Nursing Administration; Purpose: -To provide direct nursing care to the residents, and to supervise and lead the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the DON to ensure that the highest degree or quality care is maintained at all times; Duties Include: -Place phone calls to the physician to report patient's condition changes, need for medication changes, accident/incidents, behavior changes, etc.; -Enter orders in Matrix (electronic medical record (EMR)) for all orders changed by the physician over the phone; -Notify family members of any changes, transfers out of the facility or any other significant or insignificant needs of the resident; -Prepare, administer and chart medication according to house policy; -Perform all skilled nursing procedures according to house policy; -Complete the admission process on all new admits received during your scheduled shift. If unable to complete the admission process on your shift, give the oncoming nurse a detailed report of what is completed/not completed; -Maintain frequent communication with the DON on the conditions existing on your assigned division; -See that all physician's orders are carried out or appropriate arrangements made;' -Re-order medications as needed. Review of the facility Certified Medication Technician job description, undated, included the following: Reports To: -Charge Nurse and/or Nursing Administration; Purpose: -To assist in administering of medications to residents as ordered by the attending physician, under the direction of the attending physician, the nurse supervisor or charge nurse, and DON. The administration of medication shall be in accordance with established nursing standards, the policies, procedures, and practices of this facility and the requirement of this stats; Duties Include: -Complete and accurate charting in the medication administration record (MAR) according to facility policy and procedures; -Administer medications; -Prepare, administer and chart on all medication and report observation to charge nurse; -Pour and pass medications to all residents according to their medication sheets, crushing medications as ordered; -Add new medications and reordered medications to proper areas of the medication cart and storage areas; -Understands that errors in preparing or administering medication may have serious consequences for residents; -Can identify what constitutes a medication error and notifies charge nurse of error. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/16/23, showed: -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Behavioral Symptoms: No behaviors exhibited; -Rejection of Care: Behavior not exhibited; -Limited assistance of one person required for bed mobility, transfers and dressing; -Eating: Independent, setup assistance only; -Diagnoses of medically complex conditions, anemia (a deficiency of oxygen carrying blood), high blood pressure, diabetes mellitus (insufficient insulin production characterized by high blood sugar), anxiety and depression. Review of the resident's care plan, showed: Problems: -Cognitive Loss/Dementia; -Diabetes; -Activities of Daily Living Status(ADL)/Rehabilitation Potential; Approaches: -Administer oral diabetic medications per physician's orders; -Monitor blood sugars as ordered; -Assist of one person for bed mobility, transfers, and dressing/hygiene. Review of the resident's physician's order sheet (POS), showed: -An order dated 10/11/22, for levothyroxine (thyroid medication that replaces a hormone normally produced by the thyroid gland to regulate metabolism) 75 micrograms (mcg) once a morning at 6:00 A.M.; -An order dated 10/11/22, for metformin (an anitdiabetic agent that manages high blood sugar levels in diabetes mellitus) 1000 milligrams (mg) twice a day at A.M. med pass (7:15 A.M. - 11:15 A.M.) and hour of sleep med pass (7:15 P.M. - 11:00 P.M.). Review of the resident's medication administration record (MAR), dated 6/1/23 through 6/26/23, showed staff documented unavailable on the following dates and times: Levothyroxine 75 mcg at 6:00 A.M.: 6/2, 6/3, 6/6, 6/7 and 6/8; Metformin 1000 mg: -7:15 A.M. - 11:15 A.M.: 6/17, 6/18, 6/21, 6/22, 6/24, 6/25 and 6/26; -7:15 P.M. - 11:00 P.M.: 6/15, 6/17, 6/21, 6/22, 6/23, 6/24 and 6/25. Review of the resident's progress notes from 6/1/23 through 6/27/23, showed no documentation that staff notified the resident, resident's physician or family about the missing doses of the levothyroxine and metformin. During an interview on 6/27/23 at 12:43 A.M., the resident said no one had told him/her he/she had missed any doses of his/her levothyroxine and metformin. He/She would have liked to have been informed of that. During the interview, Nurse Practitioner (NP) J entered the room. He/She said he/she is in the facility every day Monday through Friday. He/She had not been told by staff the resident missed any doses of the levothyroxine or metformin. They should have told him/her. During an interview on 6/30/23 at 12:30 P.M., the Director of Nurses (DON) said she did not know why the resident's levothyroxine and metformin were unavailable. The computer system has a refill tab that a CMT or Nurse can use to reorder a medication before it runs out. The CMTs and Nurses should communicate when a medication is unavailable. The Nurse should contact the resident's physician and representative when a medication is not administered as ordered. It should be documented. 2. Review of resident #6's admission MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Behavioral Symptoms: No behaviors exhibited; -Rejection of Care: Behavior not exhibited; -Independent for bed mobility; -Supervision-oversight required for transfers; -Diagnoses of medically complex conditions, anemia, wound infection, anxiety and depression. Review of the resident's care plan, showed: Problems: -Skin: Surgical incision/wound located on sternum (chest) that is non-healing; -Nutritional Status: Has potential for nutritional variances due to anemia; -ADL Functional Status/Rehabilitation Potential: Independent for bed mobility and transfers Approaches: -Provide wound healing supplements per physician order; -May consult with Registered Dietician (RD) due to anemia. Review of the resident's progress note, dated 6/13/23 at 1:52 P.M., and documented by the RD, showed the resident had a surgical incision on the chest. Recommend Juven (therapeutic nutrition powder given for nutrition and wound healing) twice a day for wound healing. Review of the resident's POS, showed: -An order dated 6/9/23 for ferrous gluconate (a type of iron used to treat anemia) 324 mg one time a day at A.M. Med Pass (7:15 A.M. - 11:15 A.M.); -An order dated 6/13/23 for Juven two packets a day, A.M. Med Pass and 3:15 P.M. - 6:45 P.M. Review of the resident's MAR, showed staff documented unavailable on the following dates and times: Ferrous gluconate 324 mg: 6/9, 6/10, 6/11 and 6/12; Juven: -7:15 A.M. - 11:15 A.M.: 6/19 and 6/23; -3:15 P.M. - 6:45 P.M.: 6/22 and 6/23. Review of the resident's progress notes from 6/9/23 through 6/23/23, showed no documentation that staff notified the resident, resident's physician or family about the missing doses of ferrous gluconate and Juven. 3. Review of Resident #2's admission MDS, dated [DATE], showed: -admission date of 4/23/23; -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Behavioral Symptoms: No behaviors exhibited; -Rejection of Care: Behavior not exhibited; -Extensive assistance of one person required for bed mobility, transfers and dressing; -Eating: Independent, setup assistance only; -Diagnoses of stroke and thyroid disorders; -Cancer not indicated; -Special Treatments: Chemotherapy while a resident. Review of the resident's care plan, showed: Problems: -ADL functional status/rehabilitation potential; -Pressure Ulcer/Injury: Unspecified ulcer to the left lateral shin; Approach's: -Transfer Status, Bed Mobility: Assist with one; -Staff to monitor skin during care. Nursing to complete weekly skin audits and document as required. Review of the resident's POS, showed: -An order dated 4/23/23 for Mucinex DM (used to treat cough and chest congestion caused by the common cold or allergies) two tablets every 12 hours at 8:00 A.M. and 8:00 P.M. Review of the resident's MAR from 5/1/23 through 6/22/23, showed staff documented the Mucinex DM was unavailable on the following dates and times: -8:00 A.M.: 5/21, 5/22, 5/23, 5/24, 5/25, 6/10, 6/11 and 6/12; -8:00 P.M.: 5/21, 5/22, 5/23, 5/24, 5/25 and 6/10. Review of the resident's progress notes dated 5/21/23 through 6/10/23, showed no documentation that staff notified the resident, resident's physician or family about the missing doses of Mucinex DM. During an interview on 6/27/23 at 11:18 A.M., Nurse G said Mucinex DM is a OTC medication that is in the facility stock room so he/she does not know why the resident would not have received it. The CMTs did not tell him/her about the medication being unavailable or he/she would have told them to check the stock room. He/she went to the supply room and returned with a bottle of Mucinex DM. During an interview on 6/27/23 at 12:15 P.M., the resident said he/she not aware he/she missed doses of Mucinex DM. No one told him/her. He/she would have liked to have been informed. 4. Review of Resident #1's admission MDS, dated [DATE], showed: -admission date of 4/28/23; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Extensive assistance of one person required for bed mobility, transfers, locomotion on/off the unit and dressing; -Limited assistance of one person required for personal hygiene; -Diagnoses of medically complex conditions, cancer (with or without metastasis (the spread of an pathogenic agent from a primary site to a secondary site within the body)), thyroid disorder and respiratory failure. Review of the resident's care plan showed: Problem: -ADL Functional Status/Rehabilitation; Approaches: -Assist resident with repositioning in bed and in wheelchair frequently; -Assistance of one with transfers and bed mobility. Review of the resident's hospital admission orders, dated 4/28/23, showed: Primary Discharge Diagnoses: -Adrenal mass (adrenal gland, located on top of both kidneys) with left adrenalectomy (surgical removal of one or both adrenal glands) and left nephrectomy (surgical removal of a kidney); -An order for the resident to continue to use a incentive spirometer. Review of the resident's POS, MAR and treatment administration record (TAR), from 4/28/23 through 5/14/23, showed no order for the incentive spirometer. During an interview on 6/26/23, the DON said the admission nurse should have clarified the order for the incentive spirometer (when and how often should it be used) and placed on the resident's POS and TAR. 5. During an interview on 6/26/23 at 8:06 A.M., CMT A said CMTs are supposed to let the nurses know if the medication is not available. He/She is supposed to reorder a medication when it is down to the last 7 doses. During an interview on 6/26/23 at 8:06 A.M., CMT A said when a medication is down to the last 7 doses, you are supposed to pull the label and order it from the pharmacy. He/She always informs the charge nurse when a medication is unavailable. During an interview on 6/26/23 at 8:25 A.M., Nurse B said CMTs should let the nurse's know when a medication is getting low so the nurse's can contact the family or pharmacy to reorder the medication. If the resident misses a dose of any medication, CMTs should let the nurse's know so the resident's physician and responsible party can be notified. This should be documented in the resident's progress notes. During an interview with the Director of Clinical Services, Administrator and DON on 6/26/23 at 9:50 A.M., the DON said if a medication is unavailable for any reason, CMTs should let the Nurse know. The Nurse or CMT should contact the pharmacy to find out how long a medication will be unavailable. Staff should check the facility medication supply room for any OTC medication that is needed. The Nurse should update the resident's physician, the resident and the resident representative and document it in the progress notes. The Director of Clinical Services said staff should reorder a medication when the medication is down to it's last three days. If a medication cannot be obtained, staff should document who they spoke to, what was discussed and any new orders they received in the progress notes. During an interview on 6/26/23 at 12:33 P.M., CMT C said if a medication is unavailable, they are supposed to order it from the pharmacy. A medication should be reordered when there was 7 days left to ensure it is delivered before running out. During an interview on 6/26/23 at 1:05 P.M., CMT D If a medication is unavailable he/she would tell the nurse. If the medication is reordered through the pharmacy, he/she would call the pharmacy and tell the nurse. During an interview on 6/27/23 at 8:22 A.M., the DON said the electronic MAR would not alert staff if a medication was unavailable on previous days unless staff click on the look-back tab, which would show the last 14 days. This past May, she realized there was a problem with residents missing their medications. At that time she began to print off a daily missed medication report. She had been giving those reports to the Nurse Managers to follow up. She had not been checking with the Nurse Managers to ensure they were following up though. During an interview on 6/27/23 at 11:18 A.M., Nurse G said any time a medication is not administered for any reason, the CMT should notify the Nurse. Part of their protocol is to also call the physician and family if a dose is missed and document it in the progress notes. MO00219644

Based on interview and record review, staff failed to contact one resident's physician on 5/13/23, after Nurse Practitioner (NP) I noticed increased swelling in the resident's left lower leg and recommended staff contact the resident's physician and obtain an ultrasound (an imaging test using sound waves) of the left lower extremity to rule out a deep vein thrombosis (DVT, blood clot). The resident was sent to the emergency room on 5/14/23, where he/she was diagnosed with a DVT (Resident #1). The census was 191. Review of the facility Condition Change, of the Resident policy, revised 7/21, showed: -Purpose: To observe, record and report any condition change to the attending physician so proper treatment will be implemented; -Procedure: -After all resident falls, injuries or changes in physical or mental function, monitor the following: -Observe for swelling and discoloration; if present, chart size, site, amount, and color; -Observe for pain. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/5/23, showed: -admission date of 4/28/23; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Required extensive assistance of one person for bed mobility, transfers, locomotion on/off the unit and dressing; -Required limited assistance of one person for personal hygiene; -Diagnoses of cancer, thyroid disorder and respiratory failure. Review of the resident's undated care plan, showed: -Problem: -Skin; -Activity of Daily Living (ADL) Functional Status/Rehabilitation; -Approaches: -Observe and report signs of localized infection (e.g. localized pain, redness, swelling, tenderness, loss of function, heat at infected area); -Assist resident with repositioning in bed and in wheelchair frequently; -Assistance of one with transfers and bed mobility. Review of the resident's progress notes, showed: -5/13/23 at 2:30 P.M. and documented by NP I: Chief complaint: Mobility and ADL deficits secondary to adrenal mass and status post open left adrenalectomy (surgical removal of adrenal glands), radical nephrectomy (surgical removal of one or both of the kidneys), lymph node dissection, now with lower extremity edema, left (lower extremity) greater than right. Assessment/Plan: Bilateral lower extremity edema, left greater than right. May be prudent to test ultrasound to rule out DVT. Nursing is notifying physician; -No documentation between 5/13/23 at 2:30 P.M. and 5/14/23 at 5:02 P.M., showing nursing staff contacted the resident's physician to update him about NP I's assessment of increased swelling in the left lower extremity and recommendation for an ultrasound to rule out a DVT; -5/14/23 at 5:02 P.M.: Resident's family has concern about edema (swelling) to the left leg, edema is non-pitting (no indention remains in the skin after pressure is applied with a finger), thigh to foot compression stockings (used to help prevent clots and swelling in the legs) in place, pedal (foot) pulses intact. Resident has no complaints of pain or discomfort, no shortness of breath or cough noted. Resident's family said resident has a cough although none observed by staff. Resident's family said they called a friend who is a physician and was told the resident needs to go to the emergency room. Resident's physician notified of concerns and gave order to send resident out per family request. Review of the resident's hospital emergency department records beginning 5/14/23 at 8:05 P.M., showed: -Resident presenting for left leg swelling. Resident reports he/she had bilateral leg swelling since his/her surgery, however his/her left leg has been more swollen over the past couple of days. He/she has been wearing compression stockings. Resident found to have left lower extremity DVT. During a telephone interview on 6/26/23 at 1:56 P.M., Certified Nursing Assistant (CNA) E said he/she took care of the resident on 5/14/23, during the day shift. The resident's legs were always somewhat swollen, but he/she did not recall any changes to his/her legs at that time. He/She put the resident's compression stockings on the resident that morning and took them off later that day. CNA E did not see any redness or feel any warmth in the legs. The resident did not complaint to him/her about his/her left lower leg. During an interview on 6/27/23 at 9:15 A.M., NP I said he/she saw the resident on 5/13/23. The resident was in his/her room with his/her spouse. He/She was wearing thigh high compression stockings, but he/she did not remove the compression stockings, but he/she did notice the resident's left leg was bigger than the right. He/She palpated the right leg but did not feel any warmth. He/She told the nurse, but could not recall which nurse, to call the resident's physician and request an ultrasound to rule out a DVT. He/She cannot write the orders himself/herself because he/she is on a consulting basis only for residents who are receiving skilled therapy. He/She expected the nurse to have contacted the resident's physician with his/her recommendations. During an interview on 6/27/23 at 12:33 P.M., Nurse F said he/she worked on the day shift on 5/13/23 and 5/14/23. He/She did not recall NP I telling him/her to contact the resident's physician to request an ultrasound of the resident's left leg. He/She was not aware the resident had increased swelling in the left leg. During an interview on 6/22/23 at 1:30 P.M., the facility Wound Nurse said the resident did not have any wounds so she did not see the resident. No one told her the resident had increased swelling in his/her left leg. During an interview on 6/27/23 at 10:08 A.M., the Director of Nurses said she did not know what nurse NP I had asked to notify the resident's physician recommending an ultrasound. She expected that nurse to have contacted the physician per NP Is recommendation and documented it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff would follow the resident's wishes to request or refuse lifesaving treatments in the event the resident was found with no signs of life, by failing to ensure the resident's code status was consistently documented in the medical record, for two residents (Residents #134 and #136). In addition, the facility failed to have a written policy to implement advanced directives. The sample was 24. The census was 155 with 137 in certified beds. During an interview on [DATE] at 11:20 A.M., the administrator said the facility does not have an advance directive policy. 1. Review of Resident #134's electronic medical record, showed: -An electronic face sheet with an admission date of [DATE]; -A physician order dated [DATE], for cardio pulmonary resuscitation (CPR, lifesaving measures are to be performed); -No documentation the resident's wishes for code status were discussed with the resident or resident's representative and/or if the resident's wishes were to receive CPR. Review of the code status binder, located at the nurse's station, showed no documentation of the resident's code status. 2. Review of Resident #136's electronic medical record, showed: -An electronic face sheet with an admission date of [DATE]; -An active physician order for CPR; -No documentation the resident's wishes for code status were discussed with the resident or resident's representative and/or if the resident's wishes were to receive CPR. Review of the code status binder, located at the nurse's station, showed no documentation of the resident's code status. 3. During an interview on [DATE] at 9:20 A.M., Social Services A said when a resident is admitted , admissions is responsible for obtaining advance directives information and then nursing is notified. If the resident does not have an advanced directive, then staff should let the social worker know and facility staff take care of it immediately. The orders come from the physician. There is also a book on the units with code status. If not in the book or in the notes, facility staff call family immediately and assume full code until told otherwise. If the resident is their own responsible party, then facility staff would ask the resident their preference. A resident's code status is reviewed at care plan meeting, on admission, quarterly, annual, and with any significant change. 4. During an interview on [DATE] at 9:35 A.M., medical records staff said if a resident is a full code then they should have a physician note and a progress note or documentation of code status. If the resident is not their own responsible party, there should be a note in the electronic medical record that the family was notified. The facility only has the resident sign an advanced directives form if they are a Do Not Resuscitate (DNR, no lifesaving measures performed). If the resident is a full code, not having an advance directive is appropriate, but no progress note is not. The staff should check code status every time they do a care plan meeting. Then it is reviewed quarterly for the long term residents. The medical records staff looked up Residents #134 and #136 and verified both had a full code order but no progress note showing the code status had been discussed with the resident or the resident's responsible party. 5. During an interview on [DATE] at 10:20 A.M., the Director of Nursing said the nurse is responsible for documenting the resident's code status. If they are a DNR, then facility staff fill out the code status sheet. If they are full code, then it is noted in the admit progress notes and should be done as soon as they are admitted .

Based on interview and record review, the facility failed to provide the appropriate Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notices (SNF ABN) for two of two residents sampled as part of the Beneficiary Notice review who remained in the facility after being discharged from skilled services (Residents #7 and #43). The census was 155 with 137 residents in certified beds. 1. Review of the list of residents discharged from skilled services within the last six months, provided by the facility, showed Resident #7 discharged from skilled services on 7/5/21, and remained in the facility. Review of the notices provided to the resident, showed no SNF ABN notice provided. 2. Review of the list of residents discharged from skilled services within the last six months, provided by the facility, showed Resident #43 discharged from skilled services on 10/9/21, and remained in the facility. Review of the notices provided to the resident, showed no SNF ABN notice provided. 3. During an interview on 11/17/21 at 5:15 A.M., the administrator said the facility was not aware of the need to provide the SNF ABN notices. 4. Review on 11/23/21 at 3:08 P.M.,of an email from the administrator, showed the facility has no policy available for the SNF ABN and NOMNC notices.

Based on interview and record review, the facility failed to implement their grievance policy by not ensuring a prompt resolution to a grievance regarding a missing tablet computer for one resident (Resident #338). The sample was 24. The census was 155 with 137 residents in certified beds. Review of the facility's Grievance Procedure, reviewed June 2021, showed: -Purpose: Residents and resident representative(s) are always encouraged to visit with administration any time they have input or concerns. In the majority of instances, the concern will be resolved. For those wishing to file a grievance, the following procedure would apply; -Procedure: -Any resident or resident's representative who wishes to file a grievance in regards to care and treatment which has been furnished (or not furnished), conditions, or violations of rights while under the care of the facility or any other concern is welcome to submit a written account of the details of the grievance to the administrator without fear of discrimination or reprisal. In the event the resident is unable to do so in writing, he/she may select someone to write the report for him/her or state the complaint orally to the administrator; -The administrator is considered the Grievance Official and will oversee the grievance process, receive and track grievances through to their conclusions; lead any necessary investigations by the facility, provide a reasonable expected timeframe for completing the review; issue written grievance decisions, if requested, to the resident or resident representative; -The administrator will ensure that all written grievance decisions include the date the grievance was received, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; -The administrator/Grievance Official or designee will issue a prompt resolution to the complainant and the aggrieved party (if someone other than the complainant). If a written grievance is requested, the Grievance Decision Form will be used to compile written response; -In the event the administrator or designee is unable to resolve a grievance of a resident under the procedure outlined above, he/she will refer the issue to Home Office for further investigation. Review of Resident #338's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/21, showed: -admission date of 6/19/21; -Moderate cognitive impairment; -Extensive assistance of one person physical assist required for bed mobility and locomotion; -Diagnoses included anxiety and depression. Review of the resident's medical record, showed his/her friend listed as the resident's Power of Attorney (POA). Review of the resident's progress notes, showed no documentation of a missing tablet. During an interview on 11/15/21 at 9:27 A.M., the resident said he/she has been at the facility for two years. He/she cannot walk on his/her own and requires staff assistance to get out of bed. Two weeks ago, his/her tablet was stolen from his/her room. He/she told staff the tablet was missing, but could not recall which staff he/she notified. During an interview on 11/16/21 at 12:54 P.M., the resident said his/her main concern with the facility is his/her missing tablet. He/she recently received the tablet from his/her family, who has the receipt for it. He/she could not recall the brand of the tablet, but said it cost around $320. During an interview on 11/19/21 at 10:15 A.M., Certified Nurse Aide (CNA) X said he/she works on the resident's hall regularly. The resident is alert and oriented, and all the way with it. He/she had a tablet but it has been missing for a month. Staff has been looking for the tablet, but it has not been located. When he/she found out the tablet was missing, he/she reported it to the nurse who usually works on the hall. He/she could not recall the nurse's name, but knows the nurse did notify the front office about the missing tablet. During an interview on 11/19/21 at 10:27 A.M., CNA S said he/she works on the resident's hall at times. The resident does not leave his/her room often. He/she has seen the resident with a tablet, which was given to the resident by his/her friend. He/she last saw the tablet on the resident's table a few months ago, but does not know where it is. During an interview on 11/19/21 at 10:47 A.M., CNA Y said he/she usually works on the resident's hall. He/she has seen the resident with a tablet, with the last time being approximately around the beginning of October, 2021. The resident's family purchased the tablet for him/her. The resident told him/her the tablet was missing and he/she reported this to the charge nurse, who notified the front office. The resident is normally in his/her room, so he/she does not know where the tablet could have gone. Review of the resident's family concern form, dated 9/3/21, showed: -Concern, filed by resident's POA: Resident's tablet is missing. His/her name and room number are on the tablet; -Facility staff involved in resolution: 9/3/21 all staff; -Resolution, dated 9/3/21: Tablet not found at this time. All staff looking and room was searched. During an interview on 11/19/21 at 11:20 A.M., Social Services (SS) A said he/she is the social worker (SW) assigned to the long-term care residents. When a grievance is filed by a resident or family member, it goes to the SW first and then to the administrator. All department heads are notified about the missing item and staff will try to locate the item. The outcome of a grievance is up to administration. In September 2021, the resident reported a missing tablet. The resident does not leave his/her room often and refuses to get out of bed most of the time. Staff looked everywhere for the missing tablet, including the resident's room and the nurse's station, but the tablet was not located. The admission contract says the facility is not responsible for items coming to the facility. During an interview on 11/22/21 at 11:40 A.M., SS A said he/she recalled telling the resident they facility is not responsible for missing items, but the resident might not remember. He/she does not think he/she discussed this with the resident's POA. During an interview on 11/22/21 at 9:02 A.M., the administrator said the SW handles grievances and the administrator oversees them. She is the facility's grievance official. Grievances are discussed in the daily morning meetings. If the grievance is regarding lost or stolen items, staff will check throughout the facility to locate the missing item. The facility tries to resolve grievances right away, within 24 hours. Resolutions to grievances should include a conclusion to the investigation into the missing item and a solution to the issue. Sometimes, the resolution might include replacing the missing item. She is aware of the resident's missing tablet. Staff did investigate and could not locate the tablet. She apologized to the resident and reminded him/her of the admission policy, which encourages residents not to bring expensive items into the facility. She was going to bring police to the facility to in-service staff about theft, but this has not been done. The resident's grievance resolution of the tablet not being found is not really considered a resolution, but the residents are encouraged not to bring in expensive items and when they do, the responsibility is on them. It could be that the resident's POA removed the tablet from the facility. She was not aware the resident's POA is the one who filed the grievance. Review of the facility's admission agreement, showed: -Your personal property: -We take steps to maintain security of resident's personal property and belongings and strongly urge and encourage family to take items of high value with them or lock such items in the facility safe; -This facility does not request or require any resident to waive liability for losses of personal property. During an interview on 11/22/21 at 11:35 A.M., the administrator said the resident's grievance was a verbal report. When a verbal grievance is received, staff writes it up, and the resolution is provided verbally. Written responses to grievances are only provided for grievances received in writing. The resident's grievance does not have a resolution because the administrator could not prove what happened with the missing tablet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow acceptable nursing practice when staff failed to provide treatments as ordered by the physician for one resident who had a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) (Resident #336) and failed to routinely assess one resident who was at risk for developing pressure ulcers (Resident #84). The sample was 24. The census was 155 with 137 in certified beds. Review of the facility's Wound Care Protocol, revised 8/2018, showed: -Goals of assessment: Provide uniform description, facilitate communication among staff, adequate monitoring of progress or deterioration; -How to assess/document: Initially assess the ulcer(s) for location, stage, size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, the presence or absence of granulation and epithelization; treatment should be based on the assessment; Initiate and complete a causal risk factors analysis for pressure ulcer assessment form or the casual risk factors analysis for pressure ulcers in the Electronic Health Record (EHR) for each pressure ulcer upon finding, admission, re-admission and quarterly. Utilize the findings for development of the care plan; Documentation of the initial and weekly assessment findings should be noted in the wound management section of the EHR or on the weekly wound assessment form; -Other Considerations: Identify pre-existing signs (such as purple or very dark area that is surrounded by profound redness, edema, or induration) suggesting that Deep Tissue Injury (DTI) has already occurred and additional deep tissue loss may occur. In darker skinned individuals focus more on other evidence of pressure ulcer development, such as bogginess, induration, coolness or increased warmth as well as signs of skin discoloration; Adjust and provide support surfaces for pain relief and pressure redistribution. 1. Review of Resident #336's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/13/21, showed: -admitted : 7/3/19; -Diagnosis included: Alzheimer's disease, high blood pressure, high cholesterol and depression; -Short and long term memory problems; -No behaviors; -No rejection of care; -Required extensive assistance of staff for bed mobility, transfers, locomotion on and off the floor, toilet use and personal hygiene; -Required total assistance of staff for eating and bathing; -Always incontinent of bowel and bladder; -At risk for skin breakdown; -No wounds at Stage I or higher. Review of the resident's care plan, showed: -Problem: Stage III pressure ulcer to left buttocks/sacrum (triangular bone located above coccyx) area related to weight loss, decline in health status, start date 8/4/21; -Goal: resident will not develop additional pressure ulcers; -Interventions: apply dressing per physician order: cleanse with normal saline, apply Santyl (sterile enzymatic debriding ointment) and foam dressing daily and as needed; assess the pressure ulcer for stage, size (length x width x depth), presence/absence of granulation tissue and epithelization and condition of surrounding skin weekly; turn and reposition every 2 hours; AMP (special mattress to help relieve pressure) mattress; resident is on hospice-comfort care. Review of the resident's wound team notes dated 10/6/21, showed Assessment: location: sacrum, type: pressure ulcer/injury: Stage III; wound bed description: 50% granulation (new connective tissue), 30% non-granular and 20% slough (dead tissue separating from living tissue); measurements: 5.5 centimeters (cm) length X 3.5 cm width x 1.0 cm depth; undermining: 1.0 cm from 12:00 to 3:00; exudate (drainage): moderate sero-sanguineous (yellowish drainage will small amounts of blood); additional notes: improving. Review of the resident's treatment administration record (TAR), dated 10/1/21 through 10/6/21, showed: -An order for metronidazole (medication used to help decrease odor and drainage) apply a small amount twice a day (BID), special instructions please send [NAME] (combination of metronidazole and lidocaine) wound powder: -On 10/2/21 evening shift, drug/item unavailable; -On 10/3/21 day shift, not administered, comment: time constraints; -On 10/6/21 evening shift, not administered, comment: floor emergency; -An order for Dakin's 0.25% (used to prevent and treat skin and tissue infections) apply to sacrum once a day, documentation showed: -On 10/3/21, not administered, comment: time constraints; -An order for cleanse sacral ulcer with Dakin's 0.25% apply [NAME] powder, pack with Dakin's moistened gauze, cover with sacral foam BID and as needed (PRN), documentation showed: -On 10/6/21 evening shift, not administered, comment: floor emergency. Further review of the resident's wound notes, dated 10/13/21, showed Assessment: location: sacrum, type: pressure ulcer/injury: Stage III; wound bed description: 30% necrotic (death of cells) at 12:00 and 70% non-granular; measurements: 6.0 cm X 3.0 cm x 1.5 cm; undermining: 1.0 cm from 11 to 1:00; exudate: moderate clear yellow; additional notes: improving. Further review of the resident's TAR, dated 10/7/21 through 10/13/21, showed: -An order for metronidazole apply a small amount BID, special instructions please send [NAME] wound powder: -On 10/7/21 day shift, not administered, comment: utc; -On 10/7/21 evening shift, not administered, comment: utc, -On 10/9/21 day shift, not administered, comment: utc time constraints; -On 10/13/21 evening shift, not administered, comment: utc assisting on floor; -An order for Dakin's 0.25%, apply to sacrum once a day, documentation showed: -On 10/7/21, not administered, comment: utc; -On 10/9/21, not administered, comment: utc time constraints; -An order for cleanse sacral ulcer with Dakin's 0.25% apply [NAME] powder pack with Dakin's moistened gauze, cover with sacral foam BID and PRN, documentation showed: -On 10/7/21 day shift, not administered, comment: utc; -On 10/7/21 evening shift, not administered, comment: utc; -On 10/9/21 day shift, not administered, comment: utc time constraint; -10/13/21 evening shift, not administered, comment: utc assisting on floor. During an interview on 11/18/21 at 1:00 P.M., Registered Nurse (RN) R said UTC means unable to complete. Sometimes he/she will chart UTC when he/she is unable to complete the task because of time constraints. The computer will not clear the item off unless something is charted. Further review of the resident's wound notes, dated 10/20/21, showed Assessment: location: sacrum, type: pressure ulcer/injury: stage III; wound bed description: 20% granulation, 30% necrotic at 12:00 and 50% non-granular; measurements: 6.5 cm X 4.0 cm x 1.0 cm; undermining: 1.0 cm from 11 to 1:00; exudate: moderate clear yellow; additional notes: ulcer is larger with more necrotic tissue at 12:00. Further review of the resident's TAR, dated 10/14/21 through 10/20/21, showed: -An order for Dakin's 0.25% apply to sacrum once a day: -On 10/17/21, not administered, comment: utc time constraints; -An order for cleanse sacral ulcer with Dakin's 0.25% apply [NAME] powder pack with Dakin's moistened gauze, cover with sacral foam BID and PRN: -On 10/16/21 evening shift, not administered, comment: time constraints; -On 10/17/21 day shift, not administered, comment: utc time constraint; -On 10/17/21 evening shift, not administered, comment: nurse prior unable to complete. Further review of the resident's wound notes, dated 10/27/21, showed Assessment: location: sacrum, type: pressure ulcer/injury: Stage III; wound bed description: 20% granulation, 30% necrotic at 12:00 and 50% non-granular; measurements: 8.5 cm X 5.5 cm x 1.5 cm; undermining: 1.0 cm from 11 to 1:00; exudate: moderate sero-sanguineous; additional notes: ulcer is larger but has less necrotic tissue and no obvious signs of infection. Further review of the resident's TAR, dated 10/21/21 through 10/27/21, showed: -An order for Dakin's 0.25% apply to sacrum once a day: -On 10/21/21, day shift, not administered, comment: day shift, documented at 4:15 P.M. Further review of the resident's wound notes, dated 11/3/21, showed Assessment: location: sacrum, type: pressure ulcer/injury: Stage III; wound bed description: 30% granulation, 40% necrotic tissue from 9;00-2:00 at 12:00 and 30% non-granular; measurements: 9.0 cm X 5.0 cm x 1.5 cm; undermining: 4.0 cm from 9:00 to 10:00; exudate: small tan drainage with mild odor; additional notes: declined. Further review of the resident's TAR, dated 10/28/21 through 11/3/21, showed: -An order for Dakin's 0.25% apply to sacrum once a day: -On 10/30/21, not administered, comment: time constraints; -An order for Dakin's 0.25%, apply to necrotic tissue at 12:00, pack with Dakin's moistened gauze, cover with sacral foam daily and PRN: -On 10/30/21 day shift, not administered, comment: time constraints; -On 11/2/21, not administered, comment: unable to complete; -An order for Dakin's solution 0.25% apply to sacrum ulcer once a day; documentation showed: -On 11/2/21 not administered: comment unable to complete. Further review of the resident's TAR, dated 11/3/21 through 11/17/21, showed: -An order for Dakin's solution 0.25% apply to sacrum ulcer once a day: -On 11/14/21, not administered, comment: assisting on the floor; -An order to cleanse sacral ulcer with Dakin's 0.25%, apply [NAME] powder, pack with dry gauze, cover with abdominal pad (ABD, highly absorbent dressing that provides padding and protection) and tape BID and PRN: -On 11/10/21 evening shift, not administered: comment unable to complete; -On 11/14/21 day shift, not administered, comment: assisting on the floor; -An order for standard APM mattress, check every shift for inflation: -On 11/12/21 night shift comment: unable to complete; -On 11/15/21 day shift, comment: previous shift. Observation and interview on 11/17/21 at 9:47 A.M., showed the resident lay in his/her bed on an AMP mattress, facing the window. The Nurse Practitioner (NP) removed the resident's dressing from his/her coccyx. The NP measured and described the wound as 8.8 centimeters (cm) x 6.2 cm x 2.9 cm, he/she said there was undermining 2 cm from 12:00 to 3:00, 1.1 cm from 3:00 to 6:00 and 1.9 cm at 9:00 to 12:00, slough at 12:00 and said the wound was now a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling), he/she can feel bone in the center of the wound, and there is a new spot above the wound that is yellow that will probably join the wound. This new area measured 0.8 cm x 0.6 cm x 0. He/she described the wound as non-healing. Further review of the resident's wound notes, dated 11/17/21, showed Assessment: location: sacrum, type: pressure ulcer/injury: Stage IV; wound bed description: 30% granulation, 20% necrotic tissue in the center of the wound bed and bone is palpable just below it and 50% non-granular; bed structures: bone palpable (not visible) in center of wound bed measurements: 8.8 cm X 6.2 cm x 2.9 cm; undermining: 2.0 cm from 4:00 to 9:00, 1.0 cm from 9-12:00; peri wound: edges are unattached-there is a new small open wound at 12:00 that measures 0.8 cm x 0.6 cm. It is 100% slough and will likely join the sacral ulcer; exudate: moderate sero/sanguineous; additional notes: less necrotic tissue and less odor today. During an interview on 11/19/21 at 4:30 P.M., Licensed Practical Nurse (LPN) MM, said he/she can't get all of his/her work done. We have to focus on priorities like tube feeding bolus, narcotics and any falls. Dressing changes are not considered a priority. LPN MM said if the previous shift is unable to complete a task, he/she said sometimes he/she was unable to complete the task. During an interview on 11/22/21 at 8:11 A.M., the Director of Nursing (DON) said if it was noted unable to complete, in the resident's TAR, it signifies that the treatments were not administered due to time constraints. She expects the nurse on the next shift to administer wound treatments if it was not administered from the prior shift. 2. Review of Resident #84's admission MDS, dated [DATE], showed: -admitted : 12/20/20; -discharged to the hospital: 1/15/21; -Diagnoses included fractured left clavicle (collarbone), cancer, high blood pressure and Alzheimer's disease; -Brief interview for mental status (BIMS, a brief screener of cognition): blank; -Required supervision and set up with eating; -Required extensive assistance of staff for bed mobility, transfers, walking in room, locomotion on the unit, dressing, toilet use, personal hygiene and bathing; -Always incontinent of bowel and bladder; -At risk for developing pressure ulcers. Review of the resident's progress notes, dated 12/22/20 at 10:19 P.M., showed the resident arrived to the facility, skin warm and dry to touch and within normal limits on observation. Further review of the resident's progress notes, dated 1/6/21 at 4:51 A.M., showed upon certified nurse aide (CNA) removing socks, a very large blister surrounding entire left heel noted. Blister was oozing sero drainage, blackened 2 x 2 area also noted to center of heel. Review of the resident's wound management notes, showed: -On 1/7/21, fluid filled blister on left heel was identified, measurement 8 cm x 11 cm, intact resolving blood blister. Review of the resident's ePOS, showed: -An order for wound team evaluation and treatment for fluid filled blister left heel, dated 1/8/21. Review of the Resident's wound management notes, showed: -On 1/10/21, a deep tissue injury (DTI, are persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues) on right ankle was identified, measurement 2.4 cm x 1.5 cm; -On 1/13/21, fluid filled blister on left heel measurement 7 cm X 12 cm, intact resolving blister; DTI right ankle 1.5 cm x 5 cm, intact skin. Further review of the resident's ePOS, showed: -An order for Betadine (antiseptic) apply to right heel every day, dated 1/13/21; -An order for Betadine apply to left great toe daily, dated 1/13/21; -An order to cleanse left heel with normal saline, Betadine, cover with ABD, wrap with Kerlix (gauze) daily and PRN, dated 1/13/21. Further review of the Resident's progress notes, showed staff did not address the DTI on right ankle. Review of the resident's wound team notes, dated 1/13/21, showed: -Assessment: left heel, type: pressure ulcer/injury: unstageable (depth obscured), wound bed description: 100% intact resolving blood blister, measurements 7.0 cm x 12 cm, exudate: none; -Assessment: right lateral heel, type: pressure ulcer/injury: DTPI (Intact skin, deep tissue injury), measurements: 1.5 x 5.0 exudate: none; -Assessment: left great toe distal (away from the center), pressure/injury: DTPI, measurements: 1.0 x 0.7 exudate: none. Review of the resident's shower sheets, showed showers were documented as done on 12/23, 12/25 and 12/29/20 and 1/5, 1/7, 1/9 and 1/12/21. No visual diagram was included. During an interview on 11/17/21 at 6:50 A.M., LPN K said the CNAs complete a shower sheet when they give the resident their showers and the nurse reviews it. If a resident had a new wound, he/she would measure and describe the wound, call the doctor to get treatment orders and notify the family and document it in the progress notes. The wound nurse comes every Wednesday and he/she would stage the wound. During an interview on 11/17/21 at 10:27 A.M., the wound nurse said the CNAs complete shower sheets when the resident receives their bath. The shower sheet is given to the nurse and the nurse reviews and signs it. The nurse on the floor is responsible for doing the residents' treatments, and completing weekly skin assessments. If a new wound is noted, the nurse who finds the wound is responsible for describing and measuring the wound, notifying the physician and obtaining treatment orders, if needed. The wound is documented either in the progress notes or under wound management. Wounds are documented weekly. Weekly wound documentation would include: the location of the wound, stage, description and measurements. During an interview on 11/18/21 at 12:34 P.M., LPN GG said nurses on the unit are responsible for completing the weekly skin assessments. They know who needs a skin assessment because it comes up in the computer. During an interview on 11/22/21 at 9:30 A.M., medical records staff said the facility did not have weekly skin assessments completed or a care plan for the resident. 3. During an interview on 11/22/21 at 8:11 A.M., the DON said she expected the nurses to follow physician's orders and document timely and appropriately. In addition, she expected staff to follow the facility's policy and procedures. MO00181504

Based on observation, interview and record review, the facility failed to ensure residents are free from any significant medication errors, for one resident (Resident #28) who was administered two different insulins more than two hours after they were ordered to be administered. The census was 155 with 137 in certified beds. Review of the facility's medication administration policy, revised January 2021, showed: -Medications are to be given at the time ordered, within sixty minutes before or after designated time, or according to liberalized medication pass time. Review of Resident #28's electronic Physician Order Sheet (ePOS) showed: -An order dated 9/28/20, for Lantus-Solostar U-100 (long-acting insulin), 28 units twice a day, 7:30 A.M. and 4:30 P.M.; -An order dated 7/6/21, for Humalog Kwikpen Insulin (insulin lispro, short acting insulin), 14 units twice a day, morning med pass 7:30 A.M., and noon pass 11:30 A.M.; -An order dated 8/2/21, to check the resident's blood sugar before meals (AC) and at bedtime (HS) with times listed: 7:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M. During an observation on 11/15/21 at 9:50 A.M., Licensed Practical Nurse (LPN) G checked the resident's blood sugar level. The results read 374. LPN G verified the resident was to receive 14 units of insulin lispro and 28 units of Lantus. LPN G went to the medication cart to obtain the insulin pens and took out the lispro pen. LPN said the Lantus pen was empty so he/she would administer the lispro first and then go get the Lantus pen. LPN G verified the resident's name on the lispro insulin pen and dialed the pen to 14 units. LPN G administered 14 units of insulin to the resident. LPN G left the resident's room, went to the medication room and returned with the Lantus insulin pen. LPN G verified the resident's name on the Lantus pen, primed the pen and dialed it to 28 units. LPN G administered 28 units of insulin to the resident. During an interview on 11/22/21 at 10:20 A.M., the Director of Nursing said she would expect insulin to be given at the time it was ordered and then an hour before or after it was due. She also said if the insulin was due at 7:30 A.M., it would not be acceptable to give insulin at 9:50 A.M. when the next dose due is at 11:30 A.M.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the transmission of infection, when staff failed to clean glucometer machines (used to check blood sugar levels) before and/or after use and failed to clean the injection site prior to administering an insulin injection for two residents (Residents #134, and #75). The sample was 24. The census was 155 with 137 in certified beds. 1. Review of the facility's Medication Administration policy, dated January 2021, showed: -Wash your hands before and after each resident contact. An alcohol based wash may be substituted; -The policy did not address injectable medication such as insulin. Review of #134's medical record, showed: -Diagnoses included concussion, diabetes and peripherally inserted central catheter (PICC, a tube/catheter inserted into a vein for medication administration). -A care plan revised, 11/18/21, showed: -Problem: Resident admitted with a PICC line to left upper extremity to administer intravenous (IV, administered into a vein) fluids; -Goal: Resident will not experience complications related to PICC line; -Approach: Assess PICC site every shift for signs/symptoms of infection, assess for swelling. Review of #75's medical record, showed: -Diagnoses included respiratory syncytial virus pneumonia, diabetes and non-pressure chronic ulcer of right foot; -A care plan revised 10/27/21, showed: -Problem: Ulcer to right 3rd, 4th and 5th toe related to peripheral vascular disease (disease in which the blood flow to the extremities is reduced) and diabetes; -Goal: Ulcer will not increase in size, ulcer will not exhibit signs/symptoms infection; -Approach: Dressing change per physician order, assess ulcer weekly with specialized wound management. Observation on 11/17/21 at 4:10 P.M. showed Registered Nurse (RN) H in front of a nurse/treatment cart. Without cleaning the glucometer prior to use, RN H entered Resident #134's room and checked the resident's blood sugar. RN H administered insulin as ordered without wiping the area of the resident's skin he/she injected before he/she administered the medication. RN H did not clean the glucometer machine after use. RN H took the cart and parked it in front of Resident #75's room. Without cleaning the glucometer prior to use, RN H checked Resident #75's blood sugar and the glucometer machine showed error. The nurse went back to the cart and obtained the Sani wipes with the plastic seal still on the wipes. RN H removed the plastic seal to open the container of wipes and cleaned both machines. RN H left one glucometer machine on the medication cart and went into the room with the other glucometer and a test strip. He/she went to put the test strip in the glucometer and dropped the test strip on the floor. RN H went back to the treatment cart with the glucometer in his/her hand to get a new test strip. RN H got the new test strip and entered the resident's room with the glucometer and test strip. RN checked the resident's blood sugar and went to the cart to check the insulin order in the electronic chart. He/she reentered the resident's room and administered Resident #75's insulin as ordered without wiping the area he/she injected before he/she administered the medication. During an interview on 11/22/21 at 10:20 A.M., the DON said the skin at the site of an injection should be cleaned before a resident is given an injection. She would expect shared equipment, such as glucometers, to be cleaned before and/or after use on a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were provided with dignity and respect by failing to administer insulin injections in a private area for three residents (Residents #341, #340 and #342) and by failing to sit next to one resident while assisting the resident with a meal (Resident #77). The sample was 24. The census was 155 with 137 residents in certified beds. 1. Review of Resident #341's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/30/20, showed: -admission date of 12/30/15; -Severe cognitive impairment; -Diagnoses included diabetes, dementia, Alzheimer's disease and depression; -Insulin injections received 7 of 7 days. Review of the resident's November 2021 medication administration record (MAR), showed: -An order, dated 12/10/20, for insulin aspart (short acting insulin) insulin pen; 100 units per milliliter (ml); administer 30 units subcutaneous (under the skin) three times daily; -On 11/15/21 at 12:34 P.M., Licensed Practical Nurse (LPN) G documented the medication administered. Observation on 11/15/21 at 12:30 P.M., showed the resident sat in the dining room among 16 other residents. LPN G approached the resident and performed a blood sugar finger stick. Other residents sat in view of the resident and ate as LPN G obtained a blood sample for the blood sugar finger stick. The resident began eating his/her sandwich. At 12:32 P.M., LPN G approached the resident with a syringe and asked if the resident wanted the insulin in his/her belly. While the resident held his/her sandwich in his/her left hand, LPN G lifted the resident's shirt to expose his/her abdomen and administered an injection. LPN pulled the resident's shirt back down and left the dining room. During an attempted interview on 11/16/21 at 3:45 P.M., the resident presented as alert with confusion, and was unable to respond appropriately to questions. 2. Review of Resident #340's admission MDS, dated [DATE], showed: -admission date of 5/11/21; -Resident is rarely/never understood; -Diagnoses included diabetes and dementia; -Insulin injections received 7 of 7 days. Review of the resident's November 2021 MAR, showed: -An order, dated 10/19/21, for insulin aspart insulin pen; 100 unit/ml; administer 4 units subcutaneous three times daily; -On 11/15/21, LPN G documented the medication administered during the 11:30 A.M. to 2:45 P.M. medication pass. Observation on 11/15/21 at 12:35 P.M., showed the resident sat at a table in the dining room among 16 other residents. While the resident ate coleslaw, LPN G approached the resident, greeted him/her, and performed a blood sugar finger stick on the resident's right hand. LPN G told the resident his/her blood sugar was 125 and left the dining room. At 12:39 P.M., the resident continued to eat coleslaw when LPN G approached with a syringe and told him/her it was time for a shot. The resident did not say anything and LPN G stood in between the resident and surveyor, which prevented the surveyor from viewing the administration of the insulin, but in a location where other residents had a view of the administration, administered the injection and left the dining room. During an attempted interview on 11/16/21 at 3:32 P.M., the resident presented as alert with significant confusion, and did not verbally respond to questions. 3. Review of Resident #342's quarterly MDS, dated [DATE], showed: -admission date of 3/15/19; -Severe cognitive impairment; -Diagnoses included diabetes, dementia, anxiety and depression; -Insulin injections received 7 of 7 days. Review of the resident's November 2021 MAR, showed: -An order, dated 9/11/20, for insulin lispro insulin pen; 100 unit/ml; administer per sliding scale. If blood sugar is 201 to 250, give 4 units; -On 11/15/21 at 12:45 P.M., LPN G documented the medication administered as ordered. Observation on 11/15/21 at 12:40 P.M., showed the resident sat at a table in the dining room among 16 other residents. While the resident ate coleslaw, LPN G approached the resident and performed a blood sugar finger stick on the resident's right hand. LPN left the dining room and went to the medication cart, where he/she drew up a syringe of insulin. At 12:43 P.M., the resident continued to eat coleslaw when LPN G approached with the syringe and asked if it was ok to inject the resident in his/her stomach. LPN G lifted the resident's shirt to expose his/her abdomen and administered the injection. LPN pulled the resident's shirt back down and left the dining room. 4. During an interview on 11/22/21 at 11:29 A.M., Certified Nurse Aide (CNA) S said he/she knows the residents well. Residents #341, #342, and #340 are all alert and oriented to themselves. All three residents have periods of confusion and they are unable to make sound judgments regarding their care. When providing care, staff should treat the residents in the way a reasonable person would expect. 5. During an interview on 11/22/21 at 8:31 A.M., Certified Medication Technician (CMT) Z said he/she does not do insulin administration, but he/she observed LPN G administer insulin to residents in the dining room on 11/15/21. The nurse should have administered the insulin in the resident's rooms. Administering the insulin in the dining room was not appropriate due to privacy and dignity issues. 6. During an interview on 11/22/21 at 8:32 A.M., LPN CC said insulin must be administered in a private area. It is not appropriate to administer insulin in the dining room in front of other residents, particularly while they are in the middle of eating. If a resident is in the middle of eating and the nurse needs to administer the insulin, the nurse should tell the resident they will be back to administer the medication later and then move the resident to a more private area. Administering insulin to residents in the middle of the dining room is a dignity and privacy issue. 7. During an interview on 11/22/21 at 8:43 A.M., LPN DD said insulin administration should be done in a private area. This is in order to protect the resident's privacy, dignity, and respect. If staff needs to administer insulin, they should wait until the resident is done eating and then administer the insulin in the resident's room, the spa room, or somewhere private. It is not appropriate to pull up a resident's shirt and inject them in the middle of the dining room. 8. During an interview on 11/22/21 at 8:50 A.M., the Director of Nursing (DON) said she was aware of the observation on 11/15/21 in which a nurse administered insulin to residents in the dining room. Insulin administration should not be done in the dining room, in front of other residents. The nurse should have waited until the residents were done eating and then brought them to their room, the spa, or a private area to administer the insulin. It is inappropriate to pull up a resident's shirt and administer insulin to a resident while they are eating in the dining room as this is a dignity and privacy issue. 9. During an interview on 11/22/21 at 9:02 A.M., the administrator said nurses are expected to administer insulin in resident rooms or a secluded area. It is not appropriate for a nurse to administer insulin while a resident is eating in the dining room as this is a privacy issue and is not considered to be dignified. If a resident is eating, staff should wait until the resident is finished and then bring them to their room, spa room, or a private area to administer insulin. 10. Review of Resident #77's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Total dependence on staff for bed mobility, toileting, dressing and personal hygiene; -Limited assistance required by staff for eating; -Diagnoses included: Fractures and other trauma, legal blindness, coronary artery disease (CAD, disease of the arteries of the heart), dementia, cancer, anxiety and depression. Review of the resident's care plan, dated 11/2/21, showed: -Problem: Nutritional Status; -Goal: Will provide balanced nutritional diet and prevent any unintended weight loss; -Approach: Provide regular diet as ordered; Monitor for signs/symptoms of dysphagia (difficulty swallowing), coughing and choking with liquid and/or meal intake; Provide assistance/supervision with eating. Observation on 11/15/21 at 12:25 P.M., showed staff assisted the resident with lunch. The staff member stood over and next to the resident on the resident's left side. The staff member fed the resident bites of a sandwich and rearranged the sandwich in between bites taken by the resident. During an interview on 11/22/21 at 10:20 A.M., the DON said she would not consider standing over a resident while feeding the resident to be dignified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their transfer or discharge policy by not providing to the resident and/or their representative the written transfer notice at the time of the resident's facility initiated transfer, for 4 residents (Residents #84, #72 #135, and #71). The sample was 24. The census was 155 with 137 in certified beds. Review of the facility's Hospital Transfer of Resident policy, revised January 2019, showed: -Purpose: To provide prompt and safe transfer of resident from the facility and to ensure continuity of care through provision of pertinent resident information; -Procedure: An interact nursing home to hospital transfer form (tool used to help the nursing home clearly communicate a wide range of critical information about the resident to emergency room) observations will be completed by the nurse unless it is an urgent 911 and/or time doesn't allow; -Notify resident representative and document that their intent to have resident transferred to the hospital; -If non-emergent and time allows, the interact nursing home to hospital transfer form and interact Situation, Background, Assessment Recommendation form (SBAR, tool used to communicate the residents condition) observations will be sent along with copies of the Electronic Medical Record (EMR) to include, but not limited to: Notice of Emergency transfer to hospital. Document in the resident's progress notes the basis for transfer, conversations with the physician/nurse practitioner, family and hospital nurse. Nurse will complete documentation in the Electronic Health Record (EHR) to include but not limited to: Resident representative called, relationship to the resident, time of call. If resident and/or representative agrees with transfer, document, it was resident's intent to transfer to the hospital, depicting the transfer was resident-initiated and their intent to seek urgent medical treatment. 1. Review of Resident #84's medical record, showed: -admission date of 12/22/20; -discharged to the hospital 1/15/21; -A progress note dated 1/15/21, showed: -At 4:30 A.M., 911 was notified and was en route; -At 4:57 A.M., family member was contacted and made aware of the situation; -No documentation the transfer was resident initiated and no documentation that the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfer. 2. Review of Resident #72's medical record, showed: -admitted to facility on 8/25/21; -discharged to hospital on [DATE]; -A progress note dated 10/20/21, showed: -At 7:38 P.M., new order to send resident to the emergency room. Power of Attorney (POA) made aware; -No documentation the transfer was resident initiated and no documentation that the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfer; -Returned to facility on 10/26/21; -discharged to hospital on [DATE]; -A progress note dated 10/26/21, showed: -At 5:45 P.M., 911 called. Resident will be sent to the emergency room per fire department. Family present; -No documentation the transfer was resident initiated and no documentation that the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfer; -Returned to facility on 10/29/21. 3. Review of Resident #135's medical record, showed: -admitted to facility on 11/4/21; -discharged to hospital on [DATE]; -A progress note dated 11/16/21, showed -At 10:17 A.M., EMS notified of transport request. Family notified; -At 11:01 A.M., family member is giving the facility a pre-authorization request to send the resident to the hospital if emergent attention is needed; -At 11:56 A.M., EMS and family here. Resident being transferred to the hospital; -No documentation the transfer was resident initiated and no documentation that the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfer; -Returned to facility on 11/17/21. 4. Review of Resident #71's medical record, showed: -admitted to facility on 8/30/21; -discharged to hospital on [DATE]; -A progress note, dated 10/19/21, showed: -At 10:15 A.M., ambulance called. Will send transportation; -At 10:28 A.M., physician suggested staff call next of kin to get permission to send to the hospital. Next of kin called, agreed to send resident to the hospital; -No documentation the transfer was resident initiated and no documentation that the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfer; -Returned to facility on 10/29/21. 5. During an interview on 11/18/21 at 12:34 P.M., Licensed Practical Nurse (LPN) GG, said when a resident is transferred to the hospital, they complete a transfer packet. The written notification is not always documented. A copy of the form is put in the drop box for nursing management to pick up. 6. During an interview on 11/19/21 at 8:50 A.M., the administrator said the facility did not have the written notifications of the transfer to the hospital for the Resident's #84, #72 #135 and #71. 7. During an interview on 11/22/21 at 8:01 A.M., the Director of Nursing (DON) said, when a resident is transferred to the hospital, the nurse who is transferring the resident should complete a transfer packet. When the nurse documents the resident was transferred to the hospital, the note should include the written discharge notice was provided to the resident/resident representative. The facility should keep a copy of the written notice to be uploaded into the resident's medical record. The DON's expectation is the staff should provide written notice of transfer to the resident and/or their representative at the time of transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident and/or resident representative of the bed hold requirements at the time of transfer to the hospital for various medical reasons for four of the 24 residents sampled (Resident #84, #72, #135, and #71). The census was 155 with 137 residents in certified beds. Review of the facility's Bed Hold Policy, undated, showed: -Purpose: To notify the resident and/or representative(s) of the Bed Hold Policy in writing at the time of admission, upon change or revision and when transferred to a hospital or during therapeutic leave, as well as the intent for readmission according to state and federal regulations; -Procedure: The facility will also give a copy of this policy to the resident and/or representative if transferred to a hospital. In addition, the facility will call the representative, if applicable, within 24 hours of the transfer or leave. 1. Review of Resident #84's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed: -admission date of 12/22/20; -discharged to the hospital on 1/15/21; Review of the resident's progress notes, dated 1/15/21, showed at 4:30 A.M., 911 was notified and was en route. At 4:57 A.M., family member was contacted and made aware of the situation; no documentation that the resident and/or the resident's representative received information in writing of the facility's bed hold policy at the time of the transfer. During an interview on 11/19/21 at 8:50 A.M., the administrator said the facility did not have a copy or documentation the resident was provided the bed hold policy at time of transfer to the hospital. 2. Review of Resident #72's medical record, showed: -admitted to facility on 8/25/21; -discharged to hospital on [DATE]; -Returned to facility on 10/26/21; -discharged to hospital on [DATE]; -Returned to facility on 10/29/21. Further record review, showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of the transfers. 3. Review of Resident #135's medical record, showed: -admitted to facility on 11/4/21; -discharged to hospital on [DATE]; -Returned to facility on 11/17/21. Further record review, showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of the transfer. 4. Review of Resident #71's medical record, showed: -admitted to facility on 8/30/21; -discharged to hospital on [DATE]; -Returned to facility on 10/29/21. Further record review, showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of the transfer. 5. During an interview on 11/18/21 at 12:34 P.M., Licensed Practical Nurse (LPN) GG, said, when a resident is transferred to the hospital, they complete a transfer packet. He/she does not always document if the resident and/or representative is given written information of the facility's bed hold policy at the time of transfer. Staff place a copy of the provided bed hold policy in the drop box for nursing management to pick up. 6. During an interview on 11/22/21 at 8:01 A.M., the Director of Nursing (DON) said, when a resident is transferred to the hospital, the nurse who is transferring the resident should completed a transfer packet. When the nurse documents the resident was transferred to the hospital, the progress note should include the resident and/or representative was provided written information on the facility's bed hold policy. The facility should keep a copy of the bed hold policy provided, to be uploaded into the resident's medical record. The DON's expectation is for staff to provide a copy of the bed hold policy to the resident and/or their representative at the time of transfer. MO00181504

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive assessment of residents at least annually for nine residents (Residents #20, #5, #339, #284, #338, #136, #28, #335 and #334). The sample was 24. The census was 155 with 137 in certified beds. 1. Review of Resident #20's medical record, showed admitted on [DATE]. Review of the residents Minimum Data Set (MDS, a federally required assessment instrument completed by facility staff) record, showed: -An annual assessment dated [DATE]; -A quarterly assessment dated [DATE]; -No annual assessment completed [DATE]. 2. Review of Resident #5's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An annual assessment dated [DATE]; -No comprehensive assessment completed [DATE]. 3. Review of Resident #339's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -A change in condition assessment dated [DATE]; -No comprehensive assessment completed [DATE]. 4. Review of Resident #284's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An annual assessment dated [DATE]; -No comprehensive assessment completed [DATE]. 5. Review of Resident #338's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An annual assessment dated [DATE]; -No comprehensive assessment completed [DATE]. 6. Review of Resident #136's medical record, showed admitted on [DATE]. Review of the resident's MDS record, reviewed on [DATE], showed: -No admission MDS completed. 7. Review of Resident #28's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An annual assessment dated [DATE]; -No comprehensive assessment completed [DATE]. 8. Review of Resident 335's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An annual assessment dated [DATE]; -No comprehensive assessment completed [DATE]. 9. Review of Resident #334's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -A significant change assessment dated [DATE]; -No comprehensive assessment completed [DATE]. 10. During an interview on [DATE] at 7:36 A.M., the administrator said Remote MDS Worker C is responsible for doing the MDS assessments. He/she is in Kansas City working remotely. He/she works at the facility at least once a month. All quarterly and annual MDS assessments that were due after the waiver expired in [DATE] should be completed timely. Nurse D is also assisting to complete MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument not less frequently than once every 3 months for six residents (Residents #20, #41, #8, #284, #335 and #334). The sample was 24. The census was 155 with 137 in certified beds. 1. Review of Resident #20's medical record, showed admitted on [DATE]. Review of the residents Minimum Data Set (MDS, a federally required assessment instrument completed by facility staff) record, showed: -An annual assessment dated [DATE]; -A quarterly assessment dated [DATE]; -No quarterly assessment completed [DATE]. 2. Review of Resident #41's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An admission assessment dated [DATE]; -No quarterly assessment completed [DATE]. 3. Review of Resident #8's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An admission assessment dated [DATE]; -No quarterly assessment completed [DATE]. 4. Review of Resident #284's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An annual assessment dated [DATE]; -A quarterly assessment completed [DATE]; -No quarterly assessment completed [DATE]. 5. Review of Resident 335's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An annual assessment dated [DATE]; -A quarterly assessment dated [DATE]; -No further quarterly assessments completed. 6. Review of Resident #334's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -A significant change assessment dated [DATE]; -A quarterly assessment dated [DATE]; -No further quarterly assessments. 7. During an interview on [DATE] at 7:36 A.M., the administrator said Remote MDS Worker C is responsible for doing the MDS assessments. He/she is in Kansas City working remotely. He/she works at the facility at least once a month. All quarterly and annual MDS assessments that were due after the waiver expired in [DATE] should be completed timely. Nurse D is also assisting to complete MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for five of 24 sampled residents (Residents #61, #71, #135, #11 and #84). The census was 155 with 137 residents in certified beds. 1. Review of Resident #61's admission Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 10/15/21, showed: -Moderate cognitive impairment; -No behaviors; -Required the assistance of one staff for walking, transfers, dressing, toileting and personal hygiene; -Always continent of bowel and bladder; -Diagnoses included high blood pressure, diabetes, dementia and depression. Review of the resident's November 2021 electronic physician order sheet (ePOS), showed: -An order, dated 10/20/21, for palliative care (specialized medical care for people living with a serious illness); -An order, dated 11/6/21, for female certified nurse aides (CNA) only for all shifts. Review of the resident's medical record, showed an elopement assessment, dated 11/2/21, which included the following: -Resident has cognitive impairment; -History of wandering; -Interventions included: Care plan for high elopement risk, add name and picture to elopement book. Review of the resident's care plan, last reviewed on 11/12/21 and in use during the survey, showed; -Staff failed to include the resident's receipt of palliative care. Staff failed to include individualized goals and approaches; -Staff did not address the resident's preference for female CNAs. -Staff did not address the resident's high risk for elopement or any correlating individualized approaches. Further review of the resident's medical record, showed the following nurses' notes: -On 11/13/21 at 5:46 A.M., resident sitting on the floor next to his/her recliner; -On 11/13/21 at 3:03 P.M., resident observed to have small abrasion on back of head from earlier fall; -On 11/13/21 at 11:28 P.M., resident lying on bathroom floor, resting quietly; -On 11/17/21 at 10:25 P.M., resident got up from recliner and did not use walker. Resident found on floor on left side; -On 11/21/21 at 9:52 A.M., resident found on floor sitting next to his/her closet with walker nearby. Further review of the resident's care plan, last revised on 11/12/21, and in use during the survey, showed staff had not updated the resident's care plan to reflect his/her most recent falls. Staff also failed to include any new individualized approaches. During an interview on 11/19/21, the Director of Nursing (DON) said the care plan should reflect the resident's current needs. She updates the falls and infections on care plans. The care plan should be updated to reflect every fall. 2. Review of Resident #71's admission MDS, dated [DATE], showed: -Brief interview of mental status (BIMS) score of 8 out of a possible score of 15; -Moderately impaired cognition; -Extensive assistance with toileting, personal hygiene, bed mobility and dressing; total dependence with transfer; supervision with eating; -Diagnoses included medically complex conditions, anemia (decrease in the number of red blood cells), diabetes, arthritis and high blood pressure. Review of the resident's progress notes, showed: -On 9/2/21 at 2:51 P.M., the resident was agitated this shift. Resident constantly yelling out and then refusing assistance from staff. Resident refused to eat lunch; -On 9/30/21 at 9:24 P.M., the nurse went into the resident's room to flush intravenously (IV, administered into a vein) and resident yelled out to the nurse that he/she was going to strangle staff and punch staff in the face, if staff didn't turn the damn lights off. IV flushed without difficulty, but is leaking. Awaiting IV nurse for further treatment; -On 9/30/21 at 11:24 P.M., this registered nurse (RN) tried three times unsuccessfully to place IV. Resident was yelling at RN and swinging his/her arms; -On 10/13/21 at 10:55 A.M., the resident was extremely angry and rude towards staff members today. The resident was in room with the call light in reach but continually yelling out. Speech therapist reported to this nurse that resident called them a bitch whore. Resident refusing assistance from staff members and threatening to beat staff up. Redirection unsuccessful. Will continue to monitor; -On 11/10/21 at 8:22 A.M. the resident was very angry and combative this morning. Lab here for blood draw. The resident hit lab technician in the face and called the lab technician a racial slur. Resident too combative for blood draw. Will continue to monitor; -On 11/11/21 at 9:46 P.M., the resident was combative with lab technician three days in a row. Labs unable to be drawn three days. The physician was made aware. Labs not reordered at this time; -On 11/15/21 at 7:29 A.M., the resident continues with constant refusals. Resident refusing to get out of bed for breakfast at this time. Will attempt to feed resident in bed. Will continue to monitor; -On 11/16/21 at 5:52 A.M., the resident remains on observation for fall. Nursing unable to check range of motion due to resident being combative. No acute distress noted. Resident resting in bed. Call light and personal belongings within reach. Refused vitals. Review of the resident's care plan, last reviewed 10/15/21, and in use at the time of the survey, showed staff failed to address the resident's aggressive and combative behaviors. Staff failed to identify triggers as well as interventions staff could employ to provide individualized care for the resident's behaviors. Review of the psychiatric mood and affect/neurological section on the specialized wound management reports for November 2021, showed: -11/3/21: somewhat uncooperative during exam today; -11/10/21: easily agitated and combative; -11/17/21: easily agitated. Observation on 11/18/21 at 2:45 P.M., showed Licensed Practical Nurse (LPN) F and RN E provide care for the resident. The resident lay in bed. RN E entered the resident's room and put on gloves. RN E grabbed the bed control and adjusted the resident's bed height. The resident asked what the nurse was doing. RN E said it was time to do the dressing change. RN E then said he/she knew the resident didn't like it, but it needed to be done. The resident has refused care and can be combative. LPN F entered the resident's room with supplies and shut the door. LPN F put on gloves and turned the resident onto his/her right side. The resident yelled out Take it easy. LPN F and RN E rolled the resident back to his/her back. The resident yelled out, Come on already, you two idiots. The resident yelled out to hurry up. RN E and LPN F rolled the resident back to his/her left side. The resident then said, I am so God damn mad now! I'm ready to start swinging. The resident then yelled out, That's enough already. LPN F said they were almost done. The resident said, I'm warning you, fists are going to start flying. RN E and LPN F attempted to pull up the resident's pants. The resident yelled again, I'm so mad. LPN F and RN E covered the resident up. The resident yelled to turn out the lights. LPN F washed his/her hands, turned off the lights, shut the resident's door and left the room with supplies. During an interview on 11/18/21 at 3:05 P.M., LPN F and RN E said combative and aggressive behavior is typical for the resident. The resident's behavior has worsened. The resident also hits, spits, and bites staff. LPN F and RN E said management was aware but told staff to bring two people into the room whenever they needed to provide care. The family was aware of the behavior but are far away and don't really understand. LPN F and RN E said when the resident was really angry and combative, then they try to redirect him/her and stay positive. If that doesn't work, then they will step out of the room and let the resident take a breath before they go back in to finish care. The resident also refuses care a lot. For staffing, they said the resident is typically assigned to familiar staff, but at times, agency staff will be assigned to the resident. LPN F and RN E checked the electronic chart to see if the behaviors were in the care plan. They verified the behaviors were not addressed in the care plan. LPN F said the resident's behaviors should be on the care plan but the facility doesn't have an MDS coordinator at the moment. 3. Review of Resident #135's progress note in the electronic medical record, showed: -The resident has a gastronomy tube (g-tube, a tube placed through the abdomen and into the stomach to provide nutrition, hydration, and medication), the resident receives nothing by mouth (NPO); -The resident has an indwelling catheter (a sterile tube inserted into the bladder to drain urine) and is incontinent of bowel at times but does ask for a bedpan; -The resident is unable to bear weight on his/her lower extremities and transfers with the Hoyer lift (mechanical lift); -The resident's speech is slurred and aphasic (inability to express speech). Review of the resident's care plan, dated 11/5/21, and in use at the time of the survey, showed staff failed to address the resident's g-tube, use of a catheter, NPO status, and the resident's inability to bear weight on his/her lower extremities. During an interview on 11/19/21 at 11:20 A.M., the administrator said the facility has never had a consistent MDS nurse, so it has been a challenge. They do have a corporate nurse that works remotely on care plans. The administrator said she strongly feels they have caught up quite a bit. The social workers review their own care plans and behavior issues should be updated by nursing and social services. The administrator said that if a resident is on the rehabilitation unit or the long term unit, she would expect the care plans to be reflective of their care needs. 4. Review of Resident #11's quarterly MDS, dated [DATE], showed: -Cognition not assessed; -Rarely/never understood. Sometimes understands others; -No behaviors; -Requires total assistance from staff for dressing and transfers. Requires extensive staff assistance for personal hygiene; -Always incontinent; -Diagnoses included stroke, high blood pressure, dementia and aphasia (loss of ability to understand or express speech). Review of the resident's medical record, showed a nurse's note, dated 8/15/21 at 4:31 A.M., showed, reported to nurse by a CNA, resident had bruising that appeared new to both upper arms and left hand. Further assessment to the legs revealed red discoloration to bilateral lower extremities, reddish bruising to left thigh and old bruising to right thigh. Resident has no complaint of discomfort to any bruising. The resident has a history of being combative with staff, propels self in wheelchair and is a Hoyer (mechanical) lift for transfers. Review of the facility's investigation summary, dated 8/15/21, showed the resident has a history of combative behaviors during care and had recently been agitated. The resident is able to propel him/herself in his/her wheelchair and has poor safety awareness. The resident requires frequent reminders to keep arms near his/her body during Hoyer lift transfers, as he/she will swing his/her arms, bumping on the Hoyer lift frame. Bruising is not suspicious in appearance. Bruising likely resulted from combative behaviors when staff attempt care and/or performing Hoyer lift transfers. Review of the resident's care plan, last revised on 8/3/21, showed: -Staff did not address the resident's aphasia and individualized communication needs; -Staff did not address the incident on 8/15/21; -Staff did not identify the resident as having combative behaviors or include triggers and approaches; -Staff did not address the resident's poor safety awareness or include individualized approaches to maintain his/her safety. During an interview on 11/19/21 at 9:15 A.M., the DON said the care plan should reflect the resident's current needs. The bruising incident should have been included on the care plan. The resident's combative behavior should have also been included on the resident's care plan. 5. Review of Resident #84's admission MDS, dated [DATE], showed: -admitted : 12/20/20; -discharged to the hospital: 1/15/21; -Diagnoses included: fractured left clavicle (collarbone), cancer, high blood pressure and Alzheimer's disease; -Should a BIMS be conducted? Yes. The summary score left blank; -Should the staff assessment for mental status be conducted? Left blank; -Required supervision and set up with eating; -Required extensive assistance for bed mobility, transfers, walking in room, locomotion on the unit, dressing, toilet use, personal hygiene and bathing; -Always incontinent of bowel and bladder; -Swallowing disorder: coughing and choking; -At risk for developing pressure ulcers. Review of the resident's physician orders sheet, dated 12/19/20 through 1/31/21, showed: -An order for a sling for left upper extremity for comfort every shift, dated 12/22/20; -An order for non-weight bearing left upper extremity, dated 12/22/20; -An order to maintain contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled. Contact precautions usually require medical staff and visitors to wear gowns and gloves when entering the patient's room) and droplet isolation (used when the patient has an infection with germs that can be spread to others by speaking, sneezing, or coughing. Everyone coming into the room of a patient under droplet precautions will be asked to wear a mask), dated 12/22/20 through 1/15/21; -An order for mechanical soft diet (type of texture-modified diet for people who have difficulty chewing and swallowing) with nectar thick liquids, aspiration (food or liquids get into the airway) precautions, dated 12/22/20 through 12/28/20; -An order for pureed diet (food which requires no chewing) diet with nectar thick liquids, aspiration precautions, dated 12/28/20 through 1/15/21; -An order to apply half sheet Kerracel Ag (fiber dressing used to maintain moisture balance over the wound to help promote healing), abdominal pad (ABD, dressing used to keep wounds dry), Kerlix (gauze) to left heel fluid filled blood blister daily, dated 1/7/21 through 1/13/21; -An order for wound team evaluation and treatment, dated: 1/8/21; -An order showed needs to be fed all meals, dated 1/12/21; -An order for Betadine 10% solution (antiseptic), apply to right heel daily, start date: 1/13/21; -An order for Betadine 10% solution, apply to left great toe daily, start date 1/13/21; -An order to cleanse left heel with normal saline (NS), apply Betadine, cover with ABD, wrap with Kerlix daily and as needed, start date 1/13/21. Review of the resident's medical record, showed staff did not complete a care plan. During an interview on 11/22/21 at 9:30 A.M., the medical records representative said the resident did not have a care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess two residents for medication self-administration and obtain physician's orders (Resident #384 and #492), obtain physician's orders for a wanderguard (a device worn by a resident that triggers alarms and can lock monitored doors to prevent the resident leaving unattended) for one resident (Resident #61) and obtain oxygen orders for one resident utilizing oxygen (Resident #33). Facility staff also failed to provide showers as ordered for one resident (Resident #1), provide treatments as ordered for two residents (Resident #203 and #53) and perform weekly skin assessments for one resident (Resident #53). The sample was 24. The census was 155 with 137 residents in certified beds. 1. Review of the medication administration policy, dated January 2021, showed residents are allowed to self-administer medication specifically ordered by the attending physician. 2. Review of the facility's self-administration policy, dated 6/21, showed: -Self administration of medications is to be addressed in the care plan by the interdisciplinary team and reviewed quarterly, annually, and with any signification change of status. Appropriate documentation on the care plan will include storage, administration documentation and location of the drug administration. -Over the counter (OTC) medications will be in the original container, sealed and labeled with the resident's name. If brought into the facility by family or the resident, they must be approved by the charge nurse before giving them to the resident for administration. -Medications will be stored in the resident's room in a secured area. 3. Review of the resident handbook under resident responsibilities, showed residents are not permitted to keep medications (prescription, over the counter, topical) in their room without a physician's order. 4. Review of Resident #384's care plan, dated 11/18/21, showed: -Problem: ADL (activities of daily living) Functional/Rehabilitation Potential; -Goal: The resident will participate in ADL activities promoting maximum independence; -Approach: Encourage ADL participation and allow resident sufficient time to perform ADLs without being rushed; Bed mobility, bathing, and dressing with assistance of one. Review of the resident's electronic physician's order sheet (ePOS), showed: -An order dated 11/12/21 for Albuterol Sulfate HFA aerosol inhaler; 90 milligrams (mg)/actuation; 2 puffs; inhalation every 6 hours as needed; -No order for saline nose spray. Observation on 11/15/21 at 4:00 P.M., showed the resident had a small bottle of nasal spray and an albuterol inhaler sitting on his/her bedside table. Observation on 11/22/21 at 8:35 A.M., showed the resident had a small bottle of nasal spray on his/her bedside table. 5. Review of Resident #492's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/9/21, showed: -Cognitively intact; -Diagnoses included: high blood pressure, high cholesterol, depression and Parkinson's disease; -Required supervision with eating and personal hygiene; -Always incontinent of bladder and occasional of bowel. Observation on 11/15/21 at 9:15 A.M., showed a box of hemorrhoid cream sat on the resident's bedside table; at 10:40 A.M. the hemorrhoid cream remained on resident's bedside table. Review of the resident's medical record, showed no physician's order for hemorrhoid cream and no self-administration assessment completed. During an interview on 11/19/21 at 11:00 A.M., the resident said his/her family brought the hemorrhoid cream in and he/she keeps the creams in his/her drawer. The staff has not asked him/her any questions regarding his/her medications. The facility does not know the cream is here. 6. During an interview on 11/22/21 at 8:01 A.M., Certified Nurse Aide (CNA) JJ said if he/she saw medication in a resident room, he/she would report it to the nurse because he/she would not know how much the resident can have. This would include over the counter medications/creams/ointments. He/she is not aware of any residents who have medications at their bedside. 7. During an interview on 11/22/21 at 8:01 A.M., the Director of Nursing (DON) said residents should not have medication in their rooms, unless they are assessed and have an order. If a resident wanted to self-administer medications, the resident would need to be assessed and a physician order obtained. The medication would need to be stored in a secure place. If a family member brought the medication in, the family member should give the medication to the nurse or the certified medication technician (CMT). The DON was not aware of any residents who had any creams or ointments at the bedside for self-administration. 8. During an interview on 11/22/21 at 10:10 A.M., the administrator said, if a resident wants to self-administer their medications, the resident would need an assessment completed, a physician's order, and the medication would need to be stored away in a safe place. Over the counter medications would be considered medications and would follow the same protocol. If a family member brought the medication in, they should take the medication to the nurse. This topic is discussed with the family and resident during the admission process. The administrator was not aware of any residents who had medications at bedside. 9. Review of Resident #61's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -No behaviors; -Required the assistance of one staff for walking, transfers, dressing, toileting and personal hygiene; -Always continent of bowel and bladder; -Diagnoses included high blood pressure, diabetes, dementia and depression. Review of the resident's medical record, showed: -An elopement assessment, dated 11/2/21, which included: -Resident has cognitive impairment; -History of wandering; -Interventions included: Care plan for high elopement risk, add name and picture to elopement book. -A nurse's note, dated 11/18/21 at 4:46 P.M., wanderguard in place on left wrist. Review of the resident's November 2021 ePOS, showed: -No order for the use of a wanderguard bracelet; -No order for staff to check the function and placement of the wanderguard bracelet. Observation of the resident on 11/19/21 at 10:47 A.M. and 11/21/21 at 8:27 A.M., showed a wanderguard bracelet on the resident's left wrist. The resident said he/she thought he/she has worn it for about two weeks. Review of the elopement book at the unit nurse's station and at the front desk on 11/19/21 at 11:50 A.M. and 11/21/21 at 9:10 A.M., showed staff failed to include the resident's information and picture in either elopement book. During an interview on 11/21/21 at 10:30 A.M., the administrator said the elopement assessment interventions should be in place. The resident's information should be in the elopement book. There should be an order for the use of a wanderguard including an order for staff observation of the bracelet on each shift. During an interview on 11/22/21 at 12:45 P.M., the DON said there should be an order for the use of a wanderguard. 10. Review of the facility's Oxygen Administration Policy, dated 7/2016, revised on 5/2021, showed that there must be a physician's order to apply oxygen. Review of Resident #33's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Able to report correct day, month and year; -No evidence of acute change in mental status; -Able to complete interview; -Requires one person physical assist in bed mobility, transfers, dressing, toilet use and personal hygiene; -Diagnoses included stroke, heart failure, high blood pressure and kidney disease. Review of the resident's ePOS, from admission date to present, showed no physician's order for oxygen supplementation. During an observation and interview on 11/15/21 at 11:17 A.M., the resident's room had an oxygen concentrator. The resident said he/she did not require oxygen supplementation since his/her pacemaker was implanted about two weeks ago. The resident said he/she was using oxygen regularly prior to that. During an interview on 11/17/21 at 9:37 A.M., Registered Nurse (RN) V said the resident required oxygen supplementation but the resident does not like it. He/she said the facility provided oxygen devices, such as the concentrator, in almost all resident rooms during the Covid pandemic, in the event of a resident's oxygen level became low. RN V expects to have a physician's order prior to administering oxygen supplementation to the residents. He/she then checked the ePOS and found no orders for oxygen. During an observation and interview on 11/18/21 at 10:20 A.M., the resident propelled him/herself and received oxygen through a nasal cannula attached to an oxygen tank behind his/her wheelchair. The resident said he/she had to use the oxygen during therapy. During an interview on 11/19/21 at 2:13 P.M., the DON said the resident required oxygen as needed during activities, such as therapy. He/she expects to have a physician's order prior to administering oxygen supplementation to the residents. 11. Review of the facility's Bathing Policy, revised on 1/2017 and 6/21, showed bath days and the type of bath to be given will be assigned by the charge nurse according to the resident's preference. Review of Resident #1's quarterly MDS, dated [DATE], showed: -Short-term memory problem; -Modified independence for cognitive skills; -Limited assistance in toilet use and requires supervision with personal hygiene; -Diagnoses included diabetes and anxiety disorder. Review of the resident's care plan, in use at the time of survey, showed: -History of falls related to poor vision and poor safety awareness; -Complete bath and skin reports on shower days; -Provide peri-care and apply moisture barrier; -One assist for transfers. Review of the resident's ePOS, dated 5/20/21, showed the resident's shower preference scheduled for Tuesday, Thursday, and Saturday during day shift. During an observation and interview on 11/15/21 at 11:26 A.M., the resident was noted to have body odor. The resident said he/she had not had a shower for three weeks. Staff always promise to give him/her showers but do not come back. The resident said he/she needed assistance with showers because he/she had become weaker. During an interview on 11/16/21 at 2:50 P.M., the resident said he/she finally had a shower today after three weeks without having one. The resident said the staff may have heard his/her complaints the day before. The resident added he/she would want at least one shower a week. Review of the resident's medical record, both electronic and hard copy, showed the following documentation on baths and showers: -On 7/8/21, shower given with no skin issues noted; -On 8/10/21, noted refused until Thursday; -On 8/18/21, shower given and noted, old red marks, no location specified; -On 8/19/21, noted refused wants shower 2X a week; -On 9/14/21 at 2:50 P.M., shower was done; -On 9/16/21 at 2:53 P.M., shower was done; -On 9/21/21 at 1:11 P.M., shower was not done, resident refused; -On 9/25/21 at 2:13 P.M., shower was done; -On 10/07/21 at 1:31 P.M., shower was done; -On 10/19/21 at 2:29 P.M., shower was not done, resident refused; -On 10/26/21 at 2:45 P.M., shower was not done, resident refused; -On 10/28/21 at 2:42 P.M., shower was not done, resident refused; -On 10/30/21 at 2:20 P.M., shower was not done, resident refused; -On 11/02/21 at 2:39 P.M., shower was not done, resident refused; -On 11/16/21, shower given with no skin issues noted; -On 11/16/21 at 1:50 P.M., shower was done. During an interview on 11/17/21 at 10:42 A.M., CNA AA said all residents get showers three times a week. He/she said if a resident refuses a shower, it will be noted in the shower sheets and will be given to the nurse. The CNA added he/she does not document electronically because the nurse does all electronic documentation after reviewing the shower sheets. During an interview on 11/19/21 at 11:58 A.M., RN V said the residents receive showers two times a week. The CNAs refer to a book located in the nurse's station to check for shower schedules at the beginning of their shift. If a resident refused showers, he/she would talk to the resident and find out the reasons of refusal. It will be noted in the shower sheets if a resident continues to refuse, then he/she notifies the staff on the next shift. RN V said he/she does not document electronically. If the CNAs do not notify him/her of a resident's refusal to shower immediately or before their shift ends, he/she will not be able to talk to the resident. He/she expects the CNAs to provide the residents showers as scheduled, and notify the nurse immediately if a resident refused a shower. During an interview on 11/19/21 at 2:13 P.M., the DON said the residents receive showers two times a week and as needed. CNAs note the refusal on the shower sheets and notify the charge nurse. The nurse then should talk to the resident and encourage a shower, and if the resident continues to refuse they will try again the next day, or let the next shift be aware so they can also try to provide the shower. The DON expects for nurses to document in the progress notes. He/she also expects the staff to provide residents their showers as scheduled or ordered and document appropriately. 12. Review of Resident #203's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Memory/recall ability that he/she is in a nursing home; -Required extensive assistance for bed mobility, transfers, dressing, eating, toilet use and personal hygiene; -Diagnoses included anemia, high blood pressure, dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), malnutrition, anxiety disorder and respiratory failure. Review of the resident's care plan, in use at the time of survey, showed: -Currently receives hospice services; -Resident has a non-pressure ulcer to coccyx related to previous rash; -Apply dressing per physician's order by Specialized Wound Management (SWM): normal saline, Santyl (debriding agent used to help wounds heal), and foam daily and as needed; -Obtain treatment orders and initiate. Review of the resident's ePOS, dated 6/23/21, showed to cleanse the resident's sacral ulcer with normal saline, apply Santyl, pack with Kerracel AG (a gelling fiber dressing containing silver) and cover with 4 inch foam daily and as needed. During an interview on 11/16/21 at 7:50 A.M., the resident said he/she has a wound on his/her buttocks but was unable to tell how the area looks. The nurse checks and cleanses the wound every Wednesday. Staff only change his/her incontinence pad daily, but not the wound dressing. During an observation and interview on 11/17/21 at 11:18 A.M., Licensed Practical Nurse (LPN) DD performed wound treatments. He/she said his/her documentation is found under Wound Management in the resident's electronic health records (EHR). On 11/22/21 at 7:22 A.M., LPN DD said he/she only does treatments on Wednesdays, and the floor nurses are responsible for the other days of the week. The floor nurses' documentation can be found in the Treatment Administration Record (TAR) in the resident's EHR. Review of the resident's Wound Management documentation, showed LPN DD documented wound treatments were administered every Wednesday, with multiple late entries noted. Review of the resident's TARs from August to November 2021, showed: -On 8/13/21 at 1:05 P.M., Not administered. Resident unavailable. Up in wc still; -On 9/1/21 at 2:41 P.M., Not administered. Unable to complete; -On 9/4/21 at 3:02 P.M., Not administered. Not enough time to complete; -On 9/20/21 at 3:07 P.M., Not administered. Busy on division; -On 9/24/21 at 2:23 P.M., Not administered. Resident unavailable; -On 10/31/21 at 8:45 P.M., Not administered. Completed by prev. nurse -On 11/14/21 at 2:02 P.M., Not administered. Unable to complete; -On 11/19/21 at 2:40 P.M., Not administered. Unable to complete; -On 11/20/21 at 2:46 P.M., Not administered. Unable to complete resident is still in broda chair per his/her request. 13. Review Resident #53's admission MDS, dated [DATE], showed: -admitted : 9/14/21; -Diagnoses included high blood pressure, diabetes, high cholesterol, thyroid disorder and anxiety; -Should brief interview for mental status be conducted? left blank; -Should the staff assessments for mental status conducted? left blank; -No rejection of care; -Required set up for eating; -Required limited assistance of staff for personal hygiene; -Required extensive assistance of staff for bed mobility, transfers, locomotion on and off the unit and bed mobility; -Required for total assistance for dressing; -Always incontinent of bowel and bladder; -At risk for pressure ulcers. Review of the resident's ePOS on 11/15/21, showed: -An order for perform head to toe skin assessments. Complete nursing weekly skin assessment observation; -An order for ace wraps to both lower extremities (BLE), apply in A.M. Review of the resident's skin assessments, dated 10/8/21 through 11/10/21, showed: -On 10/8/21, there were no abnormalities; -On 11/10/21, there was an open area on left heel, treatment in place; -No skin assessments were documented for the weeks of 10/10 through 10/16, 10/17 through 10/23, 10/24 through 10/30 and 10/31 through 11/6/21. Review of the resident's progress notes, dated 10/8/21 through 11/16/21, showed: -On 10/27/21 at 11:47 A.M., open area noted to bottom of resident's left heel. Resident states area is new and states I believe it came from a pair of tennis shoes I was brought no depth noted; -On 10/30/21 at 10:47 A.M., small area of broken skin was noted to sacral area. Review of the resident's TAR, dated 10/1/21 through 11/3/21, showed: -An order for ace wraps to BLE, apply in AM, dated 10/4/21 through 11/3/21, documentation showed: -On 10/6/21, not administered, comment: unable to complete; -On 10/7/21, not administered, comment: unable to complete, multiple divisions; -On 10/8/21, not administered, comment: utc; -On 10/9/21, not administered, comment: utc; -On 10/10/21, not administered, comment: unable to complete; -On 10/12/21, not administered, comment: unable to complete; -On 10/16/21, not administered, comment: could not complete; -On 10/17/21, not administered, comment: unable to complete; -On 10/18/21, not administered, comment: utc, -On 10/19/21, not administered, comment: unable to complete; -On 10/21/21, not administered, comment: unable to complete; -On 10/22/21, not administered, comment: unable to complete; -On 10/23/21, not administered, comment: unable to complete; -On 10/24/21, not administered, comment: unable to complete; -On 10/25/21, not administered, comment: unable to complete; -On 10/26/21, not administered, comment: unable to complete; -On 10/27/21, not administered, comment: unable to complete; -On 10/28/21, not administered, comment: unable to complete, multiple divisions; -On 10/30/21, not administered, comment: unable to complete; -On 10/31/21, not administered, comment: unable to complete; -On 11/1/21, not administered, comment: unable to complete; -On 11/2/21, not administered, comment: unable to complete. Further review of the resident's progress notes dated 10/6/21 through 10/31/21, did not show the doctor was notified staff was unable to complete applying the residents ace wraps as ordered. 14. During an interview on 11/18/21 at 1:00 P.M., RN R said utc means unable to complete. Sometimes he/she will chart utc when he/she is unable to complete the task because of time constraints. The computer will not clear the item off unless something is charted. 15. During an interview on 11/18/21, LPN GG, said nurses on the unit are responsible for completing the weekly skin assessments. 16. During an interview on 11/22/21 at 8:11 A.M., the DON said she expects the treatment nurse to follow physician's orders and document timely and appropriately. The DON said if a resident is up in their chair, she expects the staff to transfer the resident to bed, if necessary, to complete the treatments on time. If it was noted unable to complete, on a resident's TAR, it signifies the treatments were not administered due to time constraints. She expects the nurse on the next shift to administer wound treatments if it was not administered from prior shift. She would expect the staff to follow physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff were knowledgeable about hazardous chemical protocol with utilization of safety data sheets (SDS) when one resident (Resident #339) ingested alcohol-based hand sanitizer. The facility staff failed to lock the medication/treatment cart when not in direct sight of the staff, failed to complete a smoking assessment for one resident (Resident #284) and failed to complete fall follow up for four residents (Residents #61, #490, #487 and #5). The sample was 24. The census was 155 with 137 residents in certified beds. Review of the facility's Emergency Safety Procedures for Hazardous Chemicals policy, effective November 2021, showed: -Purpose: Manage potential or actual exposure to hazardous material. Provide directives regarding the best way to respond quickly and appropriately. First aide procedures include inhalation, ingestion, skin, and eye; -Procedure: -Ensure the resident is safe and free of harm; -Notify the charge nurse; -Notify the Director of Nurses (DON), administrator or nurse manager immediately; -Notify the physician; -Reference the SDS related to the item involved in exposure; -Call poison control; -Notify the responsible party; -Follow guidance from SDS and poison control; -Assess and monitor the resident's status and respond ongoing according to needs, guidance and physician orders; -Notify medical director. 1. Review of Resident #339's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/21, showed: -admitted [DATE]; -Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, showed moderate cognitive impairment; -No behavioral symptoms exhibited; -Diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD, lung disease), high blood pressure, seizure disorder, dementia, anxiety and depression. Observation on 11/16/21 at 3:25 P.M., showed the resident wore a surgical mask as he/she propelled him/herself in a wheelchair in front of the conference room. He/she stopped at a table on which a bottle of alcohol-based hand sanitizer was placed. He/she picked up the bottle of hand sanitizer, lifted the bottom of his/her surgical mask, and pumped the sanitizer into his/her mouth. He/she pulled the mask back down over his/her mouth, then lifted it again and pumped more sanitizer into his/her mouth. He/she pulled the mask back down over his/her mouth and placed the sanitizer bottle back onto the table. Staff walked by the resident and told him/her to put his/her oxygen nasal cannula back into his/her nose. The resident said he/she was going back to his/her room and continued to propel down the hall. The surveyor notified Licensed Practical Nurse (LPN) M about the incident. LPN M brought to the resident to the nurse's station and performed an assessment. When asked if he/she drank something, the resident said he/she did and whatever he/she drank burned and his/her eyes were blurry. Review of the hand sanitizer drug facts, showed: -Active ingredient: ethanol 70%; -Warnings: For external use only; -Avoid contact with eyes. In case of eye contact, flush with water for 15 seconds; -No instruction for protocol regarding ingestion through the mouth. Observation on 11/16/21 at 3:32 P.M., showed the resident sat at the nurse's station on the 100 hall, drinking water from a small cup. LPN M spoke on the phone with the resident's family and notified them of the incident. He/she gave the resident the phone and the resident told his/her family he/she thought the bottle of hand sanitizer was green water. As LPN M searched through paperwork at the nurse's station, the DON approached and asked if LPN M found the Material Safety Data Sheets (MSDS). LPN M shook his/her head no, and the DON pulled a SDS binder from one of the cabinets at the nurse's station and began looking through it. During an interview on 11/16/21 at 3:43 P.M., LPN M said the resident's physician was notified and gave new orders for labs and said for the resident to drink plenty of water. The physician did not think the resident needed to be sent out to the hospital. The resident was able to answer all questions asked of him/her and was alert and oriented to his/her baseline. Observation on 11/16/21 at approximately 3:46 P.M., showed 54 bottles of alcohol based hand sanitizer located throughout the facility as follows: -5 bottles in the main dining room and sitting room, including the table accessed by the resident; -7 bottles on 100 hall; -7 bottles on 300 hall; -10 bottles on 400 hall; -8 bottles on 500 hall; -17 bottles on 700 hall. During an interview on 11/16/21 at 3:50 P.M., the DON said he/she could not locate a MSDS in the safety binder at the 100 hall nurse's station regarding alcohol-based hand sanitizer. The MSDS should have been in the SDS binder for staff to access. The MSDS provides guidance to staff in the event of a resident ingesting chemicals. During an interview on 11/16/21 at 4:10 P.M., the administrator said if a resident ingests any chemical, staff should consult the MSDS for that particular chemical, and follow its protocol. MSDS are located in the SDS binders at each nurse's station, as well as the housekeeping closets and the kitchen. The maintenance director is responsible for ensuring SDS binders are placed at each of these locations. She would expect the maintenance director to review the SDS binders on a monthly basis. He/she was aware the MSDS for alcohol based hand sanitizer was not located in the SDS binder at the 100 hall nurse's station. The MSDS should have been in the SDS binder. All SDS binders will be reviewed and all hand sanitizer bottles will be removed from the floor. Staff will be provided with pocket-sized hand sanitizer bottles and wall-mounted hand sanitizer dispensers will be ordered. The resident's physician and family were notified of the incident and poison control will be notified. The resident has moderate cognitive impairment and confusion. He/she demonstrates attention-seeking behaviors, but has no prior history of ingesting sanitizer, self-harm, or substance abuse. The resident will continue to be monitored and the administrator and social worker (SW) will follow up with him/her. During an interview on 11/16/21 at 5:15 P.M., the administrator said poison control was notified and they said the resident should be fine. Staff should continue to monitor for signs and symptoms of an adverse reaction. Review of the resident's care plan, revised 11/17/21, showed: -Problem: Behavioral symptoms. Resident is at risk for socially inappropriate/disruptive behavioral symptoms such as fighting, paranoia, resisting activities of daily living (ADLs) and screaming/yelling as evidenced by routine used of an anxiolytic (anti-anxiety medication). Resident has attention seeking behaviors when he/she feels things are not going his/her way. Needs assistance with coping mechanisms; -Approach, start date 11/16/21: resident ingested hand sanitizer gel after a conversation with his/her family regarding his/her family's ability to visit. Family has been unable to visit over the last two weeks; -Approaches did not include ensuring the resident did not have access to hand sanitizer bottles. During an interview on 11/17/21 at 6:09 A.M., Certified Nurse Aide (CNA) N said if he/she witnessed a resident ingest chemicals or anything other than food, he/she would remove the item and let the nurse know. He/she would rinse the resident's mouth and assess the resident. He/she was not aware of a safety book or policy available and said the nurse takes care of that. During an interview on 11/17/21 at 6:10 A.M., CNA O said if he/she witnessed a resident ingest something that was not food, he/she would remove the item and tell the nurse. He/she would keep that particular item away from the resident in the future. He/she did not make reference to consulting a SDS binder. During an interview on 11/17/21 at 6:25 A.M., LPN P said if he/she witnessed a resident ingest chemicals or anything other than food, he/she would call the physician, ask what they wanted to do, and follow the physician's guidelines. He/she has not been orientated on whether or not the facility has a manual or guidelines to follow in the event of something like this happening. During an interview on 11/17/21 at approximately 6:25 A.M., Certified Medication Technician (CMT) Q said if he/she witnessed a resident ingest something that was not food, he/she would try to give the resident water and have them rinse their mouth out. He/she would remove the item ingested and tell the nurse. Once the nurse gets there, the nurse would take over. When asked about a reference available to the staff, CMT said he/she thought there might be information in the emergency book (list of emergency phone numbers, disaster plans, and protocols for abuse and elopements) or communication binder (fever guidelines) at the nurse's station. He/she did not make reference to consulting a SDS binder. During an interview on 11/17/21 at 6:28 A.M., Registered Nurse (RN) R said if a resident ingested chemicals, he/she would call poison control first. He/she would notify the physician, family and his/her supervisor. There is a safety book somewhere but he/she did not know where. During the interview, another staff member told RN R the safety binder was located under the cabinet at the nurse's station. During an interview on 11/17/21 at 6:50 A.M., LPN K said if a resident ingested something toxic, he/she would check the resident's code status and call a stat (medical emergency). He/she would rinse the resident's mouth with water, obtain vital signs, perform neurological assessments (neuro checks), and check their list of allergies. He/she would notify the resident's physician and ask for suggestions, and would notify the resident's responsible party. Most chemicals have directions on them. There should be a safety manual but he/she does not know where it is. Observation on 11/17/21 at 10:17 A.M., showed a bottle alcohol-based hand sanitizer on the handrail on the back wall of the 100 hall dining room. During an interview on 11/17/21 at 10:17 A.M., CNA S said he/she heard about the incident in which the resident ingested hand sanitizer. The resident does not have a history of ingesting chemicals. Since this incident, all hand sanitizer bottles have been removed from the floor and should not be within reach of residents. During the interview, the CNA observed the bottle of hand sanitizer in the 100 hall dining room and removed it from the handrail. Observation on 11/17/21 at 4:04 P.M., showed the resident sat in a wheelchair in the bathroom in his/her room, rubbing his/her hands together. A bottle alcohol-based hand sanitizer was on top of his/her toilet. During an interview, the resident said he/she just put on lotion and pointed to the hand sanitizer. He/she is able to have it in his/her room. He/she denied ever ingesting sanitizer. Observation and interview on 11/17/21 at 4:27 A.M., showed the DON entered the resident's bathroom and observed hand sanitizer on top of the resident's toilet. The DON removed the hand sanitizer and exited the room. During an interview, the DON said the hand sanitizer should not have been in the resident's room and staff should have removed all hand sanitizer bottles from the floor. The resident should not have access to hand sanitizer because he/she ingested it yesterday. The facility has been in-servicing staff on this and staff will have to be in-serviced again. During an interview on 11/23/21 at 11:05 A.M., the maintenance director said he has been in his position for approximately 5 months and started taking over the responsibilities of his role within the past few weeks. Prior to him taking the position, SDS binders were handled by the housekeeping supervisor. SDS binders are located at the housekeeping supervisor's desk, the maintenance director's desk, the front desk, and the DON's office. He was not sure if they are also located at the nurse's stations. When the facility receives new chemicals, the housekeeping supervisor was updating the binders by adding new SDS and removing SDS for chemicals no longer in use. The maintenance director will be taking over this responsibility. The SDS binders should include information on all chemicals used in the facility. SDS tell staff additional information about the chemical and what to do if the chemical is ingested in the mouth or eyes, or if contact is made with skin. He would expect the SDS binders to include information regarding hand sanitizer and he was not aware this information was missing from the binder located at the 100 hall nurse's station. During an interview on 11/22/21 at 8:50 A.M., the DON said she expects all staff to be knowledgeable of safety protocols for incidents such as ingesting chemicals. SDS should be reviewed with facility staff on an annual basis. New hires are educated on safety protocols during orientation. If agency staff is not sure of what to do in the event of a resident ingesting chemicals, they should call the charge nurse or DON to receive instruction on how to look in the SDS binders. The facility is working on a plan to improve communication with agency staff. Resident care plans should accurately reflect the resident's status and care needs at the time of assessments. Care plans should be updated upon a change in condition and should include interventions for identified areas. The resident's care plan should have been updated with interventions to address his/her ingestion of hand sanitizer, including for staff not to leave hand sanitizer in the resident's room. During an interview on 11/22/21 at 9:02 A.M., the administrator said she expects staff to be knowledgeable of safety protocols for incidents such as ingesting chemicals. Safety meetings are held on a monthly basis with department heads. If the facility identifies an issue, they do rounds and educate staff as needed. New hires are educated on safety protocols during orientation. Agency staff should be oriented as much as possible before they come to the facility and their CNA training should encompass safety protocols as well. She expects resident care plans to accurately reflect a resident's condition and care needs at the time of assessment. Care plans should be updated upon a change in condition and should include resident-specific interventions under identified care areas. The resident's care plan should include interventions regarding the recent incident of hand sanitizer ingestion, including for staff not to leave hand sanitizer within the resident's access. 2. Review of the facility's Medication administration policy, revised 1/2021, showed to keep the cart in visible range or lock all items before going into the resident's room. Review of the facility's Pharmacist and Consultant Duties and Responsibilities Policy, with one section named medication storage, labeling, and disposal, dated effective November 2017 and reviewed May 2021, did not address how to safely store medications on the medication and treatment carts. Observation on 11/15/21 at 9:40 A.M., of the 100 hall nurse/treatment cart, showed the cart positioned against the wall behind the nurse's station with a resident sitting in a wheelchair next to the cart. There were no staff present at the nurse's station. The smaller cart door closest to the resident was partially open. LPN G was observed coming out of the 100 hall medication room that was located across from the nurse's station. LPN G gave the resident a cup of medications to take. LPN G got in med cart and then walked away, leaving the cart unlocked in the same spot. At 9:45 A.M., LPN G came back to the cart and rolled it down the 100 hall and parked the cart in front of room [ROOM NUMBER]. Observation on 11/17/21 at 4:10 P.M., showed RN H on the 700 hall with the nurse/treatment cart. RN H had two glucometer machines on the cart and multiple lancets sitting on top of the cart. RN H went into Resident #134's room with supplies to check the resident's blood sugar and left the keys on the cart. The cart was in the hallway outside of the resident's room. RN H dropped gauze on the floor and went out of the room to the cart. RN H grabbed the keys and changed his/her gloves. RN H finished with the resident's care and took the cart to the next resident's room. The nurse parked the cart in front of Resident #75's room. RN H put one glucometer in his/her pocket, obtained supplies and the other glucometer and went into the resident's room. RN H checked the resident's blood sugar. RN H went back to cart and put the lancets away. RN H entered Resident #75's room, leaving the keys on the cart parked out side the room. He/she dropped the lancet and went back to the cart to get a new one. He/she went back into the resident's room, leaving the keys on the cart. RN H went back to cart to check orders after the blood sugar result was obtained. RN H left the door open and the keys on the cart and went into the resident's room to give insulin. RN H completed care and left the resident's room. RN H then took the keys, locked the cart, and moved the cart towards the nurse's station. During an interview on 11/22/21 at 10:20 A.M., the DON said the medication/treatment cart should be locked if the cart is not in the staff's view because it is a safety risk. Someone could get in there and steal the drugs. The DON also said that the keys should not be left unattended. 3. Review of the facility's Smoking Nursing Policy and Procedure Manual, reviewed 5/2021, showed: -Title: Smoking; -Purpose: To promote resident safety when residents smoke; -Procedure: -Upon admission, residents with a current or past history of smoking who desire to keep smoking are to be assessed for smoking privileges; -Re-assessment/observation of smokers will be completed quarterly and/or with a significant change in condition; -Department Managers and Charge Nurses will be responsible to monitor the smoking access door, setting of alarm doors, and appropriate supervision of residents that require supervision while smoking during routine daily rounds. Review of the facility's list of residents who smoke, showed Resident # 284 was not identified as a smoker on the list. Review of the resident's electronic medical record, showed: -admitted on [DATE]; -Diagnoses included Alzheimer's disease, dementia with behavioral disturbances and nicotine dependence, cigarettes, uncomplicated. Review of the resident's Observation Detail List Report, dated 10/22/19, showed: -Resident is a smoker; -Cognitively impaired; -Supervised smoking by staff in designated area. Review of the resident's Observation Detail List Report, dated 11/24/19, showed: -Resident is a smoker; -Not cognitively impaired; -Not able to call for help if lit cigarette falls on his/her person or on others; -Supervised smoking by staff in designated area. Review of the resident's Observation Detail List Report, dated 12/18/19, showed: -Resident is a smoker; -Cognitively impaired; -Supervised smoking by staff in designated area. Review of the resident's Observation Detail List Report, dated 8/22/20, showed: -Resident is a smoker; -Cognitively impaired; -Supervised smoking by staff in designated area. During an interview on 11/15/21 at 9:03 A.M., Nurse BB said Resident #284 was the only smoker on the unit. Observation on 11/15/21 at 12:55 P.M., showed the resident approached Nurse BB and asked to go outside to smoke. Nurse BB took the resident to the designated smoking area. During an interview on 11/18/21 at 12:56 P.M., Nurse BB said the resident was supposed to have a smoking assessment done, but one had not been done in over a year until he/she was told to complete one today. The nurses were responsible for completing the smoking assessments, but he/she was not sure how often they were to be completed. Review of the resident's Observation Detail List Report, dated 11/18/21, showed the resident was not a smoker. During an interview on 11/19/21 at 7:41 A.M., the administrator said smoking assessments should be completed upon admission, as needed and annually. The residents who smoke should also be identified by staff as smokers. She thought assessments had been completed on the resident. 4. Review of the facility's Post-Fall Assessment Policy, dated: revised 4/20/21, showed: -Purpose: All falls are investigated to determine the reason for the fall and to develop interventions to minimize or eliminate future falls; -Fall Definition Guidelines: -An episode where a resident lost his/her balance and would have fallen, were it not for staff intervention, is still a fall; -A fall without an injury is still a fall; -When a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and try to put into place an intervention to prevent this from happening again; -The distance to the next lower surface (in this case, the floor) is not a factor in determining whether or not a fall occurred. If a resident rolled off a bed or mattress that was close to the floor, this is a fall; -Procedure: -The nurse on duty will complete a post-fall assessment event for each fall; -Neurological assessment should be initiated with all falls: Initiate neurological assessment form DGE047A for falls with head injuries. Initiate neurological assessment form DGE047B for unwitnessed falls without head involvement; -The charge nurse will review the resident's plan of care and make any additions to the care plan as needed. Be sure to note the date of the fall, any injuries and any new/revised interventions; -Nurses must assess the resident's condition following the fall and document every shift for 72 hours after the fall. 5. Review of Resident #61's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -No behaviors; -Required the assistance of one staff for walking, transfers, dressing, toileting and personal hygiene; -Always continent of bowel and bladder; -Diagnoses included high blood pressure, diabetes, dementia and depression. Review of the resident's care plan, last revised on 11/12/21, and in use during the survey, showed: -Problem: Resident has a history of falls related to deficit in mobility and activities of daily living (ADLs, self-care). Diagnosis: Neuropathic pain (as pain resulting from injury to, or dysfunction of, the somatosensory system (part of the sensory nervous system that is associated with the sense of touch)); -Goal: No further incident of falls with/without injury through the next review; -Approaches included: Physical therapy to screen. Evaluate and treat as indicated. Evaluate history/cause of past falls. Incorporate findings into care needs. Assess for ability to understand use of call light and ability to use; -Non injury fall on 10/12/21. Neuro checks-assisted to wheelchair and taken to the nurse station for closer observation; -Non injury fall on 10/17/21. Neuro checks. Frequent checks-assist with ADLs; -Non injury fall on 10/30/21. Neuro checks. Reeducated on importance of calling for assistance. Call light within reach; -Found sitting on floor at bottom of the recliner. Resident reoriented to use of call light. Staff to make frequent checks when in room. Further review of the resident's medical record, showed: -A nurse's note, dated 11/13/21 at 5:46 A.M., resident sitting on the floor next to his/her recliner; -A nurse's note, dated 11/13/21 at 3:03 P.M., resident observed to have small abrasion on back of head from earlier fall. Review of the resident's Neurological Assessment for falls without head injury, showed: -Neuro checks for falls without head involvement are to be documented every shift for 72 hours; -Day 1, 11/13/21, staff documented neuro checks for all three shifts; -Day 2, 11/14/21, staff failed to document any neuro check information; -Day 3, 11/15/21, staff failed to document any neuro check information. Review of the resident's Post Fall Assessment, showed: -Event date: 11/13/21, 5:30 A.M.; -Location of fall: Resident room; -What was resident doing just prior to fall? Sitting in recliner; -Was fall witnessed? No; -Describe exactly what happened: Resident seen sitting up on her bedroom floor possibly slid out of recliner with no apparent injuries; -Improper transfer, attempting to transfer; -List immediate interventions taken to promote resident's safety: Other: staff educated to assist with care; -Was there an injury? No; -Behavioral characteristics that may have contributed: Does not use call light, poor safety awareness, history of falls; -Describe the environment at the time of the fall: Lights on in room; -Neuro checks within normal limits. Further review of the resident's progress notes, showed a nurse's note, dated 11/13/21 at 11:28 P.M., resident lying on bathroom floor, resting quietly. Review of the resident Post Fall Assessment, dated 11/13/21 at 11:34 P.M., showed: -Description: Fall 11/13/21, resident found lying on bathroom floor; -Location of fall: Bathroom; -What was resident doing prior to fall? Resting in bed; -Was fall witnessed? No; -Describe exactly what happened: Observed lying on bathroom floor with eyes closed; -Resident was trying to use the toilet; -List immediate interventions taken to promote resident safety: Close observation, in recliner; -Behavioral characteristics that may have contributed: History of falls; -Describe the environment at the time of the fall: Call light in reach; -Was there an injury? No; -Resident last observed at 9:30 P.M.; -Neuro check: Within normal limits; -Vital signs: Within normal limits; -Progress note: 11/13/21 at 11:28 P.M., Lying on bathroom floor, resting quietly. Alert, denies discomfort. No pain with active and passive range of motion. Does not give statement regarding fall. Assisted to chair with gait belt and two staff. No new marks or injury to head noted. Review of the resident's Neurological Assessment for falls without head injury, showed: -Neuro checks for falls without head involvement are to be documented every shift for 72 hours; -Day 1, 11/14/21, night shift neuro checks documented twice. Staff failed to document neuro checks for day or evening shifts; -Day 2, 11/15/21, afternoon shift neuro checks documented. Staff failed to document neuro checks for day and night shifts; -Day 3, 11/15/21, staff failed to document neuro checks for all three shifts. Further review of the resident's progress notes, showed a note dated 11/15/21 at 6:00 P.M., resident sitting on floor in bathroom. States fell trying to use toilet and hit his/her back on the commode. No bruising or open areas seen. Voices mild discomfort at site. Assisted up with gait belt by two staff. Assisted to wheelchair. Review of the resident's Neurological Assessment for falls without head injury, showed: -Neuro checks for falls without head involvement are to be documented every shift for 72 hours; -Day 1, 11/15/21, staff documented neuro checks on all three shifts; -Day 2, 11/16/21, staff documented neuro checks on the night shift. Staff failed to document neuro checks on the day and evening shifts; -Day 3, 11/17/21, staff failed to document neuro checks for any shift. Review of the resident's medical record, showed no Post Fall Assessment completed by staff. Further review of the resident's progress notes, showed a note, dated 11/17/21 at 10:25 P.M., resident was in room in recliner. Resident got up and did not use walker and fell. Resident was found lying on ground on left side of the body, range of motion to bilateral arms and legs are within normal limits. Resident did not hit head. Resident stated feet hurt which is a chronic pain for resident. No area of concerns found on body. 6. Review of Resident #490's admission MDS, dated [DATE], showed: -admitted : 7/24/21; -Diagnosis included: Alzheimer's disease and protein-calorie malnutrition; -Severe Cognitive Impairment; -Required extensive assistance of staff for bed mobility and eating; -Required total assistance of staff for transfers, locomotion on and off the unit, toilet use, personal hygiene and bathing; -Functional limitation in range of motion in one lower extremity; -Always incontinent of bladder and frequently incontinent of bowel. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Falls, resident has a recent history related to recent fracture left hip/deficit in ADLs and mobility. Diagnoses of dementia and weakness; -Goal: No further incident of falls with/without injury thru next review; -Interventions: 9/9/21, resident noted on fall mat next to bed 9/9/21, wrapped in blanket. Appears resident slid out of bed. Hospice RN to order bolster bed to prevent further incidents; 10/13/21, witnessed to resident rolling out of bed on 10/4/21 and hit top of head on dresser. Neuro checks, frequent monitoring, nurse to ask for bolster mattress and pad dresser, monitor all head precautions due to hitting head. Abrasion to left side of temple area on head. Review of the resident's progress notes, dated 9/9/11 through 9/30/21, showed on 9/9/21 at 4:45 A.M., patient found lying on floor mat next to bed with a blanket around him/her. Patient slid out of bed sustaining no injury and did not hit head. Review of the resident's Neurological Assessment for falls without head involvement, dated 9/9/21 through 9/11/21, showed: -Day 1, 9/9/21, completed; -Day 2, 9/10/21, 11-7 shift wrote unable to complete in the VS section; -Day 3, 9/11/21, 3-11 shift, the VS section was blank. Further review of the resident's progress notes, dated 10/4/21 through 10/10/21, showed: -On 10/4/21 at 9:28 A.M., nurse was doing bedtime rounds and saw resident on the edge of the bed, the nurse ran into the room but it was too late. Resident rolled out of bed and onto the floor. He/she did hit the top of her head on the dresser; -On 10/5/21 at 6:36 A.M., remains on IFU (incident follow up)/fall. Vital signs stable (VSS). Abrasion to left side of head appears healed such as scabbed over. Review of the resident's Neurological Assessment for potential head injuries, dated 10/4 through 10/6/(year not documented), showed: -Neuro checks for potential head injuries are to be completed as follows, every 15 minutes for the first hour; every 30 minutes for the next two hours; every hour for the next five hours; then every shift for 72 hours; -Documentation showed: -Day 1, Every (Q) 15 minutes X 4: the second, third and fourth sections were blank; -Q 30 minutes X 4, all were blank; -Q 1 hour X 5: all were blank; -Q shift were blank; -Day 2, 11-7 shift was blank. 7. Review of Resident #487's quarterly MDS, dated [DATE], showed: -readmitted : 10/8/18; -Diagnoses included: Arteriosclerotic heart disease (ASHD), is a thickening and hardening of the walls of the coronary arteries, high blood pressure, hypothyroidism (thyroid is not making enough thyroid hormones) -Should a BIMS be conducted? Yes was marked; BIMS summary score was left blank; -Required supervision for eating; -Required extensive assistance of staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene; -Required total assistance of staff for bathing; -Always incontinent of bowel and bladder; -Had two or more falls since admission, reentry or prior assessment. Review of the resident's care plan, in use at time of the survey, showed: -Problem: resident has a history of falls related to: blank; -Goal: no further incident of falls with/without injury thru next review; -Interventions: 10/15/21, non-injury fall on 10/1/21, neuro checks, assisted to reclin[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the quality of the labs obtained when they failed to meet the applicable requirements for obtaining their own labs. The facility failed to ensure accurate results of the blood glucose test machines by not completing daily quality control checks and then used expired control check solution. The census was 155 with 137 in certified beds. Observation of the 700 hall treatment cart on [DATE] at 1:45 P.M., showed two boxes of control solution (solution used to test the accuracy of the blood glucose machine). The two boxes showed expiration dates of [DATE] and [DATE]. Each box had two bottles of control solution, one bottle of normal solution and one bottle of high control solution, used to test the accuracy of the glucometer. During an interview on [DATE] at 1:45 P.M., Licensed Practical Nurse (LPN) LL said he/she wasn't sure which control solution was used because the night shift does that. LPN LL then took the two expired boxes and placed them in the medication room. Observation of the 700 hall treatment cart on [DATE] at 4:10 P.M., showed two boxes of control solution in the treatment cart. Each box had the two bottles of control solution used to test the accuracy of the glucometer. During an interview on [DATE] at 4:10 P.M., Registered Nurse (RN) E said neither box had been opened. The facility got rid of the old ones the previous day because they were expired. Review of the facility provided control log, dated [DATE], for unit 100 showed: -For the dates of [DATE] to [DATE]: -9 out of 18 opportunities were missed; -11/1, 11/5, 11/9, 11/13, 11/14, 11/15, were blank on the control long; -11/16, 11/17, 11/18 were blank and had a note over each of the three days that said no glucose solution. -Normal control lot number listed was 9B22B02 with expiration date 10/21 for: -11/2, 11/3, 11/4, 11/6, 11/7, 11/8, 11/10, 11/11, 11/12. -High control lot number listed was 9B27B02 with expiration date 10/21: -11/2, 11/3, 11/4, 11/6, 11/7, 11/8, 11/10, 11/11, 11/12. Review of the facility provided control log, dated [DATE], for unit 100 showed: -For the dates of [DATE] to [DATE]: -14 out of 31 opportunities were missed; -10/3, 10/4, 10/7, 10/8, 10/12, 10/16, 10/17, 10/18, 10/21, 10/22, 10/26, 10/29, 10/30 and 10/31 were blank on the control log. Review of the facility's Resident Matrix, completed by the facility and provided for the current survey, showed: -27 residents received insulin injections; -10 residents on the 100 hall; -7 residents on the 700 hall. During an interview on [DATE] at 10:20 A.M., the Director of Nursing (DON) said staff should complete the glucometer machine control checks every night to make sure the glucometer reading is accurate and not getting an error. The DON also said staff should check the expiration date on the control solution.

Based on interview and record review, the facility failed to implement the facility Abuse and Neglect policy when a resident alleged a certified nurse aide (CNA) grabbed him/her by the neck. The facility failed to suspend the CNA pending an investigation. (Resident #172) The census was 189 with 172 in certified beds. Review of the facility's Nursing Policy and Procedure Manual, revised January 2019, Abuse, Neglect and Exploitation Policy, showed: -Resident Safety Position Statement: It is the policy of the facility to maintain a work and living environment that is professional and residents are free from threat and/or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms; -Physical Abuse includes but is not limited to, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment; -Procedure for investigation: Any employee suspected of violation of these resident safety policies, may be suspended pending investigation. Review of Resident #172's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/9/18, showed: -No cognitive impairment; -No moods; -No verbal behaviors; -Extensive assistance with bed mobility and dressing; -Transfers with assist of two staff; -Diagnoses of multiple sclerosis and depression. Review of the resident's nurse's note, dated 1/13/19 at 10:45 A.M., showed CNA U informed the nurse, while assisting resident to the side of the bed, the resident continued to fall back. The resident called the CNA an idiot and scratched the CNA on the hand. The resident then called the nurse's station and said he/she was having problems with his/her CNA. The resident said the CNA grabbed him/her by the neck and admitted to calling the CNA an idiot. The nurse informed the resident the Social Worker that day is the manager on duty and would be in to speak with him/her. The resident said he/she did not want to speak with the Social Worker. Review of the resident's Social Service Note, dated 1/13/19 at 1:43 P.M., showed the Social Worker met with the resident along with the charge nurse. The Social Worker said the resident requested to speak to someone. The resident said he/she wanted to speak a person who was not at the facility. The resident said it is the weekend and no one is there to speak with him/her. The Social Worker corrected the resident and said he/she was the Manager on Duty and was there to talk to the resident. The resident said he/she was no longer talking and the conversation is over. The Social Worker explained the resident continues to pick and choose when he/she receives help from people and his/her unwillingness may prolong a positive outcome. The resident said he/she was done talking. The Social Worker will continue to monitor and support the resident's psychosocial needs. Further review of the resident's medical record, showed no further documentation on 1/13/19, regarding the resident's incident. During an interview on 2/6/19 at 12:46 P.M., Social Worker (SW) T said he/she was the only manager in the building on the day of the allegation. He/she did remove CNA U from the assignment of the resident but did not send the CNA home and did not start an investigation. SW T said he/she did not know if the allegation was true at that time. During an interview on 2/7/19 at 7:10 A. M., CNA U said he/she was trying to assist the resident out of bed. He/she used his/her hand to support the resident's back and all at once the resident became agitated and started to curse and said not to touch his/her neck. CNA U said he/she reported the incident to the charge nurse. He/she was put on another assignment but was not sent home pending an investigation. He/she continued to work on an different assignment for the next few days. During an interview on 2/6/19 at 1:00 P.M., the administrator said she would have expected the Social Worker to follow the facility's policy and suspend the CNA pending an investigation.

Based on observation, interview and record review, the facility failed to ensure two administrative staff members had the appropriate training and/or documentation showing completion of an approved feeding course and failed to ensure these employees did not feed residents with complicated feeding problems. The census was 189 with 172 in certified beds. Observation on 2/5/19, showed: -At 8:01 A.M., Office Assistant R fed a resident a mechanical soft meal; -At 12:10 P.M., admission Coordinator S fed a resident a mechanical soft meal. Review of Office Assistant R's and admission Coordinator S's employee files, showed no documentation of feeding assistance training. During an interview on 2/5/19 at 2:00 P.M., admission Coordinator S said he/she had some inservicing on feeding but did not attend a state approved training. During an interview on 2/5/19 at 2:10 P.M., Office Assistant R said he/she had not been through a state approved training course on feeding. During an interview on 2/5/19 at 2:20 P.M., the administrator said she was aware the staff needed to attend a state approved training program for feeding. The issue must have been overlooked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to follow acceptable infection control practices to prevent the spread of infection for three of three sampled residents observed receiving personal care. (Residents #67, #49 and #115). The census was 189 with 172 in certified beds. 1. Review of Resident #67's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/22/18, showed: -Diagnoses of dementia, diabetes and high blood pressure; -Short/long term memory loss; -Extensive staff assistance for bed mobility, transfers, dressing, toilet use and personal hygiene; -Total staff assistance for bathing; -Incontinent of bowel and bladder. Review of the resident's care plan, updated 12/7/18, showed: -Problem: Incontinent of bowel and bladder; -Approach: Provide incontinence care after each incontinent episode. Apply moisture barrier to skin. Provide assistance of one for toileting. Observation on 2/3/19 at 5:45 A.M., showed the resident lay in bed with a wet incontinence brief. After washing his/her hands, Certified Nurse Aide (CNA) O applied gloves, turned the resident on his/her left side and removed the wet and soiled brief. After washing the resident's soiled buttocks, CNA O placed the soiled brief on the resident's over bed table. Without changing his/her gloves, he/she applied barrier, a clean brief and covered the resident with a sheet and blanket before removing his/her gloves. During an interview on 2/3/19 at 6:10 A.M., CNA O said the facility had in-services a couple of weeks ago on perineal care (washing the front and back of the hips, genitals, anal area and buttocks) and infection control but he/she was unable to attend. He/she should have changed his/her gloves before touching clean items. 2. Review of Resident #49's quarterly MDS, dated [DATE], showed: -Diagnoses of heart failure, respiratory failure and dementia; -Short/long term memory loss; -Required total staff assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Incontinent of bowel and bladder. Review of the resident's care plan, updated 12/3/18, showed: -Problem: Incontinent of bowel and bladder; -Approach: Keep perineal area clean and dry. Observation on 2/6/19 at 6:23 A.M., showed the resident lay in bed with a wet brief. After applying gloves, CNA P removed the wet brief and provided perineal care. Without changing his/her gloves, he/she applied a clean brief and covered the resident with a sheet and blanket. During an interview on 2/6/19 at 6:40 A.M., CNA P said he/she should have removed his/her gloves before touching clean items. 3. Review of Resident #115's quarterly MDS, dated [DATE], showed: -No short/long term memory loss; -Required limited staff assistance for transfers and dressing; -Required extensive staff assistance for toilet use and bathing; -Incontinent of bowel and bladder. Review of the resident's care plan, updated 1/9/19, showed: -Problem: Incontinent of bowel and bladder; -Approach: Provide incontinence care after each incontinent episode. Provide assistance of one for toileting. Apply moisture barrier to skin as needed. Observation on 2/3/19 at 7:48 A.M., showed the resident sat on the toilet. After applying gloves, CNA Q provided perineal care. Without changing his/her gloves, he/she applied a clean brief and pants. During an interview on 2/3/19 at 8:00 A.M., CNA Q said he/she had not attended any recent in-services. If the in-service is not mandatory he/she won't attend because it usually is held on the day shift. He/she should have changed his/her gloves before touching clean items. 4. During an interview on 2/7/19 at 1:00 P.M., the Director of Nurses said she would expect staff to change their gloves before touching clean items. 5. Review of the facility's policy on Perineal Care, dated 1/2017, showed: Purpose: To establish routine practices for providing perineal care, which will cleanse, prevent skin breakdown, prevent infection and prevent odors; -Procedure: #3, Wash hands. #10, Wash perineal area thoroughly. #14, Remove gloves, wash hands and apply clean gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physicians were notified regarding residents' significant weight changes. Review of the facility weight records showed nine residents with a recent significant weight gain or loss. Those nine resident records were reviewed and problems were found with six. (Residents #113, #272, #112, #9, #63 and #110) The census was 189 with 172 in certified beds. Review of the facility Nursing Policy and Procedure Manual for weight monitoring, revised on 12/2009 and again on 11/2018, showed: Purpose: -To obtain accurate weight of each resident and maintain control of weight changes; Note: -Residents are weighed on admission, weekly for the first four (4) weeks and monthly thereafter, unless otherwise ordered by nursing order or the attending physician; Procedure: -Residents are weighed upon admission and on a weekly basis for the first 4 weeks to establish a baseline weight. Then, completed on a monthly basis by the first week of each month; -Facility designee will record these weights in the individual resident's electronic medical record (EMR) under vital signs; -Any resident with a weight gain/loss of 5 pounds will be re-weighed within 24 hours; -Weight reports will be monitored by the Charge Nurse, Registered Dietician/Dining Services Director and Director of Nursing. The weight management committee will meet monthly to discuss residents with fluctuation; Significant weight loss is defined as residents with weight loss of 5% or more in the last 30 days, 7.5% or more in the last 3 months or 10% or more in the last 6 months; -Residents with unplanned weight loss/gain will be weighed weekly or as ordered by the physician. A Weight Change Follow-Up event will be completed by the Charge Nurse in the EMR; -The charge nurse is responsible to immediately notify the attending physician and registered dietician of weight loss/gain; -Any significant weight/loss or gain is to be in the progress notes section in the EMR, as to reason why the resident has weight loss or gain with any interventions; -After interventions in place and weekly weight times for four weeks have been obtained, the nursing management designee will close event with evaluation and further input from weight management committee. 1. Review of Resident #113's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/17/18, showed: -Independent for eating; -Diagnoses of anemia, heart failure, high blood pressure, multiple sclerosis and depression; -Weight of 149 pounds (lbs); -Dialysis not indicated. Review of the resident's Weight Variance Report, dated 2/3/19, showed a weight of 140.3 lbs on 12/11/18. Review of the resident's quarterly MDS, dated [DATE], showed: -Independent for eating; -Weight of 140 lbs; -Dialysis. Review of the resident's Weight Variance Report, dated 2/3/19, showed on 1/6/19 (the next weight identified after 12/11/18): Weight 166.5 lbs (this represents a significant weight gain of 26.5 lbs or 15.91%). Review of the resident's medical record, showed no documentation the facility notified the resident's physician or consulted with the dialysis unit regarding the weight gain identified on 1/6/19. Review of the resident's Registered Dietician's (RD) progress note, dated 1/14/19 at 12:49 P.M., showed a current body weight of 167 lbs, 166 lbs on 1/6/19, 140 lbs on 12/11/18, 144 lbs on 10/7/18, 152 lbs on 7/1/18. Weight is up 26 lbs or 19% in one month. Review of the resident's medical record, showed no documentation the facility notified the resident's physician or consulted with the dialysis unit regarding the RD's progress note. 2. Review of Resident #272's Weight Variance Report, dated 2/3/19, showed: -11/4/18: 99.2 lbs; -12/2/18: 91 lbs (this represents a significant weight loss of 8.2 lbs or 8.3%). Review of the resident's RD's progress note, dated 12/11/18 at 4:18 P.M., showed a current body weight as 91 lbs. Weight is down 8 lbs or 8.8% in one month. Resident continues on Hospice. Review of the resident's medical record, showed no documentation the facility notified the resident's physician regarding the weight loss on 12/2/18. Review of the resident's Weight Variance Report, dated 2/3/19, showed on 1/6/19: weight of 98 lbs (this represents a significant weight gain of 7 lbs or 7.7%). Review of the resident's RD's progress note, dated 1/14/19 at 1:41 P.M., showed a current body weight as 98 lbs. Weight is back up 7 lbs or 7/7% in one month. Resident continues on Hospice care. Review of the resident's medical record, showed no documentation the facility notified the resident's physician regarding the resident's weight gain on 1/6/19. 3. Review of Resident #112's admission MDS, dated [DATE], showed: -admission date of 12/17/18; -Independent for eating; -Diagnosis of cancer, -Weight of 159 lbs. Review of the resident's Weight Variance Report, dated 2/3/19, showed: -12/23/18: 159.8 lbs; -1/10/19: 149.0 lbs (this represents a significant weight loss of 10.8 lbs or 6.75%). Review of the resident's medical record, showed no documentation the facility notified the resident's physician regarding the weight loss on 1/10/19 . 4. Review of Resident #9's admission MDS, dated [DATE], showed: -admission date of 10/16/18; -Supervision - oversight, encouragement or cueing required for eating; -Diagnoses of high blood pressure and Parkinson's disease; -Weight of 118 lbs; -Hospice. Review of the resident's Weight Variance Report, dated 2/3/19, showed: -12/7/18: 116.4 lbs; -1/6/19: 108.8 lbs (this represents a significant weight loss of 7.6 lbs or 6.5%). Review of the resident's medical record, showed no documentation the facility notified the resident's physician regarding the weight loss on 1/6/19. 5. Review of Resident #63's quarterly MDS, dated [DATE], showed: -Supervision - oversight, encouragement or cueing required for eating; -Diagnoses of anemia, heart failure, high blood pressure, anxiety and depression; -Weight of 163 lbs. Review of the resident's Weight Variance Report, dated 2/3/19, showed: -12/28/18: 154.10 lbs; -1/9/19: 144.9 lbs (this represents a significant weight loss of 9.2 lbs or 5.9%). Review of the resident's medical record, showed no documentation the facility notified the resident's physician regarding the resident's weight loss on 1/9/19. 6. Review of Resident #110's admission MDS, dated [DATE], showed: -admission date of 12/14/18; -Independent for eating; -Diagnoses of heart failure and pneumonia; -Weight of 146 lbs. Review of the resident's Weight Variance Report, dated 2/3/19, showed: -12/20/18: 148.7 lbs; -1/20/19: 156.4 lbs (this represents a significant weight gain of 7.7 lbs or 5.17%). Review of the resident's medical record, showed no documentation the facility notified the resident's physician regarding the weight gain on 1/20/19. 7. During an interview on 2/7/19 at 6:17 A.M., the Director of Nurses said weights are obtained by the Certified Nurse Aides (CNAs) by the first weekend of the month. The CNAs enter the weights into their computer system. The RD is in the building two times a week and reviews the weights in the system. The RD will recommend any reweighs that need to be completed. She would like for the nurses to check the weights in the system as well and request reweighs but that is not happening. The RD will also let the facility know when there are significant weight changes, but the RD is not responsible for contacting the physician. She reviewed the residents' medical records for documentation of the physicians being notified of the weight gains/losses and could not find the documentation. The nurses are responsible to contact the physicians regarding significant weight gains and losses and document it in the medical record, but that is not happening routinely.

Based on observation, interview and record review, the facility failed to ensure opened insulin pens were dated when opened, labeled with the resident's name and discarded when outdated. In addition the facility failed to ensure eye drop bottles had a open date written on them. The census was 189 with 172 in certified beds. 1. Observation on 2/3/19 at 5:35 A.M., of the back hall of the 700 Hall medication cart, showed: -One Humalog (fast acting) insulin pen (pre-filled injectable syringe) opened without a date written when opened; -One Novolog (fast acting) insulin pen, opened and dated 12/27/18; -One Lantus (long acting) insulin pen opened without a date written when opened. During an interview on 2/3/19 at 5:35 A.M., Nurse J said all the opened insulin pens are in use for the residents on the back hall of the 700 hall. He/she verified both opened Humalog and Lantus insulin pens not dated and one opened Novolog insulin pen was dated 12/27/18. Nurse J said all the opened insulin pens should be dated with the date when opened and administered for up to 28 days from the date when opened, then discarded. 2. Observation on 2/3/19 at 6:25 A.M., of the 400 Hall medication cart, showed: -One Admelog (fast acting) insulin pen opened without a date written when opened and not labeled with a resident's name; -Two Lantus insulin pens opened without a date written when opened; -One Levemir (long acting) insulin pen opened without a date written when opened; -One Novolog insulin pen opened without a date written when opened; -One Humalog insulin pen opened without a date written when opened. During an interview on 2/3/19 at 6:25 A.M., Nurse K said all the opened insulin pens are in use for the residents on the 400 Hall. He/she verified the opened Admelog insulin pen was not dated and not labeled with a resident's name, and two opened Lantus insulin pens, one opened Levemir pen, one Novolog pen and one Humalog insulin pen not dated when opened. Nurse K said all the opened insulin pens should be dated when opened and labeled with a resident's name. 3. During an interview on 2/6/29 at 7:20 A.M., the Director of Nurses (DON) said nursing staff should date insulin vials/pens when opened, label with resident's name and administer for up to 30 days from date when opened. Any outdated insulin pens should be discarded and not administered. The charge nurses are responsible for ensuring all opened insulin vials/pens are dated, labeled with a resident's name and they should be discarding outdated insulin vials/pens. 4. Review of the facility's Insulin Administration via Pen Devices dated 5/13/16, showed: -Purpose: To safely administer insulin via pen devices according to physician orders and Facility's policy and procedure recommendations; -Procedure: Insulin pens containing multiple doses of insulin are meant for use on a single person only, and should never be used for more than one person. Insulin pens should be clearly labeled with the person's name or other identifying information to ensure that the correct pen is used only on the correct individual; -Quick reference for insulin pens: -Lantus: Expiration after first use 28 days; -Levemir: Expiration after first use 42 days; -Humalog: Expiration after first use 28 days; -Novolog: Expiration after first use 28 days. 5. Observation of the 100 hall medication cart on 2/3/19 at 6:30 A.M., showed seven bottles of eye drops: -One open bottle of Combigan 0.2%/0.5% ophthalmic solution (eye drops used to treat open-angle glaucoma) with no open date; -Three open bottles of Latanoprost 0.005% ophthalmic solution (eye drops used to treat open-angle glaucoma) with no open date; -One open bottle of Azopt 1% ophthalmic solution (eye drops used to reduce pressure within the eye) with no open date. During an interview on 2/3/19 at 6:30 A.M., Certified Medication Technician (CMT) V said eye drops should be dated when they are opened. He/she works as a float and is unaware who opened the eye drops. 6. Observation of the 200 hall medication cart on 2/3/19 at 6:27 A.M., showed 10 bottles of eye drops: -An opened bottle of Timolol ophthalmic solution (eye drop used to treat glaucoma) with no open date; -Two open bottles of Azopt with no open dates; -Four open bottles of Brimonidine (eye drop used to to treat glaucoma) with no open dates; -Three open bottles of Lantoprost with no open dates. 7. During an interview on 2/4/19 at 11:10 A.M., the DON said she expects staff to write the date the eye drop was opened on the bottle so they can be discarded if not used in the recommended time frame. Review of the package inserts/manufacturer instructions, showed: Combigan 0.2% ophthalmic solution: -Throw out any remaining solution after four weeks from the date of opening; -Eye drops contain a preservative which helps prevent germs growing in the solution for the first four weeks after opening the bottle. Latanoprost 0.005% ophthalmic solution: -Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks. Azopt 1% ophthalmic solution: -You must throw away a bottle four weeks after you first open it. Dorzolamide/Timolol solution: -Write the date on the bottle when you open the eye drops and throw out any remaining solution after four weeks; -Eye drops contain a preservative which helps prevent germs growing in the solution for the first four weeks after opening the bottle. Artificial tears: -The preservative can only ensure the drops are safe for the eye for a period of 28 days. Timolol ophthalmic solution: -The solution should be discarded after 4 weeks. Brimonidine ophthalmic solution: -The solution should be discarded after 4 weeks.

Based on observation and interview, the facility failed to ensure the main kitchen was clean during observations on three of three days. The census was 189 with 172 in certified beds. Observation on 2/3/19 at 5:20 A.M., showed the main kitchen's floor had a large amount of debris, grease and dirt build-up. The counter tops had numerous smears. The two fryers had a heavy build-up of fried food particles. During an interview on 2/3/19 at 5:28 A.M., Dietary Aide (DA) W, preparing breakfast, said he/she arrived for work this morning at 4:30 A.M. The floors, counters and fryers did not appear to be clean to him/her. They were like that when he/she arrived for work. The dietary department has two shifts, the day shift and evening shift. Each shift is suppose to clean the floors, counters and fryers. During an interview on 2/3/19 at 5:41 A.M., DA X said the floors, counter tops and fryers did not appear to be clean to him/her. The evening shift should have cleaned before they left last night. Observation of the main kitchen on 2/4/19 at 5:40 A.M. and 2/6/19 at 5:53 A.M., showed the kitchen floors to be covered with debris with black stained grout between the tiles throughout the kitchen. During interviews on 2/3/19 at 12:45 P.M. and 2/7/19 at 1:50 P.M., the Dietary Manager (DM) said the dietary department has two shifts. She reviewed pictures (taken upon entrance to the kitchen on 2/3/19 at 5:20 A.M.) of the kitchen floors, counter tops and fryers. She said these areas did not appear to have been cleaned the night before. The night shift should not have left the kitchen in that shape. They have a person from maintenance deep clean the floors once a month. It has been difficult getting the black grout out of the floor.