**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote the resident's self-determination through support of resident choices when staff failed to follow a resident's choice to be a no code (do not resuscitate (DNR), no life prolonging methods are performed), when staff performed cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) when the resident was found not breathing and without a pulse (Resident #1). The sample size was 3. The census was 150. The Administrator was notified on [DATE] of the past non-compliance. The facility responded appropriately when the incident occurred. Staff were provided continuing education on where to locate a resident codes status. They updated their CPR/Code Status policy and added an additional system in which staff can access a resident's current code status. The deficiency was corrected on [DATE]. Review of the Code Status (refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) Guidelines, dated 6/2021 showed: -Purpose: To assure the resident's code status is communicated to all direct care staff; -Procedure: -On admission a code status will be requested from the resident and/or the representative by the Social Worker or facility designee; -If the facility has not obtained resident's documented wishes on code status upon admission, the physician's orders will be entered as administer CPR; -The evening charge nurse will be responsible for printing the order report by category for code status DAILY and place on the divisions' code status clipboard. Review of the CPR Initiation, When Indicated policy, dated 1/2024, showed: Purpose: To assure we meet professional standards of quality and provide the necessary care and services to attain or maintain the highest practicable well-being of the residents according to their request and/or as stated in their advanced directives (a written statement of a person's wishes regarding medical treatment often including a living will made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). Review of the Code Status procedure, dated [DATE], showed: -A licensed nurses will confirm a resident's code status before initiating CPR, by reviewing the resident's current orders in the Electronic Health Record (EHR); -A daily report of residents' code status is generated and placed in the STAT (emergency) carts for quick reference; -The administration of CPR is guided by the physician's documented orders in the resident's EHR. Review of Resident #1's medical record, showed an admission date of [DATE], with a readmission date of [DATE] Review of the resident's Outside the Hospital Do Not Resuscitate order (OHDNR, refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest), showed it was signed and dated by the resident's responsible party on [DATE] and signed by the physician on [DATE]. Review of the resident's progress notes, showed: -On [DATE] at 6:48 P.M., The resident was having a hard time breathing, audible crackles, lung sounds course and crackly. Orders received for a chest X-ray; -On [DATE] at 7:00 P.M., The resident appeared to be unresponsive at nurses' station. While confirming code status 911 was called and CPR was started, during this time a pulse was detected and emergency medical staff (EMS) transported the resident to the hospital. During an interview on [DATE] at 9:36 A.M., the Administrator said she was aware staff initiated CPR on a DNR resident. The resident had only been DNR for one week. The DNR paperwork had been completed on [DATE]. There was a binder at the nurse's station that staff could look through for residents that were DNR. Resident code status information was also available in the EHR. That evening, the nurse working said he/she looked through the DNR binder and could not find the purple DNR paperwork for the resident. He/She told staff to initiate CPR and call 911. At the same time, he/she was accessing the EHR and noted the resident was DNR, but since CPR had been initiated, it could not be stopped. EMS arrived on the scene and were able to get a pulse, the resident was transported to the hospital. The resident was dead on arrival to the hospital. During an interview on [DATE], Family Member (FM) A said he/she had received a phone call from the facility. The nurse said the resident had expired. The nurse reported the resident had been making gurgling sounds so the nurse had an X-ray ordered. FM A said he/she wanted additional information leading up to the resident's death. The nurse told FM A he/she would call him/her back. When the nurse called back, he/she said he/she had been mistaken, EMS was able to get a pulse. This concerned FM A as the resident was a DNR. While FM A was on the way to the hospital, the hospital called to confirm if the resident was DNR. FM A confirmed the resident was DNR. The resident expired in the emergency room. During an interview on [DATE] at 8:37 A.M., Registered Nurse (RN) B said he/she worked on the evening in question. He/She was not the nurse assigned to the resident's unit. RN B was called to the unit by the nurse working on the unit to come assess the resident for respiratory distress. When RN B arrived at the unit, the resident was seated in a wheelchair at the nurse's station. The resident was having some respiratory distress with audible (could hear it) wheezing. The nurse called the on-call physician to get orders for a chest X-ray. When RN B got back around the corner, the resident appeared to be not breathing. RN B checked the DNR binder, but did not see a signed DNR for the resident. He/She instructed staff to lower the resident to the floor and initiate CPR. He/She called 911. At around the same time RN A accessed the resident's EHR which indicated he/she was a DNR. Staff continued with CPR until EMS arrived at the facility. EMS was able to get a faint pulse. RN B provided the DNR paperwork to EMS, and EMS transported the resident to the hospital. RN B went back through the DNR binder and was able to locate the resident's DNR paperwork. He/She had missed it the first time he/she looked through the book. RN B was aware DNR meant do not start CPR. It was a crisis situation and RN B made the decision to start CPR on the evidence available at the time. During an interview on [DATE] at 9:43 A.M., RN G said the code status for every resident could be found in the resident's EHR. The information could also be found on a clip board on each crash cart. There was a binder at each nurse's station with the DNR paperwork for residents that were a DNR. Nurses were responsible for verifying code status prior to calling a code. During an interview on [DATE] at 12:21 P.M. Licensed Practical Nurse (LPN) F said the facility provided inservice training about code status. All residents code status could be found in their medical record. There was a binder on the desk with the signed DNR paperwork and now there was a clip board on each crash cart with every resident's name and code status. It was the responsibility of the nurse to check the chart for code status prior to CPR being initiated. During an interview on [DATE] at 12:37 P.M., LPN H said the facility provided additional inservice training regarding code status. The code status will be in each medial record. There was a list of all the residents' names on the crash cart. The DNR paperwork was kept in a binder at the nurse's station. It was the responsibly of the nurse to verify code status before a code was called. During an interview on [DATE] at 12:58 P.M., LPN I said the facility provided inservice training about code status and where to find and verify code status. The resident's medical record had their code status and each resident's name, with their code status on a clip board at each nurse's station. Each crash cart had a clip board with all the residents' names and their code status. A nurse was responsible to verify a resident's code status prior to initiating a CPR. During an interview on [DATE] at 1:23 P.M., LPN J said a resident's code status could be found in their medical record. For quick reference, each crash cart had a clip board with every resident's name and code status. There were binders at each nurse's station with the DNR paperwork available to review. A nurse must verify a code status in the medical record prior to CPR being initiated. During an interview on [DATE] at 2:35 P.M., the Administrator and Director of Nursing said there were two ways to check a resident's code status. There were binders at the nurse's station, clipboards with all residents' code status on the crash cart and always in the resident's EHR. Staff should check and double check a code status prior to starting CPR. If no DNR paperwork could be located, staff were to treat the resident as a full code. The code status paperwork should be signed by the resident or his/her responsible party, and the physician. The code status should be accessible, documented as a physician order and match in the electronic system and on paper forms. The resident's code status choice should be honored. MO00252205

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when residents were involved in physical resident to resident altercations resulting in two of the involved residents to be struck in the face, leaving a reddened area to their faces (Residents #59, #140, #129 and #21). The sample was 32. The facility census was 164. The facility was notified of past non-compliance on 3/27/24. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on abuse and neglect prevention. The deficiency was corrected on 3/15/24. Review of the facility's Abuse and Neglect policy, revised 9/2022, showed: -Resident safety position statement: It is the policy of the facility to maintain a work and living environment that residents are free from threat or occurrence of harassment, abuse (verbal, physical, mental of sexual), neglect, corporal punishment, involuntary seclusion, and misappropriation of property; -Providing a safe environment for the resident is one of the most basic and essential duties of the facility; -Residents must not be subjected to abuse by anyone, including, but not limited to facility staff and other residents; -Definitions: -Abuse: is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Includes verbal abuse, physical abuse, and mental abuse. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Physical abuse: includes, but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 1. Review of Resident #59's medical record, showed: -An admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 2/27/24, showed severe cognitive impairment and diagnoses of Alzheimer's disease, bipolar disorder (moods that swing from high and lows), and anxiety disorder; -A care plan, revised 3/12/24, showed problem: the resident is at risk for harm related behaviors, related to cognitive impairment. Goal: the resident will be safe and free from harm to self and others. Interventions: staff assess and document behaviors as they occur. Communicate the behavior issues with the physician and family. Consider/obtain order for geriatric psychiatric evaluation. Treat the resident with respect. Review of Resident #140's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses of major depressive disorder, insomnia, and attention deficit hyperactivity disorder (ADHD, inability to focus and pay attention to tasks). Review of the facility's investigation, dated 3/11/24, showed Certified Nursing Assistant (CNA) E heard two residents exchanging words in a loud tone in the TV area. CNA E immediately went to intervene, before he/she reached the residents, he/she observed Resident #59 made contact with his/her closed fist to Resident #140's left side of the face and scratched Resident #140. As CNA E was intervening, Resident #59 hit the CNA in the head with a closed fist. CNA E separated the residents. Resident #140 was immediately assisted to the recliner in the TV room. Resident #59 was taken to the common area by the nurse's station. Upon investigating the incident through interviews of staff and residents, it appeared Resident #140 had sat on the right-side of the couch across from Resident #59. Resident #59 aggressively told Resident #140 to move. Resident #140 explained to Resident #59 that he/she was just sitting there. Resident #59 then made contact with Resident #140 on the left side of his/her face with his/her closed fist, pulled back his/her hand and scratched Resident #140's face with the same hand. During an interview on 3/25/24 at 8:07 A.M., Resident #59 said he/she did not remember an altercation. During an interview on 3/22/24 at 8:01 A.M., Resident #140 said he/she did not remember an altercation. During an interview on 3/22/24 at 8:12 A.M., CNA E said he/she was working on 3/11/24 when the altercation happened between Resident #59 and Resident #140. CNA E said he/she stood at the nurse's station and reviewed paperwork, when he/she heard Resident #59 yell out at Resident #140 move bitch. CNA E ran to the TV lounge and observed Resident #59 sat on the couch close to Resident #140. Resident #59 was attempting to hit Resident #140. CNA E got in between both residents to break up the altercation when Resident #59 hit CNA E on the back of the head and then hit Resident #140 with a closed fist on the left side of his/her face. Registered Nurse (RN) Q came to assist and stop the altercation. RN Q said Resident #59 was uninjured and Resident #140 had redness to his/her left side of the face. He/She said Resident #59 has not had additional behavioral concerns since the incident on 3/11/24. During an interview on 3/26/24 at 9:55 A.M., RN Q said he/she was at the nurse's station when he/she heard CNA E yell for assistance. RN Q ran into the TV lounge to find Resident #59 and Resident #140 being separated by CNA E. RN Q did not witness the altercation and Resident #140 had redness to the left side of his/her face. RN Q notified the physician, family members of both residents, and facility management. Resident #59 was the aggressor in the altercation. 2. Review of Resident #129's medical record, showed: -Diagnoses included: dementia with behavioral disturbances, stroke, urinary track infection and hearing loss; -A quarterly MDS, dated [DATE], showed short and long term memory ok. Modified independence with decision making-some difficulty in new situations. Physical and verbal behaviors toward others one-three days a week; -A care plan, revised 3/15/24, showed problem: history of behaviors at prior facility and grabbing at staff and can become possessive of space at times. Goal: will be safe and free from harm to self and others. Approach: Involved in resident to resident altercation 3/12/24, the resident and his/her former roommate will remain separated on different divisions, staff supervision at activities and events, assess and document behaviors, staff communicate behaviors to physician and psychologist. Review of Resident #21's medical record, showed: -Diagnoses included Alzheimer's dementia, depression, stroke, and aphasia (difficulty speaking); -An annual MDS, dated [DATE], showed severe memory impairment. No behavior issues; -A care plan, revised 3/14/24, showed problem: the resident is at risk for harm related to Alzheimer's disease. Goal: the resident will be safe and free from harm to self and others. Approach: assess, document behaviors as they occur, communicate behavior issues with the physician and the family, involve psychologist as needed, the resident was involved in a resident to resident altercation on 3/12/24. Review of the facility's investigation, dated 3/12/24, showed Resident #21 propelled himself/herself to the bedroom doorway and reported to staff that his/her roommate Resident #129 had stuck him/her. Staff removed Resident #21 from the area and the nurse provided an assessment. Resident #21 noted to have a slightly pink right cheek and glasses askew on his/her face. Resident #129 admitted to slapping Resident #21 with an open hand because Resident #21 had been going through Resident #129's personal belongings. During an interview on 3/20/24 at 9:12 A.M., Resident #21 said he/she had been hit in the cheek by one of them. The resident touched his/her right cheek. The resident could not identify when, where, or who had stuck him/her. Resident #21 said he/she felt safe and staff were nice. During an interview on 3/20/24 at 10:13 A.M., Resident #129 said he/she moved into a new room recently. His/her personal belongings are important, and he/she does not like others touching his/her stuff. He/she has not struck any staff or residents. During an interview on 3/26/24 at 3:10 P.M., CNA L said he/she did not witness the altercation between Resident #21 and Resident #129 on 3/12/24. He/She observed Resident #21 in the doorway of his/her room on the evening of 3/12/24 around 8:10 P.M. The resident's glasses were crooked on his/her face and the resident said that his/her roommate had struck him/her in the face. CNA L said he/she had been in-serviced regarding abuse, neglect, de-escalation techniques and distraction. During an interview on 3/26/24 at 3:40 P.M., LPN M said he/she did not witness the resident to resident altercation between Residents #21 and #129. On the evening of 3/12/24 at approximately 8:00 P.M., an aide brought Resident #21 and said Resident #21 alleged his/her roommate struck him/her in the face. Resident #21's right cheek was slightly reddened and his/her glasses were crooked on his/her face. Resident #21 denied pain and no injuries were noted. The resident's were immediately separated with close monitoring. The facility has provided in-servicing for abuse, neglect, de-escalation techniques and resident distraction. 3. During an interview on 3/26/24 at 9:32 A.M., the Administrator and Director of Nursing said residents have the right to be free from abuse. The facility provided in-servicing on abuse and neglect prevention, de-escalation techniques, and distraction techniques. All facility and agency staff have been in-serviced. MO00233031 MO00233113

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to verify an intravenous (IV, medical technique that administers fluids, medication, and nutrients directly into the vein) therapy order for one resident (Resident #91). The facility also failed to ensure oxygen administration orders were completed and accurate and orders were obtained for a specialty mattress for one resident (Resident #10). The sample was 32. The census was 164. 1. Review of the Following Physician Order policy, dated 6/29/21, showed: -Purpose: To ensure that all licensed professional nurses Registered Nurses, Licensed Practical Nurses and Licensed Vocational Nurses (RN, LPN and LVN) and other healthcare professionals, follow physician orders in accordance to state, federal regulations and respective practice acts; -Procedure: -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record; -If an order is questionable according to the seven rights of medication administration, a clarification order will be obtained; -All physician or other health care professional's verbal, telephone or written order will be immediately entered in the electronic health record by the nurse obtaining the order. 2. Review of the administration of IV fluids policy, reviewed 5/2021, showed: -Purpose: To maintain life by supplying the body with fluid, electrolytes, calories, vitamins, protein and medication and to restore acid-base balance to the body; -Flow rate amount: -1000 centiliters (cc) at a rate of 8 hours, equals 125 cc/hour -1000 cc, rate 10 hours, equals 100 cc/hour; -1000 cc rate 12 hour, equals 84 cc/hour. -Document procedure and resident tolerance. Review of Resident #91's medical record, showed diagnoses included diabetes, chronic kidney disease, depression, and anxiety. Review of the resident's progress notes, showed: -On 3/19/24 at 12:24 P.M., the resident in the dining room for lunch, where he/she vomited. Physician onsite and assessed the resident. New orders received; -On 3/19/24 at 6:06 P.M., labs reported to the physician. New orders for 1 liter of normal saline, administer subcutaneous (under the skin) at 75 cc/hour to the lower left abdomen. Review of the resident's paper physician order sheets, showed an order dated 3/19/24: Complete blood count (CBC, used to assess overall health and check for infection, and blood disorders) and Comprehensive metabolic panel (CMP, assess body's fluid balance, electrolyte levels and kidney function), due to vomiting. Review of the laboratory results, dated 3/19/24, showed: -Blood urea nitrogen (Bun, measures amount of nitrogen in the blood, nitrogen is a waste product): 23 high. Normal 10-22; -Creatinine (used to monitor kidney function): 1.1 milligrams per deciliters (mg/dL), normal (0.6-1.0); -BUN/Creatine ratio (used to assess dehydration and kidney function): 20.9091- high, normal: 8.6-16.7; -Chronic kidney disease ration: 63.6356 - low. Normal range above 90; -New order written by hand: normal saline (NS) subcutaneous for 1-Liter (1L). Repeat BMP and CBC on 3/21/24. Review of the physician order sheet, showed an order, dated 3/19/24 at 8:51 A.M.: -Start: 3/19/24; -End: 3/21/24; -Order description: sodium chloride, 0.9 percent (%) 1L by IV; -Frequency: every shift, days, evening and nights; -Special instructions: give 1 liter subcutaneous. Review of the Medication Administration Record (MAR), dated 3/1/24 through 3/20/24, showed an order dated 3/19/24, for sodium chloride 0.9 %. Administer 1-Liter IV, every shift, give one liter subcutaneous. Scheduled for days, evenings and nights. Staff documented as administered on 3/19/24 for evening and night shift. During an observation and interview on 3/20/24 at 9:15 A.M., the resident said he/she did not feel well. The day before on 3/19/24 at lunch, he/she had been sick and vomited. He/She was seen at the facility by the physician. Staff placed an IV in his/her belly and did other tests. A one liter bag of NS noted at the resident's bedside actively infused. The NS fluid bag dated 3/19/24 at 6:00 P.M. During an observation and interview on 3/20/24 at 1:22 P.M., LPN P reviewed the resident's current physician order sheet. LPN P said the order should have been clarified. The order appeared to read the resident should receive 1 liter of NS every 8 hours or every shift. The handwritten order on the laboratory results from 3/19/24, showed 1 Liter of NS to be administered. The order was confusing. The IV infusion is due to be completed the morning of 3/21/24. Observation and interview on 3/21/24 at 8:13 A.M., showed the resident in his/her bathroom performing self-hygiene. The resident said staff removed the IV from his/her stomach earlier in the morning. He/She felt better. During an interview on 3/26/24 at 9:32 A.M., the Director of Nursing (DON) said all orders should be verified and clarified. Orders should be complete. Unclear or incomplete orders could be confusing to staff who administer the medication. The IV order should have been clarified and written as a one-time administration of 1-Liter of fluid. The order should include the rate of administration. 3. Review of Resident #10's medical record, showed diagnoses included pneumonia, heart failure, dysphagia (difficulty swallowing), history of pulmonary embolism (blood clot in the lungs), weakness, cognitive deficit, and muscle weakness. Review of the resident's physician orders, showed: -An order, dated 3/4/24, oxygen per nasal cannula at ( ) liters/min ( ) as needed ( ) continuous; -The order did not identify how many liters and if the oxygen should be administered as needed or continuous; -No order for a specialty mattress. Review of the resident's care plan, in use at the time of the survey, showed: -Respiratory Category Problem: Resident requires oxygen therapy related to low oxygen saturation (percentage of oxygen in the blood) due to pneumonia: -Goal: The resident will not exhibit signs of hypoxia (low levels of oxygen in the blood) through next review; -Approach included: Administer 3 liters via nasal cannula; -Skin Category: Problem: The resident is at risk for skin breakdown related to decreased mobility: -Goal: The resident's skin will remain intact through next review; -Approach: Provide pressure reducing device on bed and chair as needed. Observation and interview on 3/20/24 at 8:49 A.M., showed the resident lay in bed. The resident's low air loss mattress turned off and deflated. The resident wore oxygen per nasal cannula at 3 liters. The resident said his/her tailbone was stinging but is better now after he/she lowered the head of the bed. On 3/21/24 at approximately 11:00 A.M., the resident sat in his/her wheelchair in his/her room with the nasal cannula positioned in the resident's nose and oxygen concentrator not on. During an interview on 3/26/24 at 10:40 A.M., the Administrator and DON said staff know which residents require oxygen by looking in physician orders for oxygen rate and duration. Residents with oxygen should have orders with rate and duration included. Residents should have orders for specialties mattresses.

Based on interview and record review, the facility failed to check for a federal indicator (identifies when an employee who has ever held a Certified Nurse Aide (CNA) certificate has ever been found to have abused, neglected, or misappropriated resident property) through the state Nurse Aide (NA) registry prior to hiring a new employee, in accordance with the facility's abuse policies, for three of eight employees files reviewed. The census was 163. The administrator was notified on 3/26/24, of the past non-compliance. The facility has changed their process on newly hired employees and in-serviced staff on the requirement to check the NA registry on all newly hired staff ongoing. The deficiency was corrected on 9/13/23. Review of the facility's Abuse, Neglect, and Exploitation, Freedom From policy revised 9/22/19, showed: -Policy: It is the policy of the facility to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment, abuse (verbal, physical, mental, or sexual), neglect, corporal punishment involuntary seclusion and misappropriation of property; -Screenings included: -New employee screening (Employee background check policy); -All potential employees shall have a criminal background check. The facility must not employee or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation misappropriation of property or mistreatment by a court of law; -The policy did not specify that the NA registry check should be performed for employees hired in positions other than nurse assistants. 1. Review of Licensed Practical Nurse (LPN) B's employee file, showed: -Date of hire 8/14/23; -NA registry federal indicator not checked until 9/13/23. 2. Review of LPN D's employee file, showed: -Date of hire 2/5/23; -NA registry federal indicator not checked until 3/22/23. 3. Review of Social Worker (SW) I's employee file, showed: -Date of hire 5/31/23; -No NA registry federal indicator check. 4. During an interview on 3/26/24 at 10:40 A.M., the Administrator said the NA registry checks should be completed on all staff, not just CNAs. The policy does not reflect this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control for one resident observed during personal care. The resident's urinary catheter tubing disconnected and fell to the floor. Staff did not cleanse the tubing and then re-inserted the tubing into the catheter port (Resident #19). The facility also failed to ensure 3 out of 8 sampled staff's two-step tuberculin (TB) skin test were read prior to staff working with residents. In addition, staff failed to change their gloves or sanitize their hands when exiting a resident room, and handled clean linen supplies. The sample was 32. The census was 164. 1. Review of the facility's catheter care policy, revised 3/2021, showed: -Suprapubic catheter (urinary catheter surgically inserted through the abdomen and into the bladder, to drain urine): every effort will be made to minimize unnecessary opening of the closed system. When it is necessary to disconnect tubing, it will be done carefully to prevent contamination. Review of the facility's infection control policy, revised 2/2024, showed: -Purpose: to prevent infections whenever possible; -The facility will require staff to perform hand hygiene when necessary; -Linens are properly handled; -Any staff member that suspects a breech in infection prevention and control practice is to report this to the person responsible for the infection prevention and control program or the Director of Nursing (DON) as soon as possible. Review of Resident #19's medical record, showed diagnoses included dementia, history of urinary tract infection (UTI), and use of suprapubic catheter. Review of the resident's laboratory urinalysis (UA, urine test to check for a UTI) with culture, dated 3/1/24, showed: -Clarity: cloudy (normal is clear); -Blood: 3+ (normal is negative); -Leukocyte (a type of white blood cell, indicate UTI when found in the urine): 500 (normal is negative); -White blood cells (WBC): above 50 (normal is 0-2); -Bacteria: 3+ (normal is negative); -Culture: -Organism 1: positive Klebsiella pneumoniae (bacteria commonly found in the intestines); -Organism 2: positive Proteus mirabilis (bacteria commonly found in fecal matter); -A handwritten note, dated 3/2/24: new order for Augmentin (antibiotic). Review of the resident's electronic physician order sheet (ePOS), showed: -An order dated 3/2/24, for Augmentin 500 milligram (mg). Take one tablet twice a day for UTI. Administration completed on 3/9/24; -Provide suprapubic catheter care twice daily. Documented as completed twice daily. During an observation and interview on 3/22/24 at 3:55 A.M., Certified Nurse Aide (CNA) T and Licensed Practical Nurse (LPN) U prepared to provide catheter care. CNA T assisted the resident onto his/her right side. As the resident turned onto his/her side, the catheter drainage tubing dislodged from the port access site. The drainage tubing fell onto the floor. LPN U held the resident onto his/her side and instructed CNA T to hand him/her the tubing. CNA T handed the catheter tubing to LPN U. LPN U placed the tubing back into the access port. LPN U did not cleanse the tubing or the port access before placing the tube into the access site. During an interview on 3/26/24 at 9:32 A.M., the Director of Nursing (DON) said if catheter tubing comes disconnected, the tubing and the port access should be cleaned with alcohol before re-inserting the drainage tubing back into the access port. If the tubing or the port are not cleaned, the resident could develop an infection. 2. Review of the facility's Handwashing policy, revised 2/2024, showed: -Purpose: to provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention of the transmission of infections; -When to use alcohol and hand sanitizer: -Before entering the resident's room; -Before exiting the resident's room. Observation on 3/21/24 at 2:56 P.M., showed CNA A exited out of room [ROOM NUMBER] with gloved hands, lifted the clean linen cart cover, retrieved two hand towels, pulled cart cover back down, and returned to room [ROOM NUMBER] with the same gloves on. During interview on 3/26/24 at 10:40 A.M., the Administrator and DON said gloves should be removed prior to staff leaving resident rooms and hand hygiene performed. Staff are trained on glove protocol upon hire, quarterly, and annually. 3. Review of the facility's Tuberculosis Control Policy, Employee and Resident policy dated January 2018, showed: -Procedure for Employees: -All new employees are required to take a Mantoux purified protein derivative (PPD, TB skin test) 2-step tuberculin test at least 1 month prior to the start of employment unless they have a documented previous significant reaction; -Those with a documented significant reaction will be required to complete screen of symptoms and obtain a chest X-ray or present the community with completed chest x-ray within a year. They will complete a screen of symptoms annually thereafter. If they become symptomatic, they will be referred to the Health Department for evaluation and/or treatment; -Complete Employee Tuberculosis Screening Form to document administration of the TB test; -The first test will be read in 48-72 hours. If the first test results are 0-9 millimeters (mm) a second test will be given in one week and no more than three weeks after the first test; -The second test will be read in 48-72 hours after administration. Review of Staff AA employee file, showed: -Date of hire 11/8/23; -First date working with residents, 11/8/23; -First step PPD administered on 11/6/23 and read negative on 11/9/23. Review of Staff BB employee file, showed: -Date of hire 1/29/24; -First date working with residents, 1/31/24; -First step PPD administered on 1/29/24 and read negative on 2/1/24. Review of Staff CC employee file, showed: -Date of hire 2/5/23; -First date working with residents, 2/18/23; -First step PPD administered on 2/15/23 and read negative on 2/19/23. During interview on 3/26/24 at 10:40 A.M., the Administrator and DON said the first step PPD should be completed and read prior to resident contact.

Based on interview and record review, the facility failed to ensure neurological (neuro) checks were completed, consistently, per the facility policy after a resident (Resident #1) fell and hit his/her head. Staff transferred the resident to the hospital over three hours after the fall, and the resident was diagnosed with a small subarachnoid hemorrhage (bleeding in the space that surrounds the brain). The sample size was three. The census was 144. Review of the facility's Post Fall Assessment Policy, revised date 10/2021, included the following: -The nurse on duty will complete a Post-Fall Assessment Event for each fall; -Physician and resident representative must be notified of all falls; -Neurological Assessment should be initiated with all falls: Initiate Neurological Assessment Form DGE 047A for falls with head injuries. Initiate Neurological Assessment Form DGE047B for unwitnessed falls without head involvement. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/29/22, showed the following: -Diagnoses included: heart failure, high blood pressure, stroke and hemiplegia (partial paralysis on one side of the body); -Cognitively intact; -One person assistance required for transfers and bed mobility; -No falls since prior assessment. Review of the resident's care plan, last care conference 10/5/22, showed the following: -Problem: At risk for falls related to resident requires assistance with transfers and hemiplegia/hemiparesis (weakness on one side of the body); -Approaches included: Assess for ability to understand the use of the call light and ability to utilize. Provide appropriate call light system. Occupational therapy to screen, evaluate and treat as indicated/ordered. Physical therapy to screen, evaluate and treat as indicated/ordered. Transfer status of assist of one staff. Review of the resident's current physician's orders sheet (POS) showed the following: -An order, dated 4/22/22, for aspirin (pain reliever/blood thinner) tablet, delayed release, 81 milligrams (mg), once a day during morning medication pass; -An order, dated 9/25/20, for clopidogrel (blood thinner) tablet, 75 mg, once a day during morning medication pass. Review of the progress notes showed: -An entry on 11/4/22 at 11:19 P.M., At 10:50 (P.M.), the resident was found in the room on the floor with the call light on. The resident had a gash on the left side of the forehead, gash on the left elbow, and the toe nail on the right foot came off. The resident was oriented to time, place, self and had no changes in speech. The resident denied dizziness or loss of vision. The resident was able to explain that he/she was asleep and fell out the bed. Left message on the doctor on-call's phone number. Family notified; spoke with daughter. As of right now, no new orders received. Vitals: blood pressure 139/92 (normal 90/60 to 120/80) , heart rate 64 (normal 60-100), oxygen saturation 98 percent (normal 95-100), respirations 20 (normal 12-18). Resident cleaned up and put back into bed. -An entry on 11/5/22 at 2:35 A.M., Floor nurse placed call to this nurse to notify that resident had a fall earlier in the night and asked about protocol to send resident out to hospital. Nurse stated he/she called on call for primary doctor and received an order to send the resident to the hospital. Reported that resident did not answer questions regarding orientation status and had fresh bleeding to affected areas. The nurse stated he/she called for emergency medical services (EMS) to transfer. The floor nurse was instructed to contact the family to notify of transfer. The resident was assessed by this nurse, resident observed lying in bed upon entering the room. The resident was awake and had complaints of generalized pain. Dressing in place to right of forehead with some bright red blood to right side of dressing, swelling present to affected area, swelling to right eye with purple discoloration. Dressing present to lower extremity toes with bright red blood observed through the dressing. The resident was able to answer questions asked at this time, alert and oriented times three (person, place and time). Hand grasps are equal and fair, lower extremity movement equal and fair. Facial symmetry within normal limits. Left eye 3 millimeters (mm), round and reactive, unable to assess right eye due to swelling. Resident had occasional groans during assessment. EMS arrived shortly after exiting resident's room to take resident to the hospital. During an interview on 11/16/22 at 1:00 P.M., nurse aide (NA) A said he/she has worked at the facility for about six weeks and still attends class. The resident can make his/her needs known and stand with assistance. The resident has not had any previous falls during NA A's shifts. The resident does like to sleep toward the edge of the bed and will refuse to move when asked. On the evening of the fall (11/4/22), the resident was on NA A's assignment. The resident was his/her normal self during the shift and went to bed about 9:30 P.M. At approximately 10:15-10:20 P.M., the resident's call light activated. When NA A walked in, the resident was on the floor on his/her stomach. NA A called for assistance, and Nurse D and certified nurse aide (CNA) B responded. The nurse assessed the resident, and they moved the resident back to bed. The nurse cleaned the resident's injuries. The resident's roommate said he/she fell out of bed. NA A did walking rounds with the night shift CNA and told him/her about the resident's fall. During an interview on 11/10/22 at 1:15 P.M., CNA B said he/she was not aware of any previous falls with the resident, but he/she does sleep at the edge of the bed. CNA B responded when NA A called for assistance on the evening of the fall (11/4/22). The resident was on the floor, face-first. There was blood, so CNA B grabbed a towel. The resident's toe was stuck on the carpet. They moved the resident back to bed, and the nurse assessed the resident. The nurse said he/she would contact the doctor and family. During an interview on 11/10/22 at 2:00 P.M., CNA C said the resident was not on his/her assignment at the time of the fall, but he/she assisted staff with helping the resident up. The resident was on the floor between his/her bed and the roommate's bed. It looked like the resident may have hit his/her head on the roommate's bed. The resident's head was bleeding. Both the resident and his/her roommate said the resident rolled over and hit his/her head. The resident also had a skin tear on his/her elbow. The resident winced but did not say he/she was in pain. The nurse assessed the resident. CNA C left the room and clocked out from his/her shift five minutes later. During an interview on 11/29/22 at 11:25 A.M., Nurse D said he/she worked at the facility through agency, and it was the first time he/she had worked at this facility in a while. Nurse D had worked at another facility within the same corporation in the past so knew some of the protocols. Nurse D did not know the resident well. When Nurse D checked the resident's blood sugar, the resident was lying on the edge of the bed. The resident refused to move into the edge of the bed. Nurse D went back to complete charting at the desk. At approximately 10:45 P.M., the resident's call light activated, and the nurse asked the aide to answer it. The aide said the resident fell. When Nurse D entered the room, he/she saw the resident was face down on the floor and his/her toenail came off. The nurse did a thorough assessment, including neuro checks, range of motion and vital signs. They moved the resident back into bed, and the nurse cleaned the resident's scrapes. The nurse documented his/her assessment in the computer. He/she could not remember if he/she did a second set of neuro checks before leaving, but if he/she did, they would be in the computer. Nurse D could not find a neuro check form or a fall assessment form, so he/she did not document on a paper neuro check sheet. Someone should have done additional neuro checks on the resident on the next shift, but Nurse D did not document any neuro checks on a paper form. Nurse D called the family and left a message for the on-call doctor. By the time Nurse D was done with the evening shift, the doctor had not called back yet. When Nurse D left the shift, the resident was resting in bed, alert and able to answer questions. Nurse D gave a thorough report to the on-coming night shift nurse, including that the resident hit his/her head and Nurse D had completed neuro checks. During an interview on 11/17/22 at 1:35 P.M., CNA E said he/she has worked at the facility since February 2022. The resident usually sleeps fine, and CNA E is not aware of any previous falls with this resident. The resident does sometimes sleep on the edge of the bed. When night shift started, the resident had already fallen. Staff said the resident was fine and had some bandages in place. When CNA E did rounds between 1-1:30 A.M., the resident was sleeping in bed, but there was blood on the bandages, so CNA E told the nurse. During interviews on 11/9/22 at 3:00 P.M. and on 11/16/22 at 3:45 P.M., Nurse F said he/she worked at the facility through agency, and this was his/her first time working at this facility. The evening shift nurse told Nurse F that the resident fell, but he/she was okay. Nurse F did not know the resident had hit his/her head. If Nurse F had known the resident hit his/her head, he/she would have checked on the resident at the very beginning of the shift, to get a baseline on the resident's condition. Nurse F was working two halls that night and could not log onto the facility's computer, he/she had to use someone else's login. About 1:00 A.M. (11/5/22), Nurse F checked the resident's blood sugar and left out. Nurse F did not turn on the lights and did not notice anything wrong with the resident. Later, the CNA said the resident's bandages were bleeding, so the nurse went into the resident's room. There was bright, red, fresh blood on the bandages on the resident's elbow, head and toe. The resident had racoon eyes, and the nurse knew the resident needed to be sent out to the hospital. Nurse F called upstairs to Nurse G, since he/she was a facility nurse, to find out the facility protocols for sending a resident out. Although Nurse F did not know the resident's baseline, the resident had jibbering speech, and the nurse suspected a brain bleed. The nurse called the doctor and 911. Since the resident hit his/her head, neuro checks should have been done. The only neuro checks Nurse F did were when he/she assessed the resident as he/she was preparing to send him/her out. This assessment was documented in the computer progress notes. Nurse F did not complete any prior neuro checks on the resident because he/she did not know the resident hit his/her head. Nurse F did not document on a paper neuro check sheet because he/she did not have that form. If there is documentation on a neuro check sheet that Nurse F completed neuro checks on the resident at 12:05 A.M. and 12:35 A.M., this is not accurate. Nurse F did not complete that documentation. Nurse F and Nurse G were the only nurses in the building on night shift. During an interview on 11/9/22 at 3:55 P.M., Nurse G said Nurse F said the resident had racoon eyes and was not responding well and asked the protocol for sending the resident out. When Nurse G assessed the resident, the resident was at baseline but not as vocal as usual. The resident was still alert and could answer orientation questions. There was blood (not perfuse) on the bandages on the resident's head and toe. Since the resident had hit his/her head, staff should have been doing neuro checks. When Nurse G did neuro checks prior to sending the resident out, everything was normal, although the resident's right eye was swollen and could not be assessed. Review of the resident's Neurological Assessment for Potential Head Injuries form, day one dated 11/4/22, showed the following: -Neurochecks 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, and then every shift for 72 hours; -Neuro checks completed on 11/4/22 at 10:50 P.M., 11:05 P.M., 11:20 P.M. and 11:35 P.M. (Nurse D's initials); -Neuro checks completed on 11/5/22 at 12:05 A.M., 12:35 A.M., 1:05 A.M. and 1:35 A.M. (Nurse F's initials); -Neuro checks completed on 11/5/22 at 2:35 A.M. (Nurse G's initials). Review of the hospital record, dated 11/5/22, showed the following: -Arrival time 3:17 A.M.; -Large hematoma (area of broken blood vessels) laceration (cut) to right forehead; -Skin tear to left forearm; -Left great toe without skin and nail; -Very small, post-traumatic subarachnoid hemorrhage of right frontal lobe (frontal lobes are the largest lobes of the brain and control cognitive functions). During an interview on 11/30/22 at 11:05 A.M., the Director of Nursing said he found the resident's paper neuro check sheet from 11/4-11/5/22 at the desk at the nurses' station. During interviews on 11/28/22 at 12:50 P.M., on 11/30/22 at 11:05 A.M. and on 12/8/22 at 11:25 A.M., the administrator said she would not have expected staff to send the resident to the hospital immediately after the fall because the resident was alert and oriented and at his/her baseline. The information about the resident's condition, including that he/she hit his/her head and was on neuro checks, should have been passed on from evening shift to night shift. Documentation should be completed by the staff member who completed the task. The administrator spoke to all nursing and management staff and was unable to find anyone who completed the paper neuro check form, so she removed it from the resident's medical record. MO00209563 MO00209554 MO00209517

Based on observation, interview and record review, the facility failed to ensure residents' right to self-administer medications had been determined as clinically appropriate for one of 29 sampled residents (Resident #45). The census was 188 with 143 residents in certified beds. Review of facility's resident self administration of medications policy, dated 6/21, showed: -Before a resident is considered for self-administration of medications an assessment will be performed by the charge nurse and reviewed by the interdisciplinary care plan team for approval. A re-assessment will be repeated quarterly unless there is a significant change in condition affecting cognitive abilities and safety regarding self-administration; -Following approval of the assessment the charge nurse will obtain a physician's order for the resident to self-administer medications noting which medications may be self-administered; -The resident's medication administration record will indicate that the resident may self-administer their medication. The certified medication technician (CMT)/charge nurse is to initial the electronic medication administration record (EMAR) after questioning the resident during medication pass if they have taken their prescribed medication. The CMT/charge nurse will report to their supervisor if there are any problems; -Self-administration of medications is to be addressed in the care plan by the interdisciplinary team and reviewed quarterly, annually and with any significant change of status. Appropriate documentation on the care plan will include storage, administration, documentation and location of the drug administration. Review of Resident #45's medical record, showed: -admission date of 8/19/20; -Diagnoses included acute respiratory disease, chronic congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should) and high blood pressure. -No assessment for the ability to self-administer medications. Review of the resident's care plan, dated 1/25/22, showed no documentation for the ability to self-administer medication. Review of the resident's 2/22 physician's order sheet on 2/23/22, showed no order to self-administer medications. Observation and interview on 2/23/22 at 7:10 A.M., showed the resident lay in his/her bed. A paper medication cup with two pills sat on the bedside table. A third orange pill lay on the table beside the medication cup. The resident said the CMT left the medication on the bedside table because he/she was running behind. The orange pill was on the table because he/she was not supposed to get it in the morning. He/she did not know why the CMT gave him/her the evening medication early. During an interview on 2/23/22 at 7:35 A.M., CMT KK said when he/she got to work the 6:00 A.M. medications had not been passed yet, so he/she was running behind trying to get the 6:00 A.M. medications passed. He/she knew the resident did not self-administer his/her medications. When he/she got to the resident, the resident was not ready to take his/her medications yet so told him/her to leave them. The resident gets upset if he/she does not get his/her medication on time, and the CMT wanted to make sure the resident had his/her medications, so left them for him/her. The CMT identified the orange pill as Senna (laxative) and verified it was supposed to be given at 8:00 P.M. The CMT said it was his/her medication error. During an interview on 2/23/22 at 10:50 A.M., the Director of Nursing said before a resident can self-administer medication, a self assessment must be done to demonstrate the resident was capable of self-administering the medication. Once the resident passed the assessment, the nurse would get an order from the resident's physician. This would be added to the resident's care plan. If a resident did not have an order, staff should not leave medication at his/her bedside. The medications given should be checked with the EMAR to make sure they are correct. The 8:00 P.M. medication should not have been administered at 7:00 A.M. He had just in-serviced staff about medication self-administration. During an interview on 2/23/22 at 11:15 A.M., the administrator said staff should ensure residents were assessed to self-administer before leaving medication in their rooms. It was not acceptable to leave medication with a resident to take later. The staff member should have compared the medication given to the EMAR and signed off on it when given.

Based on interview and record review, the facility failed to notify a resident's representative when the resident developed a wound on his/her right foot. (Resident #505). The sample was 29. The census was 188 with 143 residents in certified beds. Review of the facility's Condition Change of the Resident (Observing, Recording and Reporting), revised 7/21, showed the following: -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 change in physical or mental function, monitor the following: -Document the change in the Process Notes on the respective event; -Notify resident's responsible party; -Monitor the resident condition frequently until stable. Review of Resident #505's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/19/20, showed the following: -Severe cognitive impairment; -No moods or behaviors; -Required limited assistance with bed mobility, transfers and dressing; -Required extensive assistance with personal hygiene; -Diagnoses of high blood pressure., thyroid disorder and Alzheimer's Disease; -Risk for pressure ulcers. Review of the resident's facesheet, showed documentation to notify Family Member MM for any medical issues or information. Review of the resident's medical record, showed the following: -1/13/21 at 2:11 P.M., the resident was seen by the Wound Doctor and the charge nurse. The resident continued with a current treatment to his/her left foot. New treatment orders were added for the resident's right great toe, third toe and fifth toe; -1/20/21 at 1:22 P.M., the resident was seen by the Wound Doctor and the charge nurse with regards to ulcers. The resident's left heel was noted as resolved. The resident's left toes were stable and will continue with the current treatment in place. The resident's right foot great, third and fifth toe have all merged and one. Further review of the resident's medical record, showed no documentation notifying Family Member MM regarding the new area on the resident's right foot. During an interview on 2/16/22 at 1:25 P.M., the Director of Nursing (DON) said the charge nurse should contact the resident's representative listed in the resident's chart on his/her facesheet regarding any type of condition change or new treatment. The DON did not know why the charge nurse did not contact the resident's representative. MO00181479 MO00177769 MO00177031

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents reviewed for unnecessary medications was free from chemical restraints. Staff administered Lorazepam (Ativan, a benzodiazepine medication used to treat anxiety) as well as other bedtime medications that included Donepezil (medication used to treat dementia) and Trazodone (antidepressant) to Resident #65, outside the parameters ordered by the physician in an attempt to prevent behaviors. Two additional residents from the memory care unit were sampled and two residents were identified in which staff did not document behaviors and notify the physician of changed administration times (Residents #82 and #152). The sample size was 29. The census was 188 with 143 in certified beds. Review of the facility's Abuse, Neglect, and Exploitation, Freedom From policy, revised January 2019, showed: -It is the policy of the facility to maintain a work and living environment that is professional and residents are free from threat 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; -Restraint refers to ensuring that residents are free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing reevaluation of the need for restraints. Review of the facility's undated Behavior Management policy, showed: -Purpose: To assist nursing staff in understanding behavior management concepts as a team approach to coincide with Federal Regulations in regards to medication use. To assist with assessing, documenting, developing interventions in dealing with behaviors with nonpharmological interventions; -To reduce the number of chemical restrained used through documentation, assessment of behaviors, and development of interventions; -Psychotropic Drugs/Chemical Restraints Include: -Antipsychotics; -Anxiolytics, Antianxiety drugs; -Sedative-hypnotics; -Antidepressants; -The potential side effects and risks of Benzodiazepine drugs include: -Drug dependence; -Amnesia; -Rebound sleep disturbance; -Delirium and worsened cognitive function; -Sedation; -Psychosocial dysfunction (zombie syndrome); -Physician's progress notes should address the use of the chemical restraints. Also include specific target behaviors being controlled, dose reductions, outcomes, and benefits seen with the resident, necessity for the dose, durations, or monitoring clinically appropriately; -The Behavior management team will rule out environmental stressors. The documentation of behaviors will be used to help develop interventions to curb or manage behaviors before medication intervention; -Behaviors: Common behavior symptoms in Long Term Care: -Yelling, screaming, moaning, constant request for attention, fighting, muttering or strange noises, wandering, anxiety, fearfulness, resisting care, biting, sleep problems, spitting, cursing, arguing, inappropriate sexual behavior, unsafe movement, pacing, unjustified complaining, delusions, entering other resident's room, and hallucinations; -Dementia is the most common cause of behavior symptoms; -Stress and feelings of hopelessness an helplessness from personal losses of belonging, loved ones, personal freedom can cause the symptoms; -Skillful care giving and environment management can help prevent behaviors; -A person with dementia has problems with memory, judgement, decision making, problem solving and communicating. Personality changes and problems with motor function also may occur. These changes in residents can often result in the case of the behavior symptoms. Reducing the environment stressors will reduce behaviors seen; -To reduce behavior symptoms: -Know the resident; -Improve communication skills; -Reduce stress caused during care giving; -Structure the environment; -Get to know the family; -The way the resident is approached can determine the response that will be received: -Approach the resident with a positive attitude; -Identify yourself by name, role and function; -Talk slowly; -Use simple words and concrete images; -Use a normal tone of voice; -Be specific with limited choices; -Remain calm; -Stay flexible; -Be patient; -Assume equal position, make eye contact, place yourself in resident's line of vision, equal or lower position; -Move slowly, quick actions without warning can startle to increase anxiety; -Match actions to words, care by touch. Review of the facility's Liberalized Medication Administration policy, dated December 2016, showed: -Purpose: To administer medications in a safe and efficient manner in accordance with person-centered care; -Procedure: Medications will be given within a liberal time frame in order to incorporate the resident's wishes and daily schedule. Medications that are ordered by the physician for a specific time, as well as medications that must be given at a certain time per manufacturer recommendations, will be given as such; -Medications will be given during the following liberal pass times unless specified otherwise. Specific liberal time frames are outlined in each facility's frequency configuration; -Early A.M.; -A.M. medication pass; -Noon medication pass; -P.M. medication pass; -HS (bedtime) medication pass; -Medications that are given multiple times per day, at a specific frequency, or at a specific time will be given as such based on each facility's frequency configuration. If a medication is scheduled for a specific time instead of a time interval, it must be given within one hour before or one hour after the scheduled time. Medication administration should also reflect timing in relation to meals or other medications as ordered; -The following principals will be taken into account when developing an individualized medication administration plan for each resident; -All medications are therapeutically necessary based on current guidelines, physician and pharmacist recommendations, and resident/caretaker preference. Unnecessary medications are eliminated when possible and appropriate; -Frequency of medications is minimized whenever possible; -Resident's daily routine, activities, and preferences are considered, including: relation to mealtimes or food, drug interactions, spacing out doses appropriately to maintain a consistent blood level of the drug, physician or pharmacist recommendations, or other specifications. Review of the facility's Medication Administration policy, dated May 2007, showed: -Only licensed Registered Nurses, Licensed Practical Nurse, or Certified Medication Aides 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 attending physician, charted in detail on the progress notes, and described in a full incident report; -Procedure: Read medication name, dosage, and interval ordered from the Medication Administration Record (MAR); -Prepare all medications for the resident as ordered for the time pass; -Medications are to be given at the time ordered, within 60 minutes before or after designated time; -If the resident is unable to take the medication or refuses it is to be charted by: -Circle initials on the Medication Administration Record; -Write the reason refused or not given on the designated place on the back of the MAR; -Notify the physician as necessary. 1. Review of Resident #65's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/16/21, showed: -Severe cognitive impairment; -Diagnoses include dementia, anxiety and depression; -Resident's mood assessment showed feeling down, depressed, or hopeless; -Required limited assistance with bed mobility; -Required extensive assistance with transfers, dressing, toileting and hygiene; -Antianxiety and antidepressants administered in the last seven days. Review of the resident's care plan, revised 12/17/21, showed: -Problem: Resident is at risk for changes in his/her mood or behavior related to his/her cognitive impairment, desire to live at home and diagnosis of depression and anxiety; -Goal: Resident will be safe and free from harm to self and others; -Approach: Assess and document behaviors as they occur; -Communicate behavior issues with physician and family; -Monitor conditions that could cause delirium such as dehydration, encourage adequate fluid intake, monitor for signs and symptoms of infection, monitor labs per physician's order; -Monitor for signs and symptoms of an acute delirium such as onset of attention span disturbances, altered levels of consciousness, perceptual disturbances and incoherent speech; -Psych available as needed; -Staff invite resident to participate in activities daily; -The behavior team meets routinely to discuss mood and behaviors to ensure appropriate interventions are in place; -Treat resident with respect. Maintain consistent staff who can attempt to anticipate the resident's needs, provide routine and develop a relationship of trust; -Problem: Resident receives daily psychotropic medications to assist with managing his/her depression and anxiety; -Goal: To utilize the lowest dose to achieve efficacy without adverse effects; -Administer psychotropic medications per physician's order; -Monitor for signs and symptoms to physicians as needed; -Update family and psych with behavior/mood changes; -Encourage activities to promote socialization and prevent loneliness; -The behavioral team meets regularly to monitor medications for appropriateness and to make recommendations to the physician for dose adjustment; -The physician, staff, family are involved in implementation of a plan of care that promotes psychological well-being and dignity; -Problem: Resident has cognitive deficits related to his/her diagnosis of dementia; -Goal: Resident will exhibit comfort and have needs met; -Approach: Encourage family to bring in familiar items from resident's home; -Encourage resident and family activity participation; -Maintain consistent staff who can attempt to anticipate his/her needs, provide routine and develop a relationship of trust; -Provide verbal remainders. Redirect as needed. Review of the resident's electronic Physician's Orders Sheet (ePOS), dated 2/1/22 through 2/28/22, showed: -An order, dated 4/30/20, for Trazodone (antidepressant) 50 milligrams (mg) tablet. Give 10 mg at bedtime between 7:15 P.M. and 11:00 P.M.; -An order, dated 8/3/20, for Ativan 0.5 mg tablet. Give 0.5 mg tablet twice a day at 1:00 P.M. and 8:00 P.M.; -An order, dated 8/4/20, for Ativan 0.5 mg tablet. Give 0.25 mg tab at 8:00 A.M. daily; -An order, dated 8/20/20, for Donepezil (a medication used to treat dementia) 10 mg tablet. Give 10 mg at bedtime between 7:15 P.M. and 11:00 P.M.; -An order, dated 9/23/20, to target behavior: anxiousness. At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -An order, dated 9/23/20, to target behavior: crying. At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -An order, dated 9/23/20, to target behavior: cursing. At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -An order, dated 9/23/20, to target behavior: increased confusion. At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -An order, dated 9/23/20, to target behavior: paranoia. At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -Further review of the POS, showed no diagnoses or specific behavior that required the use of Lorazepam and Trazodone. Review of the resident's electronic Medication Administration Record (eMAR), dated 1/1/22 through 1/31/22, showed: -On 1/4/22 at 2:53 P.M., RN GG administered Ativan 0.5 mg scheduled at 1:00 P.M. It was documented charted late; -At 6:31 P.M., RN JJ administered the following medications: -Ativan 0.5 mg tablet scheduled at 8:00 P.M.; -Donepezil 10 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -Trazodone 50 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -RN JJ documented early administration: resident will sleep; -On 1/8/22 at 9:24 A.M., RN GG administered Ativan 0.5 mg scheduled at 1:00 P.M. RN GG documented early administration: resident request; -On 1/28/22 at 6:01 P.M., RN JJ administered the following medications: -Ativan 0.5 mg tablet scheduled at 8:00 P.M. RN JJ documented, early administration: resident will sleep; -Donepezil 10 mg tablet scheduled between 7:15 P.M. to 11:00 P.M. RN JJ documented, early administration: will refuse later; -Trazodone 50 mg tablet scheduled between 7:15 P.M. to 11:00 P.M. RN JJ documented, early administration: will refuse later. Review of the resident's narcotic record, showed: -On 1/4/22, staff documented the Ativan 0.5 mg was administered at 1:00 P.M. and 8:00 P.M.; -On 1/8/22, staff documented the Ativan 0.5 mg was administered at 1:00 P.M.; -On 1/28/22, staff documented the Ativan 0.5 mg was administered at 5:00 P.M. Review of the resident's Behavior Monitoring Administration, dated 1/1/22 through 1/31/22, showed: -On 1/1/22 through 1/31/22, the resident had anxiousness on 1/16/22 during the evening shift; -On 1/1/22 through 1/31/22, staff documented no crying on all three shifts; -On 1/1/22 through 1/31/22, staff documented no cursing on all three shifts; -On 1/1/22 through 1/31/22, the resident had increased confusion on 1/13/22 during the day shift and 1/16/22 during the evening shift; -On 1/1/22 through 1/31/22, staff documented no paranoia on all the shifts. Review of the resident's progress notes, dated 1/1/22 through 1/31/22, showed no documentation of the resident's behaviors, rationale of administering medications outside of parameters, notification of the physician or Director of Nursing (DON). Review of the resident's eMAR, dated 2/1/22 through 2/14/22, showed: -On 2/1/22 at 6:42 P.M., RN GG administered the following medications: -Ativan 0.5 mg tablet scheduled at 8:00 P.M.; -Donepezil 10 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -Trazodone 50 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -RN GG documented early administration: resident request; -On 2/2/22 at 6:01 P.M., Licensed Practical Nurse (LPN) HH administered the following medications: - Ativan 0.5 mg tablet scheduled at 8:00 P.M.; -Donepezil 10 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -Trazodone 50 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -LPN HH documented early administration: resident request; -On 2/5/22 at 2:04 P.M., RN GG administered Ativan 0.5 mg tablet scheduled at 1:00 P.M. It was documented as charted late -At 4:10 P.M., RN GG administered the following medications: -Ativan 0.5 mg tablet scheduled at 8:00 P.M.; -Donepezil 10 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -Trazodone 50 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -RN GG documented early administration: resident request; -On 2/6/22 at 6:24 P.M., RN GG administered the following medications: -Ativan 0.5 mg tablet scheduled at 8:00 P.M.; -Donepezil 10 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -Trazodone 50 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -RN GG documented early administration: resident request. Review of the resident's narcotic record, showed: -On 2/1/22, staff documented the Ativan 0.5 mg was administered at 1:00 P.M. and 2:00 P.M.; -On 2/2/22, staff documented the Ativan 0.5 mg was administered at 7:00 P.M.; -On 2/5/22, staff documented the Ativan 0.5 mg was administered at 1:00 P.M. and 7:00 P.M.; -On 2/6/22, staff documented the Ativan 0.5 mg was administered at 8:00 P.M. Review of the resident's Behavior Monitoring Administration, dated 2/1/22 through 2/13/22, showed: -On 2/1/22 through 2/13/22, the resident had anxiousness on 2/7/22 during the evening shift; -On 2/1/22 through 2/13/22, staff documented no crying on all three shifts; -On 2/1/22 through 2/13/22, staff documented no cursing on all three shifts; -On 2/1/22 through 2/13/22, staff documented no increased confusion on all three shifts; -On 2/1/22 through 2/13/22, staff documented no paranoia on all three shifts. Review of the resident's progress notes, dated 2/1/22 through 2/13/22, showed no documentation of the resident's behaviors, rationale of administering medications outside of parameters, notification of the physician or DON. During an interview on 2/14/22 at 12:00 P.M., the resident's family said they were concerned with the number of falls he/she had. The resident attempts to stand and he/she falls down. Observation and interview on 2/15/22 at 11:52 A.M., showed the resident sat in the dining room with two tablemates. The surveyor asked the resident how he/she was doing, and the resident said he/she was fine. the surveyor asked if the resident ate breakfast this morning. RN GG yelled out, you know you are in the dementia unit, don't you. They get frustrated because they do not remember. At 12:10 P.M., the resident sat at table and ate his/her meal. No observation of behaviors during the meal observation. During an interview on 2/16/22 at 9:35 A.M., RN GG said he/she worked at the facility since June 2021 and was familiar with the resident. RN GG said the resident is confused. The resident can sundown really bad (a term referring to changes in behavior of a person with dementia in the late afternoon and evening), so when that happens, he/she falls and will not take the medication from anyone else except RN GG. If there was not a regular staff on the unit, the resident will fall. He/she takes scheduled Ativan, and the resident will take it for one other nurse, but if the resident did not get Ativan, he/she will sundown and fall. The resident's falls are in the evening. The resident will attempt to go from the chair to the bed, the couch to the chair, back and forth. He/she can ambulate, but needs help and cannot use the call light in the room. The resident can express his/her needs at times, but gets confused at words. The resident packs his/her belongings every day because he/she is moving out. Sometimes he/she tells staff that someone would not let him/her be in the play or being mean. The resident's behaviors are mostly verbal, but he/she would pull hair. He/she has verbal behaviors and will get paranoid if he/she did not have the Ativan. The resident is administered Ativan three times a day: breakfast, lunch, and dinner. The medications help with the behaviors and there is a big difference when he/she is administered them. The resident is not able to ask for his/her medications, and he/she does not want them. Staff have to bargain with him/her. RN GG was asked about the early administration of Ativan on the resident's MAR. RN GG said he/she stayed over and administered the resident's medications. RN GG administered the medications at 7:00 P.M. and it was due at 8:00 P.M. The resident will not take his/her nighttime medications with anyone else, and not for the agency nurse. When RN GG leaves for the day, he/she will administer the medications sometimes at 6:00 P.M. because the resident likes to take his/her medications when he/she is eating. The resident starts to sundown at dinnertime. RN GG said the behavior charting is completed daily and the only documentation regarding administering the medications early is in the MAR. The physician was not notified and the resident has a Nurse Practitioner (NP) that is familiar with the resident. There is communication with the NP daily. The only concern that was relayed to RN GG from the NP was not to use wipes, only soap and water. Observation on 2/16/22 at 9:50 A.M., showed the resident returned to the unit with assistance from staff. No observation of behaviors. 2. Review of Resident #82's quarterly MDS, dated [DATE], showed: -No documented of Brief Interview for Mental Status (BIMS, a brief screener of cognitive status) score; -Diagnoses included Alzheimer's disease, dementia and depression; -No verbal or physical behaviors; -Independent with bed mobility, transfers, dressing, eating, toileting; -Supervision with hygiene; -Antipsychotic and antidepressants administered in the last seven days. Review of the resident's care plan, revised 1/4/22, showed: -Problem: Resident has cognitive deficits related to diagnosis of dementia; -Goal: Resident will exhibit comfort and have needs met; -Approach: Behaviors: 5/18/20 episode of resident allowing another male resident to touch her breast, possibly thinking resident was deceased husband; -Attempt to anticipate resident needs; -Discourage relationships with male residents; -Encourage family to bring in familiar items from resident's home; -Encourage resident and family activity participation. Give resident choices of activities to participate in the ones of his/her liking and that will give him/her a feeling of self-worth; -Provide verbal reminders. Redirect as needed; -Problem: Resident receives daily psychotropic medications to assist in managing his/her depression; -Goal: Resident's mood will be stable, lowest dose possible will be utilized to achieve efficacy; -Approach: Assess and document behaviors as they occur; -Communicate behavior issues with physician and family; -Consider/obtain order for geri-psych evaluation; -The behavior team meets routinely to discuss medications, mood and behaviors and ensure appropriate interventions are in place; -Treat resident with respect. Monitor signs and symptoms for adverse reactions. Review of the resident's ePOS, dated 2/1/22 through 2/14/22, showed: -An order, dated 5/12/20, for Donepezil 10 mg tablet. Give 10 mg at bedtime between 7:15 P.M. and 11:00 P.M.; -An order, dated 3/31/20, for Trazodone 50 mg tablet. Give 50 mg at bedtime between 7:15 P.M. and 11:00 P.M.; -An order, dated 3/31/20, to target behavior: Quetiapine. At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -An order, dated 3/31/20, to target behavior: combative. At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -An order, dated 3/31/20, to target behavior: crying. At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -An order, dated 3/31/20, to target behavior: increased confusion. At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -An order, dated 3/31/20, to target behavior: refusing medications. At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -An order, dated 3/31/20, to target behavior: resisting activities of daily living (ADLs). At the end of each shift mark frequency, how often behavior occurred and intensity, how resident responded to redirection. Intensity code: 0= did not occur, 1= easily altered, 2= difficult to redirect every shift; -Further review of the POS, showed no diagnoses or specific behavior that required the use of Trazodone. Review of the resident's eMAR, dated 2/1/22 through 2/14/22, showed: -On 2/1/22 at 6:52 P.M., RN GG administered the following medications: -Donepezil 10 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -Trazodone 50 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -RN GG documented, early administration: resident request; -On 2/2/22 at 6:02 P.M., LPN HH administered the following medications: -Donepezil 10 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -Trazodone 50 mg tablet scheduled between 7:15 P.M. to 11:00 P.M.; -LPN HH documented, early administration: resident request; -On 2/5/22 at 4:15 P.M., RN GG administered the following medications: &n

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review,, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to follow the facility policy for wound management. The staff failed to document weekly skin assessments in the electronic medical record (EMR), failed to document the discovery of a wound and the wound assessment and also failed to ensure an ordered treatment remained in place. When assessed by the wound management company several days later, the resident's newly developed wound was documented as an unstageable pressure ulcer (Resident #131). In addition, facility staff failed to report one newly developed opened area to the charge nurse for 24 hours and when assessed by the surveyor the next day, the resident had developed two open areas. When the facility wound nurse assessed the two new wounds, the areas were documented as Stage II pressure ulcers (Resident #142). The census was 188 with 143 residents in certified beds. Review of the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers; quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014: showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., wound improvement, wound deterioration, more or less exudate (drainage), signs of infection, or other complications); -Address the signs of deterioration immediately. 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 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) 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; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy; -Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. Review of the facility's Wound Care Protocol Policy, revised 8/2018, showed: -Goals of the assessment: -Provide uniform description; -Facilitate communication among staff; -Adequate monitoring of progress or deterioration. Assess the entire person not just the ulcer; -Assess for Pain and implement interventions to relieve; -How to access/document: -Initially assess the ulcer(s) for location, stage, size, sinus tracts (also known as tunneling, a narrow opening or passageway extending from a wound underneath the skin in any direction through soft tissue and results in dead space with potential for abscess formation), undermining, tunneling, exudate, necrotic tissue, the presence or absence of granulation (new tissue growth) and epithelialization (tissue growth); -Treatment should be determined based on the assessment; -Initiate and complete a Causal Risk Factors Analysis for Pressure Ulcer assessment/the Causal Risk Factors Analysis for Pressure Ulcers in the electronic health record for each pressure ulcer upon initial finding, admission, re-admission and quarterly. Utilize the findings for development of the care plan; -Weekly reassessment should be done indicating the size and other descriptive characteristics consistent with the initial assessment in order to clearly communicate progress or decline; -If an ulcer/wound is assessed as unchanged at the 2nd weekly assessment the physician or nurse practitioner must be notified and the treatment plan modified; -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; -Consult Wound Care Expert: -All unstageable pressure ulcers, upon admission or at first discovery; -Stage 2 ulcers, and any other non-healing wound that show signs of deterioration or remain open after 2 weeks; -Other considerations: -Determine what medical conditions present may prevent or limit wound healing; -Assess the resident for complications; -Identify pre-existing signs (such as purple or very dark area that is surrounded by profound redness, edema (swelling), or induration (abnormal hardening of the tissue caused by edema) suggesting that deep tissue injury has already occurred and additional deep tissue loss may occur. In a darker skinned individual focus more on other evidence of pressure ulcer development, such as bogginess (squishy), induration, coolness or increased warmth as well as signs of skin discoloration; -Screen the resident for nutritional deficiencies. Ensure adequate nutrition to support healing. Provide high potency vitamin and mineral supplements, per registered dietician (RD) recommendations; -Wound Care Protocol: -Assess pain relative to the resident's ulcer and ulcer treatment. Notify the provider and administer medication as needed. Adjust and provide support surfaces for pain relief and pressure redistribution; -Assess psychosocial needs relative to the resident's life activities which are limited or changed due to the development of the ulcer; -PRESSURE ULCERS/INJURIES: -Definition: A pressure ulcer is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence, or related to a medical or other device. The injury can present as intact skin or related to a medical or other device. The injury occurs as a result of intense pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue; -Avoidable: the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions and revise the interventions as appropriate; -Unavoidable: the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate; -Prevention and early intervention: -To identify residents at risk for pressure ulcers; -To create an environment to promote the prevention of pressure ulcers; -Goals of Therapy: -Treat the underlying cause; -Remove and prevent necrosis and infection; -Provide a moist environment; -Disturb the wound bed as little as possible; -Maintain or improve nutrition and hydration status, where feasible; -Prevention: -Braden scale (used to identify risk of developing a pressure injury) upon admission, readmission, quarterly and with any significant change of condition or the Braden Scale for predicting pressure sore risk in the EHR; -Regardless of the resident's risk score, the charge nurse is responsible to review each risk factor on the Braden Scale and potential causes individually and provide interventions written on the care plan; -Frequent turning; -Evaluate pressure redistribution measures for bed and chair; -Manage moisture, and shear, keep skin soft and supple; -Recommendations/treatment: -Use moisturizers/lubricating ointments after cleansing with mild soap and water; -Use of absorbent pads and briefs that wick and bold moisture; -Offer routine toileting; -Offer hydration in conjunction with turning schedules; -Skin prep to soft heels every day with off-loading heels while in bed; -Pain: Assess and Address -Definitions: - Intact or non-intact skin with localized area of persistent non-blanchable deep maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change may precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue (the deepest layer of the skin), granulation tissue, fascia (connective tissue), muscle or other underlying structures are visible, this indicates a full thickness pressure injury, or unstageable; -Pressure redistribution: -Adjust turning schedule to eliminate turning to compromised area; -Evaluate pressure reduction/pressure relief measures, i.e. mattress and chair cushion Reduce friction and shearing forces; -Use positioning devices to avoid placing resident on an ulcer or other at risk areas. Place cushioning devices or pillows between legs/ankles and other bony prominence's to maintain alignment and prevent touching of bony prominence's; -Frequent turning or repositioning; -Wound Care Protocol: -Stage 2 Pressure Ulcer: commonly result from adverse microclimate and shear in the skin over the pelvis (area from front of the hips in between legs and back of the hips) and shear in the heels. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, bums, abrasions); -Treatment: -Adjust turning schedule to eliminate turning to compromised area; -Evaluate pressure reduction/pressure relief measures, i.e. mattress and chair cushion; -Reduce shearing forces; -Use positioning devices to avoid placing resident on an ulcer or other at risk areas; -Place cushioning devices or pillows between legs/ankles and other bony prominence to maintain alignment and prevent touching of bony prominence; -Frequent turning or repositioning; -Recommendations: -Use moisturizers or lubricating ointments after cleansing with mild soap and water every shift and as needed (PRN); -Do not massage red areas; -Use absorbent pads and briefs that wick away and hold moisture; -Offer routine toileting; -Offer hydration during turning schedule; -Unstageable pressure ulcer: full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is covered by slough or eschar. If slough or eschar is removed, a stage III or stage IV pressure injury will be revealed. Stable eschar (dry, adherent, and intact without erythema) on an ischemic (poor blood flow area) limb or heel should not be removed; -Pressure redistribution: -Adjust turning schedule to eliminate turning to compromised area; -Evaluate pressure reduction/pressure relief measures, i.e. mattress and chair cushion; -Reduce shearing forces; -Use positioning devices to avoid placing resident on an ulcer or other at risk areas; -Place cushioning devices or pillows between legs/ankles and other bony prominence to maintain alignment and prevent touching of bony prominence; -Frequent turning or repositioning; -Protocol: -Initial assessment and cleansing the wound: remove the dressing and assess wound color, odor, edges, dressing and exudate. Cleanse wound with normal saline. Change dressing every 3 days or PRN based on saturation. Date and initial dressing; -Measure and document the length, width and depth of the wound. Document wound bed and characteristics; -If full thickness, consult wound care expert. If not healed within two weeks, consult wound care expert. If signs or symptoms of infection are present, apply Silvercel non-adherent dressing (antimicrobial dressing) and cover with silicone boarder dressing (dressing that adheres to the skin but prevents injury upon removal) and consult and notify physician and wound care expert; -If under 25% necrotic, apply Santyl (ointment with an enzyme that breaks down collagen in damaged tissue and helps healthy tissue to grow) and an appropriate secondary dressing and consult wound expert. 1. Review of Resident #131's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/17/22, showed: -Brief interview of mental status (BIMS) score, blank; -One staff person assist required for transfers, dressing, toileting, personal hygiene, and bed mobility; -Eating, set up only; -No behaviors; -Wheelchair/walker for mobility; -Frequently incontinent of bladder; -At risk pressure ulcers, yes; -Unhealed pressure ulcers, no; -No pressure ulcers, wounds and/or skin problems; -Diagnoses: heart failure, high blood pressure, diabetes, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and seizure disorder. Review of the resident's undated care plan, in use during the survey, showed: -Problem: Skin, start date: 10/14/2020, the resident is at risk for skin tears (topical tears in the skin)/bruises related to decreased mobility and changes in skin associated with age: -Approach: staff apply lotion frequently to areas of concern, as needed. Assess skin with activities of daily living (ADL, daily self-care tasks); dressing changes/showers/as needed for bruises and skin tears. Complete bath/skin reports with showers. Transfer with fragile skin in mind; -Problem: Fracture, start date, 1/21/22, resident has decreased mobility and increased need for ADL assistance due to a fractured 5th cervical (neck) vertebrae, support the head and allow for the neck's flexibility and head's range of motion: -Approach: staff provide assistance with one staff assist for daily ADL's, lay self-care items within reach and in the order they are needed, and monitor for presence of pain/intolerance during self-care activities. Review of the facility wound tracking report, dated 11/14/21 through 2/14/22, showed the resident had no identified wounds and/or open areas. Review of the resident's electronic physician order sheet (ePOS), showed an order dated 2/7/22, to perform skin assessment and complete weekly skin assessment observation every week on Tuesday evening shift, scheduled every Tuesday from 3:00 P.M. to 11:00 P.M. Review of the resident's shower sheets, dated 2/8/22 through 2/18/22, showed no open areas identified. Review of the resident's Nurse Practitioner progress note, dated 2/9/22 at 1:52 P.M., showed the patient seen today and noted sitting up in a chair in his/her room. The patient is alert and oriented to his/her previous baseline. Today, the patient offers no new complaints. Nursing staff offered no new complaints. No change in functional status and no behaviors reported by nursing. Medication, chart, and laboratory tests reviewed. No documented skin concerns. Review of the Registered Dietician's progress note, dated 2/10/22 at 11:57 A.M., showed, weight gain significant and desirable, the resident eats in the main dining room with variable intakes of regular diet. His/her skin is intact. Continue to encourage the resident with intake of foods/fluids. Review of the resident's nurse's progress notes, dated 2/19/22 at 6:44 P.M., showed the resident was noted to have a 0.3 centimeter (cm) X 0.3 cm slough area to the right buttock, Santyl applied and covered with a foam dressing, the physician is aware and ordered the resident also needs to been seen by the wound team. Further review of the resident's ePOS, showed an order dated 2/19/22, for right upper buttocks, cleanse with normal saline and apply Santyl and foam dressing daily. Further review of the resident's shower sheets, showed on 2/22/22, a circle drawn on the rear buttock area, and a hand written note, showed redness noted. The intervention put in place: the resident will see wound nurse on 2/23/22. Review of the Wound Nurse's Wound Management detailed report, dated 2/22/22 at 11:54 A.M., showed: -Right buttocks; -Wound type: pressure ulcer; -Present on admission/re-entry: no; -Length (head to toe direction): 0.2 cm; -Width (side to side direction): 0.2 cm; -Can depth be measured: no; -Stage: Unstageable - Slough and/or Eschar; -Wound edges/margin: edge not attached to wound base; -Comments: Noted peri-wound (skin surrounding the wound opening) is approximated 1.1 cm x 2.0 cm. Dry slough present. New treatment order obtained. During an observation and interview on 2/23/22 at 6:40 A.M., showed the resident lay in bed. Certified Nurse Aides (CNA) T and CNA M greeted the resident and said the resident was incontinent of urine, and wore a brief. The resident wore a urine saturated brief. The CNAs unfasted and lowered the brief. The urine observed dark colored and odorous. The resident said he/she had a sore on his/her hip. The aides provided care and assisted the resident to turn onto his/her side and exposed the resident's buttocks and the right upper hip. An open area noted to the right upper buttocks/hip area. The wound uncovered and exposed directly to the urine-saturated brief. The skin to the wound noted as red and wet with urine. The open wound noted to have a small circular area in the center of the wound, yellow colored and approximately measured 0.2 cm x 0.4 cm x 0.0 cm depth. The aides said the wound would had been uncovered and exposed all night shift. The time of the observation was the first time the aides had been able to provide care to the resident. The aides had not been notified the resident had a wound prior to beginning the night shift the evening before at the report and shift change. During an interview on 2/23/22 at 8:36 A.M., the facility wound nurse said staff notified her that the resident might have an open area to the coccyx (tailbone). She assessed the tailbone and found no open areas. When she informed the surveyors the resident had no open areas to the tailbone, the surveyors asked the wound nurse if she conducted a full skin assessment. She said she did not conduct a full head to toe skin assessment, and usually will only assess the area of skin concern the charge nurse or aides reported to her. She had not been aware the resident had an open, exposed wound to the right buttocks/hip area. The surveyor informed the wound nurse of the open area to the buttocks/hip area observed to be undressed. The wound nurse said if a wound is discovered during the week, Monday through Friday, the charge nurse should assess the area, clean the wound and cover the area with a dry dressing. The nurse should open a wound management task in the resident's EMR. Opening the wound management task would trigger the wound nurse the resident had a skin concerns. During the work week, the wound nurse would assess the area, contact the physician and get treatment orders. If the wound is discovered on the weekend, the charge nurse should assess the wound, obtain measurements, open the wound management task and enter the measurements, contact the resident's physician for orders, notify the next of kin (NOK) and document in the medical record. Aides should report uncovered wounds to the charge nurse and the nurse would be responsible to apply the treatment. The facility wound nurse said she would assess the resident's right hip and if she located a wound, she would inform the surveyors. During an interview on 2/23/22 at 9:13 A.M., the facility wound nurse said she re-assessed the resident and agreed the resident had an open, uncovered wound to the right buttocks/hip. She staged the wound as unstageable due to the slough in the center of t he wound. After she spoke with the surveyors, she reviewed the progress notes and agreed the wound was first noted on 2/19/22. She had not been notified of the wound at that time, and was notified by the surveyors. The nurse at that time did not open the wound management task, and it did not trigger to the wound nurse. Wounds should not be uncovered or exposed to urine. Exposure could risk infection and slowed healing. The resident's wound had not been on the wound report because the wound nurse had not been aware of the wound. The current wound measurements were 0.2 cm x 0.2 cm x 0.0 cm with dried slough in the center. During an interview on 3/3/22 at 12:15 P.M., the resident's physician said he expected the nurses to conduct and document head to toe weekly skin assessments in the medical record. If skin assessments are not documented it would be difficult to determine when a wound developed and when the skin was last assessed. He expected treatments to be applied and in place. Residents who are incontinent should be changed and cleaned every few hours and if a wound is found to be uncovered, the aide should notify the nurse so a treatment can be applied. Unstageable wounds occur over time, if slough is present in a wound that could signify infection. Santyl is used to clean out the slough and to better visualize the wound base under the dead tissue. Once the slough is removed from the wound, the stage of the wound could change based on the wound bed and how deep the wound is. Wounds should be documented on the wound report and tracked for progress or decline in healing. 2. Review of Resident #142's quarterly MDS, dated [DATE], showed: -Cognitively intact, able to make needs and wants known; -No behaviors or refusal of care; -Extensive staff assistance needed for bed mobility, dressing and toileting; -Total staff assistance needed for transfers and locomotion; -Diagnoses of vascular disease and diabetes; -At risk to develop pressure ulcer/injury; -Has one or more unhealed pressure ulcers; -Current number of Stage I: 0; -Current number of Stage II: 0; -Current number of Stage III: one; -Receives: pressure reducing device to chair and the bed, nutrition and hydration interventions, applications of non-surgical dressings other than to feet, application of ointment to the feet. Review of the resident's care plan, in use at the time of the survey and reviewed 2/2/22, showed: -Problem: The resident has diagnoses that put him/her at risk for skin alterations. He/she had a right heel wound that re-opened on 2/10/22 and is receiving treatment; -Goal: The wound will progress; -Approach: Incontinent of bowel, staff use wedge pillow for positioning, nurses to audit skin once weekly and document as required. Staff to communicate/notify the nurse of any changes or areas of skin concern. Encourage and offer frequent repositioning in bed and the wheelchair. Keep skin clean and dry, apply clean dressings when soiled, apply barrier cream after incontinent episodes, obtain treatment orders and initiate. Review of the resident's ePOS, showed an order for stock barrier cream to the coccyx. Apply three times a day. Review of the resident's electronic medical record, showed no documented weekly skin assessments from 2/1/22 thru 2/17/22. During an interview on 2/15/22 at 8:42 A.M., the resident said he/she had wounds to his/her heels. He/she is seen weekly by the wound care team for the heel wounds. He/she had bowel incontinence and staff provided incontinence care as needed. During an interview on 2/18/22 at 10:30 A.M., the resident said his/her buttock felt sore. Staff provided his/her morning care and staff did not tell him/her of any additional skin issues. He/she told staff during morning care that his/her buttocks was sore and the staff applied cream to the area. Review of the resident's weekly nursing skin assessment, dated 2/18/22 at 2:00 P.M., showed: -Weekly skin a

Based on observation, interview and record review, the facility staff failed to ensure drugs and biologicals used in the facility are stored and labeled in accordance with accepted professional principles, when staff failed to date four out of six insulin pens, on the 200 hall after opened and check and/or record the refrigerator temperature daily for five out of five medication refrigerators. The census was 188 with 143 in certified beds. Review of the facility's Insulin Administration via a Pen Device policy, dated as reviewed 5/21, showed: -Purpose: To safely administer insulin via pen devices according to physician orders and the facility's policy and procedures; -Procedure: If a pen is being used for the first time, date the pen on the label. 1. Observation on the 200 hall on 2/18/22 at 10:00 A.M., of the top drawer of the treatment cart, showed six insulin pens. Four of the six insulin pens did not have a date that showed when the insulin pen was removed from the refrigerator for use. During an interview on 2/18/22 at 10:00 A.M., Licensed Practical Nurse (LPN) EE said he/she did not see a date on the insulin pens, and he/she did not know when the insulin pen was started. There should be a date on them so he/she would discard the insulin pens by the expiration date placed on the insulin pen by the manufacturer. During an interview on 2/18/22 at 1:55 P.M., the Director of Nursing (DON) said insulin should be refrigerated until opened. Once the insulin is opened, it should be dated. Then, the insulin can be stored on the cart. Insulin is discarded according the manufacturer guidelines. The DON would expect staff to date insulin when it is opened. 2. Review of the facility's Storage of Drugs policy, dated as reviewed on 1/14, showed, medication which require refrigeration are kept in a refrigerator in the locked medication room. All refrigerated areas and devices have a temperature between 36 degrees through 46 degrees Fahrenheit (F). Review of the facility's medication refrigerator temperature logs, showed: -On the 100 hall, in December 2021, six out of 31 opportunities blank and in January 2022, 10 out of 31 opportunities blank; -On the 200 hall, in December 2021, 14 out of 31 opportunities blank and in January 2022, 12 out of 31 opportunities blank; -On the 300 hall, in December 2021, 11 out of 31 opportunities blank and in January 2022, 13 out of 31 opportunities blank; -On the 400 hall, in December 2021, nine out of 31 opportunities blank and in January 2022, 13 out of 31 opportunities blank; -On the 500 hall, in December 2021, 17 out of 31 opportunities blank and in January 2022, 11 out of 31 opportunities blank. During an interview on 2/18/22 at 1:55 P.M., the DON said staff should check the refrigerator temperatures daily and the refrigerator temperature log should be posted in the medication rooms. During an interview on 2/22/22 at 5:20 A.M., Registered Nurse (RN) FF said the night shift staff are responsible for checking the refrigerator temperature and documenting it in the log. 3. During an interview on 2/25/22 at 2:00 P.M., the administrator said medications should be stored within the manufacturers guidelines, including medications that need to be refrigerated. The refrigerator temperature should be checked daily and documented on the log.

Based on record review and interview, the facility failed to establish a system to ensure all staff followed requirements from the state board of nursing for one registered nurse who held a nursing license on probation at the time of hire. The census was 188 with 143 residents in certified beds. Review of Registered Nurse (RN) GG's employment record, showed: -Employment application: Date of hire: 5/4/21; -Status: Full time; -Job Title: Registered Nurse; -Review of RN GG's license verification report, showed: -License original date: 4/14/11; -License status: Probation; -Date of action take: 4/6/21; -Basis for action: Failure to maintain adequate or accurate records; -Effective dates: 4/6/21 through 4/6/2024. Review of RN GG's State Board of Nursing Hearing Commission, dated 4/6/21, showed: -Employment Restrictions: The following employment restrictions are in place for a minimum of one year of employment as a nurse. Employment is defined as working in a licensed nursing position at least 96 hours per month. Respondent: -May not work more than 80 hours per two weeks or more than 48 hours in a seven day interval; -Shall not work more than 12 hours in a 24 hour period; -Shall not Float from unit to unit within a facility; -Shall work under supervision of Physician, or Registered Nurse, if licensed as a Registered Nurse, or by a Physician, or Licensed Practical Nurse, or a Registered Nurse, if licensed as a Licensed Practical Nurse. The supervising physician or nurse is not required to be on the same unit or ward as Respondent, but should be on the facility grounds and readily available to provide assistance and intervention if necessary. Record review throughout the survey process from 2/14/22 through 2/18/22, 2/21/22 through 2/25/22, 2/28/22 and 3/1/22, showed the survey team identified three residents on the memory care unit received their bedtime medications outside of physician ordered parameters and the facility's liberalized medication schedule for a minimum of two months by RN GG. Review of RN GG's time card, dated 12/26/21 through 2/16/22, showed: -Week ending date 1/1/22, RN GG worked on the following dates: -On 12/26/21, RN GG worked a total of 9.25 hours; -On 12/27/21, RN GG worked a total of 16.75 hours; -On 12/31/21, RN GG worked a total of 12.67 hours; -On 1/1/21, RN GG worked a total of 6 hours; -Total of 44.67 hours worked; -Week ending date 1/8/22, RN GG worked on the following dates: -On 1/1/22, RN GG worked a total of 12.75 hours; -On 1/4/22, RN GG worked a total of 10.25 hours; -On 1/6/22, RN GG worked a total of 8 hours; -On 1/7/22, RN GG worked a total of 16 hours; -Total of 47 hours worked for the week; -Total of 91.67 hours worked during the two week period; -Week ending date 1/15/22, RN GG worked on the following dates: -On 1/13/22, RN GG worked a total of 8.75 hours; -On 1/14/22, RN GG worked a total of 8 hours; -On 1/15/22, RN GG worked a total of 8.25 hours; -Total of 25 hours worked; -Week ending date 1/22/22, RN GG worked on the following date: -On 1/16/22, RN GG worked a total of 7.25 hours; -Total of 7.25 hours worked; -Week ending date 1/29/22, RN GG worked on the following dates: -On 1/26/22, RN GG worked a total of 8.25 hours; -On 1/27/22, RN GG worked a total of 7.67 hours; -On 1/28/22, RN GG worked a total of 11.42 hours; -On 1/29/22, RN GG worked a total of 5.50 hours; -Total hours worked 32.84 hours; -Week ending date 2/5/22, RN GG worked on the following dates: -On 1/31/22, RN GG worked a total of 10.25 hours; -On 2/1/22, RN GG worked a total of 12.50 hours; -On 2/3/22, RN GG worked a total of 11.50 hours; -On 2/4/22, RN GG worked a total of 7.67 hours; -On 2/5/22, RN GG worked a total of 11.75 hours; -Total hours worked for one week 53.67 hours; -Total hours worked for a two week period 86.51 hours. -Week ending date 2/12/21, RN worked on the following dates: -On 2/6/22, RN GG worked a total of 12.50 hours; -On 2/7/22, RN GG worked a total of 8.25 hours; -On 2/9/22, RN GG worked a total of 7.92 hours; -On 2/10/22, RN GG worked a total of 8.25 hours; -On 2/11/22, RN GG worked a total of 9.25 hours; -Total hours worked 46.17 hours; -Week ending date 2/19/22, RN worked on the following dates; -On 2/14/22, RN GG worked a total of 9 hours; -On 2/15/22, RN GG worked a total of 8.25 hours; -On 2/16/22, RN GG worked a total of 8.67 hours; -Total hours worked 25.92. During an interview on 2/23/22 at 11:00 A.M., Human Resources Manager (HR) PP said he/she completes the background check on new hires and the Director of Nursing (DON) reviews it. If an employee has a nursing license on probation, he/she would give it to the administrator and DON. They would contact the corporate office and have corporate sign off on it. Corporate would tell them to put it in the file. HR PP said someone else was in charge of the background checks; however, he/she left in August/September 2021. During an interview on 2/23/22 at 11:44 A.M., the administrator and DON said if a nurse's license was on probation, they would check to see why that nurse was on probation and interview them to get their side of the story. They would also interview former employers as well. There is a difference with making a mistake in the past and moving forward. They would not hire anyone with a suspended license. The administrator and DON confirmed they were not aware RN GG's license was on probation, but he/she was hired before the administrator or DON were hired. The wound nurse had been completing the employee evaluations and any documents sent to the board of nursing. They would expect the same person to be responsible for that. If they were aware RN GG was on probation, they would monitor to ensure he/she would be compliant. During an interview on 2/23/22 at 12:09 P.M., the wound nurse confirmed he/she does not not communicate with the state nursing board. He/she did not know RN GG was on probation until January 2022. The wound nurse ran all the nursing licenses and that was how he/she found out. He/she informed the DON that RN GG's license was on probation, but they did not believe there were any restrictions. The DON said as long as RN GG's nursing license was not suspended, then he/she was okay to work. There was another time when RN GG brought something to the office to give to the DON and the wound nurse asked why. RN GG said it was just a couple of questions, and the wound nurse filled it out and gave it back to her. The wound nurse did not remember what was on the form. The only thing RN GG said was he/she needed to work full time. During an interview on 2/23/22 at 12:19 P.M., the staffing coordinator said he/she was not aware of the number of hours or any stipulation on the nursing license. He/she would expect to be made aware of it. RN GG never mentioned anything about it. During an interview on 3/1/22 at 1:00 P.M., the administrator said RN GG knew his/her own restrictions better than anyone and should have been accountable. He/she actually volunteered to pick up shifts. If the administrator were aware of the restrictions, she would not have allowed that.

Based on interview and record review, the facility failed to develop a plan that identified and corrected quality deficiencies as well as opportunities for improvement, which would lead to improvement in the lives of the nursing home residents, through continuous attention to quality of care, quality of life and resident safety, by administering medications outside parameters and ensuring the narcotic sheets are accurate, completed and maintained. This deficient practice had the potential to affect all residents living in the facility. The census was 188 with 143 in certified beds. Throughout the survey process from 2/14/22 through 2/18/22, 2/21/22 through 2/25/22, 2/28/22 and 3/1/22, the survey team identified three residents on the memory care unit who received their bedtime medications outside of physician ordered parameters and the facility's liberalized medication schedule for a minimum of two months. The survey team also identified the narcotic count sheets were either not accurate, signed, or maintained by the facility. Review of the facility's Quality Assessment and Assurance (QAA) policy, dated November 2017, showed: -Purpose: To assist in improving the quality of care and quality of life specific to the resident population. To identify and respond to quality deficiencies within each facility and develop positive outcomes that are sustainable over time. To develop systems for monitoring departmental performance in order to identify variations in performance and adverse events/issues. These events/issues will be prioritized based on high risk, high volume, or problem prone. The QAA committee will report findings and potential solutions; -Definitions: High risk: those care and services associated with significant risk to the health and safety of residents. Examples of high risk, include but are not limited to falls, wounds, behaviors, high risk medications and new onset of antipsychotic medications; -Procedure: The QAA committee will meet regularly on a monthly basis; -The Interdisciplinary QAA Committee collects and reports data and findings, then develop action plans. Performance Improvement Projects (PIP) will be identified and assigned as needed to identify issues that may adversely affect quality of care and services to residents; -Nursing management will report findings, data and action plans to include, but not limited to, pressure injury development, incident/accidents, weight loss, restraints, infection control, antipsychotic rates and the pharmacy consultants monthly drug regimen review; -The Director of Nursing (DON) /designee will report findings, data and compliance on survey findings if applicable; -Additional reports will be presented as deemed relevant by the administrator and the QAA committee. Review of the facility's Quality Assurance and Performance Improvement (QAPI) policy, dated November 2017, showed: -Design and Scope: QAPI is integrated into all aspects of care and services in each community. The process is ongoing and uses a comprehensive and collaborative approach utilizing all departments in the community; -The QAPI plan is ongoing, comprehensive and addresses the full range of care and services provided by the community; -The QAPI program will address all areas of clinical care, quality of life, resident centered care and resident choice. The QAPI program will also address all areas of services that affect the daily life of residents to include environmental services, food and nutrition services, therapeutic recreation, administration, business, and therapy services; -Governance and Leadership: The administrator of each community is the leader of the QAPI program. The administrator collaborates with the DON and the medical director and is responsible for the QAPI plan execution; -The QAA Committee will consist of members from all departments within the community. Each member will be responsible for identifying potential areas for process/system improvement in their perspective departments. The result of each member's QAPI project will be reviewed monthly at the QAA meeting and also with the community's staff in which it relates; -Feedback, Data Systems, and Monitoring: Each community has systems in place to monitor care and services and collect data from various sources. These systems actively incorporate the input/feedback of residents, families, staff, and members of the healthcare team; -The source of data that will be monitored through QAPI includes, but is not limited to, the [NAME] report, survey findings, complaints/grievances, adverse events, resident charts, the electronic medical record (EMR), reviews of psychotropic usage, the monthly pharmacy consultation to include the monthly drug regimen review, medication errors, fall and wound reports, staffing and turnover rates, census data, financial reviews, discharges, emergency department visits, the facility assessment, direct observations and input from staff, residents, families, and others; -PIP: As areas for improvement are identified by staff, families and others, the communities will develop a PIP; -These PIPs will review, examine and work towards resolutions to the problems, issues, or concerns; -System Analysis and System Action: Each community will use a root cause analysis process for improvement of performance and services; -After the systematic root cause analysis is completed by each QAPI team, corrective actions will be taken that may result in improvement or at a minimum, reduction of the reoccurrence of the problem/issue/concern; -The corrective action/system changes identified by the root cause analysis will be communicated to staff as they are developed, upon orientation, annually and as necessary; -The corrective action/system changes identified by the root cause analysis will be discussed in the monthly QAA meetings; -The follow up measurement to ensure the corrective action/system changes have been achieved and are sustained will be undertaken by a Care PIP team. During an interview on 2/16/22 at 4:15 P.M., the administrator and the DON said they have a liberalized time window for medication administration. The DON said medications could be administered one hour before and one hour after, but the goal was for the medications to be administered within the time frame. The DON said it was in the facility's policy. The administrator and DON said if a medication was ordered at a specific time, it could be administered one hour before and up to one hour after the scheduled time. If a resident requested their medications early, they expected staff to try and get the resident to stay up if they can, but if the resident wanted to take the medication outside the realm, the DON expected staff to contact the physician to see if it was okay. They expected this to be documented. The electronic medical record prompts staff to state why a medication was administered early. If a resident started to request their medications early on a regular basis, they expected staff to contact the physician to possibly change the medication times. The DON said he briefly looks over the MARs, progress notes, labs of facility residents, but does not go in depth. There is no real audit at this time. The administrator and DON were not aware that it was documented in the resident's MAR that he/she requested their medications early. They look at missed medications, it does not flag if a medication was administered early or late. Since Ativan was a scheduled medication, and not on a liberalized schedule, they expected it to be administered one hour before at the earliest and one hour after at the latest, per their facility's policy. It is not appropriate for staff to administer medications early because the resident will sundown around dinner time, or did not allow new or unfamiliar staff to administer medications. It is not an excuse to administer medications outside physician orders and without communication from the physician and DON. They expected staff to contact the physician each time, assess the resident, and consult with the physician about an administration time change. They were not aware there were other residents on the memory care unit who received their medications early. They expected the physician to be notified and to start an assessment on the resident. They expected there to be documentation of behaviors as well. The medical record needs to reflect the resident's care. There needs to be communication with the physician. During an interview on 2/23/22 at 11:45 A.M., the DON said the facility's medical records consultant completed a medical records audit on the residents on the memory care unit and there was great concern. During an interview on 2/24/22 at 3:56 P.M. and on 2/25/22 at 1:24 P.M., the administrator said she has been unable to locate any additional count sheets, she said there is no real system in place to keep count sheets, other than they are given to the DON to keep in his records. The requirement is to keep medical records for 7 years. The administrator said when PRN medications are administered, the nurse should give the medication and sign the resident's MAR. The medication, when dispensed, should align with the MAR. The facility does not have a system in place to monitor narcotic sheets. The narcotic sheet should be part of the medical record and scanned into the record, and she did not know why the facility is missing the narcotic sheets. Those should be in the DON's record for review and to file in the record. During an interview on 2/28/22 at 4:00 P.M., the DON said the facility conducts their monthly QAPI meetings; however, the concerns addressed to the facility by the survey team in regards to the accuracy and maintaining of controlled substance sheets and issues with administering medications had not been identified. During an interview on 3/1/22 at 1:00 P.M., the administrator said she expected there to be a system in place for checks and balances to ensure staff are documenting with expectation to be notified if there are concerns.

**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 out of 29 sampled residents (Residents #58, #84, #4, #35 and #95). The census was 188 with 143 residents in certified beds. Review of the facility's care management policy, undated, showed the following: Purpose: To provide for management of resident care that is conducted systematically and comprehensively by a facility-wide (interdisciplinary) Team knowledgeable in current concepts of geriatric care. Resident care management should be consistent with the medical plan of care. Nursing uses the five steps of the nursing process: Assessment, diagnosis, goal setting, implementation and evaluation as a guide. Policy: -All resident care is designed to meet a resident's individual needs and is directed toward conservation and restoration of an optimal physical and emotions state; -Coordination of the plan of care is the responsibility of nursing. However, planning, implementation, and evaluation requires joint participation by each discipline rendering service; - Activities relating to the management of resident care are as follows: -admission to the facility focuses staff attention on losses experienced by older residents when entering a communal setting and each person's unique potential for coping with change; - An initial assessment of a new resident's status and needs is conducted by each service represented in the Interdisciplinary Team. Reassessments are made when change in condition occurs and at specific intervals during the resident's stay; - The above assessments are used to develop and maintain an individualized plan of care for each resident; - The plan of care is reviewed and revised to reflect current needs of the resident; - Assessment is an ongoing process during every encounter with the resident. 1. Review of Resident #58's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by faciliy staff, dated 12/20/21, showed the following: -admission date 9/14/20; -Cognitively intact; -Always incontinent of bowel and bladder; -High risk for developing pressure ulcers (injury to skin caused by unrelieved pressure or friction); -Requires extensive assist from staff with bed mobility, toilet use and dressing; -Diagnoses included heart disease, congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should), hypertension (HTN, high blood pressure), peripheral vascular disease (PVD, a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), respiratory failure, diabetes, depression and anxiety. Review of the resident's care plan, in use at time of survey, showed the following: Category: Cardiovascular: The resident has an active diagnosis of CHF requiring post-acute care education; -Goal: The resident will verbalize understanding and return demonstration of CHF post-acute education; -Approach: Call primary care physician if any of the following occurs: Increased weight of 2-3 pounds a day, chest pain, feeling dizzy, shortness of breath, new or worsening cough. Education on oxygen conservation during activity with return demonstration. Education provided on individualized exercise program with return demonstration; Education provided to resident and/or family; Encourage the resident to comply with current diet; Identify decrease in endurance; Instruction in wound and energy conservation; Review low sodium diet with examples of high sodium foods; Review durable medical equipment (medical equipment that may include walkers, crutches and wheelchairs) (DME); Review of medication; Review of readmission for continue care needs; Review signs and symptoms of CHF exacerbation (symptoms become worse); Teach how to monitor for edema (swelling); Teach planned rest periods; Teaching of daily weight monitoring. Review of the resident's face sheet, showed diagnoses that included, presence of pacemaker (device implanted under the skin on the chest to control heart rate), cardiac arrhythmia (irregular heartbeat) and atrial fibrillation (irregular heartbeat). An observation and interview with the resident on 2/16/22 at 1:20 P.M. showed the resident had a white monitor box in the corner of his/her room on a table with a green light on. The resident said the monitor box is how his/her pacemaker is being monitored 24 hours a day. The information goes straight to the resident's cardiologist. If there is any problem with the pacemaker, the heart monitoring company will call the facility to let them know of the irregularities. If there is a problem detected with the monitor, a red light will come on. The resident also added he/she is incontinent of his/her bowel and bladder. Due to taking a water pill that makes him/her urinate more than normal, his/her family member have been purchasing special briefs for his/her incontinent episodes. During an interview on 2/18/22 at 8:30 A.M. with RN BB, said he/she is aware that the resident has a pacemaker and the heart monitor company will call if there is an abnormality. The resident wears briefs that are designed for residents who urinate more than normally. The resident's family does purchase the special briefs. Further review of the care plan, showed it did not address the resident's pacemaker or that the resident is incontinent of bowel and bladder and requires special briefs that the family provides. 2. Review of Resident #84's quarterly MDS, dated [DATE], showed the following: -admission date 7/1/21; -Cognitively intact; -Has ostomy (a surgical procedure that brings one end of the intestine out through the abdominal wall) appliance and is always continent of bladder; -At risk for developing pressure ulcers; -Requires extensive assistance from staff with dressing and limited assist with bed mobility, bathing, toilet use and personal hygiene; -Diagnoses included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), HTN, coronary artery disease, PVD, diabetes and depression. Review of the resident's care plan, in use during the survey, showed: Category: Incontinence of bowel and or bladder related to impaired mobility and neuromuscular (nerves and muscle are affected) dysfunction; Goal: Will be free/dry of odors and attain highest level of continence; Approach: The resident is an assist of one person; The resident is to use a bedpan and bedside commode for all toileting for safety; The resident is able to communicate and ask for assistance when needing to use the restroom; Cleanse the resident's peri-area (genital area) after each incontinent episode; Apply protective barrier ointment and cream as ordered; Offer fluids frequently to prevent urinary tract infections (UTI). Observation and interview on 2/15/22 at 12:04 P.M. showed the resident had an intravenous (IV) port to the left side of his/her chest and an ostomy to his/her abdomen. The resident said he/she has had the ostomy since 2005 and cares for it him/herself and will request the facility to order his/her ostomy supplies. The IV port that the resident has is used to give him/her monthly magnesium IV infusions. Further review of the resident's care plan, showed it did not address the resident's ostomy or IV port. 3. Review of Resident #4's significant change MDS, dated [DATE], showed the following: -An admission date of 5/13/21; -Receiving hospice care; -Always incontinent of bowel and bladder; -At risk for developing pressure ulcers; -Requires total dependence on staff for bed mobility, transfers and toilet use; -Requires extensive assist for dressing and personal hygiene; -Diagnoses include anemia, HTN, PVD, diabetes, dementia and anxiety. Review of the resident's physician's orders sheet (POS) showed an order, dated 11/2/21, for hospice to evaluate and treat. Review of the resident's care plan, in use at the time of survey, showed it did not address that the resident was on hospice. 4. Review of Resident #35's quarterly MDS, dated [DATE], showed the following; -admission date 5/20/21; -Rarely or never understood; -Receiving oxygen therapy; -Always incontinent of bowel and bladder; -At risk for developing pressure wounds; -Diagnoses included anemia, heart failure, diabetes, seizures, pneumonia, dementia and respiratory failure; -Total dependence on staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the resident's POS, showed an order, dated 5/22/21, for oxygen 3-4 liters per nasal cannula (device that administers oxygen) during evening and night hours. Observations of the resident on 2/15/22 at 12:17 P.M. and 2/16/22 at 12:59 P.M. showed the resident lying in bed on his/her back. The resident had an oxygen nasal cannula on and oxygen concentrator set at 3 liters. Review of the resident's care plan, in use at the time of survey, showed it did not address oxygen therapy. 5. Review of Resident #95's quarterly MDS, dated [DATE], showed: -No documented Brief Interview of Mental Status (BIMS) score; -Diagnoses included hyperlipidemia (elevated lipid level), Huntington's disease (progressive breakdown of nerve cells in the brain), depression; -Does the resident have a condition or chronic disease that may result in a life expectancy of less than six months: Yes. Review of the resident's electronic (e)POS, dated 2/1/22 through 2/28/22, showed an order, dated 2/1/22 to admit resident to hospice. Review of the resident's progress notes dated 10/1/21 through 2/28/22, showed on-going documentation of the resident receiving visits from the Chaplain and hospice nurse. Review of the resident's care plan, in use at the time of survey, showed no updated documentation to reflect the resident's current needs regarding hospice. There was no documentation of diagnoses for the resident's hospice admission. 6. During an interview on 2/25/22 at 10:32 AM., MDS coordinator LL said he/she is responsible for updating the care plan. He/she finds out about changes in the residents during the daily morning meeting. The Director of Nursing (DON), MDS coordinator and clinical nurses attend the meetings. He/she expected oxygen, ostomy, IV ports, briefs the family provides, hospice, transfer status, immobilizers, and cardiac pacemakers to be on the care plan. It is important for the care plan to be updated because it drives the resident care and it is individualized for that resident. 7. During an interview on 2/25/22 at 2:00 P.M., the administrator said the facility has a clinical meeting Monday through Friday. The DON, wound care nurse, activities, social services, dietary and the nurses attend this meeting. Anyone on the nursing staff can update the care plan but usually it is the MDS coordinator who has been updating the care plans. Changes should be made on the care plan in 24-72 hours. Care plans should be updated and a reflection of the care the resident needs. 8. During an interview on 2/28/22 at 9:10 A.M., the DON said anyone can add to the care plan or start it. The MDS nurse is made aware of changes in the residents during their daily clinical meetings. Any nurse can change a care plan. The DON expected the care plan to be updated within 24-72 hours after a fall or a resident begins hospice. The care plan should address ostomies, oxygen and IV ports. The DON expected the care plan to be a reflection of the care the resident needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when staff did not follow physician orders. Staff failed to ensure an arm immobilizer (used to restrict movement in and around the shoulder by reducing abduction -moving arm away from the body and arm rotation) was applied, report out of range blood sugar parameters, document weekly skin assessments, and ensure ordered weekly weights and fluid restrictions were followed. In addition, the facility failed to complete neurological assessments in accordance with their policy after a fall These affected 10 out of 29 sampled residents (Residents #16, #63, #58, #35, #84, #4 #133,#153, #70 and #357). The census was 188 with 143 in certified beds. Review of the facility's Following Physician Orders policy, dated 6/29/21, showed: -Purpose: it is the policy of the community to ensure that all licensed professional nurses and other health care professionals, follow physician orders in accordance to state, federal regulations and to their respective practice acts; -Procedure: -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record; -If an order is questionable according to the rights of medication administration, a clarification order will be obtained; -All physician or other health care professional's verbal, telephone or written orders will be immediately entered in the electronic health record (EHR) by the nurse obtaining the order. 1. Review of Resident #16's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/21, showed: -admitted : 3/23/21; -Brief interview for mental status (a brief screener of cognition) coded 99, which indicated unable to complete; -Required extensive assistance of one staff for bed mobility, dressing, personal hygiene and bathing; -Required extensive assistance of two staff for transfers, walking in the room and toilet use; -Required total assistance of one staff for locomotion; -Functional limitation in range of motion (ROM) in one upper extremity (arm); -Mobility devices: walker and wheelchair; -Diagnoses included arthritis, dementia and fracture. Review of the resident's care plan, showed: -Problem: Start Date: 3/24/2021, the resident has a deficit in activities of daily living (ADL, the ability to complete self-care tasks) functioning and impaired mobility related to generalized weakness, arthritis and dementia with not always remembering how to care for him/herself, left elbow fracture; -Goal: The resident will participate in ADL activities promoting maximum independence; -Interventions: transfers status: assist two staff, weight bearing status: non-weight bearing to left upper extremity (LUE), LUE immobilizer. Review of the resident's electronic physician order sheet (ePOS), dated 2/14/22, showed: -Start date 11/9/21, transfer status: assist times two, non-weight bearing LUE with immobilizer; -Start date 11/15/21, for non-weight bearing LUE; -Start date 11/15/21, take splint off once a day for personal hygiene as needed. Observation on 2/14/22 at 2:00 P.M., showed the resident lay in his/her bed, with no arm immobilizer noted on the resident's LUE. Observation on 2/15/22 at 9:50 A.M., showed the resident sat on the edge of his/her bed. The resident said he/she needed to go to the bathroom. A staff person entered the resident's room, put a gait belt around the resident's waist and assisted the resident to stand up, turn and sit in the wheelchair. The staff person removed the gait belt, propelled the resident's wheelchair into the bathroom and then assisted the resident to stand up then turn to sit down. After the resident finished in the bathroom, the staff person propelled the resident down the hall to the common room to watch TV. No arm immobilizer/splint was on the resident's LUE. Observation on 2/16/22 at 7:53 A.M., showed the resident sat on the side of his/her bed. The resident's wheelchair sat locked in front of the resident. No immobilizer was observed on the resident's LUE. At 1:25 P.M., the resident sat in his/her room in the wheelchair. No immobilizer was observed on the resident's LUE. Further review of the resident's ePOS, showed on 2/17/22, the transfer status changed to assist times one, non-weight bearing to the LUE. The order for the immobilizer to the LUE was not noted on the new order. Review of the resident's progress notes, dated 2/14/22 through 2/17/22, showed no documentation the resident refused to wear his/her immobilizer. During an interview on 2/25/22 at 11:00 AM, Nurse Assistant (NA) Z said the resident used to have a cast, then he/she had a sling, but it has been off the resident for about a month. During an interview on 2/28/22 at 9:10 A.M., the Director of Nursing (DON) said staff would know how a resident is transferred or if a resident required assistive devices, through shift report, the medical record or the care plan. The resident would refuse to wear his/her immobilizer a lot. If a resident refused to wear their immobilizer, it should be documented in the progress notes. The DON expected for staff to follow the physicians orders and document if the resident refused to wear his/her immobilizer. 2. Review of Resident #63's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -No behaviors or rejection of care; -Required extensive staff assistance for bed mobility, dressing and personal hygiene; -Required total staff assistance with transfers, locomotion and toileting; -Diagnoses of diabetes, stroke and one sided paralysis; -Received insulin injections 7 days a week. Review of the care plan, dated 9/15/21, showed it did not address the resident's diabetes or need for insulin injections. Review of the resident's December 2021, diabetes administration history, showed: -An order dated 3/1/21, for Novolog (short acting insulin) flex pen (pre-filled insulin pen), administer per sliding scale (the dose based on the blood sugar level). Scheduled daily from 7:15 A.M. to 11:15 A.M. and 3:15 P.M. to 6:45 P.M.: -If blood sugar is 70-180 milligrams (mg)/deciliter (dL), give 0 units; -If blood sugar is 181-220 mg/dL, give 2 units; -If blood sugar is 221-260 mg/dL, give 3 units; -If blood sugar is 261-300 mg/dL, give 4 units; -If blood sugar is 301-350 mg/dL, give 5 units; -If blood sugar is greater than 350 mg/dL, give 6 units and call the medical doctor; -On 12/20/21 at 7:15 A.M. to 11:15 A.M., staff documented a blood sugar result of 376 mg/dL. Staff administered the resident 6 units of insulin. No documentation regarding physician notification. Review of the resident's December 2021 progress notes, showed no physician notification regarding the blood sugar result on 12/20/21. Review of the resident's January 2022 diabetes administration history, showed: -An order dated 3/1/21, for Novolog flex pen, administer per sliding scale. Scheduled daily from 7:15 A.M. to 11:15 A.M., and 3:15 P.M. to 6:45 P.M.; -On 1/17/22 at 7:15 A.M. to 11:15 A.M., showed a blood sugar result of 389 mg/dL. Staff administered the resident 6 units of insulin. No documentation regarding physician notification; -On 1/21/22 at 7:15 A.M. to 11:15 A.M., showed a blood sugar result of 351 mg/dL. Staff administered the resident 6 units of insulin. No documentation regarding physician notification; -On 1/26/22 at 7:15 A.M. to 11:15 A.M., showed a blood sugar result of 357 mg/dL. Staff administered the resident 6 units of insulin. No documentation regarding physician notification. Review of the resident's January 2022 progress notes, showed no physician notification regarding the blood sugar result on January 17, 21 and 26, 2022. During an interview on 2/21/22 at 1:15 P.M., the DON said physician orders should be followed. If a blood sugar result is out of order parameters, the nurse should contact the physician and document any new orders from the physician. 3. Review of the facility's weight monitoring policy, dated as revised 5/21, showed: -Purpose: To obtain accurate weights of each resident and maintain control of weight changes; -Note: Residents are weighed on admission, weekly for the first four weeks and monthly thereafter, unless otherwise ordered by nursing order or attending physician. Review of the facility's skin monitoring program, dated as reviewed 5/21, showed: -Purpose: To identify residents who are at risk for skin breakdown and to initiate immediate treatment when skin breakdown occurs; -Procedure: The weekly wound rounds are completed by the DON or his/her designee. Review of Resident #58's quarterly MDS, dated [DATE], showed the following: -admission date 9/14/20; -Cognitively intact; -Always incontinent of bowel and bladder; -High risk for developing pressure ulcers (injury to the skin caused by unrelieved pressure or friction); -Required extensive assist from staff with bed mobility, toilet use and dressing; -Diagnosis included heart disease, heart failure, high blood pressure, vascular disease, respiratory failure, diabetes, depression and anxiety. Review of the resident's care plan, showed the following: -Category: Cardiovascular: The resident has an active diagnosis of heart failure requiring post-acute care education: -Goal: The resident will verbalize understanding/return demonstration of heart failure post-acute care education; -Approach: Call the physician if any of the following occurs: Increased weight gain 2-3 pounds a day, chest pain, feeling dizzy, shortness of breath, new or worsening cough; -Category: Pressure Ulcer: The resident is at risk for developing alterations in skin integrity and pressure injury. The resident has a history of pressure injury: -Goal: Maintain/improve skin integrity related to risk factors and healing potential; -Approach: Communicate skin concerns with showers. Review of the resident's ePOS, showed an order dated 4/30/21, for weekly skin assessments every Friday on day shift. Review of the treatment administration record (TAR), dated December 2021, January 2022 and February 2022, showed weekly skin assessments initialed as completed. Review of the resident's skin assessment forms, showed: -A skin assessment, dated 12/10/21, scars and bruises; -A skin assessment, dated 12/24/21, reddened areas to groin barrier cream noted; -A skin assessment, dated 1/14/22, reddened areas face and bilateral (both) lower extremities; -A skin assessment, dated 2/4/22, reddened areas to bilateral groin, genitals and left hip area; -A skin assessment, dated 2/18/22, full body assessment completed, no abnormalities noted; -A skin assessment, dated 2/24/22, rash on one side almost healed, treatment in place; -No skin assessment completed on 12/3, 12/17 and 12/31/21; -No skin assessment completed on 1/7, 1/21 and 1/28/22; -No skin assessment completed on 2/11/22. Observation on 2/14/22 at 1:50 P.M., and 2/16/22 8:15 A.M., showed staff assisted the resident to change his/her brief. Multiple red raised areas noted to the resident's left flank, abdomen and hip. On 2/16/22 at 8:15 A.M., the resident said the rash had been there for a couple of months. Further review of the resident's ePOS, showed an order dated 3/8/21, for daily weights. Review of the resident's weights, showed: -For December 2021, the resident's weight not documented as obtained 15 out of 31 opportunities; -For January 2022, the resident's weight not documented as obtained 23 out of 31 opportunities; -For February 2022, the resident's weight not documented as obtained 14 out of 22 opportunities. During an interview on 2/14/22 at 2:30 P.M., the resident said he/she is not weighed daily and felt it is important for staff to complete this because he/she has heart failure and a pacemaker. Further review of the resident's ePOS, dated February 2022, showed an order dated 2/14/22, for fluid restriction 2000 milliliter (ml), 3 purple facility cups per day, 650 ml per shift or one facility cup per shift. During an interview on 2/15/22 at 12:05 P.M., Certified Nursing Assistant (CNA) E said the aides are responsible for obtaining weights and a list of who needs to be weighted is located on the daily sheets. The completed weights are placed in the computer under vital signs. Residents that are on fluid restrictions have an identifier on the door with a water glass symbol, indicating that resident is on a fluid restriction. The dietary department also has the fluid restrictions listed on the daily diet sheets. Observations and interview on 2/15/22 at 2:00 P.M. and 2/16/22 at 8:15 A.M. and 1:20 P.M., showed the resident in his/her room with multiple cups of different sizes that contained orange liquid and water. There was no fluid restriction identifier on the resident's door. The resident said staff said he/she was on a fluid restriction, but he/she was not sure how staff was keeping track of what he/she took in. He/she is unable to get fluids him/herself and is dependent for staff to provide his/her fluids. During an interview on 2/18/22 at 8:00 A.M., Dietary Aide X said he/she was not aware the resident was on a fluid restriction. He/she reviewed the diet sheet, dated 2/18/22, and said a fluid restriction was not noted next to the resident's name. The dietary sheets are printed every day in case there are any changes. Review of the dietary sheet, dated 2/22/22, showed the resident not listed as to having a fluid restriction. Observation on 3/1/22 at 9:05 A.M., showed no fluid restriction symbol posted outside the resident's door. 4. Review of Resident #35's quarterly MDS, dated [DATE], showed the following: -admission date 5/20/21; -Rarely or never understood; -Always incontinent of bowel and bladder; -At risk for developing pressure wounds; -Diagnosis included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), heart failure, diabetes, seizures, pneumonia, dementia and respiratory failure; -Total dependence on staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the resident's care plan, showed: -Pressure Ulcer: At risk for developing alterations in skin integrity/pressure injuries; -Goal: Maintain/improve skin integrity related to risk factors and healing potential; -Approach: Complete bath/skin reports on shower days. Communicate to the charge nurse concerns noted on the skin. Review of the resident's ePOS, showed an order dated 5/22/21, to complete weekly skin assessment observations on Saturdays, day shift. Review of the resident's TARs dated, December 2021, January 2022 and February 2022, showed the weekly skin assessments initialed as completed. Review of the resident's weekly skin assessment forms, showed: -No skin assessments for December 2021; -An assessment, dated 1/8/22, reddened areas noted to bottom; -An assessment, dated 2/19/22, reddened areas to bottom and perineal area (genital area); -No further skin assessments documented in January or February 2022. Further review the resident's ePOS, showed an order, dated 5/22/21, and a discontinue date of 2/17/22, for daily weights. Review of the resident's weights, showed: -For December 2021, the resident's weight not documented as obtained 27 out of 31 opportunities -For January 2022, the resident's weight not documented as obtained 28 out of 31 opportunities; -For February 2022, the resident's weights not documented as obtained 9 out of 17 opportunities. 5. Review of Resident's #84 quarterly MDS, dated [DATE], showed the following: -admission date 7/1/21; -Cognitively intact; -At risk for developing pressure ulcers; -Required extensive assist from staff with dressing and limited assist with bed mobility, bathing, toilet use and personal hygiene; -Diagnosis included anemia, high blood pressure, heart disease, vascular disease, diabetes and depression. Review of the resident's care plan, showed the following: -Category: Pressure Ulcer: The resident is at increased risk for skin breakdown. The resident was admitted to the facility with a pressure injury but has resolved since admission; -Approach: Complete wound management assessment weekly. Review of the resident's ePOS, showed an order dated 9/21/21, to complete weekly nursing skin assessment observations on Monday evenings. Review of the resident's TAR, dated December 2021, showed the weekly skin assessment initialed as completed by staff on 12/6/21 and 12/13/21 only. Review of the resident's TAR, dated January 2022, showed the weekly skin assessments initialed as completed by staff on 1/3/22, 1/10/22 and 1/31/22 only. Review of the resident's TAR, dated February 2022, showed all weekly skin assessment initialed as completed. Review of the resident's weekly skin assessment observation forms, showed: -No skin assessments for December 2021; -An assessment, dated 1/31/22, a reddened area to the coccyx (tailbone area); -An assessment dated [DATE], a reddened area to the coccyx; -An assessment dated [DATE], a reddened area under the right breast; -An assessment dated [DATE], a reddened area under the breasts; -An assessment dated [DATE], a box checked as other; -No skin assessment completed on 1/3, 1/10, 1/17 and 1/24/22. 6. Review of Resident #4's significant change MDS, dated [DATE], showed the following: -admission date of 5/13/21; -At risk for developing pressure ulcers; -Always incontinent of bowel and bladder; -Total dependence on staff for bed mobility, transfers and toilet use; -Required extensive assist for dressing and personal hygiene; -Diagnosis included anemia, high blood pressure, vascular disease, diabetes, dementia and anxiety. Review of the resident's care plan, showed: -Category: Pressure Ulcers: The resident is at risk for developing alterations in skin integrity and pressure ulcer. The resident has a history of developing pressure injury; -Goal: Maintain/improve skin integrity related to risk factors and healing potential; -Approach: Complete bath/skin reports on shower days. Communicate to charge nurse concerns noted on the skin. Review of the resident's ePOS, dated February 2022, showed no order for weekly skin assessments. Review of the resident's TARs, dated December 2021, January 2022 and February 2022, showed no weekly skin assessments initialed as completed. Review of the resident's skin assessment observations for December 2021, January 2022 and February 2022, showed no documentation the skin observations were completed. 7. During an interview on 2/16/22 at 11:09 A.M., the wound nurse said the floor nurse should complete skin assessments on all residents on a weekly basis. Nursing staff is expected to sign off on the TAR and it is expected to complete a skin assessment observation form even if there is no skin abnormalities. The skin assessment is located under observations in the chart. 8. During an interview on 2/18/22 at 1:50 P.M., the DON said daily weights are expected to be completed as ordered and placed in the computer under vital signs. Skin assessments are to be completed by the floor nurse weekly. The nurse is to sign off on the TAR and a skin assessment observation form is expected to be completed, even if there is no skin abnormalities noted on the resident. The skin assessment forms are located under observations in the resident's electronic medical chart. If a resident is on a fluid restriction, the fluid restriction symbol that looks like a glass with blue liquid in it, should be placed on the resident's door and dietary is also notified of the fluid restriction by nursing staff and when the order is entered into the computer. All residents are to have orders for a weekly skin assessment. It is a nursing and physician order that would be placed on the POS under general orders. 9. Review of the facility's Neurological Checklist Policy, dated 7/21, showed: -Purpose: to establish a baseline neurological assessment, to recognize neurological trends and changes in the resident's condition, to provide an evaluation tool for reference when evaluating the resident's neurological status; -Procedure: Assess vital signs (VS), including blood pressure, respiratory rate and rhythm, radial pulse, temperature. Frequent monitoring is important. Changes in blood pressure and pulse are late neuro signs of increased intracranial pressure. Report changes in vital signs to physician immediately; -Assess resident's level of consciousness: -Alert, oriented to time, place, and person. Responds immediately and recall remote and recent events; - Drowsy, oriented to person and disoriented to time and place. Usually lethargic, alternates between being cooperative and uncooperative. Easily aroused, but falls back to sleep; -Assess resident's verbal response; -Notify the physician of any changes. Dangerous trends needing to be reported to physicians immediately are: pupillary reaction changes, especially with decrease in level of consciousness, any decrease in level of consciousness from a baseline assessment or from resident's normalcy, any motor decline, any marked changes in vital signs, nausea and vomiting, seizure activity, visual field disturbances, headache; -Complete neurological assessment DGE047A for potential head injuries and DGE047 B for falls without obvious head involvement at the frequency identified on the form. Review of Resident #133's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/23/22, showed -Severe cognitive impairment; -Diagnoses include hyperlipidemia (high cholesterol), osteoporosis, dementia, anxiety and asthma. -Required extensive assistance from staff with dressing and toileting; -One fall without injury and one fall with an injury since last assessment. Review of the resident's care plan, dated 10/21/20, showed: -Problem: At risk for falls related to chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe), degenerative arthritis in his/her spine and mobility status; -Goal: Decrease the risk of falls and/or injury should a fall occur; -Approach: Related to fall on 12/7/21: continue administer antibiotics (ABT) related to urinary tract infection (UTI). MD to start prophylactic interventions after current ABT course; -Assess need for additional safety devices; -Assess the ability to use call light and keep within reach; -Ensure environment is clean, clutter free and has adequate lighting; -Maintain consistent staff who can attempt to anticipate his/her needs, provide routine and develop a relationship of trust; -Resides in a room with carpeted flooring; -Review medications as needed; -Transfer status: Up ad lib (as desired) at this time. Review of the resident's progress notes, dated 1/15/22 at 8:10 P.M., showed the resident entered another resident's room, and trying to remove something from the refrigerator and that resident hold him/her to get outside of the room. He/she did not listen and that resident became violent and pushed and kicked him/her. Resident was taken outside and comforted him/her, and assess him/her body. Small bluish discoloration noticed under right eye lid. Informed physician and sister. Review of the facility's investigation summary, dated 1/18/22, showed on 1/15/22 at approximately 8:00 P.M., yelling was noted by staff coming from Resident #95's room. Upon entry, staff noted that Resident #133 attempted to retrieve something from Resident #95's refrigerator. Before staff could intervene, Resident #95 began to swing and kick at Resident #133, making contact with Resident #133's face. The two were separated and assessed by staff. Resident #133 had bruising under his/her right eye. Resident #95 was without injury. The family members and physician of both residents were notified of the incident and Resident #95 was given his/her as needed (PRN) Ativan (medication used to treat anxiety) because he/she was unable to be consoled by staff and continued to be anxious and agitated. Neither resident was able to express what exactly had happened or initiated the event. Medication review was performed by nursing and the physician and no areas of concern were noted. Further review of the resident's progress notes, showed: -On 1/16/22 at 1:22 P.M., resident slept until around 10:30 today. Resident is up and cooperative. Resident ate a fair amount at lunch, which is better than his/her intake has been in recent days. Resident given health shake and water. Resident does answer questions, but generally the answers do not correlate with the question being asked. Resident is happy this morning and ask for multiple hugs. Resident allows certified nurse aides (CNAs) to do activities of daily living (ADLs) without complications. Resident has a blackened area under right eye. The area is deep purple. Resident states no when this nurse asked if it hurt. Other areas of skin intact; -On 1/17/22 at 1:43 A.M., resident resting in bed, no visual signs of pain or discomfort noted. Darkened area noted underneath right eye, healing within normal limits. No signs of agitation at this time. Bed in lowest, safest position and all personal belongings are within reach; -On 1/19/22 at 11:32 A.M., Resident has a bruise (purple in color) on right eye and two bruises on left knee (one medial knee and one on anterior knee, dark purple in color). No complaints of pain, no signs or symptoms of distress, resident pacing until after he/she got shower. Resident sitting in recliner watching TV Family is here visiting. Further review of the facility's investigation and the medical record, showed no documentation of neuro checks or ongoing assessment. During an interview on 2/28/22 at 4:00 P.M., the Director of Nursing (DON) said he expected staff to start neuro checks when a resident sustained an injury to the face after being kicked by another resident. 10. Review of Resident #153's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors or refusal of care; -Independent with bed mobility and eating; -Required limited staff assistance with transfers, locomotion, dressing and toileting; -Uses a walker and wheelchair for mobility; -Diagnoses included diabetes, seizure, anxiety, depression, bipolar disease (a mental disorder involving irregular emotional and behavior highs and lows); -Any falls since prior assessment: yes; -Number of falls since prior assessment, with no injury or no evidence of any injury is noted on physical assessment by nurse or primary clinician, no complaint of pain or injury by the resident: 2. Review of the progress notes, showed: -On 2/9/22 at 1:21 P.M., the resident resting comfortably in bed during shift. No complaints of concerns noted. Incident follow up (IFU) for fall with neurological checks within normal limits and range of motion (ROM) x 4. No complaints of pain or discomfort noted; -On 2/9/22 at 1:49 P.M., remained on close monitoring for sliding out of the wheelchair onto the floor. No acute changes noted in condition. He/she able to make needs known. Complained of pain to the buttock one time during shift. Pain pill administered per order. Range of motion (ROM) within normal limits. No noted bruising or injury. Assessment completed will continue to monitor; -On 2/9/22 at 10:35 A.M., the resident on IFU for fall, vitals and neurological checks within normal limits, he/she in bed with call light in reach. Will continue to monitor. Review of the neurological assessment for falls without head involvement, showed: -Neurochecks for falls without head involvement are to be completed every shift for 72 hours; -Date: Day 1: 2/8/22; -7:00 A.M., to 3:00 P.M.,shift: -Alert: Y; -Lethargic: N -Non-responsive: N; -Orientation to person, time and place: Y; -Slurred speech: N; -Aphasic (difficulty speaking): N; -Change in communication: N; -Left and right pupil size/reactions: 2+; -Unusual verbalizations: No; -Facial symmetry: within normal limits (WNL); -Arm movement: 3 out of 3; -Leg movement: 3 out of 3; -Vital signs: blood pressure 137/75, pulse: 108, temperature: 98.2, pulse oxygenation (pulse ox): 97%, respiration: 17, respirations rhythm: even; -Unusual observations: none; -3:00 P.M., to 11:00 P.M., shift: all areas blank; -11:00 P.M., to 7:00 A.M., shift: -Alert: Y; -Lethargic: N -Non-responsive: N; -Orientation to person, time and place: Y; -Slurred speech: N; -Aphasic: N; -Change in communication: N; -Left and right pupil size/reactions: 2+; -Unusual verbalizations: No; -Facial symmetry: WNL; -Arm movement: 3 out of 3; -Leg movement: 3 out of 3;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to fully implement the facility's Restorative Therapy (RT) program and ensure residents received RT as ordered for 11 residents (Resident #63, #132, #142, #42, #65, #95, #58, #35, #357, #16 and #70). The sample was 29. The census was 188 with 143 in certified beds. Review of the facility's Restorative Therapy (RT) Program Policy, dated revised 5/21, showed, purpose: It is the policy of the facility to assist each resident to attain and/or maintain their individual highest most practicable functional level of independence and well-being, in accordance to State and Federal regulation; -Procedure: Each resident will be screened and/or evaluated by the nurse or therapist designated to oversee the restorative nursing process for inclusion into appropriate facility restorative program(s) when it has been identified by the Interdisplinary Team (IDT) that the resident is in need or may benefit from such program(s); -The facility restorative nursing program will include, but not limited to the following programs: -Hygiene-bathing, dressing, grooming and oral care; -Mobility- transfer and ambulation, including walking, prosthetic and/or splint applications with or without active (A) and/or passive (P) range of motion (ROM), and bed mobility; -Dining-eating including meals and snacks; -Communication, including speech, language and other functional communication systems; -The above programs will be documented on the facility designated restorative care forms/tools in the residents electronic Medical Record (EMR); -The designated nurse will evaluate the restorative documentation monthly to determine if there are any changes needed to the existing program and make a monthly progress note, in the resident's EMR related to the evaluation. 1. Review of Resident #63's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, dated 12/14/21, showed: -Moderate cognitive impairment; -No behaviors and does not reject care; -Total staff assistance needed for transfers, locomotion and toileting; -Functional limitation ROM: lower extremity one side; -Diagnoses: diabetes, stroke and paralysis; -Number of days the following RT programs were performed for at least 15 minutes a day in the last 7 days: -ROM passive: 2; -ROM active: 0. Review of the residents current physician order sheet (POS), showed: -An order dated 4/1/21 for RT to upper and lower extremities. Exercise 1 to 2 times per week as tolerated. Review of the care plan, revised 12/15/21, showed: -Problem: Mobility: Resident has a deficit in mobility related to: altered mobility and gait due to RLE amputation. Current weight bearing status is: full weight bearing (FWB); -Goal: the resident will reach highest level of mobility; -Approach: staff assess current level of function and document, do ROM to reduce potential ROM loss unless contraindicated. Physical Therapy (PT) and/or Occupational Therapy (OT) Evaluation. Restorative therapy for upper extremity (UE)/Lower Extremity (LE) exercise as tolerated. Safety measures as needed to maintain weight bearing status as ordered. Encourage daily care participation to maximize independence. Provide setup/cueing/assistance as needed. OT and/or PT Evaluation. Provide assistance with Activities of Daily Living (ADL's) as indicated: (dependent) and document as required. Review of the RT plan of care, dated 3/11/21, showed: -Description: RT for UE and LE exercises as tolerated; -Goal: RT to maintain current level of function; -Choose all that apply: UE and LE Active ROM (AROM), UE and LE Passive ROM (PROM); -Describe plan of care: UE exercise with 1 pound weight all planes x 10 repetitions, LE exercise passive and active ROM in sitting or supine x 10-15 repetitions as tolerated; -Initiate plan of care. Review of the monthly RT record, dated December 2021, showed: -Number of treatments per week: 2; -Received therapy on 12/1/21, 12/8/21 and 12/10/21; -Notes/comments: blank; -Reviewed by nursing administration: blank. Review of the monthly RT record, dated January 2022, showed: -Number of treatments per week: 2; -Received therapy on 1/5/22, 1/19/22, 1/20/22, 1/27/22 and 1/28/22; -Notes/comments: blank; -Reviewed by nursing administration: blank. Review of the monthly RT record, dated February 2022, showed: -Number of treatments per week: 2; -Received therapy on 2/1/22, 2/8/22, 2/10/22, 2/16/22, 2/17/22 and 2/23/22; -Notes/comments: blank; -Reviewed by nursing administration: blank. Review of the RT plan of care, dated 3/11/21, showed: -Description: RT for UE (upper extremities) and LE (lower extremities) exercises as tolerated; -Goal: RT to maintain current level of function; -Choose all that apply: UE and LE Active ROM (AROM), UE and LE Passive ROM (PROM); -Describe plan of care: UE exercise with 1 pound weight all planes x 10 repetitions, LE exercise passive and active ROM in sitting or supine x 10-15 repetitions as tolerated; -Initiate plan of care. 2. Review of Resident #132's RT plan of care, dated 10/27/21, showed: -Description: RT as tolerated for exercise as tolerated. Standing attempts as tolerated and moist hot pack, bio freeze (topical medication used to treat pain) to both shoulders, the neck and the right hand as needed for pain; -Goal: the resident will participate in RT as tolerated in order to maintain current functional level; -Choose all that apply: UE and LE AROM and PROM, therapeutic exercise to the UE and LE, moist hot pack and standing attempts as tolerated. Moist hot pack, bio-freeze for 15 minutes to both shoulders, neck and right hand as needed for pain; -Describe RT plan of care: precautions: Hoyer (full weight bearing lift) lift assist x 2 staff for all transfers, FWB- due to right sided paralysis. UE: exercise in all planes for 15 repetitions for 1-2 sets, PROM RUE all planes for 15 repetitions for 1-2 sets, LE: LLE AROM for 25 repetitions all planes, RLE AROM 25 repetitions all planes. Gentle prolonged stretching of the right knee extension and right ankle dorsiflexion for 3 repetitions each. Standing attempts at a wall bar with dependent assistance of two; -Plan of care: continue plan of care; -Describe plan of care changes: also moist hot pack, bio-freeze to both shoulders, neck and the right hand for 15 minutes as needed for pain. All exercise and standing attempts are as tolerated. Review of the current POS, showed the following: -An order dated 4/1/21 for RT as tolerated. Standing attempts as tolerated and moist hot pack/Biofreeze (for pain relief) to both shoulders, neck and right hand as needed for pain for 1 to 2 times per week as tolerated. Review of the December 2021 monthly RT record, showed: -Number of treatments per week: 2; -Received therapy on 12/1/21, 12/8/21, 12/16/21, 12/20/21 and 12/29/21; -Notes/comments: blank; -Reviewed by nursing administration: signed 1/7/22. Review of the quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors and does not resist care; -Extensive staff assistance needed with bed mobility, dressing and toileting; -Total staff assistance needed with transfers, locomotion and bathing; -Functional limitation to ROM: to upper and lower one side extremities; -Diagnoses: heart disease, heart failure, kidney disease, stroke and paralysis; -Not documented in any RT programs or as having received RT. Review of the January 2022 monthly RT record, showed: -Number of treatments per week: 2; -Received therapy on 1/5/22, 1/19/22, 1/27/22 noted as refused and 1/28/22; -Notes/comments: On 1/27/22 the resident was tired and wanted to keep sleeping; -Reviewed by nursing administration: signed 2/1/22. Review of the February 2022 monthly RT record, showed: -Number of treatments per week: 2; -Received therapy on 2/8/22, 2/10/22, 2/15/22, 2/16/22 noted as refused and 2/23/22; -Notes/comments: blank; -Reviewed by nursing administration: unsigned as of 2/24/22. During an interview on 2/16/22 at 10:29 A.M., the resident sat up in his/her wheelchair in his/her room. His/her right noted as contracted. The resident said he/she is supposed to have RT several times a week. He/she had not been receiving therapy much and the RT aides had told him/her that RT was hard to do because the RT aides had been pulled to work the floor several times. The resident added that he/she missed having the individual RT services, and he/she felt better after getting the RT. Review of the care plan, revised 2/18/22, showed: -Problem: the resident requires assistance with his/her activities of daily living (ADL) tasks related to history of a stroke with right sided paralysis and history of falls. Staff continue to encourage and educate him/her to allow staff assistance; -Goal: staff encourage the resident to allow staff assistance and to participate in his/her ADL's to the best of his/her abilities; -Approach: Encourage the RT to attend and participate in Restorative Therapy, as tolerated, to maintain current level of function. 3. Review of Resident #142's RT plan of care, updated 1/28/21, showed: -Description: RT as tolerated for exercises; -Goals: the resident will participate in RT in order to maintain current functional level; -Treatment plan: UE and LE AROM, LE PROM, Therapeutic exercise to the UE, other: stand with sit stander with assist of two staff; -Describe RT plan of care: -Precautions: Hoyer lift assist of 2 staff, weight bearing as tolerated with surgical shoes, otherwise float boots at all times. Bilateral UE seated exercises or supine (laying on back) with one pound cane exercises for 20 times; -Stretch all fingers into extension for 10 for two repetitions; -Bilateral LE exercises seated or supine for all planes 20 repetitions, AROM for ankle pumps; -Standing in sit stander assist of two staff with surgical shoes on as tolerated (cannot use counter weight. Use to block knees); -As tolerated; -Plan of care: plan of care updated; -Plan of care changes if necessary: Updated on 1/28/21 to include stretching to all fingers for contracture management. Review of the December 2021 monthly RT record, showed: -Number of treatments per week: 3; -Received therapy on 12/1/21, 12/6/21, and 12/8/21: resident Leave of Absence (LOA), 12/14/21: documented as R or refused, 12/20/21 and 12/22/21; -Notes/comments: Documented on 12/14/21 the resident had visitors and refused to participate; -Reviewed by nursing administration: signed 1/7/22. Review of the monthly RT record, dated January 2022, showed: -Number of treatments per week: 3; -No RT documented as offered or provided from 1/1/22 through 1/31/22. Review of the monthly RT record, dated February 2022, showed: -Number of treatments per week: 3: -No RT documented as offered or provided from 2/1/22 through 2/14/22; -A hand written note on 2/15/22, showed discontinued (D/C) to skilled therapy. Review of the quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors, does not resist care; -Extensive staff assistance needed for bed mobility, dressing and toileting; -Total staff assistance needed for transfers and locomotion; -Diagnoses: vascular disease, kidney disease and diabetes; --Number of days the following RT programs were performed for at least 15 minutes a day in the last 7 days: -ROM passive: 0; -ROM active: 2. Review of the care plan, revised 2/2/22, showed: -Problem: ADL functional/rehabilitation potential: the resident has a deficit in ADL function related to generalized weakness; -Goal: the resident will participate in ADL activities promoting maximum independence; -Approach: staff encourage ADL participation to maximize independence. Provide set-up, cueing and assistance as needed. Therapy evaluation and the resident to participate in RT program for exercise and standing as tolerated. Staff provide assistance with ADL's as indicated, the resident needs limited to extensive assistance. The resident is a total lift with a Hoyer. During an interview on 2/15/22 at 9:44 A.M., the resident said he/she had not received RT on a regular basis over the last several months. The last time he/she received RT the RT aide (RTA) apologized and told him/her that the RT had not been provided much was because the RTA had been scheduled to work the floor as an aide and could not administer RT to any facility residents. The resident added that he/she enjoyed RT and felt it helped with hand movement and strength. It bothered him/her when he/she did not receive RT services. Review of the resident's current POS, showed: -An order dated 2/15/22 for skilled therapy. 4. Review of Resident #42 quarterly MDS, dated [DATE], showed the following: -admission date 4/26/21; -Severe cognitive impairment; -At risk of developing pressure ulcers; -Requires extensive assist from staff with toilet use and dressing; -Diagnosis included high blood pressure, renal failure, hyperlipidemia (too many fats in the blood), Alzheimer's disease, anxiety, and asthma. Review of the resident's care plan, revised 2/18/22, showed the following: Category: ADL functional and rehabilitation potential. The resident has a deficit in ADL functioning related to generalized weakness. Current weight bearing status is: WBAT; Goal: The resident will reach highest level of mobility; Approach: PT and/or OT evaluation. Restorative therapy for ambulation and exercises as tolerated. Review of the resident's physician order sheet (POS), dated 2/1/22 through 2/28/22, showed: -An order, dated 6/17/21, RT 1 to 2 times a week to include ambulation and exercises as tolerated. Review of the resident's Monthly RT Record, dated December 2021, showed: -The resident received one total treatment; -The resident refused three times; -On 12/22/21 through 12/28/21, the resident was not offered RT. Review of the resident's Monthly RT Record, dated January 2022, showed: -The resident received two total treatments; -The resident refused one time; -On 1/1/22 through 1/7/22, the resident was not offered RT. 5. Review of Resident #65's quarterly MDS, dated [DATE], showed: -admission date 3/1/19; -Severe cognitive impairment; -At risk of developing pressure ulcers; -Requires extensive assist from staff with transfers, toilet use, hygiene, and dressing; -Diagnosis included high blood pressure, inflammatory bowel disease, dementia, anxiety, and depression. Review of the resident's care plan, revised 5/18/21, showed the following: Category: ADL functional and rehabilitation potential. Requires assist with ADLs related to increasing weakness and with not always remembering to request assistance; Goal: Participate in restorative therapy and ADL care to fullest ability. Maintain highest level of independence and functioning; Approach: Encourage to participate in ADL care to increase strength, endurance, gait stability, balance control, and independence in mobility. Resident participates in walking club and RT as tolerated for exercises and ambulation to maintain current level of function. Review of the resident's POS, dated 2/1/22 through 2/28/22, showed: -An order, dated 2/3/22, RT for exercise and ambulation, 1-2 times a week as tolerated. Review of the resident's Monthly RT Record, dated January 2021, showed the resident did not have RT. 6. Review of Resident #95 quarterly MDS, dated [DATE], showed the following: -admission date 2/14/19; -Severe cognitive impairment; -At risk of developing pressure ulcers; -Requires limited assist from staff with toilet use and dressing; -Diagnosis included hyperlipidemia, Huntington's disease, and depression. Review of the resident's POS, dated 2/1/22 through 2/28/22, showed: -An order, dated 4/1/21, RT for exercise and ambulation, 1-2 times per week or as tolerated. Review of the resident's care plan, revised 2/18/22, showed the following: Category: ADL functional and rehabilitation potential. Requires assist with ADLs related to recent physical decline and diagnosis of Huntington's disease; Goal: Participate in therapy to fullest ability; maintain highest level of independence and functioning; Approach: Encourage to participate in restorative therapy 1 to 2 times per week, as tolerated, for exercise and ambulation in order to maintain current functional level. Review of the resident's Monthly RT Record, dated December 2021, showed: -The resident did not receive treatments; -The resident refused one time; -On 12/1/21 through 12/7/21, 12/15/21 through 12/28/21, the resident was not offered RT. Review of the resident's Monthly RT Record, dated January 2022, showed: -The resident did not receive treatments; -The resident refused one time; -On 1/1/22 through 1/14/22, and 1/22/22 through 12/28/22, the resident was not offered RT. Review of the resident's Monthly RT Record, dated February 2022, showed: -The resident received two treatments; -The resident refused one time; -On 1/1/22 through 1/7/22, the resident was not offered RT. 7. Review of resident #58's quarterly MDS, dated [DATE], showed the following: -admission date 9/14/20; -Cognitively intact; -Always incontinent of bowel and bladder; -High risk for developing pressure ulcers; -Requires extensive assist from staff with bed mobility, toilet use and dressing; -Diagnosis included heart disease, congestive heart failure (CHF), hypertension, peripheral vascular disease (PVD, poor circulation), respiratory failure, diabetes, depression and anxiety. Review of the resident's care plan, in use at the time of survey, showed the following: Category: ADL functional and rehabilitation potential. The resident has a deficit in ADL functioning related to generalized weakness, decreased mobility, left arm amputation and arthritis; Goal: The resident will participated in his /her ADL activities promoting maximum independence; Approach: RT as tolerated for exercise, ROM and standing attempts. Review of the resident's POS, dated 2/22 showed: -An order, dated 5/17/21, RT for exercise and ROM up to 5 times a week or as tolerated, and for standing attempts 1 to 2 times a week or as tolerated, within those days already being seen for exercise and ROM. Review of the resident's Monthly RT Record, dated December 2021, showed, the resident received 8 total treatments. Review of the resident's Monthly RT Record, dated January 2022, showed, the resident received 5 total treatments. Review of the resident's Monthly RT Record, dated 2/1/22 through 2/21/22, showed, the resident received 7 treatments. During observation and interview of the resident on 2/26/22 at 1:20 P.M. showed he/she sat in his/her wheelchair looking at his/her I-Pad. His/her left arm was partially amputated. The resident was observed with a black Copper-Fit support brace to both of his/her knees. The resident said, he/she wears them for pain relief and joint stiffness. The resident also said, he/she has right elbow joint pain and stiffness. He/she said, he/she does not receive RT 5 times a week and believes why he/she does not receive is because the facility is short staffed. The resident said, his/her goals are to try to self -propel him/herself in his/her wheelchair and to be able to stand at bedside with assistance. The resident also added that the ROM exercises help with pain relief and his/her joint mobility. 8. Review of Resident #35's quarterly MDS, dated [DATE], showed the following; -admission date 5/20/21; -Rarely or never understood; -At risk for developing pressure wounds; -Always incontinent of bowel and bladder; -Diagnosis that include anemia, heart failure, diabetes, seizures, pneumonia, dementia and respiratory failure; -Total dependence on staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the resident's care plan, in use at the time of survey, showed the following: -Category: ADL/functional and rehabilitation potential, The resident has a deficit in ADL functioning and impaired mobility related to advanced dementia and recent motor vehicle accident with multiple traumas; -Goal: The resident will participate in ADLs to the best of his/her ability; -Approach: RT for PROM (passive range of motion) of both upper extremities and left lower extremity to maintain ROM. Review of the resident's POS, for February 2022, showed: -An order, dated 10/27/21, RT one to two times a week PROM of both upper extremities and left lower extremity. Review of the resident's Monthly RT Record, dated December 2021, showed, the resident received 7 total treatments. Review of the resident's Monthly RT Record, dated January 2022, showed, the resident received 5 total treatments. Review of the resident's Monthly RT Record, dated 2/1/22 through 2/21/22, showed the resident received 7 treatments. Observations of the resident on 2/15/22 at 12:17 P.M. and 2/16/22 at 12:59 P.M. showed, the resident lay in bed on his/her back, unable to speak. The resident was unable to lift his/her arms or legs. Both of the resident's arms and left leg were stiff and slightly contracted. 9. Review of Resident #357's quarterly MDS, dated [DATE], showed: -admitted : 1/2/18; -Cognitively intact; -No rejection of care; -Required set up with eating and limited assistance of one staff for personal hygiene; -Required extensive assistance of one staff for bed mobility, dressing and assistance of two staff for toilet use and bathing; -Required total assistance of two staff for transfers; -Functional limitations in ROM in both lower extremities (BLE); -Mobility device: wheelchair; -Diagnoses included: non-traumatic spinal cord dysfunction, paraplegia (impairment in motor or sensory function of the lower extremities). Review of the residents care plan in use at time of survey, showed: -Problem: The resident has a deficit in mobility related to: paraplegia and spinal infarction (a stroke either within the spinal cord or the arteries that supply it) at T10 (thoracic spine, lower part of mid back) level; -Goal: Continue to encourage resident's participation in his/her care and therapy to maintain her current level of function; -Interventions: encourage resident's participation in RT, as tolerated, for exercise and ROM to maintain current level of function. Review of the resident's POS, dated 2/14/22, showed: -An order for Restorative Therapy up to 5 x's per week to include: UE/LE ROM, Active Assist range of motion (AAROM)/PROM, Moist Hot Pack (MHP)/Bio freeze to left shoulder as needed for pain. All is as tolerated, start date 11/18/21. Observation and interview on 2/14/21 at 2:07 P.M., the resident sat in his/her wheelchair with his/her feet on the foot pedals on the chair. The resident had a brace on right LE. The resident said, he/she signed up to get therapy five times a week, but sometimes the facility will pull the staff from RT to work on the floor. He/she needs therapy to move and exercise his/her legs because he/she had a blood clot in his/her back which caused him/her to become paralyzed and he/she is unable to move his/her legs on his/her own. When RT is pulled to the floor, the other CNA's do not do his/her leg exercises and he/she does not get RT that day. Review of the resident's Monthly RT Record, dated December 2021, showed, the resident received 13 total treatments. Review of the resident's Monthly RT Record, dated January 2022, showed, the resident received 8 total treatments. Review of the resident's Monthly RT Record, dated 2/1/22 through 2/27/22, showed, the resident received 12 treatments and refused twice. 10. Review of Resident #16's significant change MDS, dated , 11/17/21, showed: -admitted : 3/23/21; -Brief interview for mental status was coded 99, which indicates the resident unable to complete; -Required extensive assistance of one staff for bed mobility, dressing, personal hygiene and bathing; -Required extensive assistance of two staff for transfers, walking in the room and toilet use; -Required total assistance of one staff for locomotion; -Functional limitation in ROM, in one upper extremity (arm); -Mobility devices: walker and wheelchair; -Diagnoses included: arthritis, dementia and fracture; Review of the residents care plan, in use at the time of survey, showed: -Problem: Resident has a deficit in ADL functioning and impaired mobility related to generalized weakness, arthritis and dementia with not always remembering how to care for him/herself and left elbow fracture; -Goal: Resident will participate in ADL activities promoting maximum independence; -Interventions: RT for exercise and ambulation as tolerated. Review of the resident's physician order sheet, dated 2/14/22, showed, -An order for RT 1 to 2 times per week for exercise and ambulation as tolerated, start date 11/20/21. Review of the resident's Monthly RT Record, dated December 2021, showed, the resident received 1 total treatment and refused once; -No therapy was offered 12/1/21 through 12/14/21 and 12/22/21 through 12/31/21. Review of the resident's Monthly RT Record, dated January 2022, showed, the resident received 2 total treatments and refused twice; -No therapy was offered 1/1/22 through 1/7/22. 11. Review of Resident #70's significant change MDS, dated [DATE], showed: -admitted : 9/9/21; -Moderate cognitive impairment; -No rejection of care; -Required extensive assistance of one staff for dressing, eating, and personal hygiene and walking in the room; -Required extensive assistance of two staff for bed mobility, transfers, toilet use and bathing; -Functional limitation in ROM on one side, both upper and lower extremity; -Mobility devices: walker and wheelchair; -Diagnoses included: cancer, arthritis, hip fracture, multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness impairment of speech and muscular coordination, blurred vision and severe fatigue). Review of the residents care plan in use at the time of survey, showed: -Problem: Resident has a deficit in ADL functioning and impaired mobility related to breast cancer, covid infection 11/13/21, subdural hematoma (buildup of blood on the surface of the brain), and right femur (thigh bone) fracture status post hemi arthroplasty (surgical procedure where half the joint is replaced)11/13/21; -Goal: Resident will participate in ADL activities promoting maximum independence; -Interventions: RT for exercise and ambulation as tolerated. Review of the resident's POS, dated 2/14/22, showed: -An order for RT 1 to 2 times per week to include: exercise and ambulation as tolerated, start date 1/17/22. Review of the resident's Monthly RT Record, dated January 2022, showed, the resident received 0 treatments and refused four times; -Therapy was not offered 1/1/22 through 1/14/22 and 1/22/22 through 1/28/22; -Notes/comments: 1/18/22, resident reported he/she had the flu this week and refused to participate, 1/20/22, resident just returned from doctor's appointment and refused to participate, 1/21/22, resident said he/she was not feeling well, and 1/31/22, resident refused wanting to nap. 12. During an interview with the Restorative Aide KK on 12/16/22 at 1:00 P.M., said, he/she is pulled to the floor quite a bit to work as a CNA due to staffing issues and isn't able to provide restorative therapy when he/she is pulled to the floor. 13. During an interview on 2/23/22 at 9:40 A.M., OT CC, said, when a resident is discharged from skilled therapy, sometimes they are given orders for RT, if the resident and family agree. The residents don't have set days to for RT, but they do try to space out the treatments so residents does not receive their treatments back to back and have a long period until their next treatment. Since Covid started, the RTA aides sometimes are pulled to the floor, but it has gotten better over the last month. The therapy department is made aware when the RTA are pulled to the floor, and one of the therapist will try to pick up some of the treatments. RT is documented in matrix and on paper. If a resident refused RT it would be documented on the paper RT form. 14. During an interview on 2/23/22 at 10:21 A.M., Restorative aide OO, said he/she is aware of which residents received RT by checking the therapy book and the therapist would tell them. When a resident is seen by RT, it is documented on the therapy form or in the matrix. If a resident refused RT, it would be documented on the paper therapy form. Starting on the 29th on each month, they have make up days, to try to make sure the residents got their therapy. Restorative aide OO, said he/she works in RT 2-3 days per week, the other days he/she is pulled to the floor. There is a new occupational therapist who sees the resident when they get pulled to the floor. They do their best to provide RT for the residents but resident care comes first. 15. During an interview on 2/25/22 at 10:57A.M., the Therapy Team Lead, said there was no RT nurse. The Director of Nursing (DON) signs off on RT. 16. During an interview on 2/28/22 at 9:10 A.M., the DON said, there was no RT nurse, therapy oversees the RT program. RT is offered 7 days a week. If a resident refused or was not available, the staff should offer therapy at another time or a different day. If a resident refused therapy it should be documented. A blank on the RT form meant, staff did not document the treatment. Occasionally RTA's are pulled to the floor, but that is the last resort. When RTA is pulled to the floor, the CNA's on the units are doing some therapy with routine care, it just is not getting documented. 17. During an interview on 3/1/22 at 8:20 A.M., the Administrator said, pulling a RTA out of RT to work the floor would be the facility's last resort. The facility has three RTA's and they always try to leave at least one RTA in therapy. When one of the RTA 's are pulled, the licensed staff and CNA's are doing some type of ROM and ambulating the residents with routine care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide supervision as required for residents in an assisted dining room, utilized for residents who required assistance and/or oversight during meals. One resident was served his/her meal and consumed the meal without staff present (Resident #96). The facility also failed to ensure sharps were disposed properly. The census was 188 with 143 residents in certified beds. 1. Review of Resident #96's annual MDS, dated [DATE], showed: -Unclear speech, slurred or mumbled; -Usually understood, difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Sometimes understands, responds adequately to simple, direct communication only; -No brief interview for mental status (BIMS, a screener for cognitive status) completed; -Eating: Required supervision/oversight, encouragement or cueing; -Primary medical condition category: Non-traumatic brain dysfunction; -Diagnoses included dementia and arthritis; -Care area assessment summary: Nutritional status triggered and documented as care planned. Review of the resident's electronic physician order sheet (ePOS), showed an order, dated 11/5/20, for a mechanical soft diet; Review of the resident's pain observation for cognitively aware assessment, dated 2/4/22, showed: -Moderately impaired-decisions poor, cues/supervision required; -No complaints of pain; -Expresses pain with anxiety and moaning; -Continue current care plan. Review of the resident's care plan, dated 2/9/22. showed: -Problem: Cognitive loss/dementia: The resident has cognitive deficits related to forgetfulness and diagnosis of dementia; -Goal: The resident will exhibit comfort and have needs met; -Approach: Provide care for all needs as indicated. Provide verbal reminders as needed. Redirect as needed; -Problem: Nutritional status: Potential for nutritional deficits related to poor appetite and need for mechanically altered diet: -Goal: Provide balanced nutritional diet and to prevent unintentional weight loss; -Approach: On mechanical soft diet with fair to poor intake. Assess ability to feed self, offer assistance as needed. Assess for signs and symptoms of dysphagia (difficulty swallowing), coughing and choking. Provide a pleasurable dining experience, monitor tablemates for appropriateness and make adjustments as needed. Provide diet as ordered, monitor for changes in appetite and offer appropriate alternatives as needed. He/she currently receives a mechanical soft diet. Observation on 2/23/22 at 7:55 A.M., of the assisted dining room on the 100 hall, showed three residents sat at tables with drinks within reach. No staff present. Resident #96 sat with a bowl of oatmeal and took bites. Observation on 2/23/22 at 8:11 A.M., of the assisted dining room on the 100 hall, showed eight residents sat in the dining room. Resident #96 had a bowl of oatmeal and three cups of liquids, one with water, one with an orange drink and a third drink in a Styrofoam cup. One resident had applesauce and two drinks, and two other residents had drinks within reach. No staff were present in the dining room. At 8:12 A.M., the staffing coordinator came out of the kitchen, which is attached to the assisted dining room, provided a resident with three cups of liquids and returned to the kitchen. Resident #96 continued to feed him/herself oatmeal. At 8:15 A.M., the staffing coordinator came out of the kitchen and asked a resident about their drink preference. A resident in the far corner started to cough. He/she had three cups of liquids in front of him/her. The staffing coordinator re-entered the kitchen. A staff person brought another resident into the dining room, placed them at the table and immediately left. Resident #96 took a drink from a cup. At 8:17 A.M., the staffing coordinator exited the kitchen with drinks and passed them to another resident. She placed a clothing protector on the resident and at 8:18 A.M., she reentered the kitchen. No staff were present in the dining room. At 8:19 A.M., staff brought in three more residents, placed them at tables and immediately left the dining room. At 8:23 A.M., the staffing coordinator exited the kitchen with a plate of food and set it down in front of Resident #96 and immediately returned to the kitchen. The plate contained scrambled eggs and toast with jelly. No staff were present in the dining room. The resident immediately started to eat the food at a rapid pace. As the resident chewed, food fell out of his/her mouth and into his/her lap. The resident appeared to have random movements, such as shoulder shrugs, neck movements and head drops. The resident continued to add food to his/her mouth, despite there already being food in his/her mouth. At 8:26 A.M., the staffing coordinator came out of the kitchen and gave a different resident drinks and immediately reentered the kitchen. Resident #96 appeared to struggle to keep his/her head up as it dropped frequently while he/she chewed. At 8:27 A.M., the staffing coordinator exited the kitchen with drinks and passed them to a different resident and then reentered the kitchen. Resident #96 continued to feed him/herself. He/she appeared to struggle to take a bite of the bread and tore it in his/her teeth. The resident, with a mouthful of bread, took a drink and then placed another bite into his/her mouth before clearing the prior bite. The resident finished the drink in the Styrofoam cup, the orange drink, all of the eggs and all but two bites of bread. At 8:30 A.M., other staff entered the dining room and begin to assist residents. During an interview on 2/23/22 at 12:21 P.M., the staffing coordinator said she fills in where needed, including in the kitchen. She helps in the 100 hall assisted dining room every morning. There should always be staff present in the dining room when residents have food or drink served. If she is in the kitchen, there should be other staff in the dining room to watch over the residents. 2. Review of the facility's Syringe Disposal Policy, reviewed 5/21, showed sharps containers must be monitored daily and secured for disposal when two thirds full. During observation of the spa room on the 400 hall, on 2/16/22 at 8:35 A.M. and on 2/22/22 at 5:35 A.M., showed a red sharps container attached to the wall overflowing with used razors and coming out of the top of the container. During an interview on 2/25/22 at 1:05 P.M., Registered Nurse (RN) BB said the sharps container can be changed by nursing staff and should be emptied when it is two thirds full. The razors overflowing out of the sharps box could cause injury to a resident or an employee. During an interview on 2/28/22 at 9:12 A.M., the DON said the sharps container is approved to use to dispose of used razors and should be emptied when it is two thirds full. The maintenance department is in charge of replacing the sharps containers when requested by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have adequate nursing staff to meet the needs of the residents as evidenced by incontinence care and/or toileting not provided, for four of 29 sampled residents (Residents #9, #131, #120 and #101). This had the potential to affect all residents. The census was 188 with 143 in certified beds. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/3/22, showed: -Cognitively intact: -No behaviors; -Required extensive staff assistance with dressing, toileting and hygiene; -Diagnoses included vascular disease, diabetes and Parkinson's (a nerve disorder affecting motor control) disease; -Urinary and bowel incontinence: incomplete; -Takes a diuretic (used to remove excessive fluid from the body) medication seven days a week. Review of the care plan, reviewed 2/9/22, showed: -Problem: the resident experienced incontinence; -Goal: the resident will be dry, odor free and have the highest level of continence; -Approach: cleanse the groin area after each incontinence episode, use incontinence products to prevent soiled clothing and maintain dignity, and maintain consistent staff who can attempt to anticipate needs and provide a routine. During an observation and interview on 2/23/22 at 7:10 A.M., showed the resident's bedroom door open to the hallway and a very strong urine odor noted. The resident sat on the edge of the bed and his/her call light activated on the wall. The resident said I am soaked, and had been waiting for staff to come help him/her for almost an hour. Agency Certified Nurse Aide (CNA) L assisted the resident to walk to the bathroom with a walker. The resident ambulated to the bathroom and used one hand to hold up a urine saturated brief. As he/she stood in front of the toilet, the brief slipped down the resident's leg and plopped' onto the bathroom floor. The brief contained dark colored urine and noted to be very odorous. CNA L said he/she was the only aide scheduled to work the floor during the night shift. He/she had not been able to check on or provide incontinence care to all the residents who needed it. He/she had been an agency aide at the facility for several months and during the night shift, there frequently is only one aide for over 30 residents. Often care tasks are not completed due to not enough staff. 2. Review of Resident #131's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Required extensive staff assistance with dressing, toileting and hygiene; -Urinary and bowel incontinence: incomplete; -Diagnoses: diabetes, heart failure, Parkinson's disease and seizures; -Takes a diuretic medication daily. Review of the care plan, last revised on 2/14/22, did not address bowel, bladder or incontinence needs. During an observation and interview on 2/23/22 at 6:40 A.M., showed the resident lay in bed. Agency CNA L and agency CNA M greeted the resident and said the resident is incontinent of urine and wore a brief. The resident wore a urine saturated brief. CNA L said he/she had been the only aide scheduled to work the floor during the night shift. CNA M said he/she was scheduled to work day shift. He/she had worked at the facility for several months due to staffing issues. It was not unusual to have one aide per floor on the night shift or to share one aide on multiple floors. It is not possible to meet the care needs of the residents with one aide. It can be difficult to get the nurse to help if needed because the nurse could be doing other care needs. The CNAs unfastened and lowered the brief. The urine observed to be dark colored and odorous. The aides provided care to the resident and CNA L added this was the first time he/she had been able to provide incontinence care to the resident since he/she started the shift at 11:00 P.M., the night before. He/she had not taken a break during the night, because he/she had been trying to meet care needs. 3. Review of Resident #120's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required one staff person assist for dressing, transfers, toileting, personal hygiene, and bed mobility; -Set up only for eating; -Walker/Wheelchair for mobility; -Diagnoses included high blood pressure, kidney failure, anxiety and depression. Observation and interview on 2/23/22 at 7:05 A.M., showed two call lights were illuminated on the 100 Hall, with no staff present. Resident #120 was heard moaning from the hallway. The resident lay in his/her bed on his/her left side. A pungent odor of urine was present at the resident's bedside. The resident asked for an additional blanket, and said, no one came in all night to change him/her and he/she is soaking wet and so cold. 4. Review of Resident #101's quarterly MDS, dated [DATE], showed the following: -admission date of 10/14/19; -Diagnoses included congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should), dementia, acute respiratory disease, metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body) and acute embolism and thrombosis of unspecified deep veins in lower extremities (blood clots that block the veins); -Adequate hearing and vision; -Able to understand and make self understood; -Required extensive physical assistance of two + person for bed mobility and toileting; -Mobility: Substantial assistance needed to roll left to right. Review of the resident's care plan, dated 2/21/22, showed the following: -Problem: Requires assistance with activities of daily living (ADLs) related to generalized weakness; -Approach: Provide assistance with ADLs as indicated. Requires limited/extensive assistance; -Problem: Incontinence - Bowel and/or bladder. Experiences stress and urge urinary incontinence and receives daily diuretic medication; -Approach: Staff assists with check and change toileting according to resident's individual routine; -Problem: Pressure ulcer: At risk for an alteration in skin/pressure injury. Additional risks include changes in skin associated with aging, incontinence, anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues) and daily medications; -Approach: Frequent repositioning in bed and wheelchair as tolerated. During an interview on 2/22/22 at 7:00 A.M., the resident said he/she did not get turned or changed the night before. The staff member only came in once at the beginning of the shift, checked the top of the pad where he/she was not wet and walked out without saying anything. He/she never came back the rest of the night. Staff regularly do not check or reposition him/her at night. The resident was soaked by the time staff got him/her up in the morning. The resident was concerned about being left wet because he/she felt like his/her skin would break down. 5. During an interview on 2/22/22 at 1:35 P.M. with the resident council, Resident #45 said staff are not assisting residents with changing positions or not checking on them at all on the night shift. The staff are agency and the help they send are inadequate. They will answer the call light and tell residents they will be right back, but they do not return. On the 100 unit, there is one aide on the night shift. On the 500 unit, the call lights are not answered timely. No one came in to provide care. Resident #45 was left soiled on 2/21/22 and today. Resident #56 said on 2/20/22, his/her call light was on for an hour, he/she became incontinent in his/her bed as a result. Resident council members confirmed that sometimes the facility does not have enough staff to operate the Hoyer lift (a mechanical lift), so they do it by themselves. 6. During an interview on 2/25/22 at 1:45 P.M., the Staffing Coordinator said staffing has been a challenge since Covid and the recent bad weather. The schedule is based on the census of the hall and the acuity on the rehabilitation hall. Currently, he/she is trying to schedule 14 to 15 CNAs for day and evening shifts, and 10 CNAs for night shift, and three Certified Medication Technicians (CMTs); one for the 100, 400 and 500 halls for days and evening shift, and five to six nurses for the day and evening shift and three to four nurses for the night shift. If someone calls off or there is an open spot on the schedule, he/she will try to replace the staff member with one of the facility's own staff first. If he/she is unable to fill the open spot, he/she will call the agency to see if they can fill the spot. If he/she is still unable to fill the spot, the staffing coordinator will work the floor or one of the nurse managers will fill in. The facility's last resort is to pull a restorative therapy aides (RTA) to work the floor. If the staffing coordinator needed to pull from RT, he/she tried to leave one of the three RTAs in therapy. The staffing coordinator does not know if all the RT treatments are completed when a RTA is pulled to the floor. Residents sometimes complain about staffing, and not getting their baths. The facility does try to make up the residents' baths, either later that day or the next day. 7. During an interview on 2/28/22 at 10:39 A.M., the Director of Nursing (DON) said the staffing coordinator makes out a schedule depending on the census and the acuity of the residents. If there is an open shift, the facility will try to fill the opening with the facility's staff first. If they are unable to fill the opening, the staffing coordinator will call the agency to try to fill the opening. If he/she is still unable to fill the opening, either someone from nurse management or the staffing coordinator would fill-in, pulling a staff member from RT would be the facility's last resort. Typically, the facility would schedule 14 CNAs, three CMTs and six nurses for day shift and 12 CNAs, three CMTs and six nurses for evening shift and eight or more CNAs, and three to four nurses for night shift. The DON was aware the facility had staffing challenges, but he/she felt the facility was meeting those challenges. Residents and staff sometimes do complain about being short staffed, however the DON was not aware of any complaints from residents and/or families regarding delays in resident care. The DON expects staff to answer call bells timely and for the residents to be clean and dry. Also, the facility should ensure there are enough licensed staff to provide services to the residents and assist in monitoring the nurse aides and if a staff member was pulled to another assignment due to staffing, the facility would have something in place to ensure the residents' care is not interrupted. 8. During an interview on 3/1/22 at 8:20 A.M., the administrator said the facility is staffed through census and acuity. Sometimes, residents do complain about staffing and the agency staff. The residents would like all regular staff. If the facility was unable to fill an open spot on the schedule, a nurse manager would fill in. If the nurse manager was unable to fill in, they would reassign the staff. If staff member needed to be reassigned, the expectation would be for staff to provide the same care, and communicate with the residents and to prioritize care. If a staff member was unable to give a resident a bath, the facility would offer the bath either later that day or the next day. If a resident or family had a complaint, the administrator would try to address the issue and put interventions into place to address the issue. The administrator was aware of staffing challenges and said the facility is putting into place some new interventions to try to help with staffing. MO00177769 MO00177031 MO00186727 MO00189777 MO00190795 MO00195536 MO00174441 MO00177991 MO00179328 MO00186609 MO00192972 MO00178184 MO00186793 MO00189367 MO00194775 MO00195600 MO00196189 MO00192609 MO00192610

Based on observation, interview and record review, the facility failed to ensure nursing staff with the appropriate competencies and skill sets assisted residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The facility failed to ensure nursing staff are able to demonstrate competency in skills and techniques necessary to care for residents, by failing to administer medications per physician's orders and accurately document and maintain a controlled substance record. In addition, the facility failed to ensure all staff, were adequately trained and informed of facility policies and expectations per acceptable nursing standards. The census was 188 with 143 in certified beds. Review of the facility's 2020-2021 assessment tool, showed: -Staff training/education and competencies: -All Staff: The facility has an orientation and program designed for new hires and continued education for the development and improvement of skills appropriate to each job function as well as the needs of the resident population cared for; -Training includes: Communication with the elderly and specific populations of the facility; -Resident rights; -Abuse, neglect and exploitation and reporting as such; -Certified Medication Technicians (CMTs): Annual in-service consist of at least 12 hours of which two hours are dementia management and resident abuse prevention; -Additional in-service may address special needs related to the medication administration, documentation, storage or error; -CMT competencies include but are not limited to: -Medication administration; -Oral medication -Transdermal medication administration -Nurses: Professional Nursing Orientation and competencies to include but not limited to: -Managing and assisting the Certified Nurse Aides (CNAs) and CMTs with Activities of Daily Living (ADLs); -Dementia management and caring for residents with Alzheimer's and related dementia; -Mental, psychological, behavioral disorders as well as residents with a history of trauma and/or post-traumatic stress disorder, and implementing non pharmological interventions. Observations during the survey, showed: -The facility failed to ensure residents reviewed for unnecessary medications was free from chemical restraints. Staff administered Lorazepam (Ativan, a benzodiazepine medication used to treat anxiety) as well as other bedtime medications that included Donepezil (medication used to treat dementia) and Trazodone (antidepressant) to Resident #65, outside the parameters ordered by the physician in an attempt to prevent behaviors. Two additional residents from the memory care unit were sampled and two residents were identified in which staff did not document behaviors and notify the physician of changed administration times (Residents #82 and #152); -Resident #65: The facility failed to administer medications as ordered. Staff administered Lorazepam, Donepezil and Trazodone early in order to prevent behaviors. The Medication Administration Record (MAR), showed staff administered medications early on 1/4/22, 1/8/22, 1/28/22, 2/1/22, 2/2/22, 2/5/22, and 2/6/22 without documentation of the resident's behaviors, rationale of administering medications outside of parameters, or notification of the physician or Director of Nurses (DON); -Resident #82: The facility failed to administer medications as ordered. The MAR showed staff administered medications early on 2/1/22, 2/2/22, 2/5/22, 2/6/22, 2/7/22, and 2/14/22 without documentation of the resident's behaviors, rationale of administering medications outside of parameters, or notification of physician or DON; -Resident #152: The facility failed to administer medications as ordered. The MAR showed staff administered medications early on 1/4/22, 1/29/22, 1/30/22, 2/5/22, 2/6/22, 2/7/22, and 2/14/22 without documentation of the resident's behaviors, rationale of administering medications outside of parameters, or notification of physician or DON; -Resident #86: The facility failed to provide missing controlled substance sheets for the resident's hydrocodone-acetaminophen (contains an opioid pain reliever and a non-opioid pain reliever for moderate to severe pain) and Fentanyl patch (synthetic opioid for severe pain) for October 2021, November 2021, and December 2021; -Resident #9: The facility failed to provide controlled substance sheets for the resident's hydrocodone-acetaminophen for 2/1/22 through 2/16/22; -Resident #115: The facility failed to ensure the controlled substance sheet for the resident's morphine was documented by the nurse after administration; -The facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for five out of five units; During an interview on 2/18/22 at 1:50 P.M., the DON said it is expected every day and every shift, narcotics are to be counted and documented by one oncoming nursing staff member for the shift and one off going nursing staff member. There are 11 med carts in the building. During an interview on 2/24/22 at 3:56 P.M. and on 2/25/22 at 1:24 P.M., the administrator said she has been unable to locate any additional count sheets. She said there is no real system in place to keep count sheets, other than they are given to the DON to keep in his records. The requirement is to keep medical records for 7 years. The administrator said when PRN medications are administered, the nurse should give the medication and sign the resident's MAR. The medication when dispensed should align with the MAR. The facility does not have a system in place to monitor narcotic sheets. The narcotic sheet should be part of the medical record and scanned into the record, and she did not know why the facility is missing the narcotic sheets. Those should be in the DON's record for review and to file in the record. During an interview on 2/28/22 at 10:01 A.M., the wound nurse said the last nurse educator left the facility in August 2021 and the DON took over the training. There was no specific training or education for staff who work in the memory care unit. Hospice would come and do training, but it is not mandatory. The education and/or in-service regarding administration of medications and documentation on the MAR is case by case, but if a trend was noticed, there would be training. There was training six months ago on the change of the narcotic policy, education, counting at the beginning of the shift and signing of the sheets. There were no concerns brought to his/her attention. The wound nurse was responsible for educating staff except for the registered nurses (RNs). Review of the facility's in-service training record, dated 9/21/21 and 9/28/21, showed the facility's licensed practical nurse (LPN) and RN staff received the following education: -Counting/narcotic sheets: The facility noticed the resident count sheets are not being signed out when they are given, and sometimes not in the computer. The facility has to know when the resident is getting their as needed (PRN) medications. During an interview on 2/28/22 at 4:00 P.M., the DON said he is responsible for in-service and educating of the nurses. He expected staff to all receive in-service and training in the areas of medication administration and the documentation and maintain narcotic sheets. There is a need to re-focus efforts on that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they had a system in place to record and document all controlled drugs with sufficient detail to enable an accurate reconciliation, for two of 29 sampled residents (Residents #9 and #115) and five out of five halls. This had the potential to affect all residents with orders for controlled substances. The census was 188 with 143 residents in certified beds. Review of the facility's Controlled Medications policy, dated as last reviewed on 6/21, showed the following: -Purpose: A controlled drug record of individual resident form is accurately maintained on all resident requiring controlled medications. Strict control of narcotics is maintained always. A physician order is required for administration of controlled drugs. Controlled drugs are administered by licensed personnel. Appropriate storage, recording and use of controlled drugs are maintained on all units always; -All as needed (PRN), control substance schedule III, IV and V (CIII, CIV, CV, classification of controlled medications) medications will be documented on shift audit sheets. When controlled keys change hands during a shift, controlled drugs are recounted and the counted record is signed by nurse/Certified Medicine Technician (CMT). The use of routine CIII, IV and V medications is documented by initialing and dating on each bubble and or documenting on the Controlled Drug Receipt/Record/Disposition form and shift audit sheet. Monitoring of accuracy will be completed routinely by nursing administration and pharmacy. All CII's will be audited at shift change. 1. Review of Resident #9's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 2/3/22, showed: -Cognitively intact: -No behaviors; -Extensive staff assistance needed with dressing, toileting and hygiene; -Diagnoses included vascular disease, diabetes and Parkinson's disease (a nerve disorder affecting motor control). Review of the resident's care plan, undated, showed; -Problem: Pain, onset date 8/12/20: At risk for discomfort related to chronic back and bilateral (both side) shoulder pain; -Approach: Give analgesics (pain medication) as ordered. Document if pain medicine is effective or not, update physician as needed. Review of the resident's electronic physician order sheet (ePOS), showed: -An order dated 6/29/21, for hydrocodone-acetaminophen (narcotic pain medication combined with acetaminophen) 5-325 milligram (mg). Administer 2 tabs oral, every 4 hours as needed for pain; -An order dated 7/20/21, for hydrocodone-acetaminophen 5-325 mg. Administer 2 tabs oral, every 6 hours, for pain. Review of the Resident's electronic medication administration record (eMAR), dated 2/1/22 through 2/28/22, showed: -Order dated 6/29/21, for Norco (hydrocodone-acetaminophen) tablet; 5-325 mg. Administer: 1 tab oral, every 6 hours as needed for pain, documented as not administered on 2/1/22 through 2/16/22; -Order dated 7/20/21, for hydrocodone-acetaminophen 5-325 mg. Administer 2 tabs oral every 4 hours as needed for pain: -Documented as administered on 2/2/22 at 12:04 A.M., 2/3/22 at 8:56 P.M., 2/7/22 at 8:35 P.M., 2/11/22 at 7:52 P.M., 2/14/22 at 8:47 A.M., and 2/15/22 at 10:53 P.M.; -No controlled drug receipt/record/disposition form, documentation provided for 2/1/22 through 2/16/22. 2. Review of Resident #115's quarterly MDS, dated [DATE], showed: -Brief interview of mental status (BIMS) score, blank; -One staff person assist required bed mobility and personal hygiene; -Two staff person assist required for transfers, toileting, and toileting; -Wheelchair for mobility; -Diagnoses included high blood pressure, dementia and depression. Review of the resident's ePOS, showed: -An order dated 2/9/22 and discontinued on 2/10/22, for morphine sulfate (schedule II narcotic pain medication) solution. 10 mg/5 milliliter (ml); amount: 0.25 ml oral every 1 hour. Scheduled administration times: 12:00 AM, 1:00 AM, 2:00 AM, 3:00 AM, 4:00 AM, 5:00 AM, 6:00 AM, 7:00 AM, 8:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, 6:00 PM, 7:00 PM, 8:00 PM, 9:00 PM, 10:00 PM, and 11:00 PM; -An order dated 2/9/22 and discontinued 2/10/22, for morphine solution. 10 mg/5 ml; amount: 0.25ml oral every 4 hours as needed; -An order 2/9/22 and discontinued 2/10/22, for morphine solution. 10 mg/5 ml; amount: 0.25ml oral every 6 Hours. Scheduled administration times: 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM. Review of the Resident's eMAR, dated 2/1/22 through 2/28/22, showed morphine solution 10 mg/5 ml, amount: 0.25 ml: -On 2/9/22 at 7:00 P.M., 8:00 P.M., 9:00 P.M., and 10:00 P.M., 0.25 ml documented as administered; -On 2/10/22 at 7:00 A.M. and 9:00 A.M., documented as refused. Review of the Resident's Controlled Drug Receipt/Record/Disposition Form for Morphine 20 mg/ml solution, showed on 2/1/22, quantity dispensed 15 ml: -On 2/9/22: 0.25 ml withdrawn at 9:00 P.M., amount remaining, 14.75 ml, signed as administered; -On 2/10/22: 0.25 ml withdrawn at 12:00 A.M., no signature; -On 2/10/22 0.25 ml withdrawn at 1:00 A.M., no signature; -On 2/10/22 0.25 ml withdrawn at 2:00 A.M., no signature; -On 2/10/22 0.25 ml withdrawn at 3:00 A.M., no signature; -On 2/10/22 0.25 ml withdrawn at 4:00 A.M., no signature; -On 2/10/22 0.25 ml withdrawn at 7:00 A.M., no signature; -On 2/10/22 0.25 ml withdrawn at 8:00 A.M., no signature; -On 2/10/22, .25 ml withdrawn at 9:00 A.M., no signature. 3. During an interview on 2/24/22 at 3:56 P.M. and on 2/25/22 at 1:24 P.M., the administrator said she has been unable to locate any additional count sheets. There is no real system in place to keep count sheets, other than they are given to the Director of Nursing (DON) to keep in his records. The requirement is to keep medical records for 7 years. When as needed medications are administered, the nurse should give the medication and sign the resident's eMAR. The medication when dispensed should align with the eMAR. The facility does not have a system in place to monitor narcotic sheets. The narcotic sheet should be part of the medical record and scanned into the record, and she did not know why the facility is missing the narcotic sheets. 4. Review of the Narcotic Shift Count Sheet 100 hall nurses cart, dated January 2022, showed: -Nine of 96 shifts with only one nurse signature of the shift change count; -Six of 96 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 100 hall CMT cart, dated January 2022, showed: -Three of 96 shifts with only one nurse signature of the shift change count; -Nine of 96 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 100 hall nurses cart, dated February 2022, showed: -Five of 60 shifts with only one nurse signature of the shift change count. Review of the Narcotic Shift Count Sheet 100 hall CMT cart, dated February 2022, showed: -Two of 60 shifts with only one nurse signature of the shift change count; -Five of 60 shifts with no count of narcotics. 5. Review of the Narcotic Shift Count Sheet 200 hall nurses cart, dated February 2022, showed: -Six of 60 shifts with only one nurse signature of the shift change count; -Six of 60 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 200 hall CMT cart, dated February 2022, showed: -Three of 60 shifts with only one nurse signature of the shift change count; -Eight of 60 shifts with no count of narcotics. 6. Review of the Narcotic Shift Count Sheet 300 hall nurses cart, dated January 2022, showed: -Three of 96 shifts with only one nurse signature of the shift change count; -54 of 96 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 300 hall starters, located in medication room, dated January 2022, showed: -Seven of 96 shifts with only one nurse signature of the shift change count; -36 of 96 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 300 hall nurses cart, dated February 2022, showed: -Six of 60 shifts with only one nurse signature of the shift change count; -Six of 60 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 300 hall starters located in medication room, dated February 2022, showed: -Nine of 60 shifts with only one nurse signature of the shift change count; -23 of 60 shifts with no count of narcotics. 7. Review of the Narcotic Shift Count Sheet 400 hall nurses cart, dated January 2022, showed: -Four of 96 shifts with only one nurse signature of the shift change count; -26 of 96 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 400 hall CMT cart A, dated January 2022, showed: -Four of 96 shifts with only one nurse signature of the shift change count; -26 of 96 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 400 hall CMT cart B, dated January 2022, which contained the following information: -Seven of 96 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 400 hall CMT cart A, dated February 2022, showed: -19 of 60 shifts with only one nurse signature of the shift change count; -One of 60 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 400 hall CMT cart B, dated February 2022, showed: -Two of 60 shifts with only one nurse signature of the shift change count; -18 of 60 shifts with no count of narcotics. 8. Review of the Narcotic Shift Count Sheet 500 hall nurses cart, dated January 2022, showed: -Two of 96 shifts with only one nurse signature of the shift change count; -21 of 96 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 500 hall CMT cart, dated January 2022, showed: -Nine of 96 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 500 hall nurses cart, dated February 2022, showed: -Two of 60 shifts with no count of narcotics. Review of the Narcotic Shift Count Sheet 500 hall CMT cart, dated February 2022, showed: -Three of 60 shifts with only one nurse signature of the shift change count; -Six of 60 shifts with no count of narcotics. 9. During an interview with CMT Y on 2/18/22 at 10:30 A.M., he/she said every day and every shift, narcotics are to be counted and documented by one oncoming nursing staff member and one off going nursing staff member on the narcotic shift-to-shift count sheet. He/she has been informing the DON for the last month and a half about the missing signatures on the narcotic count sheet. There are two CMT carts on the 400 hall and he/she just calls them A and B carts. 10. During an interview on 2/18/22 at 1:50 P.M., the DON said it is expected that every day and every shift narcotics are to be counted and documented by one oncoming nursing staff member for the shift and one off going nursing staff member. There are 11 med carts in the building.

Based on interview and record review, the facility failed to ensure they had documentation to show they notified residents when they reached $200 within the Supplemental Security Income (SSI) resource limit ($3,000). This affected two of two residents for whom the facility held funds for and reached the $200 limit (Residents #30 and #102). The sample was 29. The census was 175 with 144 in certified beds. 1. Review of Resident #30's trust account on 4/2/19, showed: -July 2018, a balance of $4,620.45; -August 2018, a balance of $3,685.29; -October 2018, a balance of $2926.71; -No documentation to show staff notified him/her of being within the limit for eligibility. 2. Review of Resident #102's trust account on 4/2/19, showed: -November 2018, a balance of $3,561.73; -No documentation to show staff notified him/her of being within the limit for eligibility. 3. During an interview on 4/2/19 at 1:30 P.M., the bookkeeper said he/she started in June 2018 and took over the resident trust account. There was some cleaning up to do. He/she could not provide letters showing they had notified the residents that they were within the SSI limit or over the limit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to issue a written transfer/discharge notice to two sampled residents who were transferred to the hospital (Residents #59 and #129). The sample was 29. The census was 175 with 144 certified beds. 1. Review of Resident #59's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/4/19, showed: -admission date: 2/21/18; -Severe cognitive impairment; -Extensive assist from staff for most activities of daily living; -Diagnoses including heart failure, stroke and dementia. Review of the resident's nurse's notes, showed: -4/1/19 at 6:30 P.M., Emergency Medical Services (EMS) arrived to transport the resident to the hospital; -4/2/19 at 11:12 A.M., medical appointment was canceled due to the resident being admitted to the hospital on [DATE]. Review of the resident's medical record, showed no documentation of a transfer/discharge letter being sent to the resident or his/her representative. During an interview on 4/5/19 at 7:15 A.M., the administrator said the transfer/discharge letter is sent with the resident to the hospital. This should be documented in the resident's progress notes. The administrator was unable to find the resident's transfer/discharge letter. 2. Review of Resident #129's admission MDS dated [DATE], showed: -admission date: 12/28/18; -No cognitive impairment; -Extensive assistance from staff for activities of daily living; -Diagnoses including heart failure, high blood pressure, chronic obstructive pulmonary disease (COPD, a chronic lung disease, making it hard to breathe) and respiratory failure. Review of the resident's nurse's notes, showed: -On 1/19/2019 at 12:10 P.M., nurse spoke to his/her family about resident's condition. He/she is being sent out to hospital. Nurse called EMS to transport, awaiting arrival resident laid down for EMS to pick up; -On 1/19/2019 at 12:19 P.M., EMS here to pick up the resident. He/she was not happy about going to the hospital. Oxygen saturation level (amount of oxygen in the blood) at 62. EMS talked to resident about wanting him/her to get checked out because his/her oxygen is so low, resident said fine, belongings and medications packed and put up. Review of the resident's medical record, showed no documentation of a transfer/discharge letter given to the resident or his/her representative. During an interview on 4/3/19 at 11:03 A.M., Nurse R said they send the packet with EMS when the resident goes out. He/she calls family and asks for choice of hospital and asks the resident. He/she does not think copies are made of anything in the packet. 3. During an interview on 4/3/19 at 10:05 A.M., the Director of Nurses said they give information when residents are transferred out but they don't sign anything or keep a copy. She said the nurse who sends the resident out, gives them a transfer folder. It should be documented in the progress note and the reason why the resident is being transferred. 4. Review of the facility's bed hold and transfer policy, undated, showed when a resident is transferred to an acute care hospital, a copy of the bed hold and transfer policy will accompany them.

Based on interview and record review, the facility failed to provide written notice to the resident or their legal representative of the facility bed hold policy at the time of transfer to the hospital, for one of 29 sampled residents who was recently transferred to the hospital for medical reasons (Resident #59). The census was 175 with 144 in certified beds. Review of Resident #59's medical record, showed: -Discharge to the hospital on 4/1/19; -Returned to the facility from the hospital on 4/4/19; -No documentation the resident and/or the representative received written notice of the facility's bed hold policy at the time of transfers. During an interview on 4/5/19 at 7:15 A.M., the administrator said the resident receives the bed hold policy when transferred to the hospital. The bed hold policy is discussed during the resident's initial admission and at the time the transfer to the hospital. If there is no documentation that the bed hold policy was provided or discussed at the time of the transfer, then it did not happen. Review of the facility's bed hold and transfer policy, undated, showed when a resident is transferred to an acute care hospital, a copy of the bed hold and transfer policy will accompany them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff changed their gloves and did not touch residents and clean items with soiled gloves during incontinence care. Four residents receiving incontinence care were observed and problems were found with three (Residents #39, #58 and #53). The sample was 29. The census was 175 with 144 residents in certified beds. 1. Review of Resident #39's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/21/19, showed: -Diagnoses of high blood pressure and diabetes; -Short/long term memory loss; -Extensive staff assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Incontinent of bowel and bladder. Observation on 4/1/19 at 8:55 A.M., showed the resident sat on the toilet as Certified Nurse Aide (CNA) D washed his/her hands and applied gloves. After wetting a towel, the CNA applied soap and washed the resident's perineal area the front and back of the hips, genitals and anal area) and buttocks. Without changing his/her gloves, he/she applied barrier cream to the resident's buttocks. During an interview on 4/1/19 at 9:15 A.M., CNA D said he/she should have changed gloves before applying barrier cream. 2. Review of Resident #58's significant change MDS, dated [DATE], showed: -Diagnoses included stroke and dementia; -Required total assistance from staff for bed mobility, transfers, dressing, toilet use, hygiene and bathing; -Incontinent of bowel and bladder. Observation on 4/2/19 at 2:00 P.M., showed the resident sat in his/her Broda chair (reclining chair). CNA B and CNA C washed their hands, applied gloves and touched the resident's Broda chair, resident and Hoyer (mechanical lift) machine with their gloved hands. Both CNAs attached the Hoyer lift straps to the machine, transferred the resident from the chair to the bed, removed the Hoyer lift straps from the machine and removed the Hoyer lift pad from under the resident. Both CNAs unfastened the resident's incontinence brief and verified the brief was wet with urine. While wearing the same gloves, CNA B cleansed the resident's perineal area, touched the resident, turned him/her onto his/her right side, removed the soiled incontinence brief, cleansed the resident's buttocks, picked up a tube of barrier cream, applied barrier cream to the resident's buttocks, picked up a clean incontinence brief and put the brief on the resident. Then both CNAs removed their gloves for the first time and washed their hands. 3. Review of Resident #53's quarterly MDS, dated [DATE], showed: -Diagnoses of high blood pressure stroke and Alzheimer's disease; -Short/long term memory loss; -Required extensive staff assistance for bed mobility, transfers, dressing, toileting, personal hygiene and bathing; -Incontinent of bowel and bladder. Observation on 4/3/19 at 4:59 A.M., showed the resident lay in bed. CNA E washed his/her hands, applied gloves and washed the resident's perineal area. He/she turned the resident onto his/her left side and washed the resident's buttocks. Without changing his/her gloves CNA applied barrier cream and a clean incontinence brief. During an interview on 4/3/19 at 5:06 A.M., CNA said he/she should have changed his/her gloves before applying barrier cream and clean brief. 4. During an interview on 4/5/19 at 7:10 A.M., the Clinical Educator said she expected nursing staff to wash their hands before and after gloves were applied and/or removed. Nursing staff should change their gloves after providing perineal care, prior to providing incontinence care to the resident's buttocks and should not touch residents and/or clean items with soiled gloves due to infection control concerns. 5. Review of the facility's Perineal Care Policy and Procedure Manual, dated December 2006, showed: -Purpose: To establish routine practices for providing perineal care, which will cleanse, prevent skin breakdown, prevent infection and prevent odors; -Procedure: -Wash hands; -Apply gloves; -Complete perineal care; -Remove/discard gloves and wash hands.