**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff cared for residents in a dignified manner when they obtained blood sugars and administered insulin in the dining room which affected two of the 18 sampled residents, (Resident #4 and Resident #38). The facility census was 86. Review of the facility's policy, Providing Privacy, dated 4/27/14, showed: - It is the policy of this facility to provide privacy to each and every resident, competent or incompetent; - Facility staff must examine and treat residents in a manner that maintains the privacy of their bodies; - Only authorized staff directly involved in treatment should be present when treatments are given; - People not involved in the care of the individual should not be present without the individual's consent while he/she is being examined or treated; - Staff should provide privacy by pulling curtains, shutting blonds, closing doors, and otherwise removing the resident from public view and provide clothing or draping to prevent unnecessary exposure of body parts during the provision of personal cares and services. 1. Review of Resident #4's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/25 showed: - Cognitive skills severely impaired; - Diagnoses included diabetes mellitus, dementia, psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and malnutrition. - The resident had seven insulin injections in the last seven days. Review of the resident's care plan, edited 4/22/25 showed: - The resident occasionally had outbursts and verbally makes accusations or denials, or gets visibly upset with situation and person. Occasionally will refuse treatments such as fingersticks for blood sugar. Assess the resident's blood sugar if he/she is having behaviors. - The resident was dependent on staff for blood sugar monitoring and insulin administration. - Resident eats meals in the dining room. Review of the resident's Physician Order Sheet (POS) dated, April 2025, showed: - Start date: 2/18/25 - regular diet with diabetic precautions, thin liquids. - Start date: 3/26/24 - Accuchecks before meals and at bedtime for diabetes mellitus; - Start date: 4/4/25 - Novolog Flexpen (fast acting ) insulin per sliding scale three times daily. For blood sugars 251 - 300 - six units for diabetes mellitus. Blood sugar was 296. Review of the resident's Medication Administration Record (MAR), dated April 2025 showed: - Accuchecks before meals and at bedtime for diabetes mellitus; - Novolog Flexpen insulin per sliding scale three times daily. For blood sugars 251 - 300 - six units for diabetes mellitus. - Accuchecks and insulin was provided to the resident in the Month of April. Observation on 5/7/25 at 11:07 A.M., showed: - The resident sat at the dining room table with two other tablemates and 17 other residents in the dining room in view of the resident; - Certified Medication Technician (CMT) A obtained the resident's blood sugar at the dining room table and administered the insulin in the resident's left upper arm. 2. Review of Resident #38's care plan, revised 6/5/24 showed: - The resident had a diagnosis of diabetes mellitus. Follow the resident's diet order. Remind and encourage meals, snacks appropriate for diabetics. - The resident was dependent on staff for blood sugar monitoring and insulin administration. - Resident eats meals in the dining room. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Upper and lower extremity impaired on one side; - Diagnoses stroke, diabetes mellitus and hemiparesis (partial paralysis on one side of the body) and hemiplegia (complete paralysis on one side of the body). Review of the resident's POS (Physician Order Sheet), dated May 2025, showed: - Start date: Accuchecks before meals and at bedtime for diabetes mellitus; - Start date: 8/28/18 - Humalog (fast acting) insulin per sliding scale. For blood sugar 251 - 300, give six units for diabetes mellitus. - Start date: 5/14/20 - Humalog insulin 5 units before meals and at bedtime for diabetes mellitus. Review of the resident's MAR, dated May 2025, showed: - Accuchecks before meals and at bedtime for diabetes mellitus; - Humalog insulin per sliding scale. For blood sugar 251 - 300, give six units for diabetes mellitus. - Humalog insulin 5 units before meals and at bedtime for diabetes mellitus. - Resident received Accuchecks and Insulin in the month of May. Observation on 5/7/25 at 11:20 A.M., showed: - The resident sat at the dining room table with a male resident and 17 other residents in the dining room in view of the resident; - CMT A obtained the resident's blood sugar at the dining room table and pulled the resident's blanket back exposing his/her right upper thigh and administered the insulin. During an interview on 5/7/25 at 12:03 P.M., CMT A said: - He/She thought he/she could check blood sugars and administer insulin in the dining room. - He/She did not think there was an issue with privacy. During an interview on 5/8/25 at 9:11 A.M., Licensed Practical Nurse (LPN) A said he/she did not know if they had a policy for obtaining blood sugars and administering insulin in the dining room. During an interview on 5/8/25 at 9:49 A.M., Registered Nurse (RN) B said nursing staff normally take the residents to his/her room to check blood sugars and administer the insulin for privacy. During an interview on 5/8/25 at 11:45 A.M., the Director of Nursing (DON) said staff should not obtain residents blood sugars in the dining room or administer insulin in the dining room because the reisdents have a right to privacy and to be treated with dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN), the form Centers for Medicare and Medicaid (CMS) - 10055 to two of the three sampled residents (Residents #32 and Resident #139). The SNF ABN provides information to residents/beneficiaries to inform them of their rights that skilled services may not be paid by Medicare and resident or guardian will assume the financial responsibilities. The facility failed to provided the correct Notice of Medicare Noncoverage (NOMNC), which provides information to residents/beneficiaries to inform them of their covered services, and their right to appeal their discharge, for two of the three sampled residents (Resident #32, Resident #190, and Resident 139. The facility additionally failed to provided the correct SNF/ABN form for one of three sampled residents (Resident #190). The facility census was 86. The facility did not have a policy to address SNF Beneficiary Protection Notifications or the Notice of Medicare Non-coverage and right to appeal discharge policy. 1. Review of Resident #32's admission Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 2/21/25, showed: - Resident was cognitively intact; - Required assistance with activities of daily living (ADL's); - Diagnoses: Coronary Artery Disease, High Blood Pressure, Obstructive Uropathy. Review of the residents medical records showed: - No advance beneficiary notice in the medical record. - Facility is using outdated NOMNC and should be using form CMS-10123 with expiration date of 11/30/27 listed on bottom; - discharged from Medicare A services on 03/14/25. During an interview on 05/08/25 at 12:28 P.M., the Resident said he/she was unable to recall if the SNF/ABN or NOMNC forms were provided to or signed by the resident. 2. Review of Resident #139's admission MDS, dated [DATE]., showed: - Resident was cognitively intact; - Required supervision with ADL's; - Diagnoses included: Arthritis, Atrial Fibrillation, Gastro Esophageal Reflux Disease (GERD). Review of the Resident's electronic medical records showed: - discharged from Medicare A services on 12/24/24; - No advance beneficiary notice documentation in the medical record. - Resident had planned to return home but changed his/her mind and stayed until 01/18/25; - Facility is using outdated Notice of Medicare Noncoverage (NOMNC) and should be using form CMS-10123 with expiration of 11/30/27 listed on bottom; - discharged from facility on 01/18/25. 3. Review of Resident #190's Discharge MDS, dated [DATE], showed: - Resident was cognitively intact; - Required substantial assistance with ADL's; - Diagnoses included: Heart failure, High Blood Pressure, GERD. - discharged from facility on 04/03/25. Review of the Resident's electronic medical records showed: - Advance beneficiary notice showed Medicare A services would end on 04/17/25. The resident signed the form on 04/14/25; - Facility used form CMS-10055 (2018) and should have used form CMS-10055 (2024); - Facility is using outdated Notice of Medicare Noncoverage (NOMNC) and should be using form CMS-10123 with expiration of 11/30/27 listed on bottom; During an interview on 05/08/25, at 11:14 A.M., the Assistant Director of Nursing (ADON) said: - He/She is responsible for completing the SNF/ABN and NOMNC forms; - He/She recently took over this responsibility and needed to review previous records; - He/She wasn't sure where to find updated SNF/ABN and NOMNC forms. During an interview on 05/28/25 at 11:45 A.M., the Director of Nursing (DON) said: - The current SNF/ABN forms should be used; - The current NOMNC forms should be used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff maintained a safe, clean, comfortable environment for the residents when staff did not keep all areas of the facility clean and safe. The facility failed to address repairs and cleanliness deficiencies in the 500 Wing Dining Room and failed to fix and repair one resident's faucet (Resident #188) that was unable to be shut off for seven days and when two Resident's sinks were blocked (Resident #28 and #21) and would not drain. The facility census was 86. Review of facility policy, housekeeping room cleaning, dated February 2025, showed: -Housekeeping was 7 days a week. General cleaning is required daily for each occupied unit. Wednesdays are for deep cleaning which was also to be completed when resident discharged or was out to the hospital or on an extended leave of absence. -Wing 4 if it had less than 4 residents would do general cleaning on Wednesdays only and nursing was responsible for others days of the week. -Housekeeping was once a day in each resident's room with spot cleaning and removal of bodily fluid spillage by nursing in between cleanings. 1. Review of Resident #188's Entry tracking Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/30/25, showed he/she entered from short-term general hospital stay on 4/30/25. Observation on 5/5/25 at 9:01 A.M. showed the water at the sink faucet in his/her room was flowing rapidly with a steady stream of water from faucet. During an interview on 5/5/225 at 9:01 A.M., the Resident said: -His/Her water had been running from the sink faucet in his/her room since he/she moved into the facility on 4/30/25; -He/She had been told the facility was supposed to be fixing it. Observation on 5/5/25 at 9:17 A.M. showed Maintenance Worker B in resident's room working on faucet. Observation on 5/7/25 at 10:54 A.M. showed water was still running in resident's room. During an interview on 5/7/25 at 10:54 A.M., Resident said that staff came in and said they needed to order a part for the resident's faucet. During an interview on 9/5/8/24 at 9:20 A.M., Maintenance Director said: -He/She did not know exactly what was going on with the faucet running in resident's room; -The water that was running in resident's room was hot water; -The faucet in the resident's room was old and needed to be replaced; -If the handles on the resident's faucet did not get pushed back all the way then the water would not shut off to the faucet. During an interview on 5/8/25 at 9:29 A.M., Maintenance staff said: -Resident's faucet was streaming because the shut off valve was frozen and he/she could not turn off water to fix the problem; -The only way he had to turn water off was turning off the water to the wing; -The only day he/she could turn the water off to the building was on Wednesdays because the staff did showers every other day of the week; -When the faucet would be fixed he/she would have to shut off water to the entire wing and do it on a Wednesday. 2. Review of Resident #28's admission MDS, dated [DATE], showed: -Cognition moderately impaired; -He/She admitted from a skilled nursing facility on 4/3/25; -Diagnoses included renal failure, dementia, and diabetes. Observation on 5/5/25 at 10:14 A.M. showed the sink in resident's room wasn't draining and water was observed standing in sink. During an interview on 5/5/25 at 10:14 A.M., the Resident said that water in the sink would not drain and it had just started to become plugged up. Observation on 5/6/26 at 8:25 A.M., showed Therapy staff ask the resident what happened to the sink and the Resident said it was stopped up and that staff had tried to unclog it a couple of times. Observation on 5/6/26 at 8:49 A.M. showed two plumbers arrived and entered resident's room to look at sink. A machine was hooked up to the sink and a line was placed down the drain. During an interview on 5/6/25 at 8:49 A.M., the plumber said: -The sink was stopped up in other rooms on the same side of the hall in the facility; -The sink and plumbing was just old in the facility and that is what had caused the issues. During an interview on 5/8/24 at 9:20 A.M., Maintenance Director said: -He/She did not know exactly what was going on with sinks being stopped up in the building; -He/She would called the plumber if he/she had plumbing issues; -When building was built if one sink had problems the one in the room next to it had problems because the plumbing was tied together; -The resident's room was in an older part of the building and the building was built with concrete blocks; -The maintenance staff had been helping him repair issues in the building. During an interview on 5/8/25 at 9:29 A.M., Maintenance staff said: -The drain in resident's room had been slow draining for awhile and it was plugged up again; -The drain had been cleared a few weeks ago by the plumbers and became plugged up again during time resident had COVID and the facility could not have plumbers into service the drain in room while he/she was on isolation; 3. Review of Resident #21's Annual MDS, dated [DATE], showed: -Cognition intact; -He/She had clear speech and was able to make self understood and understand others; -Diagnoses included stroke, renal failure, diabetes, and respiratory failure Observation on 5/5/25 at 1:24 P.M. showed the sink in resident's room was stopped up with water in it. During an interview on 5/5/25 at 1:24 P.M. the resident said: -The facility was aware of the plumbing issue with his/her sink; -His/Her sink had not been draining for a couple of days. During an interview on 5/8/24 at 9:20 A.M., Maintenance Director said: -He/She did not know exactly what was going on with sinks being stopped up in the building; -He/She called the plumber if he/she had plumbing issues; -When building was built if one sink had problems the one in the room next to it had problems because the plumbing was tied together; -The resident's room was in an older part of the building and the building; During an interview on 5/8/25 at 9:29 A.M., Maintenance staff said the drain in resident's room had been slow draining for awhile and it was plugged up again. 4. Observation on 5/05/25 at 9:56 A.M. showed the water fountain in hallway between room [ROOM NUMBER] and 215 had pieces of hair observed in sink and a broken plastic container. Observation on 5/5/25 at 9:56 A.M. showed the hallway had dust accumulated observed along the walls in 200 hall. Observation on 5/5/25 at 11:00 A.M. showed the handrail outside of room [ROOM NUMBER] on the memory care unit was loose and moved when touched. During an interview on 9/5/8/24 at 9:20 A.M., Maintenance Director said: -He/She became aware of maintenance needs by staff telling him/her in hallway; -Staff were supposed to fill out a maintenance log at the nurses station on each hall. During an interview on 5/8/25 at 9:29 A.M., Maintenance staff said: -Hand rails should be securely attached to the wall; -He/She was not aware of a handrail that was loose on memory care unit; -Facility staff was supposed to write up a work ticket located at the nurses station for him/her to be aware of items needing repaired in the facility. During an interview on 5/8/25 at 9:46 A.M., Director of Environmental Services said: -He/She was supervisor over the floor technicians, janitorial staff, and housekeeping staff; -Maintenance was responsible for cleaning the return vents in the building; -The facility was deep cleaned on Wednesdays; -Resident rooms were cleaned every single day; -Hallways were swept every single day; -He/She did not expect the hallway to have dust accumulated. During an interview on 5/8/25 at 11:45 A.M., Administrator said: -He/She did not expect a resident's room faucet to be running for seven days and be unable to shut off; -He/She expected hand rails to be firmly attached to the wall; -He/She did not expect sinks in resident rooms to be stopped up and not draining; -He/She expected resident rooms to be maintained and cleaned daily;Observation of the 500 Wing Dining Room on 5/7/25 at 8:00 A.M., showed: - Multiple window blinds dirty with dust and spilled stains throughout the room; - Heavy dust on ceiling tiles and light covers from ventilation system, five in total; - 20-30 dead bugs on window sills; - Missing ceiling tile over dishwashing station; - Broken window pane with tape over a large crack; During an interview on 5/7/25 at 9:09 A.M., the Dietary Manager (DM) said /he/she would alert maintenance or housekeeping of the need for repairs or of cleanliness issues in the 500 Hallway Dining Room. She was aware of the cracked window and that is the only issue she knows of in that dining room; During an interview on 5/8/25 at 9:29 A.M., the Maintenance Director said he replaces ceiling tiles when he sees them or when someone tells him. He is not aware of any ceiling tiles that need replacement on the 500 Hall Dining Room. Window repairs, are contracted out to be repaired. He was not aware of any windows in the 500 Hall Dining room that needed replacement; During an interview on 5/8/25 at 10:03 A.M., the Housekeeping Supervisor said: - Housekeeping staff, are responsible for cleaning the 500 hallway dining room. The housekeeping staff clean the floors, but they don't do the window sills or walls unless they have a deep cleaning scheduled. The housekeeping staff are supposed to do deep cleaning weekly on Wednesday. None was done yesterday (Wednesday the 7th) due to low staffing issues. Staffing had been an issue in the housekeeping department. For items that needed to be fixed, such as the window and ceiling tile, a maintenance slip would be submitted to the Administrator who would send it onto the maintenance department to be fix. The window in the dining room had been broken for a long time, and was not sure where maintenance was with fixing that item. She was not aware of any missing ceiling tiles.

Based on observation, interview, and record review, the facility failed to ensure 12 of 12 residents who participated in a group meeting knew how to file a grievance in writing, and how to file anonymously. The facility census was 86. Review of facility policy titled Grievance Policy, dated 03/06/17, showed: - Grievances may be filed verbally or in writing and may be filed anonymously; - A verbal grievance can be reported to the Grievance Officer or any member of the facility staff, the staff member will report the grievance to the Grievance Officer; - Grievance forms are available in the front office and nurse's stations. This form can be completed and submitted to the Grievance Officer. An anonymous form will be accepted. 1. During a group meeting on 5/06/25 at 03:10 P.M., 12 of the 12 residents said: - They did not know where a form to file a grievance would be located; - They were not sure how to file the form for a grievance if one was located; - One of the 12 thought Social Services might be the one who handles them. During an interview on 05/07/25 at 10:32 A.M., Registered Nurse (RN) B said: - To file a grievance the residents can contact the ombudsman or can ask to talk to the social worker; - There are no grievance forms or drop box available that he/she knows of; - The residents can go through resident council for a grievance; - He/She has seen a resident ask and the resident was directed to the appropriate resources. During an interview on 05/07/25 at 11:02 AM the Assistant Director of Nursing (ADON) said: - For grievances the residents are sent to the social worker to take the grievance and keep it as anonymous as much as possible; - There is a drop box near the payroll office but he/she didn't think the residents knew how to access it and didn't think it had been opened in awhile. During an interview on 05/07/25 at 11:41 A.M., Licensed Practical Nurse (LPN) A said: - If a resident has a grievance they notify the social worker to get the greivance form; - There is no drop box or greivance forms out for the residents. During an interview on 05/07/25 at 12:00 P.M., LPN C said: - If a resident had a grievance they usually write it on any paper and put it under the Administrator's door; - There is a suggestion box by the front the residents can place it in. During an interview on 05/05/25 at 11:45 A.M., the Administrator said: - Residents with a grievance can see the social worker who will address the complaint with the resident, but is kept confidential; - After hours, the residents can go to their charge nurse with a grievance.

Based on the interview and record review, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected eight of nine sampled staff (Licensed Practical Nurse (LPN) B, Certified Nurse Aide (CNA) A, Activity Aide A, Registered Nurse (RN) A, CNA B, Dietary Aide A, Housekeeping Aide A, and Receptionist). The facility also failed to have a criminal record check on file prior to employee's first date working for one of eight sampled staff (Housekeeping Aide A). The facility census was 86. Review of facility policy, dated 11/20/2003, showed: -Policy of the facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property. -Screening A. All applicants for employment in the facility shall, at minimum have the following screening checks conducted: -Appropriate licensing board or registry check; -Criminal background check pursuant to facility policy or state law. 1. Review of LPN B's employee file showed: -Hired on 6/19/24; -No CNA Registry check found. 2. Review of CNA A's employee file showed: -Hired on 1/15/25; -No CNA Registry check found. 3. Review of Activities Aide A employee file showed: -Hired on 12/23/24; -No CNA Registry check found. 4. Review of RN A's employee file showed: -Hired on 4/9/25; -No CNA Registry check found. 5. Review of CNA B's employee file showed: -Hired on 10/28/24; -No CNA Registry check found. 6. Review of Dietary Aide A's employee file showed: -Hired on 11/13/24; -No CNA Registry check found. 7. Review of Housekeeping Aide A's employee file showed: -Hired on 2/26/24; -No background check prior to date of hire; -No CNA Registry check found. 8. Review of Receptionist A's employee file showed: -Hired on 6/12/24; -No CNA Registry check found. During an interview on 5/7/25 at 11:31 A.M., the Assistant Administrator said: -The CNA Registry was checked for just CNA's; -The facility did not check the CNA registry for staff that work in dietary or environmental services; -The receptionist completed the background and registry checks for employees; -Housekeeping Aide A was hired on 2/26/25, and he/she started working on 2/26/25; -Housekeeping Aide A's family care registry check was done on 3/12/25, there was no criminal background check in the employee's. During an interview on 5/7/25 at 11:43 A.M., Receptionist A said: -He/She only checked the Certified Nurse Aide registry on CNA's; -He/She printed off the CNA Registry check form and placed in employee file when he/she completed the checks; -Background checks were completed upon hire; -He/She did not have system in place to check the current employees backgrounds on a periodic basis; -If an employee had been employed for longer than two years he/she recently re-ran their family care registry checks. During an interview on 5/7/25 at 11:47 A.M., the Assistant Administrator said: -He/She did not have a criminal back check for Housekeeping Aide A upon hire; -He/She did not do CNA registry checks for all employees, just the nurse aides. During an interview on 5/8/25 at 11:45 A.M., Administrator said: -He/She expected all employees to have a background check completed and on file prior to working in facility; -He/She did not know that all employees should be searched on the CNA Registry for federal indicators, but now expects all employees to have a CNA Registry check completed upon hire to check for federal indicators; -He/She expected the facility abuse and neglect policy regarding employee screening checks to be followed for criminal background checks and registry checks according to facility policy or state law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge notice, including providing the statement of appeal rights or the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) within the transfer and discharge notices for two residents (Residents #16 and #21) out of eighteen sampled residents. The facility's census was 86. Facility did not provide a policy on transfer notices. 1. Review of Resident #16's Face Sheet showed: -He/She admitted to facility 3/31/25. -Diagnoses included stroke, muscle weakness, depression, and surgical aftercare following surgery to digestive tract. Review of Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, completed for the month of April 2025.,showed: -On 4/5/25 the Resident had an unplanned discharge to short term general hospital, with return anticipated; -On 4/6/25 returned to the facility; -On 4/13/25 the Resident had an unplanned discharge to short term general hospital with return anticipated; -On 4/15/25 returned to the facility. Review of progress notes in electronic medical record, dated 4/5/25-4/14/25, showed: -4/5/25, Resident transferred to the emergency room after complaints of chest pain; -4/6/25, Resident transferred back to the facility; -4/13/25, Resident transferred to hospital due to incision from surgery being red, and inflamed; -4/14/25, Resident was admitted to hospital for cellulitis of abdominal wall; Review of resident documents in electronic medical record, dated 3/31/25-5/7/25, showed no documentation of the written notification to the resident and/or the resident's representative for the resident's transfer to the hospital with ombudsman contact information. 2. Review of Resident #21's face sheet showed: -He/She admitted on [DATE]; -Diagnoses included pneumonia, respiratory failure, muscle weakness, peripheral vascular disease, and chronic pain. Review of past MDS, showed: -On 12/14/24, the Resident had an unplanned discharge to hospital with return anticipated; -On 12/24/24, returned to the facility; -On 4/13/25, The Resident had an unplanned discharge to hospital with return anticipated; -On 4/17/25, returned to the facility; During an interview on 5/05/25 at 1:24 P.M., the Resident said he/she had been frequently in and out of the hospital. Review of progress notes in the electronic medical record, dated 12/14/24-4/17/25, showed: -On 12/14/24, he/she was transferred to hospital after a change in condition; -On 4/13/25, he/she was transferred to the hospital for a change in condition; -On 4/17/25, he/she was admitted back to the facility. Review of resident documents in electronic medical record, dated 12/14/25-5/7/25, showed: -There was no documentation of the written notification to the resident and/or the resident's representative for the resident's transfer to the hospital with ombudsman contact information. 3. During an interview on 5/06/25 at 1:57 P.M., the Director of Social Services said: -He/She emailed a list of discharges to the ombudsman at the beginning of each month. -He/She did not handle the discharge or transfer paperwork when a resident went to the hospital. During an interview on 5/7/25 at 9:37 A.M., Licensed Practical Nurse C said: -When they send resident's out of facility they send a medication list, continuity of care document, the resident's last laboratory results, bed hold notices; -The resident's bed hold notices were then scanned into the electronic medical record under the other tab in resident documents. During an interview on 5/08/25 at 8:56 A.M. Registered Nurse (RN) B said: -He/She did not have a form or any document that showed ombudsman contact information to send out with resident discharges and/or transfers; -When he/she discharges a resident to the hospital he/she would send two copies, one for the emergency medical responders and one for the hospital. Documents were sent with the resident to include their physician's orders, continuity of care document that included their vitals, medications, and diagnosis, a history and physical, the resident's last laboratory results, code status, care plan, and a bed hold notice. During an interview on 5/8/25 at 9:33 A.M., Licensed Practical Nurse (LPN) A said the facility did not have any discharge forms that they send out with resident or family representatives with the ombudsman contact information on them. During an interview on 5/8/25 at 11:45 A.M., the Director of Nursing said: -He/She did not know of the requirement that information should be provided to the resident regarding the ombudsman's name, mailing address, email address, and telephone number of the office of the state long-term care ombudsman was to be provided to resident in the discharge notice discharge. -Currently the Assistant administrator provided a list of transfers and discharges to the ombudsman at the end of each month. During an interview on 5/8/25 at 11:45 A.M., the Administrator said he/she did not know of requirement for residents or their representatives to be notified of state long-term care ombudsman name, mailing address, email address, and telephone number was to be provided upon transfer or discharge.

Based on observation, interview and record review, the facility failed follow their policy regarding expired medications, and insulin when the facility staff did not date opened insulin pens or dispose expired insulin pens, which affected six of the 18 sampled residents, (Resident #7, #10, #12, #23, #61 and #70). The facility census was 86. Review of the facility's policy titled, Expired Meds and Supplies, dated 3/27/19 showed: - On the first of every month when change over is complete, the nurses and Certified Medication Technicians (CMTs) will audit the med carts, treatment carts, refrigerators, cabinets and supply rooms; - Any medication or supply found to be expired or that will expire that month will be destroyed. Review of the facility's policy titled, Insulin Pens,, dated 11/1/16, showed: - Every vial or insulin pen must be dated upon opening; - If the expiration date on the pen falls before the 42, 28, 14 days after opening, please discard. 1. Observation and interview on 5/7/25 at 8:44 A.M., of the 2A medication cart showed: - Resident #61's Lantus (long acting) insulin pen was opened and did not have a date when it was opened; - Resident #23's Lispro (fast acting) insulin pen was opened and did not have a date when it was opened; - Resident #23's Lantus insulin pen was opened and did not have a date when it was opened; - Resident #12's Humalog (fast acting) insulin pen was opened on 4/6/25 and expired on 5/4/25 and was still being used; - CMT F said the insulin pens should be dated when opened, and should not use insulin pens that are expired or not dated. Whoever is working would check the medication cart for expired medications. During an interview on 5/8/25 at 9:11 A.M., Licensed Practical Nurse (LPN) A said: - The insulin pens should be dated when opened; - The nurses or CMTs should not use insulin pens that are expired or not dated when opened. During an interview on 5/8/25 at 9:49 A.M., Registered Nurse (RN) B said: - The insulin pens should be dated when opened; - The insulin pens should not be used after the expiration date; - The CMTs on days should be checking the insulin pens when they use them and/or the nurses who are on the cart should be checking the insulin pens. During an interview on 05/06/25 at 11:03 A.M., CMT C said all stock meds and insulin should be dated when opened by nursing staff; During an interview on 05/06/25 at 02:08 P.M., CMT D said when opening insulin we label with date opened; Observation of medication cart and interview with CMT B on 05/07/25 at 10:11 A.M., showed: - Resident #7's Lantus pen open and not dated, sitting in top drawer of medication cart; - Resident #70's two Tresiba pens open and not dated, sitting in top drawer of medication cart; - Resident #10's Lispro pen open and not dated, sitting in top drawer of medication cart; - Certified Medication Technician (CMT) B stated that is night shift's medication cart and all insulin pens should be dated when opened; Review of Medication Administration Record for Resident's #7, #70, and #10 on 05/08/25 showed all three were administered insulin on night shift on 05/05/25 through 05/07/25. During an interview on 05/08/25 at 11:45 A.M., the Director of Nursing (DON) said: - Staff should date insulin pens when opening; - Staff should not use expired insulin pens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to record food temperatures in the temperature log after cooking food items and failed to ensure staff served food to the residents that was palatable and at an appetizing temperature when hot food was served at unappetizing temperatures for five (Residents #5, #14, #21, #40, and #42) out of 18 sampled residents. The facility census was 86. Review of facility policy, Food Temperatures, undated, showed: - All hot food items must be served at a temperature of at least 140F; - Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking. A recording form is also needed to document temperatures. To take hot food temperatures insert the thermometer and record the temperature and then remove the thermometer from the food item. Repeat these guidelines until all hot food temperatures have been taken; - Temperatures should be taken periodically to ensure hot foods stay above 140F and cold foods stay below 40F during the portioning, transporting and serving process until received by the resident; 1. Review of Resident #42's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/21/25, showed: - Resident is cognitively intact; - Diagnosis included: neurological disorder and diabetes; During an interview on 5/6/25 at 8:37 A.M., the Resident said the food is edible but it's not hot at all and it's not enjoyable to eat when it's cold; 2. Review of Resident #5's Annual MDS, dated [DATE], showed: - Resident was cognitively intact; - Resident is independent for eating and requires no assistance; - Diagnosis included: heart rhythm disorder, heart failure, and high blood pressure; During an interview on 5/5/25 at 1:59 P.M., the Resident said: - The food is cold when he/she gets a room tray. Many times the meal tray is delivered uncovered. The vegetables are either overcooked or under cooked. He/she was able to eat the florets today but the stem was hard and couldn't chew them. He/she does not enjoy meals when they are not cooked correctly or served hot. 3. Review of Resident #40's Quarterly MDS, dated [DATE], showed: - Resident had moderately impaired cognition; - Resident is independent for eating and requires no assistance; - Diagnosis included: heart disease, dementia, and Parkinson's disease; During an interview on 5/5/25 at 11:13 A.M., the Resident said: - He/she eats in the dining room and the facility makes them wait 30 minutes or longer before staff delivers meal trays and it happens for all meals. The food is cold when he/she gets it and the breakfast meal is the worst for being cold. He/she does not like it when the food is cold and they won't eat it at all. It makes him/her feel mad and disgusted. 4. Review of Resident #14's Quarterly MDS, dated [DATE], showed: - Resident had moderately impaired cognition; - Resident is independent for eating and requires no staff assistance; - Diagnosis included: stroke, heart failure, high blood pressure, and diabetes; During an interview on 5/5/25 at 2:33 P.M., the Resident said the food does not taste good and it's normally cold when it's served which makes him/her upset; 5. Review of Resident #21's Annual MDS, dated [DATE], showed: - Resident is cognitively intact; - Resident had clear speech and was able to make self understood and understands others; - Diagnosis included: stroke, renal failure, diabetes, and respiratory failure; During an interview on 5/525 at 1:19 P.M., the Resident said the food could be much better because it does not come out hot and today it was cold again which he/she doesn't like. During an interview on 5/5/25 at 1:20 P.M., a family member said: - The resident is not eating well and is concerned about how much the resident is eating because they hardly eat anything at meals. The resident always wants food from outside the facility brought in and for family member to feed him/her. Observation on 5/7/25 at 10:35 A.M. showed: - Hot food items mashed potatoes, mixed vegetables and chicken nuggets temperature checked by Dietary Aide B and then placed on the steam line and covered in foil and/or with steel container tops. The temperatures were not recorded in the temperature log before placing on the steam line; During an interview on 5/7/25 at 11:00 A.M., the Dietary Manager (DM) said food items are temperature checked to make sure they are done cooking, but the only temperatures recorded in the log are the ones that are taken from the steam line right before meal service starts; Observation on 5/7/25 at 11:20 A.M., showed temperature checks done by Dietary Aide B on all steam line items, all were above 140F; Continuous observation on 5/7/25, showed: - 11:35 A.M. test tray for 200 hallway loaded onto food cart last and departed kitchen; - 11:37 A.M. cart sitting in 200 hallway and cart heating coil unplugged; - 11:44 A.M. first food tray is removed from cart and delivered to a room [ROOM NUMBER]; - 12:10 P.M. last food tray delivered to residents on 200 hallway and test tray turned over for temperature checks; During a temperature check on hallway 200 test tray on 5/7/25 at 12:10 P.M., showed: - Chicken nuggets were recorded at 111F which is below requirement; - Mixed Vegetable were recorded at 106F which is below requirement; - Mashed potatoes and gravy were recorded at 117F which is below requirement; During an interview on 5/7/25 at 12:25 P.M., the (DM) said the cart would normally be plugged in while handing out trays but the switch has been broken for about a week and parts are on order. During an interview on 5/8/25 at 11:45 A.M., the Administrator said he would expect hot foods to be served to residents in their room in accordance with state and federal regulations. During an interview on 5/14/25 at 9:20 A.M., the Dietician said: - Temperatures should be taken after cooking according to state and federal guidelines for temperature requirements. These temperatures should be recorded in the temperature log. Temperatures should be taken on all food items on the steam line prior to serving; - Food should be served that is palatable to residents and normally at 140F but at the minimum food served in the dining room or in resident rooms should be no lower than 120F.

Based on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food safety when staff failed to annotate receipt dates on incoming deliveries of food, failed to dispose of expired food items, failed to store food items at least 6 inches off the ground, failed to properly label and seal opened food items, and failed to maintain cleanliness in the storerooms and 500 Wing dinging room. This affected all residents by putting them at risk for food borne illness. The facility census was 86. Review of facility policy Food Storage, dated 2005, showed: - All storage areas should have adequate humidity controls to prevent condensation and moisture; - Food items will be stored on shelves, food is stored a minimum of six inches above the floor on clean racks or other clean surfaces; - All containers must be legible and accurately labeled; - Food should be dated as it is placed on the shelves, old stock is always used first; - Leftover food is store in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated, leftover food is used within three days or discarded; - All refrigerator units are kept clean and in good working condition at all times; - All foods should be covered, labeled, and dated. Review of facility policy Use of Leftovers, dated 2005, showed: - Leftovers should be covered, labeled, and dated. Do not serve leftovers that have not been properly stored, throw it out if in doubt; - Any food that was served for a meal and not served is a leftover; - Leftovers must be used within 72 hours or discard. A facility policy covering the use by times of various food items used in the facility was requested but not provided. Observation of the Kitchen Storeroom at 9:00 A.M., showed: - Box of Cream of Wheat opened, not resealed with no dates written on the box. The box had a expiration date of 2/24 (expired); - No received dates annotated on any of the canned foods stored on the shelves; - Food cases opened did not have dates written on boxes of when they were received or opened. Observation of the Paper Storeroom at 9:10 A.M., showed: - Cleaning gear (Vacuum Cleaner) stored next to cases of canned foods; - Insulation debris and wood pieces on the ground in the paper storeroom; - Floor has dirt under the storage racks; - (5) boxes of liquid shortening stored on the ground with one holding the door open. Observation of the Walk-in Refrigerator at 9:14 A.M., showed: - Package of provolone cheese opened 4/27 not discarded; - Side wall of refrigerator has condensation on wall and inside junction box with rust on walls and heavy rust on junction box; - Onion skins on the floor and under the storage racks; - Repackaged green onions dated 4/24; - Beef base paste opened 4/22; - Pickles in plastic container opened 4/23; Observation of the stand-up Freezer at 9:18 A.M., showed a bag of green vegetables, resealed, unlabeled and undated. During an interview on 5/5/25 at 9:30 A.M., the Dietary Manager (DM) said: - We use the First-In First-Out (FIFO) method for stock rotation and do not write down receipt dates on products that come into the facility kitchen. The staff knows to place new food items in the back of the shelves so older items are picked from the front; - All dates annotated on food items are open dates not when it will be expired, Normally three days for items that are leftovers or have been cooked for meals but it varies. It is everyone's responsibility to check for expired food items and we currently have 15 kitchen staff. The staff learn about expiration dates through our internal training. Observation in Main Dining Room on 5/6/25 at 1:45 P.M., showed: - Juice labeled CB with a date of 5/2/24 stored in a plastic jug in the refrigerator expired, not discarded; - Prune juice in 48oz bottle opened 4/28/25 stored in the refrigerator not discarded; - Apple juice box in the refrigerator, open and not sealed, not dated, and not discarded. Observation in 500 Wing Dining Room on 5/7/25 at 8:00 A.M., showed: - Wall at drink station had liquid and food stains embedded; - Microwave had caked on burnt food covering the entire inside of the cooking area; - Back splash of sink was dirty near the dishwasher area; - Floor area around hand washing station was very dirty; - Refrigerator #1: Had food debris and spilled liquids on the interior surfaces; - Refrigerator #2: Sign on front: Label and date refrigerated items, juices, food, etc - Refrigerator #2: Applesauce leftover 5/2 (expired) not discarded; - Refrigerator #2: Had heavy spills and debris inside panels and on top of racks; - Refrigerator #2: (1) bowl with foil, not labeled or dated and not discarded. During an interview on 5/7/25 at 8:25 A.M., CNA G said: - The responsibility for cleaning this area is on dietary and maintenance and the CNAs will sometimes clean something if they have time but will notify staff responsible to clean those areas but it's not always done. For the microwave meals staff will heat the item up in the microwave for them and serve. The current state of cleanliness of the microwave is not satisfactory to CNA G and she would tell dietary about it. During an interview on 5/7/25 at 8:30 A.M., CNA H said the date on a food item is the date it was made or stored. It is good for three days from the initial date. So an item that has a date of 5/2 on it would be discarded on 5/5. During an interview on 5/7/25 at 3:00 P.M., the DM said: - The dishwasher and dietary staff are responsible for cleaning the equipment and food prep areas in the main dining room and the 500 Wing Dining Room. This falls mainly on the dishwashers. The DM is responsible for inspecting those areas for cleanliness such as label and dating and general cleanliness of the area. - There is currently no written policy on how long to keep foods. Leftovers are kept for three days. Condiments are kept for two weeks but it varies. Cereal for 30 days but not sure. For raw frozen foods she looks for freezer burn especially if the item has been there for a while. She also monitors for dates for when boxes are opened. - Every Monday there is a freezer walk through for inspection; - Juices have a three day window for using no matter what the container; - She goes by the expiration date on the container for milk; - There is no cleaning schedule published for staff members to sign off that they have completed their assignments; - She would expect the microwave to be clean and this is the responsibility of a dietary staff member; - She would expect the janitorial staff or housekeeping to keep the dining room clean and devoid of heavy dirt areas; - She would expect the inside of refrigerators to be wiped down and spills cleaned up; - A plastic container of pickles opened on 4/23 should be disposed of within two to three weeks but she is not sure; - Cleaning gear which is currently stored next to the spice rack will be moved due to it being unsanitary. During an interview on 5/14/25 at 9:15 A.M., the Dietician said: - She would expect dietary staff to monitor and clean kitchen equipment and drink stations in the dining rooms. This would include the ice coolers, microwave, and sink areas; - She would expect the floors of the walk-in refrigerator to be free of food debris and packages; - She would not expect food items to be stored on the floor or holding doors open; - Frozen vegetables repackaged should be sealed and the date of opening annotated; - Incoming food items should have a date of receipt placed on them. All items should be labeled with a sharpie or a label maker; - A plastic pickle container opened and resealed with a date of 4/23 should be good for 7 to 14 days but she would have to check with the guidelines. These should be posted on the refrigerator at the facility; - Different foods can have different use by dates based on the food item. During an interview on 5/8/25 at 11:45 A.M., the Administrator said: - He would not expect incoming food items to have dates written on them, new stock is put in the back and items are pulled from the front. When boxes and items are opened yes they should have dates; - Leftovers can be held two to three days depending on the food item; - He is not sure on all food items and would have to refer to the DM for clarification; - The food storage policy should cover all the different categories of food items and how long they can be kept when opened; - He would expect the inside of refrigerators to be free of debris and dried liquid spills; - He would not expect dirty cleaning equipment to be stored near food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #16's admission MDS, dated [DATE], showed: - Cognition moderately impaired; - He/She had a feeding tube; - He/She received 51% or more of total calories through parenteral or tube feeding; - He/She received 51% 501 cc/day or more of his/her fluid intake via tube feeding; - He/She was independent with eating; - Diagnosis included: surgical aftercare following surgery on digestive system, dysphagia, absence of part of digestive tract, and malnutrition. Review of care plan, revised 4/14/25, showed: - Resident required enteral feeding tube for nurtrition; - He/She used a EnFit 20 g-tube (type of gastrostomy or jejunostomy tube designed for delivering enteral nutrition directly into the stomach or intestines). - Administer medications through the g- tube. Evaluate/record/report effectiveness and any adverse side effects. - Administer enteral feeding at three times a day via bolus. Currently taking Isosource 1.5; Review of physician's orders, dated 5/7/25, showed: - Diet-mechanical soft thin liquids for pleasure feedings as needed; - Started 4/3/25, Geri-Lanta (alum-mag hydroxide -simeth) OTC) suspension; 200-200-20 mg/5mL; amt: 30 cc via peg tube; oral, special instructions: for indigestion, every 6 hours PRN - Started 4/21/25, Isosource 1.5 gastric tube. 1 can three times a day with 100 cubic centimeters (cc) water flushes before and after use. Verify placement after use, check residual prior to administration (TID) 8:00 A.M., 2:00 P.M., and 10:00 P.M.; Observation and interview on 05/05/25 at 01:14 P.M., showed: - Licensed Practical Nurse (LPN) C entered the room to administer enteral medications for the Resident #16; - There were no gloves, gowns, or masks available in the room at this time; - LPN C went back and forth from where? getting supplies and stated resident had just recently moved onto the unit; - LPN C returned with new 60 cc syringe for flushing of medications/water, a graduate (A measuring container for liquids), and labeled the graduate 5/5/25; - LPN C washed hands again and applied gloves, but did not use gown as none were available in room; - Opened syringe, checked tube for placement with air and stethoscope and drew back checking for residual tube feeding; - Poured in medications with water as ordered and the nutritional supplement in to the enteral feeding tube, flushed tube and clamped off; completed without wearing isolation gown; - LPN C stated resident had an EBP box in front of other room but staff didn't bring it over here. He/She totally forgot it, but stated staff do use them for the resident; Observation on 5/7/25 at 1:12 P.M.-1:29 P.M. showed Registered Nurse (RN) B providing Resident #16 his/her eternal feed as per his/her feeding tube by using a 60cc/ml syringe and gravity. RN B obtained the eternal syringe that was sitting in the resident's room on his/her sink. The syringe was removed from an undated and opened plastic bag that sat inside a graduate dated 5/5/25. The syringe and plastic bag the syringe was removed from, were both undated. During an interview on 5/7/25 at 1:29, RN B said: - Night shift was responsible for changing out the eternal feeding syringes; - The syringe bag was normally dated but the syringe bag that he/she had pulled the syringe out of today to use for Resident #16's eternal feed did not have a date on it; - He/She did not know when the syringe had been opened; - He/She did not know how often the graduates were replaced; - He/She planned to go and obtain a new syringe and ensure it was dated. Observation on 5/8/25 at 8:13 A.M. showed the resident's eternal feed syringe was sitting in a graduate on the sink inside an opened syringe plastic bag. The plastic bag was dated 5/7/25, and the graduate was labeled and dated 5/7/25. During an interview on 5/8/25 at 9:33 A.M., Licensed Practical Nurse (LPN) A said - The syringe for eternal feeds should be dated; - Eternal feeding syringes would be replaced nightly. During an interview on 05/08/25 at 09:34 A.M., the Infection Preventionist said staff should use EBP with Resident #16's cares; During an interview on 5/8/25 at 11:45 A.M., the Director of Nursing said: - Eternal feed syringes should be changed daily; - The charge nurse was responsible for changing the syringes; - He/She expected staff to date the graduate and put the syringe in the graduate to store it; - He/She did not expect staff to date the syringe but only the graduate. Based on observation, interview, and record review the facility failed to ensure staff followed infection control practices regarding urinary catheters (a flexible tube inserted through the urethra or suprapubically, through a small incision in the abdomen, into the bladder to drain urine) and a enteral feeding tube (a tube that is inserted into the digestive tract to deliver nutrition) care for two Residents (Residents #16 and #66) when proper Enhanced Barrier Precautions (EBP) were not utilized by staff when emptying catheter drainage bag for Resident #66 and when providing medication administration by use of enteral tube for Resident #16. This affected two of the 18 sampled residents. The facility census was 86. Review of the facility policy Foley Catheters, dated 5/28/19, showed drain spouts are to be cleaned with an alcohol wipe before placing it back into its container. Review of the facility policy EBP, dated 11/14/24, showed: - EBP are to be used to decrease the transmission of resident to resident spread of the Centers for Disease Control (CDC) target Multi-Drug Resistant Organisms (MDRO's) for the duration of their stay when contact precautions do not apply and to protect those with indwelling medical equipment such as, indwelling urinary catheters, accessed IV's, tracheotomies, central lines, ventilators, dialysis shunts and feeding tubes, these precautions are also used for chronic open wounds and surgical sites that are unhealed; - EBP includes the use of gloves and gowns for all high risk/contact activities; - EBP is the use of gloves and gowns with dressing, bathing or showering, transfers in residents rooms or in the shower room, all hygiene you are performing of resident peri/cath care, toothbrushing, hairbrushing, changing linens, toileting, device care (cleaning and emptying), wound care, therapy sessions, and lab draws; - Carts will be placed inside room for gowns or place in a dedicated drawer if resident does not want cart. Review of the facility policy, Enteral Feeding Procedure, dated 6/30/14, showed: - Tubing should be changed every time the enteral feed bottle is changed; - The bottle should be dated and initialed at each change; - The 60 cc syringe should be changed as well when the enteral feed bottle is changed; - The graduate is replaced on the last day of the month and as needed. 1. Review of Resident #66's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 4/8/25., showed: - Resident was cognitively intact; - Required substantial nursing assistance with toileting hygiene; - Had an indwelling catheter; - Diagnoses: obstructive uropathy, borderline intellectual functioning, arthritis. Review of comprehensive care plan, dated 01/20/25, showed: - Required Enhanced Barrier Precautions due to suprapubic catheter; - Required assistance with some activities of daily living (ADL's); - Needed assistance with site care, catheter care and emptying of the drainage bag. Observation on 05/06/25 at 08:27 A.M., showed: - CNA C entered room to empty Resident #66's catheter drainage bag; - Washed hands and applied gloves but did not apply gown; - Emptied urine into graduate, wet a wash rag, and wiped the end of the drain spout. During an interview on 05/06/25 at 08:12 A.M., Resident #66 said: - Sometimes nursing staff don't wear gowns and gloves when providing catheter care; - He/She wasn't sure it was a big problem but thought staff should wear them. During an interview on 05/06/25 at 08:30 A.M., Certified Nursing Assistant (CNA) C said: - He/She had been there two months and recieved about a week of training; - When performing catheter care for residents, staff should wear gowns and gloves, then said, I forgot didn't I; - There should be a red barrel for EBP trash, but he/she thinks that's just for isolation people; - Staff should clean the catheter spigot with a wash rag then take the dirty rag to laundry/hazmat. During an interview on 05/05/25 at 02:27 P.M., LPN E said: - There are EBP gowns and gloves at nurses station and in the rooms in a box with drawers; - Staff can use the gown for the day then just throw in regular trash can; - The catheter spigot should be cleaned with alcohol; - For enteral feedings, staff should apply gowns and gloves and possibly a mask. During an interview on 05/06/25 at 10:50 A.M., Certified Medication Technician (CMT) E said: - When cleaning catheters staff would wash hands then put on gloves and gown; - Have alcohol wipes, graduate, and towel to put graduate on; - Clean spigot with alcohol wipe, drain, and clean spigot again; - Empty graduate into the toilet and cover with a bag. During an interview on 05/06/25 at 02:08 P.M., CMT D said: - He/She would wash hands and apply gowns and gloves; - Then place a towel under the graduate, empty it, then use alcohol wipe to clean the drain spout. During an interview on 05/07/25 at 08:01 A.M., Registered Nurse (RN) B said he/she always uses EBP gowns and gloves, and throw away in trash or remove in trash. Observation and interview with CNA E on 05/07/25 at 12:16 P.M., showed: - CNA E knocked and entered room, sanitized hands, and applied gown and gloves; - Placed graduate on paper towel on floor; - Drained catheter leg bag into graduate, closed drain, and wiped drain spout with alcohol wipe; - Put towel and wipe into trash, measured then emptied graduate into toilet; - Returned graduate to cover on toilet and removed gown and gloves then washed hands; - Stated staff should use gown and gloves and the drain should be wiped with an alcohol wipe. During an interview on 05/08/25 at 09:20 A.M., the Director of Nursing (DON) said: - Resident #16 had just been moved to the memory care and the nurse told me he/she forgot to use the gown. Staff should use EBP with these cares; - CNA C who didn't use a gown with Resident #66 should have used EBP with his/her cares. During an interview on 05/08/25 at 09:34 A.M., the Infection Preventionist said: - Staff should use EBP with Resident #16's cares; - Staff should use EBP with Resident #66's cares.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident and/or representative (Resident (R) 65) of five residents reviewed for unnecessary medications out of a total sample of 21 residents was informed of the risk and benefits of physician ordered psychotropic medications. This failure placed the resident and/or representative at risk of not knowing the risks and benefits of the use of the medications. Review of the Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R65 was admitted to the facility on [DATE] with diabetes, heart failure, and chronic obstructive pulmonary disease (COPD). Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/07/23 revealed, R65 had a Brief Interview of Mental Status (BIMS) of 14 out of 15 which indicated she was cognitively intact for daily decision-making. Review of a 10/24/23 Psychotropic Medication Change [Recorded as Late Entry on 11/07/23] located in the Progress Notes tab of the EMR revealed NEW ORDER for Seroquel [an antipsychotic medication] 12.5 mg at HS [hour of sleep] for increased behaviors, hallucinations and paranoia .Resident has been having increasing behaviors and imagining things that are not there. Thinking that everyone is talking about her and spreading her personal information around .Unable to redirect. The Psychotropic Medication Change Progress Note did not show that R65 or her representative was informed of risks and benefits prior to the initiating a new Physician Order for Seroquel. Review of a 12/05/23 Nursing Progress Note, located in the Progress Notes tab of the EMR, revealed Resident with new order received .Rexulti [an antipsychotic medication] 0.5 mg by mouth every day for Depression/Behaviors. The Progress Note indicated that R65's representative was notified of the medication however, the documentation did not show that R65 was informed or that the risks and benefits of the medication were explained to the resident representative or to the resident. During an interview on 04/05/24 at 8:19 AM, Licensed Practical Nurse (LPN) 1 was asked what the process was to explain the risks and benefits for psychotropic medications, when ordered by the physician. LPN1 stated, We have never had a form for them to sign, we just call and tell them a new medication was ordered. We are then to document it [the phone call] in the progress notes. LPN1 further stated, If it's not documented in the Progress Notes then it didn't happen. During an interview on 04/05/24 at 11:29 AM, the Director of Nursing (DON) was asked what her expectation was regarding informing the resident and/or representative of new orders for psychotropic medications including the risk and benefits. The DON stated, We just document it in the 'Progress Notes' that the family was called.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to investigate an injury of unknown source for one resident (Resident (R) 65) of one resident reviewed in a total sample of 21. This failure to investigate a fractured leg placed the resident at risk for potential abuse. Review of the facility policy titled, Policy and Procedure Regarding Investigation and Reporting of Alleged Violation of Federal and State Laws involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Residents property, dated 11/20/03 revealed, Investigation: All investigations shall be conducted by the Administrator or DNS (Director of Nursing Services) .The investigation shall include interviews of employee's, visitors or residents who may have knowledge of the alleged incident .Written statements from involved parties should be requested .The medical record should be reviewed to determine the resident's past history and condition and its relevance to the alleged violation . Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R65 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, history of falls, and heart failure. Review of a 10/27/23 at 10:24 AM, Psychotropic Medication Change Progress Note located in the Progress Notes tab of the EMR revealed, .Resisting Care: Resident called this nurse to room stating she was unable to stand d/t knee popped. Resident's ROM WNL [range of motion within normal limits]. Resident was using BLE [bilateral lower extremities] to move around her room while in her W/C [wheelchair], but when came to standing to pivot to her bed, resident was stating she was unable to stand on her leg . Review of a 10/28/23 at 5:47 AM, Nursing Progress Note located in the Progress Notes tab of the EMR revealed, .Resident called this nurse to her room to ask this nurse to put a piece of furniture on her leg. This nurse asked her why she would want me to do that. Resident stated you know I broke my femur again . Review of a 10/28/23 at 12:13 PM Psychotropic Medication Change Progress Note located in the Progress Notes tab of the EMR revealed, .Resident tearful and crying at times this morning. Calling family telling them that she fell last night and that CMT [Certified Medication Tech] that has not been working last couple of days is one that picked her up off of the floor then told her daughter that 2 people she didn't know picked her up and lifted her back to bed this morning. No noted falls and or reports from previous shift . Review of a 10/28/23 at 12:17 PM Nursing Progress Note located in the Progress Notes tab of the EMR revealed, .Resident c/o left knee pain this morning .Stated she fell last night and named a CMT that has not been working last couple of days is [sic] the one that picked her up and put her to bed. Then while her daughter was here visiting, resident stated that 2 staff she didn't know picked her up and 'heaved' her back to the bed. This nurse was raising PJ pant leg up over left knee to apply pain cream when resident stated, 'I broke my femur down there on my knee, look I have 36 stitches in there' .left knee does appear slightly swollen at this time In addition to the voltaren gel application, prn [as needed] NORCO administered and ice pack applied to left knee x20 min. Resident appeared to be resting with eyes closed The Nursing Progress Note did show that pain medication was administered. Review of a 10/31/23 at 12:22 PM Nursing Progress Note located in the Progress Notes tab of the EMR revealed, .Resident's daughter came to the desk and stated, 'Mom's lips are so dry, I want her sent to the hospital.' Resident sent to the hospital per family request . Review of an 11/03/23 at 4:29 PM, Nursing Progress Note located in the Progress Notes tab of the EMR revealed, .Res. readmitted to the facility from the hospital due to a diagnosis of UTI [urinary tract infection] . Report from the hospital states: there is an intramedullary rod which extends down femur. The acuity of this fracture is uncertain. Cannot exclude that is an acute fracture . Review of a significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/07/23 revealed, R65 had a Brief Interview of Mental Illness (BIMS) score of 14 out of 15 which indicated R65 was cognitively intact, had range of motion impairment on one side, lower extremity, was dependent on staff for transfers and did not ambulate. During an interview on 04/02/24 at 1:41 PM, R65 was observed seated in her recliner. She was alert, oriented and easily conversed with this surveyor. She stated that she had been to the hospital for a broken knee. R65 further stated that she could not longer walk and needed help to getting into her wheelchair as her legs no longer worked. During an interview on 04/04/24 at 3:36 PM, Family Member (FM) 1 stated, .When they brought her back, it wasn't too long that when mom started calling me with increased hallucinations .I asked the nurses, and they said her knee was hurting. My mom kept saying 'they dropped me.' Several days went by, she stopped walking and then got another UTI. When she got to the hospital, they took x-rays and said she had a 'crack' in her femur.' We asked staff about it, and they said they 'heard a low pop' and now she no longer walks . During an interview on 04/05/24 at 8:19 AM, Registered Nurse (RN) 1 was asked about the Nursing Progress Note in which she documented about the x-ray report from the hospital indicating the acute fracture was an investigation started. RN1 stated, I did not start an investigation when I became aware of it. During an interview on 04/05/24 at 11:32 AM, the Director of Nursing (DON) was asked if an investigation into R65's statements had been investigated as possible abuse due to the fracture of unknown origin. The DON stated, I wasn't aware of the x-ray report or the resident's statements as documented in the progress notes. The DON further stated had she been made aware of the allegation, she would have investigated it, but no one told her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's preferences for one resident (R84) of nine residents reviewed for activities in the secured dementia unit out of a total sample of 21 residents. This failure placed R84 at risk of a diminished quality of life. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R84 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date of 02/27/24 revealed R84 had a Brief Interview of Mental Status (BIMS) score of four out of 15 which indicated she was severely impaired in cognition. In addition, her staff assessed activity preferences revealed R84 liked to spend time away from the nursing home, doing her favorite activities including religious activities. Review of the 04/01/24 Activity Care Plan located in the Care Plan tab of the EMR revealed, Problem: Need for Activity Involvement .R84 was always on the go and did not like to sit still. She attended the Baptist Church. She was very involved with her church. She would be found there every Wednesday evening and on Sundays. She enjoys watching TV. She enjoyed the Dr. [NAME] show and [NAME] News channel. R84 loved hiking around the (name withheld). R84 loves all things chocolate. She enjoys drinking Mountain Dew. In the past R84 enjoyed reading the newspaper every day. During an observation on 04/02/24 at 1:19 PM, R84 was observed sitting on the floor, then would get up and start walking around. There was one other resident observed in the common room, watching a game show on TV. All other residents were observed in their room, lying in bed except for one resident whose family was visiting with her, in her room. During an observation and interview on 04/04/24 at 9:28 AM, Certified Nurse Aide/Certified Medication Aide (CNA/CMA) 2 was observed trying to help and redirect R84 off the floor. She obtained washcloths out of the cabinet and encouraged R84 to fold them for her. R84 was unable to perform this activity due to not being able to sit down long enough before getting up and walking around and then sitting on the floor. The CNA/CMT 2 was asked why there were no other residents in the common area. She stated, I don't know why they are not here. CNA/CMA2 was asked if she was the only staff person in the unit. She stated, Yes. CNA/CMA2 stated, We just moved all the residents from the 400 hall to this unit to consolidate for staffing. We are all just getting used to it here. In an interview, CNA/CMA 2 was asked how she knows what activities R84 was interested in or enjoyed. CNA/CMA 2 stated, I just try things like the washcloths. She was asked if there was an activity logbook so staff could account for what the residents were able to do for their activity preferences. CNA/CMA 2 stated, I thought there was a book on the desk. An observation with CNA/CMA 2 of the desk in the secured dementia unit, showed no activity logbook. During an interview on 04/04/24 at 1:10 PM, the Activity Director (AD) was asked why R84's Activity Care Plan was not developed for over 30 days after admission to the facility. The AD stated, I had trouble getting in touch with her family [to find out what activities interested R84]. The AD further stated, I spend a lot of time with all the residents on the unit, but with R84 we do hand holding and walking with her. The AD stated, I know the residents are laying [sic] in bed more, the aide on the dementia unit is supposed to do activities with them. They have games and widgets which are in the new cabinet. My activity assistant does not do one-on-one activities in the unit The AD further stated, We used to be on the 400 hall and there was a patio for the residents to go and sit in the sun on nice days during the summer. We would have popsicles and reminisce, now we don't have that. We tried bingo on the unit the other day as a trial, and it went well, considering it took awhile for the residents to find the numbers.

Based on observation, interview, and record review, the facility failed to ensure one of four Certified Medication Aide (Certified Medication Aide (CMA) 3) observed during medication pass, had the skills and competency to safely perform medication administration. Refer to F761. Review of the Staff Roster provided by the Director of Nursing (DON) revealed CMA 3 was hired by the facility on 07/11/02. Review of the 2023 and 2024 Skills and Drills sheet provided by Licensed Practical Nurse (LPN) 5 showed CMA 3 had not been assessed for medication competency since 04/11/23. The Skills and Drills sheet further revealed that CMA 3 was only observed for insulin, eye drops, and inhalers and had not been assessed for any other medication pass requirements. During an interview on 04/05/24 at 10:39 AM LPN 5 confirmed that CMA 3 had not been assessed for competency since 2023 and that overall medication pass observation had not been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure resident Care Plans were updated/revised for two residents (Residents (R) 84, R6) of 21 sampled residents. The facility failed to update the Care Plan for R84 related to her behaviors and oxygen usage for R6. This failure created an increased risk for the residents to care and services that may not be appropriate for their current clinical condition. Review of the facility policy titled, Updating Care Plans, dated 04/05/18 revealed, . Care Plans need to be continually updated as the resident's needs change. The Care Plan needs to reflect the resident's current status at any given moment . 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R84 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/27/24, revealed R84 had a Brief Interview of Mental Status (BIMS) score of four out of 15 which indicated she was severely impaired in cognition, had physical and verbal behaviors, rejected care for one to three days during the observation period. In addition, it was documented that R84's behaviors had worsened since admission. Review of the 03/05/24 Behavior Care Plan located in the Care Plan tab of the EMR revealed, R84 has episodes of inappropriate behavior which interfere with her care and the care of other residents. She can be combative and strike out. Approaches, dated 03/05/24 include the following: .R84 has a scheduled anti-psychotic medication for management her [sic] behavior and anxiety. She also has a prn [as needed] for management of breakthrough behavior which presents as a safety issue . R84 verbalizes delusions about family and events. Provide reassurance and distract as much as possible with activities or conversations. R84's anxiety sometimes presents with verbal and physical behavior. Try to remove her from the situation, allow her to calm [sic]. Limit stimulation if she appears upset. When she refuses or resists care, reapproach at a later time. Wandering: R84 is up wandering and pacing throughout the unit. She tries doors to find her care/family, etc. She also wanders into other resident rooms. Staff to [sic] monitor her where abouts [sic] and redirect as needed to keep her safe. Take her to group activities or common areas and encourage her participation. During an observation on 04/02/24 at 1:19 PM, R84 was observed sitting on the floor in the common area. Certified Medication Technician (CMT) 4, upon observing the surveyor having entered the secured dementia unit, stated She is care planned to be sitting on the floor. CMT 4 tried to assist R84 to stand up however, R84 was able to stand independently without assistance. During an observation on 04/04/25 at 9:28 AM, R84 was observed to ambulate independently in the common area, then lean over and sit on the floor, then stand up again and continue to ambulate, then repeat this behavior. Review of the Behavior Care Plan did not show the behavior of sitting on the floor as a problem nor was there an approach which included how staff were to address this behavior with R84 safely. During an interview on 04/04/24 at 12:21 PM, Licensed Practical Nurse (LPN) 4 was asked when the behavior of sitting on the floor start. LPN 4 stated, It's been that way all along. During an interview on 04/04/24 at 12:23 PM the Unit Manager (UM) 1 was asked about the behavior of sitting on the floor. UM 1 stated, Her family at home stated she was a floor sitter. It was reported to MDS about the behavior so it could be care planned. UM 1 was told that that information was not in the Care Plan. UM 1 reviewed the comprehensive Care Plan and the Care Plan book located at the nurses' station and stated, There is nothing in her Care Plan about the behavior. 2. Review of R6's Face Sheet, located in the resident's electronic medical records (EMR) section titled Face Sheet, revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic congestive heart failure and chronic atrial fibrillation. Review of R6's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/24, located in the resident's EMR under the MDS tab indicated the facility assessed R6 to have a Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating R6 had intact cognition. Review of R6's Care Plan, located on Unit five in the Care Plan book, revised 03/28/24 revealed the resident did not have a oxygen care plan to address their continuous oxygen order. Review of R6's Physician's Orders, located in the resident's EMR under the Orders tab, revealed R6 the following orders: -O2[oxygen] Titrate via nasal cannula to maintain O2 sats>PRN [as needed] with 2 Liters and O2 sats with start date of 03/20/24. Observation and interview on 04/02/24 at 10:00 AM, R6 was observed sitting in wheelchair with oxygen on face. R6 stated they had been using oxygen since their last hospital visit last month in March 2024. An interview on 04/05/24 at 1:55 PM, with the Assistant Director of Nursing (ADON) revealed they were the MDS Coordinator and ADON and they were responsible for initiating and updating care plan as they are completing any quarterly, annual, or significant change MDS's. ADON revealed they updated R6's care plan when they updated their last significant change MDS, and they just missed the oxygen. ADON stated it was important to include oxygen on the care plan so that staff would be aware of and know how to care for R6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide showers to two residents who preferred showers (Residents (R)8, and R73) of five residents reviewed in a total sample of 21 residents. This failure placed the residents at risk of a diminished quality of life. Findings include: 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R8 was admitted to the facility 03/01/10 with diagnoses that included Parkinson's disease (a progressive neurological disorder), dementia, and anxiety. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/06/24 revealed R8 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact for daily decision-making. In addition, the assessment revealed she required substantial assistance with showering. Review of an 01/22/19 ADL [activities of daily living] Care Plan, revised on 11/16/23 which was located in the Care Plan tab of the EMR, revealed R8 is at risk for decline in ADL abilities related to progressive dementia and general weakness. At this time, she is independent with her ADLs, only needing help if having illness or when she requests. A 01/22/19 intervention revealed, Bathe per choice of whirlpool, shower, or bed bath twice weekly. R8 requires extensive assist of 1 for bathing. During an interview on 04/02/24 at 12:15 PM, R8 was asked if she was provided showers per her schedule. R8 stated, I am to get two showers [her choice of bathing] per week . I haven't had a shower since last Tuesday [lapse of seven days]. R8 was asked if she was aware of any reason as to why she had not received her showers. R8 stated, I haven't heard a word as to why, but I think it's due to being short staffed. Review of the Shower Sheet located in a binder at the nurses' station, revealed the following dates that there was no documentation of R8 having received a shower. January 2, 2024. January 9, 2024. February 16, 2024. March 26, 2024. March 29, 2024. 2. Review of the Face Sheet located in the Face Sheet tab of the EMR revealed, R73 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (a condition marked by impaired muscle coordination) and mental illness. Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 03/19/24 revealed R73 had a BIMS score of 15 out of 15 which indicated she was cognitively intact for daily decision-making. In addition, R73 required substantial assistance with showering. Review of the 01/19/23 ADL Care Plan, located in the Care Plan tab of the EMR revealed, Self-Care Deficit: R73 showers herself with supervision for safety and assistance to safely transfer to the shower chair . During an interview on 04/02/24 at 10:06 AM, R73 was asked if she received her showers per her preference. R73 stated, I never refuse a shower as it is important to me. My showers are twice a week, they are short-staffed, and they can't always give me one. R73 was asked if they were able to provide a shower later in the day or the next day. R73 stated, No, I just have to wait until next week. I wish it didn't happen. Review of the Shower Sheet located in a binder at the nurses' station, revealed the following dates that there was no documentation of R73 having received a shower. January 4, 2024. January 15, 2024. February 1, 2024 March 25, 2024. April 1, 2024. During an interview on 04/02/24 at 2:25 PM, Licensed Practical Nurse (LPN)5 was asked about the missing documentation in the shower book. LPN 5 stated, It was probably due to a staffing issue. If we have two CNAs [Certified Nurse Aides], it cannot be done. If we have three CNAs, I will assign an aide to showers. I do try and help out with showers, but it's not always possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and family interviews, and facility policy review, the facility failed to (1) assess resident (R) 23's falls, monitor the effectiveness of the interventions, or modify the interventions to prevent further falls and/or injuries for one of three residents reviewed for falls (R23, R46, and R57); (2) provide a fire blanket and fire extinguisher in the three designated resident smoking areas to reduce the risk of harm for the three residents who smoke (R26, R30, and R42); and (3) to conduct a smoking assessment for one of three residents (R)26, to determine independent versus supervised smoking needs. 1. Review of the facility's 2006 policy titled, Unusual Occurrences, provided by the Administrator, revealed the following: All incidents will require that an incident report be filled out by the charge nurse. Incidents are falls, bruises, skin tears and anything that the charge nurse would consider an unusual occurrence. Once the incident report is complete . the coordinator will log all incidents to the unusual occurrence tracking log. From the tracking log, the unit coordinator will report at the monthly quality assurance meeting as to whether there has been any trending of these occurrences and what measures were put in place for prevention of further occurrences. Review of R23's Census, located in the electronic medical record (EMR) under the Resident tab, revealed R23 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; other intervertebral disc degeneration, lumbar region; other abnormalities of gait and mobility; unspecified lack of coordination; difficulty in walking; muscle weakness; cognitive communication deficit; unsteadiness on feet; syncope and collapse; and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/12/24, located under the RAI tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R23 was cognitively intact. Review of the facility's Incident Reports for R23 revealed fourteen falls in a six month time period. Falls were reported to have occurred on 09/06/23, 10/9/23, 10/22/23, 11/8/23, 11/15/23, 11/19/23, 11/19/23 (second fall same day), 01/20/24, 01/25/24, 01/27/24, 02/3/24, 02/7/24, 02/10/24, and 02/11/24. R23 was identified to have been ill December 2023 and initiated hospice care on 12/08/23. Each fall noted as found on floor. There was no documentation of fall assessments or root causes analysis after the falls. During an interview with the Unit Manager (LPN1) on 04/04/24 at 9:52 AM, regarding R23's fourteen falls. LPN1 was asked about a timeline of interventions, what was put in place when for R23. LPN1 stated, you'll have to look in the care plan book, at the nurses' station, I don't know. Review of R23's most recent care plan, located at the nurses' station, updated 03/21/24, revealed R23 was at risk for falling d/t (due to) taking an antidepressant for DX (diagnosis): depression and anxiety. She has been on this medication since her admission to this facility and is stable on this med (medication). and having a seizure d/o (disorder) . due to a decline in mobility and functional status. The interventions were listed as: Maintain a safe environment. Limit clutter and keep frequently used items within reach. Keep bed in lowest position with brakes locked. Reinforce safety precautions as (R23) does not always remember. Remind her to use call light and how to use it. She is not to attempt to get up without assistance. Remand resident not to ambulate/transfer without assistance. (R23's) ability to bear weight is limited, she is to transfer via Hoyer lift and two helpers. (R23) has been prescribed antiplatelet therapy, may take longer to stop bleeding if an injury. On 04/03/24 at 11:43 AM, R23 was observed in her room seated in a Geri-chair visiting a family member (FM2). R23 and FM2 were interviewed regarding the numerous falls sustained by R23. FM2 stated, the fall in November was the big one where (R23) hurt her back, then they put her in this (Geri chair) or in the bed. When asked about interventions post falls, FM2 stated, the bed was changed, but it's not always down low when we visit and she's in the bed, but the mats are usually on the sides of the bed now. During the family visit, R23 was transferred into bed which remained in the high position after family left. This was observed on 04/03/24 at 1:27 PM. On 04/04/24 at 11:19 AM, a telephone interview was conducted with R23's family member (FM3). FM3 stated, she has had multiple falls, I am concerned about the falls and making sure (R23) always has her call light, that is her only lifeline. FM3 stated, I requested a bed alarm and was told no. Observation of R23 on 04/02/24 at 9:44AM, revealed the resident in her room, in bed which was raised. A staff member walked into the room to provide personal care. Observation of R23 on 04/04/24 at 11:57 AM, revealed R23 in bed. The bed was not in a low position. During an interview with the Director of Nurses (DON), on 04/05/24 at 1:10 PM the DON was asked if a root cause analysis and/or evaluation of R23's fourteen falls had been completed. The DON stated, She had that many? No, we don't do that. When asked if R23 was reviewed in the facility's weekly clinical meeting, the DON looked at three pages of typed notes from a meeting and said, not since January. When asked what interventions had been put in place and when, the DON stated, I cannot tell you when interventions were put in place, I don't know. When asked if the DON could locate when interventions were implemented to prevent further falls and/or injuries for R23, the DON stated, no, it's not in the medical record. 2. Review of the facility's undated Resident Smoking Policy, provided by the Administrator, revealed Residents of [NAME] Nursing and Rehabilitation Center are allowed to smoke under to levels of supervision: 1) If the resident has been assessed by the nursing dept. to be physically and cognitively able to smoke without supervision, then we ask that the resident inform their unit if going outside. Residents may continue to smoke unsupervised so long as their condition continues to allow. If there is an injury to the smoker, i.e. they burn themselves or become inattentive, then they will be placed on supervised smoking schedule. 2) If the resident has been assessed not to be safe due to physical or cognitive issues, then the resident will have to comply with the supervised smoking times. All smokers will use the designated smoking areas regardless of whether you are supervised or not. There is never to be any smoking within the facility. Violation of this policy can result in facility issuing a 30 day notice of discharge. Review of the posted smoking times, at the 200 hall nurses' station, revealed the times to be 9:00 AM, 1:00 PM, 3:00 PM, 6:00 PM, and 9:00 PM. Review of R 26's Face Sheet, located in the EMR under the Resident tab revealed R26 was admitted on [DATE] with diagnoses that included cervical disc disorder with myelopathy, metabolic encephalopathy, muscle weakness, unspecified lack of coordination, and cognitive communication deficit. Review of the quarterly MDS, located under the RAI tab with an ARD of 01/02/24, revealed a Brief Interview for BIMS score of 14 out of 15 indicating R26 is cognitively intact. Review of R26's care plan, located under the RAI tab in the EMR, revealed R26 may smoke as desired unless condition changes and requires supervision. Smoking materials are kept by nursing staff. (R26) is to turn in all smoking materials after smoking. Offer smoking apron for protection from burns. He often declines to use it. Edited 03/30/23. The last date, written at the bottom of the care plan page was 10/16/23, and read Cont. (continue) with POC (plan of care) x90d (times ninety days). Observation of one of the designated smoking areas, on the 200 hall, on 04/02/24 at 10:32 AM, revealed R26 in his electric wheelchair, with a smoking apron on, and Registered Nurse (RN) 1 supervising. A self-extinguishing ashtray was visible. There was not a smoking blanket or fire extinguisher available in the designated smoking area in case of a fire emergency. RN1 and the Infection Preventionist (IP), smoking at the time, both stated there had never been a smoking blanket or a fire extinguisher at any of the smoking areas. When asked about resident smoking assessments, the IP stated, the Director of Nurses (DON) completes the smoking assessments. Observations were conducted of the three designated smoking areas, 200 hall, the front of the building, and the 500 hall on 04/02/24 at 10:45 AM, 04/03/24 at 12:30 PM, and 04/04/24 at 9:30 AM. All areas had self-extinguishing ashtrays. No area had a fire blanket or a fire extinguisher available for an emergency. On 04/04/24 at 9:45 AM, R26 drove, in his electric wheelchair, to the 200 hall nurses' station and requested a cigarette and a cigar from the Licensed Practical Nurse (LPN) 4. LPN4 was observed to hand R26 the cigarette, cigar, and lighter and R26 drove to the 200 hall smoking area. R26 was outside smoking for approximately five minutes before LPN4 left the nurses' station to supervise R26. LPN4 was asked if R26 was an independent smoker, she stated, no, he has to be supervised. On 04/05/24 at 9:52 AM, the Unit Manager (LPN1) was asked for R26's smoking assessment for review. LPN1 stated, if there is one, it's in the care plan book at the nurses' station, I don't do them. Review of the care plan book, located at the nurses' station, nor the EMR contained a smoking assessment for R26 when reviewed on 04/04/24 at 10:33 AM. In an interview with the DON on 04/05/24 at 1:15 PM, she stated we don't do smoking assessments, should we? When asked where information was documented to show the facility assessed R26 for his smoking abilities, the DON stated, it's in the care plan, (R26) was independent until he burned a hole in his blanket, then he was supervised. When asked when did R26 burn a hole in his blanket, the DON said, I don't know. The DON was informed of the observation of LPN4 providing R23 a cigarette, cigar, and lighter as she stayed at the desk on the computer, the DON said, she should not have given him the cigarette, cigar, or lighter until she was ready to supervise him. On 04/05/24 at 1:45 PM, the MDS Coordinator (LPN3), in charge of care plans, was asked for documentation that R26 had been assessed for smoking. LPN3 showed the care plan that read resident is a smoker. The facility had no documentation to present that R26's smoking abilities had been assessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and facility policy review, the facility failed to: have a system in place to ensure respiratory equipment to include oxygen tubing was dated/labeled when changed out, failed to ensure documentation of cleansing of C-pap masks(Continuous positive airway pressure- a form of positive airway pressure that is continuously applied to the upper respiratory tract of a person), C-pap tubing, and water chamber were being cleaned and changed as per physician orders on Sundays, failed to ensure a C-pap machine was kept off the floor, and failed to have clean oxygen filters, maintain oxygen in the nose, and apply oxygen continuously for two of two residents (Resident (R) 51 and R48) reviewed for respiratory therapy out of a total sample of 21 residents. This failure placed the residents at risk for respiratory illnesses, and further increased the risk of contamination of the respiratory equipment. Review of the facility's untitled policy, dated 02/28/2019and provided by the Director of Nursing (DON), indicated, All oxygen concentrator filters need to be cleaned every week on Sunday night. Even concentrators that are not being used. Oxygen tubing must be changed weekly and dated. Oxygen tubing and nebulizer tubing must be stored in a plastic bag, and CPAP's hose, mask, and H20 (water) chamber must be cleaned weekly 3 parts water and 1 part vinegar. 1.During an observation of R51 made on 04/02/24 at 2:35 PM, upon entrance into R51's room R51 was observed to be lying in bed with oxygen on via nasal cannula. The oxygen tubing was observed to have no date/label as to when the oxygen tubing had been changed out. Further observation revealed R51's C-pap machine was located on the floor on the left side of the resident's bed by the head of the bed. At this time, R51's C-pap machine mask, hose, and H20 chamber were observed to be sitting on a ledge of a window. The C-pap tubing was observed to be hanging down off the window ledge. There was no evidence of when the C-pap mask, H20 chamber or tubing had been cleaned, or changed out. During an interview made on 04/02/24 at 3:30 PM, R51 stated that she was on oxygen for shortness of breath. When asked if staff were changing out the oxygen tubing or cleaning her C-pap mask and H20 chamber regularly, R51 stated, I don't know. During a second observation of R51 made on 04/03/24 at 9:41 AM, Certified Nursing Assistant (CNA) 7 was observed pushing R51 in her wheelchair from the 500-unit dining room with the oxygen concentrator behind it. At this time, observation of the oxygen tubing on the oxygen concentrator was still not dated/labeled as to when it was changed out. During an observation of R51 made on 04/03/24 at 12:17 PM, CNA1 was observed pushing R51 in her wheelchair from the 500-unit dining room with the oxygen concentrator behind it. At this time, observation of the oxygen tubing on the oxygen concentrator was still not dated/labeled as to when it was changed out. During an observation and interview made on 04/03/24 at 12:22 PM, R51 was observed to be sitting in her wheelchair in her room. At this time R51 was wearing her oxygen via nasal cannula. During the interview, when asked if staff were cleaning her C-pap mask with warm water and vinegar, R51 stated, Well, no. Not really. When asked if staff were coming to change the oxygen tubing either from the oxygen concentrator, or changing the C-pap hose and H20 water chamber regularly, R51 stated, Well, no. At this time, R51's C-pap machine was again observed sitting on the floor on the left side of the resident's head of the bed. The C-pap machine mask, hose, and H20 chamber were observed again to be sitting on a ledge of the window. The C-pap tubing was observed to be hanging down off the window ledge. There was no evidence of when the C-pap mask, H20 chamber or tubing had been cleaned, or changed out. During an interview on 04/03/24 at 12:30 PM regarding R51's oxygen tubing and C-pap machine, CNA7 and CNA1 stated, If they need to be changed then we will just do that on a as needed basis. CNA7 stated, We change out the water and oxygen tubing. When asked how often, CNA7 stated, Just whenever. CNA 7 further was asked if there would be any documentation of when the oxygen tubing is changed out, she stated, We are supposed to put a piece of tape on the oxygen tubing with the date and our initials when we change it out. That is the same with the humidifiers. We are supposed to put the date and our initials when we change those out, but with [name of R51] she has her own humidifier bottle, so we just add distilled water to when needed. Regarding R51's C-pap machine mask, tubing, and H20 water chamber, CNA7 stated, The night shift is supposed to change out the water and clean the C-pap masks. Review of an undated Face Sheet located in R51's electronic medical record (EMR) under the Resident tab indicated diagnoses to include Acute and chronic respiratory failure with hypoxia, COPD (Chronic Obstructive Pulmonary Disease), acute respiratory distress syndrome, congestive heart failure, and obstructive sleep apnea. Review of a Significant Change Minimum Data Set [MDS] located in R51's EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 01/02/24 revealed R51 was receiving oxygen therapy and had a Brief Interview for Mental Status [BIMS] score of 14/15 indicated no cognitive impairment. Review of Physician Orders, dated 12/27/23, located in R51's EMR under the Orders tab indicated, Admit to [name of hospice] d/t (due to) Respiratory failure. Review of Physician Orders, dated 01/01/24, located in R51's EMR under the Orders tab indicated, Cleanse C-pap mask, tubing and H20 chamber weekly on Sunday with 3 cups of warm water and 1 cup of white vinegar, let air dry and be ready for use by HS (evening) once a day on Sunday 7am-7pm. Review of Physician Orders, dated 04/03/24, located in R51's EMR under the Orders tab indicated, Change all oxygen and nebulizer tubing the last Sunday of each month on day shift. (CMT's, nurse to monitor to assure it was completed) once a day on last Sunday of the month at 5pm. During an interview on 04/03/24 at 12:37 PM, Licensed Practical Nurse (LPN)3 was asked who changes out the oxygen tubing and who cleans the residents C-pap masks, changes out the tubing and ensures the H20 water chamber is clean, LPN3 stated, The med tech would change out the tubing. It used to be weekly, but now I think its monthly just as needed. Regarding the humidifiers, The med tech or me can change those out when we see it needs to be changed. We are supposed to be documenting when they are changed out on the MARS [Medication Administration Record]. LPN3 stated, With the C-pap, she just has distilled water in her room, so we just replace that when we see its low. LPN3 then stated, Regarding the cleaning of the C-pap mask, that is supposed to be done weekly by the night shift. That would be documented in the ADL [Activities of Daily Living] book. The CNAs are supposed to clean the C-paps, sanitize, and wipe down after each use. That would be the night shift. Review of the ADL (Activities of Daily Living) Flowsheets dated 01/02/24-01/31/24 indicated no documentation of cleansing R51's C-pap mask, tubing & H20 chamber was being documented as completed on Sundays as ordered. Review of the ADL Flowsheet dated 02/01/24-02/29/24 indicated three inconsistencies on Sunday 02/04/24, Sunday 02/18/24, and on Sunday 02/25/24 in which there was no documentation of cleansing R51's C-pap mask, tubing & H20 chamber as ordered to be done on Sundays. Review of the ADL Flowsheet dated 03/01/24-03/31/24 indicated inconsistencies on Sunday 03/03/24, Sunday 03/10/24, Sunday 03/17/24, Sunday 03/24/24 and on Sunday 03/31/24 in which there was no documentation of cleansing R51's C-pap mask, tubing, & H20 chamber as ordered to be done on Sundays. During an observation made on 04/03/24 of R51 at 12:49 PM with LPN3, R51 was observed to be lying in her bed with the oxygen on. When observing the oxygen tubing connected to the oxygen concentrator not being dated/labeled, LPN3 confirmed and stated, No, I do not see a date or initials as to when the oxygen tubing was changed out. At this time, R51's C-pap machine was again observed to be on the floor on the left side of the resident's bed. R51's C-pap mask and tubing were again observed to be still sitting on the window seal ledge. During interview, LPN3 stated, I will have to get a table and put her C-pap machine on it because I see its on the floor and it should not be. LPN3 stated, The C-pap mask should be cleaned every Sunday but I'm not seeing a date as to when it was cleaned last. I will need to get some new oxygen tubing as well because I don't know the last time this was change out. During an interview made on 04/3/24 at 1:00 PM, regarding resident's oxygen tubing, and C-pap machines, Certified Medication Aide (CMA)1 stated, We are supposed to change out the oxygen tubing once a week. We run the C-pap masks through water, and I believe it is the med techs and the nurses that do that, but I'm not sure. CMA1 stated that she had not cleaned R51's C-pap mask or changed out the oxygen tubing that she could recall. During an interview made on 04/03/24 at 1:16 PM, regarding oxygen tubing, respiratory equipment, and C-pap machines, the DON stated, The oxygen tubing is changed out monthly and its usually the last day of the month. The C-pap mask, and tubing should be in a plastic bag. That would be my expectation. The DON further stated, I'm thinking anybody can change out the humidifiers anytime they are empty, and with the oxygen tubing, it should be changed out by the night shift aides. The nurse would ensure its done and should be signing off on that. The DON further stated, It would be my expectation the C-pap masks are being cleaned as ordered as well. When the documentation of the inconsistencies was shown to the DON regarding R51's C-pap mask not being cleaned and 02 not being dated/labeled, the DON stated, I was not aware that it wasn't being done. Unfortunately, if it wasn't documented, then it didn't happen. 2. Review of the Face Sheet located in the Face Sheet tab of the EMR revealed R48 was admitted to the facility on [DATE] with diagnoses which included dementia, stroke, and heart failure. Review of an 07/30/22 Physician Order located in the Orders tab of the EMR revealed, Oxygen titrate to maintain sats above 90%. Diagnosis is hypoxia. Review of the quarterly MDS located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 01/02/24 revealed, R48 had a BIMS score of three out of 15 which indicated she was severely impaired in cognition and used oxygen daily. During an observation on 04/02/24 at 10:32 AM, R48 was observed sitting in her high-back wheelchair, in her room. The nasal cannula was not positioned in both nares and was only observed in one naris. The oxygen concentrator filter was covered with white lint and there was no humidifier bottle attached. During an observation 04/02/24 at 11:46 AM, R48 was observed with the oxygen nasal cannula was observed on her face, but not in her nares. During an observation on 04/02/24 at 12:03 PM, Certified Medication Technician (CMT) 4 was asked why her nasal cannula was not in her nares. CMT 4 was then observed to reposition R48's nasal cannula into her nares. CMT 4 was asked who was responsible for ensuring the filter was clean and there was a humidifier bottle. CMT 4 confirmed that the filter was dirty and stated, We all are responsible for ensuring that it is clean, and tubing is changed. During an observation on 04/03/24 at 9:25 AM, R48 was observed sitting in her wheelchair at the dining room table. R48 was not wearing her oxygen and the concentrator was observed in her room. Certified Nurse Aide (CNA) 3 was asked why she wasn't wearing her oxygen. CNA 3 confirmed she wasn't wearing her oxygen but then stated, I don't know why she isn't wearing [the oxygen].

Based on observations, interviews, record reviews, and review of the facility assessment, the facility failed to ensure sufficient nurse staffing to meet the needs of the residents resulting in residents not receiving showers for two (Residents (R) 73, R8) of five sampled residents, activities to meet residents' needs in the secured dementia unit. These failures placed residents at risk of a diminished quality of life and potential unmet care needs. 1. This tag is cross-referenced to F676; ADL [maintain activities of daily living] as not diminish or decline. Based on interview and record review, including shower schedules, the facility failed to consistently provide showers for R73, and R8. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 02/06/24 revealed R8 was cognitively intact for daily decision-making. During an interview on 04/02/24 at 12:15 PM, R8 stated, I am to get two showers [her choice of bathing] per week .I haven't had a shower since last Tuesday [lapse of seven days]. R8 was asked if she was aware of any reason as to why she had not received her showers. R8 stated, I haven't heard a word as to why, but I think it's due to being short staffed. Review of the quarterly MDS located in the MDS with an ARD of 02/06/24 revealed R65 was cognitively intact for daily decision-making. During an interview on 04/02/24 at 1:36 PM, R65 stated, Yes, I don't think there is enough staff. It is mostly on the afternoon shift. When I put my call light on, sometimes they don't come at all (to answer the call light). Review of the quarterly MDS located in the MDS tab of the EMR with and ARD of 03/19/24 revealed R73 was cognitively intact for daily decision-making. During an interview on 04/02/24 at 10:06 AM, R73 stated, I never refuse a shower as it is important to me. My showers are twice a week, they are short staffed, and they can't always give me one. 2. This tag is cross-referenced to F679: Activities. Based on observation, interview, and record review, the facility failed to provide a program of meaningful activities for residents who reside in the secured dementia unit. During observations on 04/02/24 and 04/04/24, in the secured dementia unit, there were nine residents in total who resided on the unit. During these observations, residents were not observed in an activity but instead were laying in the beds. One resident, R84, was observed wandering around the unit, sitting on the floor and then getting up and walking again. During the survey from 04/02/24 to 04/04/24The secured dementia unit showed that only one staff member was available to assist the residents with ADL [activities of daily living] needs, pass medications, intervene if there were behaviors and provide activities for the nine residents. During an interview on 04/04/24 at 9:08 AM, Certified Nurse Aide (CNA) 2 [who was also a CMA-Certified Medication Aide) was asked why there were no residents in the common area. She stated, I have no idea why. CNA2 was asked if she was the only person to care for the nine residents on the unit. She stated, Yes. CNA 2 confirmed that she provided the nine residents with ADL care, their medications, handled behaviors, and provided activities. CNA 2 further stated that we just moved to this unit, on the 200 hall from the 400 hall this week, so we are just getting used to it here. During an interview on 04/04/24 at 12:21 PM, Licensed Practical Nurse (LPN) 3 stated, I used to be on the secured dementia unit prior to coming to the 200 hall, so I am familiar with the residents on the dementia unit. LPN3 further stated, The dementia unit used to be on the 400 hall, we had a nurse and a CNA/CMA available on the unit and we were able to do activities but now I have to be at the desk on the 200 hall and be available to the dementia unit. During an interview on 04/04/24 at 1:10 PM, the Activities Director (AD) stated, I know they (the dementia unit residents) are laying in their beds. The Administrator told me that the census is low so the aides have to the activities. We moved to the 200 hall to consolidate staffing. The Administrator stated they couldn't put anyone back their so the CNAs had to do activities. The AD was asked if she felt the facility was short-staffed. She stated, Yes, I do. The AD further stated that on 400 hall, we used to have a patio, and during the summer we would take the residents outside, have popsicles and reminisce but with the new unit on the 200 hall, we don't have a way for them to go outside. During an interview on 04/05/24 at 8:50 AM, the Infection Preventionist (IP) stated that she was also responsible for staffing. The IP stated that she was on a 30 hour per week employee, and it was difficult to both jobs. The IP was asked if she attended the weekly QAA (Quality Assessment and Assurance) meetings. She stated, No, they hold the meetings when I am not here. The IP stated that she has to make a list for the to discuss regarding infection control and staffing. Review of the 02/28/24 Facility Assessment, (based on information from 2023) provided by the Administrator, revealed the average daily census on the 400 hall was 13.6 residents. Staffing the unit included the following breakdown: DAY SHIFT: Unit Manager: 0.5 (part-time) Licensed Nurse; 1.0 (full-time) CMT: 1.0 (full-time) CNA: 1.0 (full-time) NIGHT SHIFT: CMT: 1.0 (full-time) CNA; 1.0 (full-time) During an interview on 04/05/24 at approximately 12:00 PM, the Administrator stated, If we don't have money for a staff position, we just won't have a position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an Abnormal Involuntary Movement Scale [AIMS-a test that rates involuntary muscle movements (tardive dyskinesia) on residents who are administered antipsychotic medications] assessment for two residents (Resident (R) 65 and R84) and failed to re-evaluate the need for an antipsychotic medication for one resident (R4) of five residents reviewed for unnecessary medications in a total sample of 21. These failures placed residents at risk for unrecognized side effects. 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R65 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes, and pulmonary disease. Review of a 10/24/23 Psychotropic Medication Change Progress Note, located in the Progress Notes tab of the EMR and recorded as a late entry on 11/07/23, revealed NEW ORDER: Seroquel [an antipsychotic medication] 12.5 mg at bedtime for increased behaviors, hallucinations, and paranoia. Seroquel can have the side effect of tardive dyskinesia which can be permanent. Review of an 11/03/23 Physician Order located in the Orders tab of the EMR revealed on 11/03/23, the Seroquel was discontinued. Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/07/23 revealed R65 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated she was cognitively intact and had hallucinations (a perception of something not present). Review of a 12/05/23 Physician Order located in the Orders tab of the EMR revealed, Rexulti [an antipsychotic medication] 0.5 mg daily for depression/behaviors. Rexulti can cause tardive dyskinesia. Review of the Observations tab and the Resident Documents tab of the EMR revealed no documentation that an AIMS assessment was completed at the time R65 was started on the antipsychotic medications. During an interview on 04/05/24 at 11:29 AM, the Director of Nursing (DON) was asked if the AIMS assessment was completed and what the expectation was regarding staff doing the assessment. The DON stated, The Unit Managers were responsible, and they are to be done upon admission and every six months afterwards. The DON was unable to confirm or deny the AIMS assessments were completed for R65. 2. Review of the Face Sheet located in the Face Sheet tab of the EMR revealed R84 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 02/27/24 revealed R84 had a BIMS score of four out of 15 which indicated she was severely impaired in cognition, had physical and verbal behaviors, rejected care, and wandered daily. In addition, the MDS showed that she was administered an antipsychotic medication. Review of the 03/13/24 Psychotropic Medication Review located in the Resident Documents tab of the EMR revealed the following: Olanzapine 5 mg BID (02/28/24). Risperidone 0.5 mg BID (02/19/24). Review of the Observations tab and the Resident Documents tab in the EMR did not show an AIMS assessment was completed, at the time of admission and when the Olanzapine was started. Olanzapine and Risperidone can cause tardive dyskinesia. During an interview on 04/04/24 at 12:31 PM, Unit Manager (UM)1 was asked if AIMS was completed upon admission for the Risperidone and when the Olanzapine was started. UM1 stated, No, it wasn't done. I don't know why as she came in with them. 3. The facility failed to complete AIMS assessments, every three months, for R4 as directed in the care plan for psychotropic drug use. Review of R4's Continuity of Care Document, located in the electronic medical record (EMR) under the Resident tab, revealed R4 was admitted on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified dementia with behavioral disturbance; bipolar disorder; and anxiety disorder. Review of the annual MDS assessment with an ARD of 01/02/24 revealed a BIMS score of 99 indicating an inability to participate in the assessment. Review of the physician's orders, located in the EMR under the Resident tab revealed R4 received the following medications: a. fluoxetine (Prozac) solution 5ml (milliliters) one time a day at 8:00 AM for depression /appetite, ordered 06/16/21. Fluoxetine (an antidepressant may cause tardive dyskinesia, a movement disorder). b. Seroquel 25 mg, one tablet twice a day for bipolar disorder, increased to twice a day on 09/22/23. Seroquel is an antipsychotic and may cause tardive dyskinesia. Review of R4's Psychotropic Drug Use care plan, initiated 02/05/21 and last updated on 04/04/24, revealed R4 takes Seroquel for bipolar disorder . Prozac for depression. Included in the care plan approaches was AIMS (abnormal involuntary movement scale) every three months for antipsychotic use; monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms; and monitor for therapeutic and side effects of anti-psychotic medications. On 04/02/24 at 10:01 AM R4 was observed, , in her room seated in her geri-chair. The resident was awake and observed to exhibit tongue thrusting. R4 engaged in a very brief conversation/introduction and stated, thanks for stopping, upon exiting her room. On 04/02/24 at 11:44 AM, R4 was observed seated at a table in the assisted dining room. R4 was observed to exhibit tongue thrusting while feeding herself a pureed meal with thickened liquids. The resident responded with hello when spoken to. Review of a facility report titled Antipsychotic Medication Evaluation (AME), dated 09/26/23, located in the EMR under the documents tab, specific to Seroquel, revealed recent change to BID (twice a day), wait one month then reassess. There were no evaluations found in the EMR to address the specified reassessment. Review of a Nurses Progress Note, dated 02/18/24, located in the EMR under the Resident tab revealed Daughter here in facility. Complaints of resident saying unusual things. Resident was observed with hallucinations early this shift. Pointing across room and stated do you see those little boys over there? Reassured resident no little boys in room at this time. Daughter left and called facility. Would like resident to be checked for UTI (urinary tract infection). Placed resident on UTI protocol. Will speak to NP tomorrow. Daughter advised that resident usually sticks tongue out when UTI is present. In an interview with the Unit Manager (LPN1) on 04/05/24 at 9:52 AM, she stated, ask the DON (Director of Nurses) for AIMS assessments. When asked about R4's tongue thrusting, LPN1 stated, she is? When asked about the 02/18/24 progress note, written by LPN1, she stated she didn't have a UTI, I don't remember writing about sticking her tongue out. LPN1 stated, she doesn't have a UTI now. During an interview, on 04/05/24 at 1:01 PM, with the Director of Nurses (DON), the DON was asked about the follow up to the AME dated 09/26/23. The DON stated, I would hope the charge nurse would identify it. When asked if R4 had been reviewed in the facility's weekly Clinical Meeting, the DON stated, every resident on an antipsychotic would be reviewed. When asked what was discussed in regard to R4, the DON stated, I don't have any notes on her. The DON was asked to locate any AME evaluations, AIMS evaluations, or documentation that R4's psychotropic medication use was being evaluated on a routine basis, the DON stated there's nothing in her record, we don't have anything.

During an observation, interview, and review of facility policy, the facility failed to prepare, store, and label medications according to standard nursing practice for one of four Certified Medication Aide (Certified Medication Aide (CMA3) observed during medication pass. This failure placed prescription-based medications readily accessible to residents, increased health complications, and the possibility of giving the wrong medication to the wrong resident. Review of an untitled facility policy, dated 04/29/14, revealed, Medication is never to be left unattended. If you must leave your cart, then all medications are to be locked inside. During a medication pass observation on 04/05/24 at 7:40 AM, Medication cart 5 [NAME] was parked outside a room. CMA3 was not stationed at the cart but was in a resident's room. The cart showed that there were three individual plastic cups on top of the cart which were observed to contain powder mixed in liquid, which had gelled at the bottom of the cup. Inside each cup was a plastic spoon. The individual cups were not labeled. CMA 3 returned to the cart and was asked what was in the cups sitting on her medication cart. CMA3 stated, These are medications for the morning med pass. CMA3 was asked if she premixed medications often. CMA3 stated, Yes, I can't lie. CMA 3 further stated, I am supposed to lock them up and not prepare the meds until I administer them. CMA 3 was asked what was in the medication cups. She stated, Lactulose (a liquid medication for constipation), liquid protein and Miralax (a medication for constipation.) CMA3 returned the 5 [NAME] medication cart to the nurses' station and placed the medications into the bottom drawer and locked the cart. CMT3 then obtained the 5 East medication cart and proceeded down the hall. On top of the medication cart revealed five individual plastic cups of medications, unlabeled. CMA3 was asked what was in the cups. She stated, Miralax. CMA3was asked when the medications were premixed. She stated, I mixed them up about an hour ago. CMA3 was asked if the medications were labeled. She stated, No. CMA 3 was asked how she knew which medication was to be used for each resident. She stated, I just know. During an interview on 04/05/24 at 9:46 AM, the Director of Nursing (DON) was asked what her expectation was regarding labeling, storing, and preparing medications. The DON stated, My expectation is that meds are not prepared in advance and not left out unattended on the carts.

Based on employee record review and interviews, the facility failed to have documentation of completion of a minimum of 12 hours of required in-service training to include Dementia care and Abuse, Neglect, and Exploitation for five of five Certified Nursing Assistants (CNAs) (CNA 1, 2, 4, 6, and 7). By not ensuring employees are meeting the required trainings and in-services, residents may be at risk and unable to get their needs met. Review of the facility's Facility Assessment updated February 28, 2024, indicated, Staff Education: Orientation, Annual: Required annual education/training (minimum of 12 hours annually for Nursing Assistants) . During an interview on 04/04/24 at 9:52 AM, CNA1 was asked about trainings and in-services on dementia care and abuse and neglect. CNA1 stated, We have annual in-services, and we cover abuse and neglect. When specifically asked about dementia care, the CNA stated, Prior to coming here, I got trainings, but not really here. No, I don't believe so. During an interview on 04/04/24 at 9:55 AM, CNA7 was asked about annual trainings on abuse, neglect and dementia care. CNA7 stated, Once a month we get trainings, and also on abuse and neglect. When specifically asked about dementia care, the CNA stated, No, not really. We learn on the go. Review of the Employee Personnel files for CNA1, date of hire 08/30/21, indicated annual trainings that were conducted throughout 2023 to include abuse/neglect and dementia care, however there was no evidence of the required 12 hours completed. Review of the Employee Personnel file for CNA2, date of hire 09/04/07,indicated annual trainings that were conducted throughout 2023 to include abuse/neglect and dementia care, however there was no evidence of the required 12 hours completed. Review of the Employee Personnel file for CNA4, date of hire 12/15/10, indicated annual trainings that were conducted throughout 2023 to include abuse/neglect and dementia care, however there was no evidence of the required 12 hours completed. Review of the employee Personnel file for CNA6, date of hire 02/18/20 indicated annual trainings that were conducted throughout 2023 to include abuse/neglect and dementia care, however there was no evidence of the required 12 hours completed. Review of the employee Personnel file for CNA7, date of hire 05/16/18, indicated annual trainings that were conducted throughout 2023 to include abuse/neglect and dementia care, however there was no evidence of the required 12 hours completed. During an interview on 04/04/24 at 10:27 AM with the Infection Preventionist (IP) (person who conducts the annual trainings) stated, do most of the in-services with the assistance of the Director of Nursing (DON). We cover abuse/neglect and dementia care. The IP then stated, I don't keep track of the actual hours though. We do not keep track of employee hours completed. I only make sure I train them on the required trainings for the year. The IP then stated, We have trainings and meetings that can be 30 minutes or up to 1-hour ½, just depends. Once a year, we do trainings and that usually takes a couple of hours to go through all our policies, etc. We do orientation, then skills drills annually. During an interview on 04/04/24 at 11:50 AM, with the DON she stated, At least once a month we are doing trainings, or addressing something. When specifically asked how do you ensure the staff are meeting the required 12 hours of trainings and in-services, the DON stated, Well, other than the fact that they sign in when we do our trainings, I don't have a way to track how many hours they are completing. I've never been questioned about the number of hours before. I haven't kept track of their hours, and I don't have a specific policy. During orientation, there is a checklist that we go by. During a second interview on 04/05/24 at 8:15 AM, the IP stated, I do general orientation and we sign all paperwork, do background checks, etc. With dementia care, we talk about dementia care, and give various scenarios. I know they are supposed to have the 12 hours of in-services. I've never been asked to document the number of hours they are completing. I'm aware they have to have at least 12 hours of trainings on things like Abuse, neglect, and dementia care, I just haven't been documenting that.

Based on observations, interviews, and facility policy review, the facility failed to keep the scoops out of food storage bins and ensure stored food was dated. This had the potential to affect 86 of 86 residents who resided in the facility and consumed food prepared from the facility's kitchen. Review of the facility's undated policy titled Resident Food Storage, revealed 1 .Food or beverages brought into the facility for resident consumption will be labeled and dated for monitoring food safety. Food or beverages in the original container marked with manufacturer expiration dates and unopened do not have to be re-labeled for storage During an initial tour of the kitchen on 04/02/24 at 8:55 AM, with the Dietary Manager (DM), the following observations were made: Dry Storage and kitchen: a. One 5-pound bag, containing yellow cake mix, was observed open and undated. b. A large clear container labeled, containing thickener, were observed with scoops lying in the thickener. The thickener was also undated. Interview on 4/03/24 at 8:55 AM, DM stated scoops should not be kept in the containers. DM stated they expect scoops to be placed in a plastic bag and placed on top of the container. During a follow-up tour of the kitchen on 04/03/24 at 11:48 AM, with the DM, the following observations were made: Freezer and kitchen: a. Two loafs of Rye bread covered in ice crystals, was observed undated. b. 1 large bag of frozen chicken breast, was observed undated. During an interview on 04/03/24 at 8:55 AM, the DM stated they expect staff to place opened bagged items into an empty clear container and label and date or place in a clear bag and date. During an interview on 04/03/24 at 11:48 AM, the DM stated their expectation is for items to be closed when they were done being used. DM stated the two loaves of bread were left over and should have been dated. DM stated the chicken package must have been the last one in the box and someone took it out because normally keep items in the box and date the box. DM stated all dietary staff were responsible for ensuring items were dated and their expectation was that it would be done.

Based on interview and record review, the facility failed to have the Medical Director and/or designee attend the last two quarterly QAPI (Quality Assurance and Performance Improvement) committee meetings. Review of the 11/28/23 QAPI sign-in sheet for the quarterly meeting revealed the Medical Director did not attend and was marked, unable to attend. Review of the 02/20/24 QAPI sign-in sheet for the quarterly meeting revealed the Medical Director did not attend and was marked as, unable to attend. During an interview on 04/05/24 at 11:53 AM, the QAPI Nurse was asked if the Medical Director or their designee attended the quarterly meetings. The QAPI Nurse stated, He does attend the meetings, but not the last ones. The QAPI Nurse was asked if she was aware that the Medical Director or their designee are to attend the meetings, as required in the regulation. She stated, Yes.

Based on observations, interviews, and record reviews the facility failed to assure staff treated two sampled residents (Residents #44 and #18) in a manner that maintained their psychosocial well being and dignity when staff treated one resident (Resident #44) rudely. The facility census was 95. The facility did not provide a policy on dignity. Review of Resident #44 admission Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff ) dated 2/8/22 showed: -Brief Interview of Mental Status (BIMS) of 15 (indicates no cognitive impairment); -No exhibited behaviors; -Resident able to understand and make self understood. Review of Resident #44 Face Sheet showed diagnosis of: -Diabetes Mellitus (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high) with neuropathy(damage to the nerves located outside of the brain and spinal cord that often causes weakness, numbness and pain, usually in the hands and feet); -Hypertension; -History of Myocardial Infarction (also known as heart attack: where blood flow is effected to the heart and the heart muscle dies); -Gastro-esophageal reflux ( condition in which the stomach contents leak backward from the stomach into the esophagus ); -Constipation . During interview on 04/12/22 at 12:14 P.M. the resident #44 said: - One night shift staff is rude when coming to assist him/her, telling him/her to do it on his/her own. -The staff members behavior makes him/her feel bad here, indicating his/her chest. -He/she has notified other staff of the night shift staff member being rude. -He/she does not know the staff members name. During an interview on 04/13/22 at 10:20 A.M. the resident said: - A night shift aide shut the door to the resident room, across the hall while that resident was yelling for help. -He/she saw the staff member shut the door, as he/she was sitting in his/her chair and could see across the hall. -The staff member left the other resident in a dark room, alone, and that is not right to do to someone. -He/she didn't want others to know he/she reported this, as staff wouldn't be nice to him/her. -Staff also shut the door of another resident room next to him/her that yells out. -He/she feels he/she needs to speak out for those who cannot. During an interview on 4/13/22 at 2:59 P.M. Unit Coordinator A said: -He/she was aware of Resident #44 complaints that a night staff member has been rude. -The staff member has been counseled. -He/she is aware the the resident states the rude behavior is still occurring. -He/she didn't escalate the complaint or discipline process; -He/she did not report the complaint to anyone and no investigation was completed. During an interview on 4/19/22 at 11:51 A.M. the Director of Nursing (DON) said: -She is unaware of any staff being rude to residents. -She would expect it to be reported and addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge. This affected 3 additional residents (Residents #247, #248, and #250). the facility census was 95. Review of the undated facility policy for Resident Trust Funds showed: -If a patient leaves, the funds are disbursed to the patient. -If a patient passes away, a funds report is emailed to mhd.costrecovery.dss.mo.gov. (A program that states any open estate may not be closed with respect to a decedent who, at the time of death, was enrolled in MO HealthNet until a release of the Estate Recovery Claim by MO HealthNet is obtained.) Response from this program will determine where money will be refunded. Refund within 3 days of response. Review of the facility's Aging Report dated 3/31/2022 showed the following residents had money in the facility's operating account: -Resident #248 discharged [DATE]: $75.28 -Resident #250 discharged [DATE]: $487.81 -Resident #247 discharged [DATE]: $2640.00. During an interview on 04/13/2022 at 10:41 A.M , the Business Office Manager (BOM) said: -He/she said that the amount left for Resident #248 could be an insurance credit, or a change in Medicare/Medicaid amount. -He/she said that the amount left for Resident #250 was because the resident has no next of kin. The situation has been sent to the facility's attorney to look into. -He/she said that the amount left for Resident #247 was because the resident's family accidentally paid the facility twice. The amount needs to be sent back to the family. - He/she is responsible for sending the remaining funds back to the resident's responsible party. -The BOM said that the time frame to send back funds is dependent on the resident's situation. During an interview on 4/19/2022 at 3:33 P.M. the Administrator said: -If the funds left after a resident discharges are funds that belong to Medicaid, the facility waits to hear from Medicaid what to do with the funds. -If the funds left after a resident discharges are private pay funds, the resident's estate must go through probate, so it could be months before the facility is directed what to do with the funds.

Based on record review and interviews, the facility failed to purchase a surety bond in a sufficient amount to ensure the security of all residents' personal funds deposited with the facility. The facility census was 95. Review of the undated facility policy for Resident Trust Funds showed: -There was no mention of maintaining a surety bond. Review of the facility's surety bond dated 3/30/2017, showed a bond amount of $9,000.00. Review of the Residents Funds Worksheet on 4/13/2022, completed with the last twelve months of reconciled bank statements and petty cash amounts showed the required bond amount needed was $21,000.00. During an interview on 4/13/2022 at 10:41 A.M , the Business Office Manager (BOM) said: -He/she is aware the bond amount is not high enough. The resident's stimulus money has increased the required amount of the bond. -He/she has contacted the surety company this week, notifying them the need to increase the bond. During an interview on 4/19/2022 at 3:33 P.M., the Administrator said: -He/she is aware the bond amount needs to be high enough to cover the resident's funds. The resident's stimulus money has caused the need to increase the bond. -The BOM is working with the surety company to increase the amount.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe, clean and comfortable homelike environment. This had the potential to affect all residents. The facility census was 95 1. Observation on 4/11/22 beginning at 11:00 A.M. showed the following in the following rooms: - #616- Beach ball brown stain on a ceiling tile in the bathroom, ceiling tile sagging; - #621- Four ceiling tiles with brown stains varying in size from a softball to beach ball; - #619- Two cantaloupe size stains on a ceiling tile and one watermelon sized stain in bathroom; - #320- Cantaloupe sized stain on a ceiling tile; - #318, 3 stained ceiling tiles of various sizes up to the size of a beach ball, one beach ball sized stain on the ceiling in the shared bathroom; - #315- 2 beach ball stains on the ceiling tiles; - #312- Missing ceiling light cover in the shared bathroom; - #311- Watermelon sized stain on the ceiling; - #204- Multiple stains of the ceiling of various sizes; 2. During an interview on 4/14/22 at 10:27 A.M. Licensed Practical Nurse (LPN) A said: - He/she could not provide wound treatment to residents on the 200 hall because there was no water in the sink in the shower room. Observation on 4/14/22 at 3:15 P.M. showed the 200 hall shower room sink's water supply was shut off. 3. Observation on 4/19/22 beginning at 10:10 A.M. showed room [ROOM NUMBER] had a faucet that would not shut off. 4. During an interview on 4/14/22 at 3:21 P.M. the Assistant Maintenance Director said: - When environmental issues are identified, staff were supposed to fill out a work order and hang it up at a nurse station. He checked for work orders daily, throughout the day. He signed and dated the order when it was completed; - The missing/moved ceiling tiles were due to Information Technology (IT) staff, they will not put the tiles back; - He was also ordering some more ceiling tiles; - He did not know about 200 hall shower sink. Staff did not usually use that room. 5. During an interview on 4/20/22 at 11:00 A.M. the Maintenance Director and the Assistant Maintenance Director said: - The Maintenance Director started working at the facility in the fall of 2021. The facility had a lot of maintenance needs when they began working at the facility and they were trying to catch up. They had replaced several plumbing fixtures since they began working at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents and their representative, including the reason for the transfer, in writing and in a language they understood. This affected three of 19 sampled residents, (Resident #28, #74 and #97). The facility census was 94. The facility did not provide a policy for transfers and discharges. 1. Review of Resident #28's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/22, showed: - Cognitive skills severely impaired; - Dependent on the assistance of two staff for bed mobility, transfers, and dressing; - Dependent on the assistance of one staff for toilet use; - Upper and lower extremities impaired on both sides; - Had a supra pubic catheter (enters the bladder through the lower abdomen); - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Diagnoses included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), neurogenic bladder (a dysfunction that results from interference with the normal nerve pathways associated with urination), high blood pressure, paraplegia (paralysis characterized by motor sensory loss in the lower limbs and trunk), seizure disorder, anxiety, depression and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's electronic medical record showed: - On 1/9/22 the resident was transferred to the hospital for elevated and temperature and wounds to both buttocks with foul odor; - There was no documentation in the medical record that a discharge letter was given to the resident or responsible party or sent with the resident to the hospital; - The medical record did not have a copy of any discharge letter that would have been issued to the resident. 2. Review of Resident #74's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Dependent on the assistance of two staff for bed mobility, transfers, and toilet use; - Required extensive assistance of two staff for dressing; - Frequently incontinent of urine; - Had a colostomy; - Diagnoses included anemia, congestive heart failure (CHF, a decrease in the ability of the heart to pump blood resulting in an accumulation of fluid in the lungs and other areas of the body), anxiety, depression and dementia. Review of the resident's electronic medical record showed: - On 2/15/22 the resident was transferred to the hospital because the resident's mental status had declined dramatically throughout the day; - There was no documentation in the medical record that a discharge letter was given to the resident or responsible party or sent with the resident to the hospital; - The medical record did not have a copy of any discharge letter that would have been issued to the resident. 3. Review of Resident #97's five day assessment MDS, dated [DATE], showed: - Cognitive skills intact; - Dependent on the assistance of two staff for bed mobility, transfers, dressing and toilet use; - Lower extremities impaired on both sides; - Frequently incontinent of urine; - Occasionally incontinent of bowel; - Diagnoses included anemia, high blood pressure, respiratory failure, anxiety and depression. Review of the resident's electronic medical record showed: - On 1/17/22 the resident was transferred to the hospital due to low oxygen saturation; - There was no documentation in the medical record that a discharge letter was given to the resident or responsible party or sent with the resident to the hospital; - The medical record did not have a copy of any discharge letter that would have been issued to the resident. During an interview on 4/14/22 at 8:51 A.M., Licensed Practical Nurse (LPN) A said: - The only paperwork that is sent with the resident when they are transferred to the hospital is the face sheet, physician's order sheet (POS), medication administration record (MAR), code status, recent history and physical, a copy of their COVID (an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions) card and the transfer form; - The transfer form does not have any phone numbers on it. It basically has the resident's pertinent information (name, address, date of birth , date of transfer, where the resident is transferring from and to), attending physician's information, nursing evaluation and social evaluation; - He/she did not send a discharge letter with the resident to the hospital. During an interview on 4/14/22 at 9:18 A.M., Social Services said: - He/she did not send any paperwork with the residents when they are transferred to the hospital. During an interview on 4/19/22 at 11:51 A.M., the Director of Nursing (DON) said: - The only paperwork the staff send with the resident to the hospital is their POS, MAR, code status and the transfer form; - Transfer or discharge letters are not sent with the resident to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident and the resident's family/legal representative of the facility's bed hold policy at the time of transfer/discharge to the hospital for three of 19 sampled residents, ( Resident #28, #74 and #97). The facility census was 94. Review of the facility's undated bed hold policy, showed, in part: - The resident may need to be absent from the facility temporarily for hospitalization or therapeutic leave. The resident may request that the facility hold open the resident's bed during this time. This is known as bed hold. The resident and a family member or legal representative shall be given notice of the bed hold option at the time of hospitalization or therapeutic leave; - Medicaid residents - if the resident's care is paid under the Medicaid program, the facility will allow 12 grace days every six months for hospitalization, therefore there will be no charge to hold the room. These days do not carry over and this policy will be based on a calendar year. If the Medicaid resident's hospitalization exceeds the bed hold period allowed by the facility, the resident may request an additional bed hold period from the facility by agreeing to pay the private daily rate during the additional bed hold period. 1. Review of Resident #28's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/22, showed: - Cognitive skills severely impaired; - Dependent on the assistance of two staff for bed mobility, transfers, and dressing; - Dependent on the assistance of one staff for toilet use; - Upper and lower extremities impaired on both sides; - Had a supra pubic catheter (enters the bladder through the lower abdomen); - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Diagnoses included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), neurogenic bladder (a dysfunction that results from interference with the normal nerve pathways associated with urination), high blood pressure, paraplegia (paralysis characterized by motor sensory loss in the lower limbs and trunk), seizure disorder, anxiety, depression and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's electronic medical record showed: - On 1/9/22 the resident was transferred to the hospital for elevated and temperature and wounds to both buttocks with foul odor; - There was no documentation in the medical record that the bed hold letter was given to the resident or responsible party or sent with the resident to the hospital; - The medical record did not have a copy of any bed hold letter that would have been issued to the resident. 2. Review of Resident #74's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Dependent on the assistance of two staff for bed mobility, transfers, and toilet use; - Required extensive assistance of two staff for dressing; - Frequently incontinent of urine; - Had a colostomy; - Diagnoses included anemia, congestive heart failure (CHF, a decrease in the ability of the heart to pump blood resulting in an accumulation of fluid in the lungs and other areas of the body), anxiety, depression and dementia. Review of the resident's electronic medical record showed: - On 2/15/22 the resident was transferred to the hospital because the resident's mental status had declined dramatically throughout the day; - There was no documentation in the medical record that the bed hold letter was given to the resident or responsible party or sent with the resident to the hospital; - The medical record did not have a copy of any bed hold letter that would have been issued to the resident. 3. Review of Resident #97's five day assessment MDS, dated [DATE], showed: - Cognitive skills intact; - Dependent on the assistance of two staff for bed mobility, transfers, dressing and toilet use; - Lower extremities impaired on both sides; - Frequently incontinent of urine; - Occasionally incontinent of bowel; - Diagnoses included anemia, high blood pressure, respiratory failure, anxiety and depression. Review of the resident's electronic medical record showed: - On 1/17/22 the resident was transferred to the hospital due to low oxygen saturation; - There was no documentation in the medical record that the bed hold letter was given to the resident or responsible party or sent with the resident to the hospital; - The medical record did not have a copy of any bed hold letter that would have been issued to the resident. During an interview on 4/14/22 at 8:51 A.M., Licensed Practical Nurse (LPN) A said: - The only paperwork that is sent with the resident when they are transferred to the hospital is the face sheet, physician's order sheet (POS), medication administration record (MAR), code status, recent history and physical, a copy of their COVID (an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions) card and the transfer form; - The transfer form does not have any phone numbers on it. It basically has the resident's pertinent information (name, address, date of birth , date of transfer, where the resident is transferring from and to), attending physician's information, nursing evaluation and social evaluation; - He/she did not send a bed hold letter with the resident to the hospital or give one to the resident's family. During an interview on 4/14/22 at 9:18 A.M., Social Services said: - He/she did not send any paperwork with the residents when they are transferred to the hospital; - The resident only signed a bed hold policy on admit. During an interview on 4/19/22 at 11:51 A.M., the Director of Nursing (DON) said: - The only paperwork the staff send with the resident to the hospital is their POS, MAR, code status and the transfer form; - Transfer or discharge letters and bed hold letters are not sent with the resident to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff met as an interdisciplinary team with the resident and/or representative to establish and provide the resident a baseline or 48 hour care plan for one of 19 sampled residents, (Resident #147). The facility census was 94. The facility did not provide a policy for baseline care plans. 1. Review of Resident #147's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/22, showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; - Lower extremity impaired on one side; - Always continent of bowel and bladder; - Diagnoses included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), coronary artery disease (CAD, a narrowing or blockage of the coronary arteries), high blood pressure, hip fracture and depression. Review of the resident's electronic medical records showed: - The resident was admitted on [DATE]; - The resident did not have a baseline care plan. During an interview on 4/13/22 at 3:54 P.M., the MDS Coordinator said: - The resident did not have a baseline care plan because the charge nurse did not do one; - The resident had just signed the Care Area Assessment (CAA, provides guidance to focus on key issues identified in comprehensive MDS and directs staff to evaluate triggered areas) so he/she had seven days to get the resident's care plan finished. During an interview on 4/14/22 at 8:51 A.M., Licensed Practical Nurse (LPN) A said: - He/she did not get the resident's baseline care plan done because he/she had two admissions back to back. During an interview on 4/19/22 at 11:51 A.M., the Director of Nursing (DON) said: - The new admissions should have a baseline care plan; - The charge nurse should fill out the baseline care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of Resident #15's quarterly MDS, dated [DATE], showed: -Five out of 15 on the Brief Interview for Mental Status (BIMS), a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. A score of 5 indicates severe cognitive impairment. -Limited assistance with activities of daily living, including dressing, hygiene, bathing. -Dialysis is marked. -Diagnoses include: hemiplegia (paralysis on one side of the body), cardiovascular accident (the medical term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel.), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), end stage renal disease (is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life. Review of the resident's care plan, dated 3/23/2022, showed: -The resident is receiving hemodialysis (a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood). The resident is at risk for weakness, and/or increased need for assistance with activities of daily living, as the resident requires hemodialysis three times a week for end state renal disease. -Check the resident's bruit & thrill (A bruit is an audible vascular sound associated with turbulent blood flow. Although usually heard with the stethoscope, such sounds may occasionally also be felt as a thrill/vibration) to left forearm shunt daily if not present, call the physician. -Monitor compliance with fluid restriction of 1500 (cubic centimeter) cc per 24 hours. -Monitor labs as ordered. -Monitor blood pressure per orders and as needed. -No care plan for any assessments or vitals prior to or after dialysis. -No care plan addressing any issues or bleeding involving the shunt. Review of the nurses notes, dated April 2022, showed: -No documentation regarding assessments prior to leaving or returning from dialysis. No documentation of communication with the dialysis center. During an interview on 4/19/2022 at 10:20 A.M., LPN A said: -The resident attends hemodialysis three times per week on Monday, Wednesday, Friday. - He/she does not conduct or document assessments on Resident #15 prior to or after returning from dialysis. During an interview on 4/19/22 at 11:51 A.M., the Director of Nursing (DON) said: -There is not a policy on dialysis, nor to document weights and vs before residents go or return. The standards are monitor intake. 8. Review of Resident #24's quarterly MDS, dated [DATE], showed: -He/she has adequate hearing and vision, is able to make self understood and understand others. -He/she scored 15/15 on the BIMS, indicating the resident is cognitively intact. -He/she scored 3 on the Patient Health Questionnaire 9 (PHQ9), (a screening tool for assessment of the severity of depressive symptoms). A score of 3 indicates minimal depression. -He/she is independent with activities of daily living, such as dressing, toileting, and personal hygiene. -Diagnoses included chronic kidney disease (kidneys are damaged and can't filter blood the way they should), colitis (a chronic digestive disease characterized by inflammation of the inner lining of the colon), depression, anxiety. -He/she intends to remain in the facility. Review of the physician order sheet (POS), dated 4/1/22, showed: -Order for psychiatric evaluation and medication management as needed -Buspirone 10 mg tablet (a medication to treat anxiety), once per day -Seroquel 50 mg (a medication for insomnia and depression) once per day at bedtime During an interview on 4/11/22 at 11:51 A.M., the Resident said: -He/she wishes to discharge from the facility, either home or to an assisted living facility. -He/she has spoken with the social worker about this. The social worker told the resident he/she cannot leave as his/her money comes to the facility. Review of the care plan, dated 1/20/22, showed: -No care plan addressing the resident's diagnosis of depression -No care plan addressing the resident's desire for discharge. During an interview on 4/19/22 at 11:45 A.M., the Director of Nursing (DON) said: -The Care Plan should reflect the resident for dialysis. -He/she doesn't know about including discharge planning in the care plan. -Any updates are done by coordinators as needed. charge nurse are capable of doing it. -Care plans should reflect the need of resident During an interview on 4/19/22 at 2:45 P.M., the Social Services Director (SSD) said: -He/she has spoken with the resident regarding discharge. A referral has been sent to the Money Follows the Person program, to another long term care facility, and an assisted living facility. He/she denies telling the resident he/she could not leave due to money. -The SSD has not care planned the resident's desire to discharge. -The SSD said that a resident's desire to discharge should be care planned. During an interview on 4/19/22 at 3:50 P.M., the MDS Coordinator said: -He/she is also responsible for writing care plans. -Residents receiving dialysis should be care planned for assessments prior to and after returning from dialysis. -Residents receiving dialysis should be care planned for what to do if there is bleeding or issues with the shunt. -A resident's desire to discharge should be included in the care plan. 4. Review of Resident #23 Quarterly MDS dated [DATE] showed: -Brief Interview of Mental Status (BIMS) of 15. (indicates no cognitive impairment) -No behaviors. -Extensive assistance with Activities of Daily Living (such as bathing, toilet use, personal hygiene, etc) -Bed and chair alarm daily. -No use of side rails. -One fall with injury. -One fall without injury. Review of the Face Sheet showed diagnosis of : -Cerebellar Ataxia (sudden, uncoordinated muscle movement due to disease or injury to the brain) -Unsteadiness on feet -Difficulty walking -History of falling Review of resident's April 2022 Physician Orders showed: -1/2 side rails times two at resident request for positioning and mobility. Review of the care plan dated 1/14/22 showed: -Problem: at risk for falls dated 2/10/2019. -Pressure alarm in place to all surfaces for safety and to alert staff to unsafe transfers. -No care plan for use of side rails. -Review of Nurse Assessment (an assessment used to review the residents overall condition and health) documentation dated 4/11/22 showed: -Directions to assessor: Devices and Restraints - If any checked, besides none of the above, complete Restraint/Adaptive Equipment Assessment -Side rails is not marked -None Of Above is marked. Observation on 04/12/22 at 8:07 A.M. showed: - Half rails to both sides of the bed. One side in the up position (not in use) one side down and latched. During an interview on 4/14/22 at 9:30 A.M. Certified Nurse Aide (CNA)F said: -All residents have side rails. -Some residents use them to turn in bed. -He/she is unsure if this resident uses it to turn in bed. During an interview on 4/14/22 at 09:32 A.M. the resident said: -He/she lays on his back in bed and does not turn. During an interview on 4/19/22 at 11:51 A.M. the Director of Nursing said: -Care plans should be specific to the resident. -He/she would expect the care plan to address the use of side rails. 5. Review of Resident #56's Quarterly MDS dated [DATE] showed: -BIMS of 7 (indicates moderate cognitive impairment) -No behaviors -Total dependence on staff for all Activities of Daily Living (ADLs) -Weight of 116 pounds -Weight loss of 5% or more -No difficulty swallowing or chewing Review of the resident's face sheet showed diagnosis of: -Intracerebral hemorrhage ( bleeding in the brain tissues, with resulting brain damage) affecting the right side, Atrial fibrillation (irregular, rapid heart rate that can lead to blood clots), dysphagia (difficulty swallowing), muscle weakness and lack of coordination. Review of the resident's care plan updated on 1/27/22 showed: -He/she requires assistance with all Activities of Daily Living(ADL's such as bathing, transfers, toileting, personal hygiene, nutrition) due to bilateral hemiparesis (limited feeling and movement due to nerve damage on one side of the body). Right side is worse than the left. -Use high back wheelchair with cushion for positioning needs. -He/she requires a mechanically altered diet due to Cerebral Vascular Accident (CVA: also known as a stroke, where blood flow to the brain is impaired, causing damage to the brain). -He/she will maintain nutritional status by: use of mechanical soft diet, eats in the dining room, fair-good appetite, offer of snacks, offer substitutes, and monitor weight, inability to feed him/herself and requires extensive assistance to total dependence on staff. -No care plan for weight loss or fluctuations in weight. -No approaches to combat weight loss. -No approaches for care of hemiplegic side. -No care plan for Restorative Services, use of edema gloves Review of April 2022 Physician order sheets showed: -Edema glove to left upper extremity on in the A.M. and off in the P.M. -OT (Occupational Therapy) 5 times a week for 4 weeks for therapeutic activity, therapeutic exercise and left upper extremity compression garment -Elastic netted tubing to left upper extremity for wound prevention Observation on 4/14/22 at 9:06 A.M. showed: -His/her left hand hanging at hip height against wheelchair seat. -His/her hand is edematous (swollen). -Stockinet( mesh dressing) is on resident left arm from knuckles to elbow. During interview and observation on 4/14/22 at 9:17 A.M. CNA G said: -This resident does not receive restorative services. -He/she stretches resident's fingers when providing care. -The resident's care plans tell specific care needs. -CNA G is assisting resident with meal intake. -Resident's left hand is hanging at hip height against wheelchair seat, is edematous with stockinet dressing in place. 6. Review of Resident #80's Quarterly MDS showed: -BIMS was not completed -Resident is difficult to understand -He/she needs extensive assistance with toileting and personal hygiene. -He/she needs supervision for locomotion in room. -He/she needs limited assistance with transfers. -He/she has occasional incontinence of urine. -Resident uses chair/bed alarm daily. -Resident has had 2 or more injury falls since last assessment. Review of the resident's face sheet showed diagnosis of: -Parkinson's Disease (a progressive nervous system disorder that effects movement and stability) -Protein calorie malnutrition (the inadequate use of protein by the body) -Cognitive Communication Deficit (Difficulty in thinking and the use of language) -Need for assistance with personal cares Review of the resident's physician order sheets for April 2022 showed: - Pressure alarm in place to all surfaces for a diagnosis of safety. -Monitor every shift. -Order date of 6/11/21. Review of resident's care plan dated 7/2/21 showed: -No care plan for the use of alarms. During an interview on 04/13/22 02:59 P.M. Unit Coordinator A said: -The MDS Coordinators complete and change the care plans. During an interview on 04/18/22 at 10:41 A.M. the Director of Nursing said: -Unit Coordinators are responsible for putting alarms on residents. -Alarms are used instead of restraints. -Alarms are used to notify staff when a resident who is high fall risk gets up. -Alarms should be evaluated with every MDS/Care Plan meeting. 3. Review of Resident #33 ' s quarterly MDS dated [DATE], included the following: - Date admitted [DATE]; - Severe cognitive impairment; - Required extensive assistance with activities of daily living; - Was at risk for pressure ulcers; - Did not have any pressure ulcers at the time of the assessment; - Treatments included pressure reducing devices for chair and bed and application of ointments/medications other than to feet. Review of the resident ' s care plan dated 1/24/22 included the following: - The resident was at risk for pressure ulcers due to incontinence, impaired mobility and impaired cognition. Interventions included pressure reliving mattress to bed and pressure relieving cushion to seated surfaces. Review of the resident ' s April 2022 physician orders sheet showed an order for cushion in the resident ' s Geri chair but did not show any order for a pressure reducing device for the resident ' s bed. Observations on 4/11/22 and 4/13/22 at various times showed the resident laying in bed and sitting in his/her wheel chair. There was not any pressure reducing device observed on the resident ' s bed. During an interview on 4/13/22 at 2:00 P.M. Certified Medication Technician (CMT) C said: - Care plans were kept at nurse station; -The resident has never had a pressure relieving device for his/her bed but did have one for his/her chair. During an interview on 4/13/22 at 9:30 A.M. Licensed Practical Nurse (LPN) C said: - The resident did not have any open areas on his/her skin at this time. Interventions for pressure ulcers for the resident included skin prep for preventative purposes, preventative cushion for his/her wheelchair and thought the resident ' s bed has bolsters. During an interview on 4/19/22 at 11:51 A.M. the DON said care plans should reflect the care needs of the resident. Based on observation, interview and record review, the facility failed to ensure they developed and implemented a comprehensive person-centered plan of care which included measurable objectives and timeframe's to meet each resident's medical, nursing, and mental psychosocial needs identified in the comprehensive assessment for eight of 19 sampled residents, ( Resident #28, #74, /#23, #56 #80, #15, 24 and #33). The facility census was 94. Review of the facility's policy for care plan, dated 7/30/07, showed: - It is very important to know exactly how to care for the residents. The care plan is a tool to aide all nursing staff on how to do just that: all nursing staff need to know where the care plans are located on the wing; all nursing staff need to know that they have access to the care plans; all nursing staff need to know that it is their responsibility to know the information contained in the care plan; all nursing staff need to know that is is their responsibility to imitate or implement interventions that best care for the resident. Review of the facility's policy for updating care plans, revised 4/5/18, showed: - All charge nurses need to be aware that it is not only the unit Coordinators and MDS Coordinators responsibility to update care plans, it is theirs as well; - Care plans need to be continually updated as the resident's needs change. The care plan needs to reflect the resident's current status at any given moment; - Unit Coordinators and MDS Coordinators and charge nurses will be responsible for putting into place and documenting interventions to address approaches taken to prevent or treat current problems; - MDS Coordinators will remove the care plans from the care plan book with each comprehensive assessment . The new care plans will be updated with any new information as well as pertinent information from the initial care plans and printed then returned to the care plan book; - Care plans will also be reviewed and updated as needed at clinical meetings weekly. 1. Review of Resident #28's significant change in status Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/22 showed: - Cognitive skills severely impaired; - Dependent on the assistance of two staff for bed mobility, transfers, dressing and bathing; - Upper and lower extremities impaired on both sides; - Had a supra pubic catheter (enters the bladder through the lower abdomen); - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Diagnoses included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), neurogenic bladder (a dysfunction that results from interference with the normal nerve pathways associated with urination), high blood pressure, paraplegia (paralysis characterized by motor sensory loss in the lower limbs and trunk), seizure disorder, anxiety, depression and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, edited 2/21/22, showed: - The resident liked to take a shower; - The resident was on Hospice services related to diagnoses of osteomyelitis (inflammation of the bone usually due to infection which may spread to the bone marrow and tissues near the bone); - The care plan did not address how many showers the facility staff would provide and/or how many Hospice would provide. 2. Review of Resident #74's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Diagnoses included anemia, congestive heart failure (CHF, a decrease in the ability of the heart to pump blood resulting in an accumulation of fluid in the lungs and other areas of the body), anxiety, depression and dementia. Review of the resident's physician's order sheet (POS) dated April 2022, showed: - An order for oxygen at 2 liters (L) via nasal cannula (NC); - Check oxygen saturation daily. Observation on 4/12/22 at 8:25 A.M., showed: - The resident had an oxygen concentrator in his/her room; - The green oxygen tubing was not dated; - Did not have a humidified water bottle on the oxygen concentrator. Review of the resident's care plan, revised 3/31/22, showed it did not address the use of oxygen. During an interview on 4/19/22 at 2:57 P.M., the MDS Coordinator said: - The oxygen use should be care planned; - The care plans do not specify who provides the showers, it just indicates that the resident is bathed twice weekly; - The care plans should reflect the resident's needs and cares provided. During an interview on 4/19/22 at 11:51 A.M., the Director of Nursing (DON) said: - The care plan should state if the resident wanted day or evening showers; - The care plan should be specific to the resident; - The care plan should address the use of oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #56's Quarterly MDS dated [DATE] showed: -BIMS of 7 (indicates moderate cognitive impairment) -Total dependence on staff for all Activities of Daily Living (ADLs) -Weight of 116 pounds -Weight loss of 5% or more -No difficulty swallowing or chewing Review of Resident #56's electronic health recorded weights showed: -11/11/2021 Weight: 137 pounds (lbs) -12/09/2021 Weight: 125 lbs -01/02/2022 Weight: 122.6 lbs -01/09/2022 Weight: 122.6 lbs -01/16/2022 Weight: 116.8 lbs -01/23/2022 Weight: 118.4 lbs -02/13/2022 Weight: 112.2 lbs -02/20/2022 Weight: 108 lbs -02/27/2022 Weight: 108.8 lbs -03/06/2022 Weight: 110 lbs -03/13/2022 Weight: 109.4 lbs -03/20/2022 Weight: 109.2 lbs -03/27/2022 Weight: 109.4 lbs -04/03/2022 Weight: 109.4 lbs -04/10/2022 Weight: 110.4 lbs -04/16/2022 Weight: 110.4 lbs -04/17/2022 Weight: 109.4 lbs -November to December 2021 showed a 12 lbs weight loss or 8.76% in 30 days. -December 2021 to January 2022 showed a 9 lbs weight loss or 7.20% in 30 days. -January to February 2022 showed a 10 lbs weight loss or 8.47% in 30 days. With a total of 31 lb weight loss or 20.15% 6 months. Review of the resident's Face Sheet showed diagnosis of: -Intracerebral hemorrhage ( bleeding in the brain tissues, with resulting brain damage) affecting the right side, Atrial fibrillation (irregular, rapid heart rate that can lead to blood clots), dysphagia (difficulty swallowing), muscle weakness and lack of coordination. Review of the resident's Care Plan updated on 1/27/22 showed: -He/she requires assistance with all Activities of Daily Living(ADL's such as bathing, transfers, toileting, personal hygiene, nutrition) due to bilateral hemiparesis: (limited feeling and movement due to nerve damage on one side of the body) right side, dominant side, is worse than the left. -He/she requires a mechanically altered diet due to Cerebral Vascular Accident (CVA: also known as a stroke, where blood flow to the brain is impaired, causing damage to the brain). -He/she will maintain nutritional status by: use of mechanical soft diet, eats in the dining room, fair-good appetite, offer of snacks, offer substitutes, and monitor weight; inability to feed him/herself and requires extensive assistance to total dependence on staff. -No care plan for weight loss or fluctuations in weight. -No approaches to combat weight loss. Review of April 2022 Physician order sheets showed: -Carnation Instant Breakfast (CIB) in milk or juice between meals twice a day for weight loss. Order date of 2/8/22. Review of April 2022 Medication Administration Record (MAR) showed: - CIB administered twice daily at 8:00 A.M. and 5:00 P.M. is initial as given April 1-18, 2022 During interview and observation on 4/14/22 at 9:17 A.M. CNA G said: -The resident's care plans tell specific care needs. -CNA G is assisting resident with meal intake, providing encouragement to eat. During an interview on 4/14/22 at 3:56 P.M. Licensed Practical Nurse (LPN) B said: -CNA's are responsible for obtaining weights for residents on their assigned unit. -CNA's report any weight changes to him/her. -He/she fills out a dietary report, and charts the weight in the computer . -Dietary makes a plan for any resident with weight loss. -He/she does not call the physician for weight loss. -He/she is unsure who notifies the physician of weight loss. During an interview on 4/19/22 at 9:24 A.M. the Dietary Manager said: -Nursing reports resident's weights to him/her. -Resident's weight changes are discussed at the weekly weight committee meeting. -He/she does not call the physician about weight loss. -He/she believes nursing notifies the physician of weight loss. -He/she said there are several residents on supplements for nutrition and weight maintenance. During an interview on 4/19/22 at 11:51 A.M. the DON said: -Residents weights are obtained monthly. -Any resident with a 5% or 10% weight loss is considered a significant loss. -Any significant loss: - the resident is placed on weekly weight until stable. -The physician is notified by nursing, and supplements are requested at that time. -The clinical team discusses weights weekly, usually on Thursdays. -The Dietician reviews and makes recommendations. -If a resident is a weight loss and they have been on CIB BID and still not maintaining then the team discusses other interventions like stimulants, or double portions. -Weight loss and interventions should be care planned for each individual and documented in progress notes -He/she is aware that Resident #56 is a weight loss. -He/she is unsure why other interventions aren't in place. -He/she would expect the physician to be notified. Based on observations, interviews, and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when staff failed to obtain a physician's order for a surgical wound treatment for one of 19 sampled residents, ( Resident #147) and failed to notify the physician of significant weight loss for one resident (Resident #56). The facility census was 94. The facility did not provide a policy for following physician's orders or notification of physician. 1. Resident #147 was admitted on [DATE] and did not have a baseline care plan. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/22 showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use; - Lower extremity impaired on one side; - Diagnoses include hip fracture, anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), coronary artery disease (CAD, a narrowing or blockage of the coronary arteries), high blood pressure and depression. Review of the resident's physician's order sheet (POS), dated April 2022, showed: - It did not have an order for surgical wound treatment to the left hip. Observation and interview on 4/13/22 at 3:15 P.M., showed: - Licensed Practical Nurse (LPN) A said the resident had a surgical wound on his/her left hip and the middle incision was draining; - LPN A removed the old dressing with light brown drainage on it and no odor noted; - LPN A cleaned the incision with wound cleanser and gauze and applied a new dressing. During an interview on 4/14/22 at 8:51 A.M., LPN A said: - The resident should have an order for wound treatment and it should be care planned. During an interview on 4/19/22 at 11:51 A.M., the Director of Nursing (DON) said: - The resident should have an order for wound treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #18 Significant change MDS dated [DATE] showed: -BIMS of 8 (indicates some cognitive impairment) -Extensive assistance to total dependence for Activities of Daily Living (i.e. toileting, bathing, personal hygiene, dressing, etc) -Incontinent of bowel and bladder. -Diagnosis of Coronary Artery Disease (buildup of plaque in the artery causing decreased blood flow), Diabetes Mellitus (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high) , Need for Assistance with Personal Care, Congestive Heart Failure (the heart doesn't pump blood efficiently) and Hypertension Observation on 04/13/22 10:30 A.M. showed -He/she sitting in his/her room in a wheelchair, yelling help me. -He/she has on 2 different socks, pants and a pajama shirt. -He/she wheeled him/her self to door, calling out for help. -Activity staff A took resident to the dining room for group activity, telling resident he/she could not go to bed due to only being 30 minutes until meal time. -Resident verbalized his/her need to go to the bathroom. -Activity staff A told the resident to stay for activities and he/she'd get the resident tea. -The resident continues to call out help me. -Activity staff A brought the resident back to his/her bedroom saying he/she could play bingo this afternoon. -The resident said this is not afternoon, and he/she needs assistance to the bathroom; - At 10:34 A.M. Activity staff A turned light on and left room. - At 10:37 AM CNA I entered resident's room , turned off call light, told the resident it was almost time for lunch and left room. -Resident came to his/her bedroom door and said he/she was unable to stand up, and staff had gone to get a machine to help him/her. -He/she then came to the door of his/her bedroom asking if staff got the machine. -Resident stopped Activity staff A requesting help. - Activity staff A laughed, shook his/her head no, then said he/she was putting up dirty dishes and would return. -At 10:43 A.M. Activity Staff A turned light on, exited room, told CNA F resident needed assistance. -At 10:45 Activity Staff A returned to resident's room, assisted the resident from the hallway back into the room. -At 10:46 A.M. CNA F entered room, turned call light off and exited resident's bedroom. -At 10:47 A.M. Resident back at his/her bedroom door yelling help. -At 10:52 CNAs F and H came to resident's room with mechanical lift. -CNAs F and H provided incontinent care to resident. During an interview on 4/13/22 at 10:52 A.M. CNA H said: -Resident #18 often yells for assistance. -Resident #18 is incontinent of bowel and bladder. -Staff assist resident as quickly as possible. -He/she wasn't able to get to resident when resident first yelled out due to helping other residents. During an interview on 04/19/22 11:51 A.M. DON said: -He/she would expect staff to assist resident who is yelling out. -He/she would expect other departments to notify nursing if resident is yelling out. Based on observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected three of 19 sampled residents, (Resident #36, #74 and #147), and when staff failed to provide morning care such as oral care and comb/brush Resident #74's hair. The facility failed to provide assistance for one resident (Resident #18) in a timely manner, when the resident asked for assistance in using the bathroom. The facility census was 94. Review of the facility's policy for male peri care, dated 3/29/19, showed: - Wash the lower abdomen, groin area and inner legs; - Using a circular motion wash the skin fold from the tip down; - The uncircumcised resident must have the skin fold retracted (pulled back) first; - Wash all the skin folds; - Replace the skin fold; - Turn the resident on his/her side; - Wash the back of the legs, the hip and lower back; - Wash the buttocks (front to back); - If dealing with fecal matter, you must remove your gloves and wash your hands otherwise you may sanitize and don new gloves; - Roll the resident to the other side; - Wash the resident's other hip; - Things to remember: always wash front to back; staff may coach one another, you must clean all areas that come in contact with urine or feces; you may use a different area of the wash cloth up to three times; you may use hand sanitizer up to three times before washing your hands. Review of the facility's policy for female peri care, dated 3/29/19, showed: - Wash the lower abdomen and inner legs; - Wash the outer skin folds from front to back; - Spread the outer skin fold and wash the inner skin fold from front to back; - Use a clean area of the wash cloth for each wipe (up to three times); - You may also use a different wash cloth each time; - Roll the resident to a side lying position; - Wash the back of the legs, the hip and the lower back; - Wash the buttocks still going from front to back; - If dealing with any fecal material, you must doff your gloves and wash your hands otherwise your may sanitize and don new gloves; - Roll the resident to the opposite side; - Wash the resident's other hip; - Things to remember: always wash front to back; staff may coach one another, you must clean all areas that come in contact with urine or feces; you may use a different area of the wash cloth up to three times; you may use hand sanitizer up to three times before washing your hands. Review of the facility's policy for A.M. cares, dated 3/29/19, showed: - The purpose is to refresh the resident, to prove cleanliness, comfort and neatness; to prepare the resident for breakfast; to assess the resident's condition; to assess the resident's needs; to promote psychosocial well-being; - All residents unable to care for themselves are to be provided total care; - Residents able to wash hands and face, brush teeth, comb hair and complete grooming are encouraged to do so and are supplied with the necessary items; - Supervision, set up, help or limited assistance may be needed. The facility did not provide a policy for showers. 1. Review of Resident #74's quarterly MDS, dated [DATE], showed: - Cognitive skills intact - Dependent on the assistance of two staff for bed mobility, transfers, and toilet use; - Required extensive assistance of two staff for dressing; - Frequently incontinent of urine; - Had a colostomy; - Diagnoses included anemia, congestive heart failure (CHF, a decrease in the ability of the heart to pump blood resulting in an accumulation of fluid in the lungs and other areas of the body), anxiety, depression and dementia. Review of the resident's care plan, reviewed 3/22/22 showed: - The resident required assistance with ADLs due to non weight bearing status and history of falls; - The resident had a full set of dentures that are in good condition. He/she required limited assistance of one staff with oral and denture care. Assist the resident to clean his/her mouth upon waking, after meals and at bedtime. Observation on 4/14/22 at 9:31 A.M., showed: - The resident was in bed with a cushion under his/her legs to prevent his/her heels from resting on the bed; - Certified Nurse Aide (CNA) C and CNA E provided incontinent care to the resident and used the mechanical lift and transferred the resident from his/her bed to his/her wheelchair; - CNA E gave the resident a warm wash cloth to wash his/her face and hands; - CNA C and CNA E did not offer oral care or offer to comb/brush the resident's hair. During an interview on 4/14/22 at 10:06 A.M., the resident said: - She would like for the staff to comb his/her hair and provide oral care. During an interview on 4/14/22 at 8:51 A.M., LPN A said: - Staff should offer oral care and comb the resident's hair when getting the resident up on the morning. During an interview on 4/14/22 at 3:15 P.M., CNA C said: - They should have offered to comb the resident's hair and offered to brush the resident's dentures. During an interview on 4/19/22 at 11:51 A.M., the DON said: - Staff should provide oral care, brush their hair and wash their face every morning. 3. Review of Resident #36's quarterly MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Dependent on the assistance of two staff for bed mobility, transfers, and toilet use; - Upper and lower extremities impaired on both sides; - Frequently incontinent of urine; - Continent of bowel; - Diagnoses included cancer, anemia, high blood pressure, stroke, anxiety, diabetes mellitus, depression, bipolar (brain disorder that causes changes in a person's mood, energy and ability to function). Review of the resident's care plan, reviewed on 1/18/22 showed: - The resident was incontinent of bowel and bladder; - Required total assistance with toileting; - Provide incontinence care after each incontinent episode. Observation on 4/11/22 at 3:18 P.M., showed: - CNA A turned the resident on his/her side and CNA B removed the bedpan; - CNA B wiped down each side of the buttocks with a different wash cloth each time; - CNA B did not wipe from front to back; - CNA A and CNA B tuned the resident onto his/her back; - CNA A used the same area of the wash cloth and wiped across the pubic area, then down the middle of the skin folds, wiped down the middle of the skin folds again, then folded the wash cloth and wiped again down the middle of the skin folds; - CNA A and CNA B placed a clean incontinent brief on the resident. 4. Review of Resident #147's admission MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use; - Lower extremity impaired on one side; - Always continent of bowel and bladder; - Diagnoses included hip fracture, peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block or spasm) anemia, coronary artery disease (CAD, a narrowing or blockage of the coronary arteries), high blood pressure and depression. Observation on 4/13/22 at 3:23 P.M., showed: - CNA E wiped across the pubic area, flipped the wash cloth then wiped down one side of the groin and back up the other side of the groin, flipped the wash cloth again and wiped down and back up the side of the groin, flipped the wash cloth again and wiped down the middle skin folds and back up the skin folds; - CNA E used a new wash cloth and wiped under the resident's buttocks and back up one side of the buttocks, flipped the wash cloth and used the same area and wiped across both sides of the buttocks and then wiped from front to back with fecal material. CNA E used a new wash cloth and wiped from front to back with fecal material, flipped the wash cloth and wiped again front to back with fecal material, flipped the wash cloth again and wiped front to back without any fecal material; - CNA E placed a clean incontinent brief on the resident. During an interview on 4/14/22 at 8:51 A.M., LPN A said: - We can only fold the wash cloths three times; - Should not use the same area of the wash cloth to clean different areas of the skin, it should be one swipe; - When cleaning fecal material, as long as there is a clean area, they can continue to use the same wash cloth; - Staff should wipe from front to back. During an interview on 4/14/22 at 3:15 P.M., CNA C said: - We can fold the wash cloth three times; - Should not use the same area of the wash cloth to clean different areas of the skin; - When cleaning the buttocks, should wipe up and not down; - When cleaning the front perineal folds should wipe down or from front to back; - If there's a lot of fecal material, it should be one wipe per swipe. If there's not a lot of fecal material, you can fold the wash cloth up to three times; - Should separate and clean all areas of the skin where urine or feces has touched. During an interview on 4/14/22 at 3:26 P.M., CNA E said: - We can fold the wash cloth up to three times, if unsure, just do one wipe, one swipe; - He/she did one wipe across the abdominal fold, folded the wash cloth, then wiped down one side of the groin, folded the wash cloth and wiped down the other side of the groin. He/she used a new wash cloth and wiped down the middle of the skin folds, folded the wash cloth and separated the middle skin folds and wiped down the middle; - Should wipe up the buttocks and wipe front to back; - When cleaning fecal material, it should be one wipe, one swipe; - Should not use the same area of the wash cloth to clean different areas of the skin; - Should separate and clean all areas of the skin where urine or feces has touched. During an interview on 4/19/22 at 11:51 A.M., the DON said: - Staff can flip and fold the wash cloth three times; - When cleaning fecal material, they can fold the wash cloth three times; - Staff should not wipe down the buttocks; - Should separate and clean all areas of the skin where urine or feces has touched; - Staff should not use the same area of the wash cloth to clean different areas of the skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Invacare Owner's, Operator and Maintenance Manual Revised 1/10/2008 by Invacare Corporation for Mechanical Lift Reliant 450 showed in part: -Care of slings: inspect with each use. -Warning: Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard Immediately. Review of Resident #18 Significant Change MDS dated [DATE] showed: -Brief Interview of Mental Status of 8 (indicates mild to moderate cognitive impairment) -Total dependence of 2 staff for transfers with use of mechanical lift. -Incontinent of bowel and bladder. -Diagnosis of : Need for assistance with personal cares. muscle weakness, heart failure, hypertension and diabetes. Observation and interview on 04/13/22 at 10:52 A.M. showed: -CNA F and CNA H provided personal hygiene to the resident. -CNA F retrieved mechanical lift sling from resident's wheelchair. -CNA F and CNA H applied sling to resident in bed. -CNA F and CNA H did not check the sling for rips/holes/tears/frays/damage. -Once sling was applied, noted two small holes in the fabric of the sling towards the right side, lower fourth of the sling. One hole was approximately the size of a dime. One hole was approximately the size of half a dime. Edges of the holes are black and burned in appearance with the fibers being melted together. -CNA F said: the holes are from being used previously on residents who smoke. -He/she has reported it to the Unit Coordinator. -He/she was not told what to do with the lift slings whey they are damaged. -The resident was assisted into his/her wheelchair by CNA F and CNA H, using the mechanical lift with damaged sling. During an interview on 04/13/22 at 2:59 P.M. Unit Coordinator A said: -He/she was not aware of any slings that were damaged. -He/she isn't sure of what would be done with a damaged sling. During an interview on 4/18/22 at 10:41 A.M. the DON said: -Staff should notify the Unit Coordinator of any sling in disrepair. -He/she would expect staff not use a damaged sling. -He/she was not aware of any damaged slings. Based on observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two of 19 sampled residents, (Resident #36 and #74) with the mechanical lift ; and use of a damaged sling to transfer one resident (Resident #18) from bed to chair. The facility census was 94. Review of the undated manufacturer's guidelines for the Invacare Reliant 450 mechanical lift, showed: - When using the adjustable base lift, the legs MUST be in the maximum opened/locked position before lifting the resident; - Invacare does not recommend locking of the rear casters of the resident lift when lifting an individual. Doing so could cause the lift to tip and endanger the resident and assistants. Review of the facility's policy for electric Hoyer lift transfer, dated 5/12/17, showed, in part: - The purpose is to transfer the resident safely with the help of two staff members. One staff member to operate the lift and the other staff member to guide the resident safely to their destination of the chair or bed; - General instructions: always lock the wheelchair brakes and secure pedals out of the way. Lift brakes must be unlocked when raising or lowering the resident. Check the resident's bed to make sure it is locked or doesn't move. Always guide the resident to their destination. 1. Review of Resident #36's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/18/22 showed: - Cognitive skills moderately impaired; - Dependent on the assistance of two staff for bed mobility, transfers, and toilet use; - Upper and lower extremities impaired on both sides; - Frequently incontinent of urine; - Continent of bowel; - Diagnoses included cancer, anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), high blood pressure, stroke, anxiety, diabetes mellitus, depression, bipolar (brain disorder that causes changes in a person's mood, energy and ability to function). Review of the resident's care plan, edited on 1/18/22, showed: - The resident required the use of the mechanical lift and total assistance of two staff for transfers. Observation on 4/11/22 at 3:18 P.M., showed: - Certified Nurse Aide (CNA) A brought the Invacare Reliant 450 into the resident's room; - CNA A placed the legs of the lift under the resident's bed with the legs opened and locked the rear casters of the lift; - CNA A backed away from the bed with the legs opened and went around the resident's wheelchair while CNA B guided the resident; - CNA A locked the rear casters on the lift and lowered the resident into the wheelchair; - CNA A and CNA B unhooked the lift pad from the mechanical lift. 2. Review of Resident #74's quarterly MDS, dated [DATE] showed: - Cognitive skills intact - Dependent on the assistance of two staff for bed mobility, transfers, and toilet use; - Required extensive assistance of two staff for dressing; - Frequently incontinent of urine; - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Diagnoses included anemia, congestive heart failure (CHF, a decrease in the ability of the heart to pump blood resulting in an accumulation of fluid in the lungs and other areas of the body), anxiety, depression and dementia. Review of the resident's care plan, reviewed on 3/22/22 showed: - The resident required assistance with activities of daily living (ADLs) and transfers due to non weight bearing status and history of falls; - The resident required total assistance of two staff for transfers with the use of the mechanical lift. Observation on 4/14/22 at 9:55 A.M., showed: - CNA C placed the mechanical lift under the resident's bed with the lift legs closed; - CNA C and CNA E hooked the lift pad up to the mechanical lift; - CNA C backed away from the bed with the legs of the lift closed and moved towards the resident's electrical wheelchair then opened the legs of the lift to go around the electric wheelchair. During an interview on 4/14/22 at 3:15 A.M., CNA C said: - When the resident was up in the mechanical lift, the legs of the lift should be opened; - The brakes on the wheelchair should be locked and the rear casters of the mechanical lift should be unlocked. During an interview on 4/14/22 at 3:26 P.M., CNA E said: - When the resident was in the mechanical lift, the legs of the lift should be opened and also when moving with the resident; - The wheelchair should be locked and the rear casters on the mechanical lift should be left unlocked. During an interview on 4/19/22 at 11:51 A.M., the Director of Nursing (DON) said: - The legs of the mechanical lift should be opened with the resident in the lift; - The rear casters on the mechanical lift should be unlocked when raising or lowering the resident in the lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #70 ' s comprehensive MDS dated [DATE], included the following: - Date admitted [DATE]; - Severe cognitive impairment; - On hospice services; - Did not show oxygen therapy. Review of the resident ' s care plan dated 2/24/22 included the following: - The resident was receiving hospice services; - Interventions included: Administer comfort medication per physician order for any pain/discomfort, restlessness, short of air, air [NAME] or increase in secretions, and allow adequate rest periods, oxygen as needed. Review of the resident ' s April 2022 physician orders did not include an order for oxygen therapy. Observation on 4/11/22 at 1:04 P.M. showed the resident asleep in bed with oxygen on. The oxygen tubing was not dated. Observation on 4/12/22 at 8:52 AM showed the resident in bed with oxygen on at 2.5 Liters. The oxygen tubing was still not dated. During an interview on 4/14/22 at 1:19 PM Certified Medication Technician (CMT) D said: - CMT ' s were responsible to change oxygen tubing weekly and date the tubing usually tagged on the tubing itself. They used to document when tubing had been changed but she had not seen the document in awhile. During an interview on 4/14/22 at 1:24 P.M. LPN C said: - The oxygen was from hospice, they automatically give concentrator; - CMT's change tubing but she did not know who cleaned the filters; - Oxygen would become an order if the resident ' s oxygen was low but hospice automatically brings that in. 3. During an interview on 4/19/21 at 11:51 A.M., the Director of Nursing (DON) said: - The oxygen tubing is changed weekly by the CNAs on Sunday and probably by the night shift; - It should be dated when changed; - The filters are cleaned weekly on Sunday; - The humidified water bottle should also be dated; - If the resident has an order for oxygen then the oxygen concentrator should be in the resident's room and ready for use. Based on observations, interviews and record review, the facility failed to assure staff provided proper respiratory care when staff failed to date oxygen tubing for one of 19 sampled residents, (Resident #74) and failed ensure physician orders were in place for one resident (Resident #70) using oxygen. The facility census was 94. Review of the facility's policy for oxygen use, dated 2/28/19, showed: - All oxygen concentrator filters need to be cleaned every week on Sunday night. Even concentrators that are not being used; - Oxygen tubing must be changed weekly and dated; - Oxygen tubing and nebulizer tubing must be stored in a plastic bag. 1. Review of Resident #74's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/22/22 showed: - Cognitive skills intact; - Diagnoses included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), CHF, anxiety, depression and dementia. Review of the resident's care plan, revised 3/31/22, showed it did not address the use of oxygen. Review of the resident's physician's order sheet (POS) dated April 2022, showed: - An order for oxygen at 2 liters (L) via nasal cannula (NC); - Check oxygen saturation daily. Observation on 4/12/22 at 8:25 A.M., showed: - The resident had an oxygen concentrator in his/her room; - The green oxygen tubing was not dated; - Did not have a humidified water bottle on the oxygen concentrator. During an interview on 4/14/22 at 8:51 A.M., Licensed Practical Nurse (LPN) A said: - The night shift should change the oxygen tubing weekly and change the disposable humidified water bottle when they are empty; - The humidified water bottle and the oxygen tubing should be dated when changed; - The night shift should clean the filters weekly. During an interview on 4/14/22 at 3:15 A.M., Certified Nurse Aide (CNA) C said: - The oxygen tubing and the water bottles should be dated and the filters cleaned; - He/she was not for sure who was responsible to do it or when.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that staff provided adequate pain control for two sampled residents (Resident #7 and Resident# 44). The facility census was 95. The facility did not provide a policy regarding pain management. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/22/22, showed: -Scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) (a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur.) A score of 3 indicates severe cognitive impairment. -Adequate hearing /vision, is able to make self understood and understand others. -He/she requires extensive assistance with activities of daily living(ADL's), including, dressing, toileting, personal hygiene. -He/she is frequently incontinent of bladder, and is occasionally incontinent of bowel. -He/she is not receiving scheduled or as needed pain medication. The pain assessment interview indicated the resident is not experiencing pain. Review of the resident's care plan, dated 1/6/22, showed: -The resident has history of chronic pain related to falls and shoulder pain. -He/she reports mild pain related to shoulders. Does not take pain medication. -Monitor and record any complaints of pain. -Monitor and record for any non-verbal signs of pain (crying, guarding, moaning, restlessness, grimacing). -Use non-medicated pain relief measures. -Assess the resident's pain and administer the as needed medication most appropriate for pain. Monitor and record effectiveness. -Position for comfort with physical support as needed. -Handle gently and try to eliminate any environmental stimuli. -Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects. -Assess effects of pain for disturbances in sleep, activity, self care, appetite. Review of the resident's Physician Orders Sheet (POS), dated 4/1/22, showed: -Diagnoses including vascular dementia ( a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), pain in left hip, repeated falls, chronic kidney disease (kidneys are damaged and can't filter blood the way they should), low back pain, other chronic pain, neuropathy ( a result of damage to the nerves located outside of the brain and spinal cord ). -Order for Voltaren Arthritis Pain gel ( medication is used to relieve joint pain from arthritis), apply to both shoulders four times per day as needed. -Order for Tylenol 325 milligrams (mg), (medication is used to treat mild-to-moderate pain associated with conditions such as headache, dental pain, muscle pain, painful menstruation, pain following an accident, and pain following operations), 2 tabs every 6 hours for pain. Review of the resident's Medication Administration Record (MAR), dated 4/1/22, showed: -Volteran Arthritis Pain gel, to be applied to both shoulders up to four times per day as needed, and no doses were given. -No MAR was provided for the Tylenol 325 mg. During an interview on 4/11/22 at 2:57 PM, the resident said: -He/she has pain daily in his/her shoulders and hips. -He/she states he/she does not get any medication for pain. During an interview on 4/19/22 at 10:15 AM, Certified Nurse Aide (CNA) A said: -Resident #7 complains of pain to his/her shoulders and hips frequently. -When the resident complains of pain, he/she reports this to the charge nurse. During an interview on 4/19/22 at 10:20 AM, Licensed Practical Nurse (LPN) A said: -He/she is aware that Resident #7 experiences pain frequently. -The resident does not request pain medication. -Staff have not approached the physician about a scheduled pain medication. -The resident has had x-rays done on shoulders and hips and there were no abnormalities. During an interview on 4/19/22 at 11:51 AM, the Director of Nursing (DON) said: -He/she would expect some type of pain control. -If the resident is taking as needed pain medication and taking it regularly, he/she would expect the staff to seek a different regimen. -If the resident is not taking it, he/she would expect the as needed pain medication to be given as ordered on a schedule for a few days and evaluate. -This is discussed in weekly meetings as well to determine any changes. 2. Review of Resident # 44 admission MDS dated [DATE] showed: -BIMS of 15 (indicates no cognitive deficit) -Independent to limited assistance with ADLs. -No behaviors. -Moderate pain frequently. -Use of daily pain medication and as needed pain medication. Review of the resident's Face Sheet showed diagnosis of: -Diabetes Mellitus (a chronic health condition that affects how your body turns food into energy) -Diabetic neuropathy (a type of nerve damage that is caused from Diabetes, and causes numbness, tingling and pain in the feet and hands) -Hypertension (high blood pressure) -History of Myocardial Infarction (also known as a heart attack, where blood flow to a certain part of the heart is impaired, causing damage to the heart muscle) Review of the resident's care plan dated 2/14/22 showed: -Alteration in comfort due to pain. -Pain will be managed to not interfere with daily activities. -Encourage position changes -He/she has scheduled pain medications and as needed pain medications. -Involve him/her in decision making about pain management. -Monitor and record any complaints of pain. Review of the resident's POS for April 2022 showed: -Tylenol 325 milligrams (mg), 2 tablets by mouth, every six hours at 6:00 A.M., 12:00 P.M., 6:00 P.M. and 12:00 A.M. Order date of 2/12/22. -Morphine (narcotic pain medication used for severe pain) extended release tablet 15 mg, twice daily at 8:00 A.M. and 8:00 P.M. Order date of 4/18/22. -Fentanyl patch (narcotic pain medication patch used for chronic severe pain) 12 micrograms (mcq), one patch transdermally (on the skin) every 72 hours at 8:00 P.M. Order date of 4/19/22 Review of the resident's MAR for April 2022 showed: -Tylenol 325 mg , 2 tablets every six hours scheduled. Administered at 6:00 A.M., 12:00 P.M., 6:00 P.M. and 12:00 A.M. daily April 1-18, 2022. -Morphine tablet administered: -4/05/2022 at 12:03 P.M. for pain level of 10. (on a 1-10 scale) -4/05/2022 at 2:52 P.M. Result: Resident Resting quietly in bed with eyes closed. -4/06/2022 at 7:27 P.M. for back pain at level 7. No follow up noted. -4/07/2022 at 8:33 A.M. for generalized pain level of 8. -4/07/2022 at 12:28 PM Result: pain level decreased to 3. -No other notations of medication being administered. Review of the resident's Progress notes showed: -On 4/6/22 Resident's daughter called to talk to Unit Coordinator A in regards to resident's pain. -His/her daughter questioned what was being doing for resident's pain. - Unit Coordinator A explained what the resident had available for pain. -His/her daughter requested the as needed pain medication be given scheduled in the morning and evening to control residents pain. -Unit Coordinator will pass on to other nurses to give resident the as needed morphine in the morning et evening. During an interview on 4/13/22 at 10:20 A.M. the resident said: - He/she is in pain. -He/she has not had a pain pill today. -He/she has to ask for the pain medication for staff to bring it to him/her. During an interview on 4/13/22 at 2:30 P.M. the Resident said: -He/she remains in pain. -No pain medication was brought to him/her. -He/she has asked multiple times for the medication. During an interview on 4/13/22 at 2:59 P.M. Unit Coordinator A said: -He/she is aware this resident has daily pain. -Resident #44 has an order for morphine at 8 :00 A.M. and 8:00 P.M. daily until evaluated by the physician. -He/she is unsure why the morphine was not signed as administered at those times daily. -Resident #44's physician is scheduled to see him/her tomorrow to evaluate pain control. During an interview on 4/19/22 at 11:51 A.M. the DON said: -He/she would expect some type of pain control. -He/she would expect if residents are taking an as needed medication frequently , he/she would expect it to be scheduled for a few days then evaluated. -If the resident is taking the medication on a scheduled basis and it is not effective , he/she would expect the physician to be notified and a different regimen attempted. -The Unit Coordinators are responsible for notification of the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure communication between the facility and dialysis center and standards of practice when staff failed to document assessments of one resident (Resident #15) before and after dialysis. The facility census was 95. The facility did not have a policy for dialysis. 1. Review of the medical record for Resident #15 dated 3/1/21 showed: -Dialysis orders read: Start date 3/1/2021, Resident to go to outside dialysis clinic for dialysis Monday, Wednesday and Friday per week. Check bruit and thrill to left forearm shunt daily. If not present call the physician at the dialysis clinic. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/29/22, showed: -Five out of 15 on the Brief Interview for Mental Status (BIMS), a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. A score of 5 indicates severe cognitive impairment. -Limited assistance with activities of daily living, including dressing, hygiene, bathing. -Dialysis is marked. -Diagnoses include: hemiplegia (paralysis on one side of the body), cardiovascular accident (the medical term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel.), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), end stage renal disease (is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life.) Review of the care plan, dated 3/23/2022, showed: -The resident is receiving hemodialysis (a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood). The resident is at risk for weakness, and/or increased need for assistance with activities of daily living, as the resident requires hemodialysis three times a week for end state renal disease. -Check the resident's bruit & thrill (A bruit is an audible vascular sound associated with turbulent blood flow. Although usually heard with the stethoscope, such sounds may occasionally also be felt as a thrill/vibration) to left forearm shunt daily if not present, call Dr. [NAME] at [PHONE NUMBER]. -Monitor compliance with fluid restriction of 1500 cc per 24 hours. -Monitor labs as ordered. -Monitor blood pressure per orders and as needed. Review of the Physician Order Sheet (POS), dated April 2022, showed: -No orders for any assessments or vitals prior to or after dialysis; nor the order from the dialysis clinic from 3/1/21. Review of the Resident's nurses notes, dated April 2022, showed: -No documentation regarding assessments prior to leaving or returning from dialysis. No documentation of communication with the dialysis center. Review of the Resident's weights showed: -Weights obtained on 2/10/22 and 1/13/22. During an interview on 4/19/2022 at 10:20 A.M., Licensed Practical Nurse (LPN) A said: -The Resident attends hemodialysis three times per week on Monday, Wednesday, Friday. -He/she does not conduct or document assessments on the resident prior to or after returning from dialysis. During an interview on 4/19/22 at 11:51 A.M., the Director of Nursing (DON) said: -There is not a policy on dialysis, nor to document weights and vs before residents go or return. The standards are monitor intake. During an interview on 5/4/22 at 11:54 A.M., the Dialysis RN said: -The clinic expects the facility to follow physician's order. -The clinic expects the facility to conduct assessments on the resident if the resident is not feeling well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to communicate the consultant pharmacist's recommendations to the resident's physicians for four of 19 sampled residents, (Resident #4, #36, #74 and #147) and failed to provide a rationale when the recommendation was declined which affected Resident #147. The facility census was 94. The facility did not provide a policy for drug regimen reviews. 1. Review of Resident #147's Drug Regimen Review (DRR), dated 2/2/22 showed the consultant pharmacist recommended: - The resident is [AGE] years old and takes citalopram 40 milligrams (mg.) for depression. The is medication is recommended to not exceed 20 mg. per day in people greater than [AGE] years old due to increased risk of QT prolongation (the time it takes the ventricles of the heart to contract and relax); - On 4/18/22 the Family Nurse Practitioner Certified (FNPC) checked disagree but failed to provide a rationale. Review of the resident's DRR, dated 4/2/22 showed the consultant pharmacist recommended: - The resident has had low magnesium levels on 2/25/22 and 3/17/22. The resident is not taking a magnesium supplement currently. Resident also takes pantoprazole (used to treat certain conditions in which there is too much acid in the stomach.) 40 mg. twice daily currently and it reduces magnesium levels. Please consider starting a magnesium supplement if clinically appropriate; - There was no documentation indicating the recommendations were relayed to the resident's physician. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/22 showed: - Cognitive skills intact; - Diagnoses included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), coronary artery disease (CAD, a narrowing or blockage of the coronary arteries), high blood pressure, hip fracture and depression. Review of the resident's physician's order sheet (POS), dated April 2022 showed: - Citalopram 40 mg. daily for depression; - Pantoprazole delayed release 40 mg. twice daily for acid reflux; - Magnesium oxide 400 mg. twice daily for supplement. 2. Review of Resident #4's DRR, dated 4/4/21 showed the consultant pharmacist recommended: - Resident is [AGE] years old and takes clopidogrel 75 mg. daily for CAD and aspirin 81 mg. daily for prophylaxis. Please evaluate the risks versus benefits for this resident to be on dual antiplatelet therapy; - There was no documentation indicating the recommendations were relayed to the resident's physician. Review of the resident's DRR, dated 9/6/21 showed the consultant pharmacist recommended: - Resident takes allopurinol (is used to prevent or lower high uric acid levels in the blood) 200 mg. daily. Based on resident's kidney function, the allopurinol dose should not exceed 50 mg. every other day. Please consider decreasing dose; - There was no documentation indicating the recommendations were relayed to the resident's physician. Review of the resident's annual MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Diagnoses included renal insufficiency, chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), anemia, CAD, diabetes mellitus and high blood pressure. Review of the resident's POS, dated April 2022, showed: - Allopurinol 100 mg., two tablets daily for increase uric acid; - Aspirin 81 mg. daily for myocardial infarction (MI) prophylactic; - Plavix (clopidogrel) 75 mg. daily for CAD. 3. Review of Resident #36's DRR, dated 8/5/21 showed the consultant pharmacist recommended: - Resident takes glipizide, metformin, Novolog and Tresiba for Type II Diabetes. Sulfonylureas are recommended to be discontinued when insulin is started due to risk of significant hypoglycemia. Resident is [AGE] years old and sulfonylureas are also recommended to be avoided in elderly. Please consider discontinuing glipizide and increasing insulin as clinically appropriate; - There was no documentation indicating the recommendations were relayed to the resident's physician. Review of the resident's DRR, dated 9/7/21 showed the consultant pharmacist recommended: - Resident takes metformin 1000 mg. extended release (ER) daily. Resident's comprehensive metabolic panel (CMP, a test that measures 14 different substances in your blood) on 9/1/21 showed an estimated glomerular filtration rate (eGFR, a test that measures your level of kidney function and determines your stage of kidney disease) of 29 milliliters (ml.)/minute (min.). Metformin is contraindicated when eGFR falls below 30 ml./min. Resident's hemoglobin A1C (hgb A1C, a blood test used primarily to monitor the glucose of diabetics over time) percent was also up 7.2% from 6.6%. Please consider discontinuing metformin and adjusting insulin accordingly. Novolog is currently only dosed as a sliding scale. Please consider scheduling set doses; - There was no documentation indicating the recommendations were relayed to the resident's physician. Review of the resident's DRR, dated 10/10/21 showed the consultant pharmacist recommended: - Resident takes colestipol (for hyperlipidemia) one gram at 8:00 A.M., and 5:00 P.M. All other morning medications are taken at 8:00 A.M. and evening medications at 5:00 P.M. Other medications are recommended to be taken one hour before or four hours after colestipol. Please consider changing colestipol administration times to 9:00 A.M. and 6:00 P.M.; - There was no documentation indicating the recommendations were relayed to the resident's physician. Review of the resident's quarterly MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Diagnoses included cancer, anemia, high blood pressure, diabetes mellitus, hyperlipidemia, stroke, anxiety, depression and bipolar (episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's POS dated April 2022 showed: - Novolog flexpen insulin per sliding scale before meals and at bedtime for diabetes mellitus; - Tresiba flextouch insulin pen 35 units at bedtime. Hold 32 units of Tresiba if blood sugar is less than 100 for diabetes mellitus; - Colestid (colestipol) one gram twice daily at 8:00 A.M. and 5:00 P.M. for hyperlipidemia; - Glipizide 5 mg. daily at 8:00 A.M. for diabetes mellitus; - Metformin extended release 500 mg. two tablets at bedtime, 5:00 P.M.; - The resident's medications remain scheduled at 8:00 A.M. and 5:00 P.M. 4. Review of Resident #74's DRR, dated 9/6/21 showed the consultant pharmacist recommended: - Resident takes Aspirin 81 mg. daily and Eliquis 2.5 mg. twice daily. The indications for these medications are unclear. Please consider conducting a risk versus benefit analysis for this resident to be on an antiplatelet and anticoagulant medication together at her age; - There was no documentation indicating the recommendations were relayed to the resident's physician. Review of the resident's DRR, dated 10/3/21 showed the consultant pharmacist recommended: - Resident has an order for Voltaren gel 1% (topical gel that blocks substances that cause inflammation and pain) to left knee daily. Please clarify for staff, in grams, how much to use with each application; - There was no documentation indicating the recommendations were relayed to the resident's physician. Review of the resident's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Diagnoses included anemia, congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), dementia, anxiety and depression. Review of the resident's POS, dated April 2022 showed: - Eliquis 2.5 mg. twice daily to prevent blood clots; - Voltaren Arthritis pain 1% gel, apply four grams to affected area topically four times a day as needed for pain. During an interview on 4/19/21 at 11:51 A.M., the Director of Nursing (DON) said: - The pharmacy consultant reviews the medical records every month and emails the recommendations to her. The DON prints them out and gives them to each of the Unit Coordinators. The Unit Coordinators addresses them with the physician and then gives the recommendations to medical records to be scanned into the resident's charts; - The physician does not like to do them and refuses to put why he disagrees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interviews and record review, the facility failed to ensure PRN (as needed) psychotropic medications were limited to 14 days unless the resident's physician believed it was appropriate for PRN use and documented their rationale and can be renewed only after being evaluated by the attending physician, which affected one of 19 sampled residents, (Resident #4). As well as, the facility failed to ensure that one resident (Resident #23), had an appropriate diagnosis for psychotropic medication, and received a gradual dose reduction (GDR), and/or a rationale from the physician as to why the GDR was not attempted for one additional residents (Resident #73). The facility census was 94. The facility did not provide a policy regarding PRN use of psychotropic medications or Gradual Dose Reduction and Medication Review. 1. Review of Resident #4's annual Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/22, showed: - Cognitive skills moderately impaired; - No behaviors exhibited; - Upper extremity impaired on both sides; - Independent with bed mobility, transfers, dressing eating, toilet use and personal hygiene; - Frequently incontinent of urine; - One fall with minor injury; - Received seven antianxiety medications seven of the previous seven days; - Hospice care while a resident of the facility; - Diagnoses included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), coronary artery disease (CAD, a narrowing or blockage of the coronary arteries), congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), anxiety, dementia, diabetes mellitus and high blood pressure. Review of the resident's Care Area Assessment (CAA, provides guidance to focus on key issues identified in comprehensive MDS and directs staff to evaluate triggered areas), signed 3/29/22, showed: - Psychotropic medication use: This triggered for the resident because he/she takes Ativan for anxiety. The resident has been doing well on this medication and is experiencing no adverse effects at this time. Review of the resident's care plan, edited on 4/13/22, showed: - The resident is at risk for adverse consequences related to receiving antianxiety medication; - Administer medications for anxiety as ordered. Monitor and record effectiveness; - Physician to set guidelines for possible reduction or increase if needed; - The resident was admitted on Hospice care on 8/8/2020. Diagnoses included chronic kidney disease Stage 5 (the kidneys are getting very close to failure or have already failed) and CHF. Review of the resident's physician order sheet (POS) dated April 2022, showed: - Start dated 8/3/2020- Lorazepam intensol concentrate 2 milligrams (mg.)/milliliter (ml.), give 0.25 ml. oral every hour for PRN shortness of air or anxiety; - Start date 8/3/2020 - Lorazepam intensol concentrate 2 mg./ml., give 0.5 ml. every hour PRN shortness of air or anxiety; - Start date 8/3/2020 - Lorazepam intensol concentrate 2 mg./ml., give 0.75 ml. every hour PRN shortness of air or anxiety; - Start date 8/3/2020 - Lorazepam intensol concentrate 2 mg./ml., give 1.0 ml. every hour PRN shortness of air or anxiety. Record review on 4/18/22 at 4:41 P.M., showed: - The last documented drug regimen review was 9/10/20. 2. Review of Resident #23 Quarterly MDS dated [DATE] showed: -Brief Interview of Mental Status (BIMS) of 15. (indicates no cognitive impairment) -No behaviors. -Extensive assistance with Activities of Daily Living (ADL's) (such as bathing, toilet use, personal hygiene, etc) Review of the Face Sheet showed diagnosis of : -Cerebellar Ataxia (sudden, uncoordinated muscle movement due to disease or injury to the brain) -Unsteadiness on feet -Anxiety disorder -Difficulty walking -History of falling -Adult Failure to Thrive Review of the POS for April 2022 showed: - Trazodone (medication used to treat depressive disorder) 50 mg, 1 tablet at bedtime for insomnia/depression, order date of 6/18/2020; - Xanax (medication used to treat anxiety and panic disorders) 2 mg at bedtime for ataxia (without coordinator and muscle weakness), order date 8/21/2019. Review of Medication Regimen Review (MMR) performed by a Registered Pharmacist showed: -No recommendations for February, April, May,June , July, August, September, November and December of 2021 -No medication review found for March of 2021. -Recommendation on 10/21/21 showed no recommendations for psychotropic medications. -No recommendations for January, February, and March of 2022 3. Review of Resident #73's quarterly MDS, dated [DATE], showed: -Diagnoses of chronic kidney disease (the kidneys are damaged and can't filter blood the way they should), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), joint pain, heart failure, paranoid schizophrenia (characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations). - Score of 15 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates the residents is cognitively intact. -No behaviors are noted. -Independent with activities of daily living, including dressing, toileting and personal hygiene -Independent with mobility. -Always continent of bladder. The resident has a colostomy ( surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon). Review of care plan, dated 3/21/22, showed: -The resident has history of paranoia and delusions, as well as expressing symptoms of anxiety and depression. The resident prefers to stay in his/her room for most activities. -The resident receives a hypnotic medication for insomnia. -He/she receives a scheduled anti-anxiety medication for feelings of anxiety and feeling unsettled. Monitor for symptoms and side effects. -He/she receives an anti-depressant with an addition of an anti-psychotic medication to manage symptom of depression. The anti-psychotic medication was restarted on 9/23/2019 due to reemergence of symptoms. Continue to monitor for target symptoms. -Coordinate with facility pharmacy consultant regarding recommendations for dosage adjustments. -Monitor for target behaviors of paranoia and delusions, tearfulness, fearfulness. Engage in conversation to provide reassurance and support. Help identify coping measures to provide options for self-assurance. Review of POS, dated April 2022, showed: -Abilify (aripiprazole) tablet; 5 mg; 1 tab; oral at bedtime, for schizophrenia -Belsomra (suvorexant) Schedule IV tablet; 15 mg, 1 tab; oral at bedtime, for anxiety disorder -Pristiq (desvenlafaxine succinate) tablet extended release 24 hour; 50 mg; oral once a day; for depression -Xanax (alprazolam) Schedule IV tablet; 1 mg oral; 3 times per day; for anxiety/depression -Record Review on 4/18/22 at 3:13 P.M. showed: -MRR were conducted by the facility pharmacy consultant monthly, January 2021 through April 2022. -No recommendations were made on any of the MMRs reviewed, to attempt dose reductions on the anti-psychotic medications. During an interview on 4/19/22 at 11:51 A.M., the Director of Nursing (DON) said: - The pharmacy consultant reviews the medical records every month and e-mails the recommendations to her. The DON prints the recommendations out and takes them to each unit coordinator. The unit coordinator addresses them with the physician then the recommendations are sent to medical records to be scanned in the electronic charts; - The physician does not like to do them and refuses to put an explanation on why he/she disagrees.

Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5%. Facility staff made two medication errors out of 31 opportunities for error, a medication error rate of 6.45%, which affected two of 19 sampled residents, (Resident #10 and #75). The facility census was 94. Review of the facility's policy for medication administration, dated 6/13/14, showed: - The right drug; - The right patient; - The right dose; - The right time; - The right route; - The right reason; - The right response; - The right documentation; - The right disbursement technique: each resident shall have their medication administered immediately after each individual's medication preparation. Review of the facility's policy for eye drops, dated 7/30/07, showed, in part: - Gently pull the lower eye lid down; - Drop the prescribed medication into the lower lid; - Instruct the resident to close his/her eye; - Gently press a tissue against the the lacrimal duct for approximately one minute; - If this cannot be accomplished then instruct the resident to close eye for approximately three minutes. 1. Review of Resident #75's physician order sheet (POS), dated April 2022, showed: - An order for artificial tear 0.4% one drop in both eyes four times daily for dry eyes. Review of the resident's medication administration record (MAR), dated April 2022, showed: - Artificial tear 0.4% one drop in both eyes four times daily for dry eyes. Observation on 4/18/22 at 11:32 A.M., showed: - Certified Medication Technician (CMT) A pulled the resident's lower eye lid down and placed one drop in the right eye; - CMT A pulled the resident's lower eye lid down and placed one drop in the left eye; - CMT advised the resident to apply pressure but did not specify where to apply pressure or for how long; - The resident used a Kleenex and wiped both eyes then put the Kleenex on the inside corner of the eye for approximately four seconds and for approximately five seconds for the other eye. 2. Review of Resident #10's POS, dated April 2022, showed: - An order for brimonidine 0.2%, one drop in both eyes twice daily for glaucoma (a condition of increase pressure within the eyeball, causing gradual loss of sight). Review of the resident's MAR, dated April 2022, showed: - Brimonidine 0.2% one drop in both eyes twice daily for glaucoma. Observation on 4/19/22 at 8:05 A.M., showed: - CMT A placed one drop in each eye; - CMT A asked the resident if he/she wanted to apply pressure and the resident used a Kleenex and dabbed at both eyes then put his/her eye glasses on; - Neither the resident or CMT A applied lacrimal pressure. During an interview on 4/19/22 at 8:20 A.M., CMT A said: - He/she should have applied lacrimal pressure for two minutes. During an interview on 4/19/22 at 11:51 A.M., the Director of Nursing said: - Staff should apply lacrimal pressure but not for sure how long. The policy would indicate the time frame.

Based on observations, interviews, and record review, the facility failed to ensure staff discarded expired medications, and biologicals stored in the medication room on the 200 hall, failed to ensure the bottles of Morphine Sulfate (used to treat moderate to severe pain) were in containers that could be measured which affected four of 19 sampled residents, (Resident #9, #35, #87 and #90) and failed to discard expired Morphine Sulfate and Ativan (used to treat anxiety and seizure disorders) which affected two Residents, (Residents #9 and #35) and failed to ensure there were no loose pills in the day medication cart on the 200 and 500 hall. The facility census was 94. Review of the facility's policy for medication destruction, dated 7/30/07, showed: - Every medication that needs to be destroyed will be logged onto the drug destruction log; - This will consist of resident name, drug name, number destroyed, date of destruction, and the signatures of two licensed nurses witnessing the destruction; - The drug destruction log will remain on the wing for accessibility. Review of the facility's policy for expired medications and supplies, dated 3/27/19, showed: - On the first of every month when change over is complete, the nurses and CMTs and CNAs will audit the: medication carts, treatment carts, refrigerators, cabinets and supply rooms. Any medication or supply found to be expired or that will expire that month will be destroyed. 1. Observation and interview on 4/19/22 at 1:47 P.M., of the medication room on the 200 hall showed: - 30 cents in the bottom of the locked narcotic box; - Resident #9 had an opened bottle of Morphine Sulfate that did not have any measurements on the bottle or on the label; - Resident #90 had an unopened bottle of Morphine Sulfate that did not have any measurements on the bottle or on the label; - Resident #87 had an unopened bottle of Morphine Sulfate that did not have any measurements on the bottle or on the label; - Resident #35 had an opened bottle of Morphine Sulfate that did not have any measurements on the bottle or on the label; - Resident #35 had an opened bottled of Ativan on 1/12/22, staff wrote expired 4/12/22 on the box. The box said to discard 90 days after it was opened; - Resident #9 had an opened bottle of Ativan with part of the label missing. Staff wrote it was opened on 12/23/21 and expired on 3/23/22. The box said to discard 90 days after it was opened; - One opened 20 milliliter (ml.) vial of Lidocaine 1% (commonly used for topical local anesthesia), expired 8/1/21; - Opened bottle of Normal Saline (used to clean wounds), expired 3/18/22; - Licensed Practical Nurse (LPN) A said he/she had not noticed there were not any measurements on the clear bottles and did not know how you would measure it. When he/she did the narcotic count they did not dump the medicine out to measure it, they just placed it next to another bottle with measurements and compared it. He/she did not know where the 30 cents had come from. They did not have a set schedule when to check the medication rooms or the medication carts for expired medications. The nurses and CMTs would check the medications as they passed them. Expired medications should not be used, they should be discarded. 2. Observation and interview on 4/19/22 at 2:40 P.M., of the day medication cart on the 200 hall showed: - One round brown pill, fragments of another brown pill, one round white pill and fragments of another white in the drawer of the medication cart; - Certified Medication Technician (CMT) A said there should not be any loose pills in the medication cart. 3. Observation and interview on 4/19/22 at 2:40 P.M., of the day medication cart on the 500 hall showed: - One round red/brown pill, fragments of another red/brown pill, white dust/powder, and dried liquid in the drawer of the medication cart. - CMT B said: -There should not be any loose pills in the medication cart. -CMTs are responsible for cleaning the cart when there is time. -There is no cleaning schedule. During an interview on 4/19/22 at 3:03 P.M., the Director of Nursing (DON) said: - The CMTs and the nurses check the medication rooms and medication carts for expired medications; - The medication carts and medication rooms should be checked weekly but it's probably not being done; - There should be some way for the staff to measure the Morphine Sulfate; - Staff should not use expired medications, they should dispose of them correctly; - Should not have any change or money in the locked boxes; - There should not be any loose pills in the medication carts.

Based on observation, record review and interview, the facility failed to maintain the kitchen in sanitary condition and ensure they stored food in a sanitary manner. The facility census was 95. Review of the facility policy titled Kitchenettes and Pantries, dated 2005, included the following: - Clean and sanitize refrigerator on a regular cleaning schedule, and as needed for spills. Review of the facility policy titled Cleaning Instructions Cleaning Refrigerators, dated 2005, included the following: - The refrigerators will be washed thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed. Spills and leaks will be wiped up as they are noticed. The facility did not provide a policy regarding dating food. Observation on 4/11/22 beginning at 10:13 A.M. showed the following: - The gas line behind the fryer was coated in sticky residue; - The following seasonings were open and did not have a date on them when they were opened: o 10 ounce (oz) Poultry Seasoning; o Two 16 oz containers of ground cumin; o 5.5 oz whole basil leaves; o 21 oz taco seasoning; o 5 pounds (lbs.) chili powder o 5 lbs ground cinnamon o 11 oz parsley flakes o 1 oz ground cinnamon with a best if used by date of February 2022 o Celery seed with a best if used by date of January 2022 - Three shelves under food preparation tables had food particles that were easily removed, the shelves contained cooking sheets and serving pans. During an interview on 4/11/22 beginning at 10:20 A.M. the Dietary Manager said: - She did not usually date the seasonings because they used them fairly quickly; - She had overlooked the outdated seasonings. Observation on 4/13/22 beginning at 8:53 A.M. showed the following: - There was a black substance on the caulking above the dishwashing tray that could be scraped off with paper towel. Observation on 4/13/22 beginning at 10:06 A.M. showed the following at the Kitchenette on Wing 5: - There was a sticky substance spilled in the refrigerator and food particles were in the freezer portion; - Water melon sized brown substance on floor under dishwater would be wiped with damp paper towel; - There was approximately 3 feet of missing baseboard under the dishwater. During an interview on 4/13/22 beginning at 10:10 A.M. Dietary Aide A said he/she: - Tried to clean the area daily and deep clean monthly; - Had not gotten the chance to clean the spills in the refrigerator yet; - Did not know how long the spot on the floor under the dishwasher had been there and was not sure what it was. Observation on 4/13/22 beginning at 10:14 A.M. in the Wing 3 kitchenette showed the following: - Several food particles were in the freezer; - 1 lb container of parmesan cheese with a best if used by date of 4/3/21 in the refrigerator; - A package of shredded lettuce in the refrigerator that had been opened, it was in an unsealed container and the lettuce was brown in color. The package had a best if used by date of 4/3/2022; - In the cabinets in the kitchenette showed the following: o Opened, undated 16 oz container of baking soda with a best if used by 6/14/19; o Opened, 1 lb container of parmesan cheese dated as opened on 9/3 with a best if used; - The ice machine was not drained through an air gap. During an interview on 4/13/22 at 2:01 P.M. the Dietary Manager said: - Dietary was responsible wing 5 daily wing 3. They tried to clean the areas daily but they did not always get it done. Cleaning duties included refrigerators and freezers; - Opened food should be dated with the date they were opened. They did not date mustard, ketchup, milk, and usually not parmesan cheese; - The lettuce was not dietary ' s and should not have been in the refrigerator on Wing 3; - They should refrigerate a food item after opening if the container says to do so; - Floors were supposed to be cleaned by the janitor; - All areas should be maintained in sanitary condition. During an interview on 4/20/22 at 11:00 A.M. the Assistant Maintenance Director said the drain for the ice machine had been like that as long as he's known. During an interview on 4/20/22 at 3:20 P.M. the Maintenance Director said the drain for the ice machine was designed in a way to not allow water to back up in to the machine.

Based on record review and interviews the facility failed to maintain quarterly quality assessment committee (QAA) meetings with the required members. The facility census was 95. Record review of the facility's QAA meeting minutes, dated May 5, 2021. showed the following: -All the members met; -The members included the administrator, the director of nursing (DON), the Medical Director (MD), the Minimum Data Set (MDS) coordinator, business office manager, human resources, environmental service director and activities director. During an interview on 4/19/22 at 11:26 A.M. The Quality Assurance Nurse said: -The last QAA QAPI (Quality Assurance and Performance Improvement) meeting held was in May 2021. -He/she reviews the CASPER report quarterly . -He/she brings the CASPER report information to weekly Clinical meetings. -There are no sign in sheets for the weekly clinical meetings. -He/she is responsible for the QAA/QAPI meetings, but struggles getting all the mandated staff to attend. During an interview on 4/18/22 at 4:00 P.M. the Administrator said: -He/she thought there was a waiver in place and QAA/QAPI meetings did not need to be held currently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public when when they failed to maintain their ceilings in good condition. The facility census was 95. 1. Observation and interview on 4/19/22 beginning at 12:45 P.M. showed the following: - room [ROOM NUMBER] had a gray substance all around the ceiling vent in the bathroom; - room [ROOM NUMBER] had a black substance all over the ceiling in the bathroom. The Maintenance Director said it looked like mold to him; - Unit 6 medication room had a baseball sized area on the ceiling that was yellow in color and flaking away from the ceiling. The Assistant Maintenance Director said he had not been in that room and did not know what the substance was. Observation 4/11/22 beginning at 11:00 A.M. showed the following areas had missing ceiling tiles: - #616 (several missing); - Corridor outside of room [ROOM NUMBER]; - #318 (two missing); - Four missing tiles in corridor with room [ROOM NUMBER]; - Two missing tiles outside the elevator area off unit 6; - Three missing in the corridor outside of therapy; - The front office was missing three; - Closet in the conference room on unit 1 was missing one - Two missing in in the electrical room by the nurse station in Unit 3. During an interview on 4/14/22 at 3:21 P.M. the Assistant Maintenance Director said: - The missing/moved ceiling tiles were due to Information Technology (IT) staff, they will not put the tiles back; - He was also ordering some more ceiling tiles. During an interview on 4/20/22 at 11:00 A.M. the Maintenance Director and the Assistant Maintenance Director said: - The Maintenance Director started working at the facility in the fall of 2021. The facility had a lot of maintenance needs when they began working at the facility and they were trying to catch up.