**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure an adequate pull string was attached to the emergency call light located in a resident's bathroom. The deficient practice had the potential to compromise resident safety and well-being in an emergency. Findings include: On 05/22/25 at 03:25 PM, an observation of the emergency call light in room [ROOM NUMBER], did not have a proper pull string (a cord which activated the device which was mounted to the wall). On 05/22/25 at 03:50 PM, the Licensed Practical Nurse (LPN) observed the emergency call light and stated the emergency call light did not have an adequate pull string to call for assistance. The LPN verbalized a resident would not be able to use the call light easily. On 05/22/25 at 03:52 PM, the Director of Nursing verbalized an emergency call light pull string must be long enough for a resident to reach in case of an emergency. On 05/22/25 at 03:53 PM, the Risk Manager stated the emergency call system should have a pull string accessible for residents. On 05/22/25, the facility policy and procedure titled Call Light System, revised 09/23/2014, documented all residents would have a call system accessible.

Based on interview and document review, the facility failed to ensure employees completed mandatory dementia training, for one of 10 sampled employees (Employee 9). The deficient practice had the potential to result in an employee being unprepared to respond appropriately to the altered mentation of residents with dementia. Findings include: On 05/22/2025, at 8:52 AM, 10 employee files were reviewed with the Director of Human Resources. Employee 9 (E9) was hired on 11/15/2024 for the position of Certified Nurse Assistant. On 05/22/2025, in the morning, the Director of Human Resources revealed mandatory dementia training was to be completed within 30 days after hire. The Director of Human Resources reported the purpose of the dementia training was to prepare employees to respond appropriately to residents with altered mentation. The Director of Human Resources verbalized E9's file lacked documented evidence dementia training had been completed. The facility policy and procedure title Mandatory Training (New Hires), dated 08/30/2018, indicated the facility provided all new hires with dementia training, to be completed within 30 days after general orientation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 15 sampled residents (Resident 35). The deficient practice had the potential to deprive the resident of concern and other residents of necessary behavioral health services. Findings include: Resident 35 (R35) R35 was admitted on [DATE], with a diagnosis of schizophrenia. On 06/04/2024 in the morning, R35 was up in a wheelchair and stated had been at the facility for about 3 months. A PASARR level one document dated 01/12/2024, indicated R35 did not have dementia, mental illness (MI), intellectual disability (ID), mental retardation (MR), or any related condition (RC) and was deemed appropriate for nursing facility placement. The admission diagnoses from an acute care facility dated 01/26/2024, documented R35 had no cognitive deficits or diagnoses. The acute care facility physician progress note dated 01/28/2024, documented after talking to R35 and the family of R35, the nurse practitioner added the schizophrenia diagnosis to the admitting diagnoses and referred for a psychiatric (psych) consult and resident was subsequently placed on antipsychotic medication. On 06/06/2024 at 1:34 PM, the Social Worker (SW) confirmed the PASSAR level one was completed prior to the resident being admitted to the acute care facility and receiving the schizophrenia diagnosis. The SW confirmed the purpose of the PASARR was to ensure residents were appropriately placed and the facility could meet the needs of the residents. The SW explained the SW was responsible for completing the online PASARR requests. The SW indicated it was believed the referral for a PASARR level two was not necessary because the resident was not receiving any psych services and was stable on antipsychotic medication. On 05/28/2024, an alert charting nurse progress note documented the patient was masturbating while staff was providing care. The unacceptable behavior was discussed with the resident and the resident agreed and was cooperative. The medical record lacked documented evidence R35 was referred for a PASARR level two. The Division of Health Care Financing and Policy- Medicaid Services Manual- for Nursing Facilities Policy dated 05/01/2015, documented when an individual has been identified with possible indicators of mental illness, intellectual disabilities, or related condition, a PASARR Level II screening must be completed to evaluate the individual and determine if nursing facility services and/or specialized services are needed and can be provided in the nursing facility. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting a presence of a mental disorder (where dementia is not the primary diagnoses), or an intellectual disability or related condition was not previously identified and evaluated through PASARR. Social services would be responsible for keeping track of each resident's PASARR screening status and referring to appropriate authority.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and document review, the facility failed to follow or clarify physician order regarding a suprapubic catheter size prior to insertion. The deficient practice had the potential to result in discomfort or inadequate drainage of the bladder. Findings include: Resident 31(R31) R31 was admitted on [DATE] with diagnoses including obstructive uropathy and severe neurocognitive deficit. On 06/04/2024 at 9:15 AM, resident was sitting in bed awake and alert. Resident indicated staff recently changed catheter. On observation the resident had suprapubic catheter inserted on right side abdomen. Dressing was soiled with yellow tinged fluid. On 06/07/2024 at 10:00 AM, a Licensed Practical Nurse (LPN) indicated all wound and any care treatments such as catheter care would be documented in the treatment book at the nurse's station. The treatment book would contain the most recent order for resident care. The treatment administration record for R31 indicated an order to change suprapubic catheter with 18 french 30 milliliter(mL) balloon monthly. A physician order in the electronic medical record indicated to change with 18 french 5 mL balloon every two weeks. On 06/07/2024 at 10:15 AM, the charge nurse confirmed suprapubic catheter currently inserted in R31 was a 16 french with 10 mL balloon. On 06/07/24 at 10:20 AM, the charge nurse indicated all catheter supplies were stored in the clean utility for residents which were not on hospice, the charge nurse confirmed resident was not on hospice. The charge nurse indicated the nurse completing the catheter change would use the order from the treatment administration record as the correct order and if the catheter was not available, the nurse would be able to get the correct size from the hospital central supply. If the correct size catheter was not available, the nurse would need to contact the physician to clarify order. The charge nurse indicated the staff should always follow the physician order and complete appropriately or clarify order. The facility policy titled Physician orders Execution (revised 08/24/2009) documented at no time was staff to execute a physician order which was inconsistent with their Practice Act or facility policies and procedures. Staff was not to perform an intervention without the required physician order. The facility policy titled Catheter Care (revised 09/06/2011) documented the facility would provide consistent care of an indwelling catheter to reduce infection, promote adequate drainage and comfort. Change catheters monthly with a physician order.

Based on observation, document review and interview, the facility failed to ensure stored foods were labeled and dated and food items were discarded prior to the expiration date. This deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness. Findings include: On 06/04/2024 at 8:15 AM, an open bag of chicken tenders was stored in the walk-in freezer without a label as to what is in the bag or a date as to when the bag was opened. The Dietary Manager explained the open bagged item should have been dated as to when the bag was opened and labeled before placing the opened bag back in the freezer. The Dietary Manager had the staff label and date the bag during the survey. The Dietary Manager was able to determine when the bag was opened by the menu details. On 06/04/2024 at 8:17 AM, a container of cottage cheese was stored in the walk-in refrigerator with an expiration date of 05/31/2024. The Dietary Manager explained the item should have been discarded. The Dietary Manager explained the process for checking for expiration dates was for staff to check the dates when a new shipment was received. The Dietary Manager discarded the expired food item during the survey. An undated policy with the subject entitled food storage revealed that all foods and supplies are to be clearly labeled. On 06/07/2024, the Dietary Manager stated did not have any specific policies on labeling and dating foods nor on expired foods.

Based on interview, record review, and document review the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted timely for 5 of 5 residents reviewed for Resident Assessment (Residents 11, 28, 27, 3, and 9). The deficient practice had the potential to impact resident care by also delaying the resident care plan. Findings include: The facility policy titled Assessments Periodic for Minimum Data Set (revised 10/25/2021) documented periodic assessments were conducted by the MDS Coordinator. The results of the assessments were used to create resident care plans and calculate resource utilization grouping categories used by regulators, payers, and surveyors. The facility MDS data from the resident assessment indicated data was more than 120 days for Residents 11, 28, 27, 3, and 9. The State MDS Coordinator documented in June 2023, there was a 20% late submission for residents at the facility. On 06/07/2024 in the afternoon, the Minimum Data Set (MDS) Coordinator indicated working remotely and only coming to the facility when there was a technical issue with connecting from home. The MDS Coordinator verbalized if there was a technical issue which prevented transmitting the resident assessment data, it could be late due to having to make preparations to come to the facility. The MDS Coordinator indicated it was the responsibility of the MDS Coordinator to notify the interdisciplinary team of assessment timeframe and develop a calendar for assessment completion. The MDS Coordinator explained having 14 days to complete transmission of the MDS data once the resident assessment was completed. The MDS Coordinator confirmed all MDS data was sent in batches, indicating there could be some assessments transmitted late based on the specific admission dates. The MDS coordinator verified the process of completing the resident assessment and as there was no direct contact with the resident, notes would be reviewed and if needed the author of assessment notes would be contacted. The MDS coordinator acknowledged the practice could lead to inaccurate or outdated information by the time the resident assessment was completed. The MDS coordinator verbalized there was no designated back up in case the MDS coordinator was not able to work, or access needed information. On 06/07/2024 in the afternoon, the Director of Long Term Care confirmed there was no access to any other staff member including the Director of Long Term Care to transmit MDS data as required. The Director of Long Term Care verbalized having to contact the MDS Coordinator on several occasions to correct data which was inaccurate on the resident assessment. The MDS Coordinator job description documented the MDS Coordinator was responsible to assess and/or coordinate the assessment of all residents and to complete the Resident Assessment Instrument (RAI) and transmit data to the appropriate entities timely.

Based on interview and document review the facility failed to ensure the quarterly payroll based journal (PBJ) data was submitted to Center for Medicare and Medicaid Services (CMS). The deficient practice prevented CMS from analyzing staffing patterns and populate the staffing component of the Nursing Home Compare website. A review of the facility Certification and Survey Provider Enhanced Reporting System (CASPER) report revealed the facility failed to submit staffing data for the first quarter of 2024. On 06/04/24 at 1:28 PM, the Minimum Data Set (MDS) Coordinator indicated being the person responsible for submitting the PBJ data and was aware the PBJ data was not submitted for the first quarter of the 2024 fiscal year. The MDS Coordinator explained being at facility once a week and was not in the facility when it was due. The MDS coordinator verbalized most of work was done remotely however, was unable to access information from remote workstation and was planning on completing the next day however became ill. The MDS coordinator revealed being the only one at the facility with access and ability to complete the report and indicated the Chief Nursing Officer was made aware the PBJ data was not submitted. 06/04/24 01:49 PM, the Director of Long-Term Care (Director) verbalized starting position in March of 2024 which was after the submission was due. The Director was aware the PBJ data was not submitted for the first quarter of 2024 and there was no system in place at the time for back up if the MDS Coordinator was not able to complete. The Director indicated the MDS Coordinator started working remote in December of 2023 and only came to the facility if required because of technical difficulties at remote workstation. The MDS Coordinator was the only staff member with access to reporting system to submit PBJ data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure admission and weekly skin assessments were completed in accordance with the facility's wound care protocol for 3 of 12 sampled residents (Residents #17, #23 and #32). The failure resulted in a delay in treatment interventions which potentially placed the residents at risk for worsened or infected wounds. Findings include: Resident #17 (R17) R17 was admitted on [DATE] and readmitted on [DATE], with diagnoses including multiple sclerosis and chronic debility. On 04/18/2023 at 9:35 AM, R17 laid awake and alert in a bariatric specialty mattress. The resident reported being a longtime resident of the facility but recently returned from the hospital. The resident indicated having a stage three pressure ulcer in the sacral area which was identified and treated by hospital staff. The resident indicated no one in the facility had examined the resident's pressure ulcer since R17's readmission on the evening of 04/17/2023, nor discussed treatment options with the resident. The Hospital Discharge summary dated [DATE], documented left ischium (a bony prominence below the buttocks area) stage three and sacral diffused moisture-associated skin damage (MASD). Wound instructions included start Triad cream daily, continue aggressive offloading, turn every two hours, low air loss mattress to aid in offloading. The medical record lacked documented evidence an admission skin assessment was completed, and wound care instructions were transcribed and carried out since R17's readmission on [DATE]. An admission note dated 04/17/2023, documented R17 had redness to buttocks. On 04/18/2023 in the afternoon, the Licensed Practical Nurse (LPN) assigned to R17 indicated visualizing R17's buttocks area during morning care and indicated the resident had more than redness to buttocks but rather had an open area described as red and beefy. The LPN indicated following old wound care orders which were in place prior to the resident's transfer to the hospital on [DATE]. The LPN acknowledged the LPN did not complete an admission skin assessment because the night shift nurse was expected to have done it. The LPN acknowledged not communicating the resident's pressure ulcer with the charge nurse, the director of nursing (DON) or a physician. On 04/18/2023 in the afternoon, the Director of Nursing (DON) indicated being a treatment nurse for many years and personally monitored residents with existing wounds. The DON indicated R17 did not have a pressure ulcer but rather a MASD in the buttocks area when R17 was sent to the hospital on [DATE]. The DON indicated R17's stage three pressure ulcer must have developed in the hospital and the LPN who identified R17's pressure ulcer on 04/18/2023 should have communicated the wound with the charge nurse, the DON, and the physician. The DON indicated it was not acceptable for the LPN to carry out old wound care orders because the orders were appropriate for R17's MASD and may not be appropriate for a stage three wound. The DON indicated an admission skin assessment must be completed within 24 hours of a resident's admission or readmission for timely interventions and to distinguish between hospital-acquired versus facility-acquired wounds. On 04/20/2023 at 8:05 AM, R17 indicated the admission nurse did not perform a head-to-toe skin assessment when the resident was readmitted on the evening of 04/17/2023. The resident recounted the pressure wound was covered with an Opti foam dressing and the nurse did not remove the dressing for visualization. Three Opti foam dressing kits were observed on the resident's bedside table, the resident indicated the resident was discharged with wound supplies in case the facility wanted to use them. On 04/20/2023 at 8:13 AM, the LPN and charge nurse were present when the resident consented to a wound observation. The nurses assisted R17 to the left side to visualize the resident's buttocks area. The charge nurse described the wound by direct observation as stage three to the left buttocks which was bright red and beefy and measured approximately 4.0 centimeters (cm) length (L) x 3.0 cm in width (W) x 0.5 cm in depth (D). The wound was covered with one piece of plain gauze, no drainage was present, and there was diffused MASD in the surrounding areas. The resident verbalized the pain from the wound was eight out of ten (8/10) on the pain scale. On 04/20/2023 at 8:21 AM, the charge nurse indicated when the resident was readmitted , medication orders from the hospital discharge summary were reviewed and discussed with the physician. The charge nurse explained not being informed the resident returned from the hospital with a stage three pressure wound. The charge nurse indicated reviewing R17's discharge medications and entered admission medication orders after discussing with the physician. The charge nurse reviewed the resident's hospital records and acknowledged not reading the document thoroughly and as a result, the charge nurse did not see the presence of a stage three ischium pressure ulcer and wound care instructions. The charge nurse acknowledged an admission skin assessment was not completed nor was the newly identified wound communicated by the LPN which resulted in a delay in wound care consult and appropriate treatment orders for R17's wounds. According to the charge nurse, the delay may potentially result in worsened wound and/or an infection. On 04/20/2023 at 8:29 AM, the Director of Nursing (DON) reviewed the Wound Care policy and confirmed an admission skin assessment was to be completed on all residents within 24 hours. The DON indicated not being familiar with the Wound Care Order sheet which was an assessment tool mentioned in the facility policy but was not being utilized. The DON indicated not being aware photographs were to be taken when a wound was identified on admission and every 72 hours thereafter to track progress in healing or failure to heal. The DON acknowledged an admission skin assessment which should have included photo documentation was not done for R17 when the resident was readmitted on [DATE]. On 04/20/2023 at 8:44 AM, the DON reviewed R17's hospital records and confirmed there was mention of a stage three pressure ulcer to the ischium with wound care instructions to use Triad cream daily. The DON indicated the charge nurse entered medication orders but failed to enter wound care orders. The DON emphasized the LPN who visualized the resident's wound in the morning of 04/18/2023 should have notified the charge nurse, the DON, and the physician to obtain orders for wound care consult and appropriate treatment orders. The Wound Care policy revised 02/06/2013, documented every resident upon initial assessment, was to be observed for the presence of a wound. If a wound was present, the Wound Care Order sheet must be initiated with a telephone order obtained from a physician upon discovery. A photograph of a presenting wound or pressure sore was taken upon admission and placed in the resident's medical record. Subsequent periodic photographs were to be taken every 72 hours showing the change in the wound or pressure sore to track healing or failure to heal. Resident #23 (R23) R23 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, severe morbid obesity, mitral and tricuspid valve insufficiency. On 04/18/2023 in the morning, R23 was seated in a wheelchair inside the resident's room. The resident indicated having multiple open wounds on back of thighs which were not improving and were painful. The resident indicated monitoring own wounds using personal cellphone camera because the facility was not monitoring the wounds. The resident indicated some nurses applied Vitamin A and D ointment on the wounds and some did not treat the wounds at all. The resident indicated had complained about the painful thigh wounds to nursing staff and a physical therapist (PT) came to evaluate the wounds, but nothing was done about it. The medical record lacked documented evidence weekly skin assessments were performed and treatment orders were obtained for the resident's thigh wounds. On 04/19/2023 at 11:07 AM, the charge nurse confirmed there were treatment orders in place for the resident's moisture-associated skin damage (MASD) to buttocks and abdominal fold redness but there were no treatment orders for the resident's back of thigh wounds. The charge nurse explained the facility did not utilize a form or tool specific to weekly skin assessments but rather, nurses documented the residents' skin condition in the nursing weekly summary notes. A four-month look back of the R23's weekly summary notes revealed the resident's skin condition was not included when the nurses performed R23's weekly assessments on 04/17/2023, 04/10/2023, 04/03/2023, 03/20/2023, 03/06/2023, 02/27/2023, 02/20/2023, 02/06/2023 and 01/23/2023. On 04/19/2023 at 11:12 AM, the Director of Nursing (DON) confirmed there were no treatment orders in place for R23's back of thigh wounds and corroborated the charge nurse's explanation skin assessments were included in the nurses' weekly summary notes. The DON indicated it was not acceptable R23's skin condition was not included in the nurses' weekly summaries. According to the DON, newly identified wounds would be communicated to the charge nurse, the DON, the physician, and the Physical Therapist (PT) who performed wound evaluations and was involved in treatment of complicated wounds. On 04/19/2023 at 11:16 AM the PT explained complicated wounds necessitating advanced wound care such as sharps debridement and wound vacuum device were referred to PT when traditional treatment performed by nurses were not improving the resident's wound. If a wound could not be managed in-house, the resident would be referred to a wound clinic or a dermatologist. The PT clarified R23's bilateral posterior thigh wounds which were first identified by the PT on 02/01/2023, were not considered pressure sores because it was not located on a bony prominence but rather caused by friction and sheer from sitting in the wheelchair complicated by the resident's morbid obesity. An Outpatient PT Evaluation dated 02/01/2023, documented resident referred for wound consult to buttocks region. R23 reported painful areas in bilateral posterior thighs. Areas of scattered denuding (removal of surface layers) on bilateral posterior thighs with no dressing present. Recommendation for nursing to continue with current intervention while PT would do product research for better interventions. On 04/19/2023 at 11:33 AM, the PT explained a wound evaluation would include wound measurements, description of wound base, presence of tunneling and undermining, odor, drainage, type, amount and condition and pain. The PT indicated a full wound evaluation was not completed for R23 and findings were not reported to the physician because the PT indicated the wounds were stable and current regimen was working. The medical record lacked documented evidence there was a treatment regimen for the resident's bilateral posterior thigh wounds. On 04/19/2023 at 11:47 AM, R23 consented to a wound observation conducted by the DON and the PT with inspector present. The resident stood from wheelchair and leaned towards the bed exposing backside. The DON counted six open wounds on the resident's left back thigh with the largest one measuring 1.5 cm length (L) x 1.0 cm width (W) x 0.00 cm depth (D). The resident sat back down in wheelchair and showed the DON an open area on the left abdominal area which was caused by the resident's fingernails when the resident tried to lift abdominal fold for the nurse. The PT described the wound as a trauma wound measuring 1.0 cm (L) x 2.0 cm (W) x 0.3 cm (D). The resident then lifted abdominal fold and pointed to two open areas which was causing the resident pain. Using a ruler, the DON described the wounds as open areas of MASD origin measuring 1.5 cm (L) x 2.0 cm (W) x 0.00 (D) for the first wound and 1.0 cm (L) x 0.5 cm (W) x 0.00 (D) for the second wound. On 04/19/2023 at 12:00 PM, the DON explained R23 was admitted on [DATE] with wounds on chest and back of head but there were no wounds on the bilateral posterior thighs, abdominal folds, and abdomen. The DON indicated performing weekly skin assessments were important for timely identification and treatment of new wounds. The DON indicated the PT who identified skin impairments to R23's bilateral posterior thighs on 02/01/2023 should have communicated findings with the charge nurse, the DON, and a physician to ascertain whether a wound consult and treatment orders were necessary. On 04/19/2023 at 12:09 PM, the PT acknowledged not communicating findings from the PT evaluation on 02/01/2023 to nursing staff because no new recommendations were deemed necessary. The PT determined the physician did not need to be notified of the findings because R23's wounds appeared to be stable, and the current regimen was working. The PT indicated not knowing there were no treatment orders in place for R23's bilateral posterior thighs and assumed the ointment used for the resident's buttocks were being applied on R23's thighs as well. On 04/19/2023 at 12:25 PM, the DON verbalized routine skin assessments allowed nurses to track whether a wound was healing or worsening and allowed for re-evaluation of current regimen to assess for effectiveness. The Wound Care policy revised 02/06/2013, documented assessment and documentation of wound status and dressing changes performed at least weekly would include clinical data demonstrating evidence of progress in healing or failure to heal. An order sheet for Wound Care was to be provided to the physician when a wound was identified to obtain comprehensive orders. Resident 32 (R32) R32 was admitted on [DATE], with diagnoses including dementia and debility. The Brief Interview of Mental Status dated 02/23/2023, documented a score of 6/15, which means R32's cognitive status was severely impaired. On 04/18/2023 at 10:16 AM, R32 was lying in bed in a supine position. An intravenous (IV) antibiotic, Cefepime was hanging and connected to R32. An odor was noted around the resident. The assigned Licensed Practical Nurse (LPN) indicated the antibiotic was for R32's wound infection in the coccyx. The PT Evaluation dated 03/14/2023, documented a stage II pressure wound in the coccyx with a size of 3.2 x 1.2 x 0.3 cm, no tunneling, no undermining, and minimal serosanguinous drainage. The PT Note dated 04/06/2023, documented the wound as a stage IV pressure injury with a size of 2.4 x 1.2 x 2.2 cm. The PT Note dated 04/10/2023, documented the coccyx wound as a stage IV pressure injury with a size of 2.7 x 2.0 x 2.2 centimeters (CM), tunneling of 1.4 cm at 1:00 o'clock, and a moderate odor. The serosanguinous amount was moderate-heavy. On 04/19/2023 at 12:03 PM, the LPN performed wound care on R32's coccyx area. The LPN confirmed the dressing was soiled, undated, and the alginate packed inside the wound had disintegrated. The LPN was uncertain when it was last treated or the dressing changed however, the treatment order was daily. R32's medical record lacked documented evidence a skin assessment or wound measurement was consistently performed. On 04/18/2023 at 11:00 AM, the charge RN confirmed the skin assessment, wound measurement, or photograph were not consistently completed per policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a physician order was obtained for the insertion of a peripherally inserted central catheter (PICC) line, and care orders were transcribed for 1 of 12 sampled residents (Resident 32). The failure to obtain a physician's order before inserting the PICC line and to manage the PICC line insertion site could potentially lead to serious medical complications for the resident which may include infections, bleeding, nerve damage, or life-threatening events. Findings include: R32 was admitted on [DATE], with diagnoses including dementia and debility. The Brief Interview of Mental Status dated 02/23/2023, documented a score of 6/15, which means R32's cognitive status was severely impaired. The Informed Consent for Procedure Administration of Anesthetic and/or the Rendering of Other Medical Services dated 04/07/2023, documented the procedure Peripherally Inserted Central Catheter (PICC) Line was consented to by a family through telephone. The PICC Insertion Record dated 04/08/2023, documented a PICC line was inserted into the RUA PICC line. On 04/18/2023 at 10:16 AM, R32 was lying in bed. An intravenous (IV) antibiotic, Cefepime was hanging and connected to R32 ' s PICC line inserted in the right upper arm (RUA). The PICC line dressing was undated and wrapped with a bandage. The Nurse Progress Note dated 04/18/2023, documented the PICC line was discontinued. On 04/19/2023 at 2:00 PM, the PICC line which had been inserted in R32's RUA was discontinued. A Licensed Practical Nurse (LPN) indicated the reason for discontinuing the PICC line was R32 would be admitted to hospice services. The medical records of R32 did not have any documented evidence a physician's order was in place for the insertion, utilization, care, or management of the PICC line, or for its discontinuation. On 04/20/23 at 10:10 AM, a Registered Nurse (RN) indicated R32's PICC line was inserted on 04/08/2023, and consent was obtained from the family via telephone conversation. The RN indicated R32 was a hard stick and required multiple antibiotic medications for the osteomyelitis and an unstageable wound in the coccyx area. The RN confirmed there were no orders in place for the PICC line insertion and care orders. The RN explained the process was to obtain and transcribe PICC line orders prior to insertion, and a care order set should have been in place. The RN explained the PICC line order set included the changing of the dressing, monitoring the site for signs of infection, and flushing, but these were not done. On 04/20/2023 at 11:15 AM, the Charge Registered Nurse (CRN) confirmed there were no orders for the PICC line insertion/discontinuation or care orders in place. The CRN indicated the process was to get consent from the resident or the family, obtain the orders, and transcribe in the resident's electronic record. On 04/20/2023 at 11:30 AM, the Director of Nursing (DON) confirmed there were no orders in place for the PICC line insertion or discontinuation. The DON indicated the nurses were responsible and expected to obtain PICC line orders and transcribe to the resident's electronic record before insertion. The DON confirmed there were no care orders for PICC line management such as: flushing, site monitoring, and dressing changes. A facility policy titled PICC lines dated 11/06/2020, documented the need to provide a reliable source of venous access for antibiotics. A physician's order would be written and signed by the physician and placed in the medical record. The PICC line should be flushed twice a day. PICC line dressing was to be changed after the first 24 hours, every 7 days, and as needed. A facility policy titled Physician Orders revised on 11/18/2012, documented the facility would provide all medication, treatment, and authorized care by staff for residents based on physician orders. The orders must be transcribed and verified by the nurse before being implemented. Medication orders must be linked to a diagnosis in the progress note or within the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure the Oxygen (O2) orders were followed and parameters were clarified for 2 out of 12 sampled residents (Residents 32 and 9). The failure to follow O2 orders and clarify parameters could have potentially led to serious health complications, such as hypoxia (O2 deficiency) and hyperoxia (excess O2 supply), organ damage, cognitive impairment, and death. Findings include: A facility policy titled Procedure for Administering Oxygen by Cannula revised 05/21/2023, documented to verify the order. Adjust the flowmeter as ordered. Resident 9 (R9) R9 was admitted on [DATE], with diagnoses including cerebrovascular accident and myocardial infarction. The Brief Interview of Mental Status dated 03/13/2023, documented a score of 15/15, indicating R9's cognitive status was intact. The Minimum Data Set, dated [DATE], documented R9 was receiving Oxygen therapy. On 04/18/2023 at 09:55 AM, R9 was lying in bed with the head of the bed elevated, receiving O2 at 1 LPM through a nasal cannula. The O2 tubing did not have a date. R9 indicated the O2 order was for 2 LPM continuously, the O2 was helpful, and there were no breathing difficulties. A physician order dated 03/21/2023, documented R9 was prescribed Oxygen therapy at 2 LPM continuously through a nasal cannula. The order specified, the O2 flow rate should be adjusted as tolerated to maintain an O2 saturation level of 92% or greater. The order did not provide any parameters regarding how much titration was required for adjusting the O2 flow rate. On 04/19/2023 at 9:30 AM, the Charge Registered Nurse (CRN) confirmed the O2 flow meter order for R9 was 2 LPM, but the O2 was being administered at only 1 LPM. The CRN indicated the Respiratory Therapist, and the nurses were expected to verify the order to ensure the correct O2 flow rate was being delivered and the titration parameters should have been clarified. On 04/19/2023 at 9:45 AM, the Director of Respiratory Services acknowledged R9's order should have been clarified as administering O2 at 2 LPM continuously through a nasal cannula, and titrating O2 at 1-6 LPM to maintain O2 saturation at 92% or greater. The Director of Respiratory Services conveyed the O2 flow rate orders and parameters should have been followed. On 04/19/2023 at 9:55 AM, the Director of Nursing (DON) confirmed R9's O2 order had not been followed. The DON indicated the staff was expected to verify and follow the orders for the O2 flow rate to ensure the residents received what had been prescribed, and if there was any confusion it should have been clarified. Resident 32 (R32) R32 was admitted on [DATE], with diagnoses including dementia and debility. The Brief Interview of Mental Status dated 02/23/2023, documented a score of 6/15 indicating R32's cognitive status was severely impaired. On 04/18/2023 at 10:18 AM, R32 lay in bed. R32 was receiving 1 LPM of O2 through a nasal cannula connected to the wall's O2 supply, and both the tubing and the humidifier bottle lacked date labels. Noisy respirations could be heard during R32's breathing, and shortness of breath was noted. A physician order dated 04/17/2023, documented 2, nasal cannula, greater than or equal to 90, PRN usage or titrate as tolerated, or off days/on nights, etc., constant indicator. On 04/19/2023 at 9:01 AM, R32 lay in bed, and O2 was being delivered at 1 LPM through a nasal cannula. A Licensed Practical Nurse (LPN) confirmed R32 was receiving O2 at 1 LPM and verified the O2 order. The LPN stated R32's O2 order was a PRN and could be titrated to maintain saturation at more than 90%, but that it was supposed to be at 2 LPM. On 04/19/2023 at 9:30 AM, the Charge Registered Nurse (CRN) confirmed the O2 orders were confusing, as it was unclear whether it was PRN or continuous and there were no titration parameters indicated. The CRN indicated the Respiratory Therapist was responsible for O2 orders. On 04/19/2023 at 9:45 AM, the Director of Respiratory Services acknowledged R32's order was of 2 LPM continuously through nasal cannula and titration parameters should have been clarified. On 04/19/2023 at 9:55 AM, the DON confirmed the prescribed setting for R32's O2 flow meter was 2 LPM continuously, but it had been administered at 1 LPM. The DON indicated the staff was expected to verify the O2 orders to ensure the residents safety. The hospice policy titled Oxygen Safety (undated) stated that Oxygen was considered a drug and that excessive or insufficient amounts could be harmful. It was advised to use Oxygen only as prescribed by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure a pharmacy recommendation which was approved and signed by a physician for a resident's psychiatric evaluation was carried out for 1 of 12 sampled residents (Resident #23). The failure potentially delayed a re-evaluation of the resident's medication regimen which was essential in maintaining the highest practicable mental, physical, and psychosocial well-being of the resident. Findings include: Resident #23 (R23) R23 was admitted on [DATE], with diagnoses including major depressive disorder and anxiety disorder. A Pharmacy note to attending physician or prescriber dated 03/07/2023, documented Resident #23 is receiving multiple psychotropic agents and due for psychiatric follow up. The document contained a physician/prescriber response dated 03/21/2023 which read, Agreed. Psychiatric consult pending. The medical record lacked documented evidence the physician order for psychiatric consult was entered into R23's medical record and staff followed up with the psychiatrist to re-evaluate R23's medication regimen. On 04/20/2023 at 10:05 AM, the charge nurse indicated being familiar with the pharmacist recommendations for R23's psychiatric consult due to being on multiple psychoactive medications. The charge nurse acknowledged not following through on R23's psychiatric consult since the psychiatrist signed the recommendation on 03/21/2023. The charge nurse verbalized agreeing R23 needed to be seen by a psychiatrist due to ensuing behaviors of yelling and cursing at staff. The charge nurse indicated R23 was last seen by the psychiatrist on 11/18/2020 for anxiety management. On 04/20/2023 at 10:12 AM, the Director of Nursing (DON) indicated the psychiatrist was in the facility on 03/21/2023 and personally signed the pharmacy note. The DON reported reaching out to the psychiatrist on 03/22/2023 to schedule R23's evaluation but the psychiatrist did not respond to the DON and there were no further attempts to contact the psychiatrist since 03/22/2023. On 04/20/2023 at 10:30 AM, the DON indicated having issues with the current psychiatric provider who was difficult to reach. The DON indicated the medical director should be notified when facility experienced issues with other providers who could not attend to the resident's needs. The DON acknowledged issues with psychiatry services had not been discussed with the medical director and should have been. On 04/20/2023 at 10:38 AM, the Consultant Pharmacist recalled writing R23's medication regimen review on 03/07/2023 wherein the pharmacist made a recommendation to have the resident seen by a psychiatrist. The Consultant Pharmacist explained residents who were on multiple psychoactive medications benefited from psychiatric oversight especially because the resident was known to continue with behaviors. The Consultant Pharmacist indicated a yearly psychiatric evaluation, at minimum was recommended for residents on multiple psychoactive medications. The Medication Administration policy reviewed 09/10/2021, documented the consultant pharmacist will do a complete review of all residents' records, medications, and orders monthly. The Consultant Pharmacist recommendations are reviewed by the charge nurse and director of nursing (DON). If action is required, the consultant pharmacist generates a note to the attending physician/prescriber. The attending physician/prescriber is asked to agree, disagree, or provide another alternative. Documentation of follow through is noted in the resident's electronic health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure there was a documented indication for use for psychotropic medications orders for 1 of 12 sampled residents (Resident #23). The failure potentially placed the resident at risk for receiving unnecessary medications. Findings include: Resident #23 (R23) R23 was admitted on [DATE], with diagnoses including major depressive disorder and anxiety disorder. The Psychotropics/Antipsychotics Use policy revised 09/02/2015, documented the resident's entire medication regimen would be managed and monitored to achieve the following goals: to achieve the highest practicable mental, physical, and psychosocial well-being in collaboration with the attending physician and facility staff. Each resident would receive only those medications, in doses and for the duration clinically indicated to treat the resident's assessed conditions. Prior to initiating an antipsychotic medication, the physician would complete the antipsychotic diagnosis form and a medical rationale must accompany the medication order. A physician order dated 03/13/2023, documented to give Buspirone 15 milligrams (mg) by mouth every six hours. The medical record lacked a documented rationale for use of Buspirone (anti-anxiety drug). A physician order dated 09/12/2022, documented to give Trazadone 100 mg by mouth at hour of sleep. The medical record lacked a documented rationale for use for Trazadone (anti-depressant). A physician order dated 12/20/2022, documented to give Xanax 0.25 mg by mouth every 8 hours routinely. The medical record lacked documented rationale for use for Xanax (anti-anxiety). A physician order dated to give Wellbutrin extended released (XL) 50 mg by mouth once daily as evidenced by isolation and feelings of depression. The medical record lacked documented rationale for use of Wellbutrin (anti-depressant). A Skilled Nursing Facility Informed Consent for Psychotherapeutic Medication and Antipsychotic diagnosis form dated 07/27/2022, documented medication orders for the following: -Trazadone 50 mg -Wellbutrin XL 150 mg -Buspirone 20 mg -Xanax 0.25 mg The consent form lacked documented diagnoses or indication for use of the above-mentioned medications. On 04/20/2023 at 2:13 PM, a Licensed Practical Nurse (LPN) reviewed the psychotropic consent form and confirmed the form which was signed by the resident, a nurse, and a physician on 07/27/2022 did not contain any medical diagnoses or indication for use for Trazadone, Wellbutrin, Buspirone and Xanax. On 04/20/2023 at 2:15 PM, the Director of Nursing (DON) reviewed the facility's policy on psychotropic medications and R23's Skilled Nursing Facility Informed Consent for Psychotherapeutic Medication and Antipsychotic diagnosis form signed 07/27/2023 and confirmed the nurse and physician who signed the document did not follow the facility's policy when they failed to document a medical diagnoses or indication for use of R23's Trazadone, Wellbutrin, Buspirone and Xanax. On 04/20/2023 at 2:26 PM, the Medical Director reviewed the facility's policy on physician orders and R23's Skilled Nursing Facility Informed Consent for Psychotherapeutic Medication and Antipsychotic diagnosis form signed 07/27/2023. The Medical Director indicated R23's medication orders for Trazadone, Wellbutrin, Buspirone and Xanax should have included had documented medical diagnoses or indication for use in accordance with the facility policy. The Medical Director indicated having signed the same forms for other residents and made sure an indication for use was present. The facility policy Physician Orders revised 11/18/2012, documented antipsychotic medications were to be prescribed for a specific identified diagnoses which is written as part of the order.