**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review the facility failed to ensure 1 of 17 sampled residents (Resident #2) and the Resident's Representative received written notification of transfer or discharge. This deficient practice had the potential to cause confusion and prevent the Resident Representative from being informed of the reason for transfer. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hypertensive heart disease with heart failure, acute and chronic respiratory failure with hypoxia, and acute on chronic systolic (congestive) heart failure. Resident #2's Minimum Data Set 3.0 (MDS) assessments, Section A, documented Resident #2 was admitted to the facility on [DATE], and discharged on 11/29/2024 to a short term general hospital. A Health Status Note dated 11/29/2024, documented Resident #2 was sent to the emergency room (ER) at an acute care hospital due to difficulty breathing and acute hypoxia. A Health Status Note dated 11/29/2024, documented Resident #2 was admitted to the hospital. Resident #2's clinical record lacked documented evidence written notification of the reason for transfer/discharge was provided to Resident #2 and/or the Resident's Representative when the resident was transferred to an acute care ER and admitted to the hospital on [DATE]. On 01/16/2025 at 3:17 PM , the Director of Nursing (DON) verbalized notification of transfer to a hospital was no longer required and had been removed from the facility's transfer check list used to guide the transfer process. On 01/16/2025 at 4:10 PM, the DON confirmed when Resident #2 was transferred and subsequently admitted to an acute care hospital on [DATE], the facility did not provide written notification of the reason for transfer to the resident or the Resident Representative. On 01/16/2025, at 4:12 PM, the facility did not to provide a policy related to facility transfers, as requested by the surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to provide a bed hold policy notification to 1 of 17 residents (Resident #2) and/or the Resident's Representative upon transfer to an acute care hospital. This deficient practice had the potential to cause confusion and prevent the Resident Representative from being informed of the right to exercise the bed hold provisions and any associated fees. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hypertensive heart disease with heart failure, acute and chronic respiratory failure with hypoxia, and acute on chronic systolic (congestive) heart failure. Resident #2's Minimum Data Set 3.0 (MDS) assessments, Section A, documented Resident #2 was admitted to the facility on [DATE], and discharged on 11/29/2024 to a short term general hospital. A Health Status Note dated 11/29/2024, documented Resident #2 was sent to the emergency room (ER) at an acute care hospital due to difficulty breathing and acute hypoxia. A Health Status Note dated 11/29/2024, documented Resident #2 was admitted to the hospital. Resident #2's clinical record lacked documented evidence written notification of the right to exercise a bed hold provision was provided to Resident #2 and/or the Resident's Representative, when the resident was discharged to an acute care hospital on [DATE]. On 01/16/2025 at 3:17 PM, the Director of Nursing (DON) verbalized notification of the bed hold policy was no longer required and had been removed from the facility's transfer check list used to guide the transfer process. On 01/16/2025 at 4:10 PM, the DON confirmed when Resident #2 was transferred and subsequently admitted to an acute care hospital, the facility did not provide written notification of the facility's bed hold policy to the resident and/or the Resident Representative. A facility policy titled Bed-Holds and Returns revised on 10/2022, documented the facility informed residents and/or the resident's representative in writing of the right to exercise a bed hold provision upon admission. A second notice was provided before transfer to a general acute care (short term general) hospital. In the event of an emergency transfer, the second notice was provided within 24 hours.

Based on observation, interview, and document review, the facility failed to ensure a fire alarm sounded in the front of the facility, including the therapy gym and resident dining hall, during a fire drill. This deficient practice had the potential to affect resident, visitor, and staff safety in the event of an actual fire. Findings include: On 01/14/2025 at 1:28 PM the fire alarm was pulled at a nurse's station in the facility. Emergency strobe lights activated throughout the facility, however the alarm did not sound in the front part of the facility, to include the front lobby, staff administrative offices, resident therapy gym, private dining room, and the resident dining room. On 01/15/2025 at 9:20 AM, the Maintenance Director verbalized the expectation was when the fire alarm was pulled, the alarm would sound throughout the building. The Maintenance Director was unaware the alarm did not sound in the front part of the building. On 01/15/2025 at 9:24 AM, a Certified Occupational Therapist Assistant (COTA) verbalized at approximately 1:30 on 01/14/2025, the COTA did not hear the fire alarm sound. The COTA explained the COTA was in the therapy gym restroom with a resident when the emergency strobe lights began flashing. The COTA confirmed the fire alarm did not sound in the therapy gym area. On 01/15/2025 at 9:29 AM, the Dietary Director verbalized the Dietary Director did not hear the fire alarm during the fire drill on 01/14/2025. The Dietary Director explained they knew there was a fire alarm because the emergency strobe lights began flashing. The Dietary Director confirmed the fire alarm did not sound in the resident dining room, where residents frequented. On 01/15/2025 at 3:51 PM, the Director of Rehabilitation verbalized during the fire alarm drill on 01/14/2025 at approximately 1:30 PM, there were five residents in the therapy gym receiving services. The facility policy titled Fire Indicated by Alarm Panel, revised 07/19/2021, documented the center attempted to extinguish fires and keep residents/staff/visitors safe as they occur.

Based on interview, personnel record review and document review, the facility failed to ensure staff were trained on the prevention of elder abuse prior to engaging with residents for 8 of 20 sampled personnel records reviewed (Employee #1, #10, #13, #14, #15, #16, #19, and #20). Findings include: On 01/15/2025 at 11:40 AM, the Business Office Coordinator (BOC) and the Administrator participated in an interview to confirm the accuracy of the Personnel Records Checklist completed by the facility for 20 employees. On 01/15/2025 at 11:40 AM, the BOC and the Administrator verbalized elder abuse training was required upon hire, annually, and as needed (PRN). Employee #1 Employee #1 was hired as the Administrator with a start date of 05/28/2024. The Administrator's elder abuse training was completed on 06/26/2024. Employee #10 Employee #10 was hired as the Director of Rehabilitation (PT) with a start date of 08/01/2024. The PT's elder abuse training was completed on 12/18/2024. Employee #13 Employee #13 was hired as a Registered Nurse (RN) with a start date of 11/11/2024. The RN's elder abuse training was completed on 12/18/2024. Employee #14 Employee #14 was hired as a License Practical Nurse (LPN) with a start date of 09/16/2024. The LPN's elder abuse training was completed on 12/18/2024. Employee #15 Employee #15 was hired as an LPN with a start date of 11/26/2024. The LPN's elder abuse training was completed on 12/18/2024. Employee #16 Employee #16 was hired as a Certified Nursing Assistant (CNA) with a start date of 09/27/2024. The CNA's elder abuse training was completed on 12/18/2024. Employee #19 Employee #19 was hired as a Dietary Aide with a start date of 12/12/2024. The Dietary Aide's elder abuse training was completed on 12/18/2024. Employee #20 Employee #20 was hired as a Housekeeper with a start date of 08/01/2024. The Housekeeper's elder abuse training was completed on 12/18/2024. On 01/15/2025 at 3:03 PM, the Administrator confirmed the aforementioned elder abuse training dates for Employee #1, #10, #13, #14, #15, #16, #19, and #20, and confirmed the employee's initial elder abuse training was not completed prior to working with residents. The facility policy titled Abuse Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, documented the facility would provide staff orientation and training/orientation programs to include topics such as abuse prevention, identification and reporting of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure physical therapy (PT) frequency of treatment was provided per the physician's order for 1 of 3 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with a diagnosis of fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing. Resident #1's Physician Order dated 02/13/24, documented PT to evaluate and treat as indicated. Resident #1's Therapy Dashboard documented PT, start date 02/14/24, five times a week, signed by the facility Physician. Resident #1's PT Evaluation and Plan of Treatment dated 02/14/24, documented PT five times a week for eight weeks. Resident #1's Comprehensive Care Plan lacked evidence of the frequency of treatments per the physician order. On 03/08/24 at 11:00 AM, Resident #1 verbalized the resident admitted to the facility for therapy to learn to walk again. The resident explained the resident was concerned about their upcoming discharge because they did not receive physical therapy (PT) for a few days due to a lack of PT staff. On 03/08/24 at 11:54 AM, a Registered Nurse (RN) verbalized Resident #1 was admitted to the facility for PT rehabilitation. The RN explained the facility recently began using a new company to provide PT services and the resident did not receive PT services for a few days due to lack of physical therapy personnel. On 03/08/24 at 1:38 PM, a Physical Therapist verbalized Resident #1 was to receive PT five times a week. The Physical Therapist confirmed Resident #1 did not receive PT five times a week due to staffing issues with the physical therapy company. Resident #1's PT Treatment Encounter Notes documented the resident received physical therapy services on 02/26/24, 02/28/24, 02/29/24, and 03/01/24 or a total of four PT sessions (treatment) for the week of 02/25/24 to 03/02/24. Resident #1's PT Treatment Encounter Notes documented the resident received physical therapy on 03/06/24 or a total of one PT session for the week of 03/03/24 to 03/09/24. On 03/08/24 at 1:46 PM, the Director of Nursing (DON) verbalized PT Director took a leave of absence. The DON explained the PT Director was a treating therapist and the facility was having a hard time finding coverage for therapy with the PT company. The DON confirmed Resident #1 did not receive PT five times a week during that time frame. The DON confirmed the discrepancy was due to staffing issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and clinical record review, the facility failed to ensure a resident's discharge status was accurately documented on a Minimum Data Set 3.0 (MDS) assessment for 1 of 5 closed resident records (Resident #40). Findings include: Resident #40 Resident #40 was admitted to the facility on [DATE], with diagnoses including encounter for surgical aftercare following surgery on the circulatory system, presence of cardiac pacemaker and paroxysmal atrial fibrillation. The resident was discharged on 11/03/23. A Progress Note dated 11/03/23, documented Resident #40 was discharging home with all personal belongings. Resident #40's clinical record documented the MDS assessment dated [DATE], section A2105, indicated Resident #40 was discharged to the hospital. On 01/09/24 at 10:56 AM, the MDS Coordinator confirmed the MDS assessment dated [DATE], section A2105 was not completed accurately for Resident #40. The MDS Coordinator verbalized the MDS assessment should have indicated Resident #40 discharged home and not to the hospital. On 01/09/24 at 11:02 AM, the Director of Nursing Services (DNS) explained the DNS worked closely with the MDS Coordinator to ensure assessments were correct and accurate prior to submission. The DNS confirmed Resident #40 was discharged to the community and was not discharged to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure 1) a care plan for administering a resident's as needed (PRN) heart medication was developed for 1 of 12 sampled residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including NON-ST elevation myocardial infarction (NSTEMI), other pericardial effusion (non-inflammatory), cardiac tamponade, presence of coronary angioplasty implant and graft, and atherosclerotic heart disease of native coronary artery without angina pectoris. On 01/08/24 at 11:30 AM, Resident #5 verbalized the resident had nitroglycerin prescribed for chest pain. The resident explained the staff needed to know what to do prior to and after administration. The resident stated vitals needed to be monitored prior to and after administration. Resident #5's physician's order dated 12/11/23, documented Nitrostat sublingual tablet 0.4 milligram (mg). Give 0.4 mg sublingually every five minutes as needed for chest pain. If chest pain persists after the second dose, give one more dose and call Emergency Management Services (EMS). On 01/08/24 at 2:27 PM, a Registered Nurse (RN) verbalized when a resident had chest pain, the RN would check for a physician order for the medication, Nitrostat, check the resident's vitals, administer Nitrostat, check the resident's vitals after administration, and monitor the resident for any adverse reactions or further chest pain. On 01/09/24 at 3:58 PM, a Licensed Practical Nurse (LPN) verbalized when a resident had chest pain and a physician order for Nitrostat, the nursing staff would check the resident's vitals, administer the medication, and assess for pain. The LPN confirmed Resident #5 had a cardiac care plan, however the cardiac care plan had not been updated to include the medication Nitrostat and interventions including taking vitals, assessing for pain, and monitoring vitals after administration. Resident #5's Comprehensive Care Plan initiated 12/01/23, documented the resident had altered cardiovascular status related to NSTEMI resulting in stenting of (Left Anterior Descending Artery) LAD with subsequent cardiac tamponade since resolved. The care plan lacked intervention specific to the administration and monitoring of the medication Nitrostat. On 01/10/24 at 4:04 PM, the Director of Nursing Services (DNS) verbalized the expectation was medications requiring monitoring, such as a resident's cardiac medication, should be care planned. The facility policy titled Medication Administration General Guidelines, revised 01/2023, documented medications were administered in accordance with physician orders, obtain and record any vital signs as necessary prior to administration. The facility policy titled Care Plan - [NAME]/Baseline Care Plan, revised 12/2019, documented direct care givers would have accurate information available to them to properly care for residents. Information would be updated as changes occurred. Problem areas and interventions, including special instructions, would be provided on the [NAME]. Cross reference with F689, F761

Based on observation, clinical record review, interview, and document review the facility failed to ensure professional standards of practice were followed by failing to develop and implement a bowel and bladder retraining program ensuring residents were provided the appropriate treatment and services needed to restore as much bowel and bladder function as possible. The failure had the potential to affect the facilities entire resident census of 48. Findings include: Bowel and Bladder Program On 01/09/24 at 12:03 PM, the Director of Nursing Services (DNS) explained the initial resident assessment drove a resident's plan of care. A bowel and bladder assessment were done upon admission as part of the required Minimum Data Set 3.0 (MDS) assessment. A resident's bowel and bladder continence status were documented in the resident's progress notes. The DNS verbalized the facility did not have a formal screening process related to bowel and bladder continence and did not have a bowel and bladder training program. On 01/10/24 at 1:56 PM, the DNS provided a blank copy of a 72-hour voiding diary and explained the expectation was the form would be used when a trend of incontinence was noticed, such as during a certain time of the day. The DNS confirmed the facility was not currently using the 72-hour voiding diary form and confirmed the form had not been used in recent memory. On 01/10/24 at 1:58 PM, the DNS confirmed the facility was not able to locate any additional forms related to screening, assessing, or implementing a bowel and bladder training program. On 01/10/24 at 2:12 PM, the DNS explained residents were ambulated and taken to the bathroom which helped to retrain the bladder. The DNS confirmed the facility did not have a policy related to a bowel and bladder program and confirmed the facility did not have a formal bowel and bladder program. The facility policy titled Bladder Incontinence, last revised 02/2019, documented the facility ensured residents incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. The policy included definitions of a bladder retraining program, a scheduled toileting plan, a 72-hour voiding diary, and incontinence management. Residents displaying incontinence were assessed as part of the admission Resident Assessment Instrument (RAI) process and an individualized care plan based directly on the conclusion of the comprehensive assessment was developed. The policy did not include bowel incontinence. Cross reference with F690.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were not left unsecured in a resident's room with the potential for accidental ingestion of the medication for 1 of 12 sampled residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including NON-ST elevation myocardial infarction (NSTEMI), other pericardial effusion (non-inflammatory), cardiac tamponade, presence of coronary angioplasty implant and graft, and atherosclerotic heart disease of native coronary artery without angina pectoris. Resident #5's Minimum Data Set 3.0 assessment dated [DATE], documented the resident had a Brief Interview for Mental Status Score (BIMS) of 14, indicating the resident was cognitively intact. On 01/08/24 at 11:30 AM, Resident #5 verbalized the resident had nitroglycerin prescribed for chest pain and the resident opened an unlocked drawer next to the bed and pulled out a pill sandwiched between two stacked clear medication cups. On 01/08/24 at 11:32 AM, Resident #5 verbalized the resident had chest pain on 12/11/23 and requested a nitroglycerin pill. The resident recalled the nurse brought two pills in a medication cup to the resident and touched the pills with their hands while attempting to administer the medication to the resident. The resident recalled the resident told the nurse they could not take the medication because it had been touched by the nurse. The nurse responded to the refusal by giving the resident another medication cup to cover the pills and left the pills with the resident. The resident confirmed the resident did not take the medication. Resident #5's physician's order dated 12/11/23, documented Nitrostat sublingual tablet 0.4 milligram (mg). Give 0.4 mg sublingually every five minutes as needed for chest pain. If chest pain persists after the second dose, give one more dose and call Emergency Management Services (EMS). A drug formulary document, printed from epocrates.com, on 01/18/24, documented Nitrostat, serious adverse reactions such as severe hypotension, syncope, anaphylactoid reaction, exfoliative dermatitis, methemoglobinemia, and nitrate tolerance. On 01/08/24 at 2:27 PM, a Registered Nurse (RN) verbalized the process when administering a medication was to verify the resident, the medication, administer the medication and watch the resident take the medication. When a resident refused to take a medication, the RN would educate the resident, honor the resident's choice, notify the provider, and document the refusal on the Medication Administration Record (MAR). The RN explained a medication should never be left with a resident. When a medication was refused or unable to be administered, the medication would be discarded per the facility process. The RN verbalized medications needed to be secured to avoid another resident accidentally ingesting the medication. On 01/08/24 at 2:33 PM, the RN confirmed there was a pill sandwiched between two clear medication cups in an unlocked drawer in Resident #5's room. The RN compared the pill found in the drawer with the Nitrostat medication prescribed to Resident #5, located in the unit medication cart. The RN verbalized the pill was stored improperly and was unsecured. On 01/09/24 at 2:41 PM, the Director of Nursing Services (DNS) verbalized it was not acceptable to have unsecured medications in a resident's room. The expectation when administering medications was nursing staff would watch the resident take the medication, or if the resident refused, the nursing staff would take the medication back, discard the medication per the facility process, and document the refusal on the MAR. On 01/09/24 at 3:58 PM, a Licensed Practical Nurse (LPN) verbalized the Medication Administration Record lacked documentation the medication was requested, administration was attempted, and the medication was refused by the resident. The facility policy titled Self Administration of Medication, revised 03/2020, documented medication at bedside was stored in closed, locked cupboards, or drawers. The facility policy titled Medication Administration General Guidelines, revised 01/2023, documented medications were administered in accordance with physician orders, obtain and record any vital signs as necessary prior to administration. Medications were to be administered at the time they were prepared. Residents were allowed to self administer medications when specifically authorized by the prescriber, the Interdisciplinary Team (IDT), and residents were always observed after administration to ensure the dose was completely ingested. If a dose was withheld, refused, or given other than the scheduled time, the space provided on the front of the MAR for that dosage administration was initialed and circled. Cross Reference F761, F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #59 Resident #59 was admitted to the facility on [DATE], with diagnoses including nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with routine healing and acute posthemorrhagic anemia. On 01/08/24 at 3:06 PM, Resident #59 was resting in bed with a nasal cannula placed under the resident's nose and the resident's oxygen concentrator was set at 1.5 LPM. A physician's order dated 01/08/24, documented oxygen continuous at 2.0 LPM via nasal cannula every shift for oxygen use. On 01/10/24 at 8:15 AM, Resident #59 was sitting in a wheelchair with a nasal cannula placed under the resident's nose and the resident's oxygen was set to 1.5 LPM. A physician's order dated 01/09/24, documented oxygen continuous at 2.0 LPM via nasal cannula every shift for hypoxia. On 01/10/24 at 11:12 AM, a Registered Nurse explained how to read the oxygen concentrator gauge was to stoop down and the line would be split between the ball. The RN verbalized it was the nurse's responsibility to ensure the resident's concentrator was set appropriately as oxygen was a medication. On 01/10/24 at 11:17 AM, the RN confirmed Resident #59's oxygen concentrator was set to 1.5 LPM and had to be adjusted to 2.0 LPM. The RN confirmed the physician's order was for 2.0 LPM and the concentrator was set to 1.5 LPM. The facility policy titled Administration Medication, revised 01/2023, documented medications were administered in accordance with written orders of the prescriber. The facility policy titled Respiratory Treatment, last revised 06/22/22, documented residents receiving respiratory treatments and monitoring per the physician's orders, standards of practice, and care plans. The amount, method, and duration of oxygen usage and diagnosis were identified on the resident's treatment record per the physician orders. The licensed nurse was responsible for checking resident's oxygen therapy each shift and validating the regulator was set for the appropriate liter flow. Based on observation, clinical record review, interview, and document review the facility failed to ensure oxygen was administered as indicated in the physician's orders for 2 of 12 sampled residents (Resident #9 and #59). Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, and systolic (congestive) heart failure. A physician's order dated 12/26/23, documented to administer oxygen continuously at 2 liters per minute (LPM) via nasal cannula (NC) for oxygen use related to chronic obstructive pulmonary disease (COPD), unspecified. On 01/08/24 at 4:11 PM, Resident #9 was resting in bed. Oxygen was being administered to the resident at 4 LPM via NC. On 01/09/24 at 9:50 AM, Resident #9 was resting in bed and oxygen was being administered at 4.5 LPM via NC. On 01/09/24 at 9:55 AM, a Licensed Practical Nurse (LPN) confirmed oxygen was being administered to Resident #9 at 4.5 LPM and confirmed Resident #9's physician's orders documented oxygen was to be administered to the resident at 2 LPM. The LPN checked Resident #9's oxygen saturation (SPO2) while oxygen was being administered at 4.5 LPM and the resident's SPO2 was 96 percent (%). The LPN adjusted Resident #9's oxygen flow rate to 2 LPM and after approximately two minutes of receiving oxygen at 2 LPM, Resident #9's SPO2 was 92%. The LPN verbalized the LPN did not know what the SPO2 goal was for Resident #9. The LPN verbalized the LPN did not know if Resident #9's diagnosis of COPD caused the resident to retain carbon dioxide (CO2) and confirmed the LPN was not aware of where to find the information. The LPN verbalized the facility's oxygen and SPO2 orders did not usually include a desired SPO2 goal or range for residents. On 01/09/24 at 10:29 AM, the Director of Nursing Services (DNS) confirmed the expectation was physician's orders would always be followed. The DNS verbalized SPO2 goals for residents with COPD were based on the instructions in the physician's orders for oxygen. The DON verbalized [NAME] was the facility's Standard of Practice (SOP). On 01/09/24 at 10:40 AM, a Physician Assistant (PA-C) verbalized the SPO2 goal for residents with COPD was between 89-92%. The PA-C confirmed SPO2 goals were to be documented in residents' oxygen orders. The PA-C verbalized staff knew to report an SPO2 below 90% and confirmed staff may not know to report if an SPO2 was too high for a resident with COPD when the resident's orders did not specify an SPO2 goal. The PA-C confirmed an SPO2 of 96% was too high for Resident #9 and explained an SPO2 of 92% was a good range for Resident #9. The facility's standard of practice titled Lippincott Manual of Nursing Practice, 11th edition, with a copyright date of 2019, documented exacerbations of COPD were associated with increased hyperinflation and air trapping with decreased expiratory flow contributing to worsening dyspnea as well as worsening ventilation/perfusion abnormalities, which could lead to hypoxemia. Exacerbations had an increased risk of mortality and morbidity and decreased quality of life, prevention and early detection and management were important. Supplemental oxygen was recommended for patients with hypoxemia and caution was to be used when increasing oxygen flow rates for patients with CO2 retention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure a resident's pain was managed and a physician was notified when pain medication was ineffective for 1 of 12 sampled residents (Resident #45). Findings include: Resident #45 Resident #45 was admitted to the facility on [DATE], with diagnoses including displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and fibromyalgia. On 01/08/24 at 1:27 PM, Resident #45 verbalized the resident had pain with movement of the resident's right leg. Facial grimacing was observed while the resident repositioned in bed. On 01/09/24 at 1:27 PM, a Registered Nurse (RN) verbalized the RN utilized a 1-10 pain scale or the pain AD for the cognitively impaired scale to assess pain if the resident was not oriented. The RN verbalized pain was assessed prior to any interventions and pain was reassessed one hour after an intervention was provided to determine effectiveness of the intervention. On 01/09/24 at 2:16 PM, Resident #45 reported the resident's pain was currently pretty bad and rated the pain at eight out of ten. Resident #45 verbalized the resident had received pain medication in the morning and was soon due for another dose of pain medication. On 01/10/24 at 2:58 PM, a Licensed Practical Nurse (LPN) verbalized pain was assessed every morning with vital signs and any time the LPN went into a resident's room. The LPN explained pain was to be reassessed no more than one hour after an intervention was provided to determine effectiveness of the intervention. The LPN verbalized if an intervention was not effective, the LPN would notify the physician and the physician would determine the next steps to manage the resident's pain. An Orders-Administration Note, dated 01/14/24 at 8:02 AM, documented Tramadol hydrochloride (HCl) oral tablet 50 milligrams (MG) was administered to Resident #45. As Needed (PRN) administration was documented to be ineffective. The follow-up pain scale was five (out of ten). An Orders-Administration Note, dated 01/14/24 at 6:58 PM, documented Tramadol HCl oral tablet 50 MG was administered to Resident #45. PRN administration was documented to be ineffective. The follow-up pain scale was seven (out of ten). Resident #45's clinical record lacked documented evidence of follow-up regarding the ineffective pain medication administered on 01/14/24. On 01/16/24 at 11:08 AM, the Director of Nursing Services (DNS) explained the expectation of nursing staff following administration of pain medication was to reevaluate for effectiveness of the medication and any potential side effects. The DNS verbalized if a pain intervention was determined to be ineffective the expectation of nursing staff was to offer another intervention and notify the physician if the interventions were not effective. The DNS verbalized pain follow-up assessment, additional interventions, and physician notification would be documented in a progress note. The DNS confirmed Resident #45's clinical record documented the administration of Tramadol HCl on 01/14/24 was ineffective. The DNS confirmed no follow up was completed on 01/14/24, after determining the Tramadol HCl was ineffective at managing the resident's pain. The facility policy titled Pain Management, revised 10/2022, documented if pain was not controlled to the resident's satisfaction, the physician was consulted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure physician ordered medications were available and administered for 1 of 5 residents observed for medication administration (Resident #61). Findings include: Resident #61 Resident #61 was admitted to the facility on [DATE], with a diagnosis of hypertensive chronic kidney disease with stage one through stage four chronic kidney disease, or unspecified chronic kidney disease. On 01/10/24 at 8:08 AM, a Licensed Practical Nurse (LPN) administered medications to Resident #61. The LPN explained to the resident one of the physician ordered blood pressure medications was not available and the LPN would call the pharmacy. A physician's order dated 01/05/24, with a start date of 01/06/24, documented diltiazem hydrochloride (HCl) extended release (ER) oral tablet 180 milligrams (MG), give 180 mg by mouth one time a day. The Medication Administration Record (MAR) for Resident #61 documented diltiazem HCl 180 MG was not administered to Resident #61 on 01/06/24 and was documented as NA. The MAR documented diltiazem HCl 180 MG was not administered to the resident on 01/07/24, 01/08/24, 01/09/24, and 01/10/24 and was documented as 9. The legend on the MAR indicated a response of NA equated to Medication Not Available and a response of 9 equated to Other / See Progress Notes. A progress note dated 01/06/24, documented diltiazem HCl was not available, awaiting delivery from pharmacy, provider aware. A progress note dated 01/07/24, documented diltiazem HCl was on order and provider was aware. A progress note dated 01/08/24, documented diltiazem HCl was on order and provider was aware. Registered Nurse would call pharmacy again to determine delivery status. A progress note dated 01/09/24, documented diltiazem HCl was on order and provider was aware. LPN would call pharmacy again to determine delivery status. A progress note dated 01/10/24 documented diltiazem HCl was on order and provider was aware of missed dosage. On 01/10/24 at 1:55 PM, an LPN confirmed Resident #61 had not received diltiazem HCl 180 MG due to the medication being unavailable in the facility since 01/06/24. The LPN verbalized the process when a medication was not available in the facility was to contact the pharmacy. The LPN explained the LPN had contacted the pharmacy on 01/09/24 and 01/10/24 via phone and fax. The LPN explained if the nurse did not hear back from the pharmacy the expectation was the nurse would report the unavailable medication to the Director of Nursing Services (DNS). On 01/16/24 at 11:14 AM, the DNS explained the expectation of nursing staff if a medication was not available in the facility the nurse was to contact the pharmacy. The DNS verbalized the facility would usually receive requested medications from the pharmacy within an hour or two. The DNS explained the facility contracted pharmacy had contracts with local pharmacies to deliver medications on the same day in the event of an emergency or inclement weather. The DNS reviewed Resident #61's clinical record and confirmed the resident had not received the ordered diltiazem HCl. The DNS verbalized there was no documentation of staff follow-up with the pharmacy regarding the missing medication. The DNS verbalized the DNS was not made aware of Resident #61's medication being unavailable in the facility. The facility policy titled Medication Administration - Errors, revised 02/2019, documented medications would be prepared and administered in accordance with physician's orders. In the event a medication was not administered per physician order, a medication error form would be completed, and the DNS was responsible to ensure an investigation was completed. The facility policy titled Provider Pharmacy Requirements, revised 01/2023, documented regular and reliable pharmaceutical service was available to provide residents with prescription medications. The provider pharmacy agreed to provide routine and timely pharmacy service 24 hours per day, seven days a week. The Pharmacy Services Agreement with the facility contracted pharmacy, effective 09/01/22 to 08/31/25, documented the pharmacy delivered products in accordance with pharmacy's routine delivery schedule. To the extent the pharmacy was unable to provide the required products or an acceptable alternative, the pharmacy would arrange for a back-up pharmacy to provide the required products or acceptable alternatives. Cross reference with F759

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure medication was administered with an error rate of less than five percent (%). There were 31 opportunities and two medication errors. The medication error rate was 6.45%. Findings include: Resident #61 Resident#61 was admitted to the facility on [DATE], with a diagnosis of hypertensive chronic kidney disease with stage one through stage four chronic kidney disease, or unspecified chronic kidney disease. On 01/10/24 at 8:08 AM, a Licensed Practical Nurse (LPN) administered medications to Resident #61. The LPN explained to the resident one of the physician ordered blood pressure medications was not available and the LPN would call the pharmacy. The Medication Administration Record (MAR) for Resident #61 documented diltiazem hydrochloride (HCl) 180 MG was not administered to Resident #61 on 01/06/24, 01/07/24, 01/08/24, 01/09/24, and 01/10/24. A physician's order dated 01/05/24, with a start date of 01/06/24, documented diltiazem HCl extended release (ER) oral tablet 180 milligrams (MG), give 180 mg by mouth one time a day. On 01/10/24 at 1:55 PM, the LPN confirmed Resident #61 had not received diltiazem HCl 180 MG due to the medication being unavailable in the facility since 01/06/24. Resident #37 Resident #37 was admitted to the facility on [DATE], with diagnoses including unspecified diastolic (congestive) heart failure and pulmonary hypertension. On 01/10/24 at 8:15 AM, a Registered Nurse (RN) began preparing medications for Resident #37. The RN placed one half tablet of furosemide 20 MG in the medication cup. On 01/10/24 at 8:22 AM, the RN administered the prepared medications to Resident #37. A physician's order dated 01/09/24, with a start date of 01/10/24, documented furosemide oral tablet 20 MG, give 20 MG by mouth one time a day. On 01/10/24 at 11:35 AM, the RN confirmed the RN gave one half tablet of furosemide 20 MG to Resident #37 during the morning medication pass. The RN reviewed the resident's clinical record and confirmed the current order was for furosemide 20 MG daily. The RN confirmed the half tablet administered to Resident #37 did not match the current physician's order. On 01/16/24 at 11:14 AM, the Director of Nursing Services (DNS) explained a medication error included a resident receiving the wrong dose of medication. The DNS confirmed if a resident received 10 MG of furosemide and the physician's order was for 20 MG, this would not be following a physician's order. The facility policy titled Medication Administration General Guidelines, revised 01/2023, documented medications were administered in accordance with written orders of the prescriber. Medication orders were reviewed and confirmed prior to administration. Cross reference with F755

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were secured for 1 of 12 sampled residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including NON-ST elevation myocardial infarction (NSTEMI), other pericardial effusion (non-inflammatory), cardiac tamponade, presence of coronary angioplasty implant and graft, and atherosclerotic heart disease of native coronary artery without angina pectoris. On 01/08/24 at 11:30 AM, Resident #5 verbalized the resident had nitroglycerin prescribed for chest pain. The resident opened an unlocked drawer next to the bed and pulled out a pill sandwiched between two stacked clear medication cups. Resident #5's physician's order dated 12/11/23, documented Nitrostat sublingual tablet 0.4 milligram (mg). Give 0.4 mg sublingually every five minutes as needed for chest pain. If chest pain persists after the second dose, give one more dose and call Emergency Management Services (EMS). On 01/08/24 at 2:33 PM, a Registered Nurse (RN) confirmed Resident #5 did not have a physician's order to self-administer and store Nitrostat in their room. On 01/09/24 at 2:41 PM, the Director of Nursing Services (DNS) verbalized it was not acceptable to have unsecured medications in a resident's room. The facility policy titled Self Administration of Medication, revised 03/2020, documented medication at bedside was stored in closed, locked cupboards, or drawers. The facility policy titled Medication Administration General Guidelines, revised 01/2023, documented medications were administered in accordance with physician orders, obtain and record any vital signs as necessary prior to administration. Medications were to be administered at the time they were prepared. Residents were allowed to self administer medications when specifically authorized by the prescriber, the Interdisciplinary Team (IDT), and residents were always observed after administration to ensure the dose was completely ingested. If a dose was withheld, refused, or given other than the scheduled time, the space provided on the front of the MAR for that dosage administration was initialed and circled. Cross reference F689, F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, clinical record review, and document review the facility failed to ensure a process was developed and implemented to assess/screen residents for participation in a bowel and bladder retraining program with the potential to affect the facility's entire resident census of 48 and 1 of 12 sampled residents (Resident #9) was assessed to determine if the resident was a candidate for a bowel and bladder retraining program. Findings include: Bowel and Bladder Program 01/09/24 at 12:03 PM, the Director of Nursing Services (DNS) explained the initial resident assessment drove a resident's plan of care. A bowel and bladder assessment were done upon admission as part of the required Minimum Data Set 3.0 (MDS) assessment. A resident's bowel and bladder continence status were documented in the resident's progress notes. The DNS verbalized the facility did not have a formal screening process to determine if a resident was a candidate for a bowel and bladder retraining program. On 01/09/24 at 4:36 PM, the DNS confirmed the facility did not have worksheets, policies, or any other material specific to a Bowel and Bladder Retraining Program. The DNS was not able to explain how the facility ensured the components of the facility's Bladder Incontinence policy were being implemented. On 01/10/24 at 10:04 AM, a Licensed Practical Nurse (LPN) verbalized a resident's continence status was discussed during a verbal report from the sending facility and the Residential Care Manager (RCM) asked cognitively intact residents about their continence status during the admission process. On 01/10/24 at 10:16 AM, the LPN verbalized incontinent residents requiring more than minimum assistance for transfers were either changed in bed or assisted to the bathroom to be changed as needed. On 01/10/24 at 10:18 AM, the RCM explained the expectation was incontinent residents would be encouraged to use the bathroom regardless of the amount of assistance required, including upon waking for the day, before mealtimes, and at bedtime. The RCM explained the facility did not have a formal bowel and bladder retraining program and the RCM was not aware of any facility forms related to bowel and bladder management. On 01/10/24 at 1:56 PM, the DNS provided a blank copy of a 72-hour voiding diary and explained the expectation was the form would be used when a trend of incontinence was noticed, such as during a certain time of the day. The DNS confirmed the facility was not currently using the 72-hour voiding diary form and confirmed the form had not been used in recent memory. On 01/10/24 at 1:58 PM, the DNS confirmed the facility was not able to locate any additional forms related to screening, assessing, or implementing a bowel and bladder retraining program. On 01/10/24 at 2:12 PM, the DNS explained residents were ambulated and taken to the bathroom which helped to retrain the bladder. The DNS confirmed the facility did not have a policy or program in place related to a bowel and bladder retraining program. The facility policy titled Bladder Incontinence, last revised 02/2019, documented the facility ensured residents incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. The policy included definitions of a bladder retraining program, a scheduled toileting plan, a 72-hour voiding diary, and incontinence management but did not include a process or instructions on how to implement a bowel and bladder retraining program. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, and systolic (congestive) heart failure. Resident #9's MDS assessment dated [DATE], section GG0100 (Prior functioning: everyday activities) documented prior to admission to the facility Resident #9 needed partial assistance from another person to complete self-care activities including toileting. Section GG0130 (functional abilities and goals - admission) documented the resident required partial/moderate assistance for toileting including perineal hygiene and adjusting clothes before and after voiding or having a bowel movement. Section GG0170 (Mobility- first three days of the resident's stay) documented the resident needed substantial/maximum assistance for toilet transfers, the ability to get on and off a toilet or commode. Section H0200 (Urinary toileting program) documented Resident #9 did not have a trial of a toileting program including scheduled toileting, prompted voiding, or bladder training attempted upon admission/entry, reentry, or since urinary incontinence was identified by the facility. Section H0300 documented the resident was occasionally incontinent of urine. Section H0400 documented the resident was frequently incontinent of bowel. Section H0500 documented a toileting program was not being used to manage the resident's bowel incontinence. On 01/09/24 at 4:32 PM, the DNS verbalized Resident #9 did not qualify for a bowel and bladder retraining program, a scheduled toileting plan, or a 72-hour voiding diary as defined in the facility's policy titled Bladder Incontinence, due to the resident being incontinent. The DNS explained the policy indicated a resident had to be aware of the urge to void and be either independent or need limited assistance with toileting. The DNS confirmed Resident #9 was not on a bowel and bladder retraining program. The facility policy titled Bladder Incontinence, last revised 02/2019, documented the facility ensured residents incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. The policy included definitions of a bladder retraining program, a scheduled toileting plan, a 72-hour voiding diary, and incontinence management. Cross reference with F658

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a baseline care plan was initiated to address a resident's dementia diagnosis with care and interventions to manage symptoms for 1 of 15 sampled residents (Resident #18). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], and was discharged on 01/24/23, with diagnoses including neurocognitive disorder with Lewy bodies, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and depression, unspecified. On 01/23/23 at 12:00 PM, Resident #18 was lying in bed and was repeatedly asking who was the person in the corner of the room. The corner of the room was empty. On 01/23/23 at 12:07 PM, the representative for Resident #18 verbalized the resident had visual hallucinations and was receiving an antipsychotic medication to manage the hallucinations. The representative was concerned about the hallucinations worsening because the resident was seeing small insects crawling on the bed when the representative was visiting the previous week. A Physician Assistant Progress Note from the resident's hospital stay prior to admission to the facility dated 12/19/22, the day of admission to the facility, documented the resident had active problems including visual hallucinations and Lewy body dementia. The clinical record for Resident #18 lacked a baseline care plan to address the resident's dementia and interventions to manage symptoms. On 01/25/23 at 10:34 AM, the Director of Nursing (DON) confirmed the resident did not have a care plan specific to Lewy body dementia and a care plan would be initiated based on an assessment of the resident's dementia symptoms completed on admission. The DON verbalized the DON did not see an assessment of the resident's dementia related symptoms completed on admission. The facility policy titled Care Plan - [NAME]/Baseline Care Plan, revised 02/2019, documented initial information would be collected on admission about the resident and the resident's needs to produce interventions related to problem areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review the facility failed to ensure 1) care plans were individualized for 3 of 15 sampled residents (Resident #193, #198, and #18), and 2) a care plan related to antibiotic use was developed for 1 of 15 sampled residents (Resident #144). Findings include: Resident #193 Resident #193 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of pressure ulcer of sacral region, unstageable. A physician's order dated 01/10/23, documented cleanse the right heel with normal saline (NS), pat dry, cover with dry dressing daily and as needed for pressure injury. Monitor for signs and symptoms (s/s) of infection and notify provider of complications. A physician's order dated 01/10/23, documented cleanse sacrum with NS, pat dry, apply stoma powder to open area, apply z guard paste, leave open to air, every shift and as needed for pressure injury. Monitor for s/s of infection, notify provider of changes/worsening. Resident #193's comprehensive care plan included a care plan dated 01/10/23, related to pressure injuries to the resident's sacrum and right heel with risk for complications. The care plan included the following interventions: -encourage and assist the resident to offload heels while in bed, -labs per physician orders, and -wound care per physician orders. The care plan did not include interventions related to monitoring for s/s of infection and did not include interventions to offload or decrease pressure to Resident #193's sacrum. On 01/25/23 at 1:59 PM, a Resident Care Manager 1 (RCM) confirmed Resident #193's care plan related to pressure injuries on the resident's right heel and sacrum did not include person centered interventions, such as repositioning and teaching the resident how to reposition. The RCM confirmed the care plan did not include the s/s of infection to be monitored. On 01/25/23 at 3:07 PM, the Director of Nursing (DON) communicated Resident #193's pressure injury care plan was not detailed. The DON confirmed the care plan did not include instructions related to wound care, interventions such as non-pharmacological modalities, and s/s of infection for each pressure injury. The DON declined to confirm or verbally acknowledge the care plan was not person centered. Resident #198 Resident #198 was admitted to the facility on [DATE], with diagnoses including sepsis, unspecified organism, type II diabetes mellitus with foot ulcer, and non-pressure chronic ulcer of other part of left foot with unspecified severity. A physician's order dated 01/19/23, documented cleanse deep tissue injury (DTI) to bilateral heels with NS, pat dry and apply skin prep. Monitor and notify provider of s/s of worsening as needed. A physician's order dated 01/19/23, documented cleanse DTI to bilateral heels with NS, pat dry and apply skin prep. Monitor and notify provider of s/s of worsening each day shift. Resident #198's comprehensive care plan included a care plan dated 01/23/23, related to DTIs, bilateral feet. The care plan included the following interventions: -encourage good nutrition to promote wound healing, -monitor for s/s of infection, and -provide treatments per order. The care plans interventions did not include nutritional needs, s/s of infection to be monitored, or treatment related interventions. The care plan did not include interventions to prevent the DTIs from worsening and did not include interventions to prevent the development of new wounds/DTIs. On 01/25/23 at 11:48 AM, RCM2 confirmed Resident #198's care plan related to DTIs did not include instructions regarding nutrition, s/s of infection to be monitored, and interventions to prevent the DTIs from worsening and new wounds from forming. On 01/25/23 at 2:57 PM, the DON communicated the expectation was care plans would be person centered and updated in a fluid manner throughout the residents stay. Wound care plans were individualized for different wound types and included the location, history, and severity of the wound. Treatments were documented on care plans as per orders because wound care orders changed frequently. The care plan would be updated if the wound had a drastic change, such as the wound deconditioned and/or progressed in stage, such as from a stage I to a stage II. On 01/25/23 at 3:01 PM, the DON communicated monitoring for s/s of infection would vary from wound to wound. Interventions for monitoring a wound were related to the history of the wound such as vascular wounds would be monitored for blood flow to the extremity. The DON confirmed Residents #198's care plan for DTIs did not indicate the s/s to be monitored. The DON confirmed the care plan referenced areas of concern but lacked detail of what needed to be done and communicated the lack of detail was due to the concerns being covered in other areas of the chart. The DON confirmed it was acceptable for a care plan to say, per orders. The DON declined to confirm or verbally acknowledge the care plan was not person centered. Resident #18 Resident #18 was admitted to the facility on [DATE], and was discharged on 01/24/23, with diagnoses including neurocognitive disorder with Lewy bodies, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and depression, unspecified. On 01/23/23 at 12:00 PM, Resident #18 was lying in bed and was repeatedly asking who was the person in the corner of the room. The corner of the room was empty. On 01/23/23 at 12:07 PM, the representative for Resident #18 verbalized the resident had visual hallucinations and was receiving an antipsychotic medication to manage the hallucinations. The representative was concerned about the hallucinations worsening because the resident was seeing small insects crawling on the bed when the representative was visiting the previous week. A Physician Assistant Progress Note from the resident's hospital stay prior to admission to the facility dated 12/19/22, the day of admission to the facility, documented the resident had active problems including visual hallucinations and Lewy body dementia. The Minimum Data Set 3.0 (MDS) Assessment for Resident #18, dated 12/26/22, documented the resident had a diagnosis of non-Alzheimer's dementia. Care Areas were triggered and care planning decision to be addressed in the care plan were checked for Cognitive Loss/Dementia, Psychosocial Well-Being, and Mood State. The Care Area Assessment and Care Plan Decision were signed by the Registered Nurse Coordinator/DON on 12/28/22. The clinical record for Resident #18 lacked a care plan to address the resident's dementia and interventions to manage symptoms. On 01/25/23 at 10:34 AM, the DON confirmed the resident did not have a care plan specific to Lewy body dementia and a care plan would be initiated based on an assessment of the resident's dementia symptoms completed on admission. The assessment would also include historical symptoms related to the resident's diagnoses. The DON verbalized the DON did not see an assessment of the resident's dementia related symptoms completed on admission. Resident #144 Resident #144 was admitted to the facility on [DATE], with diagnoses including pneumonia, unspecified organism, urinary tract infection, site not specified, and other specified bacterial agents as the cause of diseases classified elsewhere. On 01/23/23 at 12:54 PM, Resident #144 and the resident's representative verbalized the resident had been receiving antibiotics and had had loose stools for the last two days. The resident's representative verbalized the representative was concerned the loose stools were a result of the antibiotic therapy. The Medication Administration Record for Resident #144, dated January 2023, documented the resident had received the following antibiotics: - Cefdinir oral capsule, give 300 milligrams (mg) by mouth two times a day for pneumonia and urinary tract infection. The Cefdinir was administered for seven doses starting 01/17/23 at 8:00 PM through 01/20/23 at 8:00 PM. - doxycycline hyclate tablet, give 100 mg by mouth two times a day for pneumonia and urinary tract infection. The doxycycline was administered for six doses starting 01/17/23 at 8:00 PM through 01/20/23 at 8:00 AM. The Comprehensive Care Plan for Resident #144 lacked a care plan addressing the antibiotic therapy. On 01/24/23 at 7:41 AM, the Licensed Practical Nurse for Resident #144 verbalized the potential side effects of an antibiotic would be in the care plan. Potential side effects included loose stools and upset stomach. On 01/24/23 at 9:01 AM, the DON verbalized antibiotics would be care planned for potential side effects including diarrhea and upset stomach. The purpose of the care plan would be to address the issue with the goal of preventing the resident from experiencing ongoing issues and would include interventions to address the problem. The DON confirmed the care plan lacked a care plan addressing the resident's use of antibiotics. The facility standard of practice titled Lippincott Manual of Nursing Practice: Eleventh Edition, copyright 2019, by Wolters-Kluwer documented the nursing process would involve assessment to determine a resident's actual or potential health problems and develop goals and a care plan (pages 5-6).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a Comprehensive Care Plan was updated and included the use of diuretics as pharmacological interventions for Congestive Heart Failure for 1 of 15 residents (Resident #4). Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including hypertensive heart disease with heart failure and acute on chronic diastolic (congestive) heart failure. Resident #4's Comprehensive Care Plan, initiated 12/28/22, documented the resident had Congestive Heart Failure (CHF). The care plan lacked documentation of ordered pharmacological interventions for the care of CHF. A physician order dated 12/29/22, documented Lasix (furosemide), give 40 milligrams (mg) by mouth one time a day related to acute on chronic diastolic (congestive) heart failure for 10 days. A Medication Administration Record (MAR) dated 12/01/22-12/31/22, documented Resident #4 was administered furosemide 40 mg daily on the following dates: 12/29/22, 12/30/22, and 12/31/22. A MAR dated 01/01/23-01/31/23, documented Resident #4 was administered furosemide 40 mg daily from 01/01/23 - 01/07/23. A physician order dated 01/11/23, documented furosemide, give 40 mg by mouth one time a day for CHF. A MAR dated 01/01/23-01/31/23, documented Resident #4 was administered furosemide 40 mg daily from 01/12/23-01/25/23. A physician order dated 01/11/23, documented spironolactone, give 25 mg by mouth one time a day for CHF. A MAR dated 01/01/23-01/31/23, documented Resident #4 was administered spironolactone 25 mg daily from 01/12/23-01/25/23. On 01/23/23 at 4:36 PM, Resident #4's care plan for CHF, last revised on 01/05/23, did not include the intervention of diuretic/CHF medications ordered on 12/29/22 and 01/11/23. On 01/25/23 at 12:13 PM, the Director of Nursing (DON) explained the facility did not have a policy for the Comprehensive Care Plan and would follow the [NAME] standard of practice for edema, CHF, and care plans specifically. On 01/25/23 at 3:18 PM, the DON confirmed Resident #4's care planned interventions for CHF did not include the use of spironolactone or furosemide. The DON confirmed the use of pharmacological interventions was not added to Resident #4's care planned interventions until 01/25/22, by the DON, and was documented as give cardiac medications as ordered. On 01/25/23 at 4:23 PM, the Resident Care Manager explained the use of furosemide and spironolactone should have been care planned as CHF interventions for Resident #4 as they were specific to the resident's care of CHF. The facility standard of practice titled Lippincott Manual of Nursing Practice: Eleventh Edition, copyright 2019, by Wolters-Kluwer, page 6, documented the care plan should identify nursing interventions as appropriate for goal attainment to include independent nursing actions as well as collaborative interventions based on medical orders and should be detailed to provide continuity of care. Management of Congestive Heart Failure, page 1219, included the use of diuretics to manage and reduce intravascular volume (furosemide, spironolactone).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was monitored and received care for the potential side effects to antibiotics according to the facility's standard of practice for 1 of 15 sampled residents (Resident #144). Findings include: Resident #144 Resident #144 was admitted to the facility on [DATE], with diagnoses including pneumonia, unspecified organism, urinary tract infection, site not specified, and other specified bacterial agents as the cause of diseases classified elsewhere. On 01/23/23 at 12:54 PM, Resident #144 and the resident's representative verbalized the resident had been receiving antibiotics and had had diarrhea and loose stools for the last two days. The resident's representative verbalized the representative was concerned the loose stools were a result of the antibiotic therapy. The Medication Administration Record (MAR) for Resident #144, dated January 2023, documented the resident had received the following antibiotics: - Cefdinir oral capsule, give 300 milligrams (mg) by mouth two times a day for pneumonia and urinary tract infection. The Cefdinir was administered for seven doses starting 01/17/23 at 8:00 PM through 01/20/23 at 8:00 PM. - doxycycline hyclate tablet, give 100 mg by mouth two times a day for pneumonia and urinary tract infection. The doxycycline was administered for six doses starting 01/17/23 at 8:00 PM through 01/20/23 at 8:00 AM. The Comprehensive Care Plan for Resident #144 lacked a care plan addressing the antibiotic therapy. The Bowel Elimination Task for Resident #144 documented the resident had loose stool/diarrhea on 01/18/23 at 5:40 AM and at 1:59 PM and on 01/23/23 at 1:59 PM. The resident's MAR documented the resident received docusate sodium (stool softener) 100 mg at 8:00 AM on 01/18/23 through 01/22/23 and at 8:00 AM on 01/24/23. The medication was held on 01/23/23. The instructions for the docusate documented may hold for loose stools. On 01/24/23 at 7:41 AM, the Licensed Practical Nurse (LPN) for Resident #144 verbalized the LPN did not know if the resident had experienced loose stools or diarrhea. The LPN verbalized the potential side effects of an antibiotic would be in the care plan. Potential side effects included loose stools and upset stomach. On 01/24/23 at 9:01 AM, the DON verbalized antibiotics would be care planned for potential side effects including diarrhea and upset stomach. The purpose of the care plan would be to address the issue with the goal of preventing the resident from experiencing ongoing issues and would include interventions to address the problem. The DON confirmed the care plan lacked a care plan addressing the resident's use of antibiotics. The DON verbalized the 8:00 AM stool softener administered on 01/18/23, should have been held due to the documented loose stool at 5:40 AM the same morning. The DON verbalized nursing would be expected to review the flow sheet prior to medication administration. The DON confirmed there was no documentation of loose stools or diarrhea on 01/23/23, to indicate the reason the stool softener was held. The facility policy titled Antibiotic Stewardship Program, revised 04/2019, documented the facility would ensure appropriate use of antibiotics while reducing the possible adverse events associated with antibiotic use. Training and education on antibiotic stewardship would include emphasis on the relationship between antibiotic use and gastrointestinal disorders. The facility standard of practice titled Lippincott Manual of Nursing Practice: Eleventh Edition, copyright 2019, by Wolters-Kluwer documented a resident with complaints of diarrhea would be assessed for causative factors including if the resident was receiving antibiotics. The resident would be assessed to determine any actual or potential health problems and nursing would develop a care plan to include interventions to address the health problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with dementia was assessed for symptoms of the resident's dementia and staff were aware of the resident's baseline symptoms and behaviors for 1 of 15 sampled residents (Resident #18). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], and discharged [DATE], with diagnoses including neurocognitive disorder with Lewy bodies, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and depression, unspecified. On 01/23/23 at 12:00 PM, Resident #18 was lying in bed and was repeatedly asking who the person in the corner of the room was. The corner of the room was empty. On 01/23/23 at 12:07 PM, the representative for Resident #18 verbalized the resident had visual hallucinations and was receiving an antipsychotic medication to manage the hallucinations. The representative was concerned about the hallucinations worsening because the resident was seeing small insects crawling on the bed when the representative was visiting the previous week. A Physician Assistant Progress Note from the resident's hospital stay prior to admission to the facility, dated 12/19/22, the day of admission to the facility, documented the resident had active problems including visual hallucinations and Lewy body dementia. The clinical record for Resident #18 lacked a care plan to address the resident's dementia and interventions to manage symptoms. The admission Nursing Database, dated 12/19/22, did not have a check mark in the box next to the section indicating the resident had impaired cognition. The comments section under the neurological/mental status assessment was blank. On 01/25/23 at 10:34 AM, the Director of Nursing (DON) confirmed the resident did not have a care plan specific to Lewy body dementia and a care plan would be initiated based on an assessment of the resident's dementia symptoms completed on admission. The assessment would also include historical symptoms related to the resident's diagnoses. The DON verbalized the DON did not see an assessment of the resident's dementia related symptoms completed on admission. The facility's standard of practice, titled Lippincott Manual of Nursing Practice, copyright 2019, by Wolters-Kluwer, documented assessment of dementia, including neurodegenerative disease such as Lewy body where psychotic features may occur, would include assessing the onset and characteristic of symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was provided with social services assistance to access recommended mental health services for 1 of 15 sampled residents (Resident #18). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], and discharged [DATE], with diagnoses including neurocognitive disorder with Lewy bodies, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and depression, unspecified. On 01/23/23 at 12:00 PM, Resident #18 was lying in bed and was repeatedly asking who the person in the corner of the room was. The corner of the room was empty. On 01/23/23 at 12:07 PM, the representative for Resident #18 verbalized the resident had visual hallucinations and was receiving an antipsychotic medication to manage the hallucinations. The representative was concerned about the hallucinations worsening because the resident was seeing small insects crawling on the bed when the representative was visiting the previous week. A Physician Assistant (PA) Progress Note from the resident's hospital stay prior to admission to the facility, dated 12/19/22, the day of admission to the facility, documented the resident had active problems including visual hallucinations and Lewy body dementia. The clinical record for Resident #18 lacked a care plan to address the resident's dementia diagnosis and interventions to manage symptoms. A PA #1's History and Physical for the facility for Resident #18, dated 12/20/22, documented to consider a Behavioral Health Services consult for the resident. A PA #2's discharge note, dated 01/24/23, documented to consider a Behavioral Health Services consult for the resident. An admission Social Service Assessment/History, dated 01/05/23, had no documentation under the section titled Mood/Behavior Needs. On 01/25/23 at 10:24 AM, a Licensed Practical Nurse (LPN) verbalized a provider would make a Behavioral Health Services referral by notifying one of the Registered Nurse Case Managers (RNCM). On 01/25/23 at 10:34 AM, the DON confirmed the resident did not have a care plan specific to Lewy body dementia and a care plan would be initiated based on an assessment of the resident's dementia symptoms completed on admission. The assessment would also include historical symptoms related to the resident's diagnoses. The DON verbalized the DON did not see an assessment of the resident's dementia related symptoms completed on admission and confirmed a referral to Behavioral Health Services had not been ordered. The DON explained the repeated History and Physical documentation to consider a Behavioral Health Services consult for the resident was due to the initial History and Physical documentation being carried over to every subsequent note. On 01/25/23 at 10:39 AM, a PA #2 who was involved with the care of Resident #18 verbalized the PA would send a referral to Social Services when a Behavioral Health Services consult was needed. The PA verbalized the PA had not made a referral based on the documentation in the provider notes because the PA would have assumed the referral had already been made by the PA who originally entered the note. On 01/25/23 at 4:23 PM, the DON verbalized the social services assessments were completed by the RNCM/Social Services Coordinator (SSC). On 01/26/23 at 7:53 AM, the RNCM/SSC verbalized the Social Services Assessment would be completed within two weeks of the resident's admission. The RNCM verbalized the RNCM was unsure if the facility Social Worker reviewed social services assessments. The RNCM verbalized it would have been important to care plan a resident's history of visual hallucinations so staff would understand the issue was not a new problem if the resident experienced hallucinations while in the facility. The RNCM verbalized the RNCM would send a referral to Behavioral Health Services once the RNCM received an order from the provider. On 01/26/23 at 8:59 AM, the Administrator verbalized the Social Worker/Social Services Director (SSD) had not worked in 60 days and had not reviewed or assessed any of the current residents in the facility. The facility's standard of practice, titled Lippincott Manual of Nursing Practice, copyright 2019, by Wolters-Kluwer, documented assessment of dementia, including neurodegenerative disease such as Lewy body where psychotic features may occur, would include assessing the onset and characteristic of symptoms. The SSC job description, prepared 10/2022, documented the SSC reported to the SSD and would partner with the SSD to coordinate the social services program. Essential duties included meeting with new admissions to document the resident's psychosocial history and identify current psychosocial needs as directed by the SSD. The SSC would assist in completing the psychosocial care plan. The SSC would assist residents in accessing mental health services and managed behavioral health services including, tracking, meetings, care planning, care, and services. The SSD job description, prepared 10/2022, documented the SSD would direct and oversee the social services program. The SSD would meet with all new admissions to document the resident's psychosocial history and identify the resident's psychosocial needs. The SSD would ensure comprehensive psychosocial care plans were in place for each resident. The SSD would assist residents in accessing mental health services and manage behavioral health services including tracking, meetings, care planning, care, and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure medication was administered with an error rate less than 5 percent (%). There were 26 opportunities and 8 medication errors. The medication error rate was 30.77%. Findings include: Resident #195 Resident #195 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with diabetic chronic kidney disease, hypertensive heart and chronic kidney disease with heart failure and stage 1 through 4 chronic kidney disease, or unspecified chronic kidney disease, and benign prostatic hyperplasia without lower urinary tract symptoms. On 01/25/23 at 9:20 AM, a Licensed Practical Nurse (LPN) administered the following medications to Resident #195: -candesartan cilexetil 4 milligram (mg) tablet (tab), one tab, -carvedilol 3.125 mg tab, one tab, -finasteride 5 mg tab, one tab, -glipizide extended release 5 mg tab, one tab, -tamsulosin 0.4 mg capsule, one capsule, -Tradjenta 5 mg tab, one tab, and -multi vitamin tab,1 tab. Resident #195's Medication Administration Record (MAR) dated January 2023, documented the following: -Candesartan cilexetil 4 mg tab, give one tablet by mouth one time per day for hypertensive heart and chronic kidney disease with heart failure and stage 1 through 4 chronic kidney disease, or unspecified chronic kidney disease. The scheduled administration time was 8:00 AM. -Carvedilol 3.125 mg tab, give one tab by mouth two times per day for hypertensive heart and chronic kidney disease with heart failure and stage 1 through 4 chronic kidney disease, or unspecified chronic kidney disease. The scheduled administration time was 8:00 AM. -Finasteride 5 mg tab, give one tab by mouth one time per day for benign prostatic hyperplasia without lower urinary tract symptoms. The scheduled administration time was 8:00 AM. -Glipizide extended release 5 mg tab, give one tab by mouth two times per day for type II diabetes mellitus with diabetic chronic kidney disease. The scheduled administration time was 8:00 AM. -Tamsulosin 0.4 mg capsule, give one capsule by mouth one time per day for benign prostatic hyperplasia without lower urinary tract symptoms. The scheduled administration time was 8:00 AM. -Tradjenta 5 mg tab, give one tab by mouth one time per day for type II diabetes mellitus with diabetic chronic kidney disease. The scheduled administration time was 8:00 AM. -Multi vitamin tab, give one tab by mouth one time per day for supplement. The scheduled administration time was 8:00 AM. On 01/25/23 at 9:22 AM, the LPN verbalized the parameters for medication administration was for medications to be administered within one hour before or one hour after the scheduled administration time. The LPN confirmed seven medications had a scheduled administration time of 8:00 AM and had been administered late at 9:20 AM. Resident #32 Resident #32 was admitted to the facility on [DATE], with diagnosis including Guillain-Barre syndrome. On 01/25/23 at 9:28 AM, the LPN administered the following medication: -heparin sodium (porcine) injection solution 5,000 units/milliliter (ml), give 5,000 units subcutaneously. Resident #32's MAR dated January 2023, documented the following: -heparin sodium (porcine) injection solution 5,000 units/ml, inject 5,000 units subcutaneously two times per day for deep vein thrombosis (DVT) prophylaxis. The scheduled administration time was 8:00 AM. On 01/25/23 at 9:30 AM, the LPN confirmed the medication had a scheduled administration time of 8:00 AM and was administered late at 9:28 AM. The facility policy titled Medication Administration, dated September 2018, documented medications were administered within 60 minutes of the scheduled administration time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and document review the facility failed to ensure Protected Healthcare Information (PHI) was secured from view for 1 of 60 residents residing in the facility (Resident #199). Findings include: Resident #199 Resident #199 was admitted to the facility on [DATE], with diagnoses including encounter for attention to colostomy, other specified functional intestinal disorders, and slow transit constipation. On 01/26/23 at 7:43 AM, the computer terminal on the Station One medication cart located in the resident hallway outside of room [ROOM NUMBER], displayed PHI for Resident #199. A nurse was not located in the hallway at or near the medication cart. The computer terminal was open to Resident #199's morning medication list and included the resident's name, photograph, and morning medication orders. On 01/26/23 at 7:44 AM, a Registered Nurse (RN) returned to the cart and confirmed the computer terminal was open to Resident #199's morning medication screen and the resident's PHI was in view of anyone in the hallway, including other residents and visitors. The RN explained the expectation was when the nurse walked away from the computer terminal, the nurse would log out of the system. A facility document titled HIPAA and Compliance, undated, documented PHI was individually identifiable health information in any form including electronic. Identifiable health information included the individual's health condition, provision of health care to the individual, and many common identifiers such as the resident's name and birthday. Computers were to be closed or logged out of when not in use. The facility policy titled Medication Administration, dated September 2018, documented residents' health information needed to remain private and the Medication Administration Record containing residents' health information must remain closed when not in direct use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review, interview and document review, the facility failed to ensure 1 of 21 sampled employees completed annual abuse prevention training (a Certified Nursing Assistants). Findings include: The CNA's personnel record documented a hire date of 02/23/21. The personnel record for the CNA documented abuse prevention training was completed on 10/22/22, and lacked documented evidence Abuse Prevention training was completed upon hire or at any time prior to 10/22/22. On 01/26/23 at 10:20 AM, the Administrator confirmed the facility lacked documented evidence the CNA received abuse training upon hire or at any other time prior to 10/22/22. The Facility assessment dated [DATE], documented staff competencies included required skills validation, competency checks, dementia training, and abuse training. Staff competencies were completed upon hire and annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review, interview and document review, the facility failed to ensure 1 of 21 sampled employees (a Certified Nursing Assistant (CNA) and the Infection Preventionist (IP) completed dementia care training annually. Findings include: CNA The CNAs personnel record documented a hire date of 03/08/19. The CNAs personnel record documented dementia care training was completed on 03/08/21 and was not completed again until 11/29/22. On 01/26/23 at 9:53 AM, the Administrator confirmed the CNA received dementia care training on 03/08/21 and did not receive dementia care training again until 11/29/22. the Administrator confirmed the training was not provided annually. IP The IP's personnel record documented a hire date of 08/09/21. The IP's personnel record documented dementia care training was completed on 08/10/21 and was not completed again until 11/21/22. On 01/26/23 at 10:11 AM, the Administrator confirmed the IP received dementia care training on 08/10/21 and did not receive dementia care training again until 11/21/22. the Administrator confirmed the training was not provided annually. The Facility assessment dated [DATE], documented staff competencies included required skills validation, competency checks, dementia training, and abuse training. Staff competencies were completed upon hire and annually.