**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure an indication for a midline (an intravenous access inserted into a vein for administration of medications) was obtained from a physician for a resident who was admitted with a midline for 1 of 7 sampled residents (Resident 7). The deficient practice placed the resident at risk for infection related to the invasive medical device. Findings include: Resident 7 (R7) R7 was admitted on [DATE], with diagnoses including cellulitis of left foot and diabetes mellitus. On 01/28/2025 at 9:14 AM, R7 was awake and alert in bed. A left upper arm single lumen midline was observed covered with transparent dressing dated 01/22/2025. R7 indicated being on intravenous (IV) antibiotics while in the hospital for a left foot infection. R7 indicated the midline had not been used at this facility and no staff or provider had discussed whether the midline needed to be maintained or discontinued. There were no IV supplies (pole, pump, empty IV bags) observed in the resident's room. An admission nursing note dated 01/21/2025, documented R7 was admitted with a left upper arm midline. A hospital midline procedural note dated 11/14/2024, revealed a midline was inserted into R7's left upper arm on 11/14/2024 for antibiotic therapy. Review of hospital records revealed R7 was on IV antibiotic therapy from 11/14/2024 until 11/29/2024 and the infectious disease team documented R7's infection status as resolved on 12/08/2024. Hospital records lacked documented evidence on whether R7's midline was to be maintained or removed due to completion of antibiotic therapy and whether a nurse clarified with a physician regarding plans for R7's midline prior to discharge to the skilled nursing facility (SNF). R7's medical record lacked documented evidence nursing staff from the SNF obtained clarification orders from a physician on whether R7's midline was to be maintained or removed due to non-use. The medical record revealed R7 did not have any IV medication orders on admission. On 01/29/2025 in the morning, the Registered Nurse (RN) confirmed R7 was admitted with a midline which the RN flushed daily. The RN confirmed R7's midline was not in use because the resident did not have any IV medication orders. The RN indicated not knowing what the plans were for R7's midline and acknowledged not having discussed R7's midline with the provider. On 01/29/2025 at 11:21 AM, the Director of Nursing (DON) reviewed R7's medical record and confirmed the midline was last used in the hospital for antibiotic therapy on 12/08/2024 after the resident's infection status was deemed resolved. The DON stated the admission nurse, or any nurse assigned to R7 should have obtained clarification orders from a physician on whether the resident's midline was to be maintained or removed. The DON verbalized the midline was an invasive device and should not stay longer than needed because it would place the resident at a higher risk for an infection. On 01/29/2025 at 11:41 AM, the DON entered R7's room and confirmed the presence of a left upper arm midline covered with transparent dressing. The DON was present when R7 stated the midline had not been used in weeks and no staff or provider had discussed plans for the midline with the resident. On 01/29/2025 at 12:06 PM, the Nurse Practitioner (NP) indicated expecting nurses to obtain justification orders for midlines especially for residents who were admitted with IV accesses but did not have any IV medication orders. The NP indicated midlines should not be kept longer than necessary because it placed residents at a higher risk for an infection. The admission Infection Control policy revised 05/15/2023, documented invasive devices would be reviewed for residents who were being admitted with invasive devices. The Admitting a Resident policy revised 05/05/2023, documented the facility utilized Lippincott Nursing Procedures ninth edition as a professional standard of practice. The Lippincott Nursing Procedure (ninth edition), documented midline catheters were used to safely administer medications into the bloodstream and required an indication for use such as parenteral nutrition, IV fluid replacement and IV medications. Midline catheters were removed when no longer needed.

Based on interview and document review, the facility failed to ensure an annual performance evaluation was completed for 3 of 6 Certified Nursing Assistants (Employee 3, 9, and 11). The failure to complete the performance evaluation of the Certified Nursing Assistants (CNAs) in a timely manner could potentially compromise the quality of care provided to the residents. Findings include: The Personnel Records Checklist dated 01/29/2025 documented the following: Employee 3 was hired on 11/22/2019 as CNA. Employee 3 lacked an annual performance evaluation. Employee 9 was hired on 08/19/2019 as CNA. Employee 9 lacked an annual performance evaluation. Employee 11 was hired 09/13/2019 as CNA. Employee 11 lacked an annual performance evaluation. On 01/29/2025 at 11:39 AM, the Human Resources Director confirmed the Personnel Records Checklist was accurate and the three CNAs listed lacked an annual performance evaluation. The Human Resources Director acknowledged an annual performance evaluation should have been completed. On 01/30/2025 at 11:55 AM, the Administrator acknowledged CNA annual performance evaluations should have been completed annually on the month of the CNA's hire date. The Administrator explained the annual performance evaluation would have assisted the facility to ensure the CNAs training was up to date and identify areas where the CNAs needed more training and education. A facility policy titled Performance Evaluations revised 01/2007, documented performance evaluations would be completed at the 90-day introductory period and annually according to entity practices. The purpose of the performance evaluations were to assess an employee's achievements, determine areas where improvement may be needed, and establish goals for the upcoming performance period.

Based on observation, interview and document review, the facility failed to ensure the kitchen was maintained in a sanitary manner, food items were stored in accordance with facility protocol and expired food items were discarded. The deficient practice had the potential to place residents at risk for food borne illnesses. Findings include: On 01/28/2025 at 7:40 AM, a tour of the kitchen revealed the following concerns: 1. A tin can with no handle was observed inside a bulk container of flour. The Kitchen [NAME] indicated the bulk container had a 50-pound (lb.) capacity and contents must be accessed with a scooper with handle to prevent hand contamination. Furthermore, the hand scooper must never be left inside the bulk container for sanitary reasons. 2. A commercial-size double oven with five racks each was described by the [NAME] to be very dirty, with heavy grease build-up on oven doors and racks and crumbs on oven floor. The [NAME] indicated the oven should be cleaned at least once a week but had not been cleaned for two weeks due to resignation of the former dietary manager two weeks ago. The [NAME] indicated a dirty oven placed food at risk for cross contamination and was a fire hazard due to heavy grease build-up. 3. The topmost rack inside the walk-in freezer was observed to have dirt build-up. The [NAME] confirmed the topmost rack which had food items stored underneath had dust build-up because delegation of cleaning tasks had not been clearly assigned since the former dietary manager resigned two weeks ago. 4. A metal pan containing cooked ground meat was observed uncovered inside the freezer. The [NAME] indicated the metal pan contained 20 lbs. of cooked ground beef which would be used later in the day. The [NAME] acknowledged all food items in the freezer must be covered until time of actual use for sanitation reasons and to preserve food quality and taste. On 01/28/2025 at 8:15 AM, the Lead [NAME] confirmed the following observations inside the dry storage room of the kitchen: -Six bottles Dijon mustard with expiration date 12/09/2024 -Fifteen boxes of powdered sugar with expiration date 10/14/2024 -Two bottles of salted caramel syrup with expiration date June 2024 - Seven pouches of chocolate pie filling expiration October 2024 On 01/28/2025 at 8:20 AM, the Lead [NAME] confirmed the expired food items and explained the former dietary manager resigned two weeks ago and the lead cook was new to the job role. The Lead [NAME] indicated delegation of kitchen tasks which included cleaning and inspection of storage areas for discarding of expired food items was a process the Lead [NAME] was still learning. On 01/28/2025 at 9:17 AM, the Administrator explained the Kitchen Sanitation Audit Tool was a form which itemized all necessary kitchen tasks from cleaning to inspection of equipment and food storage areas. The Administrator explained the former dietary manager was responsible for completion of the form, but the dietary manager resigned two weeks ago which may have resulted in kitchen tasks not being done. The Administrator indicated the Lead [NAME] was new to the position and was still in the process of learning how to delegate kitchen tasks. The Sanitation and Food Safety policy revised 06/20/2023, documented sanitation practices were followed to minimize the risk of contamination of food preventing food borne illnesses. The Dietary Manager monitored sanitation of the kitchen and developed, implemented and monitored a cleaning schedule wherein tasks were assigned to specific individuals which would include a cleaning schedule for each area and piece of equipment in the kitchen. The Food Safety - receiving and storage policy revised 06/20/2023, documented staff would check for expiration dates to assure dates were within acceptable parameters. Refrigerated foods were properly covered, labeled and dated.

Based on observation, interview, record review, and document review, the facility failed to: 1) act promptly on a concern voiced by the resident council, and 2) demonstrate a response and rationale for resident concerns was communicated back to the members of the resident council. The deficient practices had the potential to adversely affect all residents residing in the facility skilled nursing unit. Findings include: On 01/10/2024, review of the past six months of resident council meeting minutes revealed the following: The Resident Council Meeting Minutes form dated 06/29/2023 revealed four residents had attended. The residents had voiced a concern there were insufficient food and evening snacks provided. The form lacked documented evidence of action taken or of the communication of the rationale to members of the resident council. The Resident Council Meeting Minutes form dated 07/20/2023 revealed three residents had attended. The residents had voiced a concern there was not enough food for dinner and a need for more evening snacks. The form lacked documented evidence of action taken or of the communication of the rationale to the resident council. The Resident Council Meeting Minutes form dated 08/24/2023 revealed three residents had attended. The residents had voiced a concern there was a need for more snacks throughout the day, and requested the snacks include sandwiches and chips. The form lacked documented evidence of action taken or of the communication of the rationale to the resident council. The Resident Council Meeting Minutes form dated 10/26/2023 revealed three residents had attended. The residents had voiced a concern there was a need for more snacks during the day. The form documented action taken included more PBJ and meat sandwiches in place. The persons responsible were listed as Kitchen Dietician. The form lacked documented evidence the action taken was communicated to the resident council. On 01/10/24 at 09:02 AM three members of the resident council, including the President, verbalized snacks were given when requested, as available. After hours when the kitchen was closed, there were sometimes not enough sandwiches available. The residents verbalized peanut butter and jelly, or meat sandwiches were the preferred snack. The residents revealed when sandwiches were unavailable, Jello, soda crackers, and milk were given instead. The residents verbalized they had requested more snacks, particularly sandwiches, to be made available to the skilled nursing residents at multiple resident council meetings. The residents reported there had been some improvement in the supply, but no complete resolution, as the sandwiches continued to run out sometimes. On 01/10/2024, in the morning, the Resident Council President verbalized they had not been informed by facility staff of any response or rationale regarding the council's concern about being furnished with more snacks and sandwiches. On 01/10/24 in the afternoon the Dietary Services Supervisor (DSS) verbalized snacks were prepared and sent out to the skilled nursing unit several times a day and stocked in a nourishment room near that unit. The DSS verbalized not being aware the residents had requested increased quantities of snacks, especially sandwiches. The DSS reported they had not been briefed by other staff and had never seen the resident council meeting minutes or knew of their existence. On 01/10/24 in the afternoon, the Registered Dietician verbalized not being aware or informed of any resident interested in more snacks. On 01/10/2024, in the afternoon, the Activity Director (AD) verbalized they attended the resident council meetings and wrote down in the meeting minutes any concerns the residents voiced. The AD would then report the concerns to the Social Work Director. The AD revealed the Social Work Director then reported either to the department personnel who could act, or to the Administrator. On 01/10/2024, in the afternoon, the AD reviewed the meeting minutes and verified there was no documented evidence of action taken on the forms for June, July, and August, and no communication of the rationale to the resident council on any of the forms. The AD was unable to identify the individual who had acted as documented in the October meeting minutes. The AD verbalized they were responsible for documenting actions taken on the form but had not done so. The AD verbalized at present, there was no formal process in place for reporting actions taken by the facility to be communicated back to the resident council. On 01/10/2024, in the afternoon, the Social Work Director had been unavailable for interview. On 01/10/2024, in the afternoon, the Administrator (ADM) reviewed the resident council meeting minutes and verbalized there had been a lack of a documented action in response to the resident requests for more snacks for at least three of the monthly meetings. The ADM reported not being furnished with these meeting minutes. The ADM reported there was no documented evidence the resident council members had been informed of actions taken, or a rationale, but there should have been evidence of that. The ADM reported they had not been included in the communication loop for the resident council process but should have been. The facility policy and procedure titled Patient/Resident Council or Group, revised 09/01/2022, indicated the facility assisted residents to form a resident council which met monthly. Minutes of each meeting would be documented on the Resident Council Meeting Minutes form. The resident council could voice group concerns. The Activities Director would follow up on and provide feedback on the council's concerns. For concerns mentioned at meetings identified as a grievance, the Complaints/Grievances Process policy would be followed. The facility policy and procedure titled Complaints/Grievances Process, dated 11/06/2023, indicated after receiving a complaint or grievance, facility leadership would seek a problem resolution and would keep residents informed of the progress toward resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the availability of medication, and the pharmacy provided the scheduled medications as ordered for 1 of the 10 sampled residents (Resident 5). This deficient practice posed the potential for adverse health effects, compromised treatment outcomes, and an increased likelihood of medication-related complications. Findings include: Resident 5 (R5) R5 was admitted on [DATE], with diagnoses including epilepsy and acute embolism. A Physician order dated 11/16/2023, documented Apixaban (Eliquis) 5 milligrams (mg) by mouth twice daily for deep vein thrombosis. On 01/10/2024 at 8:05 AM, during medication pass, a Registered Nurse (RN) prepared R5's medications except Apixaban mg. An RN indicated Apixaban was unavailable and would follow up with the pharmacy. An RN indicated there was no emergency medication dispenser on the skilled nursing facility (SNF) side but only in the hospital, which the nurses had no access to. An RN indicated the Apixaban had been requested already, but the pharmacy had not delivered. The Refill Reorder Form dated 01/08/2024, which documented R5's Apixaban refill was reordered on 01/09/2024 at 12:23 AM, faxed to the pharmacy and confirmed it was received. On 01/10/2024 at 11:30 AM, the Resident Care Manager (RCM) indicated the process was to request the medication ahead if the supply ran low to prevent a delay in administration. The RCM indicated the nurses were expected to ensure the medications were available and administer them as ordered. On 01/10/2024 at 3:06 PM, the pharmacist indicated Apixaban was ordered and was not delivered because the facility was obtaining the medication from the emergency medication dispenser as normal procedure. The Pharmacist indicated there was no record of Apixaban being delivered for R9. On 01/10/2024 at 3:20 PM, the Chief Nursing Officer (CNO) stated the Apixaban had been ordered and faxed to the pharmacy but was not delivered as ordered. The CNO specified the Apixaban was a scheduled anticoagulant medication, and the pharmacy was supposed to deliver it promptly. The CNO mentioned the pharmacy confirmed receiving the request for Apixaban and, if unable to deliver, was expected to communicate, but no correspondence was documented. The CNO indicated it was not the normal procedure to obtain the Apixaban from the emergency medication dispenser on the SNF side because the SNF area had no dedicated dispensing machine, unlike the hospital. The CNO indicated the pharmacy should have delivered the requested medication and communicated if it was unable to do so. A facility policy titled Medication Procurement-Medication Shortages and Unavailable Medication dated 04/01/2022, documented the facility's ability to ensure there was always an adequate supply of medication available to administer to a resident at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure their medication error rate was not five percent (%) or greater when five errors were identified with 29 opportunities observed, resulting in an error rate of 17.24%. Failure to reduce the medication error rate to less than 5% could lead to an adverse drug reaction from an overdose or underdose, which can cause harm or injury to the resident. Findings include: Resident 5 (R5) R5 was admitted on [DATE], with diagnoses including epilepsy and acute embolism. A Physician order dated 11/16/2023, documented Apixaban (Eliquis) 5 milligrams (mg) by mouth twice daily for deep vein thrombosis. On 01/10/2024 at 8:05 AM, during medication pass, a Registered Nurse (RN) prepared R5's medications except Apixaban 5 mg. An RN indicated Apixaban was unavailable and would follow up with the pharmacy. An RN indicated there was no emergency medication dispenser on the skilled nursing facility (SNF) side but only in the hospital, which the nurses had no access to. An RN confirmed the Apixaban was not administered due to unavailability. On 01/10/2024 at 11:30 AM, the Resident Care Manager (RCM) indicated the process was to request the medication ahead of time if the supply was low to prevent a delay in administration. The RCM mentioned the nurses were expected to ensure the medications were available and administer them an hour before and after the prescribed time. Resident #3 (R3) R3 was admitted on [DATE], with diagnoses including an unstageable sacral pressure ulcer, surgical amputation, and femur-displaced fracture. A Physician order dated 12/16/2023, documented Dextrose 50% in water intravenously for hypoglycemia. A Physician order dated 12/20/2023, documented Lidocaine 5% to apply two patches topically at 9 AM to the left and right abdomen daily for chest wall muscle pain. A Physician order dated 01/05/2024, documented Guaifenesin (Mucinex) 600 mg to be given by mouth twice daily at 9:00 AM and 9:00 PM for cough. A Physician order dated 01/09/2024, documented Saccharomyces Boulardii (Florastor) 250 mg capsule to be given by mouth twice daily at 9:00 AM and 9:00 PM for gut wellness. On 01/10/2024 at 8:27 AM, an RN prepared R3's medications except the following: -Dextrose -Mucinex -Lidocaine -Florastor On 01/10/2024 at 11:30 AM, an RN confirmed the following medications were active orders: Dextrose, Mucinex, Lidocaine Patch, and Florastor. An RN indicated the medications were scheduled and available but were not administered during the medication pass because they were not showing in the computer system. The RN explained the medications should have been administered one (1) hour in advance or 1 hour later than the prescribed time. The RN confirmed the medications were not administered timely as ordered. On 01/10/2024 at 11:37 AM, the RCM confirmed the medications were active and should have been administered timely as ordered and for deviations, the physician should have been notified. On 01/10/2024 at 11:50 AM, the CNO acknowledged medications were not administered timely as ordered. The CNO indicated the staff were to ensure medications were available and administer them 1 hour before or 1 hour after the prescribed medication pass time. A facility policy titled Medication Management-Medication Errors: Prevention, Identification and Management of dated 04/01/2022, the facility should strive to prevent medication errors and identify and manage them appropriately when they occur, ensuring medication error rates were not 5 percent or greater. The staff should strive to minimize the potential for medication by following the eight rights for administering medication, including the right time, and should implement and follow physician orders. A facility policy titled Medication Management Program dated 05/05/2023, documented the medications were administered no more than 1 hour before or 1 hour after the designated medication pass time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure a resident was treated with dignity and respect by a staff member for 1 of 8 sampled residents (Resident #60). The failure to treat a resident with respect and dignity had the potential for a psychosocial outcome such as depressed mood and humiliation. Findings include: Resident #60 (R60) R60 was admitted on [DATE], with diagnoses including systemic lupus erythematosus, major depressive disorder, and anxiety disorder. On 01/10/2023 at 9:23 AM, R60 was sitting in a bed inside the resident's room, alert, and oriented. R60 revealed having an undesirable weight gain. R60 indicated a staff member spoke to the resident and had been making comments about the resident's weight and how much the resident gained weight. The resident acknowledged not being comfortable with the staff member's comments and made the resident feel bad. R60 indicated the staff member was not respectful and the comments about the resident's weight made the resident feel not great about themselves. On 01/10/2023 at 9:54 AM, the Administrator explained not receiving any report about R60's concerns nor complaints from other residents about the staff member. The Administrator indicated an investigation about R60's allegation would be initiated. On 01/11/2023 at 12:26 PM, the Director of Social Services revealed the staff members were expected to be professional in their interaction with the residents. On 01/12/2023 at 7:46 AM, a Licensed Practical Nurse (LPN) explained each resident should have been treated with dignity and respect. On 01/13/2023 at 3:21 PM, the Administrator revealed the staff members were expected to treat all residents with dignity and respect, communicate honestly with residents and should have been aware of cultural differences. The Administrator confirmed R60's allegation was substantiated because the resident's perception had to be honored. The resident felt staff member's comment were hurtful and the facility had to go with resident's perception. The facility's policy titled Patient/Resident Rights dated 10/01/2020, documented the facility would treat each resident with respect and dignity. Facility Reported Incident #NV00067753

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review the facility failed to provide admission documents including a copy of resident rights in a form understandable by a resident for 1 of 8 sampled resident (Resident #3). Failure in accommodating a resident's dominant language prevented the enhancement of quality of life, not recognizing each resident's individuality. Findings include: Resident #3 (R3) R3 was admitted on [DATE] with diagnoses including hemiplegia following a cerebral accident and dementia without behavioral disturbance. On 01/10/23 at 10:35 AM, observation of R3's room revealed the resident was lying in bed and noted to be only Spanish speaking. The resident had a hard time communicating. There was no communication board for the resident to communicate to any person entering the room. The nurse in the unit indicated the resident mostly spoke Spanish and could verbalize basic needs. On 01/12/2023 at 1:05 PM, the admission nurse indicated discussing the admission packet was part of completing admissions for residents. The admission nurse confirmed the welcome packet should have been provided in the dominant language for the resident. On 01/13/2023 at 9:38 AM, a resident interview with a language line interpreter confirmed the resident could understand a little English and could read very little English. R3 conveyed to the interpreter preferring to receive materials in Spanish. On 01/13/2023 at 10:02 AM, the Resident Care Manager confirmed R3 was predominantly Spanish speaking and admission materials should have provided in Spanish. The facility [NAME] of Rights information provided to residents upon admission documented the resident had the right to and was encouraged to obtain from physicians and other direct caregivers, relevant, current, and understandable information. The facility policy titled Resident - Impaired Communication/ Limited English Proficient dated 12/09/2020, documented written notices such as Resident Rights, Facility Policy, Transfer/Discharge Notices, Room Change, will be provided in a language the resident understands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure a non-English speaking resident was provided communication tools for 1 of 8 sampled resident (Resident #3). Failure to provide communication tools for a non-English speaking resident had the potential to inhibit the provision of daily care including participation in facility activities. Findings include: Resident #3 (R3) R3 was admitted on [DATE] with diagnoses including hemiplegia following a cerebral accident and dementia without behavioral disturbance. On 01/10/23 at 10:35 AM, observation of the room revealed the resident was lying in bed and noted to be only Spanish speaking. The resident had a hard time communicating. There was no communication board for the resident to communicate to any person entering the room. The nurse in the unit indicated the resident mostly spoke Spanish and could verbalize basic needs. On 01/12/2023 at 1:05 PM, the admission nurse indicated assessment of resident communication needs should be addressed upon admission. Interventions could be put into place for the resident to communicate with staff. On 01/13/2023 at 09:38 AM, R3 interview with a language line interpreter confirmed the resident could understand a little English and could read very little English. R3 conveyed to the interpreter having limited communication with staff. On 01/13/2023 at 10:02 AM, the nurse confirmed the resident would be able to use call bell and the resident could communicate basic needs. The nurse confirmed having a hard time understanding the resident at time and acknowledged the resident could benefit from a commutation board with pictures to ease communication with the resident and to avoid confusion with what the patient needs. On 01/13/2023 at 10:02 AM, the Resident Care Manager confirmed R3 was predominantly Spanish speaking and communication materials should have provided to aide communication. The facility policy titled Resident - Impaired Communication/ Limited English Proficient dated 12/09/2020, documented communication boards or other tools may be utilized to assist with communication needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review the facility failed to ensure pain assessments were completed for a resident receiving as needed (PRN) pain medications for 1 of 8 sampled residents (Resident #4). The failure of assessing a pain level prevented the monitoring of the effectivity of the pain management for the resident. Findings include: Resident #4 (R4) R4 was admitted on [DATE], with diagnoses including open wound of the left lower leg and methicillin resistant staphylococcus aureus infection of the wound. R4 had a physician order dated 12/30/2022, for Hydrocodone 10 milligram (mg)/325mg given every four hours PRN for pain. R4's medication administration record (MAR) reveled the following Hydrocodone 10mg/325mg medication was given: 01/12/2023 - 4:00 AM- no entry 01/11/2023 - 9:10 PM - no entry 01/11/2023 - 6:06 PM - 8/10 bilateral lower leg (BLE) pain 01/11/2023 - 1:57 PM - 8/10 BLE pain 01/11/2023 - 9:01 AM - 8/10 leg pain 01/11/2023 - 4:57 AM - c/o BLE pain 8/10 01/11/2023 - 12:36 AM - c/o BLE pain 8/10 01/10/2023 - 9:37 PM - no entry 01/10/2023 - 5:28 PM - no entry 01/09/2023 - 10:12 PM - no entry 01/09/2023 - 4:30 AM - no entry On 01/11/2023 at 1:55 PM, a license practical nurse (LPN) confirmed the comments section had no entries for pain level. The LPN indicated pain levels were to be documented at the shift SNF System Review or the comment section of the MAR upon administering the PRN pain medication. R4's medical record lacked documented evidence the nurses were documenting pain assessments on the system review assessments. On 01/12/2023 at 2:57 PM, the resident care manager (RCM) confirmed the finding and indicated the expectation was for nurses to document the pain level/assessment in the comment section of the MAR with each administration. The facility policy titled Pain Management revised 06/09/2022, documented ongoing evaluations of resident's pain will be completed by the staff every shift and documented on the fifth vital sign on the residents MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure a PRN (as needed) psychotropic medication was ordered no longer than 14 days or a justification for the PRN order to be extended beyond 14 days was documented for 1 of 8 sampled residents (Resident #1). The failure to ensure the prolonged use of a PRN psychotropic medication was justified could potentially result in unnecessary use of the medication. Findings include: Resident #1 (R1) R1 was admitted on [DATE], with diagnoses including major depressive disorder, generalized anxiety disorder, and suicidal ideation. R1's medical record contained the following physician's orders: - Trazodone Hydrochloride (HCl) 100 milligrams (mg) by mouth once daily at bedtime PRN if Melatonin not effective. Indication: insomnia. Order date/Start date was 12/03/2022. Stop date was 01/02/2023. Duration: 30 days. The order was discontinued on 12/22/2022 due to order replacement. - Trazodone HCl 100 mg by mouth once daily at bedtime PRN. Indication: insomnia. Order date/Start date was 12/22/2022. Stop date was 01/21/2023. Duration: 30 days. R1's Medication Administration Record documented the resident received the PRN Trazodone HCl on the following dates: - 12/03/2022 - 12/14/2022 - 12/21/2022 - 12/27/2022 - 12/28/2022 - 01/04/2023 R1's medical record lacked documented evidence of a justification for the continued use of the PRN Trazodone HCl beyond 14 days. On 01/13/2023 at 2:47 PM, the Resident Care Manager (RCM) confirmed the findings and explained the duration of the ordered PRN Trazodone HCl should have been no more than 14 days and if the order was extended, the physician should have written a justification for the PRN order to be extended beyond 14 days. The RCM acknowledged constant monitoring of a PRN psychotropic medication was necessary to determine whether a resident needed the medication and to avoid overmedication. The facility's policy titled Psychotropic Drugs - Use Of dated 01/20/2017, documented PRN psychotropic medications should have been ordered for no more than 14 days. Each resident who was taking a PRN psychotropic drug would have the prescription reviewed by the physician or prescribing practitioner every 14 days and by a pharmacist every month. If the attending physician believed a PRN order for longer than 14 days was appropriate, the attending physician could extend the prescription beyond 14 days for the resident by documenting their rationale in the resident's medical record.

Based on observation, interview and document review, the facility failed to ensure proper food preparation utensils were used during food prep and maintain a clean floor. The deficient practice had the potential to affect all residents in the facility in cross contamination of food borne illnesses. Failure to keep the kitchen floors clean and sanitary had the potential to spread food-borne disease or attract pests. Findings include: On 01/10/2023 at 8:45 AM, the lead cook was observed to be prepping food at the prep area. The lead cook was cutting onions on a white cutting board. The Ecolab Food Safety Solution poster on the wall revealed a white cutting board was for preparing dairy products. The lead cook confirmed using the wrong cutting board and indicated should be using a green cutting board per the guide. On 01/10/2023 at 8:55 AM, observed dust and debris build-up on the floor specifically under the counters and baseboard tiles of the floors on the dishwashing area and the side of the cook and prep area. The lead cook confirmed the floors needed attention and would have been in a much cleaner state if daily floor maintenance duties were performed. The facility policy titled Nutrition - Food Preparation revised 08/01/2020, documented prepare food in a sanitary manner with minimal handling utilizing safe food handling guidelines. The facility policy titled Nutrition - Cleaning the Floor revised 08/01/2020, documented daily cleaning with sweeping and mopping. Weekly cleaning of baseboards by hand with brush and cloth.

Based on interview and document review the facility failed to ensure quarterly payroll-based staffing (PBJ) requirements were submitted to Center for Medicare and Medicaid Services (CMS). The failure to submit PBJ data prevented CMS to analyze staffing patterns and populate the staffing component of the Nursing Home Compare website Review of the facility Certification and Survey Provider Enhanced Reporting System (CASPER) Report revealed the facility had no submission of staffing data for the fourth quarter of 2022. On 01/12/2023 at 1:38 PM, the Administrator indicated the facility had not been submitting PBJ data. The Administrator indicated corporate office was responsible for sending the data. The Administrator had the impression the facility did not have to submit the report for it was only 10 beds and the requirement was for greater than 50 beds. On 01/13/2023 at 09:55 AM, the Administrator confirmed there was no waiver for a less than 50 bed facility and agreed the PBJ should have been reported to CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) Resident #3 (R3) R3 was admitted on [DATE] with diagnoses including hemiplegia following a cerebral accident and dementia without behavioral disturbance. R3's Advance Directives form was checked off as: I wish to execute an advance directive (please contact social services for assistance). The form was signed and dated on 12/21/2022. R3's progress notes lacked documented evidence a follow up was completed by the social services department in assisting the resident in formulating an advance directive. On 01/11/23 at 12:09 PM, the nurse at the 400 Hall indicated not completing the forms very often. If a form was signed by the resident wanting assistance for formulating an advance directive, the nurse would leave a message at social services department or create a 24-hour report in the electronic health record which could be directed to the appropriate department. On 01/11/23 at 12:46 PM, the Director of Social Services indicated not knowing about the form provided to resident in formulating an advance directive. The director was not able to provide documented evidence R3 was assisted in formulating an advance directive. On 01/11/23 at 3:51 PM, the RCM confirmed the process of referring a resident for formulating advance directives was to email to social services or inform the social worker personally. The RCM confirmed all advance directives request should be completed and any interventions should be documented in the medical record. Based on interview, record review and document review the facility failed to ensure, 1) the Advance Directive Acknowledgement Form was completed for 1 of 8 sampled residents (Resident #6); 2) information regarding the resident's advance directive was obtained in a timely manner for 3 of 8 sampled residents (Resident #1, #5, and #60); and 3) a resident's wish to execute an advance directive was followed through for 1 of 8 sampled residents (Resident #3). The failure to ensure advanced directives were completed had the potential to limit healthcare facilities from honoring resident's health care decisions and wishes when incapacitated. Findings include: The facility's policy titled Advance Directives dated 10/01/2020, documented upon admission to the facility, the Admissions Coordinator would: A. Provide each resident or his/her legal representative with a copy of the facility's policy and state requirements for advance directives. Obtain the resident or his/her legal representative's signature on an acknowledgement confirming receipt of this information. B. Interview each resident or his/her legal representative/family members to determine whether the resident had executed an advance directive, and if not, determine if the resident wished to formulate an advance directive. C. If the resident had executed an advance directive, obtain copies and: 1) Place them in the medical record (Advance Directives section) 2) Place them in the financial record (contained in the Business Office) 3) Provide a copy to the Social Services Director 4) Provide a copy to the attending physician. Upon admission to the facility, the Social Services Director would: A. Review the medical record/advance directives, interview resident or his/her legal representative/family member and inform them of their rights to complete advance directives. B. Assist a resident who wanted to, and had the ability to, execute an advance directive in obtaining and completing the necessary forms. C. Obtain any needed orders. D. Maintain executed copies and disseminate as appropriate. 1) Resident #6 (R6) R6 was admitted on [DATE], with a diagnosis of cellulitis of right and left lower limb. R6's Advance Directive Acknowledgement Form had the signature of the resident and the facility representative (a Mental Health Technician/MHT) and dated 10/13/2022. The following sections of the form were left blank: - The statement whether the resident had executed an Advance Directive or not. - The statement whether the resident wished to execute an Advance Directive or wished to decline an Advance Directive. R6's medical record lacked documented evidence the Social Services Director discussed or followed up with the resident about their rights to complete an advance directive or the assistance provided to the resident to execute an advance directive, per the facility's policy. On 01/11/2023 at 12:16 PM, the Social Services Director explained not having been furnished with a copy of an Advance Directive Acknowledgement Form where the residents opted to execute an advance directive. The Social Services Director revealed a social services assessment was completed usually within three days upon a resident's admission. The Social Services Director confirmed the residents were not asked about their advance directive during the initial social services assessment. On 01/11/2023 at 3:49 PM, a Resident Care Manager (RCM) indicated an admission Nurse was responsible in obtaining the consents and signatures of each resident or responsible party for the admission packet including the Advance Directive Acknowledgement Form. The MHT could have performed the task of obtaining the signatures of the residents or responsible party. The RCM explained the Advance Directive Acknowledgement Form should have been signed and completed within 24 hours upon admission. The RCM confirmed R6's Advance Directive Acknowledgement Form dated 10/13/2022 was not completed. The sections on whether the resident had executed an advance directive or not, and whether the resident wished to execute one or declined should have been completed and followed-up with the resident. 2) Resident #1 (R1) R1 was admitted on [DATE], with diagnoses including major depressive disorder, generalized anxiety disorder, and suicidal ideation. R1's admission packet including the Advance Directive Acknowledgement Form was completed and signed by the resident on 01/10/2023. On 01/11/2023 at 3:49 PM, the RCM confirmed R1's admission packet was signed on 01/10/2023. The Advance Directive Acknowledgement Form for the resident which contained the information about advanced directive was completed on 01/10/2023. The RCM explained the form should have been completed within 24 hours upon admission, or by 09/27/2022, and the information about the resident's advance directive should have been filed in the resident's medical record. The RCM acknowledged obtaining the information about R1's advance directive was not done in a timely manner. 3) Resident #5 (R5) R5 was admitted on [DATE], with diagnoses including urinary tract infection and unspecified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequelae. R5's Advance Directive Acknowledgement Form documented the following: - Resident had not executed an advanced directive. - Resident wished to execute an advance directive. - Resident unable to sign. Two nurses witnessed. - Signed by two nurses on 01/11/2023. On 01/11/2023 at 3:49 PM, the RCM explained R5's admission packet was missing. The RCM confirmed the Advance Directive Acknowledgement Form for the resident which contained the information about advance directive was completed on 01/11/2023. The form should have been completed upon admission or within 24 hours upon admission and the information about R5's advance directive should have been filed in the resident's medical record. 4) Resident #60 (R60) R60 was admitted on [DATE], with diagnoses including systemic lupus erythematosus, major depressive disorder, and anxiety disorder. R60's admission packet including the Advance Directive Acknowledgement Form was completed and signed by the resident on 01/11/2023. On 01/11/2023 at 3:47 PM, R60 confirmed the resident signed the admission packet including the Advance Directive Acknowledgement Form today, 01/11/2023, which documented the resident wished to execute an advance directive. On 01/11/2023 at 3:49 PM, the RCM acknowledged R60's admission packet including the Advance Directive Acknowledgement Form was signed by the resident today, 01/11/2023. The RCM explained R60 had been refusing to sign the admission packet since admission but the resident's refusal to sign was not documented. The RCM acknowledged the refusal of the resident to sign the consents and packet including the Advance Directive Acknowledgement Form should have been documented in the Nurse's Notes. The RCM confirmed the form should have been completed within 24 hours upon admission. On 01/13/2023 at 10:12 AM, the Administrator revealed the MHT should have obtained the signatures from the resident or responsible party for the admission packet including the information about the resident's advance directive within 24 hours upon admission. The MHT should have provided the social services with a copy of the resident's Advance Directive Acknowledgement Form. The social services would have followed through with the resident within 48 hours. The Administrator explained the information about a resident's advance directive was important so the facility would be aware of the resident's wishes, made sure their wishes would be honored, and what kind of assistance they needed to obtain an advance directive. On 01/13/2023 at 10:50 AM, the Social Services Director confirmed there was no discussion made about advance directive with R6, R1, R5, and R60 during the initial social services assessment for each resident nor a follow through was made. The Social Services Director acknowledged the social services should have asked the residents about their advance directive during the initial assessment performed within 72 hours upon admission. The Social Services Director indicated all sections in the Advance Directive Acknowledgement Form should have been filled out completely.

Based on interview and document review the facility failed to ensure the facility had a registered nurse who worked at least 8 consecutive hours a day seven days a week to oversee the Licensed Practical Nurses and a designated full-time Director of Nursing (DON) for the Skilled Nursing facility (SNF). The deficient practice prevented the residents from having the services of a registered nurse and program oversight by a DON. Findings include: Review of the staffing for the SNF from 12/30/2022 to 01/12/2023 revealed the SNF was staffed mainly with morning and night shift Licensed Practical Nurses (LPN). On 01/13/2023 at 11:29 AM, the Assistant Director of Nursing (ADON) acting as the Director of Nursing (DON) indicated working in the facility from 8:00 AM to 4:30 PM (8-hour shift). The ADON indicated if the DON was present the DON would work the same hours. The ADON confirmed the DON and ADON worked for both the hospital side and the SNF side and not completely devoting their hours to the SNF for managing the LPNs. On 01/13/2023 at 9:56 AM, the Administrator acknowledged the number of hours for nursing would not be sufficient due to the DON time was divided between the skilled nursing side and the hospital side. The administrator confirmed for an eight-hour shift, the DON devoted hours for the SNF would only be four hours instead of eight. On 01/13/2023 at 1:19 PM, the Administrator acknowledged the facility DON hours and responsibilities should be revised to be compliant with the regulations.