**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and document review, the facility failed to ensure coordination of care was maintained with the referred home health agency for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for an unsafe discharge. Findings include: Resident 1 (R1) was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, muscle weakness, multiple sclerosis, difficulty walking, chronic pain and scoliosis. On 03/21/2025 at 3:53 PM via telephone, R1 denied being contacted by the home health agency within 24 to 48 hours as indicated by the facility's case manager upon discharge, and did not receive any form of care by the referred home health agency. The Discharge summary dated [DATE], documented the resident was referred to a home health agency for physical therapy, occupational therapy, and nursing services. The agency's name and phone number were recorded in the note. On 03/26/2025 at 12:27 PM, the Licensed Practical Nurse who identified as the Case Manager Director indicated the role of a case manager entailed discharge planning and coordination of care with different organizations such as home health agencies. On 03/26/2025 at 1:20 PM, the Registered Nurse who identified as the Case Manager (CM) conveyed the home health agency would typically contact the resident within 24 to 48 hours after discharge. The CM would follow-up with the home health agency within the next four weeks post discharge to ensure care was being undertaken by the home health agency. The CM indicated the follow-up phone call with home health agency was not charted in the medical record. On 03/26/2025 at 1:32 PM, the CM explained the home health care agency informed the CM the resident was seen for one week but did not open the door for a subsequent visit. The CM could not provide the time period of the visit from today's conversation with the referred home health agency. On 03/26/2025 at 4:15 PM via telephone, the Office Manager from the referred home health agency conveyed R1 was never under the agency's care. On 03/26/2025 at 4:23 PM, the CM confirmed the referred home health agency name and phone number documented in the Discharge summary dated [DATE] was correct. The CM acknowledged preexisting issues with the home health agency regarding another resident's care prior to R1's coordination of care. The CM admitted a follow-up phone call to the agency and the resident should have been made to ensure services were provided. The CM confirmed there was a breakdown in continuity of care between the facility and the home health care agency. On 03/26/2025 at 4:47 PM, the Director of Nursing (DON) confirmed a follow-up phone call to the resident and home health care agency was crucial to sustaining continued care due to the home health agency's past performance. The facility policy titled, Discharge Summary and Plan revised 10/2022 documented the post discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and includes arrangements that have been made for follow-up care and services. Residents who are discharged to a home health agency are assisted in selecting a post-acute care provider relevant and applicable to the resident's goals of care and treatment preferences. Complaint #NV00073111

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to protect a residents protected health information. This deficient practice had the potential to cause unauthorized disclosure or misuse of protected health information (PHI). Findings Include: On 03/26/2025 at 10:33 AM, a medication cart was left unattended and unsecured in front of room [ROOM NUMBER] with a 50 milliliter (ml) intravenous bag of Saline with one milligram (mg) of Meropenem (an antibiotic medication) laying on the counter of the cart. The Registered Nurse (RN) responsible for the cart, was in room [ROOM NUMBER] and had left the laptop computer screen on the cart open with the resident name, medication profile and diagnoses of room [ROOM NUMBER]'s resident exposed to the public or other residents walking by. The RN returned to the medication cart from room [ROOM NUMBER], and indicated this is only the employees fourth day and is in training. The RN explained the computer screen should have been locked to protect the residents' medical information. On 03/26/2025 in the afternoon, a Licensed Practical Nurse (LPN), stated nurses are trained to close the laptops or to place the screen on lock before walking away from a medication cart to ensure no one could view resident information. On 03/26/2025 in the afternoon, a Registered Nurse (RN), stated the nurses were trained to protect protected health information (PHI) by ensuring laptops were locked or closed to prevent others from viewing. The facility policy titled Confidentiality of Information and Personal Privacy revised in October 2017, documented the facility would protect and safeguard the confidentiality and personal privacy of all residents' personal and medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to maintain proper linen handling procedures. This deficient practice placed patients at risk for exposure to infections. On 3/26/2025 at 8:48 AM, Certified Nursing Assistant (CNA1) was observed walking into room [ROOM NUMBER] with clean linen held beneath the CNA's left arm and up against the staff member's uniform. On 03/26/2025 at 10:40 AM, two CNAs were observed walking out of the linen room while holding clean linen against their chest and uniform. Both CNAs confirmed they were transporting the clean linen to resident rooms. CNA2 acknowledged staff should hold clean linen away from their body or place clean linen in a plastic bag during transport to prevent contamination. The Assistant Director of Nursing (ADON) who had observed the incident from the nurse's station, indicated the CNAs should have transported the clean linen away from their body to prevent infection or contamination from the clean linen being against their uniform, which may not be clean. The facility policy titled Soiled Laundry and Bedding revised on 09/2022, documented clean linen is protected from dust and soiling during transport and storage to ensure cleanliness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, document review and staff interview, the facility failed to secure 2 of 4 medication carts and 1 of 2 treatment carts. This deficient practice had the potential to compromise residents' safety and cause harm from unauthorized access to controlled substances. Findings include: On 03/26/2025 at 8:21 AM, a treatment cart was left outside of the nourishment room across from the clean linen room, unlocked and unattended. The drawers were easily accessible to a resident or visitor walking by the cart. The contents inside the treatment cart were scissors, various ointments, creams and various sized dressings. On 03/26/2025 at 10:33 AM, a medication cart was left unattended and unsecured in front of room [ROOM NUMBER] with a 50 milliliter (ml) intravenous bag of Saline with a 1mg of Meropenem (an antibiotic medication) laying on the counter of the cart. The Registered Nurse (RN) was inside of room [ROOM NUMBER] without view of the medication cart. The RN indicated this is only the employees fourth day and is in training. On 03/26/2025 at 12:00 PM, in front of room [ROOM NUMBER], an unattended medication cart was open. A Registered Nurse (RN) confirmed the medication cart was unlocked and verbalized the lock system to the medication cart could potentially be broken. The RN indicated the medication cart should be locked so residents don't come around and take the medications. On 03/26/2025 at 8:23 AM, a Certified Nursing Assistant (CNA), verified the treatment cart was unlocked and stated the cart belonged to wound care and it should not be unlocked because of the safety concerns for the residents due to the cart containing ointments, scissors and gauze. On 03/26/2025 at 8:30 AM, a Registered Nurse (RN), verbalized the treatment cart was unsecured and indicated the cart stays unlocked for treatment needs and supplies. The RN voiced the key was lost and the cart should be locked because residents could have unauthorized access to the cart. On 03/26/2025 at 12:01 PM, the wound care nurse confirmed the treatment cart contains medications. On 03/26/2025 at 12:02 PM, the Assistant Director of Nursing (ADON), confirmed the medication cart in front of room [ROOM NUMBER] should have been locked. The ADON was unaware a treatment cart and medication cart located in the south hallway could not be locked. The facility policy titled Security of Medication Cart revised in April 2007, documented the cart must be securely locked at all times when out of the nurse's view. The cart must be parked against a wall with all doors and drawers facing the wall and locked before the nurse enters a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and record review, the facility failed to honor resident rights related to the use of incontinence brief and repositioning for 1 of 26 sampled residents (R252). The deficient practice placed the resident at risk for negative psychosocial outcomes and diminished comfort. Findings include: Resident 252 (R252) Repositioning: R252 was admitted on [DATE] with diagnoses including muscle weakness. Review of R252's care plan revised on 09/09/2024, identified the resident at risk for pain related to a recent back surgery. Care plan Goals included: - The resident will be comfortable using non-pharmaceutical methods to control pain daily. Care Plan interventions: - Reposition as needed for position and comfort. - The care plan indicated R252 had the potential for skin integrity impairment and required the resident to be turned and repositioned every two hours when dependent. On 09/17/24 at 9:06 AM, R252 was observed awake lying on back in bed. R252 stated they did not get up as instructed by the medical doctor (MD) following their back surgery. R252 complained they were not repositioned and stayed in the same position all day. On 09/19/24 at 12:45 PM, R252 was observed lying in bed on their back. R252 stated the incontinent brief they were wearing was wet. On 09/19/24 at 1:48 PM, a Certified Nursing Assistant who was taking care of R252, stated R252 was total max assist (Staff Dependent) and unable to reposition or toilet self. The CNA stated the resident was alert and was able to communicate needs. The CNA stated when they needed to know resident preferences, it was communicated at shift report but did not know how to check resident preferences on the computer. On 09/20/24 at 3:37 PM, the Director of Nursing (DON) stated all residents were on a pressure relieving mattress but still required repositioning. DON was notified R252 had expressed not being turned or repositioned and stated they would investigate. On 09/19/24 at 4:53 PM, R252 was observed lying in bed on back with head of bed up thirty degrees. R252's family was at the bedside and stated were concerned R252 was not being repositioned frequently. Review of the Turn and Reposition daily log from 09/06/2024 to 09/18/2024 revealed the following regarding R252's repositioning: 09/06/2024- Not repositioned on the AM and night shifts 09/07/2024- Not repositioned on PM and night shifts. 09/08/2024- Not repositioned on night shift. 09/09/2024- Not repositioned on night shift. 09/10/2024- Not repositioned on night shift. 09/11/2024- Not repositioned on PM and night shift. 09/13/2024- Not repositioned on night shift. 09/14/2024- Not repositioned on night shift. 09/15/2024- Not repositioned on night shift. 09/16/2024- Not repositioned on PM and night shift. 09/18/2024- Not repositioned on night shift. On 09/20/24 at 4:49 PM, the DON was notified R252 did not like lying on back continuously. When asked if repositioning was attempted, DON did not answer. DON agreed R252 could have been repositioned for comfort as requested by the resident. Review of the policy titled Repositioning dated May 2013, documented: 1. The purpose of the procedure was to provide guidelines for the evaluation of resident repositioning needs. 2. To aid in the development of an individualized care plan for repositioning. 3. To promote comfort for all bed or chair bound residents. 4. Repositioning was critical for a resident who was immobile or dependent upon staff for repositioning. Incontinent Brief: On 09/17/24 at 9:06 AM, R252 stated did not get up as instructed by the medical doctor (MD) following their back surgery. R252 stated toileted using an incontinent brief while in bed. R252 stated had used a bedpan while in the hospital and were ok using the incontinent brief, if it made it easier for the nurses, but added would rather not. On 09/19/24 at 1:48 PM, a Certified Nursing Assistant who was taking care of R252, stated the resident was alert and was able to communicate needs. The CNA stated R252 was incontinent and needed to wear an incontinent brief. The CNA stated did not know if R252 chose to wear the incontinent brief. The CNA stated when needed to know resident preferences, it was communicated at shift report but did not know how to check resident preferences on the computer. Review of the care plan did not identify the R252's use of incontinent brief with goals and interventions. On 09/20/24 at 4:49 PM, the DON was asked who made the decision for the resident to wear an incontinent brief, DON stated it was done if the resident was incontinent. The DON did not give an answer when asked if R252 was asked if the resident wanted to wear an incontinent brief. Review of the policy titled Urinary Incontinence dated April 2018, lacked documentation to address resident use of incontinent briefs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and document review, the facility failed to safeguard the privacy of a resident by posting the body weight on a room's board visible from the hallway for 1 of 26 sampled residents (Resident #203). The deficient practice had the potential to violate the rights of the resident to maintain health information in a private manner. Findings include Resident #203 (R203) R203 was admitted on [DATE], with diagnoses including COPD, acute hypoxic respiratory failure, and prediabetes with steroid induced hyperglycemia, sleep apnea. R203's medical record revealed R203 was alert and oriented and able to make their own decisions. On 09/17/2024 at 9:00 AM, a board in R203's room revealed the following information that was visible from the hallway: 268.4 LB (pound) 9/10/24. When R203 was asked about the weight information posted on the board, R203 conveyed it should not be visible to everyone since it was a privacy issue. On 09/18/2024 in the afternoon, a Registered Nurse confirmed the observation and proceeded to delete the weight information from the board. On 09/19/2024 in the afternoon, the Director of Nursing indicated a family member of R203 requested to document the weight on the board. The DON acknowledged posting weight information in a visible place could be considered a dignity and privacy issue. The medical record lacked documented evidence a family requested to post R203's weight information on the board. The facility policy, undated titled Dignity, documented signs indicating the resident's clinical status or care needs were not openly posted in the resident's room unless requested by the resident or family member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure a total parenteral nutrition TPN (a medical method to directly deliver essential nutrients into the bloodstream to individuals with medical conditions that prevent normal food digestion) was administered by qualified Registered Nurses for 1 of 26 sampled residents (Resident #29). The deficient practice had the potential to expose the resident to medication errors that could cause health complications. Findings include: Resident #29 (R29) R29 was admitted on [DATE], and re-admitted on [DATE], with diagnoses including severe protein-calorie malnutrition, dementia, dysphagia, and history of venous thrombosis and embolism. A physician's order dated 08/24/2024, documented an order for the TPN intravenous solution (Clinimix [trade mark]) 5 % amino acids electrolyte with calcium in 20% dextrose to be infused at 65 milliliter per hour (ml/h) for 16 hours intravenously. one time a day for malnourishment and poor oral intake. A new physician order dated 09/14/2024, documented TPN 5 % amino acids electrolyte with calcium in 15 % dextrose to be infused at 65 milliliter per hour (ml/h) for 20 hours intravenously. The medication administration record (MAR) for August 2024 and September 2024, revealed TPN was documented as administered by licensed practical nurses (LPNs) on 08/23/2024, 08/28/2024, 09/13/2024, 09/14/2024, and 09/16/2024. On 09/18/2024 at 10:00 AM, a licensed practical nurse (LPN) explained the check marks with numeric code initials documented in the MAR on the TPN orders meant the signing nurse administered the infusion. The LPN confirmed having documented with their initials in the TPN administration on 09/14/2024 but denied having administered the infusion and only monitored the infusion. The LPN verbalized only RNs could administer TPN. On 09/20/2024 in the morning, an LPN charge nurse explained LPNs had limited privilege for the intravenous administration of medications. The LPN verbalized only RNs were allowed to administer TPN. On 09/17/2024 in the afternoon, the Director of Nursing (DON) indicated LPNs were trained in TPN administration and had IV certification. The DON confirmed by reviewing the MAR that at least 5 LPNs documented in the MAR having administered TPN to R29. The DON was not aware LPN could not administer TPN per the Nevada Nursing Practice Act that specified LPN were not delegable for the administration of TPN. The review of personnel records for five LPNs (Employees #1, #2, #3, #4, #5, and #6), revealed the administration of TPN was not a task described in the LPN's job description; drug administration function.

**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 discharged to a licensed group home per physician order for 1 of 26 samples residents (Resident 161). The deficient practice had the potential to place a resident in an inappropriate care setting. Findings include: Resident 161 Resident 161 (R161) was admitted to the facility on [DATE] and discharged on 02/16/2024, with diagnoses including restless leg syndrome, generalized muscle weakness, diabetes mellitus, unspecified protein-calorie malnutrition, legal blindness, and adult failure to thrive. The facility Initial History and Physical dated 02/07/2024, documented the resident presented to the hospital after being discharged from the Emergency Department (ED) to home on [DATE] with plans to get help vs placement but went back for uncontrolled muscle spasm. Resident reported stopping Pramipexole for restless leg syndrome and whole body felt numb. Resident reported not having any food at home and could not go back home. Resident had leg tremors and anxiety when the resident arrived to the ED. Resident was recommended to be discharged to a skilled nursing facility and would need help with placement. The Assessment and Plan included the following: - Weakness debility - physical and occupational therapy - Chronic low back pain/muscle spasm - Cyclobenzaprine (muscle relaxant), discontinue Ibuprofen per resident request and restart Percocet 5-325 milligrams every 4 hours as needed - Restless Leg Syndrome - Pramipexole - Chronic hyponatremia, hypomagnesemia - monitor electrolytes and replace as needed - Failure to thrive - Hypertension - not on blood pressure medications Discharge Plan: lives alone with no stairs, resident had not been eating well because the resident had no access to meals and unable to cook for self. Resident would like assistance with placement. A Physician Progress note dated 02/08/2024, documented resident reported decreased vision that had been ongoing. Resident was alert, oriented to person, place, time. Resident calm, cooperative, appropriate mood and affect. Therapy levels as of 02/07/2024 - bed: caregiver assist, transfers: moderate assist, gait: 5 feet front wheeled walker with moderate assist, lower body dressing: maximum assist, toileting: moderate assist. A Care Conference note dated 02/09/2024, documented an interdisciplinary team (IDT) meeting with resident. Resident reported having no place to discharge to at this time. Case management provided options. Resident desired a group home in a specific area of town. Resident was currently receiving physical therapy (PT)/occupational therapy (OT) services. Bed mobility Minimum assist, Transfer Moderate assist at this time. No issues or concerns at this time in regard to care at facility, IDT would continue to monitor provider support and assist as needed. A Physician Progress note dated 02/09/2024, documented a request for the facility social worker and the insurance social worker to assist the resident with placement options. A Physician Progress note dated 02/13/2024, documented insurance social worker referral placed as the resident reported not finding a group home and had paid this month's rent for the resident's apartment. Resident was engaged in conversations about discharge and agreed the skilled nursing facility was not the correct place for the resident. The resident was concerned about a safe discharge location. This information had been forwarded to the insurance social worker. Anticipated discharge on [DATE]. Discharge medication list sent to the pharmacy for discharge reconciliation. A Physician Progress note dated 02/14/2024, documented discussed discharge planning with the resident. Resident was agreeable with discharge to a group home with hospice services. Social worker/case manager at the facility had participated in discharge planning. A Physician Progress note dated 02/15/2024, documented the resident was admitted to the facility for rehabilitation services and pain management. Resident had participated in therapy services and was cleared for discharge with 24/7 assistance at a group home. The resident was agreeable moving into a group home. The resident's family was able to assist with the group home expenses for the next two weeks. The resident was evaluated and accepted to a group home. Hospice services were requested by the resident, and the resident would be discharged to a group home on hospice services. Therapy levels as of 02/14/2024 were bed mobility: supervised, transfers: standby assist, gait: 40 feet front wheel walker standby assist, upper/lower body dressing: contact-guard assist/standby assist, toileting: moderate assistance. Resident was discharging to a group home with hospice services. Good family support. The resident had adequate access to a safe home environment. The resident was aware the home health nurse, home physical therapy, case management and social worker will be in contact once discharged . Resident verbalized an understanding of all discharge instructions and questions answered. A Case Management note dated 02/16/2024, documented resident would be discharged to a group home with hospice per resident and family request. No other questions and concerns at this time. The Discharge summary dated [DATE], documented the resident was discharged to a home (address was documented). A review of the Bureau of Health Care Quality and Compliance Health Facility Locater website revealed there was no licensed group home located at the address the resident was discharged . On 09/20/2024 in midmorning, the facility Case Manager indicated the resident was alert and oriented and chose to go the discharge address. The Case Manager did not check to determine if the home the resident was discharged to, was a licensed group home and left it up to the insurance social worker to ensure the resident was discharging to a licensed group home. The medical record lacked documented evidence the resident was discharged to a licensed group home per physician order or the discharge plan was altered based on the resident not wanting to go to a group home and instead wanted to go to a private residence with hospice services. Complaint NV00071314

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and document review, the facility failed to ensure an arm brace and sling were placed for a resident with arm fracture for 1 of 26 sampled residents (Resident #98). The deficient practice could lead to complications such as improper healing, increased pain, reduced mobility, increased risk of further injury, and nerve damage. Fundings include: Resident #98 (R98) R98 was admitted on [DATE], with diagnoses including right humerus fracture. On 09/17/24 in the morning, R98 was lying in bed with a visible bandage on the right upper arm. R98 indicated had suffered a fracture and was experiencing significant pain. R98 was holding the right arm with the left hand and explained should have been wearing a brace to immobilize the fracture but had been removed the previous night by a staff member and could not locate it. R98 verbalized the brace helped to improve the pain caused by the fracture. A physician order dated 09/05/2024, indicated right arm [NAME] brace and a sling with abduction pillow to be used at all times for a right humeral fracture. (A [NAME] brace is a plastic brace used to stabilize humeral shaft fractures, allowing elbow freedom and movement of forearm and hand). Care plan dated 08/30/2024, revealed R98 had fracture of the right arm. Approaches included [NAME] brace and sling with abduction pillow on at all times. Physician progress noted dated 09/12/2024, revealed R98 was seen and examined by an orthopedist who placed a [NAME] brace and abduction pillow to R98. After the placement of the brace, R98 reported improvement in pain. On 09/18/2024 at 2:45 PM, the Physical Therapy (PT) Director indicated an order for a [NAME] brace and sling was obtained from orthopedist and should be placed all the time until 10/14/2024. The PT Director confirmed the brace should have been placed all the time. The facility undated policy titled Assistive Devices and Equipment, documented the facility should maintain and supervise the use of assistive devices following recommendations dictated by the resident's care plan.

Based on observation and interview, the facility failed to maintain sanitary conditions in the kitchen. The deficient practice could potentially expose residents to foodborne illnesses. Findings include: On 09/17/24 in the morning, an inspection was conducted with the kitchen manager in the kitchen area. The following issues were identified: A cook was preparing meal to be distributed to the residents. The cook had facial hair but was not wearing a beard cover. The top surface of the oven was visibly soiled with greasy matter and dust. The top surface of the dish washer machine was visibly soiled with yellowish debris and dust. An open bottle of milk was open and not dated in the walk-in refrigerator. An open milk carton was on the floor under a rack with dairy products and the milk had spilled out in the walking refrigerator. A 4 pounds (Lbs.) can of tuna and two 6 Lbs. cans of pineapple chunk were in the dry storage visibly dented. The lid of the ice machine had white stains and the inside rim of the machine was dirty and stained. The kitchen manager indicated the ice machine was cleaned two weeks ago and a service order to be checked was sent to the Maintenance Department. On 09/17/2024 at 10:00 AM, the kitchen manager explained the oven was scheduled to be cleaned on a weekly basis. The kitchen manager acknowledged the oven, and the dish washer should have been cleaned more often if they were dirty. On 09/19/2024 at 11:40 AM, during the tray line observation, a fan was placed on the floor blowing air to the food preparation area. The kitchen manager explained the fan was used to dry the floor and acknowledged the fan should not have been placed in the preparation area due to potential food contamination with dust. During the tray line observation, a cook with a beard was not wearing a beard cover while setting up meal trays. The Manager confirmed the observation and acknowledged beard cover should have been worn.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review and interview, the facility failed to ensure a resident who lacked decisional capacity did not acknowledge receipt of and sign information acknowledgment sheets provided as a part of the facility's admission paperwork for 1 of 20 sampled residents (Resident (R) 16). This failure had the potential to undermine the rights and best interests of the protected person and the guardian's rights when making decisions for the resident's options for care and treatment needs. Findings include: R16 was admitted on [DATE] with diagnoses including dementia. Review of R16's admission paperwork revealed a 37-page document that included the following: - A cover letter identified as an Informational Report. - A page titled Information Sheets Acknowledgement which documented R16 indicated being informed and provided with written information sheets on listed treatments, devices or protocols being used for resident care. - A page titled Diagnosis Information Sheets Acknowledgement, which documented R16 indicated being informed and provided written information sheets on listed conditions of the resident. - The remaining pages 4 -37 entailed information identified in the acknowledgements. Both acknowledgment pages were time stamped and e-signed with initials indicating the signature on 08/05/2023. The documents were subsequently e-signed by the admission Office Assistant. A Hospital Discharge summary dated [DATE] documented the resident was oriented to person, not oriented to place and time. An Admission/re-admission Summary Note dated 08/03/2023 documented the resident had diagnoses including dementia. A Physician Progress note dated 08/04/2023 documented at baseline, the resident was alert and oriented times one (1). The resident was unable to provide history or answer questions appropriately. A History and Physical dated 08/04/2023 documented a diagnosis of dementia and indicated at baseline, the resident was alert and oriented x1. The Physician Orders for Life-Sustaining Treatment (POLST) form, validated on 08/04/2023 documented the resident lacked decisional capability. A Psychiatric Evaluation/Consult dated 08/09/2023 documented, during the encounter the resident was pleasant but confused at baseline, a poor historian with severe forgetfulness and unable to recall past psychiatric histories. Resident alert, oriented one out of four, but was able to respond to some questions regarding present symptoms. The clinical record revealed a Certificate of Incapacity and the Need for Guardianship signed and dated 08/17/2023 by a physician. On 09/29/2023 in the evening, the Admission's Assistant explained would meet with the resident and try to assess if the resident was alert and oriented. If not, would contact the family. The paperwork would then be sent to the family by email for signature or a phone call would be made to the family to complete the paperwork. The Admission's Assistant was shown the admission paperwork R16 had acknowledged and signed on 08/05/2023; and the POLST form validating R16 lacked decisional capability dated 08/04/2023. The Admission's Assistant acknowledged not speaking with the resident's assigned nurse regarding the resident's capacity or ability to consent prior to having the resident acknowledge and sign the receipt of the admission paperwork.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and interview, the facility failed to ensure a resident who was not clinically appropriate to self-administer medications, did not receive an ordered medication by a family member for 1 of 20 sampled residents (Resident #113). The deficient practice placed the resident at risk of not receiving appropriate medications. Resident #113 Findings include: Resident #113 was admitted on [DATE], with diagnosis including sepsis, hemiplegia, and end stage renal disease. On 09/27/23 at 10:06 AM, the resident's husband was observed assisting the resident to drink an orange yellowish colored liquid in a clear plastic cup. The resident's husband reported was giving the resident their medication. A Nursing Self-Administration of Medication Observation dated 09/15/23, lacked evidence the resident was able to self-administer medication and documented no further assessment was required. A physician order dated 09/15/23, documented Sorbitol Solution 70%, 15 milliliter (ml), every 12 hours as needed for constipation. On 09/28/23 at 09:44 AM, a Licensed Practical Nurse (LPN) reviewed the resident's medication orders and confirmed the medication in the cup was Sorbitol Solution. The LPN acknowledged the medication was to be taken in front of the nurse when it was given to the resident. The LPN explained the mediation was not to be left with the resident. On 09/29/23 at 12:07 PM, the Director of Nursing (DON) confirmed the Self-Administration of Medication Observation dated 09/15/23, did not indicate the resident was able to self-administer medication. The DON confirmed the resident was not able to self-administer medication due to the resident's medical status. A facility policy titled Self-Administration of Medications revised February 2022, revealed the interdisciplinary team would assess each resident's cognitive and physical abilities to determine whether self-administration of medications was safe and clinically appropriate for the resident. If the team determined a resident cannot safely self-administer medications, the nursing staff would administer the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview, record review and document review, the facility failed to create a baseline care plan for the care and monitoring of a resident with post knee surgery and a resident with lower extremity edema for 2 of 20 sampled residents (Resident 207 and 210). The deficient practice had a potential for residents not to receive appropriate care interventions based on their diagnoses and assessments. Findings include: Resident 207 (R207) R207 was admitted on [DATE], with diagnoses including after care following joint replacement therapy and osteoarthritis of the left knee. On 09/27/2023 at 9:56 AM, R207 was observed having pain at the surgical incision of the left knee. The surgical knee had a slight degree of edema and was lying flat on the bed. R207 indicated requesting ice packs provided from the hospital sitting on top of the bedside table which needed to be frozen, and the facility staff indicated had no way in freezing the ice packs. A physician progress note dated 09/25/2023, documented an order for ice machine to use for pain control, every six hours as needed for the next week. Assist patient with repositioning self every two hours while awake, off load bony prominences, and provide prompt incontinence care as needed. R207's nursing progress notes documented resident was experiencing pain and given as needed pain meds. Pain levels were re-assessed and at times levels would still reflect a degree of pain left. On 09/28/2023 at 12:15 PM, the admission registered nurse confirmed R207's baseline care plan interventions lacked person-centered care corresponding to the resident's admission diagnosis and its appropriate interventions. The admission nurse indicated the baseline care plan should have been created with interventions for R207's post knee surgery care. Resident 210 (R210) R210 was admitted on [DATE], with diagnoses including aftercare following surgery of the digestive system and congestive heart failure (CHF). On 09/27/2023 at 10:19 AM, R10's bilateral lower extremities were observed with significant edema. R10's lower extremities were lying flat on the bed and not elevated. R10 indicated edema was one of the problems which brought the resident to the hospital. R10 indicated receiving diuretics (water pill) prior to admission to the facility. An Admission/re-admission Summary Note dated 09/21/2023, documented by a registered nurse. Diagnosis of chronic bilateral lower extremity edema. A Nursing - Comprehensive Skin Evaluation/assessment dated [DATE], documented by the wound care nurse. No shortness of breath present, edematous swelling on bilateral lower extremities. Will continue to monitor. R10's clinical record lacked documented evidence of a physician's orders and a base line care to address resident's edema. On 09/28/2023 at 12:15 PM, the admission registered nurse reviewed the diagnoses from the hospital records and confirmed R207 had a medical history of CHF. The nurse indicated the diagnosis should have been entered in the Electronic Health Record (EHR). The nurse confirmed edema was identified during two separate types of admission assessments and a base line care plan should have been created with interventions for elevation and monitoring of progression of edema. The physician should have been notified to receive an order for interventions to be entered into the EHR and medication administration record so nursing would be alerted to complete the task. On 09/28/23 at 2:32 PM, the Director of Nursing (DON) confirmed the residents' diagnosis and indicated admitting problem interventions should have been incorporated into the residents' base line care plan for both R207 and R210. The facility policy titled Care Plans - Baseline (undated), documented the baseline care plan should include instructions needed to provide effective, person-centered care of the resident, which may include the following: a) initial goals based on admission orders and discussion with the resident b) physician's orders c) dietary orders d) therapy services e) social services and f) PASARR recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to ensure care plan revisions were completed upon readmission of a resident (Resident #13). The deficient practice placed the resident at risk for not receiving appropriate care upon readmission. Findings include: Resident #13 Resident #13 was admitted on [DATE] and readmitted on [DATE], with diagnosis including encephalopathy, urinary tract infection, and chronic obstructive pulmonary disease. A Nursing Admission/readmission Evaluation assessment dated [DATE], documented Resident #13 was admitted from a hospital with diagnoses including hematuria and anemia. A Care Plan dated 09/26/23, lacked documented evidence anemia was added as a care area for the resident. On 09/28/23 at 02:02 PM, the Director of Nursing (DON) confirmed the resident's care plan was not updated upon readmission to include anemia. The DON acknowledged based on facility policy, the resident's comprehensive care plan should have been updated to include anemia which was a significant change. The facility policy titled Care Plans, Comprehensive Person Centered revised March 2022, documented care plan interventions were to be chosen after careful consideration of the relationship between the resident's problem areas and their causes. Assessments of residents are ongoing and care plans were to be revised as information about the residents and the resident's conditions change. The interdisciplinary team was to review and update the care plan when there has been a significant change in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure care plan revisions were completed to update dialysis transportation arrangements for a resident (Resident #113). The deficient practice placed the patient at risk for not having appropriate transportation for out of facility treatments. Resident #113 Findings include: Resident #113 was admitted on [DATE], with diagnosis including sepsis, hemiplegia, and end stage renal disease. On 09/27/23 at 12:20 PM, the resident and husband reported the resident waited 8 hours at the dialysis clinic to be picked up and taken back to the facility due to transportation issues. A physician order dated 09/21/23, documented Resident #113 would be transported by Transport Company 1 to and from the dialysis center. A Care Plan revision dated 09/18/23, documented the resident would be transported to the dialysis center by Transport Company 1. A Dialysis Information form undated, documented the resident would be transported to the dialysis center by Transport Company 2. On 09/28/23 at 01:50 PM, the Director of Nursing (DON) reported Resident #113 was originally scheduled for dialysis transportation with another transport company, then with Transport Company 1 and the current transportation company was Transport Company 2. The DON explained the change of transportation companies was due to the resident having been left at dialysis for an extended period of time. On 09/29/23 at 01:38 PM, The Case Manager acknowledged the care plan, the order and appointment book were not updated to reflect the new transportation company information. The Case Manager confirmed Transport Company 2 was the new transportation company since 09/23/23. The Case Manager acknowledged the information needed to be updated. On 09/29/23 at 12:44 PM, a Licensed Practical Nurse (LPN) confirmed both the clinical record and the appointment book located at the nurse's station documented Transport Company 1 as the current transportation company for Resident #113. The LPN acknowledged the information in the clinical record and the appointment book were not updated to reflect the new transportation company. The facility policy titled End-Stage Renal Disease, Care of a Resident with revised September 2010, documented the resident's comprehensive care plan was to reflect the resident's needs related to ESRD/dialysis care. The facility policy titled Care Plans, Comprehensive Person Centered revised March 2022, documented care plan interventions were to be chosen after careful consideration of the relationship between the resident's problem areas and their causes. Assessments of residents are ongoing and care plans were to be revised as information about the residents and the resident's conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 32 (R32) R32 was admitted on [DATE], with diagnoses including abnormalities of gait and mobility and muscle weakness. A Physician order dated 06/02/2023, documented Tamsulosin Hydrochloride oral capsule 0.4 milligrams (mg) to give 1 capsule by mouth in the morning at 9:00 AM for benign prostatic hyperplasia. On 09/28/2023 at 7:23 AM, a Licensed Practical Nurse (LPN) prepared the medications except the Tamsulosin. The LPN confirmed Tamsulosin was not available during the medication pass and would call the pharmacy. On 09/29/2023 at 10:56 AM, the LPN explained was unaware the Tamsulosin was not available during the medication pass. The LPN indicated the pharmacy should have been notified when the Tamsulosin supply was running low, ensuring a sufficient quantity of the medication was available. On 09/29/2023 at 9:10 AM, the Director of Nursing (DON) indicated the process of ordering medication was to request if there were a few supplies left to ensure medications were available during the medication pass. The nurses were expected to pay attention and promptly request the medication to prevent delays in administration. On 09/29/2023 at 9:25 AM, the pharmacist indicated the process of ordering medication was to call or fax the order to the pharmacy for refill. The pharmacist indicated the bubble pack had a sticker for refill requests, and if there were a few capsules left, the facility was expected to fax the order. The pharmacist indicated the facility called for refills on 09/28/2023, and Tamsulosin was delivered the same day. The pharmacist indicated Tamsulosin was delivered on the following dates: -08/13/2023, 14 capsules -09/04/2023, 14 capsules -09/28/2023, 14 capsules The Medication Administration Record dated 09/28/2023, documented the Tamsulosin was not administered due to its unavailability. Resident 153 (R153) R153 was admitted on [DATE], with diagnoses including dementia, urinary tract infection, and hypertension. A Physician order dated 09/23/2023, documented Glipizide extended-release oral tablet 5 mg to give 2.5 mg by mouth daily for diabetes mellitus. On 09/28/2023 at 7:39 AM, the LPN prepared the medications except for Glipizide. The LPN confirmed the Glipizide was not available. On the MAR dated 09/28/2023, the LPN confirmed Glipizide was not administered due to its unavailability. The LPN indicated the staff were expected to ensure residents' medications were available during medication passes. On 09/29/2023 at 9:10 AM, the Director of Nursing (DON) indicated the process of ordering medication was to request if there were a few supplies left to ensure medications were available during the medication pass. The DON confirmed the Glipizide was still active medication but not available during the medication pass, and it was missed. The DON indicated the hospice company would deliver the Glipizide, as the resident was a hospice respite resident. A facility policy titled Administering Medications dated 04/2019, documented medications were administered in a safe and timely manner and as prescribed. Medications were administered within one hour of the ordered time. Resident 198 (R198) R198 was admitted on [DATE], with diagnoses including schizophrenia and bipolar disorder. On 09/28/2023 at 08:11 AM, during medication pass a Licensed Practical Nurse (LPN) had prepared R198's 11 medications. The LPN documented on the Medication Administration Record (MAR), indicating the medications had been administered, and then clicked the submit button. The LPN then proceeded to administer the medications to R198. On 09/28/2023 in the morning, the LPN confirmed the Medication Administration Record had been documented that R198's medications were administered before they were actually given to the resident. The LPN explained it was best practice to document after ensuring the resident had successfully swallowed the medication in order to assess the resident's response. On 09/28/2023 at 11:00 AM, the DON indicated the nurses were expected to document in the MAR after ensuring the medications had been successfully administered. Based on observation, interview, record review and document review, the facility failed to ensure: 1) abnormal assessments were conveyed to the primary physician for 1 of 20 sampled residents (Resident 203), the deficient practice prevented appropriate care interventions implemented for a resident with edema; 2) medication refusals and questionable ordered medications were conveyed to the primary physician for 1 of 20 sampled residents (Resident 210), the deficient practice had a potential for an unnecessary medication to be administered; 3) medication was available during the medication pass for 1 of 20 sampled residents (Resident 32), and 4) a Medication Administration Record (MAR) was not signed off before medication administration for 1 of 20 sampled residents (Resident 198). The deficient practice led to delayed or missed medications which could have led to potential worsening of residents' health conditions. Resident 203 (R203) R203 was admitted on [DATE] with diagnoses including aftercare following surgery of the digestive system and acute appendicitis with perforation. On 09/27/2023 at 11:33 AM, R203 indicated being a non-smoker and for two days in a row a nurse came in to apply a nicotine patch. The resident had refused the medication and indicated to the nurses not being a smoker prior to admission. The resident indicated feeling fortunate having the correct mentation to ask otherwise an undesired medication could have been provided. A physician's order dated 09/21/2023 at 9:00 AM, documented Nicotine patch 24 Hour 21 milligrams/24 hours, apply 1 patch transdermally, one time a day for Smoking Cessation for 6 weeks and remove per schedule. The order was discontinued on 9/24/2023. A completed Nursing - Admission/readmission Evaluation/assessment dated [DATE], documented under section C. Social/Other History: 1. Uses tobacco / smoker? Answer: NO R203's medication administration record (MAR) for the Nicotine patch was documented as #9 -see nurses notes or #2 - Refused. Review of all nursing progress notes revealed no entries for the physician being informed of the refusals. The nursing progress notes did not reflect any documentation regarding as to what had happened to the Nicotine patch refusal event. The physician's progress notes did not reflect any history of smoking or any need for smoking cessation program. There was no documentation the physicians were made aware of the refusal of the nicotine patch medication. On 09/28/23 at 10:53 AM, a Registered Nurse (RN) indicated #9 entry would require an actual entry of what transpired during the administration of the medication. Any situation requiring physician notification would be completed and documented on the progress notes, A #2 is a refusal of which a notification to the physician was required and documented the response. On 09/29/23 at 10:00 AM, the Director of Nursing (DON) indicated the patch was an actual physician order entry from a provider and was verified by a charge nurse. The DON confirmed and agreed there was no entries for the refusal and there was no mention resident was a smoker and the need for a smoking cessation medication on the physician's progress notes. The DON agreed the physician should have been notified and questioned regarding the medication. On 09/29/23 at 10:15 AM, the charge nurse acknowledged verifying the order. The charge nurse indicated giving the first dose and the resident refusing the dose. The charge nurse indicated a call should have been placed to the physician to question the order since R203 did mention not being a smoker. Documentation of the refusal and corresponding interventions should have been completed and documented. The facility policy titled Medication Therapy revised April 2007, documented each resident's medication regimen shall include only those medications to treat exiting conditions and address significant risks. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and treatments. All medication orders will be supported by appropriate care processes and practices. The facility policy titled Documentation of Medication Administration revised November 2022, documented documentation of medication administration includes, as a minimum: f. reason(s) why a medication was withheld, not administered, or refused. Resident 210 (R210) R210 was admitted on [DATE], with diagnoses including aftercare following surgery of the digestive system and congestive heart failure (CHF). On 09/27/2023 at 10:19 AM, R10's bilateral lower extremities were observed with significant edema (swelling). R10's lower extremities were lying flat on the bed and not elevated. R10 indicated edema was one of the problem which brought the resident into the hospital. R10 indicated receiving diuretics (water pill) prior to admission to the facility. An Admission/re-admission Summary Note dated 9/21/2023, documented by a registered nurse, included diagnosis of chronic bilateral lower extremity edema. A Nursing - Comprehensive Skin Evaluation/assessment dated [DATE], documented by the wound care nurse. Included no shortness of breath present, edematous swelling on bilateral lower extremities. Will continue to monitor. R10's medical record lacked documented evidence of a physician notification and care interventions to address resident's edema. On 09/28/2023 at 12:15 PM, the admission registered nurse reviewed the diagnoses from the hospital records and confirmed R207 had a medical history of CHF. The nurse indicated the diagnosis should have been entered in the Electronic Health Records (EHR). The nurse confirmed edema was identified during two separate types of admission assessments and the physician should have been notified to obtain care interventions to treat and prevent the progression of edema. Any ordered interventions should be entered into the EHR and medication administration record so nursing would be alerted to complete the task. On 09/28/23 at 2:32 PM, the Director of Nursing (DON) confirmed a resident edema assessment should have been reported to the physician and the necessary care orders should have been obtained. The facility policy titled Assisting the Nurse in Examining and Assessing the Resident revised September 2010, documented the primary purpose of assessing the resident is to gather detailed information that will help developed a plan of care that is appropriate for the resident. Accurately documenting and reporting observations provides the interdisciplinary team with information that helps tailor the care plan to the specific needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review the facility failed to ensure a resident with a swallowing precaution received feeding assistance as ordered (Resident #3). The deficient practice placed a resident at risk for choking or aspiration of food. Resident #3 Findings include: Resident #3 was admitted on [DATE], with diagnosis including fracture of sacrum, Parkinson's disease, and dysphagia (swallowing difficulties). A Nutritional Risk assessment dated [DATE], documented one on one feeding. Speech Therapy progress notes dated 08/31/23, documented a recommendation of puree texture thick liquid diet with one on one assistance. An order dated 09/12/23, documented one on one feeding every shift. On 09/27/23 at 8:39 AM, Resident #3 was observed lying in bed awake. The words swallowing precautions were written on the board in the room. An untouched breakfast food tray was on a bedside table against the wall near the room door and away from the resident's reach. A staff member came in the room and reported they were there to pick up the tray. The staff member mentioned the tray was untouched and left without having provided or offered the resident feeding assistance. A second staff member approached this surveyor and said they would be assisting the resident to eat. The staff member left the room approximately two minutes later without feeding the resident. On 09/29/23 at 12:40 PM, a Certified Nursing Assistant (CNA) was observed at the opposite end of the dining room where Resident #3 was located. The CNA reported Resident #3 needed set up assistance and the CNA would monitor the resident during the meal and provided assistance as needed. On 09/29/23 at 12:44 PM, Resident #3 was observed eating in the dining room without assistance. The resident was picking up the food with the tip of their fingers on their right hand and placing it in their mouth in a slow and labored manner. On 09/29/23 at 02:49 PM, a Registered Nurse (RN) Supervisor, reported if Resident #3 was in the dining area the resident would be able to feed themself and if the resident was in their room, they needed feeding assistance. The RN Supervisor was unable to explain why Resident #3 needed feeding assistance in their room and not the dining area. The RN Supervisor then confirmed the resident had an order for one on one feeding assistance. The RN Supervisor acknowledged the order should have been followed and the resident should have been assisted to eat at all times regardless of where the resident was eating. The RN confirmed the order for feeding assistance was in place because the resident was at risk for aspiration. A facility policy titled Assistance with Meals revised March 2022, documented residents would receive assistance with meals in a manner that met the individual needs of each resident. The facility staff was to help residents who require assistance with eating. Residents who could not feed themselves would be fed with attention to safety, comfort, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure Oxygen orders were followed or clarified for 2 of 20 sampled residents (Residents 10 and 12). This deficient practice could potentially lead to a risk of inadequate or excessive Oxygen levels and complications in the residents' medical conditions. Findings include: Resident 10 (R10) R10 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The Brief Interview of Mental Status (BIMS) documented a score of 13/15, which indicated R10's cognitive status was intact. A Physician order dated 09/06/2023, documented O2 at 2 liters per minute (LPM) via nasal cannula continuously for shortness of breath and COPD. A Care Plan revised 07/25/2023, documented R10 had COPD and respiratory failure. The interventions included administering O2 at 2 LPM via nasal cannula. Monitor O2 saturation and document. On 09/27/2023 at 9:50 AM, R10 lay in bed, verbally alert and oriented. O2 was on at 3.5 LPM via nasal cannula, and tubing was undated. R10 indicated the O2 was continuous and unaware of how many liters per minute. On 09/28/2023 at 7:38 AM, R10 was in bed, and O2 was on at 4 LPM. R10 had no shortness of breath. On 09/28/2023 at 2:15 PM, a Licensed Practical Nurse (LPN) confirmed R10's O2 was on 4 LPM continuously. The LPN verified the O2 orders and indicated the O2 order was to administer 2 LPM and not 4 LPM. There was a titration order during or after activity. There were multiple orders of the O2 orders transcribed. The LPN indicated was unaware R10's O2 was titrated, and the activity staff were not allowed to adjust R10's O2. The LPN indicated the O2 orders were not followed and should have been clarified. On 09/29/2023 at 9:10 AM, the Director of Nursing (DON) indicated the utilization of O2 required an order. The DON indicated to ensure safety, the nurses were expected to verify and follow the O2 order during rounds, medication passes, and during the provision of care. The DON confirmed the O2 orders were confusing and should have been clarified. Resident 12 (R12) R12 was admitted on [DATE] and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia and atelectasis. The BIMS, dated 09/01/2023, documented a score of 12/12, which indicated R12's cognitive status was intact. A physician order dated 09/06/2023, documented Oxygen at 2 liters per minute via nasal cannula continuously for shortness of breath and acute hypoxic respiratory failure. A goal was to maintain O2 saturation greater than 90 percent (%). On 09/27/2023 at 2:56 PM, R12 lay in bed, awake and verbally oriented. R12 was on O2 at 5 LPM via nasal cannula. R12 had no signs or symptoms of respiratory distress. On 09/28/2023 at 7:30 AM, R12's O2 was at 5 LPM via nasal cannula; there was no shortness of breath. On 09/28/2023 at 1:45 PM, R12 lay in bed with eyes closed. R12's O2 was on at 5 LPM via nasal cannula continuously. On 09/28/2023 at 2:15 PM, the LPN confirmed R12's O2 was on 5 LPM continuously. The LPN verified the O2 orders and indicated the O2 should have been at 2 LPM and not 5 LPM. The LPN explained there was a titration order during or after activity. The LPN indicated there were multiple orders transcribed and were confusing. The LPN indicated R12's O2 orders were not followed and should have been clarified. On 09/29/2023 at 9:10 AM, the DON confirmed R12's O2 orders were confusing and should have been clarified. The DON indicated to ensure safety, the nurses were expected to verify and ensure the O2 order was followed during rounds, medication passes, and during the provision of care. A facility policy titled Oxygen Administration dated 10/2010, documented to provide guidelines for safe O2 administration, verify there was a physician order and review the physician's order. Review the resident's care plan.

**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 blood pressure ordered parameters were followed for the administration of the diuretic medication for 1 of 20 sampled residents (Resident 152). This deficient practice could potentially have led to hypotension, inadequate medication management and an increased risk of adverse reactions or treatment ineffectiveness. Findings include: Resident 152 (R152) R52 was admitted on [DATE], with diagnoses including depression, and peripheral autonomic neuropathy. A physician order dated 09/12/2023, documented Furosemide Oral Tablet 40 milligrams (mg) to give 1 tablet by mouth two times a day for lower extremity swelling. Hold if systolic blood pressure (SBP) is less than (<) 110 and heart rate (HR) < 60 beats per minute (BPM). The Medication Administration Record dated 09/12/2023, documented the Furosemide was administered on following occasions when SBP was lower than ordered parameters: -09/17/2023, SBP was 106 (BP 106/70) -09/23/2023, SBP was 103 (BP 103/69) -09/26/2023, SBP was 107 (BP 107/61) On 09/29/2023 at 3:45 PM, a Licensed Practical Nurse (LPN) confirmed that Furosemide had been ordered with specific parameters, and it was necessary to follow these instructions. The LPN explained if the resident had a Furosemide order with parameters, the blood pressure should have been taken first before the medication was administered. On 09/29/2023 at 4:50 PM, the Director of Nursing (DON) confirmed the prescribed blood pressure parameters for administering Furosemide to R152 had not been adhered to. The DON indicated it was expected for the nurses to strictly adhere to the ordered parameters in order to prevent further hypotension, especially when R152's systolic blood pressure fell below 110. The DON indicated the administration of Furosemide was unnecessary when R52's blood pressure was low and should have been held. A facility policy titled Medication Therapy dated 04/2007, documented all medication orders would be supported by appropriate care processes and practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure a consent for psychotropic medication was obtained for 1 of 20 sampled residents (Resident 25). The deficient practice prevented a resident/resident's representative from their right to be informed. Findings include: Resident 25 (R25) R25 was admitted on [DATE] and was discharged on 09/08/2023. R25 had diagnoses including major depressive disorder and anxiety disorder. R25 had a physician order for clonazePAM (Clonazepam) Oral Tablet 1 milligram, Give 1 milligram via G-Tube (a feeding tube) three times a day for anxiety manifested by verbalization of feeling anxious. Start on 9/5/2023 at 9:00 PM, to be discontinued on 9/28/2023. On 09/29/2023 at 3:20 PM, a Registered Nurse and a Licensed Practical Nurse reviewed the medical record for R25 and confirmed there was no consent obtained for Clonazepam. The nurses indicated obtaining a consent for all ordered psychotropic medications was mandatory. Consents should be discussed with the resident or resident representative with the complete discussion including the purpose of the medication with its corresponding risks and adverse reactions. On 09/29/2023 at 3:30 PM, the Director of Nursing (DON) was made aware of the consent not being found on file in R25's medical record. The DON indicated will try to locate the document as possibly the consent was still not scanned by medical records. At 4:39 PM, the DON confirmed the consent for Clonazepam could not be located and a good possibility existed it was not. The DON acknowledged the consent should have been obtained and maintained on file. The facility policy titled Antipsychotic Medication Use revised July 2022, documented residents and/or resident representative's will be informed of the recommendations, risks, benefits, purpose, and potential adverse consequences of a psychotropic medication use.

**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 two errors were identified with 28 opportunities observed, resulting in an error rate of 7.14%. 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: A facility policy titled Adverse Consequences and Medication Errors dated 02/2023, documented a medication error involved the omission of a drug order, where a drug was ordered but not administered. A facility policy titled Administering Medications dated 04/2019, documented medications were administered in a safe and timely mannered, and as prescribed. Medications were administered within one hour of the ordered time. Resident 32 (R32) R32 was admitted on [DATE], with diagnoses including abnormalities of gait and mobility and muscle weakness. A Physician order dated 06/02/2023, documented Tamsulosin Hydrochloride oral capsule 0.4 milligrams (mg) to give 1 capsule by mouth in the morning at 9:00 AM for benign prostatic hyperplasia. A Care Plan dated 09/28/2023, documented R31 was at risk for impaired complications with urinary system related to benign prostatic hyperplasia. The interventions included was to administer the medications as ordered. On 09/28/2023 at 7:23 AM, a Licensed Practical Nurse (LPN) prepared the medications except the Tamsulosin. The LPN confirmed Tamsulosin was not available during the medication pass and would call the pharmacy. On 09/29/2023 at 10:56 AM, the LPN explained was unaware the Tamsulosin was not available during the medication pass. The LPN indicated the pharmacy should have been notified when the Tamsulosin supply was running low, ensuring a sufficient quantity of the medication was available. On 09/29/2023 at 9:10 AM, the Director of Nursing (DON) indicated the process of ordering medication was to request if there were a few supplies left to ensure medications were available during the medication pass. The nurses were expected to pay attention and promptly request the medication to prevent delays in administration. On 09/29/2023 at 9:25 AM, the pharmacist indicated the process of ordering medication was to call or fax the order to the pharmacy for refill. The pharmacist indicated the bubble pack had a sticker for refill requests, and if there were a few capsules left, the facility was expected to fax the order. The pharmacist indicated the facility called for refills on 09/28/2023, and Tamsulosin was delivered the same day. The pharmacist indicated Tamsulosin was delivered on the following dates: -08/13/2023, 14 capsules -09/04/2023, 14 capsules -09/28/2023, 14 capsules The Medication Administration Record (MAR) dated 09/28/2023, documented the Tamsulosin was not administered due to its unavailability. Resident 153 (R153) R153 was admitted on [DATE], with diagnoses including dementia, urinary tract infection, and hypertension. A Physician order dated 09/23/2023, documented Glipizide extended-release oral tablet 5 mg to give 2.5 mg by mouth daily for diabetes mellitus. A Care Plan dated 09/28/2023, documented R153 had diabetes mellitus. The interventions which included was to administer the medications for diabetes as ordered. On 09/28/2023 at 7:39 AM, the LPN prepared the medications except for Glipizide. The LPN confirmed the Glipizide was not available. The MAR dated 09/28/2023, the LPN confirmed Glipizide was not administered due to its unavailability. The LPN indicated the staff were expected to ensure residents' medications were available during medication passes. On 09/29/2023 at 9:10 AM, the Director of Nursing (DON) indicated the process of ordering medication was to request if there were a few supplies left to ensure medications were available during the medication pass. The DON confirmed the Glipizide was still active medication but not available during the medication pass, and it was missed. The DON indicated the hospice company would deliver the Glipizide, as the resident was a hospice respite resident. A facility policy titled Administering Medications dated 04/2019, documented medications were administered in a safe and timely manner and as prescribed. Medications were administered within one hour of the ordered time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure food stored inside the kitchen and in 1 of 2 nourishment refrigerators, were labeled and dated. The deficient practice had a potential for prolonged stored food to be served and posed a risk for gastrointestinal issues for the residents. On 09/27/2023 at 8:50 AM, inside the walk-in refrigerator was a stainless-steel container with a brown liquid inside. The container was not labeled and dated when it was stored. The assistant dietary manager confirmed the finding and indicated all stored food should be labeled and dated. On 09/27/2023 at 9:15 AM, observed at the south hall nourishment room refrigerator, the following items were unlabeled: - [NAME] Daiz Vanilla ice cream - bottle of mayonnaise - bottle protein drink - pitcher of tea colored fluid The signage at the door of the refrigerator read as: Please label any food or drink stored in this refrigerator with the resident's name and date. On 09/27/2023 at 9:20 AM, a Certified Nursing Aide confirmed the finding and indicated all stored food should be labeled with the resident's name and date. The facility policy titled Food Receiving and Storage revised November 2022, documented all foods stored in the refrigerator and freezer are covered, labeled, and dated (used by date). The facility policy titled Food brought by family/Visitors revised March 2022, documented food brought by family and visitors that is left with the resident to consume is labeled and stored in a manner that is clearly distinguishable from facility prepared food. Perishable foods are stored in a re-sealable container with tightly fitting lids in a refrigerator,. Containers are labeled with the resident's name, the item and the 'use by date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident could understand for 3 of 20 sampled residents (R100, 106, and 98). The deficient practice had the potential to obstruct each resident's ability to make a well-informed decision about signing the arbitration agreement. Findings include: Resident 100 (R100) R100 was admitted on [DATE] with diagnoses including status post right below-knee amputation. The 5-day admission assessment dated [DATE] documented R100 had a BIMS (Brief Interview for Mental Status) Summary Score of 14 indicating the resident was cognitively intact. On 09/28/2023 at 11:35 AM, R100 verbalized that they did not know what an arbitration agreement was and did not remember signing anything. R100 indicated being out of it when admitted to the facility, and R100 did not recall signing anything later. R100 indicated they had not read an agreement, it was not read to them, nor was it explained. The resident indicated papers were just thrown at them to sign. When asked if they recalled signing the arbitration agreement on a laptop, the R100 replied they could not recall signing any legally binding document. The interview with R100 revealed the resident did not have a clear understanding of what an arbitration agreement was, understood the process or that it was a binding agreement. The list of residents who entered into a binding agreement with the facility within the past 30 days revealed R100's completed an arbitration agreement on 09/11/2023, seven days after admission. On 09/29/23 at 3:01 PM, a Registered Nurse (RN) indicated R100 was alert and oriented times four (refers to a person's level of awareness of self, place, time, and situation). The RN verbalized the resident would remember if the resident had done something, the resident's recall was good. Resident 106 (R106) R106 was admitted on [DATE] with diagnoses including sepsis, cellulitis of right leg, and hypertension. The admission MDS dated [DATE], documented the resident had a BIMS Summary Score of 12 indicating the resident had moderately impaired cognition. An Admission/re-admission Summary Note dated 09/13/2023, indicated the resident was able to verbalize needs and concerns to staff, follow commands and cooperative with care. The resident was able to sign the consent to treat, immunization consent and admission paperwork. On 09/28/23 at 3:35 PM, the resident indicated did not recall signing an arbitration agreement. The resident indicated they did not know what this was. R106 verbalized if someone would have explained it this way, they would have remembered if they had signed anything. The resident only recalled the staff indicating to sign a consent so they could take good care of them, and to get their medications. R106 verbalized just wanting to do the right thing so they could get care. The list of residents who entered into a binding agreement with the facility within the past 30 days revealed R106 completed an arbitration agreement on 09/16/2023, three days after admission. On 09/29/23 at 3:02 PM, the RN indicated R106 was alert and oriented times four. Resident 98 (R98) R98 was admitted on [DATE] with diagnoses including diabetes mellitus. The 5-day admission assessment dated [DATE] documented R98 had a BIMS summary score of 14 indicating the resident was cognitively intact. The list of residents who entered into a binding agreement with the facility revealed R106's arbitration agreement was completed 09/11/2023, four days after admission. On 09/29/23 at 10:04 AM, R98 indicated not being asked to sign anything. R98 indicated not being provided with any documents. R98 verbalized, No, I did not sign any documents. On 09/29/23 at 1:01 PM, R98 indicated not knowing the meaning of an arbitration or arbitration agreement. R98 replied, I don't have that. R98 indicated no one from admissions spoke to them about arbitration. On 09/29/23 at 3:03 PM, the RN indicated R98 was alert and oriented times three with some forgetfulness. On 09/29/23 at 2:49 PM, a Registered Nurse (RN) Supervisor, explained when a resident was admitted from a hospital, the process included the following: - Review the discharge summary or notes, - Completed a head-to-toe assessment, - Assess if resident alert, oriented and could sign for consent. If a resident could not sign for consent, call the Power of Attorney (POA) or the first emergency person on the contact list to get permission to treat. The RN indicated not being aware of what an arbitration agreement was and did not know if any of the residents had completed one. The RN explained nursing was responsible for the clinical portion of the admission packet. On 09/29/2023 in the afternoon, the admission Assistant was informed that a sample of residents were interviewed regarding the arbitration agreement. It was disclosed that the residents indicated they did not know what an arbitration agreement was or the meaning of arbitration; nor they did not remember the agreement being reviewed, explained to them, or signing the arbitration agreement. On 09/29/2023 at 3:18 PM, the Admissions Assistant, explained being responsible for informing the resident of what to expect, provided information about the facility and completion of the admission paperwork. The admission Assistant indicated being responsible for going over the admission packet rules and the policies the building with residents to make sure they understood what they were signing. The admission Assistant indicated asking the residents if they had questions and informed, they could come to the office for questions. A copy of the paperwork was provided and or emailed if the resident requested. The admission Assistant indicated the Arbitration paperwork was the last part of the information provided. The admission Assistant explained the residents needed to know that it was binding and a legal document. If something happened, the residents may have to go through arbitration. The admission Assistant indicated the resident signed the agreement on an iPad. The admission Assistant indicated that as much as possible, a summary of information regarding the arbitration agreement was provided to the resident. The admission Assistant would ask if the resident understood arbitration and what to expect. The admission Assistant indicated the time spent with the resident was approximately 15 minutes including going over all the admission information and the arbitration process. The residents were given the iPad to scroll through, and usually they knew what it was, so they would click and sign. Both the admission paperwork and the arbitration agreement were provided on the iPad when meeting with the resident to complete the review and signing of the documents. The admission Assistant disclosed the arbitration paperwork was not made available to the resident for review prior to meeting with the admissions, and the document was presented via an iPad, and the information was summarized as the resident scrolled through the document. Each part of the document was not reviewed with or explained to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure IV (intravenous) line insertion and care orders for IV dressing changes for midline and peripherally inserted central catheter (PICC) lines were obtained, transcribed, and implemented for 3 of 20 sampled residents (Residents 10, 18, and 12); a heplock IV (maintains access to the veins if a medication or fluid needs to be administered) dressing was changed as scheduled for 2 of 20 sampled residents (Residents 149 and 4); and partially used NS flushes were discarded for 1 of 20 sampled residents (Resident 38), and a hep lock IV was discontinued for 1 of 20 sampled residents (Resident 4). These deficient practices could potentially lead to an increased risk of infection and compromised residents' health. Findings include: A facility policy titled Catheter Insertion and Care documented, Midline Dressings Changes would be changed every five (5) days or if it was wet, dirty, not intact or compromised. Resident 10 (R10) R10 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure. The Brief Interview of Mental Status documented a score of 13/15, which indicated R10's cognitive status was intact. On 09/27/2023 at 9:52 AM, R10 lay in bed, verbally alert and oriented. An IV line was inserted in the right upper arm (RUA), and the edges of the transparent dressing were peeled off and undated. R10 could not remember when the dressing was changed. The Nursing Admission/readmission Evaluation/ assessment dated [DATE], documented R10 was admitted with the PICC line access. R10's medical records lacked documented evidence IV midline care orders were obtained for the utilization of midline access. On 09/28/2023 in the morning, a Registered Nurse (RN) confirmed there were no IV midline orders for R10. An RN indicated there should have been an order in place, and the dressing should have been dated and changed weekly to prevent infection. On 09/28/2023 at 2:56 PM, the Infection Preventionist (IP) indicated R10's IV midline was placed on 09/19/2023, for the antibiotic treatment of osteomyelitis and cervical discitis. The IP indicated the dressing should have been dated to indicate when it had last been changed, and orders should have been obtained and transcribed for monitoring. The IP confirmed there was no order in place for midline insertion and no care orders in place for R10. On 09/28/2023 at 3:40 PM, the Director of Nursing (DON) indicated the residents who had been admitted with IV lines should have been assessed to determine whether they had PICC lines, midlines, or heplocks. The purpose of this assessment was to identify whether there was a valid indication for the continued use of IV lines. If there was no indication, an order for discontinuation should have been obtained. The DON explained a physician order should have been obtained and transcribed for proper care, including maintenance, cleaning, dressing changes, and flushing. The DON indicated the dressings for midline and PICC lines should have been changed weekly on Sundays or as needed when they became soiled or leaked. The DON indicated to maintain continuity of care and prevent infections, the dressing should have been dated. On 09/29/2023 at 3:46 PM, the Infectious Disease Physician Assistant indicated the nurses were expected to follow the IV protocol, such as dressing changes. Resident 18 (R18) R18 was admitted on [DATE], with diagnoses including urinary tract infection and skin paresthesia. The Brief Interview of Mental Status dated 09/06/2023, documented a score of 12/15, which indicated R18's cognitive status was intact. On 09/27/2023 at 9:09 PM, R18 lay in bed, and empty bags of IV Merrem and Vancomycin were hung on the IV pole. R18's PICC line was inserted in LUA with the dressing dated 09/23/2023. R18 could not remember when the PICC line was inserted. R18's medical records lacked documented evidence care orders for the PICC line were obtained and transcribed in the administration record. On 09/27/2023 at 2:55 PM, an RN confirmed there was no order for the insertion of the PICC line and no care orders in place. The RN indicated the PICC line or midline dressing should have been changed every 7 days on Sundays at night. On 09/28/2023 at 3:21 PM, the IP confirmed there were no care orders in place for R18. Resident 149 (R149) R149 was admitted on [DATE], with diagnoses including hypertension and acute kidney failure. The Brief Interview of Mental Status dated 09/17/2023, documented a score of 15/15, which indicated R149's cognitive status was intact. The Nursing Progress Notes dated 09/19/2023, documented the 24 gauge IV catheter being inserted in R149's right arm. On 09/27/2023 at 10:07 AM, R149 lay in bed, alert and verbally oriented. R149's IV heplock in the right arm was wrapped with elastic bandage, and the dressing was dated 09/19/2023. R149 indicated had not been receiving any antibiotics for more than a week. The RN Supervisor assessed and confirmed R149's IV line was infiltrated; the dressing was old and dated 09/19/2023 (8 days old). The nurse supervisor indicated the process was to change the IV line every 7 days or to remove it if the resident was not on an IV antibiotic. The nurse supervisor confirmed R149's IV line was not changed as scheduled. Resident 12 (R12) R12 was admitted on [DATE] and readmitted on [DATE], with diagnoses including diabetes mellitus and dementia. On 09/27/2023 at 3:23 PM, R12 was in bed with eyes closed; the heplock in R12's left hand was wrapped with an undated elastic bandage. R12's medical records lacked documented evidence a physician order was obtained for the heplock insertion and care management. On 09/27/2023 in the afternoon, the Nurse Supervisor confirmed the presence of a heplock in R12's left hand, wrapped with an elastic bandage and the undated dressing. The nurse supervisor confirmed there was no physician order in place for R12's heplock. On 09/28/2023 at 3:08 PM, the IP indicated there was no indication as to why R12 had the heplock and R12 was not on active antibiotic therapy. The IP indicated a physician order should have been obtained. Resident 38 (R38) R38 was admitted on [DATE] with diagnoses including pressure ulcer of the sacral region and after care for surgery of the skin and subcutaneous region. On 09/27/23 10:05 AM, observed at R38's bedside table was a capped partially used 10 milliliter pre-filled syringe of normal saline flush. On 09/27/23 10:08 AM, the director of staff development (DSD) confirmed the finding and indicated all unused saline flushes should have been discarded. Resident 4 (R4) R4 was admitted on [DATE], with diagnoses including sepsis and urinary tract infection. On 09/27/2023 at 10:43 AM, R4 was observed with left upper arm heplock (maintains access to the veins if a medication or fluid needs to be administered) with a transparent dressing dated 09/18/2023. R4 indicated not receiving medications or fluids through the heplock. On 09/27/2023 at 10:46 AM, the DSD confirmed the finding and indicated intravenous access devices dressing should be changed every week on Sundays during the night shift. Review of R4's current and discontinued physician's order revealed orders for: - Intravenous (IV) antibiotic medication discontinued on 08/31/2023 - IV iron one-time infusion order for 08/29/2023 - IV Ondansetron as needed dated 08/28/2023 and was never needed or administered based on the medication administration record. On 09/28/2023 at 2:35 PM, the Director of Nursing (DON) confirmed nurses should have addressed the heplock not being used with the physician. The DON acknowledged the unused heplock is more of a risk to the resident due to infection complications. The expectation is an IV access not being used for two weeks should have been discontinued.