Based on interview and record review, it was determined that the facility failed to develop and implement a comphrensive care plan for 1 of 4 residents reviewed for mood and behavior in a final sample of 23 residents. (Resident identifier is #92.) Findings include:Resident #92 Review on 1/7/25 of Resident #92's medical diagnosis list revealed that Resident #92 with a diagnosis of Post Traumatic Stress Disorder (PTSD). Review on 1/7/25 of Resident #92's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/1/24, revealed that it was documented in Section I6100, Diagnosis, that Resident #92 had PTSD. Review on 1/7/25 of Resident #92's comprehensive care plan revealed that there were no focus, triggers, or interventions for Resident #92's PTSD. Interview on 1/8/25 at 9:00 a.m. with Staff I (Unit Manager) confirmed that there were no focus, triggers, or interventions for PTSD in Resident #92's comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and policy review it was determined that the facility failed to follow the professional standards of care for 3 residents in a final sample to 23 residents. (Resident identifier is #273, #101, and #73.) Findings include: Resident #101 Interview on 1/6/25 at approximately 9:15 a.m. with Resident #101 revealed that he/she was concerned that sometimes his/her medications and insulin had not been administered timely. Review on 1/7/25 of Resident #101's December 2024 and January 2025's Medication Administration Audit Report revealed the following insulin administrationswere not given within 30 minutes and other medication were not given within 60 minutes before or after the scheduled time: Insulin Glargine 100 unit/ml (milliliters) scheduled for 6:00 p.m. 12/7/24 given at 8:05 p.m. 12/8/24 given at 8:06 p.m. 12/15/24 given at 8:53 p.m. 12/27/24 given at 9:29 p.m. 12/28/24 given at 9:40 p.m. 1/1/25 given at 11:18 pm 1/2/25 given at 8:14 p.m. 1/3/25 given at 10:23 p.m. 1/6/25 given at 8:10 p.m. Humalog insulin 100 unit/ml sliding scale scheduled for 7:00 p.m. 12/11/24 given at 8:22 p.m. 12/24/24 given at 11:25 p.m. 12/26/24 given at 8:19 p.m. Metoprolol Succinate Extended Release 50 mg (milligrams) daily scheduled for 9:00 a.m. 12/8/24 given at 12:11 p.m. 12/9/24 given at 1:35 p.m. 12/11/24 given at 12:51 p.m. 12/12/24 given at 3:06 p.m. 12/17/24 given at 2:41 p.m. 12/18/24 given at 3:43 p.m. 12/19/24 given at 11:59 a.m. 12/23/24 given at 12/48 p.m. 12/24/24 given at 1:31 p.m. 12/27/24 given at 2:08 p.m. 12/29/24 given at 1:02 p.m. 12/30/24 given at 12:26 p.m. 1/1/25 given at 4:57 p.m. Gabapentin 100 mg, 3 times daily scheduled for 12:00 p.m. 12/12/24 given at 3:05 p.m. 12/15/24 given at 6:13 p.m. 12/18/24 given at 3:42 p.m. 12/21/24 given at 2:44 p.m. 1/1/25 given at 4:57 p.m. Humalog insulin 100 unit/ml sliding scale scheduled for 12:00 p.m. 12/18/24 given at 3:42 p.m. Gabapentin 100 mg, 3 times daily scheduled for 8:00 a.m. 12/19/24 given at 11:59 a.m. Humalog insulin 100 unit/ml sliding scale scheduled for 5:00 p.m. 12/27/24 given at 6:36 p.m. Gabapentin 100 mg, 3 times daily scheduled for 6:00 p.m. 12/28/24 given at 9:34 p.m. Interview on 1/8/25 at approximately 9:30 a.m with Staff D (Director of Nursing) confirmed the above findings. Standard Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #273 Observation on 1/6/25 at approximately 10:00 a.m. of Resident #273 revealed an undated dressing on his/her left knee. Interview on 1/6/25 at approximately 10:20 a.m. with Staff A (Registered Nurse) confirmed the above finding. Interview on 1/7/25 at approximately 8:30 a.m. with Staff A revealed that Resident #273 did have an order for a dressing change and there was no documentation of the dressing being done. Resident #101 Observation on 1/6/25 at approximately 9:15 a.m. of Resident #101's right leg revealed he/she had 3 undated dressings applied. (1 on right knee, 1 on right outer shin and 1 on right ankle). Interview on 1/6/25 at approximately 10:20 a.m. with Staff A confirmed the above findings. Review on 1/7/25 of Resident #101's January 2025's TAR's revealed the following order: Cleanse abrasions to right lower leg with VASHE. Leave gauze saturated with VASHE to wounds for approximately 1 minute Interview on 1/7/25 at approximately 8:30 a.m. with Staff A confirmed that the order is not clear as to how many abrasions Resident #101 had orders for a dressing to be applied to. Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021. Chapter 31 Medication Administration Page 595, .Medications that are time critical most likely cause harm or have subtherapeutic effects if they are not administered in time (usually 30 minutes before and after the scheduled dose). Non-time-critical medications most likely do not cause harm if they are given within 1 hour to 2 hours before or after the schedule time. Thus, you need to administer time-critical medications at a precise time, within 30 minutes before and after a scheduled time. You administer non-time-critical medications within 1 to 2 hours of their scheduled times . Resident #73 Interview on 1/6/25 at approximately 10:45 a.m. with Resident #73 revealed that he/she is given his/her insulin late frequently. Resident #73 thought in December that his/her insulin given over three hours late. Review on 1/8/25 of Resident #73's Medication Administration Audit Report for December 2024 and January 2025 revealed the following insulin administrations were not given within 30 minutes before or after the scheduled time: Humalog insulin 100 units/ml 5 units was scheduled for 11:30 a.m. 12/22/24 given at 12:41 p.m. 12/26/24 given at 1:17 p.m. 12/29/24 given at 1:00 p.m. 12/31/24 given at 12:25 p.m. Humalog insulin 100 unit/mg sliding scale scheduled for 11:30 a.m. 12/22/24 given at 12:41 p.m. 12/26/24 given at 1:17 p.m. 12/31/24 given at 12:25 p.m. Humalog insulin 100unit/ml 5 units scheduled for 7:30 a.m. 12/21/24 given at 8:54 a.m. 12/29/24 given at 9:21 a.m. 12/31/24 given at 9:55 a.m. 1/1/25 given at 9:21 a.m. 1/7/25 given at 10:19 a.m. Humalog insulin 100 unit/mg sliding scale scheduled for 7:30 a.m. 12/31/24 given at 9:55 a.m. Humalog insulin 100unit/ml 5 units scheduled for 4:30 p.m. 12/21/24 given at 7:54 p.m. Humalog insulin 100 unit/mg sliding scale scheduled for 4:30 p.m. 12/21/24 given at 7:54 p.m. Tresiba FlexaTouch 200 units/ml 82 units was scheduled for 8:00 a.m., 12/29/24 given at 10:08 a.m. 12/31/24 given at 9:55 a.m. 1/7/25 given at 10:19 a.m. Interview on 1/8/25 at approximately 11:00 a.m. with Staff D (Director of Nursing) confirmed the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that a resident who attends dialysis had interventions to care and monitor their access site and that they received physician ordered medications for 1 of 1 resident reviewed for dialysis in a final sample of 23 residents. (Resident identifier is #1.) Findings include: Interview on 1/7/25 at 1:35 p.m. with Resident #1 revealed that he/she attends dialysis 3 times a week on Monday, Wednesday, and Friday and is away from the facility from approximately 11:30 a.m. until 5:00 p.m. Review on 1/7/25 of Resident #1's January's 2025 Medication Administration Record (MAR) revealed that the medication Calcium Acetate (a phosphate binder) were documented as AW (away from center; meaning not administered) on 1/2, 1/4, and 1/6/25. Further review of Resident #1 MAR revealed that he/she has an order for Midodrine HCL (hydrochloride) Oral Tablet 5 MG (milligram) Give 2 tablets by mouth three times a day for low blood pressure 10 mg and to hold if the SBP (Systolic blood pressure) more than 160 and to be given with his/her meals. On the following dates it was documented as AW on 1/2, 1/4, and 1/6/25. Further review of the MAR revealed no orders to hold medications on dialysis days. Review on 1/7/24 of Resident #1's medical record revealed that he/she was readmitted to the facility on [DATE] and he/she goes to dialysis 3 times a week. Interview on 1/7/25 at approximately 11:00 a.m. with Staff C (Unit Manager) confirmed there were no orders in place to hold medications while at dialysis. Review on 1/7/25 or Resident #1's care plan revealed the care plan did not identify what kind of dialysis access site that Resident #1 had and there were no interventions to care of monitor thier access site. Interview on 1/7/25 with Staff C confirmed the above finding.

Based on observation and interview, it was determined that the facility failed to ensure that food trays were stored dry and in sanitary condition in the main kitchen. Findings include: Standard: Review on 1/7/25 of the U.S. FDA (Food Drug and Administration) Food Code (2017), retrieved from: https://www.fda.gov/media/110822/download, [page 151-153] revealed the following: 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in 151 antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination . (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted . Observation on 1/7/25 at approximately 7:15 a.m. of Staff J (Dietary Aide) and Staff K (Dietary Aide) on the breakfast serving line revealed Staff J picked up trays that were stored wet in a large stack and dried each tray off with a dish towel. Interview on 1/7/25 at approximately 7:20 a.m. with Staff L (Dietary Manager) confirming the above findings and revealed they had stored the trays wet the night before.

Based on record review and interview, it was determined that the facility failed to maintain complete records for 1 of 1 record reviewed for death in a final sample of 23 (Resident identifier is #11.) Findings include: Review on 1/07/25 of Resident #11's nursing progress note ,dated 01/04/25 at 14:48, revealed .Resident time of death at 14:42 [2:42 p.m.], 2 RN [Registered Nurse] pronouncing death . No other information was present for this entry. Review on 1/07/25 at 3:15 p.m. of the facility's policy titled NSG104 Pronouncement of Patient Death, effective 5/01/23, revealed .Nurses will comply with all applicable laws and regulations regarding determination of death .1.5. A RN who has determined and pronounced death will document the clinical criteria for such determination and pronouncement in the patient's medical record. 1.5.1 Description of the discovery of the patient; 1.5.2 Any treatment of the patient undertaken; 1.5.3 Findings from assessment (presumptive and conclusive signs identified): 1.5.3.1 No carotid and peripheral pulse, 1.5.3.2 Pupils are fixed and nonreactive to light, 1.5.3.3 No response to tactile stimuli, 1.5.3.4 No respirations for one full minute, 1.5.3.5 No heart sounds for one full minute; 1.5.4 Date and time of death; 1.5.5 Individuals notified of the patient's status/death 1.5.6 Results of any communications . Interview on 1/8/25 at 12:30 p.m. with Staff D (Director of Nursing) confirmed the above findings and that the expectation is that the nurse would document in the medical record all clinical signs of death.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was assessed for restraints for 1 of 1 residents reviewed for restraints in a final sample of 22 residents. (Resident identifier is #12). Findings include: Observation on 10/29/23 at approximately 2:00 p.m. of Resident #12 revealed that he/she was in a wheelchair with a fastened seatbelt. Review on 10/30/23 of Resident #12's medical record revealed that there was no assessment of the seatbelt since 6/24/21 and no physician order for seatbelt usage. Further review of the medical record revealed a care plan dated 3/5/21 with an intervention to utilize and release restraint per the physician's order. Observation on 10/31/23 at approximately 9:10 a.m. of Resident #12 revealed that he/she was in a wheelchair with a seatbelt fastened. Interview on 10/31/23 at approximately 9:10 a.m. of Resident #12 revealed that he/she was able to remove the seatbelt on command. Interview on 10/31/23 at approximately 9:30 a.m. with Staff C (Third floor Unit Manager) confirmed that the last assessment for the use of the seat belt was on 6/24/21 and that there were no orders for the use of the seatbelt. Staff C stated that the seatbelt use was Resident #12's preference. Review on 10/31/23 of the facility policy titled, NSG233 Restraints: Use of, Revision date 6/15/22 revealed .Patients will be evaluated for the use of restraints or protective devices during the nursing assessment process. If it is determined that a protective device is being used to improve the patient's ability to move without assistance, no further assessment is needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #250 Interview on 10/29/23 at 12:30 p.m. with Resident #250's representative revealed that Resident #250 was admitted to the facility on [DATE] and family visits daily. Resident #250's representative stated that Resident #250 liked to get into bed around 7:30 p.m. and the family would have to provide nighttime care to make sure Resident #250 was in bed prior to the family leaving the facility because the LNAs stated they were short staffed and had to finish other tasks prior to helping Resident #250 get ready for bed. Interview on 10/30/23 at 2:00 p.m. with Resident Council (Resident identifiers are #12, #13, #17, #31, #39, #47, #74, and #84) revealed that on the weekends in the main dining room residents would wait up to an hour or sometimes longer for the meal to be served. Based on observation, interview, and record review, it was determined that the facility failed to provide sufficient staff to meet residents' needs (Resident Identifiers are #12, #13, #17, #31, #38, #39, #47, #74, #84, #156 and #250). Findings include: Resident #38 Observation on 10/29/23 at approximately 11:00 a.m. of Resident #38 appeared upset, tearful, and sitting in his/her fecal matter in bed. Interview on 10/29/23 at approximately 11:00 a.m. with Resident #38 revealed he/she had been sitting in his/her fecal matter for approximately an hour, after utilizing the call bell for assistance. Interview on 10/29/23 at approximately 11:05 a.m. with Staff H (Licensed Practical Nurse (LPN)) confirmed the above finding. Staff A (Administrator) stated that a Licensed Nursing Assistant (LNA) was on break leaving them short to answer call lights. Resident #156 Interview on 10/29/23 at approximately 11:10 a.m. with Resident #156 revealed after utilizing his/her call bell last week it took staff approximately a half hour to respond on two occasions and he/she urinated himself/herself while waiting for staff assistance. Staff Interviews: Interview on 10/31/23 at approximately 9:00 a.m. with Staff I (LNA) stated, Three LNAs is not enough on the second floor for this level of acuity. Interview on 10/31/23 at approximately 9:40 a.m. with Staff G (LPN) stated, We don't have enough staff on the second floor . We have fall risk and behavioral residents and I didn't have enough LNAs on my side. Interview on 10/31/23 at 10:30 a.m. with Staff J (LPN) stated, As a licensed nurse, I don't feel that resident care needs are safely met with three LNAs on the second floor. There may be a LNA that is a Medication Aide, but their focus is on medication administration, not patient care. Review on 10/31/23 of the Facility Assessment revealed that .Function: Sufficiency/Analysis Summary .consideration .Currently, the center staffs according to residents' needs based on acuity and census . Further review of the Facility Assessment revealed the following staffing levels for direct care staff: First and Second shift - 2 Nurses (Registered Nurse or Licensed Practical Nurse)/Medication Aide/Technician TBD and Nurse Aides (LNA) 1:14. Review on 10/31/23 of the Daily Staffing Sheets from 9/29/23 to 10/31/23 revealed the following: 9/29/23 - Second floor- Day shift - 3 LNAs, 0 Medication Aide -Census - 44 10/2/23 - Second floor - Day shift - 2 LNAs, 2 Medication Aides-Census 44 10/3/23 - Second floor - Day shift - 2 LNAs, 2 Medication Aides-Census 44 10/4/23 - Second floor - Day shift - 3 LNAs, 1 Medication Aide-Census - 44 10/5/23 - Second floor - Day shift - 3 LNAs, 1 Medication Aide-Census - 44 10/9/23 - Second floor - Day shift - 2 LNAs, 2 Medication Aides-Census 41 10/23/23 -Second floor - Day shift - 2 LNAs, 1 Medication Aide-Census - 38 10/29/23- Second floor - Day shift - 3 LNAs, 0 Medication Aide-Census - 43 10/30/23- Second floor - Day shift - 2 LNAs, 1 Medication Aide-Census - 43 Interview on 10/31//23 with Staff A confirmed that the above Daily Staffing Sheets were correct. Review on 10/31/23 of Census and Condition revealed the following acuity between 9/29/23 to 10/30/23: - There were 12 falls in the second floor unit, including two falls with injuries (not major), - There were 13 resident-to-resident incidents the second floor unit, - There were 13 out of 43 residents on the second floor unit needing assistance with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure residents were offered, educated, and received the pneumococcal and/or influenza immunization 3 of 5 residents reviewed for immunizations (Resident Identifiers are #8, #55 and #67). Findings Include: Review on 10/31/23 of Summary: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)-United States, 2023-24, found at https://www.cdc.gov/flu/professionals/acip/summary/summary-recommendations.htm, revealed the .Timing of vaccination - For most persons who need only one dose of influenza vaccine for the season, vaccination should ideally be offered during September or October. However, vaccination should continue throughout the season as long as influenza viruses are circulating . Resident #8 Review on 10/31/23 of Resident #8's medical record revealed the last documented influenza immunization was administered on 12/3/21. Review on 10/31/23 of Resident #8's informed consent for the influenza vaccine revealed that they had consented to receive the influenza vaccine on 9/14/23. Interview on 10/31/23 at approximately 1:20 p.m. with Staff D (Infection Preventionist) confirmed that Resident #8 had consented to receive the influenza vaccine but had not yet received it. Staff D stated that the facility has had influenza vaccine since 10/5/23. Resident #67 Review on 10/31/23 of Resident #67's immunization record revealed no influenza information. Review on 10/31/23 of Resident #67's informed consent for the influenza vaccine revealed they had consented to receive the influenza vaccine on 10/4/23. Interview on 10/31/23 at approximately 1:20 p.m. with Staff D confirmed that Resident #67 had consented to receive the influenza vaccine but had not yet received it. Staff D stated that the facility had received their supply of influenza vaccinations around 10/5/23 and that they had not started the influenza vaccine administration for the second floor yet. Review on 10/31/23 of facility policy titled IC600 Influenza Immunization Program, revised on 5/1/23, revealed .Begin the process for the influenza (flu) program in early September. To achieve the highest level of immunity during peak flu season, flu vaccinations should not begin prior to September 1 of each year, unless otherwise advised by the Centers for Disease Prevention and Control (CDC) . Resident #55 Review on 10/31/23 of Resident #55's immunization record revealed their last administration of influenza was given on 3/15/23. Review on 10/31/23 of Resident #55's medical record revealed no proof that Resident #55 had been educated or offered the influenza immunization for the 2023-2024 flu season. Interview on 10/31/23 at approximately 1:20 p.m. with Staff D confirmed the above finding. Review on 10/31/23 of the facility policy titled IC600 Influenza Immunization Program, revised on 5/1/23, revealed .Begin the process for the influenza (flu) program in early September. To achieve the highest level of immunity during peak flu season, flu vaccinations should not begin prior to September 1 of each year, unless otherwise advised by the Centers for Disease Prevention and Control (CDC) .Review Center Flu Vaccine Action Plan .Stage General Preparation .Patients- Check each patient's existing medical record for consent & standing order for annual flu vaccine .send Vaccine information statement (VIS) & appropriate letter to the patient/representative .Place a copy of the letter &VIS in the patient's medical record . Resident #67 Review on 10/31/23 of Resident #67's immunization record revealed no pneumococcal information. Review on 10/31/23 of Resident #67's medical record revealed no information that the pneumococcal immunization had been offered to Resident #67 since admission on [DATE]. Interview on 10/31/23 at approximately 1:20 p.m. with Staff D confirmed the above finding. Review on 10/31/23 of the facilities policy titled IC601 Pneumococcal Vaccination, Revised on 11/15/22, revealed .1. Upon admission, obtain the Pneumococcal vaccination history of all patients. 1.1 Patient or resident representative may self-report vaccination history. 1.2 Document Pneumococcal vaccination history in PointClickCare (PCC) and on the Pneumococcal Consent form under Vaccination History .

Based on observation, interview and record review, it was determined that the facility failed to follow manufacturer's instruction for obtaining temperature via infrared thermometer for 2 of 3 days observed and the facility also failed to ensure that glucose test strips were labeled with open date according to manufacturer's instruction for 2 of 2 medication carts observed. Findings include: Observation on 10/17/22 at approximately 8:30 a.m. during visitor screening revealed that Staff A (Receptionist) used an infrared thermometer to obtained 4 visitor temperatures. Further observation revealed that Staff A used the thermometer on 4 visitors and held it near the visitor's neck. Observation on 10/18/22 at approximately 8:00 a.m. during visitor screening revealed that Staff A used an infrared thermometer to obtained 3 visitor temperatures. Further observation revealed that Staff A used the thermometer on 3 visitors and held it near the visitor's neck. Interview on 10/18/22 at approximately 8:00 a.m. with Staff A confirmed above findings. Review on 10/18/22 of the facility's infrared thermometer manufacturer's instruction revealed .Intended Use The device is an infrared thermometer intended to measure forehead temperature of infants and adults without contacting human body . 3rd floor high side medication cart Observation on 10/17/22 at approximately 9:10 a.m. with Staff B (Registered Nurse) of the 3rd floor high side medication cart revealed that there was 1 open bottle of glucose test strips with no open date. Review on 10/17/22 of the glucose test strip manufacturer's instruction on the glucose test strip bottle revealed use within 6 months of opening. Interview on 10/17/22 at approximately 9:10 a.m. with Staff B confirmed the above findings in the 3rd floor high side medication cart. 2nd floor low side medication cart Observation on 10/17/22 at approximately 9:15 a.m. with Staff C (Licensed Practical Nurse) of the 2nd floor low side medication cart revealed that there was 2 open bottles of glucose test strips with no open dates. Review on 10/17/22 of the glucose test strip manufacturer's instruction on the glucose test strip bottle revealed use within 6 months of opening. Interview on 10/17/22 at approximately 9:15 a.m. with Staff B confirmed the above findings in the 3rd floor high side medication cart. Review on 10/18/22 of the facility's manufacturer's instruction for the blood glucose monitoring system revealed Performing Glucose Test . Step 1 Take out the [glucose test strip brand name omitted] from the test strip bottles and close the bottle immediately. Insert the test strip to turn on the meter. Important .Record the date opened on the bottle label. Discard the bottle and any remaining test strips after 6 months from date of opening .