**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews the facility failed to invite a cognitively intact resident to participate in the planning of the resident's care for 1 of 3 residents reviewed for participation in care plan meetings. (Resident #12) Resident #12 was admitted on [DATE]. Review of the electronic medical record for Resident #12 revealed a form titled, Care Plan Attendance Sheet dated 11/11/2022 contained the Residents name, Responsible Party's (RP) name and the people who had attended the meeting. The Social Worker and the Unit Manager reviewed the plan of care with Resident #12's family member. Resident #12 did not attend the meeting. The medical record included no evidence that Resident #12 was invited to participate in the care plan meeting conducted on 11/11/2022. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact. Record review for Resident #12 revealed no evidence of any care plan meetings conducted after 11/11/2022 and no evidence that the resident was incorporated into his care planning process. An interview on 4/25/23 at 3:35 PM with Resident #12, revealed he had never attended a care plan meeting or had been asked to attend one. Resident #12 stated that he wanted to go to his care planning meetings. During an interview on 4/27/23 at 9:26 AM, Social Worker #1 (SW) explained that all residents with a cognitive score between 13-15 were cognitively intact and should have been invited to care plan meetings. SW #1 said the invitations to care plan meetings were provided to the resident and the responsible party after the MDS nurse set the assessment date. SW #1 said herself and SW #2 were responsible for distributing the care plan meeting invitations. Resident #12 was set for a meeting in February 2023 following completion of the 2/1/23 MDS assessment. There was no invitation letter sent for this care plan meeting and no care plan meeting occurred for Resident #12. SW #1 was not sure why Resident #12 had not received invitations to the care plan meetings. SW#1 further explained that care plan meetings were done upon admission and on a quarterly basis, following the completion of the quarterly MDS assessments. An interview with the Director of Nursing (DON) on 4/28/23 at 2:13 PM, revealed Resident #12 should have been invited and involved in their care plan meetings. The DON revealed care plan meetings needed to be documented in the record to include everyone in attendance. The delivery of a care plan letter to a resident and/or family member, as well as a declination to attend a meeting, needed to be documented. The DON further explained all residents needed to at least be invited to participate in the care planning process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to complete Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD), which was the last day of the assessment period) for 2 out of 12 sampled residents (Resident #19, and #52). Findings include: 1. Resident #19 was admitted to the facility on [DATE]. A review of Resident #19's 5-day/admission MDS assessment with an ARD of 11/4/22 was signed as completed on 11/14/22. An interview with MDS Coordinator on 4/27/23 at 9:31 AM, revealed she did not sign the MDS assessments as completed. The MDS Coordinator reported that the Corporate MDS Nurse Consultant signed the assessments after she filled them out and was unable to say why the assessments were signed as completed late. A telephone interview on 4/28/23 at 9:07 AM, with the Corporate MDS Nurse revealed she signed the completed assessments, both remotely and in the facility. She did not know which assessments were signed late. Interview with Administrator on 4/28/23 at 2:15 PM, indicated all MDS assessments should be completed in a timely manner. She went on to explain the facility MDS Nurse was a Licensed Practical Nurse, the corporate MDS nurses were Registered Nurses, and they signed the completed assessments. 2. Resident #52 was admitted to the facility on [DATE]. A review of Resident #52's admission MDS assessment with an ARD of 11/23/22 was signed as completed on 12/8/22. An interview with MDS Coordinator on 4/27/23 at 9:31 AM, revealed she did not sign the MDS assessments as completed. The MDS Coordinator reported that the Corporate MDS Nurse Consultant signed the assessments after she filled them out and was unable to say why the assessments were signed as completed late. A telephone interview on 4/28/23 at 9:07 AM, with the Corporate MDS Nurse revealed she signed the completed assessments, both remotely and in the facility. She did not know which assessments were signed late. Interview with Administrator on 4/28/23 at 2:15 PM, indicated all MDS assessments should be completed in a timely manner. She went on to explain the facility MDS Nurse was a Licensed Practical Nurse, the corporate MDS nurses were Registered Nurses, and they signed the completed assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare & Medicaid Services (CMS) within the regulatory timeframe for 2 of 12 residents reviewed (Resident #11 and #19). 1.Resident #11 was admitted to the facility on [DATE]. A review of Resident #11's most recent admission MDS assessments with an Assessment Reference Date (ARD) of 10/28/22 revealed it was signed as completed on 11/6/22. The assessment was transmitted to CMS on 12/8/2022. An interview with the Corporate MDS Consultant on 4/28/23 at 9:07 AM, revealed she completed facility MDS assessments. The corporate billing office transmitted the assessments. She was unaware the assessments were transmitted late. During an interview on 4/28/23 at 10:42 AM, the Director of Receivables from the Corporate [NAME] department revealed the MDS assessments were transmitted every morning by a support person from the billing department. All completed MDS assessments were transmitted Monday through Friday. Any assessments that were in the queue were transmitted. An Interview on 4/28/23 at 2:13 PM, with the Director of Nursing (DON) revealed MDS assessments needed to be transmitted in a timely manner per regulations. 2.Resident #19 was originally admitted on [DATE], discharged and subsequently readmitted on [DATE]. a. A review of Resident #19's initial admission /5-day MDS assessment with an ARD of 9/6/22, revealed it was signed as completed on 9/12/22. The assessment was transmitted to CMS on 10/13/22. b. A review of Resident #19's most recent admission/5-day MDS assessment with an ARD of 11/4/22, revealed it was signed as completed on 11/14/22. The assessment was transmitted to CMS on 12/8/22. An interview with the Corporate MDS Consultant on 4/28/23 at 9:07 AM, revealed she completed facility MDS assessments. The corporate billing office transmitted the assessments. She was unaware the assessments were transmitted late. During an interview on 4/28/23 at 10:42 AM, the Director of Receivables from the Corporate [NAME] department revealed the MDS assessments were transmitted every morning by a support person from the billing department. All completed MDS assessments were transmitted Monday through Friday. Any assessments that were in the queue were transmitted. An Interview on 4/28/23 at 2:13 PM with the Director of Nursing (DON) revealed MDS assessments needed to be transmitted in a timely manner per regulations. He was aware that there were late assessments.

Based on observations, record review and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by a medication error rate of 10.34% (3 errors out of 29 opportunities) for Resident #235 and Resident #62. The findings included: 1a. A medication administration for Resident #235 was observed on 4/27/23 at 9:26 AM, Nurse #1 administered a simethicone 125 milligram (mg) tablet orally. Review of physician orders 4/14/23 revealed Resident #235 was prescribed simethicone tablet chewable 80 mg by mouth four times a day for heartburn. An interview on 4/27/23 at 2:25 PM, Nurse #1 stated she gave the 125 mg simethicone dose, even though the order was for 80 mg. The 125 mg was the standard dosage provided in the medication cart for the over-the-counter medication. She further revealed she could have contacted Central Supply to obtain 80 mg simethicone tablets. The physician interview on 4/27/23 at 3:18 pm, revealed she was not aware that simethicone 125 mg had been administered to Resident #235 instead of 80 mg. She further revealed that 125 mg simethicone was an acceptable dosage for Resident #235. During an interview on 4/27/23 at 3:27 PM, the Central Supply Secretary revealed the facility's over-the-counter medications were supplied by a vendor. She stated she ordered over-the-counter medication as ordered by the physician. The nurse documented the prescribed over-the-counter medication and dose on a form located at the nurse's station. The vender filled and delivered orders every Tuesday. She indicated she obtained the medication from the vender, the facility pharmacy, or a local pharmacy. An interview on 4/28/23 at 3:15 PM, the Director of Nursing (DON) revealed each nursing station had a form that the nurses filled out for prescribed over-the-counter medication. He further revealed there was a back-up pharmacy to fill over-the-counter medication orders for new prescriptions. He revealed the nurse should have notified the physician when there was a discrepancy between the physician order dose and the dose that was available on the cart during medication pass. 1b. During the medication administration observed on 4/27/23 at 9:26 AM for Resident #235, Nurse #1 did not administer nasal spray sodium chloride nasal solution 0.65% (saline), one spray in each nostril. Review of the physician orders 4/14/23 revealed Resident #235 was prescribed sodium chloride nasal solution 0.65 % (saline) 1 spray in each nostril three times a day for epistaxis (nosebleeds). Nurse #1 was interviewed on 4/27/23 at 2:25 PM, and revealed the nasal spray was not given because she overlooked and missed the order for the nasal spray for morning medication pass. 2. A medication administration was observed on 4/27/23 at 4:35 PM, for Resident #62. Nurse #2 administered 2 grams of diclofenac sodium topical gel 1% to the back of the left hand. Review of the physician orders revealed two orders for diclofenac sodium external topical gel 1%: a) order dated 3/27/23 for diclofenac sodium external topical gel 1%, 2 grams applied for bilateral shoulder pain three times a day, and b) order dated 3/29/23 for diclofenac sodium gel 1%, 2 grams applied to the lower back four times a day for lower back pain. On 4/27/23 at 5:43 PM, Nurse #2 stated there were orders for diclofenac sodium topical gel 1%, 2 grams for Resident #62's back and shoulder areas. She continued Resident #62 denied pain to his back but indicated his left hand and wrist had pain. She indicated she would contact the physician for an order to include left hand and wrist treatment for pain. An interview on 4/28/23 at 3:15 PM, the DON revealed when a resident told the nurse about a pain in a new area, the nurse should have completed an assessment, notified the physician, and obtained a new order for the right patient, right location, right dose, right time, and documented what was done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews the facility failed to provide a dignified experience for Resident #149 who indicated she waited over 3 hours for her call bell to be answered and this made her feel ignored and bad. This was evident for 1 of 5 residents reviewed for dignity. Finding included: Resident #149 was admitted to the facility on [DATE] with current diagnoses of joint replacement surgery and hypertension. Resident #149 ' s admission minimum data set (MDS) assessment had not been completed yet, however Resident #149 was able to make her needs known to staff. During an interview with Resident #149 on 04/05/2022 at 11:30 am revealed her first night at the facility was horrible. Resident #149 indicated she and her roommate got hot and the call bell was put on around 8:00 PM for help with the room temperature and for assistance going to the bathroom. She stated the physician did not want her to try and go to the bathroom by herself. Resident #149 indicated she waited so long she texted a friend around 10:30 pm and her friend called the facility to get her some help. She added a male staff member came to the room around 11:00 PM. Resident #149 indicated during the time he was present in the room she went to the bathroom and got back in bed. Resident #149 stated the male staff members behavior made her feel bad and vulnerable. Resident #149 added she was a ' little afraid of the staff ' s behavior. Resident #149 was thankful for the outside help she received from her friend. Resident #149 indicated this information was reported to someone at the facility the next day, but she couldn ' t remember the name of the staff member she told because she was so new to the facility Review of the grievance log on 04/05/2022 revealed no grievance from Resident #149, however on 04/06/2022 the Administrator provided a grievance from Resident #149 and stated it had been placed under another resident ' s name. An interview was conducted with the Social Worker (SW) on 04/07/2022 at 11:35 am. She indicated she was aware of the incident and stated she had to get the information from the Administrator. SW also indicated that Resident #149 was able to communicate her needs and wants. Review of the grievance revealed the investigation was still being completed by the Administrator. The male staff member who worked with the resident was contacted and no returned call was received. An interview with Nurse Aide #2 on 04/07/22 at 10:30 PM, indicated she worked on 03/31/22, but she was not assigned to Resident #149. She indicated she had no knowledge of any call bell being on for 3 hours or longer. Nurse Aide #2 indicated they answered all the call lights whether they were their assigned resident or not. During an interview with Nurse #2 on 04/08/2022 at 11:52 AM, Nurse #2 indicated he was the Nurse on the hall on 03/31/2022. He indicated after completing the medication pass, he was at the nurse ' s station and received a call from someone outside of the facility that Resident #149 needed help to the bathroom and had waited a long time. Nurse #2 indicated he went to the room and assisted Resident #149 to the bathroom. He stated he was not aware of where the residents Nurse Aide was at that time and was not sure how long the call light had been on Interview with the Director of Nursing (DON) on 04/08/22 at 12:30 PM revealed he expected the staff to treatment residents with respect and dignity. Interview with the Administrator on 04/08/22 at 1:00 PM revealed it was her expectation all residents were treated with respect and dignity. The Administrator stated when she spoke with Resident #149, she did not say anything about her wait time only that the Nurse was unprofessional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interviews, the facility failed to assess a resident to determine if self-administration of medication was clinically appropriate. Resident #85 was observed to have medications in her hand and at bedside. This was evident during one of one observation of Resident #85. Finding included: Resident #85 was admitted to the facility on [DATE] and diagnoses included chronic heart failure, presence of cardiac pacemaker and anemia. Review of Resident #85 ' s admission Minimum Data set (MDS) indicated her cognition was moderately impaired and she needed extensive one-person assist with her activities of daily living, however she could feed herself with set up help only. During an observation on 04/05/22 at 10:33 AM in Resident #85 was observed in her room holding a medication cup of pills. The medication cup included 2 pink pills, one yellow pill, one white pill and one clear capsule. There were 2 tubes of zinc oxide ointment on the bedside table. During an interview with Resident #85 on 04/05/2022 at 10:40 AM Resident #85 indicated the nurses always left her medications with her because it took her a long time to take them. She indicated the nurses would tell her to take them all and she would respond Lord I got so many . Nurse #1 entered Resident #85 ' s room at 10:55 PM on 04/05/22 and indicated she had stepped out of the room to get the resident ' s inhaler. Nurse #1 stated Resident #85 had not been assessed for self-administration of her medication. Nurse #1 indicated she was not sure of the time that she gave Resident #85 her medication, but it was sometime after 10:00 am and it was her 9:00am scheduled medications. Nurse #1 indicated Resident #85 had not been assessed for self-administration. Review of Resident #85 ' s medical record did not reveal a physician ' s order for self-administration of medications. During an interview with the Administrator on 04/08/22 at 1:06 PM she stated it was her expectation for nurses to complete their medication pass and stay in the room with residents to ensure they took their medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to provide a written order for treatment to open skin wounds to bilateral posterior legs for 1 of 2 residents (Resident #248) reviewed for wound care. Resident # 248 was admitted to the facility on [DATE] and had a history of calcific tendinitis of left shoulder, hypertension, anemia, obstructive sleep apnea, morbid obesity, lymphedema, and gastro-esophageal reflux disease. admission minimum data set was not completed, however a review of Resident #248 ' s progress notes indicated her cognition was intact. A review of admission assessment dated [DATE] read in part skin turgor good, normal skin care required, including diabetic skin assessment, dry skin, bruises, abrasions. A review of weekly skin assessment dated [DATE] revealed existing skin conditions as follows: skin tear, resident has excoriated areas to lower back, left buttock, skin tear to rt inner lower leg. A care plan dated 4/1/22 revealed Resident #248 was at risk for pressure ulcer development due to decreased ability to assist with repositioning. Goal was to minimize risk for development of pressure ulcers through the interventions that were in place. Interventions included the use of devices to aid with positioning in bed to reduce friction/shearing. A review of the treatment record (TAR) for the month of April 2022 revealed treatment to cleanse sacral wounds with normal saline, pat dry, apply thick calazime barrier cream every other day. No order was noted for areas to lower back, left buttock, or rt inner lower leg. An interview was conducted on 4/5/22 at 12:18 pm and it was indicated Nursing Assistants (NA ' s) were instructed to provide wound care by mixing of a powder and a cream and applying it to the wounds. An interview was conducted on 4/5/22 at 12:18 pm with Resident #248 and it was indicated Nursing Assistants (NA ' s) were instructed to provide wound care by mixing of a powder and a cream and applying it to the wounds. On 4/6/22 an observation was made of NA #1 (Nurse #1 assisted) provide activities of daily living (ADL) care with Resident #248. NA #1 dried the resident ' s bottom area, she was in the process of applying a nystatin powder to Resident #248, however Nurse #1 stopped NA #1 and stated a Nurse needed to do the wound treatment. On 4/6/22 at 11:12 am an interview was conducted with NA #1. She stated another Nurse had instructed her to apply the nystatin powder to Resident #248 ' s wounds. NA #1 stated she could not recall the Nurses name who instructed her to apply the nystatin powder. On 4/6/22 at 11:15 am an observation was made of Nurse #1 in the process of applying the nystatin powder to Resident #248 ' s wounds and the surveyor noted the nystatin prescription label had another person ' s name on it, not Resident #248 ' s. The surveyor stopped Nurse #1 due to the label on the powder having another person ' s name on it. Nurse #1 asked NA #1 where she got the powder from, and NA#1 stated she got it off the treatment cart. Nurse #1 left the room and returned with a bottle of Nystatin powder with Resident # 248 ' s name on the prescription label that read in part Nyamac (Nystatin topical powder 1000,000 USP units per gram 60 grams). Nurse #1 stated she needed to go check the order and again left the room. Nurse #1 returned to Resident #248 ' s room at 11:22 am and stated she was unable to find an order on the electronic medication record (EMAR), and she stated she was not sure if it was on the treatment administration record (TAR) because she was not able to access the TAR and maybe she wasn ' t able to access the TAR because she was from the Agency, she stated she would find out from the wound nurse and would wait to do the treatment. A review of Resident #248 ' s physician orders for April 2022 revealed no order for nystatin powder. On 4/6/22 at 11:47 am a follow-up interview was conducted with Nurse #1, and she stated she was from the Agency and had been at the facility for 3 days. Nurse #1 added she found the nystatin powder on the treatment cart but could not find the order. She stated again maybe it was because she was from the agency. Nurse #1 indicated she informed the wound nurse the treatment needed to be done. On 4/06/22 at 3:11 pm an interview was conducted with the Director of Nursing (DON), and he stated they did not have an order for the nystatin powder and believed Resident #248 was getting (nystatin powder) in the hospital and that was why the powder was in the facility. He stated his expectation was any medication or treatment order for any treatment was to have an order and to be done as ordered. He also indicated Resident # 248 was alert and oriented and probably brought the medication from the hospital when she admitted to facility. On 4/7/22 at 2:00 pm an interview with the Wound Nurse was conducted and she stated she did not remember telling NA#1 or anyone else to get any medication off the treatment cart or to apply anything on Resident #248 ' s wounds. She stated there was no order for nystatin powder because when Resident #248 came from hospital, the order was on the discharge (d/c) summary, but the doctor did not want it ordered at the time. The Wound Nurse stated, I never used nystatin powder on resident because there was no order. A review of the d/c summary from the hospital dated 3/28/22 revealed medications: current discharge medication list for nystatin (myostatin) 100,00 unit/gram powder apply topical once daily. On 4/7/22 at 2:20 PM a telephone interview was conducted with pharmacy tech, and she stated the pharmacy received the d/c summary for Resident #248 with the medications list from the facility on 3/28/22 with the nystatin powder listed and that was why the pharmacy sent the nystatin powder. On 4/7/22 at 2:30 pm a follow up interview was conducted with the DON, and he indicated the discharge summary was sent to the pharmacy before the nystatin powder was removed from the order list, and they did not have an order for the nystatin powder.

Based on observations, record review, resident and staff interview the facility failed to serve food that was palatable and at an acceptable temperature for 2 of 5 residents (Resident #150 and Resident #154) that were reviewed for food palatability. Findings included: An observation was made of the steam table in the kitchen on April 6, 2022, at 12:20 PM. The lunch meal was already on the steam table and cook #1 revealed she had taken the temperatures already. [NAME] #1 used a digital thermometer to recheck the temperature of the food on the steam table and they were: tomato soup 195 degrees F, grilled cheese sandwich 187 degrees F, spring vegetable stick 168 degrees F and hamburger patties 187 degrees F. A test tray was prepared at 12:33 pm on April 6, 2022, from the kitchen steam table and contained tomato soup, grilled cheese sandwich, and spring vegetable stick. The test tray was delivered to the 200 hall with 14 resident meal trays at 12:37 pm. The last resident ' s meal tray was delivered at 12:55 PM. The Dietary Manager (DM) used the digital thermometer, and the food temperatures were tomato soup 154 degrees F, grilled cheese sandwich 90 degrees F, and spring vegetable stick 111 degrees F. The food items were tasted by the DM and surveyor. The soup was warm, the grilled cheese sandwich was hard to cut and cold and the spring vegetable sticks were hard and cold. The DM agreed that both the grilled cheese sandwich and spring vegetable sticks were hard and cold. During an interview with Resident #150 on April 6, 2022, at 1:10 PM, he stated it was hard to mess up a grilled cheese sandwich and soup, but his food was cold, and the grilled cheese sandwich was hard. Resident #150 indicated the vegetable sticks were nasty and cold. Observation of the resident ' s plate revealed he only took a few bites of the grilled cheese sandwich, spring vegetable stick and the soup. During an interview with Resident #154 on April 6, 2022, at 1:30 PM, he indicated that his lunch was cold, hard, not enough and he wanted something else. During an interview with the DM on April 8, 2022, at 9:30 am she revealed she had only been at the facility for 2 weeks and had already received resident complaints about cold food. The DM added she had conducted some test tray checks and thought the reason the food was cold was because the trays set on the halls for a while before they were delivered to the residents. The DM indicated her staff did what was expected in the kitchen with insulated bases, closed food carts and kept food temperature above the requirement on the steam table. The DM stated it was her expectation that food was served timely, at the appropriate temperature and tasted good. During an interview with the Administrator on April 8, 2022, at 10:30 am, she stated it was her expectation that that all meals were served timely, were palatable and at an appropriate temperature.