**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to accurately document the administration of 14 doses of a seizure medication in the medical record for 1 of 1 resident reviewed for accurate medical records (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included seizure disorder. The neurology visit note dated 8/06/24 revealed Resident #1 was experiencing persistent break through seizures. Resident #1 was ordered to start Cenobamate once a day at bedtime with a gradual dose increase to 100 mg. A review of Resident #1's physician orders revealed the following orders: Cenobamate 50 mg to be administered once a day at bedtime 9/05/24 through 9/18/24. Cenobamate 100 mg to be administered once a day at bedtime 9/19/24 and continue. A review of Resident #1's Medication Administration Record (MAR) from August 2024 through September 2024 revealed Cenobamate 50 mg was documented as given daily at bedtime from 9/05/24 through 9/18/24. A review of the controlled substance count sheet for Cenobamate indicated the last pill was administered to Resident #1 on 9/04/24. An interview with the ADON on 10/10/24 at 11:38 AM indicated she was notified by Nurse #1 on 9/19/24 that there was no Cenobamate on the medication cart for Resident #1. The ADON revealed she notified the Administrator, and they initiated an investigation. The ADON indicated Resident #1 received Cenobamate 12.5 mg for 14 days and 25 mg for 14 days but, the 50 mg and 100 mg doses were never requested from pharmacy. She stated the 50 mg dose was initialed on the MAR as given 9/05/24 through 9/18/24 by Nurse #2 and Nurse #3. She further stated Nurse #2 and Nurse #3 were unable to explain why they initialed administering a medication that was unavailable on the medication cart. A phone interview conducted with Nurse #2 on 10/10/24 at 2:06 PM revealed she worked 2nd shift and was assigned to Resident #1. Nurse #2 indicated she was unaware Cenobamate was not on the medication cart and documented administering the medication on the MAR because she thought she had. A phone interview was conducted with Nurse #3 on 10/11/24 at 9:48 AM. Nurse #3 indicated she worked 2nd shift and was assigned to Resident #1. She stated she was unaware there was no Cenobamate on the medication cart for Resident #1. Nurse #3 further stated she thought she was administering the medication and that was why she documented on the MAR that it was given. An interview with the Administrator on 10/10/24 at 1:50 PM indicated she was notified by the ADON on 9/19/24 that Resident #1's Cenobamate was not on the medication cart. She revealed they initiated an investigation and determined the Cenobamate was not requested from the pharmacy when the dose increased to 50mg. She stated the Cenobamate was ordered at bedtime and they interviewed the 2nd shift (3pm-11pm) nurses (Nurse #2 and Nurse #3) that initialed the MAR that the medication was administered. She stated Nurse #2 and Nurse #3 were unable to explain why they documented a medication was administered when it was unavailable on the medication cart. The Administrator further stated medication administration should be accurately documented in the resident record and on the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident, staff, and Physician Assistant interviews the facility failed to dispose of a plastic bag that had been used to crush medications for Resident #24 and the plastic bag ended up on Resident #23's breakfast tray. Resident #23 believed the crushed white substance was powdered sugar and sprinkled it on his breakfast. This affected 1 of 5 residents reviewed for medication errors. The findings included: Resident #23 was admitted to the facility on [DATE] with diagnoses that included chronic pain. A physician order dated 05/06/24 read, Acetaminophen 500 milligram (mg) by mouth give 2 tablets 3 times a day for chronic pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #23 was cognitively intact and had no behaviors. The MDS further revealed that Resident #23 frequently reported pain of a 9 on a pain scale. Resident #24 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia. A physician order dated 10/18/23 read, Acetaminophen 325 mg by mouth, give 2 tablets every 8 hours for pain. The quarterly MDS dated [DATE] revealed that Resident #24 was severely cognitively impaired and had no nonverbal signs of pain. Review of the Medication Administration Record (MAR) dated July 2024 revealed that Resident #24's acetaminophen had been initialed by staff indicating it had been administered as prescribed. Review of the MAR dated August 2024 revealed that Resident #24's acetaminophen had been initialed by staff indicating it had been administered as prescribed. Resident #23 was interviewed on 08/26/24 at 11:44 AM who stated about a month ago he received his breakfast tray, and he had French toast. Resident #23 stated he loved French toast and was excited that it was on his tray. He stated that on the side of his tray was a plastic bag that had a white powder in it, and he believed it was powdered sugar for his French toast. Resident #23 stated he sprinkled the white powder on his French toast and took a bite and the white powder was bitter and tasted like medication, so he spit the food out and did not eat anything else on his tray. Resident #23 stated he flipped the plastic bag over and it had another resident's name written on the bag and then he believed that the white powder was a medication but stated he did not ingest any because it was bitter, and he spit it out. He also did not know which resident's name was written on the plastic bag. Resident #23 stated he summoned Nurse Aide (NA) #1 to his room and told her what had occurred. Resident #23 stated that later he was interviewed by Unit Manager #1, the former Social Worker, and the Director of Nursing (DON). He also stated that Nurse #1 was giving meds that day and came back to him later and stated she had the plastic bag in her pocket, and it had accidentally fallen on his tray. Resident #23 was unable to quantify how much powder was in the bag but stated it was enough that I thought it was powdered sugar. He picked up a plastic sleeve that was on his lunch tray and approximated that the white powdered substance was one third of the plastic sleeve. Resident #23 also confirmed that nothing like that had happened since that day. Review of the facility's menu revealed that French toast was on the menu for breakfast on 07/09/24. NA #1 was interviewed on 08/26/24 at 12:42 PM. NA #1 stated that she recalled the incident but could not recall when it occurred. She stated that Resident #23 called her to his room and stated he had sprinkled powdered sugar on his French toast and when he put it in his mouth it was bitter, and he thought it was medication that was not his. NA #1 stated she told Resident #23 that they did not have powdered sugar and added that she did not see the white powder or bag on his tray at the time, but she had reported what he said to Nurse #1, and Nurse #1 went and talked to him. Nurse #1 was interviewed via phone on 08/27/24 at 10:15 AM. Nurse #1 stated that she recalled the incident but could not recall when it occurred. She stated she was working and passing medications, and she was asked to help pass out breakfast trays. She stated she had crushed 2 acetaminophen tablets for Resident #24 and administered them to her but the plastic bag that she crushed them in had Resident #24's name on it and she could not throw it in the trash. Nurse #1 stated she put the plastic bag in her pocket of her scrub top with the intention of throwing it in the shred box for destruction. Nurse #1 stated after she passed trays, she reached in her pocket to get the plastic bag out to dispose of it and it was gone. Nurse #1 stated she returned to each room that she had delivered trays to and found the bag in Resident #23's room. Nurse #1 stated that Resident #23 stated he thought it was sugar and she replied to Resident #23 you know that had a name on it and was not sugar but for my protection I reported to my supervisor which was Unit Manager #1. Nurse #1 stated Resident #23 did not report to her that he had tasted it only that he thought it was sugar. Nurse #1 again stated that there was no medication in the plastic bag that she had already given the acetaminophen to Resident #24 and could not explain how Resident #23 sprinkled it on his French toast. Unit Manager (UM) #1 was interviewed on 08/27/24 at 10:42 AM. She stated that she recalled walking up on a conversation between the DON and Nurse #1 about the incident but was not aware of what had occurred. UM #1 stated she had not been informed of the situation by anyone else and was not aware of any of the details, nor was she aware when it occurred or how the situation was handled. The former Social Worker (SW) was interviewed via phone on 08/27/24 at 10:07 AM. The SW explained that she used to be the full-time social worker and had switched to working evenings at the facility. She stated she came in one evening and NA #1 told her what had occurred and that she needed to go and speak to Resident #23. The SW stated she immediately went to talk to Resident #23 who stated that he got a breakfast tray and had French toast and when he was fixing his tray, he found a plastic bag that he thought was powdered sugar, and he had sprinkled it on his French toast and took a bite and it was bitter. Resident #23 stated he spit the food out and did not ingest the substance, but he looked at the plastic bag and it had a resident's name on it. The SW stated she reported the incident to Unit Manager #1 and to the DON and they were going to talk to him. The SW could not recall when the incident occurred but stated she thought it was reported to her on a Monday and the incident had occurred over the weekend, but she was not for sure. The DON was interviewed on 08/27/24 at 11:49 AM. The DON stated she could not recall when the incident occurred, but Nurse #1 had reported to her that she had dropped an empty pouch that had been used to crush medications on Resident #23's tray. The DON stated she asked Nurse #1 if the medication had been given to the correct resident and Nurse #1 replied yes so, the DON stated she did not think anything else about it. She added that she had instructed Nurse #1 to properly dispose of the packaging and to not put it in her pocket. The DON stated Resident #23 had not said anything to her about the situation and the former SW had not reported it to her. The DON stated she was not aware that Resident #23 had sprinkled the medication on his food which she found highly unlikely because Nurse #1 stated the plastic bag was empty. She added that it surprised her that Resident #23 would sprinkle that on his food. The Physician Assistant was interviewed via phone on 08/27/24 at 1:29 PM. He stated that Resident #23 took a lot of acetaminophen for his chronic pain but his dosage was within the acceptable parameters. The Physician Assistant stated if Resident #23 had ingested or taken an extra dose of acetaminophen 650 mg one time there would have been no adverse outcome to him. The facility provided the following corrective action plan with a completion date of 8/5/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: At the time of the incident Resident #23 spit out the food and did not consume it and sent the tray back to the kitchen. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 07/30/24 the DON did an audit of all resident rooms to ensure no medications were noted at bedside or in the room unless the resident had an order to keep medications at bedside including Resident #23. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not reoccur: From 07/30/24 through 08/05/24 all facility nurses and Medication Aides received a medication pass observation by the corporate clinic management team. From 07/24/24 through 08/05/24 all Nurses and Medication Aides received training from the facility DON or corporate clinical management team on the 6 rights of medication administration, medication storage, and limiting interruptions during medication pass for example not taking phone calls or text during medication pass times. The education included the facility's system for disposing of protected health information during medication pass. The system included that any medication packaging that contained protected health information was to be placed in a cardboard box on each medication cart and at the end of the medication pass and taken to the shred box for destruction. Any Nurses or Medication Aides that did not receive the education or medication pass observation were not permitted to work a shift until both had been completed. The education used for the Nurses and Medication Aides was included in the new hire orientation program. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Daily audits were completed by the Medical Records clerk from 08/05/24 through 08/08/24 observing for any medication at bedside or in the resident's room. Weekly audits continue until directed by the QAPI committee. The plan had been approved by the QAPI committee on 07/26/24. Facility date of compliance was 08/05/24. The plan of correction was validated on 08/26/24 through 08/27/24. Alert and oriented residents were interviewed about medications in their room or on their meal tray with no issues reported including Resident #23. A medication pass observation was completed with 30 opportunities and no errors, and no other concerns noted. Nursing staff were interviewed on the 6 rights of medication administration and how and where to dispose of resident's medication packaging that included protected health information. They were able to verbalize that the medication packaging that included protected health information was not placed in the trash can, it was placed in a small cardboard box that sat on top of the medication cart and after the medication pass was completed the box was emptied into the shred box for destruction. The new hire orientation packet was verified to include the medication administration education and medication pass observation. The daily and weekly audits were reviewed. Staff interviews revealed that they observed 10 different resident rooms to ensure there were no medications at bedside unless the resident had an order to keep medications at bedside. The compliance date of 08/05/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a resident interview, interviews with staff and record review, the facility failed to provide food in a form to meet the individual needs of a resident with a physician order for a regular diet with mechanical soft texture (Resident #19). This failure occurred for 1 of 3 sampled residents reviewed for mechanically altered diets. The findings included: A review of menus, recipes and the Diets policy, revised 9/2010 revealed residents with a physician order for a regular diet, mechanical soft texture should receive regular mechanical soft textured foods and meats from the regular menu would be ground, easy to chew and easy to swallow. Resident #19 was admitted to the facility on [DATE]. Diagnoses included dysphagia, oropharyngeal phase, dementia (mild) with mood disturbance, cognitive communication deficit, and psychosis. A review of the August 2024 Physician Order Summary revealed Resident #19 had a physician order for a regular diet with mechanical soft texture. A 8/7/24 quarterly Minimum Data Set assessment, recorded Resident #19's speech was clear, he was understood by others, able to understand, his hearing was adequate, his vision was impaired, he wore corrective lenses, his cognition was intact and he received a mechanically altered diet. A care plan, revised 8/16/24 recorded Resident #19 had a care deficit related to his dentures as he was edentulous, received a mechanically altered diet and that he was resistive to treatment/care (refused to wear his dentures). Interventions included providing his diet as ordered and referrals for dietary concerns related to any swallowing difficulties. A review of the medical record for Resident #19 revealed there was no documentation that he requested to receive crispy bacon or that he was educated on the risks of crispy bacon associated with a mechanically altered diet. Resident #19 was observed on 8/26/24 at 9:19 AM in the Activity Room with other residents and staff for the breakfast meal. Resident #19's breakfast tray was in front of him, but he was not eating. Resident #19 was not wearing dentures. His breakfast tray remained with a partially eaten cheese omelet, a small portion of grits, and crisp bacon that was cut into large pieces and was not ground. Resident #19 did not eat the bacon. The tray card recorded a mechanical soft diet, and the notes section recorded give crispy bacon daily. Resident #19 stated he did not finish eating because he did not like his food. He described that he did not eat the bacon because of his throat issues and stated that he could not eat food that was too hard or too big because if he did, the food got caught in his throat and caused him to cough. Resident #19 stated that every time bacon was on the breakfast menu, which was once or twice per week, he stated, This is what I get, and I can't eat it, so I don't. Resident #19 stated that They have been telling me they are going to fix it on my card for years and they never do, I'm supposed to get my meat ground up, I don't like this bacon because I can't chew it and I can't swallow it, but every time it's on the menu, I get it cut up like this, but I can't eat it, so I don't. Resident #19 further stated that he did not know why the crispy bacon daily was on his tray card, he stated I don't know where that came from, I never asked for bacon, I try not to eat pork/ham. Resident #19 stated that he was supposed to get his breakfast meat ground up, he did not know what kind of meat it was, but ground meat was what he needed and stated, that's what the doctor ordered and that's what I should get. He stated that he was told in therapy that he would receive ground meat and that he agreed to that. Resident #19 stated that Nurse Aide (NA) #1 knew that he was supposed to get ground meat, so when he received foods that he did not like or could not eat, if NA #1 was working that day, she took his tray back to the kitchen and brought him something he could eat. He stated that as many times as NA #1 took his tray back to the kitchen, he thought his card would get corrected, but that it never got fixed. A review of the Spring/Summer cycle breakfast menus revealed bacon was served three times in weeks one and four and twice in weeks two and three. An 8/26/24 interview at 12:00 PM with NA #1 revealed she worked at the facility for over a year and Resident #19 was on her regular assignment. NA #1 stated she did not set up his breakfast tray that morning (8/26/24) and did not know which staff member did, but that he was supposed to receive ground meat with his meals. NA #1 stated that when she did set up his breakfast tray, she made sure he received a mechanical soft diet with ground meat. NA #1 stated that sometimes she had to return his meal tray back to the kitchen, to get it fixed, but that she did not recall if that was because he did not receive something he wanted or if something else was wrong. NA #1 stated that as far as she knew, Resident #19 received a mechanical soft diet, and that she had not noticed before if he received bacon that was cut up and not ground, but that she did not always set up his tray. NA #1 stated that she was not sure why he received bacon that was in pieces too big for him to eat, but that his food came from the kitchen that way. NA #1 stated that on the days she worked, if she saw that he was not eating his food, she checked on him and if he said he did not want his food, she took his tray back to the kitchen to get him something else to eat. An 8/27/24 interview at 10:05 AM with Unit Manager (UM) #1 revealed she worked in the facility for the past four months. UM #1 stated she assisted another resident with his breakfast on 8/26/24 in the Activity Room when she noticed Resident #19 did not finish eating his breakfast. She described he was just looking ahead. UM #1 said she asked Resident #19 if he was okay, but he did not tell her what was wrong. UM #1 stated that since she was assisting another resident, she did not go over to Resident #19 to see what was wrong. UM #1 stated she did not work with Resident #19 that often, and that she was not familiar with his care needs. UM #1 stated she did not set up his breakfast tray on 8/26/24 so she did not notice that his diet order was mechanical soft but that he received large pieces of bacon. During an interview and observation on 8/26/24 at 9:26 AM of Resident #19 with his breakfast tray with the Speech Therapist (ST) and the Rehab Director, the ST stated that she worked in the facility for the past 18 months and Resident #19 discharged from ST caseload in 2023. The ST reviewed the tray card and observed the breakfast meal for Resident #19 and stated she saw on his tray card instructions to give crispy bacon daily and stated that the large pieces of bacon he received did not meet the requirement for ground meat texture for a resident with a diet order for mechanical soft foods. The ST stated that his diet recommendation from ST was for a mechanical soft diet with ground meat and that she assumed he requested the crispy bacon because it was on his tray card, but she wasn't sure. The ST stated that she saw the crispy bacon on his tray card today (8/26/24), but she did not talk to him previously about the risks of eating crispy bacon. The ST stated Resident #19 was his own responsible party and that he could have crispy bacon if he wanted but that he should be educated on the risks associated with receiving foods that were not part of his diet order. The ST stated that she educated Resident #19 on the risks associated with his difficulty swallowing when he was treated in 2023, but that she did not know when the crispy bacon was added to his tray card, and she did not know if he was educated on the risks of eating crispy bacon. The ST stated that Resident #19 refused to be evaluated for ST services since he was discharged from ST in 2023 and expressed at discharge that he would continue to receive a mechanical soft diet. During an interview on 8/27/24 at 2:00 PM with the Certified Foodservice Manager (CFM), he stated that he was the CFM for the past three weeks, he was familiar with Resident #19 because he attended Food Committee Meetings. The CFM stated he received bacon for breakfast that morning (8/26/24) because it was recorded on his tray card and that the bacon was cut up because of his diet order for mechanical soft foods. He reviewed the therapeutic spread sheet during the interview and confirmed that residents with diet orders for mechanical soft foods should receive ground meats. During an observation of Resident #19 on 8/26/24 at 9:25 AM with his breakfast meal and interview with the Registered Dietitian (RD), the RD stated she was not aware that Resident #19 received bacon with his breakfast meal, but that he attended Food Committee Meetings weekly and his concern with receiving bacon had not been discussed. The RD stated that at the Food Committee Meeting on Monday, 8/19/24, Resident #19 communicated that he wanted gravy biscuits, but because his tray card recorded no gravy he did not receive it, so that was corrected, but that he did not mention the bacon, nor had she been informed by staff that he did not want crispy bacon. The RD stated that she assumed Resident #19 must have told someone in the dietary department at some point that he wanted crispy bacon, in order for it to be recorded on his tray card, but she was not sure who because there had been several different dietary managers employed at the facility in just a few months. The RD stated she did not know if Resident #19 was educated on the risks associated with receiving crispy bacon with a diet order for mechanical soft foods, but that ground crispy bacon was impossible to make. The RD stated she had not spoken to Resident #19 about the risks associated with eating crispy bacon since his diet order was for mechanical soft foods. The RD stated Resident #19 should receive ground meat per his diet order and if he requested the crispy bacon, he should be educated on the risks. During an interview on 8/27/24 at 4:15 PM the Rehab Director reviewed the ST notes for Resident #19 and stated he was referred for ST services in 2023 from nursing when he was observed coughing repeatedly with his meal. The Rehab Director stated that nursing immediately downgraded his diet from a regular diet to a mechanical soft diet. The Rehab Director stated that after some time, ST offered to re-evaluate and treat him to upgrade his diet, but although he had dentures, he usually refused to wear them, and he never wore dentures with his meals. The Rehab Director stated that Resident #19 understood safe swallowing techniques, he was able to communicate the techniques, but that he did not implement safe swallowing techniques consistently. The Rehab Director stated that he had not received ST services since 2023, because he stated that he did not like the ST at the facility, so the Rehab Director asked another ST to eval him yesterday (8/26/24). The Rehab Director stated that Resident #19 expressed during the 8/26/24 evaluation that he still did not want to wear his dentures to eat, and if his food was not soft and ground up, he could not swallow it. He stated that he did not like pork and wanted to stay away from bacon. He declined ST treatment services and stated that he would continue with his current diet of mechanical soft foods with ground meats. The Rehab Director stated that since Resident #19 would not wear his dentures to eat, his diet order would remain mechanically soft for his safety. The Administrator stated in an interview on 8/26/24 at 11:45 AM that Resident #19 attended the weekly Food Council Meetings and had not brought up a concern about receiving bacon. The Administrator stated that Resident #19 was his own responsible party and since crispy bacon was recorded on his tray card, she assumed that it was per his request. She stated she was the Administrator at the facility since February 2024 and that in that time staff had not brought to her attention that Resident #19 did not want crispy bacon and that she was not aware if Resident #19 was educated on the risks associated with a diet order for mechanical soft foods and eating crispy bacon. The Nurse Consultant stated on 8/27/24 at 4:00 PM that she did not find documentation in the medical record for Resident #19 that he was educated on the risks associated with crispy bacon and his diet order, but that he should have been educated. She stated that she felt the education occurred, but since it was not documented, she could not be certain. She stated that residents should receive their diet as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, the facility failed to safely assist a resident without causing injury to 1 of 3 residents (Resident #1) reviewed for accidents. Resident #1 was documented to be transferred by a lift and was assisted by Nurse Aide #1 alone. The findings included: Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included dementia and hypertension. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was severally cognitively impaired and required extensive assistance with transfers. Review of Resident #1's care plan revised on 04/19/24 revealed the resident was care planned for Activities of Daily Living (ADL). The goal was for Resident #1's care to be completed with staff support as appropriate to maintain or achieve highest practical level of functioning through the next review. Interventions included chair to bed and to chair transfer required a mechanical life for Resident #1. Review of Resident #1's care guide revised on 04/19/24 revealed Resident #1 required a mechanical lift for transfers. An observation conducted on 07/09/24 at 12:35 PM revealed Nurse Aide (NA) #1 transferred Resident #1 by herself from the bed to the wheelchair to take the resident to the dining room for lunch. No injury or incident was observed. The observation further revealed no care guide was posted or lift present in Resident #1's room at the time of the transfer. An interview conducted with Nurse Aide (NA) #1 on 07/09/24 at 2:15 PM revealed she was an agency staff and had been working in the facility for two weeks. NA #1 further revealed she was not familiar with Resident #1 and assumed the resident was a one person assist because nursing staff had not educated her on Resident #1. NA #1 stated she transferred the resident from the bed to his wheelchair without any issues. NA #1 indicated she was not aware Resident #1 had a history of falls and had not been educated to look at the residents' care guide in the electronic chart for the residents ADLs. An interview conducted with Unit Manager (UM) #1 on 07/09/24 at 1:15 PM revealed Resident #1 had a history of falls. The UM further revealed she could not recall what Resident #1's status was for transfers but knew he was at least a two person assist. UM #1 indicated nursing staff was educated to follow the residents' care guide. UM #1 indicated NA #1 was agency staff and should have not transferred Resident #1 by herself. An interview conducted with Nurse #1 on 07/09/24 at 2:35 PM revealed Resident #1 was a mechanical lift for transfers from the bed to wheelchair. Nurse #1 further revealed nursing staff had been educated to review residents care guides for ADL assistance. Nurse #1 stated NA #1 should have not transferred Resident #1 without assistance due to the resident's history of falls. Interview conducted with the Director of Nursing (DON) on 07/09/24 at 3:20 PM revealed nursing staff had been educated to follow resident care guides and care plan. The DON indicated NA #1 and all staff who were agency had been educated to follow all residents care guides in the electric chart. The DON further revealed Resident #1 was documented to have a mechanical lift for transfers and should have been followed. An interview conducted with Administrator on 07/09/24 at 2:55 PM revealed nursing staff had been educated at orientation to follow resident care guides. Administrator further revealed NA #1 should not have transferred Resident #1 with one assist and followed what was reflected on Resident #1's care guide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #3 re-admitted to the facility on [DATE]. Review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively intact with no psychosis, behaviors, or rejection of care. Review of Resident #3's medical record revealed no documentation that Resident #87 had been assessed to self-administer medications. Further review of Resident #3's medical record revealed no care plan for self-administration of medications. An observation of Resident #3 completed on 05/29/24 at 10:17 AM revealed her to be in her room, sitting in her wheelchair watching television. On Resident #3's overbed tray was a bottle of antacid chewable tablets. Additional observations made on 05/29/24 at 12:50 PM, 2:44 PM, and 3:00 PM all revealed the antacid chewable tablets remained on Resident #3's overbed table. An interview with Nurse #2 on 05/29/24 at 3:58 PM revealed she did not believe that the facility allowed residents to self-administer medications. She reported she knew that none of the residents she cared for on 05/29/23 self-administered medications. Nurse #2 verified she was assigned to care for Resident #3 on 05/29/24 and stated she had not noticed the bottle of antiacid chewable tablets on Resident #3's overbed table. She stated Resident #3 should not have had the bottle of antiacid chewable tablets in her room and reported she would go and remove them and store them on the medication cart where they belonged. Nurse #2 proposed that Resident #4's family had potentially brought the antacid chewable tablets to the facility earlier in the day. An interview with Resident #3 on 05/30/24 at 12:10 PM revealed a family member had brought in the antiacid chewable tablets for her the previous day because she complained about some indigestion. She stated she was unaware she was unable to keep them at her bedside and reported that someone had removed them from her room. Resident #3 verified she had taken some of the antacid chewable tablets. An interview with the Director of Nursing completed on 05/30/24 at 1:24 PM revealed if was not customary for staff to leave medications at resident bedsides. She reported, to her knowledge, there were no residents in the facility that currently had the ability to self-administer medications. She reported the facility's policy required residents to be screened and assessed to ensure they had the cognitive ability to safely administer the medication and keep the medication safe in their room. She indicated that Resident #3 should not have had the antacid chewable tablets in her room for self-administration. An interview with the Administrator on 05/30/24 at 1:1 PM revealed she was made aware that Resident #3 had the antacid chewable tablets in her room during a facility-wide audit that was completed after being informed of other medications being found left at resident bedsides. She reported Resident #3 did not have the authority to keep the antacid chewable tablets at her bedside and indicated that Resident #3 had not been assessed to self-administer medications. The Administrator reported the antacid chewable tablets had been removed from Resident #3's room and were being kept in a secure area until Resident #3's family could pick them up. Based on observations, record reviews, staff and resident interviews, the facility failed to assess residents for the ability to self-administer medications for 2 of 2 residents (Resident #2 and #3) reviewed for self-administering medications. The findings include: 1. Resident #2 was admitted to the facility 10/29/20. A review of Resident #2's physician orders revealed orders for Gabapentin Capsule (to treat nerve pain) 300 milligram (mg) give one capsule by mouth three times a day for neuralgia (nerve pain) dated 02/10/22, and Hydrocodone-Acetaminophen (narcotic analgesic) 5/325 mg give one tablet by mouth three times a day for pain dated 02/10/22. There were no orders to self-medicate. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 was cognitively intact. A review of Resident #2's medical record revealed there was no assessment to self-administration of medications in the record. There was no care plan developed for the Resident to self-administer medications. A review of Resident #2's Medication Administration Record (MAR) for 05/2024 indicated Hydrocodone-Acetaminophen 5/325 mg was given at 12:30 PM on 05/29/24 and Gabapentin Capsule 300 mg was given at 1:00 PM on 05/29/24 and initialed by Nurse #1. On 05/29/24 at 2:46 PM an observation and interview were made of Resident #2. Noted on the Resident's over bed table was a medicine cup that had a yellow capsule and a white pill in the cup. The medication was dry and there was no indication that they were in contact with moisture. Resident #2 explained that Nurse #1 brought him the medications and he had not taken them yet, but he would take them in a little while. When asked what they were for the Resident stated one was for his legs and the other was his pain pill. An interview was conducted with the Director of Nursing (DON) on 05/29/24 at 2:50 PM who was looking for Nurse #1. The DON was asked if the Nurses were allowed to leave medications on the residents over bed table and she replied, absolutely not, there are no residents in house that are allowed to self-medicate. The DON was accompanied to Resident #2's room and the Resident was not in his room and the medicine cup was empty. During an interview with Nurse #1 on 05/29/24 at 3:05 PM the Nurse confirmed that she had medicated Resident #2 earlier and he put the medication in his mouth. She explained that he must have spit them out after he put them in his mouth. Nurse #1 continued to explain that she gave the Resident his medications at 12:45 PM and she thought he took them. On 05/29/24 at 3:45 PM during an interview with the Administrator she explained that the residents were not allowed to self-administer medications unless they had been assessed to be mentally and physically able to self-administer their medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and Resident Representative (RR) and staff interviews the facility failed to provide nail care for 2 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #4 and Resident #5). The findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, and muscle weakness. Resident #4 did not have a diagnosis of diabetes. A review of the shower schedule for Resident #4 revealed he was scheduled to receive showers on Mondays and Fridays. The last documented nail care was on 3/8/2024 and was documented in a nursing progress note. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired with impairment on both sides of the upper and lower extremities. Resident #4 was documented as maximum assist for personal hygiene. A review of the care plan dated 4/4/2024 revealed Resident #4 required staff support to achieve the highest practical level of function for activities of daily living with interventions which included Resident #4 required maximal assistance for personal hygiene. A review of a shower sheet dated 5/28/2024 revealed Resident #4 received a shower that was scheduled to be performed by NA #4. The space for intervention documentation was blank. There was no documentation regarding fingernails being cut or cleaned. An interview was conducted on 5/30/2024 at 9:42 am with NA #4. NA #4 reported she had given Resident #4 a shower on 5/28/2024. NA #4 stated she washed his hair and body but did not cut/clean his fingernails. NA #4 reported she performed nail care when she noticed nails were long and/or dirty but had not noticed Resident #4's nails. A telephone interview was conducted on 5/29/2024 at 9:52 am with Resident #4's RR. The RR stated Resident #4 always had long and dirty fingernails when she would come and visit weekly. She reported she had mentioned her concerns in March of 2024 to nursing staff, including the previous Director of Nursing, at the facility, but it continued to be an issue. An observation was conducted on 5/29/2024 at 9:57 am. Resident #4 was observed to have contractures of both the left and right hands and had quarter-inch long fingernails, on all ten fingernails on both the right and left hands, with a brown substance underneath. There were 4 of Resident #4's fingernails on the right side that touched his right palm and 4 fingernails on the left side that touched his left palm. There was no redness or open areas observed. An interview was conducted on 5/29/2024 at 2:43 pm with NA #3. NA #3 was assigned to care for Resident #4 on 5/29/2024. NA #3 reported he had not noticed Resident #4 had long, dirty fingernails. NA #3 stated the shower team usually performed nail care and that he had not cut and cleaned nails at the facility. NA #3 was asked to observe Resident #4's fingernails. NA #3 verbalized Resident #4's fingernails were long and dirty. An interview was conducted on 5/29/2024 at 2:25 pm with Nurse Aide (NA) #1. NA #1 reported she was on the shower team and was assigned to give showers to residents in the building on their assigned shower days. She reported she had not trimmed or cleaned any residents' fingernails because she was not comfortable cutting nails. NA #1 stated if she noticed a resident's fingernails were long while she was giving them a shower, she would write it down on the shower sheet and tell the hall nurse. An interview was conducted on 5/29/2024 at 2:38 pm with NA #2. NA #2 reported she was on the shower team and was assigned to give showers to residents according to their shower schedule. NA #2 stated she was not responsible for cutting fingernails or toenails and was unsure of who was. NA #2 reported if she noticed a resident had long nails she would report it to the Nurse. An interview was conducted on 5/29/2024 at 3:11 pm with the Staff Development Coordinator (SDC). The SDC reported nursing staff, both NAs and Nurses, were trained about nail care during orientation. The SDC stated both NAs and Nurses were responsible for cutting and cleaning fingernails unless the resident had a diagnosis of diabetes. The SDC stated all staff were trained to cut and clean dirty nails. The SDC reported nail care was to be performed whenever a resident had long or dirty nails regardless if it was the resident's shower day or not. The SDC was not aware if anyone audited nail care in the facility. An interview was conducted on 5/30/2024 at 8:30 am with the Unit Manager. The Unit Manager stated staff had been educated in March of 2024 regarding nail care, including cutting and cleaning. The Unit Manager stated NAs and Nurses could cut and clean nails unless the resident had a diagnosis of diabetes. She reported for residents with a diagnosis of diabetes a podiatry consultation would need to be placed. The Unit Manager was unsure if anyone monitored nail care for the residents. An interview was conducted on 5/30/2024 at 11:43 am with the Director of Nursing (DON). The DON reported nail care should be performed daily and as needed. The DON stated NAs usually cut and cleaned resident's fingernails. The DON reported she was not aware Resident #4 had long, dirty fingernails and reported they should have been cleaned and cut. The DON was unaware if anyone monitored nail care for the residents. An interview was conducted on 5/30/2024 at 11:51 am with the Administrator. The Administrator stated nail care should be performed daily by the hall NAs or as needed. The Administrator stated a lot of staff were not comfortable with cutting fingernails. The Administrator stated if an NA was not comfortable with cutting nails, they should let a Nurse know so someone would perform the task. The Administrator was not aware Resident #4 had long, dirty fingernails. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses which included vascular dementia. Resident #5 did not have a diagnosis of diabetes. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was severely cognitively impaired and required substantial/maximum assistance for personal hygiene. A review of the shower schedule for Resident #4 revealed he was scheduled to receive showers on Tuesdays and Fridays. There was no documentation of nail care in the Electronic Medical Record or shower sheets. A review of the shower sheet dated 5/24/2024 revealed Resident #5 received a shower by NA #1. The space for intervention documentation was blank. There was no documentation of Resident #5's fingernails being cut or cleaned. A review of a care plan dated 5/27/2024 revealed Resident #5 required staff support to achieve highest practical level of function for activities of daily living with interventions which included Resident #5 required substantial/maximum assistance for personal hygiene. An observation was conducted on 5/29/2024 at 10:13 am. Resident #5 was observed to have quarter-inch long fingernails with brown substance underneath all 5 fingernails on the left hand and 4 fingernails on the right hand. Resident #5's right thumb fingernail was approximately a half-inch long, jagged, and had a brown substance underneath. An interview was conducted on 5/29/2024 at 2:25 pm with Nurse Aide (NA) #1. NA #1 reported she was on the shower team and was assigned to give showers to residents in the building on their assigned shower days. NA #1 reported she had given Resident #5 a shower on 5/28/2024 and she had not noticed that her fingernails were long and dirty. She reported she had not trimmed or cleaned any residents fingernails because she was not comfortable cutting nails. NA #1 reported she would clean resident's fingernails during a shower if she had noticed they were dirty. NA #1 stated if she noticed a resident's fingernails were long while she was giving them a shower, she would write it down on the shower sheet and tell the hall nurse. An interview was conducted on 5/29/2024 at 3:11 pm with the Staff Development Coordinator (SDC). The SDC reported nursing staff, both NAs and Nurses, were trained about nail care during orientation. The SDC stated both NAs and Nurses were responsible for cutting and cleaning fingernails unless the resident had a diagnosis of diabetes. The SDC stated all staff were trained to cut and clean dirty nails. The SDC reported nail care was to be performed whenever a resident had long or dirty nails regardless if it was the resident's shower day or not. The SDC was not aware if anyone audited nail care in the facility. An interview was conducted on 5/30/2024 at 8:30 am with the Unit Manager. The Unit Manager stated staff had been educated in March of 2024 regarding nail care, including cutting and cleaning. The Unit Manager stated NAs and Nurses could cut and clean nails unless the resident had a diagnosis of diabetes. She reported for residents with a diagnosis of diabetes a podiatry consultation would need to be placed. The Unit Manager was unsure if anyone monitored nail care for the residents. An interview was conducted on 5/30/2024 at 11:43 am with the Director of Nursing (DON). The DON reported nail care should be performed daily and as needed. The DON stated NAs usually cut and cleaned resident's fingernails. The DON reported she was not aware Resident #5 had long, dirty fingernails and reported they should have been cleaned and cut. The DON was unaware if anyone monitored nail care for the residents. An interview was conducted on 5/30/2024 at 11:51 am with the Administrator. The Administrator stated nail care should be performed daily by the hall NAs or as needed. The Administrator stated a lot of staff were not comfortable with cutting fingernails. The Administrator stated if an NA was not comfortable with cutting nails, they should let a Nurse know so someone would perform the task. The Administrator was not aware Resident #5 had long, dirty fingernails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident, and staff interviews, the facility failed to provide the resident's preference of showers for 1 of 10 residents reviewed for activities of daily living (ADL) (Resident #49). The findings included: Resident #49 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included asthma, cerebral vascular accident or stroke, right side hemiplegia, aphasia, and diabetes mellitus type II. Review of Resident #49's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required total assistance with showering and bathing. The assessment also revealed Resident #49 had no rejection of care behaviors and according to the assessment, it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. An observation and interview with Resident #49 on 02/27/24 at 9:25 AM revealed her up in her wheelchair and dressed for the day. The resident's skin that was visible was dry and flakey. The resident stated she was not getting her showers two times a week as scheduled and stated she preferred to take showers because the hot water felt good to her body. Resident #49 further stated she had not refused any of her showers but had not been offered showers two times per week as scheduled. On 02/28/23 at 2:00 PM a Resident Council meeting was held and Resident #49 was in attendance and again complained during the meeting that she was not getting her showers two times a week as scheduled. Review of the shower schedule for the hall on which the resident resided revealed Resident #49 was scheduled for showers on Tuesday and Friday on 2nd shift (3:00 PM to 11:00 PM). Review of the documentation of showers in the electronic medical record for Resident #49 revealed for the month of February she had only received two showers on 02/13/24 and 02/16/24. On the other days she was scheduled for showers the following was documented: Friday 02/02/24 partial bed bath Tuesday 02/06/24 partial bed bath Friday. 02/09/24 partial bed bath on 1st shift (7:00 AM to 3:00 PM) Tuesday, 02/20/24 partial bed bath on 1st shift Friday, 02/23/24 partial bed bath on 1st shift and on 2nd shift An interview on 02/28/24 at 2:29 PM with Nurse Aide (NA) #4 who was assigned to care for Resident #49 on 02/02/24, 02/06/24, 02/20/24 and 02/23/24 revealed on the days she had not provided the resident with a shower she had given her a partial bath and documented a partial bath. She stated the resident got up early in the morning and sometimes wanted to go back to bed early afternoon before it was time for her shower so she just washed her up in bed. NA #4 further stated she had not asked if Resident #49's showers could be changed to 1st shift because she had been told all B bed residents had their showers on 2nd shift but said she would probably benefit from having her shower time changed from 2nd shift to 1st shift. A telephone interview was attempted with NA #9 who was assigned to care for Resident #49 on 02/09/24 with voicemail message left for return call with no response from the NA. An interview on 02/29/24 at 2:09 PM with Nurse #6 who was assigned to care for Resident #49 revealed she was not aware of the resident refusing showers and said the NAs had not reported to her that she had refused showers so she had not documented a progress note regarding the resident refusing showers. An interview on 02/29/24 at 3:10 PM with Unit Manager #1 revealed she was not aware Resident #49 was not receiving her showers as scheduled and said no one had reported it to her. She stated if the 2nd shift shower were not working for Resident #49, they could certainly switch her to 1st shift showers. Unit Manager #1 stated the normal process for showers was if the resident refused their shower the NA had to go back again a little later and ask the resident if she/he was ready to take their shower and if the answer was no again, the NA was to report that to the nurse. She stated then the nurse was to ask the resident and if the resident refused to the nurse, she was supposed to write a progress note indicating the resident had refused his/her shower despite being asked three times. Unit Manager #1 further stated the NA should have reported the timing of Resident #49's shower not working for her and it could have been changed to accommodate the resident. An interview on 02/29/24 at 4:53 PM with the Director of Nursing (DON) revealed they had struggled with getting the NAs to give and document showers and said it was a process they were currently working on with the NAs. She stated she expected residents to have their showers as scheduled and said if they did not receive their showers, she expected them to receive a complete bed bath not a partial bed bath and for it to be documented. The DON further stated if the resident refused their shower, she expected the nurse to document the refusal in their progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for resident with mental health diagnosis upon admission and residents with new mental health diagnoses for 3 of 6 residents (Resident# 141, #31, #49) reviewed for PASRR. The findings include: 1. Review of Resident #141's medical record revealed the resident had a PASRR level I completed prior to her admission and was admitted to the facility on [DATE]. The resident had been diagnosed with delusional disorder on 08/31/23 and dementia, severe, with psychotic disturbance as part of her admission. No PASRR level II had been completed per Resident #141 medical records. During an interview on 02/29/24 at 4:05 PM with the Social Worker (SW) revealed she had been employed as the facility SW over the past year and since that time had been responsible for completing PASRR upon a resident admission, when a change in condition or behavior had occurred, or when there had been a new diagnosis. She revealed she would review a resident's diagnosis once they were admitted seeing if they would require a level II PASRR to be completed and should be notified by nursing if a new diagnosis had been added for a resident or there had been a change in condition. The SW stated Resident #141 admission diagnosis and level of PASRR had simply been overlooked, however based on Resident #141 admission diagnosis of delusional disorder and dementia, severe, with psychotic disturbance and the preadmission PASRR level I, paperwork for a PASRR level II should have been completed. During an interview on 02/29/24 at 4:15 PM with the Administrator revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #141 admission diagnosis of delusional disorder and dementia, severe, with psychotic disturbance a PASRR level II should have been completed. 2. Review of Resident #31's medical record revealed the resident had a PASRR level I completed prior to his admission and was admitted to the facility on [DATE]. The resident was diagnosed with dementia with mood disturbance disorder on 05/05/23. No PASRR level II had been completed per Resident #31 medical records. During an interview on 02/29/24 at 4:05 PM with the Social Worker (SW) revealed she had been employed as the facility SW over the past year and since that time had been responsible for completing PASRR upon a resident admission, when a change in condition or behavior had occurred, or when there had been a new diagnosis. She revealed she would review a resident's diagnosis once they were admitted seeing if they would require a level II PASRR to be completed and should be notified by nursing if a new diagnosis had been added for a resident or there had been a change in condition. The SW stated she had not been made aware of Resident #31's new mental health diagnosis of dementia with mood disturbance and felt it could have been an oversight, however based on his new diagnosis and the preadmission level I PASRR, paperwork for a PASRR level II should have been completed. During an interview on 02/29/24 at 4:15 PM with the Administrator revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #31 newly added diagnosis of dementia with mood disturbance disorder a PASRR level II should have been completed. 3. Review of Resident #49's medical record revealed the resident had a PASRR level I completed prior to her admission and was admitted to the facility on [DATE]. The resident was diagnosed with major depressive disorder on 11/28/22. No PASRR level II had been completed per Resident #49 medical records. During an interview on 02/29/24 at 4:05 PM with the Social Worker (SW) revealed she had been employed as the facility SW over the past year and since that time had been responsible for completing PASRR upon a resident admission, when a change in condition or behavior had occurred, or when there had been a new diagnosis. She revealed she would review a resident's diagnosis once they were admitted seeing if they would require a level II PASRR to be completed and should be notified by nursing if a new diagnosis had been added for a resident or there had been a change in condition. The SW stated she was not aware of Resident #49 not having a level II PASRR, however based on her new diagnosis of major depressive disorder and the preadmission level I PASRR, paperwork for a PASRR level II should have been completed. During an interview on 02/29/24 at 4:15 PM with the Administrator revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #49 newly added diagnosis of major depressive disorder a PASRR level II should have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 51 was admitted to the facility on [DATE] with diagnoses including neurogenic bladder and a chronic autoimmune disorder that affects movement, sensation and bodily function. Review of Resident #51's current care plans initiated 3/4/21 and revised on 4/2/23 revealed a focus area for the resident being at risk for actual infection related to COVID 19 Virus. Will be free of signs and symptoms of infection through next review. Interventions Medications as ordered, treatment as ordered, encourage resident compliance with infection, encourage resident to report signs and symptoms of infection to the nurse, and isolation precautions. A care plan initiated on 3/28/22 and revised 4/2/23 stated at risk for actual infection r/t fungi candida, resident will receive appropriate treatment for infection with resolution through next review. Interventions medications as ordered by physician, and to educate care staff on performing personal hygiene. Resident #51 had a quarterly Minimum Data Set (MDS) assessment completed on 1/17/24. An interview with the MDS Coordinator #1 on 2/29/24 at 3:56 PM revealed that care plans should be reviewed and revised with each MDS assessment and be made inactive when a problem is resolved. MDS Coordinator #1 stated she was not aware that some of the care plans had not been revised in over a year. Stated that the last MDS Nurse left about two months ago had completed Resident #51 quarterly MDS on 1/17/24. MDS Nurse #1 indicated they were still trying to review and update everything. An interview with the Director of Nursing (DON) on 2/29/24 at 4:46 PM revealed that expectations were that care plans were initiated, revised, or completed as the resident condition changed. An interview with the Administrator on 2/26/24 at 5:06 PM revealed she expected all care plans to be updated and revised in a timely manner. Stated that the Corporate MDS Consultant was scheduled to be in the building the following week to help the new MDS staff with training and job duties since they are both relatively new to the position. 3. Resident #83 was admitted to the facility on [DATE] with diagnoses that include dementia, and cerebral vascular accident (CVA). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had moderate cognitive impairment. Review of Resident 83's medical record revealed the last documented care plan meeting occurred on 11/08/2022. A phone interview was conducted with Resident #83's responsible party (RP) on 02/26/2024 at 1:13 PM. The RP revealed she had not attended a care plan meeting for Resident #83 in a very long time. She further stated that she believed there was no care plan meeting scheduled for Resident #83 for the entire 2023 calendar year. Social Worker (SW) #2 was interviewed 02/29/2024 at 8:37 AM. SW#2 confirmed Resident #83 had not had a care plan meeting since 11/08/2022. She stated she had only been in her position for 3 weeks and was currently working to get the care plan meetings caught up. She further stated that there were several residents who were long overdue for care plan meetings. She also revealed she expected care plan meetings to be scheduled quarterly. She also stated it would be the SW's responsibility to create and maintain the care plan meeting calendar, send out the care plan meeting invitations, and hold the care plan meeting. An interview was completed on 02/29/2024 at 9:06 AM with the Administrator. The Administrator stated that she realized the care plan meeting process was behind schedule and the facility was currently working to ensure care plan meetings were being held. Based on record review, staff interviews, and observations the facility failed to revise a smoking care plan for Resident #75, resolve inactive care plans for Resident #51 and schedule quarterly care plan meetings (Resident #83) for 3 of 5 sampled residents. The findings included: 1. Resident #75 was admitted to the facility on [DATE] with hypertension. Review of Resident #75's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively impaired and was independent for most activities of daily living (ADL). Review of Resident #75's quarterly smoking assessments dated 01/27/24 revealed the resident was an unsafe smoker and required to be supervised. Review of Resident #75's care plan revised on 03/29/23 revealed on the resident's care guide that resident smoking status was an independent smoker and may smoke at time of own choice without supervision. A joint interview with the MDS coordinator #1 and MDS coordinator #2 on 02/29/24 at 3:30 PM revealed Resident #75 was an unsafe smoker, and the resident's care plan should have reflected that. An interview conducted with the Director of Nursing (DON) on 02/29/24 at 4:50 PM revealed Resident #75 was an unsafe smoker, and the resident's care guide should have reflected that. The DON further revealed staff review the resident's care guide for care areas. An interview conducted with the Administrator on 02/29/24 at 5:15 PM revealed residents who are considered unsafe smokers should have been care planned as an unsafe smoker. It was further revealed Resident #75's care guide on the care plan should have not stated the resident was a safe smoker.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #28 was admitted to the facility on [DATE] with a diagnosis of anxiety and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. The MDS revealed Resident #28 received an antipsychotic medication during the assessment period. The active physician's orders for December 2023 for Resident #28 included an order dated 11/09/23 for Seroquel 25 mg give 1 tablet by mouth two times a day for depression. A Medication Administration Record (MAR) dated December 2023 revealed the Seroquel 25 mg scheduled for 8:00 PM was not documented as given on 12/10/2023. 3. Resident #110 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 was cognitively intact. The active physician's orders for December 2023 for Resident #110 included an order dated 12/04/23 for Amoxicillin 500 mg give 1 tablet by mouth two times a day for a bacterial infection for 10 days. A Medication Administration Record (MAR) dated December 2023 revealed the Amoxicillin 500 mg scheduled for 8:00 PM was not documented as given on 12/10/2023. A facility investigation summary dated 12/12/23 revealed the facility interdisciplinary team was reviewing the Medication Administration Audit report for the previous 48 hours and noted the medication errors and Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88 and Resident #110 had not been administered their medication during the 7:00 PM to 11:00 PM shift. An investigation was then initiated, and the Medical Director was notified. The investigation was completed by the Regional Nurse Consultant who identified the cause of the incident was due to a nurse not reporting for the 7:00 PM to 11:00 PM shift. An interview conducted on 02/28/24 at 4:30 PM with the Director of Nursing (DON) revealed on 12/10/23 around 6:30 PM she was told by Unit Manager #1 that Nurse #2 had called out for the 7:00 PM to 11:00 PM shift. She stated Unit Manager #1 told her that Nurse #3, Nurse #4 and Nurse #5 were instructed to split the medication cart and had taken report on the residents. She stated she heard the next morning that some residents had not received their medication. The interview revealed residents including Resident #28 and Resident #110 did not receive any scheduled medication. She stated Nurse #5 told her she had completed her assigned half and thought someone else was going to administer the rest of the residents' medication. The DON stated it was a communication error between the nurses. She stated no adverse outcomes had occurred from the incident and no residents needed medical treatment due to not receiving their medication. On 02/29/24 at 11:20 AM an interview was conducted with the Medical Director. During the interview he stated he was notified by the facility that the residents had missed their medication on 12/10/23. The interview revealed he notified the Nurse Practitioner's that were in the facility of the incident and that nurses on the unit were monitoring the residents for any changes of condition. He stated no residents were having symptoms from not receiving their medication. The MD stated although medication such as anticoagulants, opioids, antipsychotics and insulin were significant, it would not be harmful to the residents to miss one dose. The interview revealed none of the residents identified to have missed their medication were sent to the hospital or experienced a change of condition. Based on observations, record review, and staff interviews, the facility failed to follow physician orders for 1 of 4 wounds (non-pressure of left knee) on 1 of 3 residents (Resident #128) reviewed for wound care and failed to administer medications as ordered by the physician for 2 of 16 residents reviewed for medication errors (Residents #28 and #110). The findings included: Resident #128 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included congestive heart failure, Alzheimer's disease, dementia, and osteoarthritis. Review of Resident #128's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely/never understood and rarely/never understands and had no speech. The assessment also revealed she was severely impaired and was dependent on staff for assistance with all activities of daily living (ADL) and anticipation of her needs. The assessment additionally revealed she had two unhealed stage II pressure ulcers and had pressure reducing device for bed, nutrition, and hydration interventions to manage skin problems, pressure injury care, and application of medications and dressings. Review of Resident #128's Treatment Administration Record (TAR) dated 02/01/24 through 02/29/24 revealed the following orders for wound care: 1. Cleanse the left knee with wound cleanser, apply dermasyn hydrogel AG (antimicrobial silver wound gel that facilitates moist wound healing), cover with gauze and dry dressing every day shift (7:00 AM to 7:00 PM) for wound healing. 2. Cleanse the right outer ankle with wound cleanser, apply xeroform (petroleum-based fine mesh gauze that has antimicrobial properties used for wound healing), and cover with dry dressing every day shift (7:00 AM to 7:00 PM) for wound healing. An observation of wound care was made on Resident #128 on 02/28/24 at 9:13 AM with the Treatment Nurse. The Treatment Nurse gathered her supplies for the four wounds and began with the right outer ankle wound. She removed the old dressing, cleaned the wound with wound cleanser-soaked gauze and applied hydrogel AG-soaked gauze and covered it with a bordered gauze dressing. The Treatment Nurse then moved to the left knee, removed the old dressing, cleaned the wound with wound cleanser and applied xeroform gauze to the wound bed and covered it with a bordered gauze dressing. As she was completing the left knee dressing, the Treatment Nurse said, I think I mixed up my dressings. An interview on 02/29/24 at 9:59 PM with the Treatment Nurse revealed she realized while doing the left knee that she had mixed up the treatments on the right outer ankle and left knee and had applied the wrong treatments to the wounds. She stated she was nervous about being watched and had just mixed up the dressings for those two wounds even though she had labeled the treatments for each wound. An interview on 02/29/24 at 11:51 AM with the Director of Nursing (DON) revealed she expected the wound treatments to be done as prescribed by the physician. She stated she thought the Treatment Nurse was nervous about being watched during wound care and just got the two wound treatments mixed up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 51 was admitted to the facility on [DATE] with diagnoses including neurogenic bladder and a chronic autoimmune disorder that affects movement, sensation and bodily functions. Resident #51's care plan initiated 1/17/24 revealed a focus area for the resident having an activities of daily living (ADL) self-care deficit due to [chronic autoimmune disorder that affects movement, sensation and bodily functions] and neurogenic bladder. The interventions included assisting with activities of daily living (ADL), dressing, grooming, toileting, promote independence and dignity, and provide positive reinforcement for all activities. Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed total dependence for toilet and bathing. Impaired range of motion was noted to bilateral lower extremities. The resident was coded as always incontinent of bowel and for the presence of a supra pubic catheter. An observation was conducted on 02/28/24 at 1:40 PM of Resident #51 receiving incontinence care from NA #1. While providing incontinence care NA #1 was observed wiping the resident starting under the scrotum and wiping up towards his penis with wash cloth that had soap and water on it. NA#1 continued wiping several more times from under the scrotum up towards the resident's abdomen while using the same surface of the washcloth. When the resident turned on his side there was visible bowel movement on his left and right buttocks and anal area. NA #1 continued with the same washcloth and continued to wipe with downward motion and was observed wiping bowel movement from anal area towards the scrotum. The NA folded the washcloth to change surfaces when cleaning the resident. This process continued until all bowel movement was removed from the resident's skin. Interview on 02/28/24 at 1:50 PM with NA #1 revealed he believed he had done a good job providing incontinence care on Resident #51 and did not realize he had been wiping from lower perineal region to upper perineal area. Stated he was nervous and must not have been thinking. NA #1 stated that he should have started at the penis and wiped down toward the anal area, and from the anal area to the upper buttocks. NA #1 further stated he should have started on the upper perineal area and wiped down towards the scrotal area, and from the anal area to the upper buttocks. NA #1 stated he had been trained in how to provide incontinence care. Interview on 02/29/24 at 4:46 PM with the Director of Nursing (DON) revealed she would expect nursing staff to follow the care plans and facility policies. The DON stated that all employees have been trained in incontinence care and the appropriate process was to always be followed. Based on observations, record reviews, resident, and staff interviews, the facility failed to provide showers and hair washing to 1 of 10 residents (Resident #94) and failed to provide incontinence care as trained for 1 of 10 residents (Resident #51). These failures occurred for 2 of 10 residents reviewed for activities of daily living (ADL). The findings included: 1. Resident #94 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II, vitamin deficiency, dementia, and anorexia. Review of Resident #94's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and required total assistance with showering and bathing. The assessment also revealed Resident #94 had no rejection of care behaviors. Review of Resident #94's care plan revealed a focus area for activities of daily living/personal care deficit related to dementia. The interventions included personal hygiene with substantial/maximal assistance and showering/bathing dependent on staff. An observation and interview with Resident #94 on 02/26/24 at 11:42 AM revealed the resident sitting in her wheelchair in her room, dressed for the day. The resident's hair appeared greasy and disheveled and she stated she was not getting her showers as scheduled two times per week. Resident #94 further stated she preferred showers because she liked to get her hair washed when she was bathed. Review of the shower schedule for the hall on which the resident resided revealed Resident #94 was scheduled for showers on Tuesday and Friday on 1st shift (7:00 AM to 3:00 PM). Review of the documentation of showers in the electronic medical record for Resident #94 revealed for the month of February she had only received one shower on 02/27/24. On the other days she was scheduled for showers the following was documented: Tuesday 02/06/24 no indication or documentation Tuesday, 02/13/24 no indication or documentation Tuesday, 02/20/24 no shower or bed bath given Friday, 02/23/24 partial bed bath (not a complete bed bath) A telephone interview on 02/29/24 at 10:46 AM with NA #8 who was assigned to care for Resident #94 on 02/06/24 and 02/13/24 stated if she were assigned to a resident and did not have time to give them a shower, she would wash them up in bed and document it as a partial bath but said it was not a complete bed bath. NA #8 stated she could not recall why she had not given Resident #94 a shower on 02/06/24 or 02/13/24 but said it was most likely due to staffing issues. An interview on 02/28/24 at 10:34 AM with NA #12 who was assigned to care for Resident #94 on 02/09/24 revealed if she was assigned to the resident and had given her a complete bed bath instead of a shower it was due to not having time to shower the resident. She stated they were short of help sometimes and it was less time-consuming to give residents a bed bath than shower. An interview on 02/29/24 at 1:45 PM with NA #7 who was assigned to care for Resident #94 on 02/23/24 revealed she could not recall why she had not given the resident a shower as scheduled. She stated there were days they worked short of help and that could have been one of those days when she did not have time to give the resident a shower and just bathed her in bed and documented it as a partial bath. NA #7 further stated when she showered residents, she tried to cut their nails and shave them as needed but did not always have time to do so due to staffing issues. An interview on 02/29/24 at 3:10 PM with Unit Manager #1 revealed she was not aware Resident #94 was not receiving her showers as scheduled and said no one had reported it to her. She stated the normal process for showers was if the resident refused their shower the NA had to go back again a little later and ask the resident if she/he was ready to take their shower and if the answer was no again, the NA was to report that to the nurse. Unit Manager #1 further stated that the nurse was to ask the resident and if the resident refused the nurse, she was supposed to write a progress note indicating the resident had refused her/his shower despite being asked three times. She indicated if the NAs were having difficulty completing their showers, they should have reported that to her so she could have provided them with additional staff to assist with showers. An interview on 02/29/24 at 4:53 PM with the Director of Nursing (DON) revealed they had struggled with getting the NAs to give and document showers and said it was a process they were currently working on with the NAs. She stated she expected residents to have their showers as scheduled and said if they did not receive their showers, she expected them to receive a complete bed bath not a partial bed bath and for it to be documented. The DON further stated if the resident refused their shower, she expected the nurse to document the refusal in their progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to follow physician orders for 1 of 4 wounds (pressure ulcer of right outer ankle) on 1 of 3 residents (Resident #128) reviewed for wound care. The findings included: Resident #128 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included congestive heart failure, Alzheimer's disease, dementia, and osteoarthritis. Review of Resident #128's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely/never understood and rarely/never understands and had no speech. The assessment also revealed she was severely impaired and was dependent on staff for assistance with all activities of daily living (ADL) and anticipation of her needs. The assessment additionally revealed she had two unhealed stage II pressure ulcers and had pressure reducing device for bed, nutrition, and hydration interventions to manage skin problems, pressure injury care, and application of medications and dressings. Review of Resident #128's Treatment Administration Record (TAR) dated 02/01/24 through 02/29/24 revealed the following orders for wound care: 1. Cleanse the right outer ankle with wound cleanser, apply xeroform (petroleum-based fine mesh gauze that has antimicrobial properties used for wound healing), and cover with dry dressing every day shift (7:00 AM to 7:00 PM) for wound healing. 2. Cleanse the left knee with wound cleanser, apply dermasyn hydrogel AG (antimicrobial silver wound gel that facilitates moist wound healing), cover with gauze and dry dressing every day shift (7:00 AM to 7:00 PM) for wound healing. An observation of wound care was made on Resident #128 on 02/28/24 at 9:13 AM with the Treatment Nurse. The Treatment Nurse gathered her supplies for the four wounds and began with the right outer ankle wound. She removed the old dressing, cleaned the wound with wound cleanser-soaked gauze and applied hydrogel AG-soaked gauze and covered it with a bordered gauze dressing. The Treatment Nurse then moved to the left knee, removed the old dressing, cleaned the wound with wound cleanser and applied xeroform gauze to the wound bed and covered it with a bordered gauze dressing. As she was completing the left knee dressing, the Treatment Nurse said, I think I mixed up my dressings. An interview on 02/29/24 at 9:59 PM with the Treatment Nurse revealed she realized while doing the left knee that she had mixed up the treatments on the right outer ankle and left knee and had applied the wrong treatments to the wounds. She stated she was nervous about being watched and had just mixed up the dressings for those two wounds even though she had labeled the treatments for each wound. An interview on 02/29/24 at 11:51 AM with the Director of Nursing (DON) revealed she expected the wound treatments to be done as prescribed by the physician. She stated she thought the Treatment Nurse was nervous about being watched during wound care and just got the two wound treatments mixed up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to complete a quarterly smoking assessment 1 of 3 residents reviewd for smoking (Resident #75). The findings included: Resident #75 was admitted to the facility on [DATE] with hypertension. Review of Resident #75s quarterly Minimum Dat set (MDS) dated [DATE] revealed the resident was cognitively impaired and was independent for most activities of daily living (ADL). Review of Resident #75's care plan revised on 03/29/24 revealed the resident had problematic manner in which the resident acts characterized by use of tobacco. The goal was for resident #75 to smoke safely in designated areas with supervision through the next review. Interventions included to evaluate residents ' ability to smoke safely on a consistent and regular basis. Review of Resident #75's quarterly smoking assessments revealed the resident did not receive a quarterly smoking assessment from 09/27/23 until 01/27/24. A joint interview was conducted with the MDS coordinator #1 and MDS coordinator #2 on 02/29/24 at 3:30 PM revealed Resident #75 was an unsafe smoker, and an assessment should have been completed quarterly. It was further revealed Resident #75 did not receive a quarterly smoking assessment from 09/27/23 until 01/27/24 and could not recall why it was not updated in the quarterly time frame. An interview conducted with the Director of Nursing (DON) on 02/29/24 at 4:50 PM revealed Resident #75 should have had a quarterly smoking assessment completed due to being an unsafe smoker. It was further revealed by the DON she was not aware Resident #75 had a late completed assessment and it should have been completed prior to 01/27/24. An interview conducted with the Administrator on 02/29/24 at 5:15 PM revealed residents who are considered unsafe smokers should have a smoking assessment completed quarterly. The Administrator stated she expected assessments to be completed in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, family member and staff interviews, the facility failed to provide effective orientation to a new nurse when Nurse #8 failed to supervise Nurse #9 during medication administration resulting in a resident receiving the wrong medications. This deficient practice affected 1 of 1 resident reviewed for medication administration. (Resident #83). The findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA), high blood pressure, dementia, and diabetes mellitus (DM). Review of the December 2023 physician orders for Resident #83 revealed the following medications: -Sertraline (antidepressant) 150 milligrams (mg) 1 tablet by mouth one time a day for depression. -Vimpat Oral Solution (anti-seizure) 250mg by mouth two times a day for seizures. -Divalproex Sodium (anti-seizure) delayed release 250 mg 3 tablets by mouth twice a day for neurological disorder. -Xarelto (anticoagulant) 20 mg 1 tablet by mouth one time a day for deep vein thrombosis prevention. -Amlodipine Besylate 10 mg 1 tablet by mouth daily for high blood pressure. Resident #30 was admitted to the facility on [DATE]. A review of the physician orders dated December 2023 revealed Resident #30 had orders for: -Diltiazem (cardiac medication) 120mg extended release 1 capsule by mouth one time a day for atrial fibrillation. -Citalopram Hydrobromide 10 mg one tablet by mouth daily for depression. -Lasix (diuretic/fluid pill) 20 mg by mouth one time day for fluid. -Seroquel (antipsychotic) 25 mg by mouth three times a day for schizoaffective disorder -Ativan (anti-anxiety) 0.5 mg by mouth twice a day for anxiety. Review of an incident report dated 12/27/2023 at 1:30 PM written by Nurse #8 revealed Resident #83 had received Resident #30's medications which included: Lasix 20 mg, Ativan 0.5 mg, Seroquel 25 mg, Celexa 10 mg, and Diltiazem 120 mg. An interview was conducted on 02/26/2024 at 13:20 PM with Resident #83's RP. The RP stated the facility reported to her that a medication error had occurred. She further stated that a new nurse who was still being oriented gave Resident #83's the wrong medications. She also stated that the nurse in training should not have been allowed to administer medications without another staff member being present. Multiple unsuccessful attempts were made to contact Nurse #8, and Nurse #9 (nurse in training) for interview. An interview was conducted on 02/28/2024 at 11:40 AM with the Director of Nursing (DON). The DON revealed that during a medication pass, Resident #83 was given the incorrect medications. Nurse #9 was being oriented by Nurse #8. Nurse #8 was standing at the medication cart and Nurse #9 went into the room to administer the medications. Nurse #9 got confused about the room numbers and got bed A and bed B mixed up. Nurse #8 went into the room when she saw Nurse #9 at Resident #83's bedside. Nurse #9 had already given Resident #30's medications to Resident #83. The DON also stated Nurse #8 and Nurse #9 were no longer employed by the facility. She further stated Nurse #8 should have stayed with Nurse #9 throughout the entire medication pass especially when actually administering the medications at the bedside. She stated nursing staff should have provided the correct medication to the correct resident. The DON also revealed Nurse #8 and Nurse #9 completed the facility nursing orientation which included a review of the Six Rights of Medication Administration (a method used during medication administration to safeguard residents before giving the medications).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #110 was admitted to the facility on [DATE]. The quarterly Minimum Data Sheet (MDS) assessment dated [DATE] indicated Resident #110 was coded for the use of a limb restraint less than daily. The previous annual MDS dated [DATE] indicated no use of restraints. Review of Resident #110's current care plans dated 12/1/23 revealed Resident #110 had no restraint care plan. An interview was conducted with MDS Coordinator #1 and MDS Coordinator #2 on 2/29/24 at 3:56 PM. MDS Coordinator #1 explained Resident #110's MDS assessment dated [DATE] was completed by another MDS Coordinator who was no longer employed at the facility. The MDS Coordinator #2 confirmed Resident #110 did not use a limb restraint now and had not used one in the past. The MDS Coordinator #2 stated it was likely an entry issue and they would look into the entry. During an interview on 2/29/24 at 5:06 PM, the Administrator stated it was her expectation for MDS assessments to be completed accurately. The Administrator further stated that MDS entries should be checked before final submission. Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 3 of 6 residents (Resident #41, #102, #84) reviewed for Preadmission Screening and Resident Review (PASRR), and 1 of 3 residents (Resident #110) reviewed for restraints. Findings Include: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, anxiety, and psychosis. Review of PASRR Level II determination letter from July 2021 revealed Resident #41 had met the requirements for a level II PASRR due to having mental illness diagnosis with specialized services required. The annual MDS assessment dated [DATE] indicated Resident #41 was cognitively intact and was not coded as having a level II PASRR. An interview with the MDS Coordinator on 02/29/24 at 3:28 PM revealed she had begun working at the facility in October 2023 and was not aware that Resident #41had a level II PASRR or that it had been coded on his MDS. She stated Resident #41's MDS did not reflect him having a level II PASRR assigned and that was an oversight based on human error and a correction would need to be made. An interview with the Administrator on 02/29/24 at 4:08 PM revealed she had just begun at the facility on Monday 02/26/24 and was not aware of Resident #41 PASRR level not being reflected on his MDS. She stated their process would be for the MDS to reflect current PASRR level and to be accurate. She felt it was just an oversight based on human error on the part of the MDS Coordinator. The Director of Nursing (DON) was interviewed on 02/29/24 at 4:45 PM revealed she was not aware of Resident #41 PASRR level was not reflected on his MDS and believed it was probably due to an oversight on the part of the MDS Coordinator. She stated MDS should reflect current PASRR level for all residents and a correction would need to be made. 2. Resident #102 was admitted to the facility on [DATE] with diagnoses that included dementia. Review of PASRR level II determination letter from May 2021 revealed Resident #102 met the requirements for a level II PASRR due to diagnosis of dementia. The annual MDS assessment dated [DATE] indicated Resident #102 was moderately cognitively impaired and was not coded as having a level II PASRR. An interview with the MDS Coordinator on 02/29/24 at 3:28 PM revealed she had begun working at the facility in October 2023 and was not aware that Resident #102 had a level II PASRR or that it had not been coded on her MDS. She stated she believed Resident #102's MDS not reflecting her having a level II PASRR assigned was an oversight based on human error by the previous MDS Coordinator and a correction would need to be made. An interview with the Administrator on 02/29/24 at 4:08 PM revealed had just begun at the facility on Monday 02/26/24 and was not aware of Resident #102 PASRR level not being reflected on her MDS. She stated their process would be for the MDS to reflect current PASRR level and to be accurate and they felt it was just an oversight based on human error on the part of the MDS Coordinator. The Director of Nursing (DON) was interviewed on 02/29/24 at 4:45 PM revealed she was not aware of Resident #102 PASRR level was not reflected on her MDS and believed it was probably due to an oversight on the part of the MDS Coordinator. She stated MDS should reflect current PASRR level for all residents and a correction would need to be made. 3. Resident #84 was admitted to the facility on [DATE] with diagnoses of dementia, schizophrenia, and anxiety. The most recent annual Minimum Data Set assessment dated [DATE] indicated Resident #84 was not currently considered by the state level II PASRR process to have serious mental illness. Review of Resident #84's electronic medical record revealed a Halted level II PASRR identification number noted in the demographic information. During an interview on 2/29/24 at 3:34 PM MDS Coordinator #1 indicated it was the responsibility of the MDS coordinator to enter PASRR information onto the MDS assessment at admission and annually. She further indicated she initially understood Resident #84's PASRR to be halted and therefore Resident #84 was not considered to have a level II PASRR determination. However, she realized the PASRR section of the MDS should have been marked as having a level II PASRR, since the Resident was admitted with a PASRR number and mental health diagnoses. The Director of Nursing (DON) was interviewed on 02/29/24 at 4:58 PM revealed she was not aware of Resident #84's PASRR level was not reflected on her MDS. She believed it was probably due to an oversight on the part of the MDS Coordinator staff changes. She stated her expectation was that MDS should reflect current PASRR levels for all residents. An interview with the Administrator on 02/29/24 at 5:10 PM revealed had just begun at the facility on Monday 02/26/24 and she expected the MDS to be reviewed and coded correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to provide sufficient nursing staff to ensure resident were administered medications per the physician orders for 8 of 16 residents reviewed for significant medication errors (Residents #7, #28, #47, #51, #73, #79, #88, and #110) and provide assistance with showers and hair washing for 1 of 10 residents reviewed for assistance with activities of daily living (Resident #94). The findings included: 1a. Resident #7 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 was coded as received insulin 7 times during the assessment period. The active physician's orders for December 2023 for Resident #7 included an order dated 08/07/23 for Insulin Detemir solution 100 units per milliliter (ml), inject 13 units at bedtime for diabetes and an order dated 11/06/2023 for Novolog flex pen solution pen- injector 100 units/ml sliding scale insulin four times a day for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Detemir Solution 13 units, scheduled for 8:00 PM, was not documented as given on 12/10/2023 and the Novolog flex pen sliding scale insulin scheduled for 8:30 PM was not documented as given on 12/10/2023. b. Resident #28 was admitted to the facility on [DATE] with a diagnosis of hypertension, anxiety, diabetes mellitus and heart failure. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 was noted to have received insulin 5 times during the assessment period. The MDS revealed Resident #28 received an antipsychotic medication during the assessment period. The active physician's orders for December 2023 for Resident #28 included an order dated 11/10/23 for Lantus Solostar pen-injector 100 units/ml, inject 10 units at bedtime for diabetes, an order dated 11/09/2023 for Carvedilol oral tablet 6.25 mg 1 tablet by mouth two times a day for heart failure and an order dated 11/09/23 for Seroquel 25 mg give 1 tablet by mouth two times a day for depression. A Medication Administration Record (MAR) dated December 2023 revealed the Lantus Solostar pen-injector 100 units/ml 10 units, Carvedilol oral tablet 6.25 mg and Seroquel 25 mg scheduled for 8:00 PM, were not documented as given on 12/10/2023. c. Resident #47 was admitted to the facility on [DATE] with a diagnosis of depression and schizophrenia and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Resident #47 was coded as receiving antipsychotic medication, antianxiety medication, antidepressant medication and opioids. The active physician's orders for December 2023 for Resident #47 included an order dated 02/19/22 for Seroquel 200 mg give 1 tablet by mouth at bedtime for mood, an order dated 03/10/22 for Lorazepam 1 mg by mouth two times a day for agitation, an order dated 08/25/22 for Trazodone 125 mg by mouth at bedtime for insomnia and an order dated 04/07/23 for Percocet oral tablet 10-325mg give 1 tablet by mouth three times a day for severe pain. A Medication Administration Record (MAR) dated December 2023 revealed the Seroquel 200 mg, Trazodone 125 mg, Lorazepam 1 mg and Percocet oral tablet 10-325mg scheduled for 8:00 PM were not documented as given on 12/10/2023. d. Resident #51 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus and atrial fibrillation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderately cognitively impaired. Resident #51 was coded as receiving insulin on 7 days during the assessment period. The MDS revealed Resident #51 had received an anticoagulant during the assessment period. The active physician's orders for December 2023 for Resident #51 included an order dated 11/15/22 Insulin Glargine solution 100 units/ml inject 12 units at bedtime for diabetes, an order dated 11/15/22 for Eliquis tablet 5 mg by mouth two times a day for anticoagulant therapy and an order dated 7/16/23 for Metformin 500 mg 1 tablet by mouth two times a day for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Glargine solution 100 units/ml 12 units, Eliquis tablet 5 mg and Metformin 500 mg scheduled for 9:00 PM were not documented as given on 12/10/2023. e. Resident #73 was admitted to the facility on [DATE] with a diagnosis of depression. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was cognitively intact. Resident #73 was coded as received an antidepressant during the assessment period. The active physician's orders for December 2023 for Resident #73 included an order dated 06/20/23 for Trazodone 50 mg 1 tablet by mouth at bedtime for insomnia. A Medication Administration Record (MAR) dated December 2023 revealed the Trazodone 50 mg scheduled for 8:00 PM was not documented as given on 12/10/2023. f. Resident #79 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was moderately cognitively impaired. Resident #79 was coded as received insulin on 7 days during the assessment period. The active physician's orders for December 2023 for Resident #79 included an order dated 11/14/23 for Insulin Glargine solution 100 units/ml inject 2 units at bedtime for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Glargine solution 100 unit/ml 2 units scheduled for 9:00 PM was not documented as given on 12/10/2023. g. Resident #88 was admitted to the facility on [DATE] with a diagnosis of hypertension, heart failure and coronary artery disease (CAD). A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was severely cognitively impaired. The active physician's orders for December 2023 for Resident #88 included an order dated 03/31/22 for Metoprolol Tartrate 25 mg give 0.5 tablet by mouth two times a day for heart failure. A Medication Administration Record (MAR) dated December 2023 revealed the Metoprolol Tartrate 12.5 mg scheduled for 9:00 PM was not documented as given on 12/10/2023. h. Resident #110 was admitted to the facility on [DATE] with a diagnosis of hypertension and atrial fibrillation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 was cognitively intact. The active physician's orders for December 2023 for Resident #110 included an order dated 1/10/23 for Carvedilol 3.125mg 1 tablet by mouth two times a day for hypertension and an order dated 12/04/23 for Amoxicillin 500 mg give 1 tablet by mouth two times a day for a bacterial infection for 10 days. A Medication Administration Record (MAR) dated December 2023 revealed the Amoxicillin 500 mg and Carvedilol 3.125 mg scheduled for 8:00 PM were not documented as given on 12/10/2023. An interview was conducted on 02/28/24 at 4:00 PM with Nurse #1. She stated on 12/10/23 she was working the 7:00 AM to 7:00 PM shift assigned to Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88, and Resident #110. The interview revealed Nurse #2 had contacted her after 12:00 PM stating she would not be coming into work for the 7:00 PM to 11:00 PM shift to take over the resident assignment. She stated she told Nurse #2 she would need to contact management and let them know. The interview revealed she then told Unit Manager #1 that she did not think Nurse #2 would be coming into the facility for her assigned shift. She stated report on the residents was given to Nurse #3, Nurse #4 and Nurse #5 who were told by the Unit Manager #1 to split the medication cart. The interview revealed she had offered to stay over to cover the shift from 7:00 PM to 11:00 PM but was told it was necessary by the scheduler. She stated she left the facility at 7:00 PM. An interview conducted on 02/28/24 at 3:36 PM with Unit Manager #1 revealed on 12/10/23 she was notified later in the day by Nurse #1 that Nurse #2 was not going to come in for the scheduled 7:00 PM to 11:00 PM shift. She stated she called the scheduler who no longer works in the facility and Director of Nursing (DON) to let them know they were going to be a nurse short. The interview revealed the scheduler could not get in touch with Nurse #2 so Unit Manger #1 then notified Nurse #3, Nurse #4 and Nurse #5 they would need to split the medication cart for the 7:00 PM to 11:00 PM shift. She stated Nurse #4 told her she needed to get some food and would look at the medication cart when she returned, and Nurse #5 stated the medication cart had too many residents to split. She stated she then left the facility at 7:00 PM and did not know until 12/12/23 that the residents had never received their scheduled medication on the evening of 12/10/23. An interview was attempted with Nurse #2 on 02/28/24 and on 02/29/24 with no return phone call received. An interview was attempted with Nurse #3, Nurse #4 and Nurse #5 on 02/29/24 with no return phone call received. An interview conducted on 02/28/24 at 4:30 PM with the Director of Nursing (DON) revealed on 12/10/23 around 6:30 PM she was told by Unit Manager #1 that Nurse #2 had called out for the 7:00 PM to 11:00 PM shift. She stated Unit Manager #1 told her that Nurse #3, Nurse #4 and Nurse #5 were instructed to split the medication cart and had taken report on the residents. She stated she heard the next morning that some residents had not received their medication. The interview revealed that Nurse #5 had given half of the assigned residents their medication, but the other 8 residents Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88 and Resident #110 did not receive any scheduled medication. She stated Nurse #5 told her she had completed her assigned half and thought someone else was going to administer the rest of the residents' medication. The DON stated it was a communication error between the nurses. The interview revealed the residents' vital signs were obtained on 12/11/23 along with blood glucose levels for the diabetic residents. She stated no adverse outcomes had occurred from the incident and no residents needed medical treatment due to not receiving their medication. 2. Resident #94 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II, vitamin deficiency, dementia, and anorexia. Review of Resident #94's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and required total assistance with showering and bathing. The assessment also revealed Resident #94 had no rejection of care behaviors. Review of Resident #94's care plan revealed a focus area for activities of daily living/personal care deficit related to dementia. The interventions included personal hygiene with substantial/maximal assistance and showering/bathing dependent on staff. An observation and interview with Resident #94 on 02/26/24 at 11:42 AM revealed the resident sitting in her wheelchair in her room, dressed for the day. The resident's hair appeared greasy and disheveled, and she stated she was not getting her showers as scheduled two times per week. Resident #94 further stated she preferred showers because she liked to get her hair washed when she was bathed. Review of the shower schedule for the hall on which the resident resided revealed Resident #94 was scheduled for showers on Tuesday and Friday on 1st shift (7:00 AM to 3:00 PM). Review of the documentation of showers in the electronic medical record for Resident #94 revealed for the month of February she had only received one shower on 02/27/24. On the other days she was scheduled for showers the following was documented: Tuesday 02/06/24 no indication or documentation Tuesday, 02/13/24 no indication or documentation Tuesday, 02/20/24 no shower or bed bath given Friday, 02/23/24 partial bed bath (not a complete bed bath) A telephone interview on 02/29/24 at 10:46 AM with Nurse Aide (NA) #8 who was assigned to care for Resident #94 on 02/06/24 and 02/13/24 stated if she were assigned to a resident and did not have time to give them a shower, she would wash them up in bed and document it as a partial bath but said it was not a complete bed bath. NA #8 stated she could not recall why she had not given Resident #94 a shower on 02/06/24 or 02/13/24 but said it was most likely due to staffing issues. An interview on 02/28/24 at 10:34 AM with NA #12 who was assigned to care for Resident #94 on 02/09/24 revealed if she was assigned to the resident and had given her a complete bed bath instead of a shower it was due to not having time to shower the resident. She stated they were short of help sometimes and it was less time-consuming to give residents a bed bath than shower. An interview on 02/29/24 at 1:45 PM with NA #7 who was assigned to care for Resident #94 on 02/23/24 revealed she could not recall why she had not given the resident a shower as scheduled. She stated there were days they worked short of help and that could have been one of those days when she did not have time to give the resident a shower and just bathed her in bed and documented it as a partial bath. NA #7 further stated when she showered residents, she tried to cut their nails and shave them as needed but did not always have time to do so due to staffing issues. An interview on 02/29/24 at 3:10 PM with Unit Manager #1 revealed she was not aware Resident #94 was not receiving her showers as scheduled and said no one had reported it to her. She indicated if the NAs were having difficulty completing their showers, they should have reported that to her so she could have provided them with additional staff to assist with showers. An interview on 2/29/23 at 12:30 PM with the Nursing Scheduler who has been in her position for the last two months. The Scheduler revealed that all call ins by nursing staff go to the Director of Nursing (DON) who then tells her what needs to be filled. The Nursing Scheduler stated she filled out the schedules in advance, so staff can pick up extra hours and staff were good about picking open shifts. She explained the problem was the call ins and trying to find someone to fill the opening. The scheduler further stated she was not on call and worked Monday through Friday 8:00 AM to 5:00 PM so after hours and on the weekends, it falls on nurse management to fill open positions. The scheduler stated she was not aware of a situation where there was not a nurse for a cart when other nurses did not step up and take care of the cart. The Nursing Scheduler indicated the following were the staffing levels she was expected to maintain. The Scheduler went on to say that it was hard to keep those levels of staffing in the building, but she tried hard to get positions filled so staff were not short, but that it happens at times and there is nothing that can be done about it. 1. 7:00 AM-3:00 PM shift 10-12 Nurse Aides (NAs) and 3 NAs on memory care. 2. 7:00 AM-3:00 PM shift 6 Nurses and 2 nurses on memory care. 3. 3:00 PM-11:00 PM shift 10-12 NAs and 2-3 NAs on memory care 4. 3:00 PM-11:00 PM shift 5 Nurses and 2 nurses on memory care 5. Memory care works 7:00 AM - 7:00 PM so this covers the third shift. 6. 11:00 PM -7:00 AM shift 9-10 NAs and 2-3 on memory care Interview on 02/29/24 at 4:46 PM with the Director of Nursing (DON) revealed she would expect nursing staff to communicate in a timely manner when they are not going to report to work so that the facility has time to try and fill the open position. They have been posting open positions on their website and have recently started using a staffing agency to assist with staffing levels. An interview on 02/29/24 at 4:53 PM with the Director of Nursing (DON) revealed they had struggled with getting the NAs to give and document showers and said it was a process they were currently working on with the NAs. She stated she expected residents to have their showers as scheduled and said if they did not receive their showers, she expected them to receive a complete bed bath not a partial bed bath and for it to be documented. The DON further stated if the resident refused their shower, she expected the nurse to document the refusal in their progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and family member, staff, and Medical Director interviews, the facility failed to prevent significant medication errors when Nurse #9 administered medications to Resident #83 prescribed for Resident #30 which included Lasix (fluid pill), Ativan (a medication used to treat anxiety, Seroquel (an antipsychotic), Celexa (an antidepressant), and Diltiazem (used to treat cardiac disorders). The facility also failed to prevent significant medication errors when medications were not administered as ordered by the physician. This deficient practice affected 9 of 16 residents reviewed for significant medication errors (Resident # 83, #7, #28, #47, #51, #73, #79, #88, and #110.) . The findings: 1. Resident #83 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA), high blood pressure, dementia, and diabetes mellitus (DM). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had moderate cognitive impairment. The MDS revealed Resident #83 was not receiving diuretics, anti-anxiety, or anti-psychotics. Review of the December 2023 physician orders for Resident #83 revealed the following medications: -Sertraline (antidepressant) 150 milligrams (mg) 1 tablet by mouth one time a day for depression. -Vimpat Oral Solution (anti-seizure) 250 mg by mouth two times a day for seizures. -Divalproex Sodium (anti-seizure) delayed release 250 mg 3 tablets by mouth twice a day for neurological disorder. -Xarelto (anticoagulant) 20 mg 1 tablet by mouth one time a day for deep vein thrombosis prevention. -Amlodipine Besylate 10 mg 1 tablet by mouth daily for high blood pressure. Resident #30 was admitted to the facility on [DATE]. A review of the physician orders dated December 2023 revealed Resident #30 had orders for: -Diltiazem (cardiac medication) 120 mg extended release 1 capsule by mouth one time a day for atrial fibrillation. -Citalopram Hydrobromide 10 mg one tablet by mouth daily for depression. -Lasix (diuretic/fluid pill) 20 mg by mouth one time day for fluid. -Seroquel (antipsychotic) 25 mg by mouth three times a day for schizoaffective disorder -Ativan (anti-anxiety) 0.5 mg by mouth twice a day for anxiety. An incident report dated 12/27/2023 written by Nurse #8 revealed Resident #83 had received Resident #30's medication which included: Lasix 20 mg, Ativan 0.5 mg, Seroquel 25 mg, Celexa 10 mg, and Diltiazem 120 mg at 10:00 AM in addition to her own morning medications. The incident was reported to the on-call provider at 1:20 PM after Nurse #8 realized Resident #83 had been given Resident #30's medications. Resident #83 was noted to be in no acute distress and at her baseline. Resident #83's responsible party (RP) was notified of the medication errors on 12/27/2023 at 1:35 PM. Resident #83's documented vital signs dated 12/27/2023 at 1:35 PM revealed the following: blood pressure123/74 (normal range systolic (top number) less than 120 and diastolic (bottom number) less than 80), temperature 97.2 (normal range 97 to 99), pulse 55 beats per minute (normal range 60-100), respirations 14 breaths per minute (normal range 12-20), oxygen saturation 94% (normal range 92% or greater) on room air. Review of the Nurse Practitioner (NP) acute visit note dated 12/27/2023 revealed Resident #83 was being seen due to a medication error. Resident #83 received Lasix, Ativan, Seroquel, Celexa, and Diltiazem in error. The NP visit note further revealed Resident #83 appeared at her baseline with stable vital signs and was awake and alert and offered no complaints. The NP's note also indicated Resident #83 was in no acute distress and no adverse reactions were noted. The provider ordered vital signs to be checked every shift for 24 hours and to closely monitor Resident #83 for low blood pressure and sedation. An interview was conducted on 02/26/2024 at 13:20 PM with Resident #83's RP. The RP stated the facility reported to her that a medication error had occurred. She further stated that a new nurse who was still being oriented gave Resident #83's the wrong medications. She also stated that the nurse in training should not have been allowed to administer medications without another staff member being present. She also indicated the facility contacted the pharmacy and Resident #83's doctor. Multiple unsuccessful attempts were made to contact Nurse #8 and Nurse #9 (the nurse in training). An interview was conducted on 03/05/2024 at 9:03 AM. The pharmacist stated there was no medication error report on file for Resident #83 for 12/27/2023. She further stated the concern with the Amlodipine and the Diltiazem would be for hypotension. She also stated hypotension would develop on the day of administration due to the short half-life of the drugs. An interview was conducted on 03/05/2024 at 09:36 with the Nurse Practitioner (NP) who evaluated Resident #83. The NP stated she was notified of the medication errors the morning of 12/27/2023 and she does not remember exactly what time she evaluated Resident #83, but she stated it was before 12:00 PM. She also indicated she was most concerned with the cardiac medications: Amlodipine and the Diltiazem and the potential for hypotension. She further added Resident #83 was stable during her evaluation and that she asked the nursing staff to monitor Resident #83 and notify her if the resident became hypotensive or had any other clinical concerns. An interview was conducted on 02/28/2024 at 11:40 AM with the Director of Nursing (DON). The DON revealed that during a medication pass, Resident #83 was given the incorrect medications. Nurse #9 (nurse in training) was being oriented by Nurse #8. Nurse #8 was standing at the medication cart and Nurse #9 went into the room to administer the medications. Nurse #9 got confused about the room numbers and got bed A and bed B mixed up. Nurse #8 went into the room when she saw Nurse #9 at Resident #83's bedside. Nurse #9 had already given Resident #30's medications to Resident #83. The DON also stated Nurse #8 and Nurse #9 were no longer employed by the facility. The DON further revealed Nurse #8 had immediately notified the physician, assessed the resident, and notified the RP following the incident. The DON stated the staff did everything they should have after the incident occurred. She further stated Nurse #8 should have stayed with the nurse in training throughout the entire medication pass especially when actually administering the medications at the bedside. She stated nursing staff should have provided the correct medication to the correct resident. 2a. Resident #7 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 was coded as received insulin 7 times during the assessment period. The active physician's orders for December 2023 for Resident #7 included an order dated 08/07/23 for Insulin Detemir solution 100 units per milliliter (ml), inject 13 units at bedtime for diabetes and an order dated 11/06/2023 for Novolog flex pen solution pen- injector 100 units/ml sliding scale insulin four times a day for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Detemir Solution 13 units, scheduled for 8:00 PM, was not documented as given on 12/10/2023 and the Novolog flex pen sliding scale insulin scheduled for 8:30 PM was not documented as given on 12/10/2023. b. Resident #28 was admitted to the facility on [DATE] with a diagnosis of hypertension, anxiety, diabetes mellitus and heart failure. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 was noted to have received insulin 5 times during the assessment period. The active physician's orders for December 2023 for Resident #28 included an order dated 11/10/23 for Lantus Solostar pen-injector 100 units/ml, inject 10 units at bedtime for diabetes, an order dated 11/09/2023 for Carvedilol oral tablet 6.25 mg 1 tablet by mouth two times a day for heart failure. A Medication Administration Record (MAR) dated December 2023 revealed the Lantus Solostar pen-injector 100 units/ml 10 units, Carvedilol oral tablet 6.25 mg and Seroquel 25 mg scheduled for 8:00 PM, were not documented as given on 12/10/2023. c. Resident #47 was admitted to the facility on [DATE] with a diagnosis of depression, schizophrenia, anxiety and bilateral chronic lymphedema with lower extremity pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Resident #47 was coded as receiving antipsychotic medication, antianxiety medication, antidepressant medication and opioids. The active physician's orders for December 2023 for Resident #47 included an order dated 02/19/22 for Seroquel 200 mg give 1 tablet by mouth at bedtime for mood, an order dated 03/10/22 for Lorazepam 1 mg by mouth two times a day for agitation, an order dated 08/25/22 for Trazodone 125 mg by mouth at bedtime for insomnia and an order dated 04/07/23 for Percocet oral tablet 10-325mg give 1 tablet by mouth three times a day for severe pain. A Medication Administration Record (MAR) dated December 2023 revealed the Seroquel 200 mg, Trazodone 125 mg, Lorazepam 1 mg and Percocet oral tablet 10-325mg scheduled for 8:00 PM were not documented as given on 12/10/2023. d. Resident #51 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus and atrial fibrillation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderately cognitively impaired. Resident #51 was coded as receiving insulin on 7 days during the assessment period. The MDS revealed Resident #51 had received an anticoagulant during the assessment period. The active physician's orders for December 2023 for Resident #51 included an order dated 11/15/22 Insulin Glargine solution 100 units/ml inject 12 units at bedtime for diabetes, an order dated 11/15/22 for Eliquis tablet 5 mg by mouth two times a day for anticoagulant therapy and an order dated 7/16/23 for Metformin 500 mg 1 tablet by mouth two times a day for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Glargine solution 100 units/ml 12 units, Eliquis tablet 5 mg and Metformin 500 mg scheduled for 9:00 PM were not documented as given on 12/10/2023. e. Resident #73 was admitted to the facility on [DATE] with a diagnosis of depression. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was cognitively intact. Resident #73 was coded as received an antidepressant during the assessment period. The active physician's orders for December 2023 for Resident #73 included an order dated 06/20/23 for Trazodone 50 mg 1 tablet by mouth at bedtime for insomnia. A Medication Administration Record (MAR) dated December 2023 revealed the Trazodone 50 mg scheduled for 8:00 PM was not documented as given on 12/10/2023. f. Resident #79 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was moderately cognitively impaired. Resident #79 was coded as received insulin on 7 days during the assessment period. The active physician's orders for December 2023 for Resident #79 included an order dated 11/14/23 for Insulin Glargine solution 100 units/ml inject 2 units at bedtime for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Glargine solution 100 unit/ml 2 units scheduled for 9:00 PM was not documented as given on 12/10/2023. g. Resident #88 was admitted to the facility on [DATE] with a diagnosis of hypertension, heart failure and coronary artery disease (CAD). A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was severely cognitively impaired. The active physician's orders for December 2023 for Resident #88 included an order dated 03/31/22 for Metoprolol Tartrate 25 mg give 0.5 tablet by mouth two times a day for heart failure. A Medication Administration Record (MAR) dated December 2023 revealed the Metoprolol Tartrate 12.5 mg scheduled for 9:00 PM was not documented as given on 12/10/2023. h. Resident #110 was admitted to the facility on [DATE] with a diagnosis of hypertension and atrial fibrillation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 was cognitively intact. The active physician's orders for December 2023 for Resident #110 included an order dated 1/10/23 for Carvedilol 3.125mg 1 tablet by mouth two times a day for hypertension and an order dated 12/04/23. A Medication Administration Record (MAR) dated December 2023 revealed the Amoxicillin 500 mg and Carvedilol 3.125 mg scheduled for 8:00 PM were not documented as given on 12/10/2023. A facility investigation summary dated 12/12/23 revealed the facility interdisciplinary team was reviewing the Medication Administration Audit report for the previous 48 hours and noted the medication errors and Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88 and Resident #110 had not been administered their medication during the 7:00 PM to 11:00 PM shift. An investigation was then initiated, and the Medical Director was notified. The investigation was completed by the Regional Nurse Consultant who identified the cause of the incident was due to a nurse not reporting for the 7:00 PM to 11:00 PM shift. An interview was conducted on 02/28/24 at 4:00 PM with Nurse #1. She stated on 12/10/23 she was working the 7:00 AM to 7:00 PM shift assigned to Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88 and Resident #110. The interview revealed Nurse #2 had contacted her after 12:00 PM stating she would not be coming into work for the 7:00 PM to 11:00 PM shift to take over the resident assignment. She stated she told Nurse #2 she would need to contact management and let them know. The interview revealed she then told Unit Manager #1 that she did not think Nurse #2 would be coming into the facility for her assigned shift. She stated report on the residents was given to Nurse #3, Nurse #4 and Nurse #5 who were told by the Unit Manager #1 to split the medication cart. The interview revealed she had offered to stay over to cover the shift from 7:00 PM to 11:00 PM but was told it was necessary by the scheduler. She stated she left the facility at 7:00 PM. An interview conducted on 02/28/24 at 3:36 PM with Unit Manager #1 revealed on 12/10/23 she was notified later in the day by Nurse #1 that Nurse #2 was not going to come in for the scheduled 7:00 PM to 11:00 PM shift. She stated she called the scheduler who no longer works in the facility and Director of Nursing (DON) to let them know they were going to be a nurse short. The interview revealed the scheduler could not get in touch with Nurse #2 so Unit Manger #1 then notified Nurse #3, Nurse #4 and Nurse #5 they would need to split the medication cart for the 7:00 PM to 11:00 PM shift. She stated Nurse #4 told her she needed to get some food and would look at the medication cart when she returned, and Nurse #5 stated the medication cart had too many residents to split. She stated she then left the facility at 7:00 PM and did not know until 12/12/23 that the residents had never received their scheduled medication on the evening of 12/10/23. An interview was attempted with Nurse #2 on 02/28/24 and on 02/29/24 with no return phone call received. An interview was attempted with Nurse #3, Nurse #4 and Nurse #5 on 02/29/24 with no return phone call received. An interview conducted on 02/28/24 at 4:30 PM with the Director of Nursing (DON) revealed on 12/10/23 around 6:30 PM she was told by Unit Manager #1 that Nurse #2 had called out for the 7:00 PM to 11:00 PM shift. She stated Unit Manager #1 told her that Nurse #3, Nurse #4 and Nurse #5 were instructed to split the medication cart and had taken report on the residents. She stated she heard the next morning that some residents had not received their medication. The interview revealed that Nurse #5 had given half of the assigned residents their medication, but the other 8 residents Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88 and Resident #110 did not receive any scheduled medication. She stated Nurse #5 told her she had completed her assigned half and thought someone else was going to administer the rest of the residents' medication. The DON stated it was a communication error between the nurses. The interview revealed the residents' vital signs were obtained on 12/11/23 along with blood glucose levels for the diabetic residents. She stated no adverse outcomes had occurred from the incident and no residents needed medical treatment due to not receiving their medication. On 02/29/24 at 11:20 AM an interview was conducted with the Medical Director. During the interview he stated he was notified by the facility that the residents had missed their medication on 12/10/23. The interview revealed he notified the Nurse Practitioner's that were in the facility of the incident and that nurses on the unit were monitoring the residents for any changes of condition. He stated no residents were having symptoms from not receiving their medication. The MD stated although medication such as anticoagulants, opioids, antipsychotics and insulin were significant, it would not be harmful to the residents to miss one dose. The interview revealed none of the residents identified to have missed their medication were sent to the hospital or experienced a change of condition.

Based on observations, staff interviews, and record review the facility failed to record an open date on multi-dose insulin pens, failed to discard an expired insulin pen and failed to store unopened insulin pens in the refrigerator for 2 of 4 medication carts (Garden City Cart #1 and Arboretum Cart #2) which were reviewed for medication storage. The findings: Review of the manufacturer's package insert for Glargine stated to store unopened Glargine insulin pens in a refrigerator and in-use (opened) insulin pens at room temperature for 28 days. 1a. An observation of the Garden City medication cart #1 was conducted on 02/28/2024 at 11:11 AM with Nurse #6 and the Director of Nursing. The observation revealed an opened Glargine insulin pen and an opened Novolin insulin pen that were not dated. The medication cart observation also revealed an opened insulin pen with an open date of 12/08/2023 which had passed the 28-day expiration date of 01/05/2024. An interview was conducted with Nurse #6 on 02/28/2024 at 11:26 AM who stated she thought 3rd shift (11:0 PM to 7:00 AM) nursing staff were responsible for checking the medications carts for expired medications and she did not realize the insulin pens were not dated and that one was expired. 1b. An observation of the Arboretum Cart #2 was conducted on 02/28/2024 at 12:03 PM with Nurse #7 and the Director of Nursing. The observation revealed 2 unopened insulin pens were stored in the medication cart and were labeled as refrigerate until opened and one Glargine insulin pen with an open date that was illegible. The ink had smeared, and the opening date was unidentifiable. An interview was conducted with Nurse #7 on 02/28/2024 at 12:24 PM who stated she did not realize there was no open date on the insulin pens, and she thought the pharmacy placed the open date on the insulin pens. She also stated she did not know the unopen insulin pens required refrigeration and she did know how long the insulin pens had been in the medication cart. She also added she did not realize the insulin pen open date was not legible. She further stated she did not know who was responsible for checking the medication carts. An interview was conducted with the Director of Nursing (DON) on 02/28/2024 at 1:12 PM. The DON revealed all insulin pens should have been labeled when opened for use with a 28-day expiration date sticker. She also indicated that all nurses were responsible for putting the date of opening on the insulin pens and checking all medications in the medication carts. She further stated that she expected all insulin pens to be labeled when opened and discarded 28 days after opening. She also stated that all unopened insulin pens should be stored in the refrigerator until ready for use and that no expired medications should be available for use in the medication carts.

Based on observation and staff interviews, the facility failed to remove expired food items and unlabeled items which belonged to staff for 1 of 3 resident's nourishment rooms. These practices had the potential to affect food served to residents. Findings included: An observation and interview was conducted with Nurse Aide (NA) #5 on 02/26/24 at 10:15 AM revealed an 8 oz. fat free milk with the best by date of 02/24/24 and three separate lunch bags not labeled in the memory care unit nourishment room. NA #5 indicated nursing staff on the memory care unit had stored their personal items in the nourishment room because the nursing staff break room was on the other side of the facility. NA #5 stated nursing staff had been educated to not store personal items in the nourishment room and to discard any expired items. An interview conducted with the Dietary Manager (DM) on 02/06/24 at 10:30 AM revealed dietary aides check nourishment rooms daily but could not recall if any staff had checked them over the weekend. It was further revealed nursing staff had been educated not to store personal items in the nourishment rooms refrigerators and to also throw away any expired items that were found. An interview conducted with the Director of Nursing (DON) on 02/29/24 at 4:55 PM revealed nursing staff were educated not to store personal belongings in the nourishment rooms because there was a staff break room available with a refrigerator. The DON further stated she was unaware staff had stored items in the memory care nourishment room refrigerator. The DON indicated dietary aides were responsible for checking nourishment rooms, but nursing staff was also responsible for throwing out items if found that needed to be discarded. An interview conducted with the Administrator on 02/29/24 at 5:10 PM revealed she expected staff to check nourishment rooms daily and to discard any expired or unlabeled items. The Administrator further revealed it was not appropriate for nursing staff to store personal items in the nourishment room refrigerator.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the focused infection control survey that occurred on 02/13/21, the recertification and complaint investigation surveys that occurred on 06/24/21 and 08/25/22. This failure was for three deficiencies that were originally cited in the areas of Accuracy of Assessments (F641), Food Procurement, Store/Prepare/Serve Food Under Sanitary Conditions (F812) and Infection Prevention and Control (F880) and were subsequently recited on the current recertification and complaint investigation survey of 02/29/24. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F641: Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 3 of 6 residents (Resident #41, #102, #84) reviewed for Preadmission Screening and Resident Review (PASRR), and 1 of 3 residents (Resident #110) reviewed for restraints. During the recertification and complaint investigation survey conducted 08/25/22 the facility failed to accurately code the Minimum Data Set (MDS) assessment related to tobacco use for residents reviewed for smoking. F812: Based on observation and staff interviews, the facility failed to remove expired food items and unlabeled items which belonged to staff for 1 of 3 resident's nourishment rooms. These practices had the potential to affect food served to residents. During the recertification and complaint investigation survey conducted 06/24/21, the facility failed to remove expired food items in the refrigerator in 1 of 4 nourishments rooms and failed to label and date opened food items stored for use in 3 of 4 nourishment rooms. During the recertification and complaint investigation survey conducted 08/25/22, the facility failed to discard produce with signs of spoilage, remove expired food items and date leftover food stored ready for use in the walk-in cooler. F880: Based on observations, record reviews, and staff interviews, the facility failed to ensure staff implemented their handwashing/hygiene policy as part of their infection control policy when the Treatment Nurse did not perform hand hygiene and don clean gloves after cleaning two wounds with wound cleanser and one wound with normal saline and before applying treatment to the wounds for two residents (Resident #128 and Resident #43) and did not doff gloves, sanitize hands and don clean gloves after wound care and prior to touching the resident's (Resident #128) pillows and bedding. The Treatment Nurse was also observed during wound care on another resident (Resident #126) with Methicillin-Resistant Staphylococcus Aureus (MRSA) and Carbapenem-Resistant Enterobacterales (CRE) in the wound and she did not doff gloves, sanitize hands and don clean gloves after cleaning the wound which had brown colored drainage and before applying the treatment to the wound and with the same gloves on the Treatment Nurse used to clean the drainage from the wound was observed touching the bed controls to lower the resident's bed and touching the trash bag on the resident's bed. In addition, another staff member (Nurse Aide (NA) #1) was observed providing incontinence care of bowel movement to a resident (Resident #51), and with the same gloves on that he had cleaned the resident with touching the resident's closet door, bedside drawer and over bed table. These failures occurred for 3 of 3 residents reviewed for wound care and 1 of 3 residents reviewed for incontinence care. During the focused infection control survey conducted 02/13/21 the facility failed to ensure dietary staff implemented the facility's infection control measures when 2 staff members failed to wear a facemask covering their mouth and nose while working in the kitchen. During an interview on 02/29/24 at 5:19 PM with the Administrator she revealed the QAPI committee meets monthly with department heads, administrative staff, the Medical Director, and at least quarterly the Pharmacist and Registered Dietician attend and monthly attend by phone. She reported they currently had Process Improvement Plans (PIPs) addressing some of the issues she and the corporate advisors had identified at the facility. Some of the PIPs currently being addressed included grievances, care plan meetings, resident weights, and physician visits. She also reported they would be putting PIPs into place to address the current concerns addressed during the current recertification and complaint survey. The Administrator stated the PIPs would be ongoing and monitored to ensure ongoing and future compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident # 51 was admitted to the facility on [DATE] with diagnoses including neurogenic bladder and a chronic autoimmune disorder that affects movement, sensation and bodily functions. Resident #51's care plan initiated 1/17/24 revealed a focus area for the resident having an activities of daily living (ADL) self-care deficit due to [chronic autoimmune disorder that effects movement, sensation, and bodily functions] and neurogenic bladder. The interventions included assisting with activities of daily living (ADL), dressing, grooming, toileting, promote independence and dignity, and provide positive reinforcement for all activities. Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed total dependence for toilet and bathing. Impaired range of motion was noted to bilateral lower extremities. The resident was coded as always incontinent of bowel and for the presence of a suprapubic catheter. An observation was conducted on 02/28/24 at 1:40 PM of Resident #51 receiving incontinence care. NA #1 was observed washing his hands and applied gloves. NA #1 was observed cleaning bowel movement from Resident #51's right and left buttocks using a wet washcloth and soap. After the bowel movement was cleaned up the NA went to the closet to get a clean adult brief without removing his dirty gloves. He returned to bedside and opened the drawer of the bedside table to retrieve the barrier cream, opened it, and applied the cream to the resident's buttocks. NA#1 proceeded to apply the adult brief and change bed linens and was still wearing dirty gloves. NA #1 was also observed touching his uniform. After NA #1 had completed the incontinence care and changed the bed linens, he removed his gloves and washed his hands. After washing his hands NA #1 was observed picking up the barrier cream, placing the cap back on the tube and putting the barrier cream back into the beside table. Then NA #1 picked up the trash and dirty linen bags, opened the resident door and continued down the hallway and placed the trash and soiled linens into barrels. NA#1 then sanitized his hands using hand sanitizer. Interview on 02/28/24 at 1:50 PM with NA #1 revealed he believed he had done a good job providing incontinence care on Resident #51 and did not realize he had to remove dirty gloves and perform hand hygiene immediately after care was completed and before touching surfaces in the room. NA #1 stated he thought since his gloves were not visibly dirty that he was okay to continue care but stated he had washed his hands before and after care. Interview on 02/29/24 at 4:46 PM with the Director of Nursing (DON) revealed she would expect nursing staff to follow the policy for hand hygiene and glove policy and procedures. The DON stated that all employees had been trained in hand hygiene and glove policy and procedures and the appropriate process was to always be followed. 2. A wound observation was made on 02/28/24 at 10:34 AM on Resident #126 with the Treatment Nurse. The Treatment Nurse gathered her supplies and placed them on a clean surface on the overbed table. She stated Resident #126 was on enhanced barrier precautions due to Methicillin-Resistant Staphylococcus Aureus (MRSA) and Carbapenem-Resistant Enterobacterales (CRE) in the wound. The Treatment Nurse washed her hands with soap and water and donned clean gloves to remove the resident's dressing from her right ankle which had a small amount of drainage on the old dressing. She doffed her gloves after removing the dressing, sanitized her hands, donned clean gloves, and cleansed the wound with wound cleanser-soaked gauze. The Treatment Nurse then doffed her gloves, sanitized her hands and donned clean gloves. She then lifted Resident #126's left foot and began cleaning the wound again with brown colored drainage observed on the gauze. The Treatment Nurse then proceeded without doffing her gloves, sanitizing her hands, and donning clean gloves, and applied the dermacol collagen and calcium alginate with silver and covered the wound with kerlix. With the same gloves on the Treatment Nurse adjusted the resident's bed with the controls, positioned her in bed with pillow between her legs, gathered her trash, doffed her gloves, left the room, and sanitized her hands in the hallway after discarding the trash. An interview on 02/29/24 at 11:51 AM with the Infection Preventionist (IP) revealed they had done several in-services on handwashing, donning, and doffing personal protective equipment (PPE) but said she would do one-on-one education with the Treatment Nurse. The IP stated any time nurses went from a dirty procedure (cleaning a wound bed) to a clean procedure (applying treatment to wounds) they should doff their gloves, sanitize their hands, and don clean gloves and especially if they are touching objects in the resident's room that the resident may later touch. An interview with the Director of Nursing (DON) on 02/29/24 at 12:00 PM revealed the Treatment Nurse had shared with them her errors during treatments for Resident #126. The DON stated she thought the Treatment Nurse was nervous having someone watching her and she and the IP would re-educate her on proper hand hygiene procedures and would be monitoring her during some of her treatments. Based on observations, record reviews, and staff interviews, the facility failed to ensure staff implemented their handwashing/hygiene policy as part of their infection control policy when the Treatment Nurse did not perform hand hygiene and don clean gloves after cleaning two wounds with wound cleanser and one wound with normal saline and before applying treatment to the wounds for two residents (Resident #128 and Resident #43) and did not doff gloves, sanitize hands and don clean gloves after wound care and prior to touching the resident's (Resident #128) pillows and bedding. The Treatment Nurse was also observed during wound care on another resident (Resident #126) with Methicillin-Resistant Staphylococcus Aureus (MRSA) and Carbapenem-Resistant Enterobacterales (CRE) in the wound and she did not doff gloves, sanitize hands and don clean gloves after cleaning the wound which had brown colored drainage and before applying the treatment to the wound and with the same gloves on the Treatment Nurse used to clean the drainage from the wound was observed touching the bed controls to lower the resident's bed and touching the trash bag on the resident's bed. In addition, another staff member (Nurse Aide (NA) #1 was observed providing incontinence care of bowel movement to a resident (Resident #51), and did not remove his gloves and perform hand hygiene before touching the resident's closet door, bedside table drawer and other surfaces. These failures occurred for 3 of 3 residents reviewed for wound care ( Resident #128, #43, and #126) and 1 of 3 residents reviewed for incontinence care (Resident #51). The findings included: The facility's policy entitled Handwashing Policy which is part of the Infection Control Policies and Procedures last revised on 04/2023 read in part: Personnel are required to wash their hands after each direct or indirect resident contact for which handwashing is indicated by acceptable standards of practice. An alcohol-based hand sanitizer may be used for handwashing unless the hands are visibly soiled. The hands should be free of dirt and organic material when using an alcohol hand sanitizer. The hands should be washed with soap and water after exposure to blood or body fluids. Personnel should wash their hands: After contact with blood, body fluids, secretions, excretions and equipment or articles contaminated by them. After removing gloves and before performing procedures in which a normally sterile part of the body is entered. Before and after touching wounds. After situations during which microbial contamination of hands is likely to occur. After touching inanimate sources that are likely to be contaminated with virulent or epidemiologically significant microorganisms. Between resident contacts. When otherwise indicated to avoid transfer of microorganisms to other residents and environments. When indicated between tasks and procedures to prevent cross contamination of different body sites. When hands are visibly and obviously soiled. 1. a. A wound observation was made on 02/28/24 at 9:13AM on Resident #128 with the Treatment Nurse. The Treatment Nurse gathered her supplies and placed them on a clean surface on the overbed table. The Treatment Nurse washed her hands with soap and water and donned clean gloves to remove the resident's dressing from her right ankle which had a small amount of drainage on the old dressing. She doffed her gloves after removing the dressing, sanitized her hands, donned clean gloves, and cleansed the wound with wound cleanser-soaked gauze. The Treatment Nurse then proceeded without doffing her gloves, sanitizing her hands, and donning clean gloves, and applied the hydrogel gauze and ankle dressing and reapplied her boot. The Treatment Nurse then moved to the wound on the left knee and doffed her gloves, sanitized her hands, donned new gloves, and proceeded to clean the left knee with wound cleanser-soaked gauze and without doffing her gloves, sanitizing her hands and donning clean gloves applied xeroform gauze to the knee and covered with a border gauze dressing. The Treatment Nurse then moved to the wound (a skin tear) on the left arm and removed the dressing and cleansed the wound with normal saline and without doffing her gloves, sanitizing her hands, and donning new gloves applied xeroform gauze to the wound and covered with a border gauze dressing. With the same gloves on the Treatment Nurse adjusted the resident's bed with the controls, positioned her in bed with pillow between her legs, gathered her trash, doffed her gloves, left the room, and sanitized her hands in the hallway after discarding the trash. b. A wound observation was made on 02/29/24 at 9:30 AM on Resident #43 with the Treatment Nurse. The Treatment Nurse gathered her supplies and placed them on a clean surface on the overbed table. The Treatment Nurse cleaned the wound with anasept (antimicrobial skin and wound cleaner)-soaked gauze and without doffing her gloves, sanitizing her hands, and donning new gloves she applied the treatment of hydrocolloid dressing to the wound. With the same gloves on, she re-attached the resident's brief and adjusted the resident's bed with the controls, repositioned the pillow under her head. The Treatment Nurse then threw away her trash, washed her hands with soap and water, brought out the trash bag, discarded it and sanitized her hands. An interview on 02/29/24 at 9:59 AM with the Treatment Nurse revealed she did not realize she had not doffed her gloves after cleaning the wounds, sanitized her hands and donned clean gloves before applying treatment and dressings to the wounds. She stated she was just nervous about someone watching her and forgot to do the correct procedure. An interview on 02/29/24 at 11:51 AM with the Infection Preventionist (IP) revealed they had done several in-services on handwashing, donning, and doffing personal protective equipment (PPE) but said she would do one-on-one education with the Treatment Nurse. The IP stated any time nurses went from a dirty procedure (cleaning a wound bed) to a clean procedure (applying treatment to wounds) they should doff their gloves, sanitize their hands, and don clean gloves and especially if they are touching objects in the resident's room that the resident may later touch. An interview with the Director of Nursing (DON) on 02/29/24 at 12:00 PM revealed the Treatment Nurse had shared with them her errors during treatments for Resident's #128 and #43. The DON stated she thought the Treatment Nurse was nervous having someone watching her and she and the IP would re-educate her on proper hand hygiene procedures and would be monitoring her during some of her treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews with residents and staff, the facility failed to provide access to control the light fixture behind the bed for 1 of 1 resident reviewed for accommodate of needs (Resident #96). The findings included: Resident #96 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] assessed Resident #96 with moderate impairment in cognition. Review of Resident #96's medical records revealed she had moved to the current room on 08/04/22. During an observation conducted on 08/22/22 at 12:42 PM the cord attached to the light fixture behind Resident #96's bed to control the light was broken. It extended approximately 2.5 inches from the light fixture and approximately 60 inches above the floor. The cord was too short for the resident to reach making the light inaccessible. During an interview with Resident #96 on 08/22/22 at 12:45 PM she stated the switching cord for the light fixture had been broken since the first day she moved into this room. She had difficulty standing up to reach the switching cord to control the light according to her choices. She had been totally dependent on the staff to control the light fixture for the past 3 weeks. It was very inconvenient to her, and she was frustrated why none of the staff would do something to fix the problem. Subsequent observation conducted on 08/23/22 at 3:47 PM and 08/24/22 at 11:12 AM revealed the cord remained out of the resident's reach. During a joint observation conducted with Nurse #2, Nurse Aide (NA)#2, and the Maintenance Manager on 08/25/22 at 10:14 AM, the cord remained broken. An interview conducted with the Maintenance Manager on 08/25/22 at 10:16 AM revealed he walked through the facility daily to identify repair needs. He also depended on staff to report repair needs through work order. He had been checking the work order boxes located at each nurse station and his office door at least once daily. His priority was the safety of the residents, then the needs of residents and other cosmetic issues. He stated he had missed the broken cord for light fixture in Resident #96's room during the daily walk through. He acknowledged that it was too short and needed to be fixed. A joint interview was conducted with Nurse #2 and NA #2 on 08/25/22 at 10:32 AM, both stated they did not notice the cord was broken. Otherwise, they would have notified the maintenance staff for repair. During an interview conducted on 08/25/22 at 12:25 PM, the Unit Manager (UM) expected nursing staff to be more attentive to resident's living environment and reported all the repair needs as indicated to the maintenance staff in timely manner. During an interview conducted on 08/25/22 at 3:31 PM, the Administrator stated it was her expectation for the staff to notify the maintenance staff for all repair needs in timely manner to accommodate residents' needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to keep a sanitary environment in a shared bathroom for 2 of 2 residents reviewed for homelike environment (Residents #35 and #70). The findings included: Resident #35 was admitted to facility on 3/16/22 and her quarterly Minimum Data Set (MDS) dated [DATE] indicated she was cognitively impaired. An interview with resident #35 on 8/22/22 at 11:05 AM revealed she and her roommate shared a bathroom with two residents in the next room. A resident in the next room had a bowel movement and placed the soiled paper towels in the unlined bathroom trash can about one week prior. She could not recall the exact date. She further revealed the smell from the soiled paper towels permeated the bathroom and her room for days. The smell bothered her. Housekeeping did not clean the trash can before placing trash bag liners in the trash can. She complained to housekeeping when the incident first occurred (one week prior) and was told it would be taken care of, but the trash can remained soiled with dried brown matter and dried paper towels since one week ago. Resident #70 was admitted to facility on 1/31/20 with a MDS dated [DATE] indicated she was cognitively intact. An interview with Resident #70 on 8/22/22 at 11:30 AM indicated she became nauseous when she smelled the odor from the bathroom after housekeeping did not clean the brown stained trash can. An observation on 8/22/22 at 11:15 AM and 8/24/22 10:55 AM of the inside the trash can (bottom and side) revealed dried brown substance and brown soiled paper towels on the bottom of the trash can. No odor detected at time of observation. An interview with Housekeeping Aide on 8/24/22 at 10:58 AM revealed she was covering an assignment for another housekeeping staff for past two days. She further revealed she just cleaned the bathroom and changed the trash bag in the trash can. She stated she did not clean the inside of the trash can and that it was usually the responsibility of maintenance to clean the trash cans if housekeeping staff informed them of the need. After she agreed to observe the soiled trash by removing the trash can liner that she placed in the trash can, she stated she did not see the dried brown substance or dried paper towels in the bottom of the trash can. She then stated that it should have been cleaned when residents reported it to housekeeping one week prior. She had not informed maintenance or her supervisor. She stated she would inform maintenance, then stated she would clean it instead. An interview with the Housekeeping Supervisor on 8/25/22 at 10:10 AM indicated he worked at the facility since March and housekeeping staff should have cleaned the trash can when they clean the bathroom, instead of placing trash can liners over the soiled trash can or make the housekeeping supervisor aware the trash can needed to be cleaned. He further indicated housekeeping is short staffed at times and that he would follow-up to make sure the trash can was cleaned. An interview with the Administrator on 8/25/22 revealed she was unaware of the issue with housekeeping and that a floor tech worked until 9 PM. She expected housekeeping to clean the trash can when Resident #70 reported it to housekeeping staff.

Based on observations, record review, and staff interviews, the facility failed to discard produce with signs of spoilage, remove expired food items and date leftover food stored ready for use in the walk-in cooler. These practices had the potential to affect food served to residents. The findings included: An observation with the Dietary Supervisor of the walk-in refrigerator occurred on 8/22/22 at 10:08 AM with the following concerns identified: -A box of 10-12 dented and gray colored cantaloupes, recorded a manufacturer's expiration date of 7/26/22. -One large open container of leftover cucumber salad in its original container from the manufacturer with no expiration date. -Thirty-five 4 oz prune juice containers, unlabeled with no expiration date, and stored in a large gray utility box that was soiled with brown and black residue. An interview with the Dietary Supervisor on 8/22/22 at 10:30 AM revealed she began her supervisory role 9 years ago. She stated the refrigerated food items should have a label indicating the date opened or use by date. She instructed a Dietary Aide (DA) to discard the expired and unlabeled food items. She further revealed she was responsible for discarding expired foods and all Dietary Staff were responsible for dating refrigerated food items. She further stated the Dietary Manager transferred to another facility at the beginning of August and she had been performing various duties that the DM would normally be responsible for. An interview with the Corporate Dietician on 8/24/22 at 2:05 PM indicated the Dietary Supervisor was responsible for inventory of refrigerated foods that may be expired or not dated. An interview with the Administrator on 8/25/22 at 4:18 PM indicated she was not aware of the expired foods and that expired foods should discarded as soon as possible. She further indicated she was in the process of hiring a Dietary Manager (DM) and stated the Dietary Supervisor had added responsibilities since DM transferred to another facility.

Based on observations, record review, and staff interviews, the facility failed to ensure garbage was contained in a closed dumpster and maintain a clean grease trap free of buildup. The findings included: An observation on 8/22/22 at 10:20 AM of the outdoor grease trap while on kitchen tour revealed the entire lid, front and sides were soiled with thick black layers of grease build-up. There was also exposed trash and an open gate to the outdoor trash dumpster. Flies were also present. The Dietary Supervisor (DS) indicated she was responsible for emptying used kitchen grease into the outdoor grease trap and the company who comes to empty it, was responsible for cleaning it. An interview with the Maintenance Manager on 8/23/22 at 4:15 PM revealed he power washed the grease trap one year ago and the gate to the trash recycle receptacle should be closed. He further revealed the waste company usually cleaned the outside of the grease trap upon request of the facility. A phone interview with the grease trap removal company on 8/25/22 at 4:35 PM indicated the last grease pick up took place on 3/21/22. A review of the Pest Prevention Service Agreement indicated there was a continuous 12 visit provision in place. Recommendations were made to facility to remove debris around the dumpster area to prevent unsanitary conditions and attraction of pests. There was no indication outlined in the agreement that the pest service included cleaning the outside of the grease trap. The last inspection took place 8/8/22. An interview with the Administrator on 8/25/22 at 4:18 PM indicated she was not aware the grease trap had not been maintained and clean. She further indicated the garbage/recycle removal company was not responsible for the grease trap disposal. A grease trap removal company was responsible for emptying the grease. However, she was unaware if they were responsible for cleaning the outside of the grease trap.

Based on observations, record review and interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place on 12/27/19. This was for a deficiency in Accuracy of Assessments that was originally cited on the 11/22/19 recertification and complaint investigation survey. The QAA committee failed to maintain implemented procedures and monitor the interventions that the committee put into place on 07/19/21. This was for a deficiency in Food Procurement Store, Prepare, Serve, Sanitary that was originally cited on the 06/24/21 recertification and complaint investigation survey. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective QAA Program. The findings included: This citation is crossed referred to: F641: Based on observation, record review and interviews with residents and staff, the facility failed to accurately code the Minimum Data Set (MDS) related to tobacco use for 3 of 3 residents reviewed for smoking (Resident #3, #138, and #139). During the recertification and complaint survey completed on 11/22/19 the facility failed to accurately code the Minimum Data Set (MDS) in the areas of ostomy status on 2 consecutive assessments for Resident #12, Preadmission Screening and Resident Review (PASRR) for Resident #75, and discharge status for Resident #149. F-812: Based on observations, record review, and staff interviews, the facility failed to discard produce with signs of spoilage, remove expired food items and date leftover food stored ready for use in the walk-in cooler. These practices had the potential to affect food served to residents. During the recertification and complaint survey completed on 06/24/21 the facility failed to remove expired items in the refrigerator in 1 of 4 nourishment rooms and failed to label and date opened food items stored for use in 3 of 4 nourishment rooms. An interview with the Administrator occurred on 08/25/22 at 5:07 PM and revealed that the during each QAA monthly committee meeting, the committee reviewed prior deficiencies and continued to monitor past deficiencies to identify how the committee could improve and if it was necessary to keep auditing for continued improvement. The Administrator stated that she attributed the repeat deficiencies related to food procurement and accuracy of assessments to recent vacancies with MDS staff and the dietary manager.