**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews with staff, Nurse Practitioner (NP), and Medical Director (MD), the facility failed to protect resident's right to be free of misappropriation of controlled substances for 1 of 4 residents reviewed for misappropriation of resident property (Resident #4). The findings included: The facility's Abuse, Neglect, Exploitation, and Misappropriation policy, last revised on 01/19/23, revealed in part the facility would ensure all residents were free from misappropriation of property. Resident #4 was admitted to the facility on [DATE] with diagnoses which included fractured hip, pain, and malnutrition. Resident #4 was discharged from the facility to the local acute care hospital on [DATE]. A review of the physician's order dated 09/27/24 revealed Resident #4 had an order to receive 1 tablet of Hydrocodone-Acetaminophen (an opioid that acts on the central nervous system to relieve pain) 10 milligrams (mg)-325 mg by mouth every 8 hours as needed for pain. The initial allegation report dated 10/04/24 revealed the Administrator became aware of the misappropriation of resident's property on 10/04/24 at 6:25 PM when the nurse medication count revealed a card of 6 tablets of Hydrocode-Acetaminophen 10-325 mg were missing. On 10/04/24, an internal investigation was initiated regarding the allegation of misappropriation of property for Resident #4. The investigation report (5-day) dated 10/09/24 revealed the Director of Nursing (DON) was alerted by Nurse #1 on 10/04/24 at 3:45 PM that a card with 6 tablets of Hydrocodone-Acetaminophen 10-325 mg was missing from the cart. An immediate search was conducted for the missing card which was not located in the cart or the medication room. Nurse #1 verified the card had been in the cart on 10/03/24 when she had counted the narcotics for her oncoming shift of 3:00 PM to 11:00 PM but was turned around backwards due to the resident being out at the hospital. Medication Aide (MA) #1 was contacted by the DON on 10/04/24 and verified when she had counted off at 8:00 AM on 10/04/24 with Nurse #2 the card had been in the medication cart turned backwards due to the resident being out at the hospital. The investigation report dated 10/09/24 revealed statements had been obtained from MA #1 and Nurse #1 and both submitted to drug testing completed on 10/04/24 which was negative. Nurse #2 who had custody of the keys and the cart on 10/04/24 from 8:00 AM to 3:00 PM was contacted and requested to return to the facility for interview and drug testing which she declined. On 10/05/24 Nurse #2 was contacted again regarding coming in for interview and drug testing and again declined. On 10/05/24 Nurse #2 contacted the facility and called out for her next shift scheduled on 10/08/24 from 7:00 AM to 3:00 PM. Nurse #2 was terminated by the facility for failure to adhere to company policy. Per the facility investigation report dated 10/09/24, all the carts were audited to ensure an accurate count of controlled substances and to ensure there were no other missing medications. All the other carts were accurate and there were no additional issues noted. The diversion was reported to the local police, the Drug Enforcement Administration (DEA), the local Department of Social Services and Nurse #2 was reported to the Board of Nursing. An interview on 11/12/24 at 3:13 PM with Medication Aide (MA) #1 revealed it had been a while since she had worked at the facility. MA #1 stated she was scheduled to work 7:00 AM to 3:00 PM on the assisted living unit; however, when she arrived at the facility on 10/04/24, she was told to go to the skilled unit to hold the keys for the nurse who was running late. She further stated she and Nurse #3 counted the cart and the card of medication for Resident #4 was in the cart and was turned around backwards when they had counted the cart at 7:00 AM on 10/04/24. She indicated she was holding the keys until Nurse #2 got to work. MA #1 further indicated she asked the other nurses if she should go ahead and start the medication pass on the hall and they told her to start so she did. She said a few minutes after 8:00 AM Nurse #2 came in to work and was screaming at her because she had started her medication pass and demanded she give her the keys to the cart and said they did not count the cart when she handed the keys over to Nurse #2 because Nurse #2 told her she was already running behind and needed to get started on her medication pass. MA #1 stated she gave the keys to Nurse #2 and went to the assisted living unit to work as a Nurse Aide (NA) from 8:00 AM to 3:00 PM. She explained that some time after 3:00 PM she was asked to write a statement and consented to a drug panel because there were missing medications from the cart, she had given medications from earlier in the day. MA #1 said she wrote her statement, and her drug panel was negative. She stated she had received education regarding resident abuse, neglect, exploitation and misappropriation and had been educated on notifying her supervising nurse when medications needed to be returned to the pharmacy. MA #1 further stated she had been educated on the proper procedure for counting carts when leaving duty station. A telephone interview on 11/12/24 at 3:27 PM with Nurse #1 revealed she was scheduled to work on 10/04/24 from 3:00 PM to 11:00 PM and when she came in, she counted off with Nurse #2 and noticed there was a card of 6 tablets of Hydrocodone for Resident #4 missing that had been in the cart on 10/03/24 at 3:00 PM. She asked Nurse #2 where the card was, and Nurse #2 told her she didn't know and said she had to leave to pick up her child. Nurse #1 stated she immediately notified the charge nurse about the missing card, and they began searching the cart and medication room and were unable to find the card of medication. She further stated while searching for the Hydrocodone they found a card of Diazepam belonging to Resident #4 in the medication room in the pharmacy return basket for non-narcotic medications but did not find the Hydrocodone tablets. Nurse #1 indicated the card was never found but was determined to have gone missing while Nurse #2 had the keys to the cart during the hours of 8:00 AM to 3:00 PM. Nurse #1 further indicated she wrote a statement and consented to a drug panel which came back negative. She explained that she had in-service training after the diversion regarding abuse, neglect, exploitation and misappropriation as well as education on printing narcotic sheets from the electronic medical record and checking the printout against what is in the cart and then both nurses sign indicating the count is correct and no pills were tampered with or missing. Additionally, Nurse #1 stated she had been educated on the proper procedure for counting carts when leaving duty station. A telephone interview on 11/12/24 at 3:40 PM with Nurse #2 revealed she had worked on 10/04/24 during the 8:00 AM to 3:00 PM shift. She stated she was no longer working at the facility. Nurse #2 stated she had not worked at the facility in over a month and could not recall anything about a resident's missing medications and said it had been so long ago that she really couldn't recall if she had worked with Resident #4. She further stated she was currently working with the North Carolina Board of Nursing (NCBON) taking courses to reinstate her license but was not currently working as a nurse anywhere. An interview on 11/12/24 at 3:51 PM with the Director of Nursing (DON) revealed during her investigation of the missing medication card that she discovered working with the business office manager (BOM) that residents who went out to the hospital were put into the electronic medical record (EMR) as hospital leave. She stated that way they were taken out of the census, but their medications remained in the count including narcotics. The DON further stated on 10/04/24, sometime during the 8:00 AM to 3:00 PM shift Resident #4's status was changed in the EMR to discharge/return anticipated which took the medications including their narcotics out of the count. She stated the EMR system did not identify who had made the change in the system, but the change had taken Resident #4's narcotic sheet and remaining tablets on her card out of the system and count which she learned from the corporate office was a flaw in their electronic medical record system. The DON indicated once they discovered the census change, they were able to narrow down the timeline to sometime after 8:08 AM and before 3:45 PM which was the time frame that Nurse #2 had custody of the keys and the cart with the missing Hydrocodone card. She further indicated the charge nurse attempted to call Nurse #2 back to the facility for drug panel testing but she declined and said she was currently out with her family at the fair and could not return to the facility. The DON explained the next day they called Nurse #2 to request she come in to fill out a statement and have a drug panel test and she again declined. She said sometime later 10/05/24 Nurse #2 called the facility and called out for her next scheduled shift which was 10/08/24 from 7:00 AM to 3:00 PM so the facility terminated her employment for failure to adhere to company policy. The DON explained they could not confirm Nurse #2 had taken the card of medication because she had not consented to interview, writing a statement or drug panel but said they were able to narrow the time down to 10/04/24 between 8:08 AM and 3:45 PM as the time the medication card disappeared off the cart. She stated they notified the local police, the state, Drug Enforcement Administration (DEA) and the Department of Social Services of the incident. The DON said she notified the pharmacy and obtained pricing from them to reimburse the resident and to report to the DEA. The DON further stated they had also reported Nurse #2 to the North Carolina Board of Nursing (NCBON). She explained they had done in-service education with all staff on abuse, neglect, exploitation, and misappropriation and they had done in-service education with the medication aides and nurses on proper disposition of patients who are discharged to the hospital, proper return of medications including narcotics and printing disposition sheet and completing it with two nurses signatures and proper storing of narcotics for return to pharmacy in red box with numbered seal. According to the DON, since putting these measures in place there had been no further issues with missing narcotic medications. A telephone interview on 11/13/24 at 9:18 AM with the consulting pharmacist revealed he was not in the facility monthly but someone from the pharmacy conducted random audits of the carts and were mainly looking for outdated medications and discontinued medications that had not been removed from the carts monthly. He stated every six months they conducted a Medication Administration Record (MAR) to cart audit to make sure the orders from the physician match the medications on the cart. The consultant pharmacist further stated they check the narcotics to ensure they are not out of date but said they did not do a narcotic cart card check. He indicated they had never found missing narcotic cards on their audit but was aware of an incident at the facility of a resident's missing narcotic medication. A telephone interview on 11/13/24 at 12:20 PM with the Medical Director (MD) revealed he recalled being told about missing narcotic medications but did not recall the details about it. He stated he had not had the opportunity to see Resident #4 since she was only at the facility for 7 days. A telephone interview on 11/13/24 at with the Nurse Practitioner (NP) at 1:49 PM revealed she recalled being told about the missing narcotic medications but did not recall all the details. She stated she was familiar with Resident #4 and said there had been questions on admission about the dosage of her narcotic medication and her anti-anxiety medication and she had worked closely with Resident #4 and with her family member on getting her medication dosage adjusted to what she was taking at home. The NP further stated it was her understanding the resident had not missed any of her narcotic medication and had suffered no ill effects from the missing medications. The facility provided the following corrective action plan with a completion date of 10/07/24. Address how corrective actions will be accomplished for the resident to have been affected by the deficient practice: On 10/04/24 the Director of Nursing and charge nurse were made aware that Resident #4 had a prescription-controlled medication card containing 6 Hydrocodone-Acetaminophen 10-325 mg pills missing from the medication cart on 10/04/24 between 8:08 AM and 3:45 PM. The resident was not adversely affected by the deficient practice. The resident was in the hospital and did not miss any medication administrations. The narcotic count was corrected. The residents remaining controlled substances (Diazepam) were returned to the pharmacy. On 10/05/24 a Root Cause Analysis was completed by the Director of Nursing and Administrator regarding the missing controlled medication for the resident. It was determined through root cause analysis the discharge census was changed in the electronic medical record (EMR) and the process to reconcile controlled medication by removing medication of discharged resident from the medication cart on 10/02/24 was not followed. How will the facility identify other residents having the potential to be affected by the same deficient practice: On 10/04/24 the Director of Nursing or Designee completed a 100% audit of all the medication carts to ensure no other residents prescribed narcotic medications were missing and reconciled the declining inventory count sheet to ensure the count and the card matched and that medications were available and on med carts on 10/04/24. No discrepancies were noted. DON or designee interviewed alert and oriented residents on 10/06/24 to ensure residents were receiving medications whey they were scheduled or when requested when experiencing pain. No issues were noted. The DON or designee assessed non-interviewable residents for signs and symptoms of pain to ensure pain was being managed appropriately. No concerns were identified. The Administrator and DON interviewed staff members related to the missing controlled medication as well. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: The DON or designee re-educated all nurses and medication aides on handling-controlled medications to ensure that all controlled medications that are in the medication cart are listed on the controlled substance count and the narcotic reconciliation were correct. The Administrator on 10/05/24 educated the Business Office Manager, DON, Resident Care Coordinator, Staff Development Coordinator and Charge Nurses regarding correct discharge census to be coded for resident who is transferred to the hospital as hospital leave until and unless the controlled substances for the resident are returned to the pharmacy. The DON or designee educated all licensed nurses and medication aides on the process on 10/05/24. The Administrator and DON re-educated staff with validation of understanding on Abuse, Neglect, Exploitation and Misappropriation with emphasis on Misappropriation of Resident's Property and Drug Diversion on 10/05/24. The Director of Nursing or designee to complete quality monitoring on medication carts weekly for 12 weeks to ensure all medications accounted for with count correct with nurses counting and documenting total medications and total count sheets beginning 10/05/24. How will facility monitor its corrective actions to ensure the deficient practice will not recur: On 10/05/24, after the missing controlled medications were identified the facility Administrator conveyed an ADHOC Quality Assurance Performance Improvement meeting to determine the root cause analysis of the deficient practice, put a plan of action in place to include quality improvement monitoring and frequency of monitoring beginning 10/07/24 to ensure all medications accounted for with count correct with nurses and medication aides counting and documenting total cards and total count sheets including the Administrator, Director of Nursing, Social Services, the Business Office Manager, Human Resources Coordinator, Admissions Director, Staff Development Coordinator and Nurse Managers. The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement (QAPI) meeting monthly to ensure ongoing compliance for 3 months. Quality Improvement monitoring schedule will be modified based on findings of monitoring. Date of Compliance: 10/07/24. The facility's corrective action plan with a correction date of 10/07/24 was validated onsite by observations and interviews with the Director of Nursing and nursing staff. (The Administrator was not available for interview). An observation was conducted during a shift transition for a medication cart between 2 nurses on 11/12/24. Nurses started with the printout from the electronic medical record and counted the total number of blister cards that contained controlled medications stored in the double locked compartment in the medication cart and verified the balance on the narcotic count log. The nurses then counted the total number of declining narcotic sheets and verified the balance in the narcotic count log. The nurses then proceeded to inspect and count each blister card of controlled medication to ensure the quantity listing in the declining narcotic count sheets were consistent with the actual pill count. After all counts were completed and without any discrepancies, the on-coming shift nurse and the off-going shift nurse signed the printout and narcotic count log, and the off-going shift nurse passed the medication cart key to the on-coming shift nurse. A random sample of 3 controlled medications were pulled from the medication cart on 700 hall for verification of accuracy. The controlled substance counts were consistent with the records documented in the declining narcotic count sheets. Interviews with nursing staff including medication aides (MA), licensed practical nurses (LPN) and registered nurses (RN) confirmed they had received education related to Misappropriation of Resident's Property and the narcotic process policy. It included the process for shift-to-shift controlled substance count, verification of on-hand controlled medications and returning discontinued medications to the pharmacy. The nurses and medication aides were able to describe the policy and procedures and verbalized understanding of the education. Review of audit records revealed all residents receiving controlled medications were audited by the DON or designee weekly beginning 10/04/24. Then monthly for 8 weeks to ensure the narcotic count was correct on each cart, shift-to-shift count was completed appropriately, and discontinued controlled medications were removed from the medication carts and returned to the pharmacy. The findings were reported to the QAPI committee for suggestions and/or recommendations; the quality improvement monitoring schedule will be modified based on findings of the monitoring. Reporting results will be continued for 3 months. Interview with the Director of Nursing (DON) revealed the facility launched an in-service related to controlled medication process and accountability immediately after the incident to re-educate all the licensed nurses and medication aides. The DON or designee audited the medication carts in-person randomly to ensure all controlled medication counts were conducted appropriately and the declining narcotic count sheets were documented properly. The DON stated the interventions were successful as the facility did not have any similar diversion issues since then. The compliance date of 10/07/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Physician Assistant interviews the facility failed to notify the physician of low blood pressures that required blood pressure medication to be withheld for 1 of 1 sampled resident reviewed for physician notification (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE] with Diagnoses that included atrial fibrillation (irregular heart rhythm), hypertension (high blood pressure), and congestive heart failure. Review of Resident #27's active physician orders revealed an order dated 10/18/23 for Metoprolol Tartrate 75 (milligrams) mg oral twice daily for diagnosis of congestive heart failure. There were no heart rate or blood pressure parameters to hold the medication included as part of the order. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively intact. Review of Resident #27's electronic Medication Administration Record (eMAR) for April 2024 was completed on 4/16/24 and revealed Resident #27's Metoprolol Tartrate was documented as not administered for the morning dose (9:00 AM dose) on: -4/1/24 -4/2/24 -4/5/24 -4/13/24 -4/14/24 Metoprolol Tartrate was also documented as not administered for the evening dose (5:00 PM dose) on: -4/2/24 -4/3/34 -4/3/24 -4/6/24 -4/27/24 -4/12/24 -4/13/24 -4/14/24 -4/15/24 The morning and evening doses of Metoprolol were documented as non-administered for the reasons: due to condition: low blood pressure or vital signs not with in parameters for administration. There was a blood pressure documented in the non-administration comments on 4/2/24 9:00 AM of 109/61 and on 4/15/24 at 5:00 PM of 97/56. No other vital signs were documented in the medication non-administration notes for Resident #27's Metoprolol Tartrate. Review of Resident #27's vital sign record revealed no documentation of a blood pressure for 9:00 AM or 5:00 PM from 4/1/24- 4/15/24. Review of Resident #27's electronic medical record revealed there was no documentation in the nursing notes or physician progress notes about Resident #27's low blood pressure or the physician being notified of Resident #27's low blood pressure. An interview with Nurse #5 was performed on 4/16/24 at 9:00 AM. Nurse #5 stated she worked on the 600-hall extension hall routinely and administered medications. She stated she would hold Resident #27's Metoprolol Tartrate sometimes because her blood pressure is too low. Nurse #5 reviewed Resident #27's eMAR and verified there were no parameters included with the order for holding the medication. Nurse #5 explained she used blood pressure parameters of 110/60 to hold Resident #27's Metoprolol Tartrate. She stated she used these parameters based on her prior nursing experience knowledge and because another blood pressure medication scheduled at a different time had parameters of 110/60. Nurse #5 stated there was not a facility standing order for blood pressure parameters to hold blood pressure medications. She stated she had not called the providers to notify them of Resident #27's low blood pressures or that she held Resident #27's Metoprolol Tartrate due to low pressure. An interview was performed on 4/16/24 at 3:54 PM with Nurse #4. She explained she checked Resident #27's blood pressure and if her blood pressure was less than 110/60, she would hold Resident #27's Metoprolol Tartrate. She explained Resident #27's blood pressure tended to run low. She stated going off nursing knowledge she used blood pressure parameters of 110/60 to hold the Metoprolol Tartrate. Nurse #4 said she did not notify the Physician of Resident #27's low blood pressure or that the medication was held. Nurse #4 stated the physician should be notified if a blood pressure mediation was held so they can add parameters to the medication. An interview was performed on 04/16/24 at 12:19 PM with the Physician Assistant (PA). She stated she was unaware that Resident #27's Metoprolol was being held frequently due to low blood pressures. The PA stated she had not been made aware that Resident #27 was having low blood pressure. She said if a resident's blood pressure was low a nurse could hold a blood pressure medication once per nursing judgement. The PA explained if a blood pressure medication had frequently needed to be held more often than once or twice, she would expect the nurses to notify her. She stated if she had been notified and new Resident #27's Metoprolol Tartrate was frequently being held she would have given orders for parameters. An interview was performed with the Director of Nursing (DON) on 4/16/24 at 4:09 PM. She reviewed the eMAR for Resident #27's Metoprolol Tartrate administration history. The DON stated looking at the non-administration history for Resident #27's Metoprolol Tartrate she did not feel like there was a trend in the medication not being administered due to low blood pressure. She said she thought nurses should notify the physician if there was a trend in low pressure and a trend in the medication not being given due low blood pressures. She explained a trend would be the same time of day for several days in a row. She did not comment on if she considered Resident #27 having low pressure for 4 days in a row at 5:00 PM as a trend. An interview was performed on 04/17/24 at 3:47 PM with the Administrator. He stated the Physician should be notified if a resident was having low blood pressures and should be involved in the decision to hold medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to follow a physician's order to apply compression stockings for 1 of 1 resident (Resident #220) reviewed for edema. The findings included: Resident #220 was admitted to the facility on [DATE] with diagnoses which included cellulitis (bacterial infection that can result in swelling and inflammation) of the left lower limb, localized edema (swelling), and lymphedema (swelling as a result of built-up lymph fluid in the body). An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #220 was cognitively intact. A review of Resident #220's physician orders revealed an order dated 4/5/2024 to apply compression stockings to bilateral lower extremities upon rising and to remove at night before bed daily. A review of Resident #220's care plan dated 4/11/2024 revealed she was admitted with weeping areas of the lower extremities related to a diagnosis of cellulitis and was at risk for further areas of skin breakdown related to edema, weeping, lymphedema, and cellulitis. Interventions included staff were to provide treatment to weeping areas on lower extremities as ordered. A review of Resident #220's MAR for the month of April 2024 revealed Nurse #2 documented she had applied Resident #220's compression stockings on 4/16/2024. An interview and observation were conducted on 4/16/2024 at 11:32 am with Resident #220 after she returned from working with Physical Therapy. Resident #220 was observed sitting in her wheelchair with her feet on the floor and did not have compression stockings on. She stated she wore compression stockings because she had experienced significant swelling. She reported the nursing staff had not put her compression stockings on and had told her that they could not find her compression stockings. Resident #220 also stated a staff member, whose name she was not able to remember, had told her they did not have any to replace them at that time. An empty extra, extra-large (XXL) compression stocking wrapper was observed on her nightstand beside her bed. She reported she always told staff to put them in her top nightstand drawer when they took them off, but stated staff had not done that, and that they were no longer there. Resident #220 opened her top nightstand drawer, which did not contain compression stockings. A telephone interview was conducted on 4/18/2024 at 9:02 am with Nurse #2. Nurse #2 reported she worked third shift (11:00 pm to 7:00 am) on 4/16/2024 and verbalized she had documented applying Resident #220's compression stockings. She stated that she had not put the compression stockings on Resident #220 and had asked a Nurse Aide (NA) that morning (4/16/2024) whose name she was not able to recall, to put them on the resident. Nurse #2 reported she had not checked to ensure the NA had placed the compression stockings on the resident because she was busy and 'it happens.' She reported the compression stockings should have been placed on Resident #220 per physician's order. An interview was conducted on 4/16/2024 at 11:38 am with Nurse #1. Nurse #1 reported compression stockings were ordered for Resident #220 to be applied daily. She reported that the third shift (11:00 pm to 7:00 am) nursing staff, either a Nurse or an NA, were responsible for applying compression stockings when they had gotten Resident #220 up in the morning. She verified that Nurse #2 had documented applying the compression stockings at 6:33 am on 4/16/2024. An observation of Resident #220 was conducted with Nurse #1 4/16/2024 at 11:40 am. During the observation, Nurse #1 verified that Resident #220 was not wearing compression stockings. Nurse #1 reported if it was charted, she would have expected the compression stockings to be on Resident #220. An interview was conducted on 4/18/2024 with the Director of Nursing (DON). The DON reported extra compression stockings were kept in stock in the facility and were readily available for staff to obtain for residents. She reported NAs or nurses could put compression stockings on the resident. The DON stated application of compression stockings was typically documented on the Electronic Medical Record (EMR). She reported that Nurse #1 notified her that on 4/16/2024 Resident #220 did not have the compression stockings on her legs and Nurse #1 had applied the compression stockings after she was made aware of the error. The DON reported the compression stockings should have been placed on Resident #220 as ordered. An interview was conducted on 4/18/2024 at 10:41 am with the Administrator. The Administrator reported compression stockings were kept in the facility and if they were ordered to be applied daily then the staff should have applied them daily. An interview was conducted on 4/18/2024 at 11:30 am with the Physician's Assistant (PA). The PA stated Resident #220 had experienced swelling of her bilateral lower extremities and was ordered to have compression stockings applied daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, sitter and staff interviews, the facility failed to provide assistance with dressing when requested for 1 of 3 dependent resident (Resident #367) reviewed for provide care with activities of daily living (ADL). The findings included: Resident #367 was admitted on [DATE] with the diagnosis of muscle weakness, unsteadiness on feet and chronic pain. A review of the care plan for Resident #367 dated 04/11/24 indicated the resident had impaired mobility and required partial to maximum assistance with activities of daily living (toileting, dressing and bathing). A review of the Minimum data Set indicated Resident #367 required partial to max assist with toileting, dressing, positing, supervision of feeding, tray set up, chronic pain, occupational therapy (OT) and physical therapy (PT), and moderately impaired cognition with short term memory problems. An interview with Resident #367 on 04/15/24 at 11:37 AM, revealed that she had asked to be dressed in regular clothes (pants and blouse) before lunch, but nurse aide (NA) #7 told her she had a sitter to dress me in the morning and I should have told asked my sitter. The Resident stated she then told the NA she wasn't quite ready to get dressed before breakfast when her sitter was with her. She then revealed she wanted to change out of her gown and wear real clothes for therapy session scheduled for after lunch. Observation of Resident #367 at the time of the interview revealed she was wearing a nightgown. An observation on 4/15/24 11:40 AM, of resident #367's closet, revealed she had several changes of clean clothes. An observation of Resident #367 on 04/15/24 at 02:35 PM, revealed that she had not been dressed in her regular clothes at this time. She was still wearing the nightgown she had been wearing that morning. An interview with NA#7 on 04/15/24 at 03:26 PM revealed when asked about dressing resident#367, she indicated that the resident had a paid caregiver that bathes and dresses her, so she needed to tell the caregiver when she is getting dressed, that she wants to put on regular clothes. An interview with Resident #367 on 04/16/24 at 08:37 AM, indicated that she did not get dressed in her regular clothes on 4/15/24, they were still lying over her chair this morning. An interview with the sitter on 04/16/24 at 9:00 AM revealed that she comes every morning to give her a bath, and it is sometimes early, so Resident #367 was not ready to get dressed until after breakfast the morning of 04/15/24. She further revealed that if the Resident had therapy in the afternoon she wanted to wait to get dressed later. An observation of Resident #367 on 04/16/24 at 9:00 AM, revealed she had been dressed in her regular clothes by the sitter. An interview with the DON 04/17/24 at 10:17 AM, revealed that her expectations are that the NA #7 regardless of a sitter still complies with her duties. An interview with Administrator on 04/17/24 at 02:18 PM, revealed his expectation would be for the NA #7 to assist as needed when Resident #367's sitter was present and after the sitter leaves to continue with her duties. An interview with the Administrator on 04/18/24 at 10:30 PM, revealed it was his expectation that regardless of if the residents had a sitter or not, that the NA#1 would assist as needed, and when the sitter left, they would continue with their duties caring for the resident's needs. An interview with the Therapy Director on 04/18/24 at 11:47 AM, indicated that Resident #367 was receiving physical and occupational therapy. They were working on upper and lower body strengthening for positioning and dressing, toileting, and bathing. He further stated that the Resident was making progress but was unsafe to get up and dress without assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident, staff and Physician Assistant interivews the facility failed to follow physician orders to check a diabetic resident's (Resident #27) blood sugar levels twice daily for 1 of 1 resident reviewed. The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type 2 (a condition when your blood sugar is too high) Review of Resident #27's active physician orders for April 2024 revealed an order dated 12/4/23 to: check blood sugar twice daily at 6:00 AM and 4:30 PM for diagnosis of type 2 diabetes mellitus. Resident #27 did not have orders for insulin. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively intact. Review of Resident #27's care plan revised 2/19/24 revealed she did not have a care plan specific for Type 2 diabetes mellitus. Review of Resident #27's electronic Medication Administration Record (MAR) for April 2024 did not show blood glucose checks twice daily at 6:00 AM and 4:30 PM being completed. A review of Resident #27's electronic health record was conducted. There were no blood glucose check results documented in the resident's record. An interview was conducted with Resident #27 on 4/16/24 at 8:40 AM. She stated she checked her blood glucose at home prior to coming to the facility but said she had never had her blood glucose checked since she had been admitted to the facility. An interview was conducted on 4/16/24 at 9:00 AM with Nurse #5. She stated she regularly worked on the 600-hall and administered medications to Resident #27. She said she did not check Resident #27's blood glucose. An interview was conducted on 4/16/24 with the Physician Assistant (PA). She stated she was not aware of an order to check Resident #27's blood glucose twice daily. The PA reviewed Resident #27's active orders and verified there was an order for Resident #27 to receive blood glucose checks twice daily. The PA opened the order entry details for the blood glucose check order and explained the order was put in incorrectly. She said because the order was put in incorrectly the order would not have popped up on the MAR for the nurses to see and know they needed to check Resident #27's blood glucose. An interview was performed with the Charge Nurse on 4/16/24 at 2:59 PM. She explained the process for entering orders in the electronic medical record. She stated sometimes verbal orders were given by the provider and then entered in the electronic medical record by the nurse. The Charge Nurse said there was not a process for orders to be checked by a second nurse. She explained when an order was entered into the electronic medical record there were different aspects of the order that needed to be entered when inputting the order that would tell the order where to show up, such as on the MAR and what time to populate on the MAR. She opened the order entry details for Resident #27's order for blood glucose checks and verified she was the nurse who inputted the order. The charge nurse explained the order did not appear on the MAR for the nurses to see because the order was entered incorrectly under the flow sheet titled general and this flow sheet did not pull orders to the MAR. An interview was performed on 4/17/24 at 3:35 PM with the Director of Nursing (DON). The DON was aware Resident #27 had not received blood glucose checks due to the order being entered incorrectly into the electronic medical record. She stated she was unsure of what happened in the process other than human error. The DON said it was easy to miss click when entering an order. The DON stated there was not a second person who checked orders when orders were put in by a nurse. She stated the nurses checked and verified orders when the order was put in by the physician. An interview was performed on 04/17/24 at 03:36 PM with the Administrator. He was made aware Resident #27 had not received blood glucose checks due to the order being entered incorrectly into the electronic computer system. He stated he thought there should have been a follow up to the order, such as a second check. He said physician orders should be followed and was unsure of what happened in this situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and Physician Assistant interviews, the facility failed to maintain infection control when staff reused urinary leg drainage bags, urinary bedside drainage bags, and connection tubing causing an increased risk of infection. This occurred for 1 of 1 resident (Resident #17) reviewed for catheter care. The findings included: Resident #17 was re-admitted to the facility on [DATE] with Diagnoses that included obstructive uropathy with urinary retention. Review of Resident #17's active physician orders for April 2024 revealed an order dated 8/29/23 that read: Place leg bag on in the AM (morning) and off at HS (bedtime). Special instructions: please remove the leg bag at bedtime and put on catheter bag while in bed. Additional orders dated 12/21/23 read: Catheter to straight drainage bag related to obstructive uropathy; Catheter care every shift; catheter change as needed for obstruction, infection, or when otherwise clinically indicated; secure strap, privacy bag and monitor every shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively impaired and had an indwelling catheter. Review of Resident #17's care plan revised 4/18/24 revealed a care plan for an indwelling urinary catheter related to urinary retention due to obstructive uropathy. The care plan interventions included: catheter care every shift and as needed, keep catheter system a closed system as much as possible, change catheter per doctor order, assess drainage every shift, avoid obstructions in drainage, position bag below level of bladder, report any signs of urinary tract infection (UTI), Do not allow tubing or any part of the drainage system to touch the floor. 4/16/24 08:20 AM an observation was made of Resident #17 up in her wheelchair outside of her room. She was wearing long pants, and a catheter drainage bag was not visible. An interview was performed on 4/16/24 at 8:48 AM with NA #1. She explained Resident #17 used a leg urinary drainage bag when she was up during the daytime and was changed to a bedside drainage bag at night. NA #1 stated she switched Resident #17 from the bedside drainage bag to the leg drainage bag when she got her up in the mornings. She explained how she switched Resident #17's urinary drainage bags. She said she wore a gown and gloves when she provided catheter care. NA #1 stated she sometimes would use a new leg bag when she switched the Resident #17's catheter over from the night side drainage bag in the mornings. She said she stored the used leg urinary drainage bag in the bathroom between uses. She stated she would reuse the leg bag a couple of days sometimes before getting a new one. She said the bedside drainage bag was reused and she would place the bedside drainage bag into a plastic bag in the bathroom when it was not in use. NA #1 stated she was unsure how long the bedside drainage bag was reused. She explained when she changed Resident #17's catheter from the bedside drainage bag to the leg bag she would sometimes wipe the tubing connection tip off with a rag or baby wipe before connecting it to the catheter. She explained a baby wipe as being an incontinent care wipe. She stated she would typically leave Resident #17's leg bag on if she laid down for a nap. She explained Resident #17 would typically lay down for a nap in the afternoon for several hours every day. NA #1 stated she had not received specific training on how to switch a catheters connection from a leg drainage bag to a bedside drainage bag. She said she had not been told when catheter bags needed to be changed or how to store them if they were reused. An observation was completed on 4/16/24 at 9:00 AM of the urinary bedside drainage bag stored in the bathroom cabinet in a wash basin, no cap was present on the tip of tubing, old urine was visible in the bag, the urinary collection system was not stored in a bag, the date on the back of drainage bag was 4/24. An Interview was completed on 04/16/24 at 3:46 PM with Nurse #4. She stated she worked on the 600-hall extension on the weekends for 7:00 AM- 7:00 PM shift. She stated she typically switched Resident #17's catheter between urinary drainage bags. She said she would not expect an NA to do that task. She explained how she switched Resident #17's catheter from the bedside drainage bag to the leg drainage bag. She said she would empty the bag, disconnect the catheter from the bedside drainage bag tubing, clean off the end of the tubing of the leg drainage bag and reattach it to the catheter. She stated she cleaned the tubing tip with an alcohol wipe before reattaching it to the catheter. Nurse #4 said she thought the bedside drainage bags were changed every month. She stated when the leg urinary drainage bag was removed, it was placed in the bathroom. She said the urinary drainage bag was placed on top of the toilet to be stored, she said she did not place the drainage bag in plastic bag for storage. She stated, it is usually just on top of the toilet. She explained, the bedside drainage bag was also kept on top of the toilet between use and stated, it is not stored in anything, it is just on top of the toilet. She stated leg urinary drainage bags are used she thought for a month before they were changed. She did not say what day of the month the urinary drainage bags were changed or how staff new when to change the urinary drainage bags. An observation was completed on 04/17/24 at 8:10 AM. Resident #17 was observed in bed with her eyes closed. She had a bedside urinary drainage bag in place. The leg urinary catheter drainage bag was observed stored in the bathroom cabinet in a wash basin, with dark old urine visible in the bag, no cap was present on the end of tubing, the leg bag was not stored in a plastic bag, the leg bag was not dated. An observation was completed on 04/18/24 at 8:30 AM of the bedside urinary drainage bag with attached tubing, in a plastic bag, stored on the back of the toilet, the urinary drainage bag was dated 4/17. An interview was performed on 4/18/24 with Nurse #5. She explained Resident #17's NA switched her urinary drainage bag between the leg bag and bedside drainage bag when they assisted Resident #17 to get up out of bed and when they lay her down. Nurse #5 said the urinary drainage bag not being used at that time was put in the cabinet of Resident #17's bathroom. She said she thought she had seen the urinary drainage bag not in use stored in something like a bag sometimes but not every time. Nurse #5 stated urinary drainage leg and bedside bags were not changed daily, that the bags were reused. She said she thought Resident #17's urinary drainage leg and bedside bags were changed monthly and then as needed if the bags were dirty or there was a lot of sediment in the tubing. Nurse #5 stated the urinary drainage bags tubing connection tip should be cleaned with an alcohol wipe before reconnecting it to the catheter. She stated no one from the facility had ever talked to her about how often urinary drainage bags should be changed, how to maintain them, where to store them between uses, or how to store them. An interview was performed on 4/18/24 at 8: 53 AM with the Staff Development Coordinator (SDC)/ Infection Preventionist (IP). He stated when a catheter was disconnected from the tubing/ urinary drainage bag he would expect staff to get a new bag. He said NA's received generalized training on catheter care but had not received training specificly on the process of disconnecting and reconnecting a catheter from the urinary drainage tubing/ bag. He stated the facility did not have specific policy and procedures on the reuse of urinary drainage bags, or how to maintain and store them. The SDC stated he was unsure if an NA could perform the task of disconnecting the catheter and switching it between a leg and bedside drainage bag. He stated he assumed the nurse would perform the task and not the NA but was unsure. He said the urinary drainage bag connected to the catheter was changed as needed and if the catheter was changed. The SDC explained if the urinary drainage bag was disconnected from the catheter frequently it would open the closed system, which was not recommended because this would introduce infection. The SDC called the Director of Nursing (DON) to his office for clarification on urinary leg and bedside bag reuse. The DON and the SDC both said urinary drainage bags should not be reused. They stated that staff should use a new bag each time the catheter was disconnected to switch between a leg and bedside drainage bag. An interview was performed with the DON on 4/18/24 at 10:34 AM. She stated staff should throw away the used urinary drainage bag and get a new bag each time the catheter was disconnected to switched between a leg and bedside drainage bag. She stated the urinary drainage bag with attached connection tubing should be changed as needed and anytime the closed urinary drainage system was opened. She stated anytime the closed system was opened bacteria could be introduced that could cause an infection. She stated indwelling urinary catheters were changed as needed and not monthly or routinely unless ordered by the urologist. She explained the process for switching a catheter between a leg and bedside drainage bag. The DON said she would disconnect the tubing from the catheter and then clean the connection tubing with an alcohol pad before reconnecting the tubing to the catheter. She stated she was unsure why staff were reusing bags and that staff needed education. An interview was conducted on 04/18/24 01:07 PM with the Physician Assistant (PA). She stated staff should be getting a new urinary drainage bag each time. She explained there was a potential for introducing new infections if not using new clean equipment or cleaning the tubing before reconnecting the catheter. The PA said she was not aware that this was occurring An interview was performed on 4/18/24 at 1:48 PM with the Administrator. He stated used urinary drainage collection bags should be disposed of and not stored anywhere for reuse. He explained staff should not be reusing urinary catheter drainage bags and a new bag should be used each time. He stated if staff were reusing bags the tubing should have been cleaned prior to reconnecting it to the catheter. He stated he was unsure why staff were reusing catheter drainage bags. The Administrator stated reusing urinary drainage bags could introduce bacteria that could cause an infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure and chronic obstructive pulmonary disease. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #5 was moderately cognitively impaired and received oxygen therapy during the MDS assessment period. A review of Resident #5's physician orders revealed an order for oxygen delivered via nasal cannula at 3 liters per minute (lpm) continuously. An observation of Resident #5 was conducted on 04/15/2024 at 11:36 AM. Resident #5 was lying in bed wearing a nasal cannula with oxygen being delivered at 3 lpm. There was no cautionary or safety signage for the use of oxygen observed in Resident #5's room, outside her room or anywhere in her environment. Another observation of Resident #5 was conducted on 04/16/2024 at 9:00 AM. Resident #5 was lying in bed wearing a nasal cannula with oxygen being delivered at 3 lpm. There was no cautionary or safety signage observed in Resident #5's room, outside her room or anywhere in her environment. An interview was conducted with the Director of Nursing (DON) on 04/16/2024 3:45 PM. The DON stated safety signage for the use of oxygen and a no-smoking sign were posted on the door at the main entrance and visible to anyone that entered the building. The DON indicated cautionary or safety signage for oxygen in use was not posted outside, in or around the resident rooms because they were a non-smoking facility and the signage at the main entrance covered the entire facility. An interview was conducted with the Administrator on 04/17/2024 at 9:26 AM. He revealed there was a no smoking sign and safety signage for oxygen in use posted on the front door at the main entrance of the facility. The Administrator indicated because the facility was non-smoking and signage was posted at the main entrance, they did not post cautionary or safety signage outside, in or around resident rooms where oxygen was in use. Based on observations, record reviews, and staff and resident interviews, the facility failed to post precautionary and safety signs that indicated the use of oxygen for 2 of 2 residents reviewed for respiratory care (Resident #117 and Resident #5). The findings included: 1. Resident #117 was admitted to the facility on [DATE] with diagnoses that included unspecified diastolic (congestive) heart failure, shortness of breath, and acute respiratory failure with hypoxia. Review of Resident #117's physician orders dated 03/18/24 revealed an order for continuous oxygen delivered at 2 liters per minute via nasal cannula. A review of Resident #117's 5-day Minimum Data Set assessment dated [DATE] revealed Resident #117 was cognitively intact. She received continuous oxygen therapy for shortness of breath (SOB) with exertion, while sitting at rest, and when lying flat. Resident #117's care plan dated 04/01/24 revealed she was at risk of complications such as decreased oxygen saturation levels, hypoxia, and shortness of breath based on her diagnoses of congestive heart failure and acute respiratory failure with hypoxia. Interventions included assisting with activities of daily living and encouraging rest periods to help conserve energy, monitoring her oxygen saturation levels, and oxygen as ordered. An observation of Resident #117 on 04/15/24 at 10:07 AM revealed she was in her room, sitting in her wheelchair, and had completed her breakfast. Resident #117 was observed with oxygen being delivered at 2 liters per minute via nasal cannula. There were no precautionary or safety signs to indicate that oxygen was in use noted in Resident #117's room, on her door, or anywhere in her environment. A subsequent observation of Resident #117 on 04/16/24 at approximately 9:50 AM revealed Resident #117 sitting in her wheelchair, speaking with her visiting family. She received 2 liters of continuous oxygen per minute via nasal cannula. There were no precautionary or safety signs to indicate that oxygen was in use posted in her environment. An interview with NA #2 was conducted on 04/17/24 at 9:48 AM. She verbalized awareness of oxygen use by residents; and, reported that no oxygen use signage was posted outside of individual resident rooms. An interview with NA #3 was conducted on 04/17/24 at 10:02 AM. She verbalized awareness of oxygen use by Resident #117. NA #3 reported that no oxygen use signage was posted outside of individual resident rooms. An interview with Nurse #6 was conducted on 04/17/24 at 10:16 AM. She verbalized awareness of residents of the facility using oxygen; however, reported that no oxygen use signage was posted outside of individual resident rooms. An interview with the Director of Nursing was conducted on 04/18/24 at 8:31 AM. She reported that the facility's oxygen in use signage was posted at the front door of the facility, which was their policy. An interview with the Administrator was conducted on 04/18/24 at 8:48 AM. He stated that the corporate office informed him that oxygen in use signage posted at entrance doors covered the entire facility per the State regulations and the facility has been non-smoking since 2016.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to provide a dysphagia mechanical consistency meal as ordered by the nurse practitioner for 1 of 1 resident reviewed for nutrition (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included history of traumatic brain injury, gastro-esophageal reflux disease without esophagitis, type 2 diabetes mellitus, and diaphragmatic hernia. A review of the Nurse Practitioner's diet order dated 11/20/23, indicated that Resident #1 was to receive a carbohydrate-controlled diet (CCD) with a dysphagia mechanical consistency (which required a change in the texture of food or liquids). A review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] indicated that she was severely cognitively impaired, required setup or clean up assistance for eating, and received a mechanically altered diet (which required a change in texture of food or liquids) and a therapeutic diet. A continuous observation was completed of Resident #1 during meal service from 12:44 PM to 12:53 PM. An observation of Resident #1's dietary communication slip for lunch on 04/15/24 at 12:44 PM was for ground kielbasa sausage with brown gravy, pureed baked beans, pureed capri vegetable blend, pureed dinner roll, unsweet tea, and pureed cake. Instead, she received a whole pork chop, which was detected by Nursing Assistant (NA) #3. NA #3 returned the meal to the kitchen at 12:45 PM. Dietary Aide #3 delivered a second meal tray to Resident #1 at 12:49 PM which had ground kielbasa sausage with brown gravy, non-pureed baked beans, non-pureed capri vegetable blend, pureed dinner roll, unsweet tea, and pureed cake. Resident #1 proceeded to take 2-3 small bites of her meal from the tip of her fork. NA #3 returned to check on Resident #1 at 12:53 PM and noticed the meal tray consistency was not correct. Again, NA #3 returned the meal to the kitchen and provided the prescribed meal to Resident #1. During an interview with NA #3 on 04/15/24 at 12:56PM, she stated Resident #1 received a pork chop, baked beans, and vegetable medley on her first tray, which NA #3 returned to the kitchen because Resident #1's mechanical pureed diet order did not include a fried pork chop in that form. Upon checking the second meal, NA #3 stated that she noticed that a tray with non-pureed vegetables had been delivered by Dietary Aide #3 and verbalized plans to return the tray to the kitchen. NA #3 reported that the residents' meals were normally prepared and delivered as prescribed and listed on the meal ticket. During an interview with Dietary Aide #3 on 04/15/24 at 1:02 PM, she stated that she delivered the wrong replacement meal to Resident #1. She reported that she was not working on the dietary line but did receive the first replacement meal, which she covered without double checking the dietary ticket for Resident #1. She stated that the process should have been for Dietary Aide #1 to provide the plate, beverages, and condiments as she read out the order to the [NAME] who placed the food on the plate. She reported that Dietary Aide #2 should have double checked to ensure that the ticket and the meal matched. An interview completed with Dietary Aide #1 on 04/15/24 at 1:27 PM revealed she was responsible for the meal tickets. Dietary Aide #1 explained she called out the diet to the cook, and placed the condiments, desserts, and silverware on the resident meal trays. Then she slid the resident meal tray down the line to Dietary Aide #2. An interview with the [NAME] on 04/15/24 at 1:09 PM revealed that Dietary Aide #1 hollered for a pork chop with noodles, capri blend, and a roll. She stated that the meal given to Resident #1 was a different ticket for a different resident's tray. She reported that the process should have been Dietary Aide #1 calling out the diet to the [NAME] who prepared the plates. She stated Dietary Aide #2 was responsible for rechecking the ticket and that Dietary Aide #1 had requested a mechanical diet for Resident #1. During an interview with Dietary Aide #2 on 04/15/24 at 1:13 PM, she reported that the mechanically altered ticket for Resident #1 did have a pork chop on the plate. She explained she understood the difference between diet types and verbalized she verified the diet ordered versus what was on the meal ticket. Dietary Aide #2 was uncertain as to why Resident #1 received the wrong meal tray two times. An interview with the Dietary Manager on 04/15/24 at 1:17 PM revealed that the process for meal plating should have been for Dietary Aide #1 to have placed the condiments and utensils on the tray, then she should have read out the ticket to the Cook, who prepared the plate. Afterwards, the Dietary Aide #1 should have slid the tray to Dietary Aide #2 for placement of the beverages and any supplements The Dietary Manager stated Resident #1 should have received the right plate the first time. Dietary Aide #2 should have verified the correct meal type prior to the meal tray leaving the kitchen. An interview with the District Dietary Manager on 04/15/24 at 1:23 PM revealed that Dietary Aide #2 should have confirmed that the plate was for Resident #1's meal ticket. She stated that she believed that Dietary Aide #2 just grabbed the wrong plate because the proper diet for Resident #1 was prepared and available. An interview with the Registered Dietician on 04/16/24 at 12:34 pm revealed that dietary staff was trained upon hire then staff received various computer-based in-services which are rotated monthly, depending upon each staff member's date of hire. She shared that all other residents that received pureed diets on 04/15/24 - except Resident #1 - received the proper meals. She stated all dietary staff were to follow the tray ticket and serve what was on the ticket. She reported that the aides on the dietary line either misread the ticket, grabbed the wrong food item, or didn't hear the ticket being read off. She reported that the last Dietary Aide (#2) on the line should have double-checked the plate before putting a lid on it. An interview with the Director of Nursing on 04/18/24, who was aware that Resident #1 received the wrong meals twice on 04/15/24, revealed that the dietary staff should have checked trays/meals before the meals left the kitchen, and that NAs and staff should have verified that tickets and meals matched before they delivered the meals to residents. During an interview with the Administrator on 04/18/24 at 8:47 am, he stated that the current process worked well because NA #3 detected the discrepancy in the meals and the prescribed diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to honor food choices for 2 of 2 sampled residents (Residents #38 and # 27) reviewed for preferences. The findings included: 1. Resident # 38 was re-admitted to the facility on [DATE]. The most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #38 was cognitively intact and did not receive a therapeutic or mechanically altered diet. An interview and observation was conducted with Resident # 38 on 4/16/24 at 8:30 AM. She was in her room and had her breakfast tray set up in front of her on the overbed table and was drinking coffee. Her meal plate had uneaten scrambled eggs and dark toast on it. She stated she had only eaten the oatmeal off her breakfast tray. Resident #38 stated the other foods on her breakfast tray were foods she did not like. She stated she did not like and does not eat powdered eggs and the toast was too hard to eat. She did not say if she had asked for anything else for breakfast. An interview and observation was conducted with Resident #38 on 4/17/24 at 8:20 AM. She was sitting up on the side of her bed with her breakfast tray sitting in front of her on the bedside table. Her breakfast tray included scrambled powdered eggs, dark toast with blacking along the edges, milk, cold cereal, oatmeal, biscuit with sausage gravy, orange juice, butter, jelly sugar packets, and coffee. Resident #38 was eating the biscuit and gravy. She stated she would only eat the biscuit and gravy off her breakfast tray. Resident #38 stated again, she disliked and would not eat the scrambled powdered eggs on her plate or the hard toast. She stated the toast was hard everyday and they served her the eggs every day. Resident #38 stated she had spoken to someone in the past from the kitchen and had told them she did not like the powdered eggs. She stated the person she had talked to from dietary no longer worked at the facility and that it had been over a year since anyone from dietary had talked to her about her food likes and dislikes. She did not say if she had asked to speak to someone in dietary over the last year. On 4/17/24 Resident #38's breakfast dietary meal tray card was reviewed and revealed she had a regular diet ordered. There were no food preference likes/ dislikes listed on the meal tray card. The bottom of the meal tray card stated, eggs instead of hashbrowns. An interview was conducted on 4/16/24 at 11:45 AM with the Director of Nursing (DON). She provided a printed form titled food preference assessment for Resident #38. The date listed at the top of the assessment was 4/16/24. The DON stated the assessment had been printed from meal tracker [meal tracker is the dietary system used for menu planning and that prints the meal tray card tickets]. She stated 4/16/24 was the date the assessment was printed from meal tracker. She stated 4/16/24 was not the date the assessment had been completed but could not provide the exact date the likes/dislikes information had been documented into meal tracker. There was no documentation on the assessment form as to who had completed or entered the information. The food preference assessment for Resident #38 did not list scrambled eggs or toast as dislikes. Review of meal tracker activity log revealed Resident #38's likes/ dislikes had last been updated on 9/10/20. An interview was conducted on 4/17/24 at 9:50 AM with the Registered Dietician (RD). She stated the Dietary Manager completed food preference likes/ dislikes for residents when they were admitted and then quarterly with reviews. She stated the Dietary Manager updated the resident's food likes/ dislikes in meal tracker. An interview was conducted on 4/17/24 at 10:40 AM with the Dietary Manager. She stated she had been the Dietary Manager for about a year and had not really received a lot of training on paperwork or the computer part of her job. She stated she had not known that she had to fill out a dietary preference form for resident food likes/ dislikes or put the information into the meal tracker computer system until about 2 months ago. The Dietary Manager stated she would see a resident and ask them their food likes/ dislikes and then put the information into meal tracker. She stated meal tracker would remove the disliked food item from the resident's profile as a food option and the disliked food would not appear on the resident's meal tray card ticket. She stated meal tracker was where the meal tray card/ tickets were printed from. The Dietary Manager stated she now would see residents within a few days of their admission and completed a foods preference likes/ dislikes form. She stated she had started the process of updating and completing the food preference likes/ dislikes form for all current and new residents when she had been made aware 2 months ago of the food preference likes/ dislikes form she was supposed to be using. She stated the facility's scrambled eggs were liquid eggs not powdered eggs. She stated fresh eggs were available if a resident preferred fried eggs, hard boiled eggs, or did not like the liquid scrambled eggs. She stated unless she removed grits as an option on a resident meal ticket profile in meal tracker the printed meal tray card/ ticket would just say hot cereal. She stated the meal tray card/ ticket contained the resident's diet, food allergies, and food items to be included on the meal tray. She stated that dietary staff plating food could only see what was printed on the meal tray card/ticket and would not know if a resident disliked a food. She stated the bottom of the meal ticket would say eggs instead of hashbrowns or rice instead of potatoes if dietary was out of an item. She stated if they were out of an item, or the item did not come in on the food truck order she had to substitute the food item for something else, such as substituting a starch for another starch. She could not say how staff would know if a resident disliked a substituted food item such as eggs if eggs instead of hashbrowns was printed on the bottom of the meal tray card/ ticket. She stated the system allowed her to use the note pad in meal tracker to put in a disliked food and this would be visible on a resident's meal tray card/ticket but stated she had not done this routinely. The Dietary Manager stated she had not been aware of the dietary preference assessment form for Resident #38 until yesterday 4/16/24. She stated the form had been printed out and given to her yesterday by the RD. The Dietary Manager stated she had not seen Resident #38 to complete the new dietary food preference likes/ dislikes form with her. An interview was conducted on 04/17/24 at 11:40 AM with Nurse Aide (NA) #4. She stated how meal trays were delivered to residents who dined in their rooms. She stated dietary brought the tray cart to the hallway, then nursing staff passed out the meal trays according to room numbers. NA #4 stated each tray had a tray meal card/ ticket that had the residents name on it, their diet, food allergies, and what food, drinks, and condiments were supposed to be on the tray. She stated when she delivered a meal tray, she helped set up the tray and checked to make sure the diet and food items on the tray matched what was on the tray meal card/ ticket. She stated if a resident told her they did not like something she would ask them if they wanted something else as a substitute. She stated she thought some tray meal card/tickets had dislikes listed at the top of the ticket with allergies but was not sure. She was not sure how she would know if a resident who was not oriented would like or dislike a food item served on their meal tray. An interview was conducted on 4/17/24 at 3:46 PM with the Administrator. He stated food likes/ dislikes should be done by the Dietary Manager within 72 hours after admission and should then be entered into meal tracker. He stated after admission dietary preference food likes/ dislikes should be done quarterly and updated as needed. The Administrator stated he could not say what happened in the process where dietary was not completing food preference likes/ dislikes. 2. Resident #27 was admitted to the facility on [DATE]. The most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #27 was cognitively intact and received a mechanically altered therapeutic diet. An interview was conducted on 4/15/24 at 10:52 AM with Resident # 27. She stated she did not like to eat grits or powdered eggs. She stated she received these items on her meal tray often. She stated she had spoken with someone from the kitchen about her food likes and dislikes but was unsure who the person was or when she had spoken to them. An interview and observation were conducted on 4/16/24 at 8:40 AM with Resident #27. She was sitting up in her bed drinking coffee with her breakfast tray set up in front of her on her overbed table. She had grits and toast on her plate that were uneaten. When asked how breakfast was, she stated, look for yourself I don't eat grits and I've told them I don't eat grits. She again stated she had spoken to someone from dietary in the past and told them she did not like grits but could not remember who she had spoken to. She did not say if she had asked for anything else for breakfast. A second observation was conducted on 4/17/24 at 8:15 AM of Resident #27 sitting up in bed with her breakfast tray set up in front of her on her overbed table. Her breakfast tray included oatmeal, powdered scrambled eggs, and coffee. Resident #27's dietary meal tray card was reviewed for breakfast, lunch, and dinner on 4/16/24 and for breakfast on 4/17/24. The meal tray card revealed she was on a consistent carbohydrate diet (CCD). There were no food preference likes/ dislikes listed on the meal tray card. The breakfast meal tray card for breakfast on 4/17/24 stated at the bottom eggs instead of hashbrowns. An interview was conducted on 4/16/24 at 11:45 AM with the DON. She provided a printed form titled food preference assessment for Resident #27. The date listed at the top of the assessment was 4/16/24. The DON stated the assessment had been printed from meal tracker [meal tracker is the dietary system used for menu planning and that prints the meal tray card tickets]. She stated 4/16/24 was the date the assessment was printed from meal tracker. She stated 4/16/24 was not the date the assessment had been completed but could not provide the exact date the likes/dislikes information had been documented into meal tracker. There was no documentation on the assessment form as to who had completed or entered the information. The food preference assessment for Resident # 27 listed grits and scrambled eggs as dislikes. Review of the meal tracker activity log revealed Resident # 27 dislike for scrambled eggs and grits had been entered last on 11/30/23. An interview was conducted on 4/17/24 at 9:50 AM with the Registered Dietician (RD). She stated the Dietary Manager completed food preference likes/ dislikes for residents when they were admitted and then quarterly with reviews. She stated the Dietary Manager updated the resident's food likes/ dislikes in meal tracker. An interview was conducted on 4/17/24 at 10:40 AM with the Dietary Manager. She stated she had been the Dietary Manager for about a year and had not really received a lot of training on paperwork or the computer part of her job. She stated she had not known that she had to fill out a dietary preference form for resident food likes/ dislikes or put the information into the meal tracker computer system until about 2 months ago. The Dietary Manager stated she would see a resident and ask them their food likes/ dislikes and then put the information into meal tracker. She stated meal tracker would remove the disliked food item from the resident's profile as a food option and the disliked food would not appear on the resident's meal tray card ticket. She stated meal tracker was where the meal tray card/ tickets were printed from. The Dietary Manager stated she now would see residents within a few days of their admission and completed a foods preference likes/ dislikes form. She stated she had started the process of updating and completing the food preference likes/ dislikes form for all current and new residents when she had been made aware 2 months ago of the food preference likes/ dislikes form she was supposed to be using. She stated the facility's scrambled eggs were liquid eggs not powdered eggs. She stated fresh eggs were available if a resident preferred fried eggs, hard boiled eggs, or did not like the liquid scrambled eggs. She stated unless she removed grits as an option on a resident meal ticket profile in meal tracker the printed meal tray card/ ticket would just say hot cereal. She stated the meal tray card/ ticket contained the resident's diet, food allergies, and food items to be included on the meal tray. She stated that dietary staff plating food could only see what was printed on the meal tray card/ticket and would not know if a resident disliked a food. She stated the bottom of the meal ticket would say eggs instead of hashbrowns or rice instead of potatoes if dietary was out of an item. She stated if they were out of an item, or the item did not come in on the food truck order she had to substitute the food item for something else, such as substituting a starch for another starch. She could not say how staff would know if a resident disliked a substituted food item such as eggs if eggs instead of hashbrowns was printed on the bottom of the meal tray card/ ticket. She stated the system allowed her to use the note pad in meal tracker to put in a disliked food and this would be visible on a resident's meal tray card/ticket but stated she had not done this routinely. The Dietary Manager stated she had not been aware of the dietary preference assessment forms for Resident #27 until yesterday 4/16/24. She stated the forms had been printed out and given to her yesterday by the RD. The Dietary Manager stated she had not seen Resident #27 to complete the new dietary food preference likes/ dislikes form her. An interview was conducted on 04/17/24 at 11:40 AM with Nurse Aide (NA) #4. She stated how meal trays were delivered to residents who dined in their rooms. She stated dietary brought the tray cart to the hallway, then nursing staff passed out the meal trays according to room numbers. NA #4 stated each tray had a tray meal card/ ticket that had the residents name on it, their diet, food allergies, and what food, drinks, and condiments were supposed to be on the tray. She stated when she delivered a meal tray, she helped set up the tray and checked to make sure the diet and food items on the tray matched what was on the tray meal card/ ticket. She stated if a resident told her they did not like something she would ask them if they wanted something else as a substitute. She stated she thought some tray meal card/tickets had dislikes listed at the top of the ticket with allergies but was not sure. She was not sure how she would know if a resident who was not oriented would like or dislike a food item served on their meal tray. An interview was conducted on 4/17/24 at 3:46 PM with the Administrator. He stated food likes/ dislikes should be done by the Dietary Manager within 72 hours after admission and should then be entered into meal tracker. He stated after admission dietary preference food likes/ dislikes should be done quarterly and updated as needed. The Administrator stated he could not say what happened in the process where dietary was not completing food preference likes/ dislikes. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to ensure accurate medical records when a resident's compression stockings were incorrectly documented as applied for 1 of 1 resident (Resident #220) reviewed for medical record accuracy. The findings included: Resident #220 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #220 was cognitively intact. A review of Resident #220's physician orders revealed an order dated 4/5/2024 to apply compression stockings to bilateral lower extremities upon rising and to remove at night before bed. A review conducted on 04/15/2024 at 3:22 pm of Resident #220's Medication Administration Record (MAR) of April 2024 for the period of 4/1/2024 through 04/18/2024 revealed Medication Aide (MA) #1 documented she had applied Resident #220's compression stockings on 4/15/2024. An interview and observation were conducted on 4/15/2024 at 3:18 pm of and with Resident #220. She was observed to not have compression stockings on her bilateral lower extremities during the interview and reported staff had not put compression stockings on her that morning (4/15/24). MA #1 was unavailable for interview. A review conducted on 04/15/2024 at 3:22 pm of Resident #220's Medication Administration Record (MAR) of April 2024 for the period of 4/1/2024 through 04/18/2024 revealed Nurse #2 documented she had applied Resident #220's compression stockings on 4/16/2024. An interview and observation were conducted on 4/16/2024 at 11:32 am with Resident #220. She reported staff had not put her compression stockings on that morning (4/16/2024) and had told her that they could not find her compression stockings. Resident #220 also stated staff had told her they did not have compression socks to replace hers at that time. An empty extra, extra-large (XXL) compression stocking wrapper was observed on her nightstand beside her bed. She reported she always told staff to put them in her top nightstand drawer when they took them off, but the staff had not done that, and that they were no longer there. She proceeded to open her top nightstand drawer, which did not contain compression stockings. An interview and observation were conducted on 4/16/2024 at 11:38 am with Nurse #1. Nurse #1 reported compression stockings were ordered for Resident #220 to be applied daily. She reported that the third shift (11 pm to 7 am) was responsible for applying compression stockings when they had gotten the resident up in the morning. She verified that Nurse #2 had documented applying the compression stockings at 6:33 am on 4/16/2024. Nurse #1 walked to Resident #220's room, made an observation of the resident, and verbalized Resident #220 was not wearing compression stockings. She reported if it was charted, she would have expected them to be on Resident #220, and reported the Nurse should not have documented application of compression stockings if the task had not been completed. A phone interview was conducted on 4/18/2024 at 9:02 am with Nurse #2. Nurse #2 reported she worked third shift (from 11:00 pm on 4/15/2024 to 7:00 am on 4/16/2024) verbalized she had documented applying Resident #220's compression stockings. She stated that she had not put the compression stockings on Resident #220, and had asked a Nurse Aide (NA), whose name she was not able to recall, to put them on the resident. She reported she had not checked to ensure the NA had placed them on the resident because she was busy and it happens. She reported the task should not have been charted as completed if the compression stockings had not been applied and the error occurred because she had not verified the NA had put them on. An interview was conducted on 4/18/2024 with the Director of Nursing (DON). The DON stated application of compression stockings were typically documented on the Electronic Medical Record (EMR). She reported tasks documented as completed by staff were expected to have been completed. An interview was conducted on 4/18/2024 at 10:41 am with the Administrator. He was not aware that Nurse #2 had documented application of compression stockings and had not applied them. An interview was conducted on 4/18/2024 at 11:30 am with the Physician's Assistant (PA). She was not aware that MA #1 and Nurse #2 had documented the application of compression stockings without having applied them. She reported if a task was documented as done, she would expect that it had been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #20 was admitted to the facility on [DATE] Review of a handwritten grievance form dated 11/28/23 revealed Resident #20 requested a call bell pull cord for her bathroom. The space on the form indicated the nursing department had received the grievance and was documented in parenthesis as 'taken care of.' The grievance was missing the conclusion, corrective action and required signatures from the Director of Nursing (DON) and the Administrator. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively intact. An interview was conducted with Resident #20 on 04/17/24 at 1:13 PM. Resident #20 stated she was not able to move or propel her manual wheelchair to reach the call bell in the shower or the call bell next to the toilet because the pull cords were just not long enough. Resident #20 reported she had filed a grievance requesting a longer pull cord to be added to her bathroom call bell multiple times and nothing had been done. An interview was conducted with the Maintenance Director on 04/17/24 at 3:50 PM who stated that he was not aware and had not received a grievance request for Resident #20 needing a longer pull cord for the bathroom. He reported when residents had a maintenance request or issues he received the grievance form request from administration, then entered a work order request into their electronic work order request system. The Maintenance Director was observed reviewing work orders and stated that Resident #20 didn't have a work order request in the system. He further stated adding a longer pull cord to the call bell was a quick fix and could be done on the same day. An interview was conducted with the Director of Nursing (DON) on 04/18/24 at 9:00 AM who stated a grievance could be initiated by a staff member, the resident or family member and during resident council meetings. She stated when a grievance was initiated the staff helped complete the form, the administration team reviewed each grievance form to determine which department or area needed to address the issue or concern. The DON stated they held daily meetings with all staff members in the morning to discuss issues and concerns that will be addressed; and that the Administrator also reviewed and kept a copy of each grievance form until it had been completed. She verbalized if the issue was related to nursing care, she completed that portion of the form and made sure the issue was addressed. She also verbalized being aware of Resident #20's request for a longer pull cord for the call bell in her bathroom and thought the issue was taken care of back in November 2023. However, she mentioned she had let the ball drop and would make sure Resident #20's request for a longer pull cord would be taken care of today (04/18/24). An interview was conducted with the Administrator on 04/18/24 at 9:30 AM who stated the departments were responsible for addressing the residents' grievances. He continued to state once the grievance had been handled, he reviewed and signed off on the form. He indicated he thought Resident #20's grievance was resolved previously. He acknowledged that their grievance policy was not followed. Based on observations, record review and resident, family member, and staff interview the facility failed to implement their grievance policies and procedures when Resident #222's Resident Representative reported the resident's top dentures were missing and when Resident #20 requested a call bell extension cord to be added in her bathroom for 2 of 2 residents reviewed for grievances (Resident #222 and Resident #20). The findings included: 1. Resident #222 was admitted to the facility on [DATE] with a diagnosis of vascular dementia. Review of the Inventory of Personal Items documentation dated 3/22/2024 completed by Nurse #3 revealed Resident #222 was admitted with upper dentures. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #222 was severely cognitively impaired. Resident #222 was not coded for dentures. Review of a nursing note dated 3/31/2024 completed by Nurse #1 revealed Resident #222's representative had reported his upper dentures were missing. Review of a handwritten grievance form dated 4/3/2024 revealed on 3/31/2024 at 10:30 am, Resident #222's family member reported his top dentures were missing. The space on the form indicating who received the grievance was blank. The investigation documentation revealed 'maybe we can look in her room as well.' The grievance was signed by the Director of Nursing (DON) and was dated 4/3/2024. The grievance was missing the conclusion, corrective action, and communication with the family member. An observation was conducted on 4/15/2024 at 1:22 pm. Resident #222 was up in his wheelchair and was not wearing upper dentures and was edentulous where upper teeth should be located. An observation and interview were conducted on 4/16/2024 at 8:48 am. Resident #222 was up in his wheelchair and was not wearing upper dentures and was edentulous. He reported he had not worn his dentures because he had not been able to find them. A telephone interview was conducted on 4/17/2023 at 11:19 am with Resident #222's representative. The representative stated she reported to the SW that Resident #222's dentures were missing on 3/31/2024. She reported she had gone to the SW's office and the SW filled out the grievance form. She reported she had not been contacted regarding the conclusion of the investigation until this morning (4/17/2024). She stated the Administrator told her 'They did not know what they could do about it' and stated the Administrator offered to take him to the dentist but she declined because he would be discharged home by that time. An interview was conducted on 4/17/2024 at 1:36 pm with the DON. The DON stated a grievance was to be completed when there was a concern or complaint and she preferred grievance forms to be completed by the Charge Nurse. She reported the Administrator was the Grievance Official and was responsible for ensuring that everyone involved in the grievance was satisfied. She stated after a grievance was filed, copies of the grievance were given to her, the SW, and the Administrator and the investigation would be initiated. She reported investigative steps taken should be documented on the grievance form as well as the conclusion and corrective action within 5 days of being notified about the grievance. The DON reported she had not investigated Resident #222's grievance and verified that her signature was on the grievance. She reported that the grievance policy and procedures had not been followed for Resident #222 because facility staff were still looking for the missing dentures and they had not reached a conclusion after 5 days. A telephone interview was conducted on 4/16/2024 at 3:23 pm with Nurse #1. Nurse #1 stated the family member of Resident #222 had reported to her that his upper dentures were missing on 3/31/2024. She reported that she looked all over his room and the nurse's station for his dentures and was not able to locate them. Nurse #1 stated she wrote a note in Resident #222's chart and reported the missing upper denture to the Charge Nurse #1 but had not filed out a grievance because she had never been instructed to. She verbalized that she was never able to find the dentures. An interview was conducted on 4/16/2024 at 3:28 pm with the Charge Nurse #1. Charge Nurse #1 verbalized she had been made aware of Resident #222's missing dentures and looked in his room, common areas in the facility, and the desk at the nurse's station and had not located them. She reported when an item was missing staff should look for the item and notify laundry, dietary, the Social Worker (SW), and admissions. She stated she had not filled out any documentation for the missing item and was not aware grievances should be completed if a resident or resident representative had voiced a concern. An interview was conducted on 4/16/2024 at 3:32 pm with the SW. The SW reported a grievance was completed whenever there was a concern or a complaint. She reported any staff member, resident, or family member were allowed to complete a grievance. She reported after a grievance was filled out, the staff member would put it under her door, in her mailbox, or in the mailbox of the DON or administrator. The SW stated staff from all departments then completed the investigation process and she would speak with the staff, resident, and/or resident representative. She also reported that grievances were discussed in the morning clinical meetings. A follow-up interview was conducted on 4/17/2024 at 11:26 am with the SW. The SW reported that she filled out the grievance when the representative for Resident #222 had reported his upper dentures were missing. The grievance was reviewed during the interview. The SW was not sure why the date the form was filled out and the date the incident took place did not match, and verbalized a grievance should be completed immediately when an issue was brought to a staff member's attention. She reported she also brought the concern up in the 4/1/2024 morning meeting. She reported she had given a copy of the grievance to the DON and the Administrator on an unknown date. She reported she had spoken to the representative after the grievance was filed, but was unsure of the date, about the missing item when the representative informed her that the dentures would cost $1800 to replace. The SW stated that Resident #222 had dementia and could have thrown the dentures in the trash or left them on a tray that was returned to the kitchen. She reported the Administrator was the Grievance Official and that the grievance process should have resulted in a conclusion within 5 days of the grievance being filed. She reported the grievance process had not been followed because they had continued to look for the missing dentures and had not come to a conclusion or completed the form within 5 days. An interview was conducted on 4/18/2024 at 10:35 am with the Administrator. The Administrator stated that he was the Grievance Official. He stated a grievance could be completed by staff, visitors, residents, and family members. He stated the SW typically filled out grievances and distributed copies to all the department managers after a grievance was completed. He reported the investigation was started, and a resolution would be identified and implemented. He stated the goal for having a grievance completed was 5 days unless there was an ongoing investigation. The Administrator was aware the DON was assigned the grievance for Resident #222 and reported she had looked for the dentures. He stated he, as the Grievance Official, had not yet come to a conclusion nor implemented any corrective actions within 5 days of the grievance being filed. He stated that he completed the remainder of the grievance form on 4/16/2024 and he had not contacted the representative until 4/17/2024 at which time he informed the representative that Resident #222's dentures had not been located. He reported he offered to make a dentist appointment and the representative declined because the appointment could not be made until after Resident #222 had been discharged , which was scheduled for 4/19/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, manufacturer's recommendations, and staff interviews, the facility failed to date opened multi-dose insulin pens, failed to discard expired insulin pens and a multi-dose insulin vial, and failed to store a multi-dose insulin vial in the refrigerator for 2 of 2 insulin medication carts (Cherry Street cart and [NAME] Hall cart) reviewed for medication storage and labeling. The findings included: 1a. The manufacturer's storage instructions for Levemir insulin indicated to store in-use vials under refrigeration or at room temperature and use within 42 days. The manufacturer's storage instructions for Levemir insulin in-use prefilled pens indicated, the pens should be stored at room temperature and used within 42 days; do not freeze or refrigerate. The manufacturer's storage instructions for Lispro indicated to store prefilled pen in the refrigerator until it is opened, but do not freeze it, prefilled pen is in use and should be stored at room temperature for 28 days. The manufacturer's storage instructions for Glargine insulin indicated prefilled pens should be stored at room temperature and used within 28 days; do not freeze or refrigerate. On [DATE] at 4:15 PM an observation of the insulin cart for Cherry Street Hall was conducted with Nurse #4. The observation revealed the following: -Levemir (is a long-acting insulin used to improve blood sugar control in people with diabetes mellitus) 100ml (milliliter) vial opened on [DATE] and placed in the insulin cart. The manufacturer's instructions stated to dispose 42 days after opening. -Levemir insulin pen opened and not dated. -Lispro insulin (is a fast-acting insulin used to lower levels of glucose (sugar) in the blood) pen opened on [DATE] and passed the manufacturer's instructed 28-day expiration date of [DATE]. -Glargine insulin (is used to improve blood sugar control in people with diabetes mellitus.) pen opened and not dated. On [DATE] at 4:25 PM an interview was conducted with Nurse #4 who stated she did not realize some of the insulin pens were not dated and had expired. Nurse #4 stated she usually tried to check the insulin cart when she came in on her shift from 3:00PM to11:00PM. She continued to state she would make the Director of Nursing (DON) aware and discard the expired insulin pens immediately. 1b. On [DATE] at 9:13 AM an observation of the insulin cart for [NAME] Hall was conducted. The observation revealed: -NovoLog (fast-acting insulin used to lower levels of glucose (sugar) in the blood) insulin Flex pen opened, and the date was illegible. The ink was smeared over the discard date, opened date incomplete, and unidentifiable. On [DATE] at 9:20 AM an interview was conducted with the Charge Nurse who stated she would discard the insulin pen (NovoLog Flex pen) and let the DON know. On [DATE] at 2:30 PM an interview was conducted with the DON. The DON stated the Charge Nurse and Nurse #4 had made her aware the insulin pens in the insulin carts had not been dated or stored properly. She stated she expected the nurses and medication technicians to be checking the insulin carts daily and each shift; as well as all insulin pens labeled when they were opened, stored correctly, and discarded 28 days after opening. She further stated the pharmacist who came in every month also checked the insulin and medication carts.

Based on observations and staff interviews the facility failed to ensure bowls, plates, metal bowls, serving pans, and baking sheets were dry before they were stacked, and to ensure dishes were clean. These practices had the potential to affect food served to residents. The findings included: a. The initial observation of the kitchen was conducted with the Dietary Manager (DM) on 4/15/2024 at 9:58 AM. The initial observation of the serving line and dish washing area revealed the following: - 12 plates stacked in a plate warmer on the serving line were wet. - 1 large serving pan, 2 baking sheets and 1 large metal bowl stacked on a storage rack in the dish washing area were wet. - 12 small red saucer plates with white crumb like particles and 1 small white saucer plate with a dried yellow substance were observed stacked on the storage rack for clean dishes in the dish washing area. b. A second observation of the serving line in the kitchen was conducted with the DM on 4/17/2024 at 11:45 AM and revealed the following: - 11 small white bowls stacked on the serving line were wet. An interview was conducted with the DM on 4/17/2024 at 2:25 PM. The DM indicated dishes and pans were washed in a low temperature dishwasher and placed on racks to dry. The DM revealed plates, bowls and pans should not be stacked while they were still wet. She indicated the dish washing area was humid and they had difficulty drying the dishes and pans before they were needed for the next meal service. The DM stated a fan was ordered and would be installed near the drying rack to ensure dishes and pans were dry before they were stacked and used for the next meal. She stated staff checked the dishes when removing them from the dishwasher to ensure they were clean and items that were not clean were washed again. The DM further stated she was not able to explain why there were dirty dishes on the clean dish rack and staff should have noticed they were dirty and washed them again. An interview conducted with Dietary Aide #3 on 4/18/2024 at 9:45 AM revealed the dish washing process included spraying the dirty dishes with a degreaser, rinsing them, placing them in soapy water to soak, rinsing them again and then placing them in the dishwasher. She stated when dishes were removed from the dishwasher staff checked them to ensure they were clean. She indicated dishes that were not clean went through the washing process again. Dietary Aide #3 revealed the dirty dishes found on the clean dish rack 4/15/2024 was due to staff not checking them when they removed them from the dishwasher the previous day. Dietary Aide #3 stated due to the humidity in the dish washing area it was difficult for dishes and pans to dry before they were needed for the next meal service. She further stated wet dishes and pans should not be stacked. An interview was conducted with the Administrator on 4/18/2024 at 1:46 PM. He stated the facility used a low temperature dishwasher and dishes removed from the dishwasher had to be placed on a rack to dry. He indicated the dish washing room was humid which made the drying process more difficult, but a fan was ordered and would be installed in the dish washing area to help dishes and pans dry more quickly. He stated dishes and pans that were wet should not be stacked. The Administrator revealed dietary staff should be checking dishes when removing them from the dishwasher to ensure they were clean. He indicated dishes removed from the dishwasher that were still dirty should be washed again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee had put into place following the recertification survey and complaint investigation completed on 10/19/2022. This failure included two repeat deficiencies in the areas of Notification of Changes (F580) and Respiratory Services (F695). Additionally, the facility's QAA committee failed to maintain implemented procedures and monitor interventions the committee had put into place following the recertification survey and complaint investigation completed on 8/20/2021. The failure included two repeat deficiencies that were originally cited in the areas of Label/ Store Drugs & Biologicals (F761), and Resident Allergies/ Preferences/ Substitutes (F806). All of the above areas were subsequently recited on the current recertification survey completed on 4/18/2024. The repeat deficiencies during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This citation is cross referred to: F580: Based on record review, staff and Physician Assistant interviews the facility failed to notify the physician of low blood pressures that required blood pressure medication to be withheld for 1 of 1 sampled resident reviewed for physician notification (Resident #27). During the recertification survey and complaint investigation of 10/19/2022 the facility failed to notify the responsible party after a resident was transferred to the hospital for 1 of 3 residents reviewed for notification. F695: Based on observations, record reviews, and staff and resident interviews, the facility failed to post precautionary and safety signs that indicated the use of oxygen for 2 of 2 residents reviewed for respiratory care (Resident #117 and Resident #5). During the recertification survey and complaint investigation of 10/19/2022 the facility failed to administer oxygen as prescribed by the physician for 3 of 3 residents reviewed for oxygen therapy. F761: Based on observations, manufacturer's recommendations, and staff interviews, the facility failed to date opened multi-dose insulin pens, failed to discard expired insulin pens and a multi-dose insulin vial, and failed to store a multi-dose insulin vial in the refrigerator for 2 of 2 insulin medication carts (Cherry Street cart and [NAME] Hall cart) reviewed for medication storage and labeling. During the recertification survey and complaint investigation of 8/20/2021 the facility failed to discard expired medications in 2 of 3 medication carts (600 Hall and 700 Hall) and failed to ensure the medication storage room was locked for 1 of 1 medication storage rooms (600 Hall) reviewed for medication storage. F806: Based on observations, record review, resident and staff interviews, the facility failed to honor food choices for 2 of 2 sampled residents (Residents #38 and # 27) reviewed for preferences. During the recertification survey and complaint investigation of 8/20/2021 the facility failed to honor food preferences for 1 of 1 resident reviewed for food preferences. An interview with the Administrator was conducted on 4/18/2024 at 3:30 PM revealed he had been in the position since December 2023. The Administrator explained he was in the process of improving the systems related to QAPI and follow-up of the Plan of Correction (POC) post survey. The Administrator verbalized the QAPI/Quality Assurance (QA) Manual was on-line and the documentation was available at any time for review. He voiced that improvement in performance was ongoing for better outcomes. The Administrator expressed it was his responsibility to make sure process and follow-ups continued and that planned outcomes were met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and legal guardian interviews the facility failed to notify the responsible party after a resident was transferred to the hospital for 1 of 3 residents (Resident #4) reviewed for notification. Findings included: Resident #4 was admitted the facility on 4/21/21 with diagnoses which included hypertension and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired. The MDS further revealed Resident #4 was coded for hospice and tube feeding. Review of Resident #4 care plan dated 9/16/22 revealed Resident #4 had behaviors and mood problems which places the resident at risk for injury and/or harm to themselves and others. The goal indicated Resident #4 will have minimal increase in behaviors and will remain free from injury, harm to self and others as evidenced by decreased episodes of physical behavior. Intervention included to notify the medical director (MD) and RP of any significant behaviors or change in condition promptly. Review of progress note by Nurse #3 dated 10/4/22 revealed Resident #4 displaced her g-tube (feeding tube) this morning and an on-call hospice nurse was notified. The note further revealed the on-call hospice nurse completed an assessment and due to the stoma being closed was unsuccessful in reinserting the feeding tube. It was advised to send Resident #4 to the hospital. An interview conducted with Nurse #3 on 10/19/22 at 11:30 AM revealed she worked on 10/4/22 when Resident #4 was sent out to the hospital at an estimated time of 6:00 AM. Nurse #3 further revealed an on-call hospice nurse came to assess Resident #4 and made the decision to send the resident out to the hospital. Nurse #3 indicated she had thought the on-call hospice nurse had contacted the family since she assessed Resident #4. An interview conducted with Nurse #4 on 10/19/22 at 12:30 PM revealed she worked on 10/4/22 during 1st shift when Resident #4 returned to the facility from the hospital. Nurse #4 stated Resident #4's family representative visited the facility to see the resident and was informed the resident had been sent out to the hospital early that morning. Nurse #4 stated the family representative was upset that she had not been notified. An interview conducted with the family representative on 10/17/22 at 12:20 PM revealed Resident #4 was sent out to the hospital on [DATE] and they were not notified. The family representative indicated she had visited the facility on 10/4/22 after lunch and was told by nursing staff that Resident #4 had been sent to this hospital early that morning around 6:00 am. The family representative revealed she had not been notified and was upset because she had attended all doctor and hospital visits with Resident #4. An interview conducted with the Director of Nursing (DON) on 10/19/22 at 4:15 PM revealed she was aware Resident #4's family representative was upset that she had not been notified when Resident #4 had been sent to the hospital. The DON further revealed nursing staff had thought the on-call hospice nurse who assessed the resident was going to notify the family but did not. The DON stated she expected the hospice nurse would have called the family, but it was nursing staff responsibility to make sure that the family was notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with resident and staff the facility failed to administer oxygen as prescribed by the physician for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for oxygen therapy. The findings included: 1. Resident #1 was initially admitted to the facility on [DATE] with diagnoses that included shortness of breath and obstructive sleep apnea. Resident #1's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed she was alert and oriented. Resident #1 was coded for oxygen use. Resident #1's care plan initiated on 07/12/22 and revised on 10/04/22 indicated Resident #1 had a focus area for oxygenation. Interventions included administer oxygen as need per physician order, monitor oxygen saturations on room air and on oxygen. A physician order dated 07/07/22 for Resident #1 indicated oxygen therapy at 2 liters via nasal cannula continuously. An observation of Resident #1 on 10/19/22 at 9:22 AM revealed the resident sitting in her wheelchair getting ready to leave the facility for a physician's appointment. Resident #1 was wearing a nasal cannula attached to a portable oxygen tank set on 2 liters. The oxygen tanks dial pointed to the red area indicating the tank was on empty and needed to be refilled. An interview conducted with Resident #1 on 10/19/22 at 9:22 AM revealed she always wore oxygen set at 2 liters via nasal cannula. She stated she normally would get short of breath without oxygen however at the time was not short of breath. Resident #1 stated she thought she saw Physical Therapy Assistant (PTA) #1 who helped her in the wheelchair check the portable tank before leaving the room. An observation of Resident #1 on 10/19/22 at 9:24 AM revealed a staff member from the transportation company going into the room and removed Resident #1 from her room into the hallway to take her to the scheduled appointment. Resident #1's portable oxygen tank was not checked prior to exiting the room. The surveyor stopped the transportation staff member and asked Nurse #1 to obtain Resident #1's oxygen saturation level and a full portable oxygen tank. Nurse #1 confirmed the oxygen tank on Resident #1's wheelchair was empty. Nurse #1 checked Resident #1's oxygen saturation with an initial reading of 86%. (Normal range for oxygen saturation level is greater than 92%). Nurse #1 then asked Resident #1 to take deep slow breaths and the oxygen saturation level reached 96% once the full oxygen tank was attached to the resident's oxygen tubing. An interview was conducted with Nurse #1 on 10/19/22 at 9:45 AM. Nurse #1 stated she was responsible for Resident #1 but had not assisted her into the wheelchair to go to her appointment. She stated she was completing her medication pass and had not gotten to Resident #1 yet to check her oxygen saturation level. Nurse #1 stated it was every staff member's responsibility to check the oxygen tank to ensure the resident had a full tank of oxygen. An interview conducted with the Assistant Director of Nursing (ADON) on 10/19/22 at 9:57 AM revealed there were steps that should have been followed by each staff member that came in contact with the resident. She stated even though the transportation was an agency employee he should have checked the oxygen tank prior to removing the resident from her room. On 10/19/22 at 2:23 PM an interview was conducted with Physical Therapy Assistant (PTA) #1. During the interview she stated that she assisted Resident #1 into the wheelchair earlier in the morning prior to the resident's appointment around 8:30 AM. PTA #1 stated she thought she checked the oxygen tank, and it was a quarter away from being empty. The interview revealed she had tried to conserve oxygen and would wait until the dial was in the red indicating it needed to be refilled before changing the tank. On 10/19/22 at 3:01 PM an interview was conducted with the Director of Nursing (DON). The DON stated it was the staff member who assisted Resident #1 into the wheelchair's ultimate responsibility to ensure the portable oxygen tank was full. She stated it had been overlooked by staff, but she expected all staff members that came in contact with Resident #1 to have checked the oxygen tank. 2. Resident #2 was admitted into the facility on [DATE] with diagnosis which included chronic obstructive pulmonary disease, pulmonary fibrosis, and shortness of breath. Resident #2's most recent quarterly MDS dated [DATE] revealed she was alert and oriented. Resident #2 was coded for oxygen use. Resident #2's care plan initiated on 05/23/22 indicated Resident #2 had a diagnosis of chronic obstructive pulmonary disease and pulmonary fibrosis which could lead to decreased oxygen saturation levels. Interventions included administer oxygen as need per physician order, monitor oxygen saturations on room air and on oxygen. A physician order dated 03/17/22 for Resident #2 read, May titrate oxygen to maintain oxygen saturation level greater than 90% as needed. An observation of Resident #2 on 10/18/22 at 3:57 PM revealed she was sitting in her wheelchair in the hallway with an oxygen setting of 1 liter via nasal cannula. The oxygen tanks dial pointed to the red area indicating the tank was on empty and needed to be refilled. An interview conducted with Resident #2 on 10/18/22 at 3:57 PM revealed she always wore oxygen. She stated the only time she removed the oxygen tubing was when she went to take a shower. Resident #2 stated she did not feel short of breath. On 10/18/22 at 3:59 PM the surveyor asked Nurse #2 if he could observe Resident #2's oxygen tank. Nurse #2 confirmed the tank was empty and needed to be refilled. He stated he was unaware the tank was on empty and checked Resident #2's oxygen saturation level which read 100%. On 10/19/22 at 3:01 PM an interview was conducted with the Director of Nursing (DON). The DON stated it was the staff member who assisted Resident #2 into the wheelchair's ultimate responsibility to ensure the portable oxygen tank was full. She stated it had been overlooked by staff, but she expected all staff members that came in contact with Resident #2 to have checked the oxygen tank. 3. Resident #3 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnosis which included acute upper respirator infection. Resident #3's most recent quarterly MDS revealed she was moderately cognitively impaired. Resident #3 was coded for oxygen use. Resident #3's care plan initiated on 11/09/18 and revised on 04/26/22 indicated Resident #3 had a focus area related to active intolerance and shortness of breath. Interventions included administer oxygen as need per physician order and to monitor oxygen saturations on room air and on oxygen. A physician order dated 10/17/22 for Resident #3 read, Oxygen at 3 liters via nasal cannula continuously every shift. An observation of Resident #3 on 10/18/22 at 4:10 PM revealed she was sitting in her wheelchair in the hallway with an oxygen setting of 3 liters via nasal cannula. The oxygen tanks dial pointed to the red area indicating the tank was on empty and needed to be refilled. On 10/18/22 at 4:10 PM the surveyor asked Nurse #2 if he could observe Resident #3's oxygen tank. Nurse #2 confirmed the tank was empty and needed to be refilled. He stated he was unaware the tank was on empty and checked Resident #3's oxygen saturation level which read 100%. On 10/18/22 at 4:15 PM an interview conducted with Nurse #2 revealed he was responsible for Resident #3. He stated he had come onto shift at 3:00 PM and had not gotten around to Resident #3 yet. He stated it was every staff members responsibility to check the oxygen tanks on the back of the residents wheelchairs.

Based on observations, and interviews with staff the facility failed to remain free of a medication error rate of 5% or more when reviewed for medication administration. The findings included: An observation was conducted on 10/19/22 at 8:25 AM of Medication Aide (MA) #1 administering medication on the 500 hall. MA #1 had an order which read, Calcium 600 milligram (mg) tablet administer 1500 mg once daily in the morning. MA #1 then placed one 600mg tablet into the medication cup and placed the bottle back into the medication drawer. An observation was conducted on 10/19/22 at 8:36 AM of MA #1 having an order which read, Vitamin B 12 500 microgram (mcg) tablet administer 1,000 mcg tablet once daily. MA #1 then placed one 500 mcg tablet into the medication cup and placed the bottle back into the medication drawer. On 10/19/22 at 8:37 AM an interview was conducted with MA #1. After reviewing the orders for Calcium and Vitamin B12 MA #1 stated she missed giving the correct dosage for both medications because of how the order read. She stated she normally was not working on the 500-medication cart and was not familiar with what medications each resident received. MA #1 stated she had only placed one 600mg tablet of Calcium into the cup and one 500 mcg tablet of Vitamin B12. An observation was conducted on 10/19/22 at 8:39 AM of MA #1 and Charge Nurse #1 ensuring the correct dosage of Calcium 1500mg and Vitamin B12 1,000 mcg was administered. An interview conducted on 10/19/22 at 8:40 AM with Charge Nurse #1 revealed MA #1 normally worked on the assisted living side of the facility as a nurse aide. She stated the facility had a nurse that was late, and they had pulled MA #1 to cover the cart. On 10/19/22 at 3:01 PM an interview was conducted with the Director of Nursing. During the interview she was notified of the medication error rate of 6.67%. She stated she was aware of the two medication errors. The interview revealed MA #1 normally did not work on a medication cart and was not familiar with giving medication on the 500 halls. She stated she would provide an in-service to staff on administering correct dosages.