**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, the facility failed to promote dignity by not providing a privacy cover over a urinary drainage bag for 1 of 1 residents reviewed for dignity (Resident #34). The findings included: Resident #34 was admitted to the facility on [DATE] with diagnosis that included retention of urine. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #34 was cognitively intact. He required extensive assistance from staff for toileting needs and had an indwelling urinary catheter. During an interview and observation with Resident #34, on 5/9/22 at 10:22 AM, he was noted to have an indwelling urinary catheter with the drainage bag attached to the right side of the bed. The drainage bag did not have a privacy cover, had dark yellow urine in the drainage bag and could be seen from the hallway. Resident #34 stated he knew the bag was visible from the hallway and to others and would prefer for it to be covered. On 5/9/22 at 1:15 PM, an observation was made of Resident #34 with the urinary drainage bag attached to the right side of the bed. The drainage bag did not have a privacy cover, had yellow urine in the bag, and could be seen from the hallway. An observation occurred of Resident #34 while he was lying in bed on 5/10/22 at 11:09 AM. The urinary drainage bag was clipped to the right side of the bed, without a privacy cover, and visible from the hallway with dark yellow urine in the drainage bag. On 5/11/22 at 10:28 AM, Resident #34 was observed while lying in bed. The urinary drainage bag with dark yellow urine, remained without a privacy cover and was visible from the doorway. An interview occurred with Nurse #1 on 5/11/22 at 10:35 AM and stated all residents with urinary catheters should have a privacy cover on the drainage bags. She stated Resident #34 had recently been to the emergency room and could be the reason why he didn't have a privacy cover on the drainage bag. Nurse #1 indicated she would make sure one was provided for Resident #34. During an interview with the Administrator and Director of Nursing on 5/12/22 at 1:14 PM, they both indicated it was their expectation for nursing staff to use a privacy cover for urinary drainage bags and was unable to state why Resident #34's drainage bag was not covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews and record review, the facility failed to ensure an adaptive call light was positioned within resident's access. This was for 1 of 1 resident (Resident #38) reviewed for accommodation of needs. The findings included: Resident #38 was admitted on [DATE]and most recently readmitted on [DATE] with a diagnosis of contractures. Review of Resident #38's revised care plan dated 9/17/21 read due to the inability to use a regular call light due to contractures, he required a soft touch call light to make his needs known. Interventions included ensuring the call light was placed so Resident #38 could reach it. His quarterly Minimum Data assessment dated [DATE] indicated he was cognitively intact and was coded with impairment of range of motion (ROM) to his bilateral upper and lower extremities. An interview and observation were completed with Resident #38 on 5/9/22 at 12:26 PM. He had bilateral hand contractures and a left elbow contracture. His adaptive call light was observed clipped to the right upper top of his fitted sheet. He stated he could not get to his call light most of the time, so he had to yell out when he needed something. Resident #38 attempted to lift his right arm and hand in an effort of reach the call light but stated his arm was too stiff. He stated he often forgot to ask the staff to ensure his call light was accessible because it had been out of his reach so much, he resorted to yelling. An observation was completed on 5/10/22 at 10:51 AM of Resident #38's. His adaptive call light was observed clipped to the right upper top of his fitted sheet. An interview was conducted on 5/11/22 at 8:20 AM with Nursing Assistant (NA) #6 stated she was assigned Resident #38 on 5/9/22 and 5/10/22. She stated he used a special soft call light because of his contractures. She stated she was uncertain if he yelled out for assistance when his adaptive call light was not in reach because it only happened on occasion. An interview was completed on 5/10/22 at 12:20 PM with the ADON. She stated Resident #38 required an adaptive call light due to his hand contractures and the contracture of his left elbow. An observation was completed on 5/12/22 at 10:05 AM of Resident #38. His call light was clipped to the upper right side of his pillow case. He stated he was unable to reach it and had not asked anyone to move it within his reach. An observation and interview were completed on 5/12/22 at 10:40 AM of Resident #38 with NA #8 present in the room. His call light was still clipped to the upper right side of his pillow case. When questioned about Resident #38's adaptive call light placement, NA #8 stated he was unable to reach his call light where it was, and she moved the call light and clipped it to the chest area of his gown within his reach. She stated Resident #38's call light should always be within his reach. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated she excepted Resident #38's adaptive call light remain within his reach at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, resident, staff and physician interviews, the facility failed to provide surgical wound care as ordered for 1 of 3 residents reviewed for non-pressure related wound care (Resident #40). The findings included: Resident #40 was originally admitted to the facility on [DATE] with a readmission date of 1/18/22. His diagnoses included necrotizing fasciitis (a severe soft tissue infection that is caused by bacteria), abscess of the perineum, and type 2 diabetes. The nursing progress notes were reviewed from 1/3/22 to 5/8/22 and indicated Resident #40 had no episodes of refusal of wound care. A physician progress note dated 1/21/22 indicated Resident #40 had been hospitalized for an abscess in the right perineum and right buttock, which was surgically debrided and consistent with necrotizing soft tissue infection. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 was cognitively intact and had surgical wounds present. Review of a Wound Clinic assessment dated [DATE] revealed the perineal surgical wound measured 8.2 centimeters (cm) in length, 0.5 cm in width and 0.5cm in depth. There was tunnelling at three o'clock with a maximum distance of 3 cm. The right buttock surgical wound measured 1.8 cm in length, 0.3 cm in width and 2 cm in depth. There was tunnelling at three o'clock with a maximum distance of 3 cm. Resident #40's active care plan, last reviewed 3/31/22, revealed a focus area for potential for/actual skin integrity impairment: diabetic/neuropathic ulcers related to: diabetic ulcer to foot, left buttock surgical incision. The interventions included to provide treatments as ordered. A review of a Wound Clinic assessment dated [DATE] revealed Resident #40's open surgical wound to the perineum measured 5 cm in length, 0.3 cm in width and 0.3 cm in depth. There was no tunneling present. The right buttock open surgical wound measured 1 cm in length, 0.2 cm in width and 0.5 cm in depth. There was tunneling at three o'clock with a maximum distance of 2.9 cm. There was no necrotic (dead) tissue in the wound bed. A review of the active physician orders for Resident #40, revealed the following orders dated 4/1/22: - Clean the perineal wound with normal saline using gauze, pat dry with clean gauze, apply Calcium Alginate with Silver (a highly absorbent gel-like covering to help maintain a moist environment that promotes wound healing) and secure every day. - Clean the right buttock wound with normal saline using gauzes, pat dry with clean gauze, apply Calcium Alginate with Silver and secure every day. A review of a Wound Clinic assessment dated [DATE] revealed Resident #40's open surgical wound to the perineum measured 8 cm in length, 1 cm in width and 0.5 cm in depth. There was no tunneling present. The right buttock open surgical wound measured 1.5 cm in length, 0.5 cm in width and 3 cm in depth. There was no tunneling or necrotic tissue in the wound bed. The April 2022 Treatment Administration Record (TAR) was reviewed and demonstrated the surgical wound care to Resident #40's perineum and right buttock were not initialed as completed on 4/23/22, 4/24/22 and 4/30/22 at 9:00 AM. On 5/12/22 at 9:20 AM, an interview was completed with the Staff Development Coordinator (SDC) who was assigned to Resident #40 on 4/24/22. She explained nursing staff were responsible for wound care when the treatment nurse wasn't present and normally the weekend supervisor (Nurse #4) completed the wound care on the weekends. The SDC further stated the weekend supervisor had been on medical leave since 4/20/22 and had not returned to work yet. The SDC reviewed Resident #40's April 2022 TAR and stated she didn't provide any wound care on 4/24/22 to the perineal or right buttock surgical wound, because she was covering the house and pushing a cart and thought the second shift (3:00 PM to 11:00 PM) nurse would complete the care. A phone interview occurred with Nurse #6 on 5/12/22 at 9:32 AM. She was the nurse assigned to Resident #40 on the second shift on 4/24/22. She could not recall being told the wound care had not been completed that morning and stated the electronic TAR did not show the wound care was needed for her shift. Nurse #6 explained she was asked by Resident #40 to change the dressing on his perineal wound, which she did, and a progress note was written, but she did not change the right buttock surgical wound dressing as she was under the impression it had already been completed on the day shift as ordered. Review of a nursing progress note written by Nurse #6 and dated 4/24/22, indicated per Resident #40's request the perineal surgical wound was cleansed and wound care was provided. The May 2022 TAR was reviewed and revealed the surgical wound care to Resident #40's perineum and right buttock were not initialed as completed on 5/1/22, 5/7/22 or 5/8/22 at 9:00 AM. On 5/11/22 at 2:50 PM, an interview was conducted with Nurse #1, who had been assigned to Resident #40 on 4/30/22 and 5/1/22. She stated she could not recall completing any wound care for Resident #40's perineal or right buttock surgical wounds and was unaware he had any wound orders. Multiple attempts were made during the course of the survey to contact Nurse #4, who was the weekend supervisor; Nurse #5, who was assigned to Resident #40 on 4/23/22; and Nurse #7, who was assigned to Resident #40 on 5/7/22 and 5/8/22, without success. A review of the Wound Clinic assessment dated [DATE] indicated Resident #40's open surgical wound to the perineum measured 3.5cm in length, 0.4 cm in width and 0.1 cm in depth. The right buttock open surgical wound was healed with all measurements at zero. The Treatment Nurse was interviewed on 5/9/22 at 3:45 PM and explained he completed wound care dressing changes Monday through Friday on the day shift (7:00 AM to 3:00 PM) and that nursing staff were responsible for completing their own wound care in the afternoon and evening shifts, if there was a need, as well as on the weekend. Another interview occurred with the Treatment Nurse on 5/11/22 at 4:50 PM. He reiterated nursing staff were responsible for wound care when he was not on duty as well as on the weekend and stated normally on the weekends the nursing supervisor completed wound care but had been out for several weeks. An observation of Resident #40's surgical wound care occurred on 5/10/22 at 2:33 PM with the treatment nurse and Assistant Director of Nursing (ADON). Resident #40 had an open surgical wound to the right posterior perineal area that had a small amount of brown drainage on the dressing and minimal odor. The wound bed was beefy red with no necrotic areas observed. Wound care was completed as ordered. The surgical wound to the right buttock area was healed. An interview occurred with Resident #40 on 5/11/22 at 12:00 PM. He was up in his wheelchair at bedside and stated that for the last month or so his surgical wound care had not been completed on the weekend as it was during the week. Resident #40 indicated the lack of wound care had occurred as recently as the weekend of 5/7/22 and 5/8/22. When he asked for someone to change the dressings he would be told they would be there soon. On 5/12/22 at 1:15 PM, an interview was held with the Director of Nursing (DON). She explained the facility had recently transitioned from paper to electronic TAR's on 4/19/22. The DON stated she was unaware surgical wound care was not provided to Resident #40 as ordered. She expected the nurses on day shift to report any wound care that had not been completed to the oncoming shift so it could be completed as well as all nursing staff to review the TARs for any needed wound care. The DON added a better system needed to be put into place to prevent wound care being missed as ordered. On 5/11/22 at 9:45 AM, an interview was completed with the Medical Director. The missing documentation for the April and May 2022 TARs were reviewed. The Medical Director stated he had not been informed the surgical wound care was not completed as ordered on the days no initials were present and stated he would have expected nursing staff to complete the wound care as ordered and document that it was done. Attempts were made to speak to the Wound Clinic during the course of the survey which were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews and record review, the facility failed to apply splints as ordered for contracture management (Resident #38). This was for 1 of 1 residents reviewed for range of motion (ROM). The findings included: Resident #38 was admitted on [DATE] and most recently readmitted on [DATE] with cumulative diagnoses neurogenic bladder and contractures. Review of Resident #38's revised care plan dated 12/1/21 indicted he required assistance to restore or maintain his maximum potential and risk for worsening of his present contractures. Interventions included the application of a left elbow splint 6 days a week for 4 hours each day. His quarterly Minimum Data assessment dated [DATE] indicated he was cognitively intact and coded for impairment to his bilateral upper and lower extremities. Review of Resident #38's April and May 2022 Physician orders did not include any orders for splinting to his contractures. Review of Resident #38's restorative documentation for April and May 2022 indicated he was to receive restorative nursing for passive range of motion (PROM) to his bilateral shoulders, left elbow, right elbow, bilateral wrist and bilateral fingers on each hand 5 times each week. Resident #38 was also to receive restorative nursing for the application of a left elbow splint and bilateral hand splints for 4 hours a day for 6 times a week. An interview and observation was completed with Resident #38 on 5/9/22 at 12:26 PM. He had bilateral hand contractures and a left elbow contracture. There was a folded pillow case placed in the crease of his left elbow contracture and nothing to his bilateral hands. He stated at one time recently, the staff were applying his bilateral hand splints and his left elbow splint but it had not been done in a while. An observation was completed on 5/10/22 at 10:51 AM of Resident #38's. There was a folded pillow case placed in the crease of his left elbow contracture and nothing to his bilateral hands. An interview was conducted on 5/11/22 at 8:20 AM with Nursing Assistant (NA) #6 stated she was assigned Resident #38 on 5/9/22 and 5/10/22. She stated she did not apply Resident #38's splint because he was on the restorative nursing caseload. An observation was completed on 5/12/22 at 9:40 AM of Resident #38. There were no observed splints in use for his left elbow and bilateral hand contractures. An interview was completed on 5/12/22 at 9:50 AM with the Assistant Director of Nursing (ADON). She stated she was over the restorative program. The ADON was questioned as to why no splints were observed in use on 5/9/22, 5/10/22, 5/11/22 and 5/12/22, she was unable to provide an answer. An interview was completed on 5/12/22 at 11:45 AM with the Restorative Aide (RA). She stated she has had to work the floor all week and that was why Resident #38 did not receive any PROM or splinting. She stated the ADON was aware but the Scheduler continued to assign her to work on the floor and nobody assisted her with splinting when she was assigned to work the floor. An interview was completed on 5/12/22 at 12:03 PM with the facility scheduler. She stated the RA was only scheduled to work the floor today. She stated anytime she needed to pull the RA to work the floor she always notified either the ADON or the Director of Nursing (DON). An interview was completed with the Administrator and the DON on 5/12/22 at 1:15 PM. The DON stated she expected the RA and ADON to ensure Resident #38's splints were applied as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident, staff, Vascular Nurse and Medical Director (MD) interviews, the facility failed to provide a dressing change to a Peripherally Inserted Central Catheter (PICC) line as ordered. This was for 1 (Resident #73) of 1 residents reviewed for infections. The findings included Resident #73 was admitted on [DATE] and readmitted [DATE] with a diagnosis of Urosepsis. Her quarterly Minimum Data Set, dated [DATE] indicated she was cognitively intact and she exhibited no behaviors. Review of Resident #73's hospital Discharge summary dated [DATE] read a PICC line was placed on 4/27/22 and she was to continue to receive an Intravenous (IV) antibiotic for another 36 doses. Review of Resident #73's readmission Physician orders dated 4/28/22 read she was to receive an IV antibiotic every 6 hours for 9 days. The completion date of her IV antibiotic was 5/7/22. Resident #73 was care planned on 5/3/22 for an actual urinary tract infection. Interventions included observation of the PICC line for signs of infection and notify the MD, PICC line site care, flushes to the PICC line per the facility protocol or as ordered by the Physician. The Administrator provided a copy of the facility's PICC Reference Sheet dated June 2020 from a procedure manual. The transparent dressing should be changed at least every 7 days or immediately when the dressing appeared compromised. Review of Resident #73's May 2022 Physician orders included an order dated 5/3/22 provide PICC line site care per the facility's protocol or as ordered by the Physician. Another Physician order was dated 5/11/22 to pull out the PICC line. Review of Resident #73's April and May 2022 Medication Administration Records and Treatment Administration Records did not include any documented evidence of Resident #73's dressing change to her PICC line for 13 days. An interview and observation was completed on 5/9/22 at 11:06 AM with Resident #73. The PICC was observed to her right upper arm. There was a dressing in place that appeared rolled up around the edges but still intact at the insertion site. Resident #73 stated she just completed her IV antibiotics and she thought the PICC line dressing was the same one she was discharged from the hospital with. An observation was completed on 5/10/22 at 10:45 AM. The same dressing was still in place to Resident #73's PICC line. An interview was conducted with the Assistant Director of nursing (ADON) on 5/10/22 at 11:15 AM. She stated it was the facility's protocol to change the dressing to a PICC line every 7 days. An observation and interview was completed on 5/11/22 8:50 AM with the Vascular Nurse (VN). She stated she was there to remove Resident #73's PICC line. The PICC line dressing had been changed on 5/10/22 by the Staff Development Coordinator (SDC). She stated she was not familiar with the facility's policy on PICC lines. The VN stated the dressing changes to the PICC line site should be completed every 7 days and as needed. An interview was completed on 5/11/22 at 10:23 AM with the SDC. She stated on 5/10/22 she noticed Resident #73's PICC line dressing had not been changed since her readmission so she did it. The SDC stated PICC line dressing changes were done every 7 days and as needed. She stated she was unsure why Resident #73's PICC line dressing was not changed 7 days after her readmission on [DATE]. An interview was completed on 5/11/22 at 9:50 AM with the MD. He stated it was his expectation that Resident #73's PICC line dressing to be changed every 7 days. An interview was completed with the Administrator and the DON on 5/12/22 at 1:15 PM. The DON stated Resident #73's PICC line dressing should have been changed last week on day 7 prior to 5/10/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.Resident #80 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD). Resident #80's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact, was dependent upon staff for assistance with activities of daily living (ADL) and received oxygen during the assessment period. The resident's comprehensive care plan was last updated on 4/27/2022 and contained a focus for potential for ineffective breathing patter related to COPD, oxygen dependence, and respiratory failure. Interventions included administer oxygen at 2 liters per minute via nasal cannula. Resident #80's medical record contained a physician's order for oxygen at 2 liters per minute continuous for cyanosis (blueish color to nail beds and membranes) and dyspnea (difficult or labored breathing). The start date for the order was 3/9/2022 and the order was entered in the electronic medical record by the SDC. On 5/9/2022 Resident #80 was observed lying in bed, alert, oriented, and using an electronic device. She was observed to be on 4 liters of oxygen via nasal cannula. On 5/10/2022 at 1:50 PM resident #80 was observed resting in bed with her eyes closed. The oxygen concentrator was set on 4 liters per minute and being administered via nasal cannula. An interview was conducted with Medication Aide #2 on 5/10/2022 at 1:54 PM. She stated she was assigned to Resident #80. She reviewed the resident's active order for oxygen and stated she thought the resident was on 4 liters, not 2 liters, per minute of oxygen continuously. She had not noticed the order was for 2 liters per minute. An interview was conducted with the SDC on 5/12/2022 at 11:42 AM. She did not recall a written order for oxygen at 4 liter per minute for Resident #80. On 5/12/2022 at 1:15 PM and interview was conducted with the Director of Nursing (DON). She stated she expected oxygen to be accurate and oxygen administered per physician's order. Based on observations, staff and Medical Director (MD) interviews and record review, the facility failed to administer continuous oxygen at the prescribed rate (Resident #73 and Resident #80). This was for 2 of 3 residents reviewed for respiratory care. The findings included: 1. Resident #73 was admitted on [DATE] and readmitted [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Her quarterly Minimum Data Set, dated [DATE] indicated she was coded for the use of oxygen. Resident #73 was care planned for ineffective breathing pattern related to COPD. This care plan was last revised on 3/11/22 and included the intervention of oxygen therapy 2L/Min via nasal cannula as ordered. Review of Resident #73's readmission Physician orders dated 4/28/22 included an order for continuous oxygen at 2 liter per minute (L/Min) due to COPD. This order was dated 10/12/21. Review of Resident #73's April 2022 Medication Administration Records (MAR) included documentation that the nurses were assessing Resident #73's oxygen rate every shift prior to her hospital transfer on 4/24/22 but it was not continued after her readmission on [DATE]. Review of Resident #73's May 2022 MAR did not include any documentation regarding her prescribed oxygen. An interview and observation was completed on 5/9/22 at 11:06 AM with Resident #73. She was wearing her oxygen with the concentrator rate set at 3.5 L/Min. Resident #73 stated she required oxygen at all times due to her COPD. An observation was completed on 5/10/22 at 10:45 AM. Resident #73 was wearing her oxygen with the concentrator rate set at 3.5 L/Min. An interview was completed with the Assistant Director of nursing (ADON) on 5/10/22 at 11:15 AM. She stated the floor nurses check the oxygen concentrators settings every shift on the residents prescribed continuous oxygen. An observation was completed on 5/11/22 8:50 AM. Resident #73 was wearing her oxygen with the concentrator set at 4.5 L/Min. An interview was completed on 5/11/22 at 9:00 AM with Nurse #3. She stated Resident #73 was prescribed continuous oxygen and she was very compliant about wearing it. Nurse #3 stated the nurses check Resident #73's oxygen concentrator setting every shift to make sure the setting was at the prescribed rate. An interview was completed on 5/11/22 at 9:50 AM with the MD. He stated it was his expectation that Resident #73's continuous oxygen be administrated at the ordered rate of 2 L/Min unless otherwise indicated. An interview was completed with the Administrator and the DON on 5/12/22 at 1:15 PM. The DON stated Resident #73's oxygen should be administered at the ordered rate of 2 L/Min.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and resident, staff, Medical Director (MD) and Physician #1 interviews, the facility failed to obtain and implement Physician orders for the care and monitoring of a resident on hemodialysis (Resident #17). This was for 1 of 1 resident reviewed for dialysis. The findings included: Resident #17 was admitted on [DATE] and readmitted on [DATE] with a diagnosis of End Stage Renal Disease (ESRD) requiring dialysis. His readmission Minimum Data Set, dated [DATE] was coded for receiving dialysis treatments. Resident #17 was care planned on 3/9/22 for ESRD with a risk for complications due to hemodialysis. Interventions included dialysis on Tuesdays, Thursdays and Saturdays, no blood draws or blood pressure (BP) in his dialysis access arm, monitoring the access site for bleeding/infection and monitoring his vital signs per facility protocol. Review of Resident #17's April and May 2022 Physician orders did not include any orders related to dialysis or his dialysis access site. Review of Resident #17's April and May 2022 medication administration records (MARs) and treatment administration records (TARs) did not include any documentation related to dialysis or his dialysis access site. Review of Resident #17's dialysis communication sheets from 4/12/22 to 5/10/22 included 3 occasions of documented evidence that his right upper arm dialysis fistula was assessed for a thrill (vibrations felt when touching the fistula) and a bruit (a loud swishing sound when listening to the fistula using a stethoscope). The dialysis communication sheets did not include any documented evidence that his fistula site was monitored for bleeding. Review of Resident #17's nursing notes from 4/10/22 through 5/11/22 included 2 occasions of documented evidence that his dialysis fistula was assessed on 5/5/22 at 5:30 PM for a thrill and bruit and on 5/6/22 at 9:20 AM his fistula was assessed for a thrill and bruit and the appearance of his fistula dressing. There was no documented evidence that his fistula was monitored after his dialysis treatments for signs of bleeding. An observation and interview was completed with Resident #17 on 5/9/22 at 2:40 PM. He stated he just returned from having his dialysis fistula unclogged (image-guided surgical procedure to reopen a fistula). An interview and observation was completed on 5/11/22 at 11:13 AM with Resident #17. He was wearing a white undershirt under a short sleeve button down shirt. Observed were several spots of blood each approximately the size of nickel on his white undershirt over his fistula site. Resident #17 stated he removed the dressing earlier this morning and it bled a little bit. He also presented a white wash cloth with multiple small spots of blood on it. Resident #17 stated the facility staff did not routinely check his vital signs or look at his fistula dressing for bleeding after his treatments, but sometimes they checked his fistula for a thrill and bruit. He stated the facility staff knew not to get any lab work or BP's in his right arm. An interview was completed on 5/10/22 at 10:50 AM with Nursing Assistant (NA) #6. She stated no lab work or blood pressure (BP) checks were done to Resident #17's right arm because that was where his dialysis site was. NA #6 stated the nurses normally asked the aides to get vital signs on Resident #17 when he returned from his treatments but the nurses were responsible for checking his fistula to make sure it wasn't clogged, absent of bleeding and removing his fistula dressing after each treatment. She stated if she noticed any bleeding from his fistula, she would immediately inform his nurse. An interview was completed on 5/11/22 at 11:30 AM with Nurse #1. She confirmed she was assigned to Resident #17 on 5/9/10, 5/10/22 and today. She stated she obtained Resident #17's vital signs before each dialysis treatment, but she was not aware that his vital signs should be obtained after his treatments. Nurse #1 stated she was not aware that Resident #17's dialysis fistula should be assessed daily for a thrill and bruit, his fistula dressing monitored for signs of bleeding or leaving the fistula dressing in place for 24 hours after his treatments. She stated Resident #17 would remove his own dressing after his dialysis treatments sometime the following day. An interview was completed on 5/11/22 at 4:10 PM with Nurse #9. She stated she received Resident #17's from dialysis on 5/5/22 and was aware that Resident #17's vital signs should be obtained before and after each dialysis treatment but must have forgotten to document it. She stated she routinely checked his fistula dressing for signs of bleeding and his fistula for a thrill and bruit. Nurse #9 stated Resident #17 knew not to remove his fistula dressing until the following day. An interview was completed on 5/12/22 at 10:10 AM with Nurse #2. She stated she was not aware of the need to obtain Resident #17's vital signs after his dialysis treatments. She stated she did assess his fistula dressing for bleeding but frequently forgot to assess for a thrill and bruit. An interview was completed on 5/11/22 at 8:55 AM with the Assistant Director of Nursing (ADON). She stated the nurses monitored Resident #17's fistula for bleeding and obtained his vital signs after each treatment. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated she excepted the staff to obtain Physician orders, implement those orders and be knowledgeable regarding the care of a dialysis resident to include Resident #17. The DON stated it was the responsibility of the floor nurses to ensure all Physician orders were obtained and any required monitoring be entered into the electronic medical record (EMAR) on admission and readmission. A telephone interview was completed on 5/12/22 at 10:44 AM with Physician #1. He stated he was under the impression that the facility implemented standing orders for dialysis residents and was not aware Resident #17 did not have any orders. The Physician stated it was his expectation that the facility contact him for any missing orders and implement those orders for Resident #17 An interview was completed on 5/11/22 at 9:05 AM with the MD. He stated he was not Resident #17's Physician but it was his expectation that there be written orders for dialysis. He stated there should be orders for the assessment of a thrill and bruit, vital signs, signs of bleeding and leaving his fistula dressing in place for 24 hours before removing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews with staff and the Medical Director, the facility failed to ensure as needed psychotropic medications were time limited in duration for 2 of 5 residents reviewed for unnecessary medications (Residents #50 and #59). The findings included: 1. Resident #50 was originally admitted to the facility on [DATE] with a recent readmission date of 3/8/22. Her diagnoses included dementia, depression, and anxiety disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #50 had moderately impaired cognition and was coded with receiving 3 days of an antianxiety medication during the assessment period. A review of the active physician orders revealed an order dated 3/24/22 for Alprazolam (Xanax-an antianxiety medication) give 0.5 milligrams (mg) every eight hours as needed (PRN) for anxiety. This order for PRN Alprazolam had no stop date and was entered into the Electronic Medical Record (EMR) by the Assistant Director of Nursing (ADON) when the facility changed over from paper to electronic medical records on 4/19/22. Further review of Resident #50's April 2022 and May 2022 Medication Administration Record (MAR) indicated she had orders for Alprazolam that had been discontinued as follows: - Alprazolam 0.5 mg 1 tablet by mouth every 8 hours as needed for anxiety from 4/7/22 to 4/17/22. Resident #50 received this medication on 4/7/22. - Alprazolam 0.25 mg give one-half tablet by mouth every 12 hours as needed for anxiety from 4/19/22 to 5/5/22. Resident #50 received this medication on 5/4/22. The April 2022 and May 2022 MARs revealed Resident #50 had received as needed dosages of the Alprazolam that was initiated on 3/24/22 with no stop date, two times in April and six times in May. A review of the pharmacy medication reviews indicated they were completed monthly with the last review dated 4/14/22. An interview occurred with the Medical Director on 5/11/22 at 9:45 AM, who stated he was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. He indicated it was error if a stop date was not included in a physician's order for the PRN psychotropic medication. The ADON was interviewed on 5/11/22 at 11:40 AM and reviewed Resident #50's medical record to include the April 2022 and May 2022 MARs. She explained the facility had recently merged over to EMR records and felt the order had been entered in error. She confirmed Resident #50 had been on Alprazolam for a while with time limited orders in the past. She was aware of the need for a stop date to provide reassessment of the medication and felt the order dated 3/24/22 was an oversight. 2. Resident #59 was originally admitted to the facility on [DATE] with a recent readmission date of 4/16/22. Her diagnoses included anxiety disorder, dementia, bipolar disorder, and paranoid schizophrenia. A review of the pharmacy medication reviews indicated they were completed monthly with the last review dated 3/17/22. The pharmacist was unable to complete a medication review on 4/14/22 as Resident #59 was in the hospital. A review of the active physician orders revealed an order dated 4/18/22 for Lorazepam (Ativan-an antianxiety medication) 0.5 milligrams (mg)- give a half of a tablet by mouth every 24 hours as needed (PRN) for anxiety. This order for PRN Lorazepam had no stop date and was entered into the Electronic Medical Record (EMR) by the Assistant Director of Nursing (ADON). A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #59 had severely impaired cognition. The use of antianxiety medications was not coded for during the assessment period. Review of the April 2022 and May 2022 Medication Administration Records (MARs) revealed Resident #59 had received as needed dosages of the Lorazepam, once in April and none in May. An interview occurred with the Medical Director on 5/11/22 at 9:45 AM, who stated he was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. He indicated it was error if a stop date was not included in a physician's order for the PRN psychotropic medication. The ADON was interviewed on 5/11/22 at 11:40 AM and reviewed Resident #59's medical record to include the April 2022 and May 2022 MARs. She confirmed Resident #59 had an order for Lorazepam with no stop date, was aware of the need for a stop date to provide reassessment of the medication and felt it was an oversight to not have obtained a stop date when the order was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Medical Director interviews, the facility failed to administer an antipsychotic medication as ordered by a physician, for a resident with aggressive behaviors (Resident #59). This was for 1 of 1 residents reviewed for behavioral and emotional status. The findings included: Resident #59 was admitted to the facility on [DATE] with a recent readmission date of 4/16/22. Her diagnoses included dementia, anxiety disorder, bipolar disorder, and paranoid schizophrenia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #59 had severe cognitive impairment and received 7 days of an antipsychotic medication during the assessment period. A psychiatric progress note was reviewed for 5/5/22 and indicated Resident #59 had noncompliance with oral medication, with a decision to begin Risperdal Consta (an antipsychotic medication) injections for improvement in her combative behaviors. Her aggression was defined as impulsive with no identifiable triggers. The active physician orders were reviewed for Resident #59 and included an order dated 5/5/22 for Risperdal Consta ER (an antipsychotic medication) 12.5 milligrams (mg). Inject 12.5 mg intramuscularly one time a day every 14 days related to paranoid schizophrenia. A review of Resident #59's May 2022 Medication Administration Record (MAR) indicated Risperdal Consta 12.5 mg injection was added to the MAR on 5/6/22. The entry dated 5/6/22 indicated the medication was not available in the facility. The next administration of the Risperdal Consta injection was marked as 5/20/22 on the May 2022 MAR. The medication had not been administered as of review on 5/11/22. Review of Resident #59's pharmacy records indicated Risperdal Consta 12.5 mg injection was dispensed by the pharmacy on 5/6/22 and received at the facility on 5/6/22. Review of Resident #59's nursing progress notes from 2/1/22 to 5/11/22 revealed she had aggressive behaviors towards staff, her family and other residents that consisted of throwing liquids and food, laying on the floor, hitting, kicking, biting, spitting, and pinching. An observation of Resident #59 occurred on 5/9/22 at 12:35 PM. While staff were assisting to the table for lunch she grabbed the Nurse Aide's (NA) arm and pinched her as well as hit her glasses to the floor. She attempted to step on the glasses, but the NA pushed them away with her foot. She was redirected to her seat and served her lunch meal. On 5/10/22 at 1:30 PM, an interview occurred with Nurse #3. She explained the psychiatric provider assessed Resident #59 on 5/6/22 and after a care plan meeting with the family a new order was provided for Risperdal Consta injections every 14 days. Nurse #3 stated she was assigned to Resident #59 on the day shift (7:00 AM to 3:00 PM) and the order was sent to the pharmacy so it would be sent with the evening medication delivery. Nurse #3 stated she had not cared for Resident #59 since then but stated the medication typically would have been provided the following day, after it was delivered from the pharmacy. The Medical Director was interviewed on 5/11/22 at 9:45 AM and stated he was aware of Resident #59's impulsive and aggressive behaviors. He added the psychiatric provider spoke with him regarding the initiation of the Risperdal Consta injections in hopes of decreasing some of the combative behaviors on 5/6/22, since Resident #59 often refused or spit out her oral medications. The Medical Director was unaware the Risperdal Consta injections had not been administered as of today and would have expected it to be started the following day after receival from the pharmacy but believed Resident #59 had no negative effects from not initiating the medication. An interview occurred with the Assistant Director of Nursing (DON) on 5/11/22 at 1:10 PM. After review of Resident #59's medical record and May 2022 MARs, the ADON verified the Risperdal Consta injection had not been provided to Resident #59 as of yet. She explained the facility had just started with Electronic Medical Records (EMR) and when the Risperdal Consta was marked as not available on 5/6/22 it didn't repopulate each day to alert staff it had not been provided. She stated the next dose to be administered was 5/20/22 at 8:00 AM and that is when it would pop up again. The ADON stated Resident #59 had daily behaviors of aggression towards staff, her family and other residents and would have expected the medication to be initiated as soon as it was received from the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to discard three expired insulin vials and failed to date one insulin vial when opened for 1 of 2 medication carts reviewed for medication storage (400 hall- SPARKS). The findings included: A review of the facility policy titled Insulin Storage dated 6/2021 read in part, that insulin vials and pens should be dated upon opening and unused portions discarded within the timeframe recommended by the manufacturer. On [DATE] at 10:56 AM, an observation of the medication cart for the 400 hall SPARK unit was conducted with Nurse #8. Items discovered included: - 70/30 Insulin vial for Resident #50 was opened and undated. - 70/30 Insulin vial for Resident #50 was dated as opened on [DATE]. A label was present that read to discard 28 days after opening. - Levemir Insulin vial for Resident #42 was dated as opened on [DATE]. A label was present that read to discard 28 days after opening. - Novolog Insulin vial for Resident #42 was dated as opened on [DATE]. A label was present that read to discard 28 days after opening. In an interview on [DATE] at 11:05 AM, Nurse #8 stated she hadn't noticed the medications were expired or not dated and wasn't assigned to that hall frequently. She was unable to state who checked the medication carts routinely for expired and undated medications and had not checked prior to giving the medications. On [DATE] at 1:15 PM, an interview occurred with the Director of Nursing. She stated it was expected for insulin vials to be dated when opened and discarded at the recommended time frame. She stated all nurses should be reviewing the medications to ensure they had not expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #89 was admitted [DATE] from the acute hospital setting. Resident #89's discharge Minimum Data Set (MDS) dated [DATE] indicated the resident was discharged to acute hospital setting and return was not anticipated. The Discharge summary, dated [DATE], with medications, physical therapy orders, and recapitulation of stay was reviewed. The discharge summary indicated Resident #89 was discharged to home. The resident's medical record indicated the resident was discharged home with her daughter on 2/15/2022 with home health services. Resident #89's medical record also contained a progress note by the social worker dated 2/21/2022 that indicated a follow up call was made to the resident's daughter to confirm home health care was in place and resident received physical therapy services at home. On 2/11/2022 at 2:11 PM and interview was conducted with the MDS nurse. She stated she had been working as MDS nurse for approximately one year. She reviewed Resident #89's discharge MDS dated [DATE] and stated the discharge was coded for acute hospital setting with return not anticipated. She reviewed the resident's discharge summary and stated the MDS was coded in error. The MDS should have been coded to reflect the resident was discharged to home. On 5/12/2022 at 1:14 PM and interview was conducted with the Director of Nursing (DON). She stated it was her expectation MDS be coded accurately. Based on record reviews, observations and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of restraints and alarms (Residents #25, #50, #59 and #67), bladder and bowel (Resident #78) and discharge disposition (Resident #89). This was for 6 of 24 resident records reviewed. The findings included: 1. Resident #25 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance. Review of a nursing progress note dated 12/18/20, read Resident #25 ambulated in the hallways frequently with a walker. She has a history of wandering and forgetfulness per family. A wander/elopement bracelet was applied to her ankle. The quarterly MDS assessment dated [DATE] indicated Resident #25 was able to understand others and make herself understood. She was independent with ambulation and was not coded for a wander/elopement alarm. An observation occurred of Resident #25 on 5/10/22 at 2:25 PM, ambulating in the hallways with her walker. A wander alarm was present to her ankle. On 5/12/22 at 12:26 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE], confirmed the wander/elopement alarm was not coded and stated it was an oversight since Resident #25 had an alarm bracelet on her ankle. An interview occurred with the Director of Nursing on 5/12/22 at 1:14 PM and indicated it was her expectation for the MDS assessment to be coded accurately. 2. Resident #50 was originally admitted to the facility on [DATE] with diagnoses that included dementia. Review of Resident #50's active physician orders revealed an order dated 1/11/22 for a wander-guard bracelet. A quarterly MDS assessment dated [DATE] indicated Resident #50 had moderately impaired cognition and was not coded for a wander/elopement alarm. On 5/9/22 at 10:15 AM, an observation occurred of Resident #50 while she was sitting in a chair in the TV lounge. A wander-alarm bracelet was visible to her right ankle. On 5/12/22 at 12:26 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarm was not coded. She stated it was an oversight since Resident #50 had an alarm bracelet on her ankle. An interview occurred with the Director of Nursing on 5/12/22 at 1:14 PM and indicated it was her expectation for the MDS assessment to be coded accurately. 3. Resident #59 was originally admitted to the facility on [DATE] with diagnoses that included dementia. A review of Resident #59's active physician orders revealed an order dated 4/27/21 for a wander guard bracelet for safety and to check placement every shift. A quarterly MDS assessment dated [DATE] indicated Resident #59 had severely impaired cognition and was not coded for a wander/elopement alarm. On 5/9/22 at 12:35 PM, an observation occurred of Resident #59 while she was sitting with a wander-alarm bracelet visible to her right ankle. On 5/12/22 at 12:26 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarm was not coded. She stated it was an oversight since Resident #59 had an alarm bracelet on her ankle. An interview occurred with the Director of Nursing on 5/12/22 at 1:14 PM and indicated it was her expectation for the MDS assessment to be coded accurately. 4. Resident #67 was admitted to the facility on [DATE] with diagnoses that included dementia. A review of Resident #67's active physician orders revealed an order dated 4/4/22 to check wander-guard placement to the ankle every shift. A quarterly MDS assessment dated [DATE] indicated Resident #67 had severely impaired cognition and was not coded for a wander/elopement alarm. A review of Resident #67's active care plan, last reviewed on 4/18/22, included a focus area for wandering and/or at risk for unsupervised exits from the facility related to impaired cognition. One of the interventions was for a wander-guard alarm bracelet, that was initiated on 6/12/19. On 5/9/22 at 10:00 AM, an observation occurred of Resident #67 while he was lying in bed with a wander-alarm bracelet to his ankle. On 5/12/22 at 12:26 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarm was not coded. She stated it was an oversight since Resident #67 had an alarm bracelet on his ankle. An interview occurred with the Director of Nursing on 5/12/22 at 1:14 PM and indicated it was her expectation for the MDS assessment to be coded accurately. 5. Resident #78 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident. Review of Resident #78's previous quarterly Minimum Data Sets (MDS) dated [DATE] and 1/26/22 indicated he was incontinent of bowel. His most recent quarterly MDS dated [DATE] indicated he was continent of bowel. Resident #78 was care planned 10/24/18 last revised 2/15/22 for toileting assistance due to incontinence related to his left sided weakness. An interview was conducted with Nursing Assistant (NA) #9 on 5/11/22 at 5:00 PM. She stated that she had worked with Resident #78 and that he has been incontinent of bowel for as long as she could recall. An interview was conducted with NA #10 on 5/11/22 at 5:05 PM. She stated Resident #78 was incontinent of bowel for as long as she could recall. An interview was conducted with the MDS Nurse on 5/12/22 at 12:26 PM. She stated she was aware that she had incorrectly noted Resident #78's bowel status and this had been an oversight. She explained she had completed a modification to the quarterly MDS dated [DATE] on 5/11/22. An interview was completed with the Administrator on 5/12/22 at 1:15 PM. She stated she expected Resident #78's MDS to be completed accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #26 was admitted to the facility on [DATE] with diagnosis that included intellectual disabilities. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #26 was severely cognitively impaired and nonverbal. The resident was dependent on staff for all activities of daily living including eating, dressing, toileting, and personal hygiene during the assessment period. Resident #26 was not coded for moods or behaviors and did not reject care during the assessment period. Resident #26's comprehensive care plan dated 3/9/2022 contained a focus for skin impairment related to having fragile skin and scratching himself. Interventions included checking fingernails frequently and keeping fingernails trimmed and filed as needed. During an observation of wound care on 5/10/2022 at 3:43 PM the Assistant Director of Nursing (ADON) and the Treatment nurse were present. The Treatment nurse stated the resident had scratched his buttocks on 5/9/2022 and had a new area of broken skin. The resident's incontinent brief was clean and dry when removed. The bilateral buttocks were observed to have blanchable redness and the right buttock had broken skin in long linear patterns. The ADON was asked to examine the resident's fingernails. The fingernails on both hands were observed to be long and had a brown substance under the nails. The resident also had a brown substance on the palm of his left hand. The ADON stated the resident needed his nails cleaned and trimmed. She further stated nail care was provided as needed by the staff. On 5/10/2022 at 3:51 PM an interview was conducted with Nursing Assistant (NA) #1. She stated she was assigned to Resident #26. She stated fingernails were checked and trimmed as needed on shower days. She stated she had not trimmed Resident #26's fingernails recently and she did not know what day he got showers. She further stated she saw that the resident's nails and hands were dirty. She was going to clean his hands and nails after she answered another resident's call bell. On 5/12/2022 at 1:14 PM an interview was conducted with the Dirctor of Nursing (DON). She stated she expected the NAs to monitor, clean , and trim nails when they provided personal care. 4. Resident #34 was originally admitted to the facility on [DATE] with diagnoses that included heart disease and urinary retention. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #34 was cognitively intact and was coded with no behaviors or refusal of care. He required extensive assistance with personal hygiene and bathing. A review of Resident #34's active care plan, last reviewed 3/14/22, included a focus area for activities of daily living/personal care. The interventions included to provide extensive assistance with tasks such as combing hair and shaving. A review of the nursing progress notes from 12/31/21 to 5/9/22, revealed no refusals of nail care or shaving assistance documented. An interview and observation was made of Resident #34 on 5/9/22 at 1:15 PM while he was sitting on the side of the bed. He was noted with a thick, long beard and long fingernails with a brown substance under them to both hands. Resident #34 stated it had been awhile since he was shaved and normally wore only a moustache. Stated he would like to be shaved but could not recall being offered. In addition, Resident #34 stated I've never kept my fingernails this long. They just cut my toenails not long ago, but not sure why they haven't done my fingernails. On 5/10/22 at 11:09 AM, Resident #34 was observed lying in bed. He stated no one had offered to shave him or cut his fingernails. The Assistant Director of Nursing (ADON) was interviewed on 5/10/22 at 3:15 PM and stated nail care was provided when needed. She observed Resident #34 and stated his fingernails did need to be cut and cleaned. She was unable to state why he had not been shaven or had his fingernails cared for during personal care assistance. Nurse Aide (NA) #1 was interviewed on 5/10/22 at 3:51 PM and explained nail care and shaving assistance was completed on shower days, when needed or requested by the resident. She further stated if a resident refused the nurse would be informed so a progress note could be written. She was unaware of any refusals from Resident #34. Resident #34 was observed on 5/11/22 at 10:43 AM. His face was clean shaven with a moustache remaining and his fingernails were short and clean. Resident #34 stated someone came by the prior evening and assisted with shaving and caring for his fingernails and added he felt much better. On 5/12/22 at 9:45 AM, NA #3 was interviewed. She indicated she was familiar with Resident #34. She explained nail care and shaving assistance should have occurred during personal care, shower days and when needed but was unable to state why Resident #34 had not been offered nail care or shaving assistance prior to 5/10/22. The Director of Nursing (DON) was interviewed on 5/12/22 at 1:15 PM and indicated it was her expectation for NAs to monitor, clean and trim nails during personal care, retrieving a nurse if the resident was a diabetic or refused. Additionally, the DON stated it was her expectation that Resident #34 be free of unwanted facial hair and expected NAs to offer shaving assistance during his scheduled shower days and during personal care tasks. Based on observations, staff, resident and family interviews and record review, the facility failed to provide shaving assistance for Resident #17 and Resident #34 dependent on assistance with activities of daily living (ADLs). The facility also failed to provide nail care for ADL dependent residents (Resident #17, Resident #38, Resident #78, Resident #34 and Resident #26). This was for 5 of 20 residents reviewed for ADLs. The finding included: 1. Resident #17 was admitted on [DATE] and readmitted on [DATE] with cumulative diagnoses of Peripheral Vascular Disease (PVD) and End Stage Renal Disease (ESRD). His readmission Minimum Data Set, dated [DATE] indicated he was cognitively intact, exhibited no behaviors and he required extensive staff assistance with his personal hygiene. Resident #17 was care planned on 2/20/22 for assistance with his ADLs but the care plan did not include assistance with personal hygiene. An observation and interview was completed with Resident #17 on 5/9/22 at 2:40 PM. His fingernails were observed with a dark substance underneath and the nails extended past his fingertips. Resident #17's facial hair was disheveled, long and extended down onto his neck. He stated he only preferred a mustache but not the beard. He stated he could not remember the last time he had a shave or had his fingernails trimmed. An observation was completed on 5/10/22 at 10:15 AM with the Treatment Nurse (TN) and the Assistant Director of Nursing (ADON) providing wound care. The TN and ADON did not mention the appearance of his fingernails or facial hair. An interview was completed on 5/10/22 at 12:20 PM with the ADON. She stated the aides provided all fingernail care and shaving during ADLs and it should be done as needed or noticed. An interview was completed on 5/11/22 at 8:35 AM with Nursing Assistant (NA) #6. She confirmed she was assigned Resident #17 on 5/9/22 and 5/10/22 but she did not notice his fingernails or facial hair. NA #6 stated nail care and shaving was completed by the aides as needed. She stated she was not aware of any refusals of assistance with his ADLs. An interview was completed on 5/11/22 at 8:55 AM with the ADON. She stated Resident #17 did not refuse assistance with his ADLs. An interview and observation was completed on 5/11/22 at 11:13 AM. Resident #17 was in his room with his wife present. He appeared unshaven and his fingernails had not trimmed. His wife stated Resident #17 never wore a beard but only a mustache and he never allowed his fingernails to extended past his fingertip. She stated he needed assistance with shaving and trimming his nails and was uncertain why the aides had not assisted him with his personal hygiene. An interview was completed on 5/11/22 at 11:22 AM with NA #8. She stated the night shift aides completed Resident #17's ADLs in order for him to be ready for dialysis but she would shave his face and trim his fingernails today. Attempts to contact NA #11 assigned Resident #17 third shift on 5/9/22, 5/10/22 and 5/11/22 were unsuccessful. An observation was conducted on 5/11/22 at 5:07 PM. Resident #17 appeared clean shaven except for his mustache and his fingernails had been trimmed and cleaned. He stated he felt much improved. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated she expected the staff to assist Resident #17 with shaving and nail care as needed. 2. Resident #38 was admitted on [DATE]and most recently readmitted on [DATE] with cumulative diagnoses neurogenic bladder and contractures. Resident #38 was care planned on 10/4/18 last revised 9/17/21 for total assistance with his personal hygiene due to his contracture to his left upper extremity. He was also care planned on 4/8/19 last revised 9/41/21 for resistance to care and treatments and was known to refuse medications, treatments and showers at times. Interventions included allowing flexibility in his ADL routine to accommodate his mood. His quarterly Minimum Data assessment dated [DATE] indicated he was cognitively intact, exhibited rejection of care and coded for total assistance with all of his activities of daily living (ADLs). An interview and observation was completed with Resident #38 on 5/9/22 at 12:26 PM. He had bilateral hand contractures and a left elbow contracture. His appeared fingernails jagged, extended beyond his fingertips and had a dark looking substance under the nails. He stated the staff had to trim his fingernails and could not recall when they were last trimmed. An observation of wound care was completed on 5/10/22 at 11:20 AM with the Treatment Nurse (TN) and the Assistant Director of Nursing (ADON). Neither the TN nor the ADON noticed the appearance of Resident #38's fingernails. An interview was completed on 5/10/22 at 12:20 PM with the ADON. She stated the aides provided all fingernail care during ADLs and it should be done as needed or noticed. An interview was conducted on 5/11/22 at 8:20 AM with Nursing Assistant (NA) #6 stated she was assigned Resident #38 on 5/9/22 and 5/10/22 but she did not observe the condition of his fingernails. She stated she had not known Resident #38 to refuse his nail care but he would say his fingernails were sensitive and picky about who he allowed to trim them. NA #6 stated the ADON trimmed and cleaned his fingernails yesterday. An interview and observation was completed on 5/11/22 at 8:35 AM. NA #7 was assisting Resident #38 with his breakfast. He stated the ADON trimmed his fingernails yesterday and they felt better because when his fingernails grew out as long as they were yesterday, they become very sensitive. NA #7 stated nail care should be done when needed. She stated Resident #38 did not refuse nail care or personal hygiene assistance. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated she expected the staff to assist Resident #38 with nail care as needed. 3. Resident #78 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident. His quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #78 was cognitively intact, exhibited no behaviors and was coded for extensive staff assistance with his personal hygiene. Resident #78 was care planned on 10/24/18 last revised 12/20/19 for assistance with his personal hygiene due to left sided weakness. An interview and observation was completed on 5/09/22 1:36 PM with Resident #78. His fingernails extended past his fingertips and appeared for have a dark substance underneath his fingernails. He stated he needed the staff to trim his nails but he always forgot to ask. An observation was completed on 5/10/22 at 3:55 PM. He was sitting in a wheelchair outside in the hall near the doorway of his room. The appearance of his fingernails were unchanged. An interview was completed on 5/11/22 at 5:00 PM with Nursing Assistant (NA) #9. She stated Resident #78 was only known to refuse showers but he did not refuse assistance with his personal hygiene or nail care. An interview was completed on 5/11/22 at 5:05 PM with NA #10. She stated Resident #78 was known to refuse ADL assistance but would agree to allow staff to assist him in his time. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated she expected the staff to assist Resident #78 with nail care as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.Resident #26 was admitted to the facility on [DATE] with diagnosis that included contractures. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #26 was severely cognitively impaired and nonverbal. The resident was dependent on staff for all activities of daily living including bed mobility, dressing, toileting, and personal hygiene during the assessment period. Resident #26 was coded as high risk for pressure injuries and had pressure reducing devices and nonsurgical dressing applied during the assessment period. Resident #26's comprehensive care plan dated 3/9/2022 contained a focus for risk of skin breakdown or pressure injuries. Interventions included ensuring appropriate pressure reducing devices and air mattress were in place. The resident's active orders revealed a physician's order for air mattress dated 3/27/2022 with no end date. The order was entered by staff development coordinator (SDC). On 5/10/2022 at 3:43 PM an observation of wound care by the treatment nurse, with the Assistant Director of Nursing (ADON) present, was conducted. Resident #26 was observed to have blanchable redness to bilateral buttocks and scrotum. When writer asked the treatment nurse to characterize the wound, the treatment nurse stated it was a stage 1. Additionally, the resident was observed to have broken skin in a linear pattern on his right buttock. When asked about the mattress, both the ADON and the treatment nurse stated the resident was not on an air mattress, he was on a wing mattress. On 5/11/2022 at 11:40 AM an interview was conducted with the treatment nurse. He reviewed Resident #26's active order set and stated he did not know the resident had an order for air mattress or why he had an order for an air mattress. An interview with the SDC on 5/12/2022 at 11:42 AM. She stated the facility recently transitioned from paper medical records to electronic medical records. When she transcribed Resident #26's active orders form paper to electronic format, the resident had an order for an air mattress. Therefore, she carried the order over. She did not know if Resident #26 was on an air mattress. Based on observations, staff and Medical Director (MD) interviews and record review, the facility failed to ensure MD ordered specialty air mattress was set according to the weight of the resident (Resident #30 and Resident #38). The facility also failed to ensure the MD ordered air mattress was implemented for Resident #26. This was for 3 of 3 residents reviewed for pressure ulcers. The findings included: 1. Resident #30 was admitted [DATE] cumulative diagnoses of a Urinary Tract Infection (UTI), urinary retention and a pressure ulcer to his sacrum. His admission Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact. He was coded for a urinary catheter, 2 stage one pressure ulcers and coded for a pressure relieving device to his bed. The MDS read Resident #30's admission weight was 190 pounds. Resident #30 was care planned on 3/4/22 for the risk of development of further pressure ulcers and the redness to his right and left buttocks. Interventions included ensuring the appropriate pressure relieving devices were in place. Review of Resident #30's skin assessment dated [DATE] indicated his stage 1 pressure ulcer to his left buttock had opened. Review of Resident #30's skin assessment dated [DATE] indicated the area to his left buttock progressed to a stage 3 and his skin assessment dated [DATE] indicated the area was unchanged. The MD ordered Resident #30 to be referred to the wound clinic due to increased drainage on 4/25/22. Review of Resident #30's wound consult dated 5/2/22 indicated the area on his left buttock was described as his sacrum. The area was debrided and a new order for an alternating air mattress (AAM). Review of a MD order dated 5/9/22 read for Resident #30 to be placed on an air mattress and to validate AAM setting range weekly on every Tuesday. Resident #30's electronic medical record read the last weight for Resident #30 was 182 pounds on 4/13/22. An interview was conducted with Resident #30 on 5/9/22 at 11:46 AM. He stated the air mattress was added to his bed while he was out for his wound clinic appointment earlier this morning. Observation of the AAM indicated the weight was set at 400 pounds. An observation of Resident #30's AAM was completed on 5/10/22 at 10:35 AM. The Treatment Nurse (TN) was present but did not noticed the AAM was set for the weight of 400 pounds. He stated that all ordered AAM's should be set accurately based on the resident's weight. An interview was conducted with Nursing Assistant (NA) #6 on 5/10/22 at 10:45 AM. She stated the aides were not responsible for setting up or checking the AAM for function or settings. She stated to her knowledge, it was either the responsibility of the floor nurse or the TN. An interview was conducted with the Staff Development Coordinator (SDC) on 5/10/22 at 10:47 AM. She stated it was the responsibility of the floor nurses to ensure any AAM's function and setting were accurate. An interview was conducted with Nurse #1 on 5/10/22 at 11:10 AM. She stated she was not sure who was responsible for ensuring AAM's were functioning properly and the air mattress pump settings were accurate based on the resident's weight. She stated she was under the impression that the TN and Assistant Director of Nursing (ADON) did it since they did wound rounds together weekly. An interview was conducted with the ADON on 5/10/22 at 11:15 AM. She confirmed she and the TN performed weekly wound assessments. The ADON stated during the wound rounds, the AAM was assessed for proper function and settings but it was the responsibility of the floor nurses to ensure the function and setting were accurate daily. An observation of Resident #30's AAM was completed on 5/11/22 at 8:45 AM. The AAM was still set for a weight of 400 pounds but he was not in his room. The Assistant Director of Nursing (ADON) stated Resident #30 was transferred to the hospital yesterday from the wound clinic. An interview was conducted with the MD on 5/11/22 at 9:50 AM. He stated Resident #30 was known to him and had a previous stay in 2021. The MD stated after this most recent hospital admission and subsequent admission to the facility, Resident #30's medical condition had progressively declined. He stated Resident #30's AAM was ordered to be set according to his weight and it was his expectation that the AAM be set according to his actual weight of 182 pounds. Another observation of Resident #30's AAM was completed on 5/11/22 at 4:45 PM. The AAM had been adjusted to the proper weight setting. An interview with the TN was completed on 5/11/22 at 4:50 PM. He stated the MD told him about the incorrect AAM settings earlier and he adjusted the setting in accordance with Resident #30's weight. He stated that all ordered AAM should be set accurately based on the resident's weight. An interview was completed with Nurse #2 on 5/12/22 at 10:10 AM. She stated it was her understanding that all the nurses and TN were responsible for ensuring proper function and setting of any resident ordered an AAM. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated Resident #30's AAM was to be set according to his most recent weight of 182 pounds and not at 400 pounds. 2. Resident #38 was admitted on [DATE]and recently readmitted on [DATE] with cumulative diagnoses neurogenic bladder, contractures, Peripheral Vascular Disease (PVD) and pressure ulcers to his right and left heels. Resident #38 was care planned on 6/24/21 and last revised on 9/17/21 for a pressure ulcer to his left heel. He was care planned on 1/26/21 and last revised 9/17/21 for bilateral arterial ulcers to his lower extremities. Interventions included ensuring the appropriate pressure relieving devices were in place. His quarterly Minimum Data assessment dated [DATE] indicated he was cognitively intact. He was coded for a urinary catheter one stage 3 pressure ulcer and 3 venous ulcers. His weight was recorded as 240 pounds. Review of Resident #38's wound ulcer flowsheet dated 4/8/22 indicated his left heel pressure ulcer acquired inhouse (date unknown) was healed as of 4/22/22. He still was receiving wound care for his venous ulcers. An interview and observation was completed with Resident #38 on 5/9/22 at 12:26 PM. He was lying on an alternating air mattress (AAM) with the weight set at 340 pounds. He stated he had a significant history of pressures to his feet and buttocks along with his venous ulcers. Review of Resident #38's May 2022 on Physician orders on 5/9/22 did not include an order for a AAM. An observation and interview was conducted with Nursing Assistant (NA) #6 on 5/10/22 at 10:45 AM. Resident #38's AAM was set for 340 pounds. She stated the aides were not responsible for setting up or checking the AAM for function or settings. She stated to her knowledge, it was either the responsibility of the floor nurses or the TN. An interview was conducted with the Staff Development Coordinator (SDC) on 5/10/22 at 10:47 AM. She stated it was the responsibility of the floor nurses to ensure any AAM's function and setting were accurate. An interview was conducted with Nurse #1 on 5/10/22 at 11:10 AM. She stated she was not sure who was responsible for ensuring AAM's were functioning properly and the air mattress pump settings were accurate based on the resident's weight. She stated she was under the impression that the TN and Assistant Director of Nursing (ADON) did it since they did wound rounds together weekly. An interview was conducted with the ADON on 5/10/22 at 11:15 AM. She confirmed she and the TN performed weekly wound assessments. The ADON stated during the wound rounds, the AAM was assessed for proper function and settings but it was the responsibility of the floor nurses to ensure the function and setting were accurate daily. An observation of wound care was completed on 5/10/22 at 11:20 AM with the TN and the ADON. The area to Resident #38's left heel was healed but noted were 3 venous ulcers to his bilateral lower extremities. The TN and ADON were not observed assessing or adjusting Resident #38's AAM setting. An observation was completed on 5/11/22 at 8:35 AM. NA #7 was observed assisting Resident #38 with breakfast. His AAM was set at 340 pounds. NA #7 stated she was not aware of who checked the AAM for function and settings. She stated she assumed it was the floor nurses. An interview was conducted with the MD on 5/11/22 at 9:50 AM. He stated Resident #38's AAM was ordered to be set according to his weight and it was his expectation that the AAM be set according to his actual weight of 240 pounds. Another observation was completed on 5/11/22 at 5:05 PM. Resident #38's AAM was still set for a weight of 340 pounds. An interview was completed with Nurse #2 on 5/12/22 at 10:10 AM. She stated it was her understanding that all the nurses and the TN were responsible for ensuring proper function and setting of any resident ordered an AAM. An interview was completed with the TN on 5/12/22 at 12:00 PM. He stated the MD informed him of the inaccurate weight setting on Resident #38's AAM but he forgot to correct the setting until late yesterday afternoon. He stated that all ordered AAM's should be set accurately based on the resident's weight. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated Resident #38's AAM was to be set according to his most recent weight of 240 pounds and not at 340 pounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #74 was admitted on [DATE] with diagnosis that included acute kidney failure. Resident #74's quarterly Minimum Data Set (MDS) dated [DATE] and indicated the resident was mildly cognitively impaired, required assistance with activities of daily living (ADL), and had an indwelling urinary catheter. Resident #74's comprehensive care plan, last revised on 3/16/2022, included a focus for altered pattern or urinary elimination related to indwelling urinary catheter. Interventions included catheter care per physician's order or the facility protocol, catheter changes per MD orders and/or facility protocol, maintain unobstructed urine flow, ensure the urinary was below the level of the bladder and the catheter secured with an anchoring device. Resident #74 had a physician's order dated 4/22/2022 for reinsertion of urinary catheter for wound healing. The order was entered by the ADON. Resident #74's May 2022 Physician orders did not include orders for changes, assessments, or maintenance of his urinary catheter. The facility's protocol for indwelling urinary catheters did not address care and maintenance of a urinary catheters. Resident #74's April and May 2022 Treatment Administration Record (TAR) did not include any documented evidence of urinary catheter care, assessment or maintenance. An interview was conducted with Resident #74 on 5/11/2022 at 2:05 PM. She stated the staff cleaned her urinary catheter every shift. An interview was conducted with the ADON on 05/11/2022 at 2:48 PM. She stated she did put in the order for Resident #74's indwelling urinary catheter. She further stated the urinary catheter was placed for wound healing. The ADON stated she should have put in catheter care orders but she did not. On 5/11/2022 at 4:11 PM an interview was conducted with Nurse #9. She stated she was assigned to Resident #74 and she provided urinary catheter care to the resident every shift. Nurse #9 reviewed Resident #74's medical record and stated she could not find urinary catheter care orders for the resident. An interview was conducted with the MD on 5/11/22 at 9:50 AM. He stated he thought the facility had a protocol for the care of residents with indwelling urinary catheters. He further stated he was not aware there were no orders for the care and assessment of Resident #74's indwelling urinary catheter. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated there should be Physician orders for daily care and maintenance of Resident #74's urinary catheter. Based on observations, staff, resident and Medical Director (MD) interviews and record review, the facility failed to ensure Physician orders were obtained and implemented for the care and assessment of residents with indwelling urinary catheters (Resident #30, Resident #38 and Resident #74). The facility also failed to place a securement device for an indwelling urinary catheter (Resident #30). This was for 3 of 6 residents reviewed for urinary catheters. The findings included: 1. Resident #30 was admitted [DATE] cumulative diagnoses of a Urinary Tract Infection (UTI) and urinary retention. His admission Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact, required extensive staff assistance with his activities of daily living (ADLs) and was coded for a urinary catheter. Resident #30's care plan last revised 4/1/22 read he had an altered pattern of urinary elimination with an indwelling urinary catheter. Interventions included catheter care per the facility protocol, change the catheter per MD orders and/or facility protocol, maintain an unobstructed urine flow and ensure the urinary was below the level of the bladder. There was no intervention of a securement device. Review of Resident #30's weekly electronic urinary catheter assessments from admission 3/4/22 to 5/5/22 all completed by the facility Treatment Nurse (TN) and once by the Assistant Director of Nursing (ADON) did not include any documentation regarding the appearance of the catheter insertion site. Review of Resident #30's May 2022 Physician orders did not include any orders for a urinary catheter, catheter changes, assessment or the maintenance of his urinary catheter. There were also no orders to follow the facility protocol for urinary catheters. Review of Resident #30's March, April and May 2022 Treatment Administration Records (TAR) did not include any documented evidence of urinary catheter care, assessment or maintenance. Review of a nursing note dated 5/9/22 at 11:05 PM read Nurse #9 noted some blood around his catheter insertion site and she notified the MD. There were no new orders. An interview and observation were conducted with Resident #30 on 5/9/22 at 11:46 AM. He stated his urinary catheter insertion site was stinging and the tube was tugging on the insertion site. He pulled back his top sheet to reveal there was no securement device attached to either thigh. He stated when he was first admitted , the staff put some sort of device that held his urinary catheter in place. He stated they stopped using it several weeks ago. An observation of Resident #30's urinary catheter insertion site was completed on 5/10/22 at 10:35 AM with the TN. Resident #30 stated his urinary catheter was hurting, pulling, tugging and the catheter insertion site was stinging. The TN pulled back the top sheet and noted no securement device. He stated the stat locks (a urinary catheter stabilization device used for securing a catheter in place to prevent pulling and trauma) had been on back order for a couple of months. The TN stated there should be some sort of securement in place even if the stat locks were on back order. He stated it could be stabilized with tape or a leg strap. The TN removed Resident #30's brief to reveal dried blood to the inside of his brief. There was also observed of dark red blood at the catheter insertion site. The TN stated he was not aware of the observed trauma. He stated he would clean the area and ensure a securement device was placed. The TN stated he was under the impression there was a urinary catheter protocol on his Physician orders. The TN stated he was not aware of where to locate the facility's urinary catheter protocol. An interview was conducted with Nursing Assistant (NA) #6 on 5/10/22 at 10:45 AM. She stated the aides were allowed the clean around the urinary catheter insertions sites but not allowed to place a securement device on Resident #30's leg. She stated the TN, or the floor nurses did that. NA #6 stated she did not notice any evidence of trauma or blood during his ADL care on 5/9/22. An interview was conducted with Nurse #1 on 5/10/22 at 11:10 AM. She stated it was her understanding that the TN changed the urinary stat locks weekly. She stated she was not aware that Resident #30 did not have a securement device in place or about the observed trauma at the urinary catheter insertion site. An interview was conducted with the Assistant Director of nursing (ADON) on 5/10/22 at 11:15 AM. She stated the and the TN performed weekly wound rounds together. She stated normally if the resident had a wound and a urinary catheter, the catheter was part of the weekly assessment as well. An interview was completed on 5/10/22 at 4:00 PM, Nurse #9 stated she observed blood in Resident #30's brief yesterday and she notified the MD but there were no orders were given. Nurse #9 stated she could not recall if there was a urinary securement device in place on 5/10/22. An interview was conducted with the MD on 5/11/22 at 9:50 AM. He stated he was under the impression that the facility had a protocol for the care of residents with urinary catheters and was not aware there were no orders for the care and assessment of Resident #30's urinary catheter. He stated Resident #30's catheter should always have a securement device in place to prevent trauma or accidental removal of his urinary catheter. The MD stated the nurses, or the TN should have obtained monthly Physician orders for Resident #30's urinary catheter, assessed and cleaned his urinary catheter insertion site daily. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated there should be Physician orders for his urinary catheter, be secured and assessed daily. 2. Resident #38 was admitted on [DATE]and most recently readmitted on [DATE] with cumulative diagnoses neurogenic bladder and contractures. Resident #38's care plan last revised 9/17/21 read he had an altered pattern of urinary elimination with a suprapubic urinary catheter (a catheter used to drain urine from the bladder). Interventions included catheter care per the facility protocol, change the catheter per MD orders and/or facility protocol, maintain unobstructed urine flow, ensure the urinary was below the level of the bladder and the catheter secured with an anchoring device. His quarterly Minimum Data assessment dated [DATE] indicated he was cognitively intact, coded for a urinary catheter and total assistance with all his activities of daily living (ADLs). Review of Resident #38's May 2022 Physician orders did not include any orders for a suprapubic catheter, catheter changes, assessment or maintenance of his urinary catheter. There were also no orders for the facility protocol for urinary catheters. Review of Resident #38's April and May 2022 Treatment Administration Record (TAR) did not include any documented evidence of urinary catheter care, assessment or maintenance. Review of Resident #38's nursing notes dated 1/28/22, 2/27/22, 3/16/22, 3/23/22, 4/9/22 and 4/20/22 all contained documentation regarding his suprapubic catheter sliding out or leaking. An interview and observation were completed with Resident #38 on 5/9/22 at 12:26 PM. He stated he was worried about the hole in his stomach. He confirmed he was describing his suprapubic insertion site. An observation and interview were conducted with Nursing Assistant (NA) #6 on 5/10/22 at 10:45 AM. She was in the process of providing Resident #38's morning ADLs. The aide lifted his abdominal fold to reveal a suprapubic insertion site with an open area to the right of the insertion site with bright red blood. His securement device was in place. NA #6 stated the area did not appear that way on 5/9/22 because she would have reported it to the nurse. An observation and interview were conducted with the Staff Development Coordinator (SDC) on 5/10/22 at 10:47 AM. She stated she was not aware Resident #38's catheter insertion site looked the way it did. The SDC stated the floor nurses and the aides provided catheter care but the Treatment (TN) and the Assistant Director of Nursing (ADON) assessed the catheter insertion sites weekly. An interview was conducted with Nurse #1 on 5/10/22 at 11:10 AM. She stated she thought the floor nurses, or the TN assessed and cleaned Resident #38's suprapubic insertion site daily. She stated she had not completed care or assessment of Resident #38's catheter on 5/9/22 or 5/10/22 and she was not aware of bleeding at the insertion site. An observation and interview were completed on 5/10/22 at 11:20 AM with the TN and the ADON. Both assessed Resident #38's suprapubic insertion site and stated the area did not appear that way when assessed last week. The TN proceeded to clean the area with gauze with fresh blood observed. The ADON stated she would notify the MD of the appearance of Resident #38's suprapubic catheter insertion site. The TN stated he was under the impression there was a suprapubic catheter protocol on his Physician orders. The TN stated he was not aware of where to locate the facility's suprapubic catheter protocol. An interview was conducted with the MD on 5/11/22 at 9:50 AM. He stated he was under the impression that the facility had a protocol for the care of residents with suprapubic catheters and was not aware that there were no orders for the care and assessment of Resident #38's suprapubic catheter. He stated the ADON contacted him on 5/10/22 and notified of the appearance of his catheter insertion site. He stated he gave new orders to clean the area daily. The MD stated the nurses, or the TN should have obtained monthly Physician orders for his suprapubic catheter, assessed and cleaned his suprapubic site daily. Review of Resident #38's Physician orders included an order dated 5/11/22 for daily and as needed cleaning of his suprapubic catheter site using normal saline and gauze, pat dry with gauze, cover site the with a T-Sponge (a precut, snug fit sponge designed to wick moisture away from the catheter site) and secure the sponge with tape for wound healing. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated The DON stated there should be Physician orders for Resident #38's suprapubic and assessed daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #40 was originally admitted to the facility on [DATE] with a readmission date of 1/18/22. His diagnoses included necrotizing fasciitis (a severe soft tissue infection that is caused by bacteria), abscess of the perineum, and type 2 diabetes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 was cognitively intact and had surgical wounds present. A review of the active physician orders for Resident #40, revealed the following orders dated 4/1/22: - Clean the perineal wound with normal saline using gauze, pat dry with clean gauze, apply Calcium Alginate with Silver (a highly absorbent gel-like covering to help maintain a moist environment that promotes wound healing) and secure every day. - Clean the right buttock wound with normal saline using gauzes, pat dry with clean gauze, apply Calcium Alginate with Silver and secure every day. The April 2022 and May 2022 Treatment Administration Record (TAR) was reviewed and demonstrated the surgical wound care to Resident #40's perineum and right buttock was not initialed as completed or refused by the resident at 9:00 AM on 4/21/22, 4/26/22, 5/3/22, 5/5/22 and 5/6/22. Review of the nursing progress notes from 1/3/22 to 5/6/22 did not include any refusals of wound care by Resident #40. The Treatment Nurse was interviewed on 5/11/22 at 4:50 PM and explained he completed wound care dressing changes Monday through Friday on the day shift (7:00 AM to 3:00 PM). After reviewing the missing documentation for Resident #40, on the April 2022 and May 2022 TARs, he stated he would have been on duty on those dates. The Treatment Nurse stated he had completed the wound care to Resident #40 as ordered and needed to get better with signing off treatments in the new Electronic Medical Record system. It's just a bunch of clickity clacks on the computer and I've just not gotten the hang of it yet. On 5/12/22 at 1:15 PM, an interview was held with the Director of Nursing (DON). She explained the facility had recently transitioned from paper to electronic TAR's on 4/19/22 but expected the Treatment Nurse as well as any other nursing staff to sign off when wound care was completed or indicate if it was refused by the resident. Based on staff interviews and record review, the facility failed to maintain complete and accurate medical records in the areas pressure ulcer treatments, (Resident #30, Resident #38 and Resident #17) and surgical wound treatments (Resident #40). This was for 4 of 20 residents reviewed for accurate and complete medical records. The findings included: 1. Resident #30 was admitted on [DATE] with a pressure ulcer to his sacrum. His admission Minimum Data Set (MDS) dated [DATE] indicated he was coded for 2 stage pressure ulcers. Review of Resident #30's wound consult dated 5/2/22 indicated the area on his left buttock was described as his sacrum. The area was debrided and a new order for an alternating air mattress (AAM). Review of Resident #30's May 2022 Physician orders indicted there were new wound care orders dated 5/3/22. Review of Resident #30's May 2022 Treatment Administration Record (TAR) revealed no documented evidence his wound care was provided on 5/3/22, 5/5/22, 5/6/22, 5/8/22 and 5/11/22. Review of Resident #30's nursing notes from 5/1/22 to 5/11/22 did not include any documented evidence of wound care refusals. An interview with the Treatment Nurse (TN) was completed on 5/11/22 at 4:50 PM. He reviewed Resident #30's May TAR and acknowledged there was no documentation of his wound care on the days identified. He stated the wound care was completed as ordered for Resident #30 but he needed to improve his documentation by initialing off in Resident #30's electronic medical record (EMR). He stated he had not gotten used to documenting in the EMR. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON explained the facility had recently transitioned from paper to electronic TAR's on 4/19/22 but expected the Treatment Nurse as well as any other nursing staff to sign off when wound care was completed or indicate if it was refused by the resident. 2. Resident #38 was admitted on [DATE]and recently readmitted on [DATE] with pressure ulcers to his right and left heels. His quarterly Minimum Data assessment dated [DATE] indicated he was coded for one stage 3 pressure ulcer and 3 venous ulcers. Review of Resident #38's April 2022 Physician orders indicted there were new wound care orders dated 4/1/22. Review of Resident #38's April 2022 Treatment Administration Record (TAR) revealed no documented evidence his wound care was provided on 4/21/22, 4/24/22, 4/26/22 and 4/30/22. Review of Resident #38's May 2022 TAR revealed no documented evidence his wound care was provided from 5/6/22 through 5/10/22. Review of Resident #38's nursing notes from 4/19/22 to 5/11/22 did not include any documented evidence of wound care refusals. An interview with the Treatment Nurse (TN) was completed on 5/11/22 at 4:50 PM. He reviewed Resident #38's May TAR and acknowledged there was no documentation of his wound care on the days identified. He stated the wound care was completed as ordered for Resident #38 but he needed to improve his documentation by initialing off in Resident #38's electronic medical record (EMR). He stated he had not gotten used to documenting in the EMR. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON explained the facility had recently transitioned from paper to electronic TAR's on 4/19/22 but expected the Treatment Nurse as well as any other nursing staff to sign off when wound care was completed or indicate if it was refused by the resident. 3. Resident #17 was admitted on [DATE] and readmitted on [DATE] after an amputation of all the toes on his left foot. His readmission Minimum Data Set, dated [DATE] was coded for a surgical wound. Review of Resident #17's April 2022 Physician orders indicted there were new wound care orders dated 4/1/22. Review of Resident #17's April 2022 Treatment Administration Record (TAR) revealed no documented evidence his wound care was provided on 4/20/22, 4/21/22, 4/23/22 and 4/24/22. Review of Resident #17's May 2022 TAR revealed no documented evidence his wound care was provided on 5/3/22, 5/5/22, 5/6/22, 5/8/22 and 5/11/22. An interview with the Treatment Nurse (TN) was completed on 5/11/22 at 4:50 PM. He reviewed Resident #17's May TAR and acknowledged there was no documentation of his wound care on the days identified. He stated the wound care was completed as ordered for Resident #17 but he needed to improve his documentation by initialing off in Resident #17's electronic medical record (EMR). He stated he had not gotten used to documenting in the EMR. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON explained the facility had recently transitioned from paper to electronic TAR's on 4/19/22 but expected the Treatment Nurse as well as any other nursing staff to sign off when wound care was completed or indicate if it was refused by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan in area of hospice for 1 of 4 residents (Resident #15) reviewed for hospice care. The findings included: Resident #15 was most recently admitted to the facility on [DATE] with diagnoses that included heart disease, hypertension, and hyperlipidemia. A physician ' s order dated 4/14/20 for Resident #15 indicated a hospice consultation was to be conducted. An admission form for hospice care indicated Resident #15 was admitted on [DATE]. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 ' s cognition was severely impaired. He was noted with a prognosis of less then 6 months and was on hospice. Resident #15 ' s active care plan was reviewed on 7/16/20 at 8:00 AM. There was no care plan in place related to hospice care. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/16/20 at 10:13 AM. The ADON confirmed Resident #15 was on hospice care since 4/16/20. The active care plan for Resident #15 was reviewed with the ADON. The ADON provided a newly initiated care plan for Resident #15, dated 7/16/20, with the focus area of hospice care due to a terminal illness. She verified there was no care plan in place related to hospice care for Resident #15 prior to 7/16/20. She reported that care plans were able to be developed by herself, the Director of Nursing (DON), the MDS Nurse, as well as the Unit Managers. The ADON was unable to explain why a care plan related to hospice care had not been developed for Resident #15 prior to 7/16/20. An interview was conducted with the MDS Nurse on 7/16/20 at 11:20 AM. The MDS Nurse confirmed Resident #15 was on hospice care since 4/16/20. She verified the ADON ' s interview that indicated there was no care plan in place related to hospice care for Resident #15 prior to 7/16/20. She reported that normally, she initiated a hospice care plan when she completed the significant change MDS assessment related to the hospice admission. The MDS Nurse was unable to explain why she had not developed a hospice care plan for Resident #15 when the 4/21/20 significant change MDS assessment was completed. During an interview with the DON on 7/16/20 at 11:30 AM she indicated that a care plan was expected to be developed for any resident who was on hospice care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to revise the care plan in the area of range of motion for 1 (Resident # 42) of 3 sampled residents reviewed for limitation in range of motion (ROM). Findings included: Resident #42 was admitted to the facility on [DATE] with multiple diagnoses including contracture of left hand, left shoulder and left elbow. The quarterly Minimum Data Set (MDS assessment dated [DATE] indicated that Residents #42 had moderate cognitive impairment and had limitation in range of motion on both sides of upper and lower extremities. On 5/28/20, Resident #42 had a doctor's order for Occupational Therapy (OT) to evaluate and treat as indicated. The OT note dated 5/28/20 revealed that Resident #42 was referred due to decline in ROM and high risk of worsening contractures, exhibits decreased shoulder flexion, shoulder abduction, elbow extension and hand extension. He had increased tone in his bilateral wrist and may benefit from change of splints or splint adjustment for greater wrist extension and improved positioning. Review of Resident #42's care plan dated 6/3/20 was conducted. One of the care plan problems was resident at risk for limitation in range of motion in lower extremities. The goal was to have no further limitation in ROM in lower extremities by the next review. The approaches included splint to left elbow and bilateral hands as resident tolerates by restorative aide/nursing aide. On 7/13/20 at 2:08 PM, Resident #42 was observed lying in bed. He was not wearing a splint on his left elbow and on his bilateral hands. On 7/13/20 at 2:10 PM, the Restorative Nursing Aide (RNA) was interviewed. The RNA stated that Resident #42 was not on her case load for splinting. She stated that the resident was picked up by the Occupational Therapist (OT) sometime in May 2020 and restorative nursing was no longer responsible for the application of the splints. On 7/15/20 at 1:13 PM, the MDS Nurse was interviewed. She verified that OT had picked up Resident #42 in May 2020 and when the OT was working with the resident, restorative nursing was not responsible for the splint application. The MDS Nurse stated that she should have removed the splint application from the care plan. On 7/16/20 at 11:05 AM, the Director of Nursing (DON) was interviewed. The DON stated that Resident #42 was picked up by OT in May 2020 and the MDS assessment was completed on 6/3/20, she expected the care plan to have been reviewed and revised by removing the splint application by restorative aide/nursing aide from the care plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff and physician interviews, the facility failed to transcribe admission orders for a urinary catheter change for 1 of 2 residents reviewed for urinary catheters (Resident #22). The findings included: Resident #22 was originally admitted to the facility on [DATE] with the most recent readmission date of 7/7/2020. His diagnoses included neuromuscular dysfunction of the bladder and chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #22 had severe cognitive impairment and required total assistance from staff for toileting. An indwelling catheter was present. The hospital Discharge summary dated [DATE] was reviewed and indicated in the Details of Inpatient Stay section to change the suprapubic urinary catheter in one month. The admission orders dated 7/7/20 for Resident #22 were reviewed and no order to change the suprapubic catheter was noted. Resident #22's current MAR and Treatment Administration Records (TAR) dated 7/7/20 to 7/31/20 were reviewed and no entry was noted to change the suprapubic catheter in one month. On 7/16/2020 at 9:10 AM, an interview occurred with the Assistant Director of Nursing (ADON) who signed the admission orders under the medications reviewed by section. She reviewed the Hospital Discharge summary dated [DATE] and visualized the instruction to change the suprapubic catheter in one month. The ADON explained when she reviewed the discharge orders, she looked at the diagnoses, discharge medication list and outpatient follow-ups, and normally didn't read the whole summary for any other instructions. She verbalized it was an oversight and should have been transcribed to the current MAR or TAR. The ADON further stated normally she or the Staff Development Coordinator reviewed the transcribed admission orders. Nurse #1 was interviewed on 7/16/2020 at 10:25 AM, whose signature was on the admission orders under the complete entries checked section. She reviewed the current MAR and TAR as well as the hospital Discharge summary dated [DATE] and verified the instruction to change the suprapubic catheter in one month was not present. Nurse #1 further stated she overlooked it as it was in the details of the hospital stay section and she should have reviewed the entire summary for other instructions that may have been present. On 7/16/2020 at 11:00 AM, the Medical Director was interviewed and stated when he assessed new admissions or readmissions, he reviewed the entire hospital discharge summary as he would often find other instructions throughout the summary. The Medical Director added he would expect the nursing staff to review the entire hospital discharge summary for orders/instructions. The Director of Nursing was interviewed on 7/16/2020 at 11:30 AM and reported she expected the admission orders to be transcribed correctly and accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and resident and staff interview, the facility failed to assess the resident prior to the use of the side rails and then quarterly for 1 of 2 sampled residents reviewed for side rail use (Resident #11). Findings included: Resident #11 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's Disease. The quarterly MDS assessment dated [DATE] indicated that Resident #11 had severe cognitive impairment and had 2 or more falls with no injury since admission /reentry or prior assessment. Review of the nurse's notes and incident reports revealed that Resident #11 had a fall on 3/6/20 and 3/19/20. The care plan was reviewed. Resident #11 had a care plan initiated on 3/20/20 for the use of the side rails. The problem was use of bed rails for increasing or maintaining current bed mobility or transfer ability, safety in transfers-bilateral quarter rails. The approaches included to assess resident for risk of entrapment from bed rails periodically and as necessary and to evaluate use of the device periodically for continued effectiveness and appropriateness. On 7/13/20 at 2:03 PM, Resident #11 was observed lying in bed with bilateral quarter rails in the up position. The resident stated that she used it for turning from side to side. On 7/15/20 at 1:13 PM, the MDS Nurse was interviewed. The MDS Nurse stated that she didn't remember why the side rails were used for Resident #11 on 3/20/20. On 7/16/20 at 8:50 AM, the Administrator was interviewed. She stated that Resident #11 had a fall on 3/19/20 and the care plan for the side rails was initiated on 3/20/20. She reported that the Nurse should have evaluated/assessed the resident prior to the use of the side rails. On 7/16/20 at 8:52 AM, the Director of Nursing (DON) was interviewed. She stated that Resident #11 was assessed for the need of the side rails on 7/15/20, and she did not need them, so they were removed from her bed. The DON further stated that the nurse on 3/20/20 should have completed a side rail assessment for the resident prior to use. On 7/16/20 at 8:55 AM, Nurse # 1, assigned to Resident #11 on 3/20/20, was interviewed. She stated that a Physical Device assessment should be completed prior to the use of side rails. Nurse #1 indicated that she didn't know why the Physical Device assessment was not completed for Resident #11 prior to the use of the side rails. On 7/16/20 at 11:05 AM, a follow interview with the DON was conducted. The DON stated that she expected the nurses to complete the side rails assessment prior to use and then quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to discard expired Purified Protein Derivatives (used in the diagnosis of tuberculosis) and to date the Prostat (a protein supplement) when opened in 1 of 2 medication rooms (main) and 1 of 3 medication carts (upper 400 hall) observed. Findings included: 1. On [DATE] at 12:42 PM, the main medication room was observed. In the refrigerator, there was 1 used bottle of Purified Protein Derivatives (PPD) with an open date of [DATE]. The instruction on the PPD box read discard 30 days after opening. On [DATE] at 12:43 PM, Nurse #1 was interviewed. The Nurse stated that she was not sure how long PPD was good once opened. She also indicated that she didn't know who was responsible for checking the medication cart and the medication room for expired and undated medication because she had to float on different halls. Nurse #1 was observed to read the instruction on the PPD box and stated that the PPD was good for 30 days after opening. The nurse verified that the PPD was already expired and she was observed to discard the used PPD bottle. On [DATE] at 2:05 PM, The Director of Nursing (DON) was interviewed. The DON stated that she expected the facility policy on medications discard dates and the manufacturer's instruction to be followed. She reported that the facility policy and the manufacturer's instruction was to date the PPD when opened and to discard 30 days after opening. She also indicated that she expected the nurses to check the medication cart and the medication room daily for expired and undated medications. 2. On [DATE] at 1:55 PM, the medication cart on the upper 400 hall was observed. There was a used bottle of Prostat about 1/3 full observed with no date of opening. The instruction on the bottle of the Prostat read discard 3 months after opening. On [DATE] at 3:01 PM, the Medication Aide (Med Aide) assigned on the upper 400 hall was interviewed. She looked at the used bottled of Prostat and verified that it was not dated when opened. She stated that it was not required to date the bottle of Prostat when opened. On [DATE] at 2:05 PM, The Director of Nursing (DON) was interviewed. The DON stated that she expected the facility policy on medications discard dates and the manufacturer's instruction to be followed. She reported that the facility policy and the manufacturer's instruction was to date the Prostat when opened and to discard 3 months after opening. She also indicated that she expected the nurses/Med Aides to check the medication cart and the medication room daily for expired and undated medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) Resident #76 was originally admitted to the facility on [DATE] and was discharged from the facility on 2/13/2020. His diagnoses included Alzheimer's disease. A physician's order dated 1/27/2020 indicated an admission to Hospice care. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was marked with an active diagnosis of Alzheimer's disease and a prognosis of less than six months but not coded with receiving Hospice care. A review of the resident's care plan indicated on 2/17/2020 a revision was made to include resident #76 received Hospice care for Alzheimer's disease. During an interview with the MDS Nurse on 7/16/2020 at 9:50 AM, she confirmed she was aware the resident had received Hospice care and Hospice was not marked on the MDS assessment dated [DATE]. She stated it was an oversight. An interview was conducted with the Director of Nursing on 7/16/2020 at 11:30 AM, and stated it was her expectation for the MDS to be coded accurately. 7a) Resident #19 was originally admitted to the facility 10/12/18 with diagnoses that included cerebral infarction (a stroke), dysphagia (difficulty swallowing) and diabetes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was coded for weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months. Resident #19's weight data revealed the following weights during the MDS assessment look back period of November 2019 to April 2020, which showed a 3.52% weight loss in a month and a 0.52% weight loss in 6 months: 4/16/2020 192 lbs. 3/10/2020 199 lbs. 11/4/19 193 lbs. On 7/16/2020 at 9:50 AM, an interview was conducted with the MDS Nurse who stated the Dietary Manager coded the nutrition section of the MDS assessment. An interview occurred with the Dietary Manager on 7/16/2020 at 10:15 AM. She reviewed the nutrition area on the 4/23/20 MDS and weight data, indicated it was coded incorrectly and should not have been coded as a weight loss. During an interview with the Director of Nursing on 7/16/2020 at 11:30 AM, she indicated it was her expectation for the MDS to be coded accurately. 7b) Resident #19 was originally admitted to the facility 10/12/18 with diagnoses that included cerebral infarction (a stroke), dysphagia (difficulty swallowing) and diabetes. Review of Resident #19's active care plan dated 4/22/2020 revealed a care plan in place for nutrition and fluids via the PEG tube due to dysphagia and nothing by mouth (NPO) status. Appropriate goals and interventions were present. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had severe cognitive impairment and required total assistance from staff for fluid intake through the PEG tube (Percutaneous Endoscopic Gastrostomy- a way of receiving nutrition and fluids) She was coded as receiving 500 milliliters (ml) or less of fluid intake per day by the PEG tube. A review of the April 2020 physician orders indicated Resident #19 received 180 ml of water every 4 hours, 50 ml of water before and after medication administration and 15 ml of water with each medication given through the PEG tube. On 7/16/2020 at 9:50 AM, an interview was conducted with the MDS Nurse who stated the Dietary Manager coded the nutrition section of the MDS. An interview occurred with the Dietary Manager on 7/16/2020 at 10:15 AM. She reviewed the nutrition area on the 4/23/20 MDS and stated the 500 ml or less of fluids through the PEG tube was marked in error and should have been 501 ml or more per day. During an interview with the Director of Nursing on 7/16/2020 at 11:30 AM, she indicated it was her expectation for the MDS to be coded accurately. Based on record review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of diagnoses (Residents # 59, # 42 & # 66), falls (Resident # 11), Nutrition (Resident # 20 & #19), hospice (Resident #76) and PASRR level II (Resident #59) for 7 of 25 sampled residents reviewed. Findings included: 1a. Resident # 59 was admitted to the facility on [DATE] with multiple diagnoses including Schizophrenia, Psychosis and Chronic Viral Hepatitis. The doctor's progress note dated 3/25/19 revealed Resident #59 had a past medical history of Chronic Viral Hepatitis C. The quarterly MDS assessment dated [DATE] indicated that Resident #59's cognition was intact, and she had an active diagnosis of Viral Hepatitis. On 7/15/20 at 1:12 PM, the MDS Nurse was interviewed. She stated that Resident #59 had Chronic Viral Hepatitis and was not currently getting treatment for it and it should not have been coded under active diagnoses on the 6/27/20 MDS assessment. On 7/16/20 at 11:05 AM, the Director of Nursing (DON) was interviewed. The DON stated that the MDS Nurse had been working at the facility as MDS Nurse for 1 and ½ years. She indicated that the MDS Nurse was still learning MDS, but she expected the MDS assessments to be coded accurately. b. Resident # 59 was admitted to the facility on [DATE] with multiple diagnoses including Schizophrenia and Psychosis. Resident #59 was evaluated on 2/5/18 for Preadmission Screening and Resident Review (PASRR) level II and was reevaluated on 2/11/19 due to mental illness. The annual MDS assessment dated [DATE] indicated that Resident #59 was a PASRR level II and was not related to mental illness. On 7/13/20 at 2:45 PM, the Social Worker was interviewed. She stated that Resident #59 was a PASRR level II due to mental illness. On 7/15/20 at 1:12 PM, the MDS Nurse was interviewed. She verified that Resident #59 was a PASRR level II due to mental illness. The MDS Nurse stated that she coded the 3/27/20 annual MDS inaccurately. On 7/16/20 at 11:05 AM, the Director of Nursing (DON) was interviewed. The DON stated that the MDS Nurse had been working at the facility as MDS Nurse for 1 and ½ years. She indicated that the MDS Nurse was still learning MDS, but she expected the MDS assessments to be coded accurately. 2. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's Disease. The quarterly MDS assessment dated [DATE] indicated that Resident #11 had severe cognitive impairment and had 2 or more falls with no injury since admission /reentry or prior assessment. The incident report and nurse's note dated 3/6/20 at 7:50 PM indicated that Resident #11 had told the nurse aide that she had a fall in the bathroom. She was found to have a small hematoma to her left eye and had a goose egg above left eye. The doctor and the responsible party (RP) were notified. An order for x-ray of face was obtained. On 7/15/20 at 1:13 PM, the MDS Nurse was interviewed. She verified that the fall on 3/6/20, Resident #11 sustained hematoma on her left eye and the MDS dated [DATE] should have been coded as fall with injury but it was not. On 7/16/20 at 11:05 AM, the Director of Nursing (DON) was interviewed. The DON stated that the MDS Nurse had been working at the facility as MDS Nurse for 1 and ½ years. She indicated that the MDS Nurse was still learning MDS, but she expected the MDS assessments to be coded accurately. 3. Resident #66 was admitted to the facility on [DATE] with multiple diagnoses including Urinary Tract Infection (UTI). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #66 had severe cognitive impairment and had received an antibiotic drug for 5 days during the assessment period. The assessment further indicated that Resident #66 did not have a diagnosis of UTI. The hospital Discharge summary dated [DATE] revealed that Resident #66 had an active diagnosis of UTI, and she was discharged to the facility on 6/24/20 on Amoxicillin (an antibiotic drug) 875 milligrams (mgs.) twice a day for 5 days for UTI. The Medication Administration Record (MAR) for June 2020 revealed that Resident #66 had received Amoxicillin 875 mgs daily for 5 days from 6/25/20 - 6/29/20. On 7/15/20 at 1:13 PM, the MDS Nurse was interviewed. She verified that Resident #66 was admitted from the hospital on 6/24/20. The resident was admitted with an order for Amoxicillin 875 mgs twice a day for UTI. The MDS Nurse indicated that she did not code the MDS for UTI since the resident did not meet the McGreer's criteria (criteria used by the long-term care (LTC) for UTI). On 7/16/20 at 11:05 AM, the Director of Nursing (DON) was interviewed. The DON stated that the MDS Nurse had been working at the facility as MDS Nurse for 1 and ½ years. She indicated that the MDS Nurse was still learning MDS, but she expected the MDS assessments to be coded accurately. The DON further indicated that since Resident #66 had received an antibiotic for UTI during the assessment period, the MDS dated [DATE] should have been coded for UTI under active diagnosis. 4. Resident #20 was admitted to the facility on [DATE] with multiple diagnoses including dysphagia and traumatic brain injury. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident # 20 had moderate cognitive impairment and had received parenteral/intravenous (IV) feeding during the last 7 days while a resident at the facility. The Medication Administration Records (MARs) for 4/2020 were reviewed. The MARs revealed that Resident #20 had received tube feeding but not parenteral/IV feeding. On 7/15/20 at 1:13 PM, the MDS Nurse was interviewed. She verified that Resident #20 was receiving tube feeding. The MDS Nurse stated that the 4/28/20 quarterly MDS assessment under nutritional status, the parenteral/IV feeding was coded incorrectly. She indicated that the resident did not receive parenteral/IV feeding during the assessment period. On 7/16/20 at 11:05 AM, the Director of Nursing (DON) was interviewed. The DON stated that the MDS Nurse had been working at the facility as MDS Nurse for 1 and ½ years. She indicated that the MDS Nurse was still learning MDS, but she expected the MDS assessments to be coded accurately. 5. Resident # 42 was admitted to the facility on [DATE] with multiple diagnoses including Chronic Viral Hepatitis. The hospital Discharge summary dated [DATE] indicated that Resident #42 had diagnosis of Viral Hepatitis. The quarterly MDS assessment dated [DATE] indicated that Resident # 42 had moderate cognitive impairment and had active diagnosis of Viral Hepatitis. On 7/15/20 at 1:12 PM, the MDS Nurse was interviewed. She stated that Resident #42 had Chronic Viral Hepatitis and was not currently getting treatment for it and it should not have been coded under active diagnoses on the 6/3/20 MDS assessment. On 7/16/20 at 11:05 AM, the Director of Nursing (DON) was interviewed. The DON stated that the MDS Nurse had been working at the facility as MDS Nurse for 1 and ½ years. She indicated that the MDS Nurse was still learning MDS but she expected the MDS assessments to be coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #15 was most recently admitted to the facility on [DATE] with diagnoses that included heart disease, hypertension, and hyperlipidemia. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 ' s cognition was severely impaired. He was noted with a prognosis of less than 6 months and was on hospice. A physician ' s order for Resident #15 dated 6/1/20 indicated Ativan (antianxiety medication) 1 milligram (mg) every 8 hours as needed (PRN). This PRN Ativan physician ' s order had no stop date. The most recent monthly pharmacy consultant medication regimen review for Resident #15 was completed on 6/12/20 by Pharmacy Consultant #2. There were no recommendations made related to Resident #15 ' s PRN Ativan (initiated on 6/1/20) that was prescribed with no stop date. A review of the 6/1/20 through 7/15/20 hard copy Medication Administration Records (MARs) for Resident #15 indicated no PRN Ativan had been administered. The July 2020 active physician ' s orders for Resident #15 were reviewed on 7/15/20 and revealed the 6/1/20 PRN Ativan physician ' s order continued to be active. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/16/20 at 8:27 AM. The ADON stated Resident #15 ' s PRN Ativan was prescribed by the hospice physician. She revealed she was aware of the regulation that required all physician ' s orders for PRN psychotropic medications to be time limited in duration, but she was not aware that the regulation applied to hospice residents. An interview was conducted Hospice Nurse #1 on 7/16/20 at 9:50 AM. She stated PRN Ativan was part of the hospice comfort package and it was prescribed without a stop date. She indicated she was not aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN psychotropic medications were required to be time limited in duration. Hospice Nurse #1 revealed that all of their hospice residents at the facility had a physician ' s order for PRN Ativan with no stop date. A telephone interview was conducted with the Hospice Medical Director on 7/16/20 at 9:05 AM. He confirmed that the hospice comfort package normally included a physician ' s order for PRN Ativan with no stop date. He stated he was aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN Ativan were required to be time limited in duration. He reported that normally, if PRN Ativan with no stop date was ordered for a facility resident, he was alerted by a pharmacy recommendation from the facility ' s Pharmacy Consultant and/or by facility nursing staff and a stop date was implemented. He revealed he received no notification related to Resident #15 ' s physician ' s order dated 6/1/20 for PRN Ativan with no stop date. A phone interview was conducted with Pharmacy Consultant #2 on 7/16/20 at 12:00 PM. She stated that she was aware that PRN psychotropic medications were required to be time limited in duration. The PRN Ativan physician ' s order dated 6/1/20 that continued to be active for Resident #15 was reviewed with Pharmacy Consultant #2. She reported that she had no notes in her June 2020 review that indicated Resident #15 had a physician ' s order for PRN Ativan with no stop date. She explained that there were times when telephone orders slipped out of the hard copy charts and/or were missed. Pharmacy Consultant #2 revealed that PRN psychotropic medication orders with no stop date had been on an ongoing issue at the facility going back as far as February 2020. She explained that every month she and/or Pharmacy Consultant #1 completed an Executive Summary of Consultant Pharmacist ' s Medication Regimen Review that provided the facility a summary of the medication regimen review results for that month. She further explained that this summary was not part of the medical record for each resident. Pharmacy Consultant #2 requested that the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review for June 2020 be reviewed for additional information. As requested by Pharmacy Consultant #2 during her phone interview, the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review dated 6/20/20 for the time period of 6/1/20 through 6/20/20, read, in part: All PRNs [psychoactive medications] require stop dates per [Centers for Medicare and Medicaid Services]. May wish to make all prescribers and nursing staff aware of this regulation. An interview was conducted with the Medical Director on 7/16/20 at 10:55 AM. The Medical Director stated he was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. He additionally stated that he was aware this regulation applied to hospice residents. He indicated that it was an error if a stop date was not included in the physician ' s order for a PRN psychotropic medication. The Medical Director reported that he depended on the Pharmacy Consultant to identify and address PRN psychotropic medication orders that had no stop date during the monthly medication regimen review. An interview was conducted with the Director of Nursing (DON) on 7/16/20 at 11:30 AM. The DON stated she was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. She additionally stated that she was aware this regulation applied to hospice residents. The DON was unable to explain why Resident #15 had an active order for PRN Ativan (initiated on 6/1/20) that had no stop date. She indicated that it was possible that the hospice staff audited the comfort packages for their facility residents on 6/1/20 and reinitiated physician ' s orders for PRN Ativan with no stop date and that this had not yet been not identified and corrected. She reported that she depended on the Pharmacy Consultant to identify and address PRN psychotropic medication orders that had no stop date during the monthly medication regimen review. 3. Resident #60 was most recently admitted to the facility on [DATE] with diagnoses that included heart disease and dementia. A physician ' s order for Resident #60 dated 6/1/20 indicated Ativan (antianxiety medication) 1 milligram (mg) every 8 hours as needed (PRN). This PRN Ativan physician ' s order had no stop date. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #60 ' s cognition was moderately impaired. He was noted with a prognosis of less than 6 months and was on hospice. The most recent monthly pharmacy consultant medication regimen review for Resident #60 was completed on 6/12/20 by Pharmacy Consultant #2. There were no recommendations made related to Resident #60 ' s PRN Ativan (initiated on 6/1/20) that was prescribed with no stop date. A review of the 6/1/20 through 7/15/20 hard copy Medication Administration Records (MARs) for Resident #60 indicated no PRN Ativan had been administered. The July 2020 active physician ' s orders for Resident #60 were reviewed on 7/15/20 and revealed the 6/1/20 PRN Ativan physician ' s order continued to be active. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/16/20 at 8:27 AM. The ADON stated Resident #60 ' s PRN Ativan was prescribed by the hospice physician. She revealed she was aware of the regulation that required all physician ' s orders for PRN psychotropic medications to be time limited in duration, but she was not aware that the regulation applied to hospice residents. An interview was conducted Hospice Nurse #1 on 7/16/20 at 9:50 AM. She stated PRN Ativan was part of the hospice comfort package and it was prescribed without a stop date. She indicated she was not aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN psychotropic medications were required to be time limited in duration. Hospice Nurse #1 revealed that all of their hospice residents at the facility had a physician ' s order for PRN Ativan with no stop date. A telephone interview was conducted with the Hospice Medical Director on 7/16/20 at 9:05 AM. He confirmed that the hospice comfort package normally included a physician ' s order for PRN Ativan with no stop date. He stated he was aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN Ativan were required to be time limited in duration. He reported that normally, if PRN Ativan with no stop date was ordered for a facility resident, he was alerted by a pharmacy recommendation from the facility ' s Pharmacy Consultant and/or by facility nursing staff and a stop date was implemented. He revealed he received no notification related to Resident #60 ' s physician ' s order dated 6/1/20 for PRN Ativan with no stop date. A phone interview was conducted with Pharmacy Consultant #2 on 7/16/20 at 12:00 PM. She stated that she was aware that PRN psychotropic medications were required to be time limited in duration. The PRN Ativan physician ' s order dated 6/1/20 that continued to be active for Resident #60 was reviewed with Pharmacy Consultant #2. She reported that she had no notes in her June 2020 review that indicated Resident #60 had a physician ' s order for PRN Ativan with no stop date. She explained that there were times when telephone orders slipped out of the hard copy charts and/or were missed. Pharmacy Consultant #2 revealed that PRN psychotropic medication orders with no stop date had been on an ongoing issue at the facility going back as far as February 2020. She explained that every month she and/or Pharmacy Consultant #1 completed an Executive Summary of Consultant Pharmacist ' s Medication Regimen Review that provided the facility a summary of the medication regimen review results for that month. She further explained that this summary was not part of the medical record for each resident. Pharmacy Consultant #2 requested that the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review for June 2020 be reviewed for additional information. As requested by Pharmacy Consultant #2 during her phone interview, the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review dated 6/20/20 for the time period of 6/1/20 through 6/20/20, read, in part: All PRNs [psychoactive medications] require stop dates per [Centers for Medicare and Medicaid Services]. May wish to make all prescribers and nursing staff aware of this regulation. An interview was conducted with the Medical Director on 7/16/20 at 10:55 AM. The Medical Director stated he was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. He additionally stated that he was aware this regulation applied to hospice residents. He indicated that it was an error if a stop date was not included in the physician ' s order for a PRN psychotropic medication. The Medical Director reported that he depended on the Pharmacy Consultant to identify and address PRN psychotropic medication orders that had no stop date during the monthly medication regimen review. An interview was conducted with the Director of Nursing (DON) on 7/16/20 at 11:30 AM. The DON stated she was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. She additionally stated that she was aware this regulation applied to hospice residents. The DON was unable to explain why Resident #60 had an active order for PRN Ativan (initiated on 6/1/20) that had no stop date. She indicated that it was possible that the hospice staff audited the comfort packages for their facility residents on 6/1/20 and reinitiated physician ' s orders for PRN Ativan with no stop date and that this had not yet been not identified and corrected. She reported that she depended on the Pharmacy Consultant to identify and address PRN psychotropic medication orders that had no stop date during the monthly medication regimen review. 4. Resident #32 was most recently admitted to the facility on [DATE] with diagnoses that included heart disease and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 ' s cognition was severely impaired. She was noted with a prognosis of less than 6 months and was on hospice. A physician ' s order for Resident #32 dated 6/1/20 indicated Ativan (antianxiety medication) 1 milligram (mg) every 8 hours as needed (PRN). This PRN Ativan physician ' s order had no stop date. The most recent monthly pharmacy consultant medication regimen review for Resident #32 was completed on 6/20/20. There were no recommendations made related to Resident #32 ' s PRN Ativan (initiated on 6/1/20) that was prescribed with no stop date. A review of the 6/1/20 through 7/15/20 hard copy Medication Administration Records (MARs) for Resident #32 indicated no PRN Ativan had been administered. The July 2020 active physician ' s orders for Resident #32 were reviewed on 7/15/20 and revealed the 6/1/20 PRN Ativan physician ' s order continued to be active. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/16/20 at 8:27 AM. The ADON stated Resident #32 ' s PRN Ativan was prescribed by the hospice physician. She revealed she was aware of the regulation that required all physician ' s orders for PRN psychotropic medications to be time limited in duration, but she was not aware that the regulation applied to hospice residents. An interview was conducted Hospice Nurse #1 on 7/16/20 at 9:50 AM. She stated PRN Ativan was part of the hospice comfort package and it was prescribed without a stop date. She indicated she was not aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN psychotropic medications were required to be time limited in duration. Hospice Nurse #1 revealed that all of their hospice residents at the facility had a physician ' s order for PRN Ativan with no stop date. A telephone interview was conducted with the Hospice Medical Director on 7/16/20 at 9:05 AM. He confirmed that the hospice comfort package normally included a physician ' s order for PRN Ativan with no stop date. He stated he was aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN Ativan were required to be time limited in duration. He reported that normally, if PRN Ativan with no stop date was ordered for a facility resident, he was alerted by a pharmacy recommendation from the facility ' s Pharmacy Consultant and/or by facility nursing staff and a stop date was implemented. He revealed he received no notification related to Resident #32 ' s physician ' s order dated 6/1/20 for PRN Ativan with no stop date. A phone interview was conducted with Pharmacy Consultant #1 on 7/16/20 at 8:54 AM. She indicated that she was new to the facility and she worked with Pharmacy Consultant #2. She stated that she was aware that PRN psychotropic medications were required to be time limited in duration. The PRN Ativan physician ' s order dated 6/1/20 that continued to be active for Resident #32 was reviewed with Pharmacy Consultant #1. She confirmed she had not completed a pharmacy recommendation that addressed the 6/1/20 PRN Ativan physician ' s order with no stop date during the June monthly medication regimen review for Resident #32. Pharmacy Consultant #1 revealed that PRN psychotropic medication orders with no stop date had been an ongoing issue at the facility. She explained that instead of writing a pharmacy recommendation specific to Resident #32, the overall issue of PRN psychotropic medication orders with no stop date was addressed in the summary of monthly regimen reviews that was provided to the facility. She indicated that Pharmacy Consultant #2 would be able to explain the monthly summary. A phone interview was conducted with Pharmacy Consultant #2 on 7/16/20 at 12:00 PM. Pharmacy Consultant #2 reiterated Pharmacy Consultant #1 ' s statement that PRN psychotropic medication orders with no stop date had been on an ongoing issue at the facility going back as far as February 2020. She explained that every month she and/or Pharmacy Consultant #1 completed an Executive Summary of Consultant Pharmacist ' s Medication Regimen Review that provided the facility a summary of the medication regimen review results for that month. She further explained that this summary was not part of the medical record for each resident. Pharmacy Consultant #2 requested that the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review for June 2020 be reviewed for additional information. As requested by Pharmacy Consultant #2 during her phone interview, the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review dated 6/20/20 for the time period of 6/1/20 through 6/20/20, read, in part, All PRNs [psychotropic medications] require stop dates per [Centers for Medicare and Medicaid Services]. May wish to make all prescribers and nursing staff aware of this regulation. An interview was conducted with the Medical Director on 7/16/20 at 10:55 AM. The Medical Director stated he was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. He additionally stated that he was aware this regulation applied to hospice residents. He indicated that it was an error if a stop date was not included in the physician ' s order for a PRN psychotropic medication. The Medical Director reported that he depended on the Pharmacy Consultant to identify and address PRN psychotropic medication orders that had no stop date during the monthly medication regimen review. An interview was conducted with the Director of Nursing (DON) on 7/16/20 at 11:30 AM. The DON stated she was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. She additionally stated that she was aware this regulation applied to hospice residents. The DON was unable to explain why Resident #32 had an active order for PRN Ativan (initiated on 6/1/20) that had no stop date. She indicated that it was possible that the hospice staff audited the comfort packages for their facility residents on 6/1/20 and reinitiated physician ' s orders for PRN Ativan with no stop date and that this had not yet been not identified and corrected. She reported that she depended on the Pharmacy Consultant to identify and address PRN psychotropic medication orders that had no stop date during the monthly medication regimen review. Based on facility staff, hospice staff, Consultant Pharmacist, Medical Director (MD) and Hospice Medical Director interviews and record review, the Consultant Pharmacist failed to identify and address as needed (PRN) Ativan orders that were not time limited in duration (Residents #40, #32, #60, #15) for 4 of 4 residents reviewed for hospice. The facility also failed to act upon Pharmacy Consultant recommendations to complete an Abnormal Involuntary Movement Scale (AIMS) for 1 of (Resident #59) 5 residents reviewed for unnecessary medications. The findings included: 1. Resident #40 was admitted on [DATE] with cumulative diagnoses of Cerebral Vascular Accident (CVA), Chronic Obstructive Pulmonary Disease (COPD) and anxiety. Resident #40's revised care plan dated 2/20/20 read he was on hospice care due to a terminal illness. Resident #40's March 2020 Physician orders included an order dated 3/11/20 for Ativan (antianxiety) one milligram (mg) by mouth three times a day as needed (hold for sedation). Resident #40's Medication Administration Records (MAR) from March 2020 to July 16, 2020 reveal he last received an Ativan dose on 3/10/20. A monthly Pharmacist Consultant Progress Note dated 3/24/20 read a medication regimen review was completed with no recommendations. A monthly Pharmacist Consultant Progress Note dated 4/18/20 read a medication regimen review was completed with no recommendations. A monthly Pharmacist Consultant Progress Note dated 5/16/20 read a medication regimen review was completed with no recommendations. A monthly Pharmacist Consultant Progress Note dated 6/20/20 read a medication regimen review was completed with a recommendation to nursing. The Consultant Pharmacist's Medications Regimen Review note for nursing dated 6/20/20 read for nursing to consider discontinuation PRN orders per the automatic stop order policy. This recommendation included Ativan. It further read that discontinuing PRNs that have not been used may prevent medications from going out of date, free up medication cart storage and save the payor money. The follow through response read that the Ativan was a hospice order for comfort care. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/16/20 at 8:27 AM. She stated the Consultant Pharmacist Physician Recommendations were given to the MD every month and she followed up with the MD to make sure they were addressed. She stated she reviewed the Medication Regimen Review notes and addressed any nursing concerns identified. She stated she wrote the follow through response on the Consultant Pharmacist's Medications Regimen Review note dated 6/20/20. The ADON stated Resident #40's PRN Ativan was prescribed by hospice and she was not aware that PRN Ativan had to be time limited in duration and reassessed by the Physician. A telephone interview was conducted with Consultant Pharmacist #1 on 7/16/20 at 8:54 AM. She stated she was new to the facility and that she had discussed at length the PRN antianxiety medications time limited duration with the facility. Consultant Pharmacist #1 confirmed she did not complete a Physician Recommendation on 3/24/20, 4/18/20 and 5/18/20. She stated she noted Resident #40's PRN Ativan orders in her Medication Regimen Review notes to be addressed by nursing by using the automatic stop policy to streamline the process in an effort not to bother the prescribing Physician. The facility's automatic stop order policy revised on 4/15/11 did not include psychotropics medications. A telephone interview was conducted with the Hospice Medical Director on 7/16/20 at 9:05 AM. He stated he was aware that Ativan had to be time limited in duration then re-evaluated for the continued use. He stated he not received any Physician Recommendations regarding Resident #40's PRN Ativan. He stated he received Physician Recommendations from his other facilities but not from this facility. He stated the Physician Recommendations were triggered by the Consultant Pharmacist during a monthly medication review and it was his expectation that any medication irregularities be address by the Consultant Pharmacist. Another interview was conducted with the ADON on 7/16/20 at 9:20 AM. She stated she did not contact the prescribing Physician when reviewing the Medication Regimen Review notes because it was her understand that a Physician Recommendation was completed by the Consultant Pharmacist and given to the Physician to address. The ADON stated the Medication Regimen Review notes are not given to the prescribing Physician but rather addressed by nursing. An interview was conducted the Hospice Nurse #1 on 7/16/20 at 9:50 AM. She stated since the PRN Ativan was part of the hospice comfort package, it was not re-evaluated. She stated she was not aware of the time limited use of PRN Ativan so all the hospice resident's Physician orders were incorrect. She stated the Hospice Medical Director received faxed pharmacy Physician Recommendations from other facilities about PRN medications but she did not recall seeing any from this facility. An interview was conducted with the MD on 7/16/20 at 10:55 AM. He stated normally the Consultant Pharmacist generated a Physician Recommendation for him to address. He stated he had not received a Physician Recommendation regarding Resident #40's PRN Ativan. The MD stated it was his expectation that the Consultant Pharmacist complete a Physician Recommendation as required during the monthly pharmacy medication review regarding any medication irregularities. Another telephone interview was conducted with Consultant Pharmacist #1 on 7/16/20 at 11:09 AM. She stated she documented her recommendations about the PRN psychotropics in the Executive Summary of the Consultant Pharmacist's Medication Regimen Review report given to the facility monthly. She stated she only comes to the facility one day a month and that she doesn't always access to the MAR's. She stated she was aware of the time limited duration for PRN psychotropics but was unable to explain why she did not complete Physician Recommendations. An interview was conducted with the Director of Nursing (DON) on 7/16/20 at 11:25 AM. She stated it was her expectation the that the Consultant Pharmacist complete a Physician Recommendation regarding Resident #40's PRN Ativan. 3. Resident # 59 was admitted to the facility on [DATE] with multiple diagnoses including Schizophrenia and Psychosis. The quarterly MDS assessment dated [DATE] indicated that Resident #59's cognition was intact, and she had exhibited other behavioral symptoms. Resident # 59 was being followed by the psychiatric services monthly for medication management. During the 3/12/20 visit, the psychiatric service had recommended to discontinue the Risperdal (an antipsychotic drug) for Resident #59. On 3/23/20, the Consultant Pharmacist had conducted the drug regimen review (DRR) for Resident #59 and had recommended to nursing for need Dyskinesia Identification System Condensed User Scale (DISCUS) due to discontinuation of Risperdal. The electronic records for Resident #59 were reviewed. The last DISCUS completed was on 2/27/20. There was no DISCUS completed after 3/23/20. On 7/15/20 at 1:45 PM, the Director of Nursing (DON) was interviewed. The DON stated that the Assistant Director of Nursing (ADON) was responsible for making sure the recommendations from the Pharmacy Consultant were acted upon. On 7/15/20 at 5:05 PM, the ADON was interviewed. She stated that she was responsible for responding to the Pharmacist recommendations. She reported that she had received the recommendation for the need of DISCUS in March 2020 for Resident #59 and she thought she had completed a DISCUS for the resident, but she did not. On 7/16/20 at 11:05 AM, a follow up interview was conducted with the DON. The DON stated that she expected the Pharmacist recommendation to be acted upon timely. She reported that the recommendation for the need of DISCUS for Resident #59 was an oversight on the part of the ADON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #15 was most recently admitted to the facility on [DATE] with diagnoses that included heart disease, hypertension, and hyperlipidemia. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 ' s cognition was severely impaired. He was noted with a prognosis of less than 6 months and was on hospice. A physician ' s order for Resident #15 dated 6/1/20 indicated Ativan (antianxiety medication) 1 milligram (mg) every 8 hours as needed (PRN). This PRN Ativan physician ' s order had no stop date. A review of the 6/1/20 through 7/15/20 hard copy Medication Administration Records (MARs) for Resident #15 indicated no PRN Ativan had been administered. The July 2020 active physician ' s orders for Resident #15 were reviewed on 7/15/20 and revealed the 6/1/20 PRN Ativan physician ' s order continued to be active. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/16/20 at 8:27 AM. The ADON stated Resident #15 ' s PRN Ativan was prescribed by the hospice physician. She revealed she was aware of the regulation that required all physician ' s orders for PRN psychotropic medications to be time limited in duration, but she was not aware that the regulation applied to hospice residents. An interview was conducted Hospice Nurse #1 on 7/16/20 at 9:50 AM. She stated PRN Ativan was part of the hospice comfort package and it was prescribed without a stop date. She indicated she was not aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN psychotropic medications were required to be time limited in duration. Hospice Nurse #1 revealed that all of their hospice residents at the facility had a physician ' s order for PRN Ativan with no stop date. A telephone interview was conducted with the Hospice Medical Director on 7/16/20 at 9:05 AM. He confirmed that the hospice comfort package normally included a physician ' s order for PRN Ativan with no stop date. He stated he was aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN Ativan were required to be time limited in duration. He reported that normally, if PRN Ativan with no stop date was ordered for a facility resident, he was alerted by a pharmacy recommendation from the facility ' s Pharmacy Consultant and/or by facility nursing staff and a stop date was implemented. He revealed he received no notification related to Resident #15 ' s physician ' s order dated 6/1/20 for PRN Ativan with no stop date. A phone interview was conducted with Pharmacy Consultant #1 on 7/16/20 at 8:54 AM. She indicated she was new to the facility and she worked with Pharmacy Consultant #2. She stated she was aware that all physician ' s orders for PRN psychotropic medications were required to be time limited in duration. She revealed that PRN psychotropic medication orders with no stop date had been an ongoing issue at the facility. A phone interview was conducted with Pharmacy Consultant #2 on 7/16/20 at 12:00 PM. She stated she was aware that all orders for PRN psychotropic medications were required to be time limited in duration. Pharmacy Consultant #2 reiterated Pharmacy Consultant #1 ' s interview that PRN psychotropic medication orders with no stop date had been on an ongoing issue at the facility going back as far as February 2020. She explained that every month she and/or Pharmacy Consultant #1 completed an Executive Summary of Consultant Pharmacist ' s Medication Regimen Review that provided the facility a summary of the medication regimen review results for that month. She further explained that this summary was not part of the medical record for each resident. Pharmacy Consultant #2 requested that the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review for June 2020 be reviewed for additional information. As requested by Pharmacy Consultant #2 during her phone interview, the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review dated 6/20/20 for the time period of 6/1/20 through 6/20/20, read, in part: All PRNs [psychoactive medications] require stop dates per [Centers for Medicare and Medicaid Services]. May wish to make all prescribers and nursing staff aware of this regulation. An interview was conducted with the Medical Director on 7/16/20 at 10:55 AM. The Medical Director stated he was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. He additionally stated that he was aware this regulation applied to hospice residents. He indicated that it was an error if a stop date was not included in the physician ' s order for a PRN psychotropic medication. An interview was conducted with the Director of Nursing (DON) on 7/16/20 at 11:30 AM. The DON stated she was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. She additionally stated that she was aware this regulation applied to hospice residents. The DON was unable to explain why Resident #15 had an active order for PRN Ativan (initiated on 6/1/20) that had no stop date. She indicated that it was possible that the hospice staff audited the comfort packages for their facility residents on 6/1/20 and reinitiated physician ' s orders for PRN Ativan with no stop date and that this had not yet been not identified and corrected. 3. Resident #60 was most recently admitted to the facility on [DATE] with diagnoses that included heart disease and dementia. A physician ' s order for Resident #60 dated 6/1/20 indicated Ativan (antianxiety medication) 1 milligram (mg) every 8 hours as needed (PRN). This PRN Ativan physician ' s order had no stop date. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #60 ' s cognition was moderately impaired. He was noted with a prognosis of less than 6 months and was on hospice. Resident #60 received no antianxiety medication during the 7-day MDS look back period. A review of the 6/1/20 through 7/15/20 hard copy Medication Administration Records (MARs) for Resident #60 indicated no PRN Ativan had been administered. The July 2020 active physician ' s orders for Resident #60 were reviewed on 7/15/20 and revealed the 6/1/20 PRN Ativan physician ' s order continued to be active. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/16/20 at 8:27 AM. The ADON stated Resident #60 ' s PRN Ativan was prescribed by the hospice physician. She revealed she was aware of the regulation that required all physician ' s orders for PRN psychotropic medications to be time limited in duration, but she was not aware that the regulation applied to hospice residents. An interview was conducted Hospice Nurse #1 on 7/16/20 at 9:50 AM. She stated PRN Ativan was part of the hospice comfort package and it was prescribed without a stop date. She indicated she was not aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN psychotropic medications were required to be time limited in duration. Hospice Nurse #1 revealed that all of their hospice residents at the facility had a physician ' s order for PRN Ativan with no stop date. A telephone interview was conducted with the Hospice Medical Director on 7/16/20 at 9:05 AM. He confirmed that the hospice comfort package normally included a physician ' s order for PRN Ativan with no stop date. He stated he was aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN Ativan were required to be time limited in duration. He reported that normally, if PRN Ativan with no stop date was ordered for a facility resident, he was alerted by a pharmacy recommendation from the facility ' s Pharmacy Consultant and/or by facility nursing staff and a stop date was implemented. He revealed he received no notification related to Resident #60 ' s physician ' s order dated 6/1/20 for PRN Ativan with no stop date. A phone interview was conducted with Pharmacy Consultant #1 on 7/16/20 at 8:54 AM. She indicated she was new to the facility and she worked with Pharmacy Consultant #2. She stated she was aware that all physician ' s orders for PRN psychotropic medications were required to be time limited in duration. She revealed that PRN psychotropic medication orders with no stop date had been an ongoing issue at the facility. A phone interview was conducted with Pharmacy Consultant #2 on 7/16/20 at 12:00 PM. She stated she was aware that all orders for PRN psychotropic medications were required to be time limited in duration. Pharmacy Consultant #2 reiterated Pharmacy Consultant #1 ' s interview that PRN psychotropic medication orders with no stop date had been on an ongoing issue at the facility going back as far as February 2020. She explained that every month she and/or Pharmacy Consultant #1 completed an Executive Summary of Consultant Pharmacist ' s Medication Regimen Review that provided the facility a summary of the medication regimen review results for that month. She further explained that this summary was not part of the medical record for each resident. Pharmacy Consultant #2 requested that the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review for June 2020 be reviewed for additional information. As requested by Pharmacy Consultant #2 during her phone interview, the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review dated 6/20/20 for the time period of 6/1/20 through 6/20/20, read, in part: All PRNs [psychoactive medications] require stop dates per [Centers for Medicare and Medicaid Services]. May wish to make all prescribers and nursing staff aware of this regulation. An interview was conducted with the Medical Director on 7/16/20 at 10:55 AM. The Medical Director stated he was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. He additionally stated that he was aware this regulation applied to hospice residents. He indicated that it was an error if a stop date was not included in the physician ' s order for a PRN psychotropic medication. An interview was conducted with the Director of Nursing (DON) on 7/16/20 at 11:30 AM. The DON stated she was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. She additionally stated that she was aware this regulation applied to hospice residents. The DON was unable to explain why Resident #60 had an active order for PRN Ativan (initiated on 6/1/20) that had no stop date. She indicated that it was possible that the hospice staff audited the comfort packages for their facility residents on 6/1/20 and reinitiated physician ' s orders for PRN Ativan with no stop date and that this had not yet been not identified and corrected. 4. Resident #32 was most recently admitted to the facility on [DATE] with diagnoses that included heart disease and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 ' s cognition was severely impaired. She was noted with a prognosis of less than 6 months and was on hospice. Resident #32 received no antianxiety medication during the 7-day MDS look back period. A physician ' s order for Resident #32 dated 6/1/20 indicated Ativan (antianxiety medication) 1 milligram (mg) every 8 hours as needed (PRN). This PRN Ativan physician ' s order had no stop date. A review of the 6/1/20 through 7/15/20 hard copy Medication Administration Records (MARs) for Resident #32 indicated no PRN Ativan had been administered. The July 2020 active physician ' s orders for Resident #32 were reviewed on 7/15/20 and revealed the 6/1/20 PRN Ativan physician ' s order continued to be active. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/16/20 at 8:27 AM. The ADON stated Resident #32 ' s PRN Ativan was prescribed by the hospice physician. She revealed she was aware of the regulation that required all physician ' s orders for PRN psychotropic medications to be time limited in duration, but she was not aware that the regulation applied to hospice residents. An interview was conducted Hospice Nurse #1 on 7/16/20 at 9:50 AM. She stated PRN Ativan was part of the hospice comfort package and it was prescribed without a stop date. She indicated she was not aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN psychotropic medications were required to be time limited in duration. Hospice Nurse #1 revealed that all of their hospice residents at the facility had a physician ' s order for PRN Ativan with no stop date. A telephone interview was conducted with the Hospice Medical Director on 7/16/20 at 9:05 AM. He confirmed that the hospice comfort package normally included a physician ' s order for PRN Ativan with no stop date. He stated he was aware of the regulation applicable to all facility residents that indicated physician ' s orders for PRN Ativan were required to be time limited in duration. He reported that normally, if PRN Ativan with no stop date was ordered for a facility resident, he was alerted by a pharmacy recommendation from the facility ' s Pharmacy Consultant and/or by facility nursing staff and a stop date was implemented. He revealed he received no notification related to Resident #32 ' s physician ' s order dated 6/1/20 for PRN Ativan with no stop date. A phone interview was conducted with Pharmacy Consultant #1 on 7/16/20 at 8:54 AM. She indicated she was new to the facility and she worked with Pharmacy Consultant #2. She stated she was aware that all physician ' s orders for PRN psychotropic medications were required to be time limited in duration. She revealed that PRN psychotropic medication orders with no stop date had been an ongoing issue at the facility. A phone interview was conducted with Pharmacy Consultant #2 on 7/16/20 at 12:00 PM. She stated she was aware that all orders for PRN psychotropic medications were required to be time limited in duration. Pharmacy Consultant #2 reiterated Pharmacy Consultant #1 ' s interview that PRN psychotropic medication orders with no stop date had been on an ongoing issue at the facility going back as far as February 2020. She explained that every month she and/or Pharmacy Consultant #1 completed an Executive Summary of Consultant Pharmacist ' s Medication Regimen Review that provided the facility a summary of the medication regimen review results for that month. She further explained that this summary was not part of the medical record for each resident. Pharmacy Consultant #2 requested that the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review for June 2020 be reviewed for additional information. As requested by Pharmacy Consultant #2 during her phone interview, the Executive Summary of Consultant Pharmacist ' s Medication Regimen Review dated 6/20/20 for the time period of 6/1/20 through 6/20/20, read, in part: All PRNs [psychoactive medications] require stop dates per [Centers for Medicare and Medicaid Services]. May wish to make all prescribers and nursing staff aware of this regulation. An interview was conducted with the Medical Director on 7/16/20 at 10:55 AM. The Medical Director stated he was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. He additionally stated that he was aware this regulation applied to hospice residents. He indicated that it was an error if a stop date was not included in the physician ' s order for a PRN psychotropic medication. An interview was conducted with the Director of Nursing (DON) on 7/16/20 at 11:30 AM. The DON stated she was aware of the regulation that required all PRN psychotropic medications to be time limited in duration. She additionally stated that she was aware this regulation applied to hospice residents. The DON was unable to explain why Resident #32 had an active order for PRN Ativan (initiated on 6/1/20) that had no stop date. She indicated that it was possible that the hospice staff audited the comfort packages for their facility residents on 6/1/20 and reinitiated physician ' s orders for PRN Ativan with no stop date and that this had not yet been not identified and corrected. Based on facility staff, hospice staff, Consultant Pharmacist, Medical Director (MD) and Hospice Medical Director interviews and record review, the facility failed to ensure physician's orders for as needed (PRN) Ativan were time limited in duration (Residents #40, #32, #60, #15) for 4 of 4 residents reviewed for hospice. The findings included: 1. Resident #40 was admitted on [DATE] with cumulative diagnoses of Cerebral Vascular Accident (CVA), Chronic Obstructive Pulmonary Disease (COPD) and anxiety. Resident #40's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and he was coded for physical behaviors. The MDS indicated he had not received any antianxiety medications. He was also coded for hospice. Resident #40's revised care plan dated 2/20/20 read he was on hospice care due to a terminal illness. Resident #40's March 2020 Physician orders included an order dated 3/11/20 for Ativan (antianxiety) one milligram (mg) by mouth three times a day as needed (hold for sedation). Resident #40's Medication Administration Records (MAR) from March 11, 2020 to July 16, 2020 revealed, the PRN Ativan order remained in effect during this time period. The MAR reflected the resident last received a dose of Ativan on 3/10/20. The Executive Summary of Consultant's Pharmacist's Medication Regimen Review dated 3/24/20 read the facility was still having issues with the Centers of Medicare and Medicaid Services (CMS) regulation regarding as needed (PRN) time limited duration of psychotropics. The Executive Summary of Consultant's Pharmacist's Medication Regimen Review dated 5/16/20 read all PRN psychotropics must have a stop date per CMS regulation. The Executive Summary of Consultant's Pharmacist's Medication Regimen Review dated 6/20/20 read all PRN psychotropics must have a stop date per CMS regulation. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/16/20 at 8:27 AM. She stated she reviewed the Executive Summary of Consultant's Pharmacist's Medication Regimen Review summary monthly. The ADON stated Resident #40's PRN Ativan was prescribed by hospice and she was not aware that PRN Ativan had to be time limited in duration and reassessed by the Physician. A telephone interview was conducted with Consultant Pharmacist #1 on 7/16/20 at 8:54 AM. She stated she was new to the facility and that she had discussed at length the PRN antianxiety medications time limited duration with the facility and documented her recommendations in the Executive Summary of Consultant's Pharmacist's Medication Regimen Review summary. A telephone interview was conducted with the Hospice Medical Director on 7/16/20 at 9:05 AM. He stated he was aware that Ativan had to be time limited in duration then re-evaluated for the continued use. He stated he not received any recommendations regarding Resident #40's PRN Ativan and it was his expectation that any medication irregularities be address by the facility. An interview was conducted the Hospice Nurse #1 on 7/16/20 at 9:50 AM. She stated since the PRN Ativan was part of the hospice comfort package, it was not re-evaluated. She stated she was not aware of the time limited use of PRN Ativan so all the hospice resident's Physician orders were incorrect. An interview was conducted with the MD on 7/16/20 at 10:55 AM. He stated he had not received any recommendations regarding Resident #40's PRN Ativan. The MD stated it was his expectation that the facility follow-up on any pharmacy recommendations regarding any medication irregularities. An interview was conducted with the Director of Nursing (DON) on 7/16/20 at 11:25 AM. She stated it was her expectation the that the facility follow-up on any Executive Summary of Consultant's Pharmacist's Medication Regimen Review summary recommendations regarding the time limited use of PRN psychotropics.