**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and resident interviews, the facility failed to provide comfortable room temperatures for one (Resident #16) of three residents reviewed for comfortable room temperatures. Findings included: Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #16 was coded as cognitively intact. An interview was conducted with Resident #16 on 2/13/2025 at 12:56 PM. Resident #16 stated the facility had been without heat for the rooms in the front of the building for three weeks. Resident #16 explained a big heater was placed in the hallway and space heaters in each of the residents' rooms. Resident #16 further explained that when everybody turned on their space heaters to keep warm, the circuit breaker would trip, and a staff member had to go into the Director of Nursing's office and reset the circuit breaker. Resident #16 stated that at night the staff did not have access to the Director of Nursing's office and was often unable to reset the circuit breaker. Resident #16 stated he did not want his door open at night due to the noise from the big heater in the hallway and the television area close to his room. Resident #16 stated it was so cold at night that he had to wear a thick hoodie and multiple blankets, and even then, he could not get warm enough. The facility Administrator was interviewed on 2/13/2025 at 1:35 PM. The Administrator explained a part had to be manufactured to fix the outside heating and air conditioning unit. The Administrator explained the facility had put an industrial heater in the hallway and individual space heaters in each resident's room. The Administrator stated that if the residents in the affected rooms kept their doors open, then the rooms would stay heated. The Administrator added that if the circuit breaker tripped, a staff member would reset the breaker located in the Director of Nursing's office. The Administrator was unaware of staff members not resetting the breaker at night. Interviews and observations were made in Resident #16's room on 2/14/2025 at 7:05 AM. Resident #16 stated his room was too cold this morning and he complained when he had to do self-catheterization, he needed to have the door closed for privacy. Resident #16 demonstrated how the space heater in his room, the adjustable bed, and the television were not working because the circuit breaker was tripped. Resident #16 stated he just wanted to get in bed and wrap up due to the cold temperature in the room, but nothing worked. An interview and observation were conducted with the Maintenance Director on 2/14/2025 at 7:20 AM in Resident #16's room. The Maintenance Director stated that it was his second week working at the facility. He explained the heating and air conditioning unit outside was broken and a part needed to be made. The Maintenance Director was asked if he had a way of measuring the room temperature. The Maintenance Director stated he had a digital thermometer to measure the air temperature. The Maintenance Director removed the sheath from a digital thermometer and held up the thermometer up in the air in the middle of the room with the door open. The room temperature was 73 degrees Fahrenheit in the room on the digital thermometer. The Maintenance Director acknowledged the room temperature did not feel like 73 degrees Fahrenheit. The Maintenance Director indicated the hallway heater would heat Resident #16's room if he left the door open. An additional interview was conducted with the facility Maintenance Director on 2/14/2025 at 11:55 AM. The facility Maintenance Director stated he was permitted to purchase a laser thermometer to measure the air temperatures. The Maintenance Director stated the temperature in Resident #16's room was 71.8 degrees Fahrenheit with the door open. The Maintenance Director did not know what the room temperatures were at night. The Administrator was interviewed on 2/14/2025 at 10:45 AM. The Administrator confirmed the current Maintenance Director had started on 2/3/2025 and would not provide the contact information for the previous Maintenance Director. The Director of Plant Operations was interviewed on 2/18/2025 at 8:38 AM and the following information was provided. On 1/19/2025 the facility reported having issues with the heat exchanger on the outside heating and air conditioning unit. On 1/20/2025 contractors unsuccessfully attempted to fix the heat exchanger. A new part will be manufactured at the factory within 30 days. On 1/21/2025 the six rooms that contained residents received space heaters and a large electric heater was put in the hallway. The facility provided documentation on a typed spreadsheet that listed room temperatures, dates, and hallway temperatures. The spreadsheet was entitled, Temp Log for Rooms 101 to 106. The log listed a daily room temperature and a hall temperature from 1/27/2025 to 2/19/2025. The lowest room temperature listed on the spreadsheet was 71 degrees Fahrenheit and the lowest hallway temperature listed was 72 degrees Fahrenheit. There was no documentation of the time of day, the exact location of the temperature, or who took the temperatures on the spreadsheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to prevent physical and verbal abuse from staff for one (Resident #4) of three residents reviewed for physical and verbal abuse. Findings included: On 2/13/2025 at 10:55 AM the Director of Nursing (DON) provided a list of alert and oriented residents which included Resident #10 and did not include Resident #4 or Resident #3. Resident #4 was admitted to the facility on [DATE] with diagnoses of C5-C7 vertebrae incomplete quadriplegia, adjustment disorder with mixed disturbance of emotions and conduct, post-traumatic stress disorder, scoliosis, and major depressive disorder. (C5-C7 incomplete quadriplegia refers to a spinal cord injury at the C5 to C7 vertebrae in the neck, resulting in paralysis affecting all four limbs due to damage to the nerves controlling movement in that area.) Documentation on a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact with verbal behaviors one to three days of the assessment period. Documentation on the care plan for Resident #4, dated as last reviewed on 12/16/2024 revealed a focus area for [Resident #4] has verbally aggressive-verbal threats, cursing at staff and other residents relative to mental/emotional illness, poor impulse control and [Resident #4] has potential to be physically aggressive relative to anger, post-traumatic stress disorder diagnosis. Both focus areas had the intervention, When the resident becomes agitated: intervene before agitation escalates; guide away from the source of distress; engage calmly in conversation; if the response is aggressive, staff to walk away calmly, and approach later. Resident #4 was interviewed on 2/13/2025 at 11:05 AM and she revealed the following information. Resident #4 revealed on 1/3/2025 she argued with Resident #3 earlier in the day. Around lunchtime, Resident #4, Resident #3, and Resident #10 were in the hallway getting ready to go out to smoke. Resident #3 was cussing at Resident #4 and Resident #4 was cussing at Resident #3. The Director of Nursing (DON) and Nurse Aide (NA) #1 took all three of the residents, Resident #3, Resident #4, and Resident #10, outside to go to smoke cigarettes. Resident #3 continued to cuss and threaten Resident #4, and Resident #4 was cussing back at him as they sat smoking. The DON told Resident #4 to be quiet. Resident #4 explained she felt like the DON was only telling her to be quiet while Resident #3 was allowed to sit and swear at her. Resident #4 revealed she told the DON she was not going to tell her to shut her mouth. Resident #4 revealed she did call the DON a [female dog] and '[racial slur], and the DON began to argue with her. Resident #4 stated she moved her wheelchair forward toward the DON and the DON shoved her and hit her. Resident #4 revealed the DON began to shout at her and Resident #4 screamed out that the DON hit her. NA #1 just stood there. The DON then fled into the building. Resident #4 called the police, and they came to the facility. Resident #4 indicated the police told her she would have to go to the police station to make a report. Resident #4 also called local Adult Protective Services and the state long-term care complaint line. Resident #4 said the DON was suspended but then returned to the facility in a few days as if nothing happened. A photograph, dated 1/3/2025, was observed on the telephone of Resident #4 depicting a visible bruise on the left side of her face near her chin. Resident #4 explained she showed the picture to the Administrator and to the facility Social Worker. An additional photograph was observed on the phone of Resident #4, of a note from Resident #10 dated 1/3/2025 explaining Resident #10 was a witness to the altercation. On the evening of 1/29/2025 Resident #4's electric wheelchair was taken from her with the pretense she had hit someone with the wheelchair, but she was not told who. Resident #4 felt the removal of her wheelchair was in retaliation for her calling adult protective services, who opened an investigation. There was no documentation in the medical record of Resident #4 using her wheelchair to run into staff or residents in January 2025. On 2/13/2025 at 12:45 PM, the DON requested that Resident #10 be removed from the list of residents deemed alert and oriented. Resident #10 was admitted to the facility on [DATE] and has diagnoses of adjustment disorder with mixed disturbance of emotions and conduct as well as anxiety disorder. Documentation on a care plan dated as last reviewed on 1/22/2025 for Resident #10 revealed she had a focus area for a behavior problem related to anxiety as well as episodes of fabrication. Documentation on a recent Brief Interview for Mental Status dated 2/5/2025, Resident #10 scored 15 out of 15, indicating she was cognitively intact. An interview was conducted with the facility Psychiatric Mental Health Nurse Practitioner (PMHNP) #1 on 2/19/2025 at 11:42 AM. PMHNP #1 indicated he saw Resident #10 weekly and provided the following insight into the reliability of the information provided by Resident #10. PMHNP #1 confirmed Resident #10 had anxiety and very negative thoughts. PMHNP #1 thought Resident #10 complained about the facility services and was unrealistic about her complaints. In addition, PMHNP #1 thought Resident #10 could be manipulative, telling people what they wanted to hear. Resident #10 was interviewed on 2/17/2025 at 5:55 PM. Resident #10 related the following events as occurring on 1/3/2025. Resident #10, Resident #3, and Resident #4 were in the hallway. Resident #3 and Resident #4 were arguing. Resident #10 stated, It was a big thing. Resident #10 indicated a nurse aide (NA #1), and a nurse (DON) took the three residents, Resident #10, Resident #3, and Resident #4, outside to smoke cigarettes. Resident #10 stated she sat in her usual spot in the smoking area with a full view of the building door and the smoking area. Resident #3 and Resident #4 continued to argue then Resident #4 and the nurse (DON) started to argue. Resident #4 did not run her wheelchair into the nurse (DON). The nurse (DON) acted like she wanted to fight Resident #4 and pushed Resident #4. Resident #10 confirmed the nurse (DON) did not slap or hit Resident #4 but pushed her. After that, Resident #4 was very upset. The nurse (DON) acted like she wanted to beat Resident #4 up. The nurse aide (NA #1) stopped the nurse (DON) and pulled her away. The nurse aide (NA #1) laughed like the whole thing was funny. The nurse aide (NA #1) tried to break them up and the nurse went back into the building. Resident #10 and Resident #4 also went back into the building. Resident #10 stated that nobody had asked her what had happened except for the police. Resident #10 added that other residents had asked her what had happened, but she did not tell them because she did not gossip. Resident #10 revealed the police told her the nurse (DON) had the right to defend herself. The nurse aide (NA #1) saw everything that happened that day. NA #1 was interviewed on 2/13/2025 at 1:03 PM and provided the following information. NA #1 stated Resident #3 and Resident #4 were fussing in the hallway. The DON was trying to calm Resident #4 down. The DON and NA #1 took Resident #4, Resident #10, and Resident #3 outside through the side door to smoke in the smoking area. Resident #4 put her wheelchair in drive and hit the DON with her wheelchair. The DON turned around and went back into the building. The DON did not do anything. The DON did nothing wrong. The DON was interviewed on 2/14/2025 at 7:25 AM. The DON described the following events and made the following statements. Resident #3 and Resident #4 were always getting into it, cursing and hollering. The DON came out of her office and told Resident #3 and Resident #4 to keep it down. The DON described the scene as chaos with visitors and a new resident in the hallway working with therapy. The DON stated she knew it had to stop. The DON stated she was trying to move Resident #3 away from Resident #4, but the two residents would not stop. The DON stated she took the residents out the back door with the help of NA #1 to the smoking area. Resident #4 would not stop swearing and kept on talking. The DON stated she told Resident #4 to be quiet. Resident #4 responded to the DON telling her, You can't tell me what to do. The DON turned to walk away from the table area. Resident #4 brought her wheelchair close to the DON and was getting mad. Resident #4 called the DON a Black [racial slur] [female dog]. The DON stated she told Resident #4 to be quiet and the DON walked to the door of the building. The DON was observed to demonstrate how as she turned, Resident #4 hit her left leg. The DON stated she almost fell, and she braced herself on the wheelchair of Resident #4 to catch herself. Resident #4 then screamed, You hit me. You hit me. The DON stated she then knew she had to go. The DON stated Resident #4 threatened her. The DON restated that she almost fell. The DON explained if her hand touched Resident #4 it was because she was trying to catch herself from falling and defend herself from Resident #4. The DON stated her arms were flaring and then corrected herself saying her arms were flying to prevent Resident #4 from hitting her. The DON explained she worked too many years to have a resident say she hit them. The DON stated, Do you think I would hit a resident? I know not to hit a resident. That would be my job. I would be fired if I hit a resident. Resident #4 is always up here talking loudly. I'm not going to ignore it. The DON stated she never said anything mean to Resident #4 and just told her to leave her alone. The DON stated she then went back into the building and sat down in her office because Resident #4 had tried to hit her with the wheelchair and then corrected herself and stated, She hit me with the wheelchair. The DON confirmed she did make contact with Resident #4 to defend herself but did not hit her. The DON stated the Administrator and the police spoke with her that day. Confidential Source #1 was interviewed on 2/13/2025 at 4:30 PM. Confidential Source #1 revealed the DON came to him/her directly after she returned to the building on 1/3/2025 and stated, I know they will fire me. I hit her twice. I just hit her. I was gonna pull her out of that chair. She called me a [racial slur]. Confidential Source #1 stated the DON confessed to hitting Resident #4 twice. Confidential Source #1 stated that if he/she came forward, he/she was certain he/she would lose his/her job because he/she thought the facility was trying to cover up what happened. Confidential Source #1 was interviewed again on 2/14/2025 at 11:56 AM. Confidential Source #1 reiterated the DON came back into the building from the side door directly after the incident outside on 1/3/2025. Confidential Source #1 confirmed the DON confessed she had hit Resident #4 because Resident #4 was calling the DON a racially charged name. Confidential Source #1 indicated he/she was told the DON had a right to defend herself. Confidential Source #1 revealed Resident #4 had aggression and had run into people with her wheelchair previously on several occasions, even having her wheelchair taken away from her by the facility previously. Confidential Source #2 was interviewed on 2/13/2025 at 5:20 PM and provided the following description of what was witnessed on 1/3/2025. Confidential Source #2 was outside in a side trailer working with the door open. Confidential Source #2 heard a commotion with people shouting and cursing in the smoking area. Confidential Source #2 heard a hit and turned around to see the DON shouting at Resident #4 saying Come on, Come on right up in Resident #4's face. Resident #4 was screaming, She hit me. She hit me. Confidential Source #2 stated, [DON] just lost it on [Resident #4]. NA #1 was standing there telling the DON to just Stop. Stop. The DON then went into the side door of the building. Confidential Source #2 stated the DON was suspended but returned to the facility in about 4 or 5 days. Confidential Source #2 confirmed he/she did not witness the DON hit Resident #4. Confidential Source #2 was told the DON had the right to protect herself, but it would set a bad precedent if it was known the DON hit Resident #4. Confidential Source #2 said there should be a video of the incident taken by the facility camera. Confidential Source #2 did not want his/her identity known out of fear of retaliation. Confidential Source #3 was interviewed on 2/14/2025 at 1:45 PM and again at 4:09 PM. The following information was provided. Confidential Source #3 witnessed Resident #4 using her power wheelchair to run into Resident #3's wheelchair on the morning of 1/3/2025. Confidential Source #3 indicated the altercation between Resident #3 and Resident #4 was reported to the Administrator and the Social Worker immediately after it happened. Later in the day, on 1/3/2025, Confidential Source #3 went to the nursing office in the back of the building for a risk management meeting that was to start at noon. As Confidential Source #3 entered the door, the DON confessed, I hit [Resident #4] two times. Confidential Source #3 immediately told the DON she must go to the Administrator to inform him what happened. Confidential Source #3 then walked with the DON directly to the Administrator. Confidential Source #3 then walked back to attend the risk management meeting in the nursing office and did not discuss what he/she heard with anyone else. Confidential Source #3 did not want the interview information used knowing he/she would be fired for revealing information. Confidential Source #3 did not know if anyone else heard the statement made by the DON in the office doorway. The Unit Manager (Nurse #4) was interviewed on 2/14/2025 at 3:15 PM and she provided the following information. Nurse #4 stated she was at the nursing station in the back hall of the building after the risk management meeting on 1/3/2025 when she saw the DON coming down the hall and she was distressed and very emotional. The DON told Nurse #4 she was going home. Nurse #4 stated she pulled the DON into the office next to the nursing station to calm her down. Nurse #4 explained the DON was shaken up and shocked because Resident #4 had run her wheelchair into her. NA #1 was reinterviewed on 2/14/2025 at 3:38 PM. NA #1 explained with the following information and additional details. Resident #4 was in the hallway swearing and cussing at Resident #3. The DON decided the residents should be taken out to smoke. The DON and NA #1 took Resident #3, Resident #4, and Resident #10 one at a time out the door to smoke. Outside Resident #4 tried to run the DON over with her wheelchair. The DON tried to run away. The DON was hit in the foot with the wheelchair of Resident #4. NA #1 explained it happened so fast he was not able to verify if the DON was swinging her arms. NA #1 was adamant that the DON never touched Resident #4 nor made contact with Resident #4 other than being hit by the wheelchair of Resident #4. Resident #4 was cussing at the DON but no direct contact was made. NA #1 reiterated it happened too fast for him to recall any more information. Documentation on a police report dated 1/3/2025 at 12:04 PM revealed the incident involved a simple assault with a hit with fist. The case was deemed closed, by other means. The narrative on the police report was redacted. There were no witnesses listed. The victim was listed as Resident #4 and others involved were listed as the DON. Offender number one was listed as the DON and offender number two was Resident #4. Both the DON and Resident #4 were listed as suspects. Documentation in the police report revealed there were no injuries. An interview was conducted with the Administrator on 2/14/2025 at 10:45 AM. The Administrator stated he completed his five-day investigation and determined Resident #4 ran her wheelchair into the DON causing her to lose her balance. The Administrator revealed the facility investigation concluded the abuse of Resident #4 was unsubstantiated. The Administrator revealed the full narrative of what happened, and the investigation results were submitted to the state. He stated that, as a company directive, there were no cameras in the building and no camera footage. An interview was conducted with the Administrator and a Nurse Consultant on 2/18/2025 at 3:22 PM. The Nurse Consultant and the Administrator confirmed that the DON and NA #1 were interviewed as a part of the investigation. The Administrator stated there was nobody else to interview because nobody else was outside at the time of the altercation on 1/3/2025 to interview except for the three residents. The Administrator stated Resident #3 told him Resident #4 hit the DON with the wheelchair and Resident #10 did not see anything. The Administrator added that Resident #10 was not an interviewable resident. The Administrator stated on 1/3/2025 he heard hollering, so he walked outside toward the smoking area. The Administrator confirmed while outside he encountered NA #1 and Resident #4. Resident #4 told the Administrator that the DON hit her. The Administrator stated the police arrived 15 to 20 minutes later. The Administrator revealed he went to the DON's office and that was where he found her. The Administrator stated he did not see the picture of the bruise on the face of Resident #4. The Administrator confirmed all the investigation information was provided.

Based on record review and staff interview, the facility failed to implement policies and procedures that promote a culture of safety and open communication in the workplace and prohibit potential retaliation for staff who report abuse allegations. Confidential Source #1, Confidential Source #2, and Confidential Source #3 all stated they did not come forward with information related to an abuse allegation due to a fear of retaliation. This was for 1 (Resident #4) of 3 residents reviewed for investigation of abuse allegations. Findings Included: Documentation on the facility's abuse, neglect, and exploitation policy, dated as last reviewed on 4/1/2024 revealed, The Company will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed. Documentation in an initial state agency report submitted to the state agency on 1/3/2025 at 3:20 PM revealed that Resident #4 stated she was struck by a nurse, who was suspended. The nurse in the initial investigation report was identified as the Director of Nursing (DON). Documentation on an investigation report submitted to the state agency on 1/10/2025 at 10:55 AM in part revealed in the summary of the facility investigation, Resident (#4) followed her (DON) to the door and struck nurse (DON) on her leg with her (Resident #4's) electric scooter and started to swing her arms and legs at nurse (DON). Nurse (DON) put up her arms up to deflect the attempts by Resident (#4) to strike nurse. Nurse went back into center. Confidential Source #1 was interviewed on 2/13/2025 at 4:30 PM. Confidential Source #1 revealed the DON came to him/her directly after she returned to the building on 1/3/2025. Confidential Source #1 stated the DON confessed to hitting Resident #4 twice. Confidential Source #1 stated that if he/she came forward, he/she was certain he/she would lose his/her job because he/she thought the facility was trying to cover up what happened. Confidential Source #1 stated he/she was conflicted about providing the information because he/she would be protecting vulnerable residents, but he/she would lose his/her job. Confidential Source #2 was interviewed on 2/13/2025 at 5:20 PM and described what was witnessed on 1/3/2025. Confidential Source #2 was outside in a side trailer working with the door open and witnessed an altercation between Resident #4 and the DON. Confidential Source #2 said there should be a video of the incident taken by the facility camera confirming what he/she witnessed. Confidential Source #2 did not want his/her identity known out of fear of retaliation and agreed only to provide information if his/her identity would not be known to the facility's administration. Confidential Source #3 was interviewed on 2/14/2025 at 1:45 PM and again at 4:09 PM. Confidential Source #3 described a confession overheard from the DON admitting to hitting Resident #4 on 1/3/2025. Confidential Source #3 did not want the interview information used knowing he/she would be fired for revealing information. Confidential Source #3 was certain facility administration would find a reason to fire him/her if it were known he/she came forward to support the claim of Resident #4 with what he/she heard from the DON. An interview was conducted with the Administrator and Nurse Consultant on 2/18/2025 at 3:22 PM. The Administrator was adamant the only people in the smoking area on 1/3/2025 who witnessed the altercation between Resident #4 and the DON were the three residents, Nurse Aide (NA) #1, and the DON. The Administrator stated he completed the investigation, and the Nurse Consultant stated she interviewed the DON and NA #1. The Administrator revealed that every building has staff who are afraid to talk despite being told they do not have to fear for their jobs if they come forward, but he did not know how to make the staff believe it. The Nurse Consultant confirmed the facility would not fire someone who came forward with information. The Administrator and the Nurse Consultant indicated they did not know how to prove or disprove an allegation of abuse if the confidential sources were not identified.

Based on record review, resident interview, and staff interviews, the facility failed to complete a thorough investigation following an abuse allegation by not assessing the alleged victim for injury for one (Resident #4) of three resident abuse investigations reviewed. Findings included: Documentation on the facility's abuse, neglect, and exploitation policy, dated as last reviewed on 4/1/2024, revealed under the heading of protection of the resident examining the alleged victim for any sign of injury, including a physical examination or psychological assessment if needed. Documentation in an initial state agency report submitted to the state agency on 1/3/2025 at 3:20 PM revealed that Resident #4 stated she was struck by a nurse, who was suspended. The nurse in the initial investigation report was identified as the Director of Nursing (DON). Documentation on an investigation report submitted to the state agency on 1/10/2025 at 10:55 AM in part revealed in the summary of the facility investigation, Resident (#4) followed her (DON) to the door and struck nurse (DON) on her leg with her (Resident #4's) electric scooter and started to swing her arms and legs at nurse (DON). Nurse (DON) put up her arms up to deflect the attempts by Resident (#4) to strike nurse. Nurse went back into center. There were no resident skin assessments and no skin assessment of Resident #4 directly after the altercation on 1/3/2025 in the facility file. Resident #4 was interviewed on 2/13/2025 at 11:05 AM and she confirmed that neither a skin assessment nor an assessment of her injuries was completed after the incident on 1/3/2025. A photograph, dated 1/3/2025, was observed on the telephone of Resident #4 depicting a bruise on the left side of her face near her chin. Resident #4 explained that she had shown the picture to the Administrator and the Social Worker. There was no documentation or statements from the Administrator or the Social Worker in the facility file regarding a photo taken by Resident #4 depicting a bruise on the left side of her face near her chin. An interview was conducted with the Administrator on 2/14/2025 at 10:45 AM. The Administrator stated he completed his five-day investigation and determined Resident #4 ran her wheelchair into the DON causing her to lose her balance. The Administrator revealed the facility investigation concluded the abuse of Resident #4 was unsubstantiated. The Administrator revealed the full narrative of what happened, and the investigation results were submitted to the state agency. An interview was conducted with the Administrator and a Nurse Consultant on 2/18/2025 at 3:22 PM. The Administrator confirmed all the investigation information was provided. The Administrator and the Nurse Consultant would not confirm or deny a skin assessment of Resident #4 was completed on 1/3/2025. The Administrator stated he did not see the picture of the bruise Resident #4's face.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and pharmacy interviews, the facility failed to have an effective system in place for putting new admission orders into the electronic record to ensure pharmacy delivery, resulting in four missed doses of antibiotics for one (Resident #7) of two residents reviewed for pharmacy services. Findings included: Resident #7 was admitted to the facility on [DATE] from the hospital and discharged back to the hospital on 1/28/2025. Resident #7 had a diagnosis of osteomyelitis. Documentation on a discharge summary from the hospital dated 1/21/2024 revealed Resident #7 was started on intravenous Vancomycin and Cefepime for osteomyelitis of the left elbow planned for a six-week (1/7/25-2/18/25) course via peripherally inserted central catheter (PICC line). (A PICC line is a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein above the heart.) Vancomycin and Cefepime are antibiotics used to treat infection. The current discharge medication list for Resident #7 included: 1 gram (g)/250 milliliters (ml) IVPB (intravenous piggyback) of Vancomycin in 0.9% sodium chloride to be injected into the vein daily for 31 days and 2 g/110 ml IVPB Cefepime in 0.9% sodium chloride to be injected into the vein every 12 hours for 31 days. Documentation in the nursing progress notes written by Nurse #7 for Resident #7 revealed he was admitted to the facility on [DATE] at 3:02 PM. Documentation on a physician order dated 1/21/2025 written by Nurse #4 revealed an order was entered into the electronic medical record of Resident #7 for 1 g/250 ml Vancomycin in 0.9% sodium chloride to be injected into the vein. The order type was selected as Other Orders (MAR). There was no evidence that a physician's order for Cefepime was entered into the electronic medical record for Resident #7 on 1/21/2025. Documentation on the Medication Administration Record (MAR) revealed Resident #7 did not receive an IV Cefepime dose on 1/21/2025 at 5:00 PM or 1/22/2025 at 5:00 AM. Documentation on the MAR revealed Resident #7 did not receive an IV Vancomycin dose on 1/22/2025 at 6:30 AM. Documentation in the physician orders revealed an order was initiated on 1/21/2025 at 3:00 PM for 5 ml Heparin 10 units/ml flush solution and 10 ml normal saline flush solution to be used intravenously every shift to maintain the PICC line. The order type was selected as, AHR Medication Orders. AHR stands for admission, transfers, and discharge report. Documentation on the MAR revealed Resident #7 was administered the Heparin flush on 1/21/2025 on the evening shift (3:00 PM to 11:00 PM) and the night shift (11:00 PM to 7:00 AM shift) by Nurse #5. Nurse #5 was interviewed on 2/19/2025 at 3:40 PM. Nurse #5 confirmed she was assigned to care for Resident #7 for the evening shift on 1/21/2025 and the night shift ending at 7:00 AM on 1/22/2025. Nurse #5 confirmed she did administer the Heparin and normal saline flush for the PICC line for Resident #5 as ordered on the 1/21/2025 evening shift and the night shift. Nurse #5 stated she did not have the antibiotics (Vancomycin or Cefepime) from the pharmacy to give Resident #5 on 1/21/2025 or 1/22/2025. Documentation in the nursing progress notes for Resident #7 dated 1/22/2025 at 8:28 AM written by Nurse #7 revealed, Notified NP (Nurse Practitioner) from [Medical Group name] that both antibiotic prescriptions [were discontinued] because it initially entered under other instead of pharmacy, therefore pharmacy did not receive [prescription]. Called pharmacy, writer advised to re-enter medications under pharmacy. Unable to enter medications, attempted to provide verbal order. Sent to voice mail. NP aware. Advised that MD (Medical Doctor) will be in office this shift and see if she can enter order and verify that verbal order was taken. Nurse #7 was interviewed on 1/18/2025 at 12:33 PM. Nurse #7 indicated when Resident #7 was admitted on [DATE] and Nurse #4 assisted with the admission orders. Nurse #7 revealed on the morning of 1/22/2025 she realized the antibiotics required for Resident #7 did not come in from the pharmacy. Nurse #7 stated the orders for the antibiotics were put in as the order type of other and those orders had to be discontinued. Nurse #7 further explained that if the order type selected had been AHR Medication Orders, the medication orders would have been sent directly from the electronic health record to the pharmacy. Nurse #7 explained she was initially unable to change the antibiotic orders, so she was on the phone with the IV (intravenous) department at the pharmacy for 20 minutes as they walked her through how to enter the orders for the IV antibiotics into the electronic medical record so the pharmacy would receive them. Nurse #7 indicated the pharmacy delivered medications to the facility between 12:00 AM and 3:00 AM so, Resident #7 was not able to receive the antibiotics until 1/23/2025. Nurse #7 did not know and could not remember if the IV antibiotics ordered for Resident #7 were in the automated medication dispensing system. Nurse #7 explained she was orienting a new nurse on 1/22/2025 on the 7:00 AM to 3:00 PM shift and she did not have time to look in the automated dispensing system or the backup pharmacy. Nurse #4 was interviewed on 2/18/2025 at 9:17 AM. Nurse #4 confirmed she put the initial orders for Resident #7 into the electronic medical record for transmission to the pharmacy. Nurse #4 stated that as the Unit Manager she helped the nursing staff with new admissions. Nurse #4 stated it looked like the orders were changed in the electronic medical record and the facility was awaiting the arrival of the antibiotics from the pharmacy. Nurse #4 explained that if an order type was entered as other then the order does not go to the pharmacy to be filled, and the nurses do not have to check off the order as being completed on the MAR. Nurse #4 stated the facility not receiving the antibiotics for Resident #7 was either a pharmacy issue or the physician changed the orders. Nurse #4 did not have an explanation why she entered the order in as other for the antibiotic Vancomycin. Nurse #4 also did not know why the order for Cefepime was not entered on 1/21/2025 for Resident #7, but she would look into it. Documentation on the Medication Administration Record (MAR) revealed Resident #7 did not receive an IV Cefepime dose on 1/22/2025 at 5:00 PM. The Medication Administration note dated 1/22/2025 at 9:02 PM by Nurse #6 stated, Rescheduled awaiting pharmacy. Nurse #6 was interviewed on 2/19/2025 at 3:53 PM. Nurse #6 confirmed he was assigned to care for Resident #7 for the IV administration of Cefepime on 1/22/2025 at 5:00 PM. Nurse #6 stated that if the Cefepime was not documented as administered then he did not have the IV antibiotic Cefepime to administer to Resident #7. Pharmacist #1 from the facility pharmacy was interviewed on 2/18/2025 at 1:04 PM. Pharmacist #1 stated the pharmacy received Resident #7's prescriptions for Vancomycin and Cefepime on 1/22/2025 with a start date of 1/23/2025. Pharmacist #1 stated the IV antibiotics Vancomycin and Cefepime for Resident #7 were delivered to the facility at 1:11 AM on 1/23/2025. Pharmacist #1 stated the only orders received on 1/21/2025 for intravenous administration for Resident #7 were for the Heparin and normal saline flush. The Director of Nursing (DON) was interviewed on 1/18/2025 at 2:17 PM. The DON stated she knew that the facility would not have the Vancomycin and Cefepime to administer to Resident #7, so she called the hospital requesting they send the IV Vancomycin and Cefepime with Resident #7. The DON revealed that Resident #7 was already en route when she called. The DON indicated that if the antibiotics were not available for Resident #7 upon admission, then the facility would have added additional doses to the end of the six-week antibiotic administration timeline so he would have received all the ordered doses. The DON did not think the antibiotics Vancomycin and Cefepime were actually in the automated medication dispensing system to be administered to Resident #7 upon his admission. The Medical Doctor (MD #1) for Resident #7 was interviewed on 2/19/2025 at 1:35 PM. MD #1 stated she did not think it was a realistic expectation for the facility to have been able to provide the scheduled Cefepime dose on 1/21/2025 scheduled at 5:00 PM to Resident #7 because he had just been admitted to the facility. MD #1 conceded Resident #7 should have gotten the antibiotics he needed when he was admitted .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Pharmacist and Medical Doctor interviews, the facility failed to administer four doses of antibiotics and one dose of insulin upon admission for one (Resident #7) of two residents reviewed for significant medication errors. Findings included: Resident #7 was admitted to the facility on [DATE] from the hospital. Resident #7 had diagnoses of diabetes and osteomyelitis. Documentation on a discharge summary from the hospital dated 1/21/2024 revealed Resident #7 was started on intravenous Vancomycin and Cefepime for osteomyelitis of the left elbow planned for a six-week (1/7/25-2/18/25) course via peripherally inserted central catheter (PICC line). (A PICC line is a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein above the heart.) Vancomycin and Cefepime are antibiotics used to treat infection. The current discharge medication list for Resident #7 included: 1 gram (g)/250 milliliters (ml) IVPB (intravenous piggyback) of Vancomycin in 0.9% sodium chloride to be injected into the vein daily for 31 days; 2 g/110 ml IVPB Cefepime in 0.9% sodium chloride to be injected into the vein every 12 hours for 31 days; and; and 10 units of Glargine insulin injected subcutaneously once daily. Insulin is used to treat diabetes mellitus. Documentation in the nursing progress notes written by Nurse #7 for Resident #7 revealed he was admitted to the facility on [DATE] at 3:02 PM. a. Documentation on a physician order dated 1/21/2025 written by Nurse #4 revealed an order was entered into the electronic medical record of Resident #7 for 1 g/250 ml Vancomycin in 0.9% sodium chloride to be injected into the vein. There was no evidence that a physician's order for Cefepime was entered into the electronic medical record for Resident #7 on 1/21/2025. Nurse #4 was interviewed on 2/18/2025 at 9:17 AM. Nurse #4 confirmed she put the initial orders for Resident #7 into the electronic medical record for transmission to the pharmacy. Nurse #4 stated that as the Unit Manager she helped the nursing staff with new admissions. Nurse #4 did not have an explanation why she entered the order in as other for the antibiotic Vancomycin. Nurse #4 also did not know why the order for Cefepime was not entered on 1/21/2025 for Resident #7, but she would look into it. Nurse #4 stated she did not know why Resident #7 missed the initial doses of his intravenous antibiotics. Nurse #4 did not know if the facility had intravenous antibiotics in the automated medication dispensing system. Documentation on the Medication Administration Record (MAR) revealed Resident #7 did not receive an IV Cefepime dose on 1/21/2025 at 5:00 PM or 1/22/2025 at 5:00 AM. Documentation on the MAR revealed Resident #7 did not receive an IV Vancomycin dose on 1/22/2025 at 6:30 AM. Documentation in the physician orders revealed an order was initiated on 1/21/2025 at 3:00 PM for 5 ml Heparin 10 units/ml flush solution and 10 ml normal saline flush solution to be used intravenously every shift to maintain the PICC line. Documentation on the MAR revealed Resident #7 was administered the Heparin flush on 1/21/2025 on the evening shift (3:00 PM to 11:00 PM) and the night shift (11:00 PM to 7:00 AM shift) by Nurse #5. Nurse #5 was interviewed on 2/19/2025 at 3:40 PM. Nurse #5 confirmed she was assigned to care for Resident #7 for the evening shift on 1/21/2025 and the night shift ending at 7:00 AM on 1/22/2025. Nurse #5 confirmed she did administer the Heparin and normal saline flush for the PICC line for Resident #5 as ordered on the 1/21/2025 evening shift and the night shift. Nurse #5 stated she did not have the antibiotics from the pharmacy Vancomycin or Cefepime to give Resident #5 on 1/21/2025 or 1/22/2025. Nurse #5 stated she did not know if the antibiotics were in the automated medication dispensing system. Nurse #5 confirmed she did have access to the automated medication dispensing system. Nurse #5 explained she would not have been able to get the IV antibiotics out of the automated medication dispensing system if they were in there, because the facility did not have the required two Licensed Practical Nurses on her shift to open the automated medication dispensing system. Nurse #7 was interviewed on 1/18/2025 at 12:33 PM. Nurse #7 revealed on the morning of 1/22/2025 she realized the antibiotics required for Resident #7 did not come in from the pharmacy. Nurse #7 explained she was initially unable to change the antibiotic orders, so she was on the phone with the IV (intravenous) department at the pharmacy for 20 minutes as they walked her through how to enter the orders for the IV antibiotics into the electronic medical record so the pharmacy would receive them. Nurse #7 indicated the pharmacy delivered medications to the facility between 12:00 AM and 3:00 AM so, Resident #7 was not able to receive the antibiotics until 1/23/2025. Nurse #7 did not know and could not remember if the IV antibiotics ordered for Resident #7 were in the automated medication dispensing system. Nurse #7 explained she was orienting a new nurse on 1/22/2025 on the 7:00 AM to 3:00 PM shift and she did not have time to look in the automated dispensing system or the backup pharmacy. Documentation on the Medication Administration Record (MAR) revealed Resident #7 did not receive an IV Cefepime dose on 1/22/2025 at 5:00 PM. The Medication Administration note dated 1/22/2025 at 9:02 PM by Nurse #6 stated, Rescheduled awaiting pharmacy. Nurse #6 was interviewed on 2/19/2025 at 3:53 PM. Nurse #6 confirmed he was assigned to care for Resident #7 for the IV administration of Cefepime on 1/22/2025 at 5:00 PM. Nurse #6 stated that if the Cefepime was not documented as administered then he did not have the IV antibiotic Cefepime to administer to Resident #7. Nurse #6 revealed the facility did not have IV antibiotics in the automated medication dispensing system. Pharmacist #1 from the facility pharmacy was interviewed on 2/18/2025 at 1:04 PM. Pharmacist #1 stated the pharmacy received Resident #7's prescriptions for Vancomycin and Cefepime on 1/22/2025 with a start date of 1/23/2025. Pharmacist #1 stated the IV antibiotics Vancomycin and Cefepime for Resident #7 were delivered to the facility at 1:11 AM on 1/23/2025. Pharmacist #1 stated the only orders received on 1/21/2025 for intravenous administration for Resident #7 were for the Heparin and normal saline flush. Pharmacist #1 revealed Resident #7 did not need to miss any doses of antibiotics because both the Vancomycin and Cefepime were in the automated medication dispensing system. The Director of Nursing (DON) was interviewed on 1/18/2025 at 2:17 PM. The DON stated she knew that the facility would not have the Vancomycin and Cefepime to administer to Resident #7, so she called the hospital requesting they send the IV Vancomycin and Cefepime with Resident #7. The DON revealed that Resident #7 was already en route when she called. The DON revealed that she did not think the IV Vancomycin and IV Cefepime were in the automated medication dispensing system on 1/21/2025 when Resident #7 was admitted . Pharmacist #1 was interviewed again on 1/18/2025 at 2:59 PM. Pharmacist #1 revealed that according to the pharmacy documentation, from 1/21/2025 through 1/22/2025, the facility had three vials of 1g of Vancomycin and three vials of 2 g of Cefepime in addition to full IV boxes with additional IV Vancomycin and IV Cefepime in the backup supply. Documentation on an inventory snapshot of the automated medication dispensing system dated 1/21/2024 through 1/22/2024 revealed the facility had three vials of 2 g Cefepime solution and three vials of 1g Vancomycin solution listed. The Medical Doctor (MD #1) for Resident #7 was interviewed on 2/19/2025 at 1:35 PM.MD #1 stated that Resident #7 shouldn't have missed the antibiotics and there were ways to mitigate this if the hospital had worked with the facility to provide the initial doses of the needed antibiotic. MD #1 explained Resident #7 would not have any long-term effects from missing the initial doses of Vancomycin and Cefepime when he was first admitted . MD #1 further explained his creatinine level was fine, and the antibiotics stayed in the system for a while. (Vancomycin may cause serious effects to kidneys for which creatinine levels are monitored.) b. Documentation on a physician order dated 1/21/2025 written by Nurse #4 revealed an order was entered into the electronic medical record for Resident #7 for 10 units of Glargine solution 100 units/ml injected subcutaneously one time a day for diabetes. This order was supposed to start on 1/22/2025 at 9:00 AM but was discontinued on 1/21/2025 at 4:15 PM by Nurse #4. There was no documentation on the Medication Administration Record (MAR) of 10 units of Glargine solution 100 units/ml administered to Resident #7 on 1/22/2025 at 9:00 AM. The documentation on the MAR revealed the order was discontinued on 1/21/2025 at 4:15 PM so, there was no space on the MAR requiring documentation of administration at 9:00 AM on 1/22/2025. Nurse #4 was interviewed on 2/18/2025 at 9:17 AM. Nurse #4 stated she thought the insulin order for Resident #7 was changed on 1/21/2025 and did not arrive until the next day as an explanation for why the order for insulin was discontinued on 1/21/2024. Nurse #7 was interviewed on 2/18/2025 at 12:33 PM. Nurse #7 stated on 1/22/2025 she was orienting a new nurse on the medication cart from 7:00 AM to 3:00 PM. Nurse #7 stated she did not recall anything about insulin for Resident #7. An interview was conducted with Pharmacist #1 from the facility pharmacy on 2/18/2025 at 1:04 PM. Pharmacist #1 revealed that the insulin Glargine was available to the facility on 1/22/2025, in a backup fridge kit. Pharmacist #1 revealed that the pharmacy received the order for the insulin Glargine for Resident #7 on 1/21/2025 with the medication filled and delivered to the facility on 1/22/2025 at 3:17 AM. The Director of Nursing was interviewed on 1/18/2025 at 2:17 PM. The Director of Nursing did not know why Resident #7 did not receive the 10 units of Glargine insulin on 1/22/2025 at 9:00 AM or if there was communication with the physician. The Medical Doctor (MD #1) for Resident #7 was interviewed on 2/19/2025 at 1:35 PM. MD #1 stated a possible reason for not administering the Glargine insulin to Resident #7 was because of a therapeutic interchange. (A therapeutic interchange is when a doctor switches a patient's prescription to a different drug that has similar therapeutic effects.) MD #1 stated Resident #7 should have been able to get the medications he was ordered to receive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to provide an environment free of hazards by putting a heater in the hallway and space heaters in 5 (Rooms 102, 103, 104, 105, and 106) of 6 resident rooms reviewed for tripping hazards. Findings included: Observations were made on an initial tour of the facility on 2/13/2025 beginning at 9:04 AM. The facility had an industrial-sized heater in the hallway outside the Admissions Office with a large cord running from the back of the unit. The cord to the industrial sized heater was not taped down but curved out the back of the unit into the admission's office. Residents in wheelchairs were observed to navigate in the hallway around the heater in the hallway. Resident # 9 was observed in his wheelchair attempting to navigate around the industrial heater in the hallway. Resident #9 stated, This is ridiculous with this thing in the hallway. Resident rooms 102, 103, 104, 105, and 106 were observed to have space heaters in the rooms. The cords to the space heaters in the resident rooms were not taped down to the floor. In rooms [ROOM NUMBERS] space heaters were located near the doorway to the room in the pathway to the bathroom, requiring residents in those rooms to roll their wheelchairs around the space heater to get to the bathroom. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #16 was coded as cognitively intact. An interview and observation were conducted with Resident #16 (room [ROOM NUMBER]B) and Resident #15 (room [ROOM NUMBER]A) on 2/13/2025 at 12:56 PM. Resident #16 was in a wheelchair and Resident #15 was ambulatory with a four-wheel rollator rolling walker. Resident #15 was observed to navigate around the space heater near the entrance of the room to exit the room. Resident #16 stated the facility has been without heat for the rooms in the front of the building for three weeks. Resident #16 explained that a big heater was placed in the hallway and that there were space heaters in each resident's room. An interview was conducted with Resident #18 in room [ROOM NUMBER]A on 2/14/2025 at 12:50 PM. Resident #18 stated his space heater at the entrance to the room did not work because it tripped the circuit breaker when it was turned on. Resident #18 stated he did have to navigate around the space heater, but it did not bother him. An observation was made on 2/14/2025 at 7:20 AM with the Maintenance Director in Resident 16's room. The room contained two space heaters with cords spread out on the floor. An additional observation was made on 2/14/2025 at 12:50 PM in room [ROOM NUMBER]. The room contained a space heater near the entrance and another space heater sitting directly next to the resident near the window of the room. The Administrator was interviewed on 2/13/2025 at 1:35 PM. The Administrator revealed the heating system went out and a part needed to be manufactured due to the age of the system. The Administrator added that an industrial heater was immediately put in the hallway and space heaters in the resident rooms to keep them warm. An interview was conducted on 2/17/2025 at 1:32 PM with the Life Safety Engineering Supervisor for the state agency. The Life Safety Engineering Supervisor revealed it was a life safety code violation to have electric heaters and/or space heaters in the hallways, resident rooms, or resident care areas due to fire risk. The Director of Plant Operations was interviewed on 2/18/2025 at 8:38 AM and the following information was provided. On 1/19/2025 the facility reported having issues with the heat exchanger on the outside heating and air conditioning unit. On 1/20/2025 contractors unsuccessfully attempted to fix the heat exchanger. A new part will be manufactured at the factory within 30 days. On 1/21/2025 the six rooms that contained residents received space heaters and a large electric heater was put in the hallway. The space heaters purchased were unapproved for safety in the facility. The facility has had someone on fire watch all night since the space heaters were purchased for the hallway and resident rooms.

Based on observations, staff interviews, and record review, the facility failed to have a medication error rate of less than 5% as evidenced by 4 medication errors out of 25 opportunities resulting in a medication error rate of 16% for 2 (Residents #11 and #12) of 5 residents observed during medication administration observation. Findings included: 1-a. On 2/14/2025 at 7:51 AM, Medication Aide (Med Aide) #1 was observed and interviewed as she prepared and administered four medications to Resident #11. Med Aide #1 stated during the preparation of medications for Resident #11 that she did not have the eye drops in the medication cart she needed for Resident #11. Med Aide #1 did not administer eye drops to Resident #11 during the medication pass observation. A review of Resident #11's medication orders revealed the resident had a current order for Carboxymethylcellulose sodium PF (preservative-free) ophthalmic solution to be instilled as one drop in both eyes one time a day for the treatment of dry eyes (ordered on 1/28/2025). Med Aide #1 was interviewed at 1:35 PM. Med Aide #1 confirmed she did not administer the eye drops Carboxymethylcellulose sodium PF ophthalmic solution to Resident #11 and the eye drops were on order. 1-b. On 2/14/2025 at 8:39 AM, Nurse # 3 was observed as she prepared and administered eight medications to Resident #12. The medications administered included one- 325 milligram (mg) tablet of Sodium Bicarbonate administered by mouth, one-667 mg capsule of Calcium Acetate administered by mouth, and one-25 mg capsule of Hydroxyzine Pamoate administered by mouth. A review of Resident #12's medication orders revealed the resident had a current order for one-650 mg tablet of Sodium Bicarbonate to be administered three times a day by mouth for indigestion (ordered on 1/29/2025). A review of Resident #12's medication orders revealed the resident had a current order for two-667 mg capsules of Calcium Acetate to be administered three times a day by mouth after meals for acute kidney injury (ordered on 2/8/2025). A review of Resident #12's medication orders revealed the resident had a current order for one-50 mg capsule of Hydroxyzine Pamoate to be administered three times a day by mouth for anxiety. An interview was conducted with Nurse #3 on 2/14/2025 at 2:05 PM. During the interview the discrepancies in the medication Sodium Bicarbonate, Calcium Acetate, and Hydroxyzine Pamoate amounts prepared and administered versus the current physician orders were discussed. Nurse #3 reviewed the order for the Sodium Bicarbonate for Resident #12 and stated that the pill bottle contained 350 mg tablets while Resident #12 was ordered to have 650 mg of Sodium Bicarbonate. Nurse #3 stated she should have given Resident #12 two-350 mg tablets of Sodium Bicarbonate to fulfill the order. (Two tablets of 350 mg Sodium Bicarbonate would have been equivalent to 700 mg of the medication.) Nurse #3 reviewed the order for the Calcium Acetate for Resident #12 and acknowledged that she had only given one-667 mg capsule of Calcium Acetate at 8:00 AM medication administration time. She stated she knew that she had given Resident #12 two-667 mg capsules of Calcium Acetate at noon on the same day and revealed she should have looked closer at the order and administered two capsules at 8:00 AM. Nurse #3 reviewed the physician's order for Hydroxyzine Pamoate for Resident #12 and looked at the blister packet of medication in the medication cart. (A blister pack is a form of tamper evident packaging where an individual pushes individually sealed tablets or capsules through the foil to take the medication.) Nurse #3 noted that the blister packet of Hydroxyzine Pamoate for Resident #12 was labeled as containing one-25 mg capsule of the medication in each preformed dome. Nurse #3 stated that she should have caught the discrepancy in the medication order and the labeled blister packet of Hydroxyzine Pamoate and administered two capsules to Resident #12 to fulfill the medication order. The Director of Nursing (DON) was interviewed on 1/18/2025 at 2:17 PM. The DON stated that the nurses were supposed to administer medications to the residents as ordered on the Medication Administration Record and that she would have to make sure the medications available on the medication carts matched the orders.

Based on observations, record review, and staff interviews, the facility failed to follow infection control policies and procedures by 1) donning a gown for enhanced barrier precautions during wound care for one (Nurse #1) of two staff members observed for enhanced barrier precautions, 2) performing hand sanitization in between residents during a medication pass observation for one (Medication Aide #1) of two staff members observed for hand hygiene, and 3) using gloves when handling medication during a medication pass observation for one (Nurse #3) of three staff members observed for glove use during care. Findings included: 1. Documentation on the facility's undated infection prevention and control program policy revealed under the heading standard precautions, All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. An observation was conducted on 2/13/2025 beginning at 1:40 PM while Resident #9 received wound care. Resident #9 was observed to have a sign on his room door for contact precautions. The documentation on the sign stated, Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces. Nurse #1 and Nurse Aide (NA) #1 were observed to enter the room of Resident #9 and not put on gowns. NA #1 moved the motorized wheelchair of Resident #9 and removed the protective boots on the lower legs and feet. Nurse #1 explained the location of the resident's wounds were on the plantar side of the left and right feet and that the right foot wound had tested positive for MRSA (Methicillin-resistant Staphylococcus aureus). (MRSA is contagious and can spread to others through skin-to-skin contact.) Nurse #1 was observed to provide wound care as ordered to both the left and right feet of Resident #9, including removing soiled bandages, application of treatments, and redressing of the wounds. Directly after the wound care observation on 2/13/2025 at 2:08 PM Nurse #1 was interviewed. Nurse #1 stated that the required PPE was not outside the door of Resident #9. Nurse #1 added that some facilities follow the procedure of putting on a gown before wound care and some do not. Nurse #1 revealed she had already put on a gown for wound care three times that day. Nurse #1 added that she did not get close to Resident #9 while performing wound care. The Director of Nursing was interviewed on 2/13/2025 at 2:10 PM. The Director of Nursing stated that Nurse #1 would need to be reeducated because for a resident on contact precautions, a gown must be worn for the provision of wound care. 2. Documentation on the facility's undated infection prevention and control program policy revealed under the heading standard precautions, Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Documentation under the facility's undated Medication Administration policy revealed under policy explanation and compliance guidelines in part, 4. Wash hands prior to administering medication per facility protocol and product; 16. Observe resident consumption of medication; and 17. Wash hands using facility protocol and product. On 2/14/2025 at 7:51 AM, Medication Aide (Med Aide) #1 was observed as she prepared and administered medications to Resident #11. The room door of Resident #11 was observed to have a contact precaution sign on the door. The contact precaution sign indicated hand hygiene was required before entering the room and after leaving the room. Medication Aide #1 did not perform hand hygiene before entering Resident #11's room and did not perform hand hygiene after administering medications to Resident #11. On 2/14/2025 at 8:01 AM, Med Aide #1 was observed as she prepared and administered medications to Resident #13. While in the room waiting for Resident #13 to consume her medications, Med Aide #1 assisted the resident, cutting up the food she was eating. Med Aide #1 did not perform hand hygiene before preparing the medications for Resident #13 nor when she returned to the medication cart after administration. On 2/14/2025 at 8:17 AM, Med Aide #1 was observed as she prepared and administered medications to Resident #14. Med Aide #1 did not perform hand hygiene before preparing the medications for Resident #14 nor when she returned to the medication cart after administration. Med Aide #1 was interviewed on 2/14/2025 at 8:20 AM. Med Aide #1 stated she usually did hand hygiene before preparing medications and after administering medications to residents, but she was just nervous. Med Aide #1 stated she especially performed hand hygiene when residents were on contact precautions. At that point, Med Aide #1 was observed to perform hand hygiene. An interview was conducted with the Director of Nursing on 2/18/2025 at 2:17 PM. The Director of Nursing stated it was her expectation that the nursing staff perform hand hygiene in-between each resident during medication pass administration. 3. Documentation on the facility's undated infection prevention and control program policy revealed under the heading standard precautions, Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. Documentation under the facility's undated Medication Administration policy revealed under policy explanation and compliance guidelines in part, 14. Remove medication from source, taking care not to touch medication with bare hand. On 2/14/2025 at 8:39 AM Nurse #3 was observed as she prepared and administered 8 medications to Resident #12. Nurse #3 was observed to put 6 of the 8 medications into her bare hands before putting them in the medication cup and administering the medications to Resident #12. On 2/14/2025 at 8:54 AM Nurse #3 was observed as she prepared and administered 6 medications to Resident #20. Nurse #3 was observed to put the 6 medications into her hand prior to putting them into the medication cup and then administering the medications to Resident #20. Nurse #3 was interviewed on 2/14/2025 at 9:04 AM. Nurse #3 stated she used to remove the medication directly from the container into the medication cup, but she was either losing the pills or they were dropping on the floor. Nurse #3 revealed she now put the medication into her hand so that she did not waste or lose medication. The Director of Nursing (DON) was interviewed on 2/18/2025 at 2:17 PM. The DON stated that a gloved hand could be used to remove pills from a medication card or medication container and then put them into the medication cup. The DON explained putting the medication into a gloved hand would keep the medication from being lost or dropped.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, Nurse Practitioner interview, and Medical Director interview, the facility failed to notify the physician that prescribed medications were not administered as ordered for 2 of 5 residents reviewed for unnecessary medications (Resident #24 and Resident #269). The findings included: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of female breast and vascular dementia. Resident #24 had an active physician order dated 6/05/24 for letrozole oral tablet (a medication used to treat some types of breast cancer by decreasing the amount of estrogen hormone the body makes) 2.5 milligram (mg) give 1 tablet by mouth one time a day for breast cancer. Review of Resident #24's Medication Administration Record (MAR) for the month of August 2024 revealed the letrozole medication was not administered on the following dates: 8/03/24, 8/04/24, 8/06/24, 08/08/24, 08/09/24, 8/10/24, 8/12/24, 8/13/24, 8/14/24, 8/15/24, 8/16/24, 8/17/24, 8/18/24, 8/19/24, and 8/21/24 through 8/27/24. The MAR documentation noted the medication was on order as the reason it was not administered. Record review of Resident #24's nursing notes for 8/01/24 through 8/27/24 revealed no documentation that the Nurse Practitioner (NP) and/or the Medical Director were notified of the missed doses of the letrozole medication. During an interview on 8/27/24 at 12:34 pm with Medication Aide #2, who was assigned to administer Resident #24's medication on 8/16/24, 8/22/24, 8/24/24, 8/25/24, and 8/27/24, revealed the letrozole medication was not available to be administered. Medication Aide #2 reported that she had previously reordered the medication from pharmacy on one of the previous dates that she worked, but she did not recall the date. Medication Aide #2 stated she notified Nurse #2, who was her assigned nurse, today that Resident #24's medication was not available so she could call the pharmacy about the medication. An interview was conducted on 8/27/24 at 12:47 pm with Nurse #2 who confirmed Medication Aide #2 notified her today (8/27/24) that Resident #24's letrozole medication was not available on the medication cart. Nurse #2 stated she planned to notify the provider and the Director of Nursing (DON) about the medication not being available, but she had not had the chance at this time. An interview was conducted on 8/27/24 at 1:09 pm with the Medical Director who revealed she was not notified by the facility that Resident #24's letrozole medication had not been administered as ordered. She stated she or the Nurse Practitioner (NP) should have been notified by the facility regarding Resident #24's medication not being administered as ordered. An interview was conducted on 8/28/24 at 1:29 pm with the NP who revealed she was made aware today (8/28/24) by the DON of Resident #24's missed doses of letrozole. An interview was conducted on 8/27/24 at 1:05 pm with the DON who revealed she was not notified or aware that Resident #24's letrozole medication had not been administered as ordered. The DON stated the nurse on the medication cart was responsible to notify the doctor that the medication was not available. 2. Resident #269 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis and complications of stump infection. Resident #269 had an active physician order dated 8/23/24, entered by the Unit Manager, for piperacillin sodium-tazobactam solution (antibiotic medication) infuse 3.375 grams intravenously (a soft, flexible tube placed inside a vein for to give medications or fluids) every 8 hours for wound infection. Review of the Medication Administration Record (MAR) revealed Resident #269's piperacillin sodium-tazobactam solution was not documented as administered on 8/23/24 at 10:00 pm, 8/24/24 at 6:00 am, and 8/24/24 at 10:00 pm. Record review of Resident #269's nursing notes from 8/23/24 through 8/27/24 revealed no documentation that the physician was notified of Resident #269's missed doses of the antibiotic. A telephone interview was conducted with Nurse #5 on 8/29/24 at 9:41 am who revealed she was not able to administer Resident #269's antibiotic on 8/23/24 at 10:00 pm because the medication had not been delivered to the facility at that time. Nurse #5 did not notify anyone that the antibiotic was not administered, but she stated she documented the reason she was unable to administer the medication on the MAR. During an interview on 8/29/24 at 1:23 pm with the Nurse Practitioner (NP) she revealed she was not notified of the missed doses of piperacillin sodium-tazobactam solution for Resident #269. The NP stated the facility should have notified the provider to make them aware of Resident #269's missed doses of the antibiotic. An interview was conducted on 8/29/24 at 10:56 pm with the Director of Nursing (DON) who revealed she was not made aware of Resident #269's antibiotic not being administered. The DON stated the nurse on the medication cart was responsible to notify the doctor that Resident #269's antibiotic medication was not administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to maintain documented evidence that an allegation of staff to resident abuse was thoroughly investigated for 1 of 3 residents (Resident #29) reviewed for abuse. The findings included: Resident #29 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included stroke and mild cognitive impairment. A review of the 5-day Investigation Report dated 8/31/23 completed by the previous Administrator revealed that on 8/29/23 Resident #29 accused a nurse aide of getting on top of him, trying to break his leg, and pull his arm off. The nurse aide was suspended immediately. The investigation report indicated all residents on the accused nurse aide's assignment were to be questioned and assessed on 8/30/23 and all residents would be assessed by 9/1/23. The investigation did not include any evidence that the resident interviews and assessments were completed. The allegation was not substantiated. An interview with the [NAME] President of Operations on 8/28/24 at 8:52 AM revealed that the abuse investigation files for Resident #29's allegation on 8/29/23 could not be found. The previous Administrator was interviewed on 8/28/24 at 2:10 PM. He stated that he maintained a folder of abuse investigation reports with evidence of the investigation when he was at the facility. He indicated there was a folder for the 8/29/23 staff to resident abuse allegation for Resident #29, but it could not be located per conversations with current facility staff. During an interview with the Administrator on 8/29/24 at 10:40 AM, she indicated she expected documented evidence of abuse investigations to be maintained to demonstrate a thorough investigation was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, and resident interview, the facility failed to obtain a physician order for the management of a peripherally inserted central catheter (PICC) for 1 of 2 residents reviewed for intravenous antibiotic use (Resident #269). The findings included: Resident #269 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis and complications of stump infection. Review of the nursing admission progress note dated 8/23/24 at 5:39 pm by Nurse #4 revealed Resident #269 had a PICC line to the right upper arm for intravenous antibiotic therapy. Resident #269 had a care plan initiated on 8/23/24 for enhanced barrier precautions related to the PICC line and wound with an intervention to monitor for redness or drainage around PICC and wound site. An observation and interview on 8/26/24 at 11:10 am with Resident #269 revealed a double lumen (2 ports) PICC line (form of intravenous access that can be used for a prolonged period of time for the administration of medications) was located in the right upper arm with antibiotic medication infusing. Resident #269 stated she just arrived at the facility a few days prior and was taking the intravenous antibiotic medication for a bad wound infection. Review of Resident #269's active physician orders on 8/26/24 revealed no physician orders for the right upper extremity PICC use and management. A telephone interview was conducted on 8/29/24 at 9:46 am with Nurse # 4 who was assigned to Resident #269 at the time of admission. Nurse #4 stated he completed Resident #269's admission assessment, but he did not enter the physician orders. Nurse #4 stated that typically the Unit Manager entered the physician orders into the system when the resident arrived at the facility. Nurse #4 stated he did not administer any antibiotics for Resident #269 during his shift. An interview was conducted on 8/27/24 at 10:16 am with the Unit Manager who revealed she entered Resident #269's physicians orders when Resident #269's arrived at the facility, and confirmed she was aware of the PICC line for antibiotic therapy. The Unit Manager stated the PICC line orders were set up as batch order set that would populate all required physician orders related to the use and management of the line when it was chosen. She stated she just forgot to click for the PICC line order set to generate all the required orders. The Unit Manager stated the physician orders were checked on new admissions and reviewed in the morning clinical meeting, but she was unable to state how she missed Resident #269's PICC line orders. An interview was conducted on 8/27/24 at 10:47 am with Nurse #2 who was assigned to administer Resident #269's antibiotic medications. Nurse #2 stated she did not notice that PICC line orders were not entered, but she stated she flushed the PICC line before and after the antibiotic medication was administered. She stated she knew from previous experience that the PICC line required to be flushed prior to the antibiotic to make sure it was not clogged and after the medication was completed to make sure all the medication was administered. Nurse #2 stated she did not know if other orders were required for Resident #269's PICC line use and management. During an interview on 8/27/24 at 1:22 pm with the Director of Nursing (DON) she revealed physician orders for the use and management of Resident #269's PICC line should have been entered when she was admitted to the facility. The DON stated the Unit Manager was responsible to enter the orders when she completed the admission orders. The DON stated the new admission review was completed by the Unit Manager and reviewed in the clinical meeting, but she was unable to state how the orders were missed for Resident #269's PICC line. An interview was conducted on 8/28/24 at 9:53 am with the Regional Nurse Consultant who revealed the nurse did not need to have an order to flush the PICC line before and after the antibiotic medication because it was part of the facility policy. The Regional Nurse Consultant stated she was not aware that Resident #269 did not have any physician orders for management and care of the PICC line and she stated those orders should have been entered upon admission. During an interview on 8/29/24 at 9:10 am the Administrator stated the DON and Unit Manager were responsible to ensure all physician orders were in place for Resident #269.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide supervision and provide a smoking apron for a resident that required supervision smoking for 1 of 2 residents sampled for smoking. (Resident #9) Findings include: Resident #9 was admitted to the facility on [DATE]. The most recent Minimum Data Set (MDS) dated [DATE], revealed Resident #9 had severe cognitive impairment and indicated Resident #9 was a tobacco user. A review of the smoking assessment dated [DATE] revealed Resident #9 was a supervised smoker. A review of the smoking policy revealed a signed copy of the policy dated 4/11/2024 signed by the Responsible Party for Resident #9. Resident #9's care plan dated 5/20/2024 revealed he was a supervised smoker and required to wear a smoking apron when smoking. On 8/27/2024 at 11:55 a.m. Resident #9 who was a supervised smoker was observed at the front entrance of the facility wheeling himself to the smoking area, which was near the front entrance of the facility. There were no observed staff members at the smoking area. Resident #9 was observed to approach Resident #55, a non-supervised smoker, at the smoking area. Resident #55 proceeded to give Resident #9 a cigarette and lit the cigarette for him. Resident #9 was observed to smoke the cigarette unsupervised and was not wearing a smoking apron. Resident #9 was observed to control and manage the lit cigarette and ash it safely. On 8/27/2024 at 11:59 a.m. Nurse Aide (NA) #1 was observed joining the residents to smoke and later assist Resident #9 back inside of the building. Resident #9 did not have any cigarette burns visible on his skin or clothing. In an interview with NA #1 on 8/27/2024 at 12:05 p.m. he revealed that he was assigned to supervise Resident #9 during his smoking times at 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., and 5:00 p.m. He revealed he had left Resident #9 outside of the main entrance to the building to go back to the building to retrieve Resident #9's cigarettes and lighter. NA #1 stated he returned and found Resident #9 at the smoking area smoking a cigarette. NA #1 stated Resident #9 was a supervised smoker and must wear a smoking apron when smoking. NA #1 stated it was an error on his part to leave Resident #9 unsupervised and without his smoking apron on. During an interview with the Administrator on 8/27/2024 at 12:10 p.m. she reported that staff knew the smoking protocol and must get cigarettes and smoking aprons for supervised smokers before exiting the building to the smoking area. The Administrator further revealed that there was a list of supervised smokers and non-supervised smokers placed in the nursing station for reference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and Consultant Pharmacist interview, the facility failed to ensure intravenous (a soft, flexible tube placed inside a vein used to give medicine or fluids) antibiotic medication was available as ordered for a newly admitted resident for 1 of 2 residents reviewed for intravenous (IV) antibiotic therapy (Resident #269). The findings included: Resident #269 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis and complications of stump infection. Resident #269 had an active physician order dated 8/23/24 for piperacillin sodium-tazobactam solution (antibiotic medication) infuse 3.375 grams intravenously every 8 hours for wound infection. The medication was scheduled to be administered at 6:00 am, 2:00 pm, and 10:00 pm. The care plan initiated on 8/23/24 revealed Resident #269 was on antibiotic therapy related to wound infection with an intervention to administer antibiotic medication as ordered by the physician. The Medication Administration Record (MAR) for 8/23/24 revealed Resident #269's piperacillin sodium-tazobactam solution was not administered at 10:00 pm. Resident #269's MAR for the 10:00 pm dose was noted by Nurse #5 as new admission, pharmacy to deliver. A telephone interview was conducted on 8/29/24 at 9:46 am with Nurse # 4 who was assigned to Resident #269 at the time of admission. Nurse #4 stated he worked during the 7:00 am-3:00 pm shift and Resident #269 was admitted to the facility at approximately 2:00 pm. Nurse #4 reported he completed Resident #269's admission and the Unit Manager put the medication orders into the system. Nurse #4 stated that the pharmacy made deliveries twice a day, with the first delivery around noon and the second delivery in the early morning hours. A telephone interview was conducted on 8/29/24 at 9:41 am with Nurse #5 who was assigned to Resident #269 on 8/23/24 during the 3:00 pm-11:00 pm shift. Nurse #5 revealed she was unable to administer Resident #269's antibiotic for the 10:00 pm dose because it was not delivered to the facility at that time. Nurse #5 stated the pharmacy did not normally deliver the medications for new admissions until around 2:00 am, so she documented the antibiotic as not administered. An interview was conducted on 8/27/24 at 10:06 am with the Admissions Director who revealed once a new admission was confirmed to arrive on that day she would give the discharge summary to the Unit Manager. She stated the discharge summary was given prior to the resident arriving at the facility and included all the medications that the resident would be taking once admitted to the facility. An interview was conducted on 8/27/24 at 10:16 am with the Unit Manager who revealed she received the discharge summary from the Admissions Director that did have Resident #269's medications listed. The Unit Manager stated that when Resident #269 arrived at the facility the orders were entered for the medications. A telephone interview was conducted on 8/29/24 8:15 am with the Consultant Pharmacist who revealed medication orders would be active once the resident was admitted to the facility. He stated the medication orders would be reviewed and verified for any contraindications before being sent to the facility. An interview was conducted on 8/29/24 at 10:56 am with the Director of Nursing (DON) who revealed medication orders were received prior to the admission but were not entered until the resident arrived at the facility. The DON stated the medication orders were entered and confirmed when Resident #269 arrived and would be expected to be delivered to the facility on the night delivery. The DON confirmed Resident #269's piperacillin sodium-tazobactam solution was delivered to the facility on 8/24/24 at 1:10 am. During an interview on 8/29/24 at 9:10 am the Administrator stated the DON and Unit Manager were responsible to ensure Resident #269's medications were available and administered as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and Consultant Pharmacist interview, the facility failed to address recommendations made by the Consultant Pharmacist based on the monthly Medication Regimen Review (MRR) for 1 of 5 residents reviewed for unnecessary medications (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with diagnoses which included vascular dementia and schizophrenia. The care plan initiated on 5/01/24 revealed Resident #24 used psychotropic medication related to diagnosis of schizophrenia. Resident #24 had an active physician order dated 6/03/24 for haloperidol (an antipsychotic medication used to treat schizophrenia) oral tablet 5 milligrams (mg) give one tablet by mouth two times a day for dementia. Review of the Consultant Pharmacist Recommendation to Physician report dated 6/18/24 revealed Resident #24 received the antipsychotic medication haloperidol but lacked an allowable diagnosis to support the use. The report provided allowable diagnoses for the medication which included schizophrenia. The diagnosis of schizophrenia was chosen, and the report was signed by the provider. Review of the Consultant Pharmacist Recommendation to Physician report dated 7/18/24 revealed Resident #24 received the antipsychotic medication haloperidol but lacked an allowable diagnosis to support the use. The report provided allowable diagnoses for the medication which included schizophrenia. The diagnosis of schizophrenia was chosen, and the report was signed by the provider. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #24 had severe cognitive impairment and was coded for use of an antipsychotic medication. A telephone interview was conducted on 8/29/24 at 8:15 am with the Consultant Pharmacist revealed he completed the MRR monthly, and the reports were sent to the Director of Nursing (DON) to be completed. He stated the normal process was to notify the facility of the diagnosis requirement and the facility would make the appropriate changes to the medication order. The Consultant Pharmacist stated if the recommendation was not completed at the time of the next MRR another recommendation would be sent to the DON. The Consultant Pharmacist stated the facility was responsible to update the physician order with the appropriate diagnosis when the report was completed by the provider. An interview was conducted with the Director of Nursing (DON) on 8/29/24 at 9:25 am who revealed she received the Consultant Pharmacist Recommendation reports and she gave the reports to the providers to complete. The DON stated she received the reports back from the providers when they were completed and signed. The DON stated she received the completed recommendation report for Resident #24's haloperidol, but she did not verify the order was corrected. The DON stated she was responsible to make sure the Consultant Pharmacist Recommendation to Physician reports were completed. During an interview on 8/29/24 at 9:13 am with the Administrator she revealed the DON received the Consultant Pharmacist Recommendation to Physician reports from the Consultant Pharmacist and the DON was responsible to ensure Resident #24's diagnosis was updated for the haloperidol medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain vaccination consents or declination forms and failed to maintain a record of education provided for COVID-19 (Coronavirus) immunizations for 2 of 5 residents reviewed for immunizations (Resident #16 and Resident #29). The findings included: The facility policy titled, COVID-19 Vaccination last reviewed June 2023, revealed in part that COVID-19 vaccinations will be offered to residents when supplies were available, as per Centers for Disease Control and Prevention (CDC) guidelines unless contraindicated, previously immunized during the time period, or refused to receive the vaccine. The policy concluded that the facility would maintain record of education to the resident or Responsible Party (RP) regarding the risks, benefits, and potential side effects of the COVID-19 vaccine, record of each dose of the vaccine administered, and if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. a. Resident #16 was admitted to the facility on [DATE]. Review of the medical record revealed Resident # 16 was administered the COVID-19 vaccine at the facility on 12/13/23. The facility was unable to provide documentation that a signed immunization consent form was obtained prior to administration and that the vaccination education was provided to Resident #16 or their Responsible Party (RP) regarding the risks, benefits, and potential side effects of the COVID-19 vaccine. An interview was conducted on 8/28/24 at 11:37 am with the Regional Nurse Consultant who revealed she was unable to locate the consent form or education documentation for Resident #16's COVID-19 vaccine. b. Resident #29 was admitted to the facility on [DATE]. Review of the medical record revealed Resident #29 was administered the COVID-19 vaccine dose #1 on 3/40/21. There was no documentation that any additional doses of the COVID-19 vaccinations were offered, administered, or declined by Resident #29. An interview was conducted on 8/28/24 at 11:37 am with the Regional Nurse Consultant who revealed she was unable to provide any further documentation of additional COVID-19 vaccine information for Resident #29. During an interview on 8/29/24 at 8:38 am with the Infection Preventionist (IP), she revealed she was new to the facility and was unable to state what occurred with Resident #16 and Resident #29 immunization information. An interview was conducted on 8/29/24 at 9:25 am with the Director of Nursing (DON) who revealed she was new to the facility and was unable to answer questions regarding Resident #16 and Resident #29's COVID-19 immunizations. An attempt to interview the previous DON was unsuccessful. An interview was conducted on 8/29/24 at 9:03 am with the Administrator who revealed the Director of Nursing and Infection Preventionist were responsible for the facility's immunization process. The Administrator stated she was unable to state why the information was not available because the administrative team was new to the facility.

Based on record review, Resident Council group interview and staff interviews, the facility failed to resolve and communicate the facility's efforts to address resident concerns voiced during 3 of 10 Resident Council meetings in October 2023, January 2024, and June 2024. Findings included: During a Resident Council group interview conducted on 8/27/24 at 1:08 PM, residents present shared an ongoing issue with the resolution of concerns voiced during Resident Council meetings. The Resident Council minutes for the period October 2023 through July 2024 were reviewed and revealed the following: Resident Council minutes dated November 2023 included no documentation of the facility's response to a concern voiced during the previous meeting of 10/26/23 which included one resident who requested money and did not receive it until 3 weeks later. Resident Council minutes dated 1/25/24 indicated residents voiced concerns related to having to beg for ice on 1st and 2nd shifts, clothing lost in laundry and yet to be found and waiting a long time to be put to bed after returning to the facility. Resident Council minutes dated 2/29/24 revealed no response from the facility for the previous month concerns. Resident Council minutes dated 06/27/24 indicated residents voiced concerns related to cold food, not enough variety at all meals, and laundry returned to other residents. Resident Council minutes dated 7/25/24 included no documentation of the facility's response to the concerns voiced during the previous meeting. An interview was conducted with the Activities Director on 8/27/24 at 1:47 PM. She revealed that when complaints were made in Resident Council meetings, she brought them to the Administrator who then delegated to department heads. The Activities Director stated she was not involved in the resolution process, unless the concern was related to activities. During an interview with the Administrator on 8/28/24 at 11:50 AM, she revealed that all grievances, including Resident Council complaints, were forwarded to the Grievance Official, who was the Social Worker (SW). The grievances were discussed in the daily morning meeting and then the complaints were distributed to the designated department heads. She stated Resident Council complaints should be included on the grievance log, and the resolution should be included in the written grievance form. A letter would then be sent to the complainant. The Administrator indicated that the department heads probably still had not yet returned the resolutions from the months of October 2023, January 2024, and June 2024. The SW was interviewed on 8/28/24 at 12:08 PM. She revealed that the Activities Director wrote up the grievances from Resident Council meetings and presented them in the daily morning meeting. The SW then delegated the complaints to the assigned department heads. The department heads were then supposed to return the resolutions to her, she logged them and wrote the resolution letter. The Administrator then signed the grievance and resolution letter and returned them back to the SW. The SW stated that all complaints from Resident Council should be attached to the meeting minutes as the resolution to previous grievances. She indicated the problem was that grievance responses were often not returned from the department heads; therefore, she could not create a resolution letter. The Social Worker could not recall if the issues from the October 2023, January 2024, and June 2024 Resident Council meetings were discussed in morning meetings or if the resolutions from the department heads were handed back to her. During a follow-up interview with the SW on 8/28/24 at 12:16 PM, she revealed that if a Resident Council grievance was discussed in the daily morning meeting, then she took notes on the grievance details. If she recorded the grievance, then she followed up with the department heads. She did not always receive the grievances discussed from Resident Council meetings. The SW stated that grievances should be resolved within 48 hours of the initial complaint. She indicated that there was not a thorough process in place to log the grievances and check their status. The SW stated she was not notified that she was the Grievance Official, but rather the Administrator thus far. During a follow-up interview with the Administrator on 8/29/24 at 10:37 AM, she revealed that the department heads were not returning the grievance resolutions to the SW. They were supposed to resolve the issue and then bring it to the SW to log and communicate the resolution to Resident Council members. The Administrator indicated that the SW should follow-up with the department heads if the resolutions were not returned, and the complaints should have been resolved within 72 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews the facility failed to provide written advance directive information and/or an opportunity to formulate an advance directive for 5 of 65 residents reviewed for advance directives. (Residents #1, #5, #28, #29, and #47). The findings include: a. Review of Resident #1's medical record revealed the resident was readmitted to the facility on [DATE], with diagnoses that include heart failure, chronic obstructive pulmonary disorder, and anemia. He held a physician order for full code status. There was no documentation in the record for education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. b. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses that include diabetes, chronic kidney disorder, and seizures. There was no documentation in the record for education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. The Medical Orders for Scope of Treatment form was signed by the Nurse Practitioner on 7/9/24. There were not any signatures by Resident #5 or their responsible party (RP). Only a note was documented on the form that the RP was called via telephone on 7/8/24. The MOST form was blank and not filled out. Resident #5's RP was interviewed on 8/28/24 at 10:32 AM. She revealed that she had assisted with Resident #5's admission paperwork and could not recall if Advance Directive Care Planning was discussed by a facility staff member. c. Review of Resident #28's medical record revealed the resident was readmitted to the facility on [DATE], with diagnoses that include diabetes, seizures, and anemia. She held a physician order for full code status. There was no documentation in the record for education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. d. Review of Resident #29's medical record revealed the resident was readmitted to the facility on [DATE], with diagnoses that include stroke, hypertension, and diabetes. He held a do not resuscitate physician order for code status. There was no documentation in the record for education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. e. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include spastic quadriplegia, emphysema, and seizures. She held a physician order for full code status. There was no documentation in the record for education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. An interview was conducted on 8/26/24 at 2:33 PM with the Regional Nurse Consultant. She stated all that was available from the facility for Advance Directives was the Medical Orders for Scope of Treatment (MOST) form stored in binders at the nurses' stations. The Administrator was interviewed on 8/29/24 at 10:44 AM. She revealed that education/discussion of Advance Directives should have been documented for each resident in the facility. The Administrator stated that residents should be reassessed for advance directives every 3 months or when there was a significant change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and Ombudsman interview the facility failed to notify the resident's responsible party in writing of the reason for transfer to the hospital for 1 of 2 residents (Resident #221) reviewed for hospitalization. The facility also failed to notify the Ombudsman in writing of the reason for the residents' transfer from the facility for 2 of 2 residents reviewed for hospitalization (Resident #119, Resident #221). The findings included: 1.Resident #221 was admitted to the facility on [DATE]. The quarterly MDS dated [DATE] revealed Resident #221 was severely cognitively impaired. Review of Resident #221's progress notes revealed Resident #221 was transferred to the hospital on 1/21/24 and did not return to the facility. Review of Resident #221's medical records on 8/28/24 revealed no documentation in the medical record that the Ombudsman, Resident or Responsible Party were notified of the reason for transfer to the hospital. Interviews attempted with the nurse that was assigned to Resident #221 when she was transferred to the hospital on 1/21/24 were unsuccessful. Interviews attempted with the Resident's Responsible Party were unsuccessful. An interview was completed on 8/29/24 at 10:20 AM with the Director of Nursing (DON). The DON stated she was unaware the facility was required to send written notification of the reason for transfer from the facility to a resident and their responsible party. Additionally, the DON revealed she did not know if the facility notified the Ombudsman of Resident #221's discharge from the facility to the hospital. A telephone interview was completed on 8/29/24 at 10:35 AM with the Ombudsman. The Ombudsman stated the facility had not notified her of resident discharges from the facility. The Ombudsman revealed she had spoken with the facility Administrator and requested notification of resident discharges. An interview was completed on 8/29/24 at 10:27 AM with the facility Administrator. The Administrator stated she was unsure if Resident #221 or her Responsible Party received written notification of the reason for the Resident's' transfer to the hospital. The Administrator revealed the facility had not sent the Ombudsman notifications of discharge from the facility for Resident #221. The Administrator revealed it was the Social Worker's responsibility to notify the Ombudsman of a resident's transfer from the facility each month. The Administrator stated she was unsure of who was responsible for providing written notification of the reason for transfer to a resident and their responsible party. An interview was completed on 8/29/24 at 11:00 AM with the facility's Social Worker. The Social Worker stated she was unaware it was her responsibility to notify the Ombudsman of a resident's transfer from the facility. 2. Resident #119 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #119 was severely cognitively impaired. Review of Resident #119's progress notes revealed Resident #119 was transferred to the hospital on 5/23/24 and did not return to the facility. Review of Resident #119's medical records on 8/28/24 revealed no documentation in the medical record that the Ombudsman was notified of the reason for transfer to the hospital. An interview was completed on 8/29/24 at 10:20 AM with the Director of Nursing (DON). The DON revealed she was not aware if the facility notified the Ombudsman of Resident #119's discharge from the facility to the hospital. A telephone interview was completed on 8/29/24 at 10:35 AM with the Ombudsman. The Ombudsman stated the facility had not notified her of resident discharges from the facility. The Ombudsman revealed she had spoken with the facility Administrator and requested notification of resident discharges. An interview was completed on 8/29/24 at 10:27 AM with the facility Administrator. The Administrator revealed the facility had not sent the Ombudsman notification of discharge from the facility for Resident #119. The Administrator revealed it was the Social Worker's responsibility to notify the Ombudsman of a resident's transfer from the facility each month. An interview was completed on 8/29/24 at 11:00 AM with the facility's Social Worker. The Social Worker stated she was unaware it was her responsibility to notify the Ombudsman of a resident's transfer from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, resident interview, Pharmacy Manager interview, Nurse Practitioner interview, and Medical Director interview, the facility failed to administer significant medications as ordered for 2 of 5 residents reviewed for unnecessary medications (Resident #24 and Resident #269). The findings included: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of female breast and vascular dementia. The care plan initiated on 5/02/24 revealed Resident #24 received oral chemotherapy related to cancer of the breast with an intervention to give medications as ordered. Resident #24 had an active physician order dated 6/05/24 for letrozole oral tablet (a medication used to treat some types of breast cancer by decreasing the amount of estrogen hormone the body makes) 2.5 milligram (mg) give 1 tablet by mouth one time a day for breast cancer. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #24 had severe cognitive impairment and was coded for chemotherapy medication. A telephone interview was conducted with the Pharmacy Manager on 8/27/24 at 1:53 pm who confirmed Resident #24's 30-day supply of the letrozole was delivered to the facility on 7/31/24 and was signed as received by Medication Aide #3. An interview conducted on 8/28/24 at 1:19 pm with Medication Aide #3 revealed when she received medications from the pharmacy she would confirm the medication was there with the order sheet and sign the slip as received. She stated she put the received medications for the residents in the appropriate medication carts after signing for them. Medication Aide #3 stated she did not specifically recall signing for the Resident #24's letrozole medication on 7/31/24, but she stated she would not have signed off on the slip if the medication was not delivered. Review of Resident #24's Medication Administration Record (MAR) for the month of August 2024 revealed the letrozole medication administration on the following dates: 8/01/24 noted as administered by Medication Aide (MA) #4. 8/02/24 noted as administered by Nurse #14. 8/03/24 noted as on order by Nurse #12. 8/04/24 noted as on order by Nurse #3. 8/05/24 noted as administered by Nurse #1. 8/06/24 noted as on order by MA #3. 8/07/24 noted as administered by MA #1 8/08/24 noted as on order by MA #3. 8/09/24 noted as on order by MA #3. 8/10/24 noted as on order by Nurse #13. 8/11/24 noted as administered by Nurse #11. 8/12/24 noted as on order by MA #3. 8/13/24 noted as not administered, no further documentation. 8/14/24 noted as not administered, no further documentation. 8/15/24 noted as on order by MA #3. 8/16/24 noted as on order by MA #2. 8/17/24 noted as on order by MA #3. 8/18/24 noted as on order by MA #3. 8/19/24 noted as on order by MA #3. 8/20/24 noted as administered by Nurse #8. 8/21/24 noted as on order by MA #3. 8/22/24 noted as not administered by MA #2. 8/23/24 noted as on order by MA #3. 8/24/24 noted as not administered by MA #2. 8/25/24 notes as not administered by MA #2. 8/26/24 noted as on order, calling pharmacy by MA #3. 8/27/24 noted as not administered by MA #2. A telephone interview was conducted on 8/28/24 at 10:34 am with Nurse #3 who was assigned to Resident #24 on 8/03/24 and documented the letrozole medication as not administered, on order. Nurse #3 stated if she marked the MAR as not administered due to being on order from the pharmacy then she was unable to find the medication to administer to Resident #24. Nurse #3 stated she was unable to recall if she reordered Resident #24's medication or was told by another nurse that it was on order. A telephone interview was conducted on 8/28/24 at 9:00 am with Nurse #1 who was assigned to Resident #24 on 8/05/24 and documented the letrozole as administered. Nurse #1 stated she was able to administer Resident #24's letrozole as ordered on 8/05/24 because it was in the medication cart. Nurse #1 reported she would not have signed out the medication as administered if it was not available. A telephone interview attempt on 8/28/24 at 9:05 am with Medication Aide #1, who was assigned to Resident #24 on 8/07/24 and documented the letrozole as administered was unsuccessful. An interview was conducted on 8/28/24 at 1:19 pm with Medication Aide #3, who was assigned to Resident #24 on 8/06/24, 8/08/24, 8/09/24, 8/12/24, 8/15/24, 8/17/24, 8/18/24, 8/19/24, 8/21/24, 8/23/24, and 8/26/24 revealed she was unable to remember for sure but if she documented Resident #24's medication was not available then she was unable to find it on that day. Medication Aide #3 stated she was unable to say where Resident #24's medication could have been put. During an interview on 8/27/24 at 12:34 pm with Medication Aide #2, who was assigned to administer Resident #24's medication on 8/16/24, 8/22/24, 8/24/24, 8/25/24, and 8/27/24, revealed the letrozole medication was not available to be administered. Medication Aide #2 reported that she had previously reordered the medication from pharmacy one of the previous dates that she worked, but she was unable to recall the exact date. She stated the medication was able to be reordered in Resident #24's electronic medical record by clicking the reorder button which sent the order notification directly to the pharmacy. Medication Aide #2 stated she was going to notify Nurse # 2, who was assigned to supervise her, to check with pharmacy on the delivery status because she stated it seemed like it was a long time since she ordered the medication. An observation was conducted on 8/27/24 at 12:34 pm with Medication Aide #2 of the medication cart drawers. Medication Aide #2 checked the medication cart with this surveyor and confirmed the letrozole was not available in the medication cart assigned to Resident #24. An interview was conducted on 8/27/24 at 12:47 pm with Nurse #2 who was assigned to supervise Medication Aide #2. Nurse #2 confirmed that she was notified by Medication Aide #2 that Resident #24 did not have the letrozole medication available to administer today. She stated she would notify the Unit Manager to follow-up with the pharmacy once Medication Aide #2 completed the medication pass. During an interview on 8/27/24 at 10:16 am with the Unit Manager she revealed she was not aware Resident #24's letrozole was not available and noted as not administered on the MAR. The Unit Manager stated she reviewed the MAR documentation before the daily clinical meeting but was only looking for blank spaces when she reviewed them to make sure the medications were being administered. The Unit Manager stated she did not look at what was being documented on the MAR regarding the medication for Resident #24. The Unit Manager reported she checked all of the facility medication carts and the medication storage room Resident #24's letrozole medication but she was unable to locate the medication. A telephone interview was conducted with the Pharmacy Manager on 8/27/24 at 1:53 pm who confirmed Resident #24's letrozole medication was not returned to pharmacy as unused. An interview was conducted on 8/27/24 at 1:09 pm with the Medical Director who revealed she was not notified by the facility that Resident #24's letrozole medication had not been administered. She stated she or the Nurse Practitioner (NP) should have been notified by the facility regarding Resident #24's medication not being available. The Medical Director stated she was not an oncologist (doctor specialized in diagnosing and treating cancer) but she understood that Resident #24's letrozole medication was needed and it should have been administered as ordered. An interview was conducted on 8/28/24 at 1:29 pm with the NP who revealed she was made aware today (8/28/24) by the Director of Nursing (DON) of Resident #24's missed doses of letrozole. The NP stated that Resident #24's medications were expected to be administered as ordered. An interview was conducted on 8/27/24 at 1:05 pm with the Director of Nursing who revealed she was not notified or aware that Resident #24's letrozole medication had not been administered as ordered. She stated the nurse on the cart was responsible to notify the doctor that the medication was not available and notify nursing management (DON or Unit Manger) so a follow-up call to the pharmacy could be made. The DON stated the Nurses or Medication Aides should have notified the Unit Manager or herself when the medication was not found on the medication cart. The DON stated she was not able to say what happened to Resident #24's medication, but stated the medication was delivered to the facility and should have been in the medication cart. An interview was conducted with the Administrator on 8/29/24 at 9:10 am who revealed the DON and Unit Manager were responsible to make sure medications were administered as ordered. 2. Resident #269 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis and complications of stump infection. Resident #269 had an active physician order dated 8/23/24, entered by the Unit Manager, for piperacillin sodium-tazobactam solution (antibiotic medication) infuse 3.375 grams intravenously (IV, a soft, flexible tube placed inside a vein for to give medications or fluids) every 8 hours for wound infection. The medication was scheduled to be administered at 6:00 am, 2:00 pm, and 10:00 pm. The care plan initiated on 8/23/24 revealed Resident #269 was on antibiotic therapy related to wound infection with an intervention to administer antibiotic medication as ordered by the physician. The Medication Administration Record (MAR) for August 2024 revealed the following: 8/23/24 at 10:00 pm the piperacillin sodium-tazobactam solution was not administered. The MAR noted as new admit, pharmacy to delivery by Nurse #5. 8/24/24 at 6:00 am the piperacillin sodium-tazobactam solution was not documented as administered with no further information noted. The nurse assigned to Resident #269 at this time was Nurse #6. 8/24/24 at 10:00 pm the piperacillin sodium-tazobactam solution was not documented as administered with no further information noted. The nurse assigned to Resident #269 at this time was Nurse #10. The MAR from 8/25/24 through 8/28/24 revealed Resident #269's the piperacillin sodium-tazobactam solution was administered as ordered. A telephone interview was conducted on 8/29/24 at 9:46 am with Nurse # 4 who was assigned to Resident #269 at the time of admission. Nurse #4 stated he completed Resident #269's admission, but the Unit Manager put the medication orders into the system. He stated he did not have any antibiotics due for Resident #269 during his shift. A telephone interview was conducted on 8/29/24 at 9:41 am with Nurse #5 who was assigned to Resident #269 on 8/23/24 during the 3:00 pm - 11:00 pm shift. Nurse #5 stated she did not administer the antibiotic to Resident #269 during her shift because the new admission antibiotics normally arrived after her shift ended. Nurse #5 stated she documented on Resident #269's MAR that she did not administer the medication. A telephone interview was conducted on 8/29/24 at 9:50 am with Nurse #6 who was assigned to Resident #269 on 8/24/24 at the time of the 6:00 am dose of the antibiotic. Nurse #6 stated the pharmacy delivery normally occurred between 1:00 am and 2:00 am. Nurse #6 stated she was unable to remember if Resident #269's medication was delivered or administered, but she stated if the medication was delivered she should have given it. An attempt to interview Nurse #10 on 8/29/24 at 10:05 am, who was assigned to Resident #269 on 8/29/24 for the 10:00 pm dose of the antibiotic, was unsuccessful. During an interview on 8/29/24 at 1:23 pm with the Nurse Practitioner (NP) she revealed she was not notified of the missing doses of piperacillin sodium-tazobactam solution for Resident #269. The NP stated Resident #269 was on two antibiotics for the wound infection and the other antibiotic was administered as ordered which covered the bacteria noted in the wound, but she stated the facility should have notified the provider to make them aware of the missed doses. The NP stated all of Resident #24's antibiotics should have been administered as ordered. An interview was conducted on 8/29/24 at 10:56 pm with the Director of Nursing (DON) revealed she was not aware of the missing doses of Resident #269's piperacillin sodium-tazobactam solution. The DON stated she was unable to determine why the medication was not administered because the medication was at the facility for the scheduled 8/24/24 administrations. An interview was conducted with the Administrator on 8/29/24 at 9:10 am who revealed the DON and Unit Manager were responsible to make sure medications were administered as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain vaccination consents or declination forms and failed to maintain a record of education provided for the influenza and pneumococcal immunizations for 4 of 5 residents reviewed for immunizations (Resident #28, Resident #16, Resident #29, and Resident #10). The findings included: a. Resident #28 was admitted to the facility on [DATE]. Review of the medical record revealed Resident #28 declined to have the pneumococcal vaccine. Resident #28's medical record did not include the date of declination. Resident #28's medical record further noted that the influenza vaccine was administered at the facility on 10/01/23. The facility was unable to provide documentation that a signed immunization consent and/or declination form was obtained, and that the vaccination education was provided to Resident #28 or their Responsible Party (RP) regarding the influenza and pneumococcal vaccines. b. Resident #16 was admitted to the facility on [DATE]. Review of the medical record revealed Resident #16 was administered the influenza immunization at the facility on 10/17/23. The facility was unable to provide documentation that a signed immunization consent form was obtained, and that the vaccination education was provided to Resident #16 or their RP regarding the influenza immunization. c. Resident #29 was admitted to the facility on [DATE]. Review of the medical record revealed Resident #29 declined the pneumococcal immunization, unknown date, and he was administered the influenza immunization at the facility on 10/16/23. The facility was unable to provide documentation that a signed immunization consent form for the influenza vaccine was obtained prior to administration, a signed and date declination form for the pneumococcal vaccine was obtained, or that the vaccination education was provided to Resident #29 or their RP regarding the influenza and pneumococcal vaccines. d. Resident #10 was admitted to the facility on [DATE]. Review of the medical record revealed Resident #10 was noted to have obtained the influenza vaccine at the facility on 10/17/23. The facility was unable to provide documentation that a signed consent form for the influenza vaccine was obtained prior to administration or that the vaccination education was provided to Resident #10 or their RP regarding the influenza vaccine. An interview was conducted on 8/28/24 at 11:37 am with the Regional Nurse Consultant who revealed she was unable to locate the documentation of consents or declinations for the immunizations for the residents reviewed. She further reported the facility was unable to locate the documentation that the vaccine education was provided to the residents or their RP's regarding the influenza or pneumococcal immunizations risks and possible side effects. The Regional Nurse Consultant stated she was unable to state what the previous administrative team did with the required immunization information. During an interview on 8/29/24 at 8:38 am with the Infection Preventionist, she revealed she was new to the position and was unable to state why the immunization information was not available for the residents or their RP's reviewed. An interview was conducted with the Director of Nursing (DON) on 8/29/24 at 9:25 am who revealed she was new to the position and was not able to state why the facility did not have the immunization consents and education documentation. An attempt to interview the previous DON was unsuccessful. An interview was conducted on 8/29/24 at 9:03 am with the Administrator who revealed the Director of Nursing, and the Infection Preventionist were responsible for the residents' immunizations and the maintenance of the documentation that was required. The Administrator stated she was unable to state why the information was not available because the administrative team was new to the facility.

Based on staff interviews and record review, the facility failed to have a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days a week for 48 of 180 days reviewed. Findings include: The Nursing Staff Schedule and the Daily Staffing Form were reviewed from 8/1/23 through 8/29/24. The Nursing Staff Schedule and the Daily Staffing Form indicated an RN was not scheduled for at least eight consecutive hours a day on the following dates: 8/5/23, 8/26/23, 8/27/23, 9/9/23, 9/10/23, 9/23/23, 11/5/23, 11/17/23, 11/19/23, 12/3/23, 12/10/23, 12/24/23, 12/25/23, 12/28/23, 1/1/24, 1/6/24, 1/7/24, 1/20/24, 1/21/24, 1/26/24, 2/4/24, 2/8/24, 2/9/24, 2/10/24, 2/11/24, 2/12/24, 2/13/24, 2/14/24, 2/15/24, 2/16/24, 2/17/24, 2/18/24, 2/19/24, 2/21/24, 2/23/24, 2/24/24, 2/25/24, 2/26/24, 2/28/24, 2/29/24, 3/2/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/12/24, and 3/14/24. Telephone interviews with the prior Director of Nursing (DON) and Scheduler were attempted but calls and messages were not returned. During an interview with the Administrator on 8/29/24 at 10:22 A.M. she revealed it was the responsibility of DON and the Scheduler to ensure 8 hours of consecutive RN coverage daily was met. The Administrator explained there had been staffing changes and things have improved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident interview and staff interviews, the facility failed to assess the capability of a resident to self-administer medications kept at the bedside for 1 of 1 resident reviewed for self-administration of medications (Resident # 29). Findings included: Resident #29 was admitted to the facility on [DATE], and diagnoses included stroke and glaucoma. A review of the physician orders Included: Timolol Maleate Solution 0.5% instill one drop in both eyes two times a day for glaucoma ordered on 3/17/2021, Miralax Powder 17 grams twice a day for constipation ordered on 8/24/2021 and Tobramycin-Dexamethasone Ophthalmic Suspension 0.3-0.1% (an eye antibiotic) instill one drop in both eyes for times a day for eye infection ordered on 5/4/2023. There was no physician order for Resident #29 to self-administer medications to himself. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 was cognitively intact, rejected care and received the following medications during the 7-day look back period: anticoagulants, opioids and diuretics. Resident #29's care plan dated 5/2/2023 for resistance to care indicated Resident #29 refused his medications at times and electronically ordered over-the-counter medications without making the nursing staff and the physician aware. Interventions included administering medication as physician ordered. There was no care plan for Resident #29 to perform self-administration of medications. Nursing documentation dated 5/2/2023 stated Resident #29 refused Timolol eye drops and Resident #29 stated he had his own eye drops in his room that was the brand his physician recommended, and he didn't want the generic eye drops from the facility. Nursing documented also indicated on 5/26/2023 Resident #29 refused his meds and recorded Resident #29 had his own personal over-the-counter supply of medications. There was no Self Administration Assessment recorded in Resident #29's electronic medical record. On 6/26/2023 at 11:52 a.m. in an interview with Resident #29, he explained one of his eye drops was ordered every six hours, and the nursing staff had given him a bottle of eyes drops (Tobramycin) for him to self-administer. A bottle of Tobramycin eye drops was observed in a small gray bag to the left of Resident #29's bed. A small bottle of Timodol eye drops was observed on the bedside table. He stated he was able to instill his eye drops but sometimes he missed the eye. On 6/28/2023 at 7:11 a.m. while observing a medication pass with Nurse #3, Resident #29 refused ClearLax (a generic form of Miralax, a laxative) Nurse #3 attempted to administer and stated that was not Miralax, and he had his own Miralax. A bottle of Miralax was observed in Resident #29's bedside cabinet. On 6/28/2023 at 7:25 a.m. in an interview with Nurse #3, he stated Resident #29 always receiving boxes from outside the facility. He stated Resident #29 verbally aggressive with staff if staff attempted to remove the Miralax from his room. On 6/29/2023 at 2:36 p.m. in an interview with Nurse #4, she stated Resident #29 insisted on administering his own eye drops located in his room and had observed Resident #29 self-administer his eye drops. She explained Resident #29 needed a self-administration of medication assessment completed to self-administer medications and unsure if Resident #29 had been assessed for self-administration of the medications. On 6/29/2023 at 2:44 p.m. in an interview with the Director of Nursing, she explained Resident #29 was care planned for ordering over-the-counter medications because he was having over -the -counter medications shipped to the facility, and the facility could not open his mail. She stated she was not aware there were bottles of eye drops (Tobramycin and Timolol) in his room and stated Resident #29 would have received the bottles of eye drops from the nursing staff. She explained based on their policy Resident #29 needed a self-administration assessment to self-administer medications, and Resident #29 did not have a self-administration assessment or physician order to self-administer any medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #40 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #40 was cognitively intact and was independent for transfer and locomotion on unit. On 6/26/23 at 12:39 p.m., Resident #40's call light was observed laying on top of a light fixture attached to the wall to the left side of the bed. Resident #40 was observed to be in her wheelchair. She stated she could not reach the call bell and explained she communicated her needs to staff by speaking with them on the hall. She stated the call bell had been on top of the light fixture for a few days but could not recall who had placed it there. On 6/27/23 at 9:11 a.m the call bell was observed again to be laying on top of the light fixture attached to the wall to the left side of the bed. Resident #40 was observed to be in her wheelchair and stated that if she were unable to get out of bed to use her wheelchair, she would need to utilize the call bell to alert staff of her needs. On 6/28/2023 at 11:03 a.m. in an interview with the Director of Nursing, she stated Resident #40's call light should be within her reach to use to communicate her needs. On 6/29/2023 at 5:54 p.m. in an interview with the Administrator, she stated call light was to be within Resident 40's reach to call for assistance. Based on record review, observations and staff interviews, the facility failed to place a resident's call light within reach to allow for the resident to request assistance if needed for 2 of 5 residents reviewed for accommodation of needs. (Resident #12 and Resident #40) Findings included: 1. Resident #12 was admitted to the facility on [DATE], and diagnoses included a stroke with hemiplegia (paralysis on one side of the body) affecting his right dominant side and aphasia (difficulty speaking). Resident #12's revised care plan dated 4/1/2022 included a focus for a deficit in performing activities of daily living due to right side weakness. Interventions included assisting Resident #12 with activities of daily living and encouraging Resident #12 to use the call light to call for assistance. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #12 was moderately impaired cognitively and had limited range of motion to one side of his body. A dietary note dated 5/17/2023 indicated Resident #12 received a pureed diet with nectar thickened liquids. On 6/26/2023 at 12:25 p.m., Resident #12's call light was observed hanging on the connection port in the wall located on the right side of the bed out of the reach of Resident #12. Nurse Aide (NA) #3 was observed delivering and setting up Resident #12's lunch meal tray before exiting his room. Resident #12's call light remained hanging on the connection port in the wall out of the reach of Resident #12. On 6/26/2023 at 12:59 p.m., Resident #12's call light was observed hanging on the connection port in the wall located on the right side of the bed. NA #2 was observed removing Resident #12's lunch meal tray from the over- the -bed table and exiting the Resident #12's room. When the surveyor requested NA #2 to return to Resident #12's room, NA #2 said she thought Resident #12 could not operate the call light. She explained Resident #12 used his left hand to feed himself using build-up utensils. NA #2 was observed removing the call light that was hanging on the connection port in the wall on the right side of the bed and placing the call light near Resident #12's left hand. NA #2 explained to Resident #12 the call light was used to call for help as needed and when NA #2 instructed Resident #12 to demonstrate using the call by pushing the button at the end of the call light, Resident #12 was able to demonstrate how to use the call light correctly. NA #2 stated the call light was to be left within reach of Resident #12 always when exiting the room. On 6/28/2023 at 11:01 a.m. in an interview with the Director of Nursing, she stated Resident #12's call light should be within his reach to use to communicate his needs. On 6/29/2023 at 5:34 p.m. in an interview with the Administrator, she stated call light was to be attached to Resident #12's bed and within Resident #12's reach to call for assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident interviews, and staff interviews, the facility failed to keep the room temperature at a comfortable level for 1 of 2 residents sampled (Resident #43). Findings included: Resident # 43 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #43 was cognitively intact and required assistance with all activities of daily living except eating. The weekly temperature log for the main building indicated Resident #43's room temperature was not checked on 6/1/2023, 6/7/2023 and 6/16/2023. On 6/16/2023, the Accuweather website recorded temperatures for [NAME], North Carolina (NC) as the high was 87 degrees Fahrenheit and low was 62 degrees Fahrenheit. Maintenance Director notes indicated on 6/16/2023 he was made aware of an air conditioner problem for the hall with rooms 107 to 114 by nursing station #1, and a Heating, Ventilation and Air Conditioner (HVAC) service company was contacted. A receipt dated 6/16/2023 revealed the facility purchased three portable air conditioners. A review of Resident #43's electronic medical record revealed on 6/16/2023 Resident #43 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] in the facility. On 6/20/2023, the Accuweather website recorded temperatures for [NAME], NC as the high was 76 degrees Fahrenheit and low was 64 degrees Fahrenheit. On 6/20/2023 at 8:30 a.m., the Maintenance Director's temperature checks for Resident #43's room indicated the room temperature was 74.8 degrees Fahrenheit. Maintenance Director notes indicated the air conditioner was serviced and repaired by the HVAC service company on 6/20/2023. A review of Resident #43's electronic medical record revealed on 6/20/2023, Resident #43 was moved back to room [ROOM NUMBER]. The Maintenance Director's temperature checks for Resident #43's room: - 6/21/2023 at 9:00 a.m. 75 degrees Fahrenheit. - 6/22/2023 at 8:25 a.m. 75.3 degrees Fahrenheit. - 6/23/2023 at 9:50 a.m. 75.6 degrees Fahrenheit. There were no temperatures logged for Resident #43's room for the mid-afternoon or afternoon hours on each day. On 6/23/2023, the weekly temperature log for the main building indicated Resident #43's room temperature was 75 degrees Fahrenheit, The Accuweather website recorded temperatures for [NAME], NC on: - 6/24/2023, the high was 82 degrees Fahrenheit and low was 64 degrees Fahrenheit - 6/25/2023, the high was 86 degrees Fahrenheit and low was 66 degrees Fahrenheit. The Maintenance Director's temperature checks for Resident #43's room: - 6/26/2023 at 9:00 a.m. 74.6 degrees Fahrenheit. - 6/27/2023 at 9:40 a.m.72 degrees Fahrenheit. - 6/28/2023 at 9:15 a.m. 73.5 degrees Fahrenheit. - 6/29/2023 at 8:45 a.m. 74.5 degrees Fahrenheit. There were no temperatures logged for Resident #43's room for the mid-afternoon or afternoon hours on each day. On 6/26/2023 at 11:00 a.m. while walking down the hallway for rooms 107-114, the air in the hall was noticeably warmer half-way down the hall after passing room [ROOM NUMBER] and room [ROOM NUMBER]. There was a fan observed in the hallway outside room [ROOM NUMBER]. In the empty room [ROOM NUMBER] across from Resident #43's room, a portable air conditioner unit was observed in the mid of the room. The air blowing from the portable air conditioner was cool to touch and a temperature reading of 79 degrees Fahrenheit was observed on the portable air conditioner unit. On 6/26/2023 at 3:41 p.m., Maintenance Director checked the hall temperature. The reading at the end of the hall temperature was observed at 91.9 degrees Fahrenheit and 92.3 degrees Fahrenheit. Resident #43's room temperature check was 75.5 degrees Fahrenheit along the side of the outside wall in the room. There was a circulating tall standing fan observed between the door and Resident #42 bed, and a portable air conditioner positioned in the doorway of the bathroom facing toward the foot of the bed. On 6/26/2023 at 3:48 p.m. the hall thermostat control for rooms 107 to 114 was observed set at 74 degrees Fahrenheit, and the temperature reading was observed at 82 degrees Fahrenheit. In an interview with the Maintenance Director on 6/26/2023 at 3:37p.m., he stated the hallway and rooms 111-114 at the back of the hall were noticeably warm the morning of 6/26/2023. He stated he had placed two portable air conditioner units in room [ROOM NUMBER] and placed one portable air conditioner in Resident #43's room the morning of 6/26/2023. He explained the air conditioner was working, but something was wrong with it, and he had called a Heating, Ventilation and Air Conditioner (HVAC) service company again on 6/26/2023. In an interview with Resident #43 on 6/26/2023 at 3:41p.m., she stated about three weeks ago when the air conditioner started messing up, the facility provided her a box fan to keep her room temperature more comfortable. She said during the weekend of 6/24/2023 and 6/25/2023 her room temperature became uncomfortable, and the nursing staff provided her plenty of fluids and attempted to locate another fan for her room but couldn't find one. In a follow- up interview on 6/29/2023 at 6:42 a.m., she explained the warmer room temperature at first was bearable because she was anemic and was given a fan in her room. She said the daily outside temperatures were getting warmer, but there were still some days with cool outside temperatures, and it wasn't that hot in her room. She stated it was hotter in the hallway because when staff entered her room, she could feel the heat come into the room. She stated the Maintenance Director was checking the room temperatures and told him the room temperature was bearable. On 6/16/2023, she said her room became really hot and although she did not want to move from room [ROOM NUMBER], the facility explained outside temperatures were to increase and needed someone to come to the facility to check the air conditioner. She said she was moved to room [ROOM NUMBER] on 6/16/2023, and Maintenance Director checked room temperatures daily reporting unable to moved back into room [ROOM NUMBER]. She stated she returned to her room [ROOM NUMBER] on 6/20/2023. She explained she was the only resident moved off the hall to return to their room on 6/20/2023 and noticed a new resident was admitted to room [ROOM NUMBER] on 6/20/2023 after she was returned to her room. She said room [ROOM NUMBER] was still warmer than usual after returning on 6/20/2023, but the cool outside temperature in the evenings and a fan in her room kept the room temperature more comfortable. She explained when the door was closed for personal care, the room would get even hotter. She stated over the weekend of 6/24/2023 and 6/25/2023, outside temperatures were not cooling down in the evenings as much and the room temperature became hotter to the point, she was wiping sweat. She said on the weekend of 6/24/2023 and 6/25/2023. she did not see the Maintenance Director, and nursing staff kept ice and water for her to drink. She stated on 6/26/2023 when the Maintenance Director asked her if it was hot in her room, she told him hotter than melted butter. She stated the Maintenance Director informed her someone had unplugged the portable air conditioners on the hall over the weekend of 6/24/2023 and 6/25/2023 and brought in a portable air conditioner to her room on the morning of 6/26/2023 and therefore, felt there was unnecessary heat in her room over the weekend of 6/24/2023 and 6/25/2023. She said after the portable air conditioner was placed in her room on 6/26/2023, her room temperature had cooled down to a comfortable room temperature for her. In a follow up interview with the Maintenance Director on 6/29/2023 at 1:13 p.m., he stated the HVAC service company informed him the air conditioner unit was working with limited airflow and needed supplemental airflow. He explained the facility received estimates on installation of ductless air conditioner units that were approved on 6/27/2023, and he was informed on 6/29/2023 to order. He explained on 6/16/2023 when the air conditioner unit was not working to keep rooms 111 to 114 cool, the residents were moved to other rooms in the facility. He stated Resident #43 wanted to go back to her room [ROOM NUMBER]. He stated he tried to keep room temperatures less than 74 degrees Fahrenheit and on 6/16/2023 room temperatures for rooms 111-114 ranged from 76-77 degrees Fahrenheit. He explained he checked room temperatures throughout the day but didn't record all the room temperatures obtained throughout the day. He stated he was on call all the time, and no one called and reported Resident #43's room being too hot on 6/24/2023 and 6/25/2023. On 6/26/2023, Resident #43 was warmer than usual and placed a portable air conditioner in her room. In an interview with Nurse #3 on 6/29/2023 at 2:03 p.m., he stated Resident #43's room was very hot the weekend of 6/24/2023 and 6/25/2023 and did not recall the resident complaining about the room being too hot. He stated she would let you know if something was wrong. In an interview with Nurse Aide (NA) #4 and NA #5 on 6/29/2023 at 2:52 p.m., NA #5 stated Resident #43 complained of her room being hot on 6/24/2023 and 6/25/2023. They stated rooms 111-114 at the end of the hall have been hot for the last two months, and Administration and the Maintenance Director were aware of the situation. In a phone interview with the operator of a local HVAC service company on 6/29/2023 at 1:38 p.m., he stated he checked the facility's air conditioner on 6/20/2023. He explained the air conditioner unit needed to be upgraded, and the facility's one unit was performing all that it could. He stated the ducts under the ground were full of water and retaining water in the duct work created a humidity issue that was more uncomfortable than heat. He said he was told by the maintenance director there were four rooms that were usually warmer than rest of the facility, but he did not check the temperature of the rooms inside of the facility. In an interview with the Administrator on 6/29/2023 at 5:15 p.m., she stated sometime before 6/15/2023 the air conditioner unit went down, and there was a noticeable increase in the temperature in rooms 109 to 114. She explained the Maintenance Director was monitoring room temperatures, fans were placed in resident rooms as needed, and residents including Resident #43 were moved off the hall. The Administrator stated Resident #43 was moved back to room [ROOM NUMBER] on 6/20/2023 after the air conditioner was serviced, and the room temperature was measuring 68-72 degrees Fahrenheit. She also stated Resident #43 was correct in saying a new resident was admitted to room [ROOM NUMBER] after Resident #43 returned to room [ROOM NUMBER] and stated Resident #43 wanted to move back to room [ROOM NUMBER]. She explained the facility purchased and placed portable air conditioners on the hall to combat the increasing room temperatures rooms for rooms 109-114. She stated during the weekend of 6/24/2023 and 6/25/2026, the portable air conditioners somehow had been turned off causing an increased in Resident #43's room temperature during that time. She stated the Maintenance Director was not informed of the increased room temperature in Resident #43's room on the weekend of 6/24/2023 and 6/25/2023. She said due to lack of communication, Resident #43's increased room temperature was not addressed on 6/24/2023 and 6/25/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to refer a resident with a newly evidence diagnosis of serious mental illness for a level II Pre-admission Screening Resident Review (PASRR) for 1 of 3 residents reviewed for PASSR (Resident #47). The findings included: Resident #47 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder. Review of a psychiatric progress note dated 1/18/23 revealed Resident #47 had been diagnosed with schizoaffective disorder. Review of Resident #47's record revealed no screening for a level II PASSR. Resident #47's quarterly MDS assessment dated [DATE] revealed he was assessed as cognitively intact with no mood symptoms. During the 7-day lookback period he had behavioral symptoms not directed towards others 1-3 days. His diagnoses on the assessment included post-traumatic disorder and schizoaffective disorder. Resident #47 received antipsychotic, antidepressant, and anti-anxiety medications 7 of the 7 days of the lookback period. Review of Resident #47's care plan dated 5/29/23 revealed he was care planned for schizoaffective disorder and post-traumatic disorder. Interventions included mental health consults as needed and compliance with medications. An interview with Social Worker #1 on 6/29/23 at 10:42 AM was conducted. She stated had been employed with the facility since May 2023 and was unsure who requested screenings for level II PASSRs. An interview was conducted with the Administrator on 6/29/23 at 12:15 PM and she stated currently there was no one in the building who had the access to request level II PASSR screenings and once the access was received a level II PASSR screening would be requested for Resident #47.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident #53 was admitted to the facility 3/3/23. Resident #53's quarterly MDS assessment dated [DATE] revealed he was not assessed for cognition and mood. The assessment indicated an interview for the assessment should have been attempted. An assessment was conducted based on staff observations which assessed him as cognitively intact with no mood symptoms. An interview was conducted with MDS Nurse #1 on 6/29/23 at 3:00 PM who stated she completed an interview with residents during their assessment period but was unable to input it into the computerized tool. She stated it was her understanding that if the interview was not placed in the tool before the Assessment Reference Date (ARD) it could not be utilized as part of the assessment. During an interview with the Administrator on 6/29/23 at 4:00 PM she stated MDS assessments should be completed with the information gathered during the assessment process. Based on record review, observations and staff interviews, the facility failed to accurately assess the use of restraints (Resident #28) and cognitive and mood patterns (Resident #45, #41, #18, #30, #47, #53) for 7 of 25 residents whose Minimum Data Set (MDS) were reviewed. Findings included: 1. Resident #28 was admitted to the facility on [DATE]. A review of nursing documentation dated 2/2/2023 to 5/2/2023 did not indicate the use of a trunk restraint or any type of restraint on Resident #28. There was no physician order for the use of a restraint for Resident #28. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 was cognitively intact and exhibited verbal behaviors toward others and other behavioral symptoms not directed toward others. The MDS also indicated the use of a trunk restraint in the seven-day look back period for the MDS. In an interview with Resident #28 on 6/26/2023, she stated the staff had not been applied any type of restraints to her while at the facility. In an interview with Nurse Aide #1 on 6/28/2023 at 3:30 p.m., she stated Resident #28 was confused at times and verbally aggressive toward other. She said Resident #28 had not been physically aggressive and restraints had not been applied to Resident #28 for her aggressive behaviors. In an interview with Nurse #2 on 6/28/2023 at 3:35 p.m., she stated restraints were not used in the facility and had not been applied to Resident #28. She explained Resident #28 sometimes exhibited outburst of loud verbal aggression to staff and other residents and was not physically aggressive toward others. In an interview with the Director of Nursing (DON) on 6/28/2023 at 11:01 a.m., she explained restraints were not used in the facility, and she was not aware of a time a restraint was used on Resident #28. She further stated the facility did not have any type of restraints in the facility to use on residents and that was an error in the coding Resident #28 for restraints. In an interview with MDS Nurse #1 on 6/28/2023 at 3:30 p.m., she stated in answering the questions for restraints on the quarterly MDS, she missed clicked trunk restraint by mistake. She explained Resident #28 should had been coded no for trunk restraint. In an interview on 6/28/2023 at 10:43 a.m. with Nurse #1, the registered nurse who reviewed and signed the quarterly MDS dated [DATE] was complete, stated she didn't review the MDS information word for word and did not see when reviewing that MDS Nurse #1 had coded in error the use of a trunk restraint on Resident #28's MDS. In an interview on 6/29/2023 at 5:12 p.m. with the Administrator, she stated the MDS assessment should reflect an accurate picture of Resident #28's condition, and the facility was not conducting audits to review accuracy of MDS assessments. 2. Resident #45 was admitted to the facility on [DATE]. Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was not assessed for cognition and mood. The assessment indicated an interview for assessment should have been attempted. An assessment was conducted based on staff observations which assessed him as cognitively intact with no mood symptoms. An interview was conducted with MDS Nurse #1 on 6/29/23 at 3:00 PM who stated she completed an interview with residents during their assessment period but was unable to input it into the computerized tool. She stated it was her understanding that if the interview was not placed in the tool before the Assessment Reference Date (ARD) it could not be utilized as part of the assessment. During an interview with the Administrator on 6/29/23 at 4:00 PM she stated MDS assessments should be completed with the information gathered during the assessment process. 3. Resident #41 was admitted to the facility on [DATE] with diagnoses that included dementia. Resident #41's annual MDS assessment dated [DATE] revealed he was not assessed for cognition and mood. The assessment indicated an interview for the assessment should have been attempted. An assessment was conducted based on staff observations which assessed him as having a moderate cognitive impairment with no mood symptoms. An interview was conducted with MDS Nurse #1 on 6/29/23 at 3:00 PM who stated she completed an interview with residents during their assessment period but was unable to input it into the computerized tool. She stated it was her understanding that if the interview was not placed in the tool before the Assessment Reference Date (ARD) it could not be utilized as part of the assessment. During an interview with the Administrator on 6/29/23 at 4:00 PM she stated MDS assessments should be completed with the information gathered during the assessment process. 4. Resident #18 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder. Resident #18's admission MDS assessment dated [DATE] revealed he was not assessed for cognition and mood. The assessment indicated an interview for the assessment should have been attempted. An assessment was conducted based on staff observations which assessed him as cognitively intact with no mood symptoms. An interview was conducted with MDS Nurse #1 on 6/29/23 at 3:00 PM who stated she completed an interview with residents during their assessment period but was unable to input it into the computerized tool. She stated it was her understanding that if the interview was not placed in the tool before the Assessment Reference Date (ARD) it could not be utilized as part of the assessment. During an interview with the Administrator on 6/29/23 at 4:00 PM she stated MDS assessments should be completed with the information gathered during the assessment process. 5. Resident #30 was admitted to the facility on [DATE] with diagnoses that included dementia. Resident #30's quarterly MDS assessment dated [DATE] revealed he was not assessed for cognition and mood. The assessment indicated an interview for the assessment should have been attempted. An assessment was conducted based on staff observations which assessed him as cognitively intact with no mood symptoms. An interview was conducted with MDS Nurse #1 on 6/29/23 at 3:00 PM who stated she completed an interview with residents during their assessment period but was unable to input it into the computerized tool. She stated it was her understanding that if the interview was not placed in the tool before the Assessment Reference Date (ARD) it could not be utilized as part of the assessment. During an interview with the Administrator on 6/29/23 at 4:00 PM she stated MDS assessments should be completed with the information gathered during the assessment process. 6. Resident #47 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder. Resident #47's quarterly MDS assessment dated [DATE] revealed he was not assessed for cognition and mood. The assessment indicated an interview for the assessment should have been attempted. An assessment was conducted based on staff observations which assessed him as cognitively intact with no mood symptoms. An interview was conducted with MDS Nurse #1 on 6/29/23 at 3:00 PM who stated she completed an interview with residents during their assessment period but was unable to input it into the computerized tool. She stated it was her understanding that if the interview was not placed in the tool before the Assessment Reference Date (ARD) it could not be utilized as part of the assessment. During an interview with the Administrator on 6/29/23 at 4:00 PM she stated MDS assessments should be completed with the information gathered during the assessment process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to place signage indicating the use of oxygen and failed to administer supplemental oxygen as prescribed for 4 of 4 residents reviewed for oxygen (Resident #19, #53, #214 and #25.) Findings included: 1. Resident #19 was admitted to the facility on [DATE] with diagnosis that included shortness of breath. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 was cognitively intact and used supplemental oxygen. Physician orders dated 6/13/2023 included oxygen at 2 liters continuously by nasal cannula for shortness of breath. On 6/27/2023 at 9:24 a.m. Resident #19 was observed wearing oxygen via nasal cannula. There was no warning signage observed to communicate oxygen in use outside the room on the door or door frame. In an interview with the Director of Nursing on 6/28/2023 at 10:58a.m., she stated a red magnetic warning sign should had been placed outside the residents' door or door frame to communicate oxygen was in use in the room. She explained the Maintenance Director had the oxygen warnings signs and was responsible for placing on the outside of resident rooms. She stated if nursing was responsible, she would make sure magnetic oxygen in use warning signs were placed on the residents' doors. In an interview with the Maintenance Director on 6/28/2023 at 11:26a.m., he stated he was not responsible for applying oxygen warning signs outside residents' rooms. He explained he had not seen the facility use magnetic oxygen in use warning signs in the facility and he would have to order some magnetic oxygen in use warning signs. He stated the nurse that admitted the residents would have been responsible to apply the oxygen in use warning sign on the door. 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #53 was cognitively intact and used supplemental oxygen. Physician orders dated 3/6/23 included oxygen at 3 liters continuously by nasal cannula for chronic respiratory failure. On 6/26/23 at 1:59 p.m., Resident #53 was observed to be receiving supplemental oxygen via nasal cannula. There was no warning signage observed to communicate oxygen in use outside the room on the door or door frame. In an interview with the Director of Nursing on 6/28/2023 at 10:58a.m., she stated a red magnetic warning sign should had been placed outside the residents' door or door frame to communicate oxygen was in use in the room. She explained the Maintenance Director had the oxygen warnings signs and was responsible for placing on the outside of resident rooms. She stated if nursing was responsible, she would make sure magnetic oxygen in use warning signs were placed on the residents' doors. In an interview with the Maintenance Director on 6/28/2023 at 11:26a.m., he stated he was not responsible for applying oxygen warning signs outside residents' rooms. He explained he had not seen the facility use magnetic oxygen in use warning signs in the facility and he would have to order some magnetic oxygen in use warning signs. He stated the nurse that admitted the residents would have been responsible to apply the oxygen in use warning sign on the door. 3. Resident #214 was admitted to the facility on [DATE] with diagnoses that included heart failure. Physician orders dated 6/15/2023 included oxygen at 2 liters continuously by nasal cannula for heart failure. The admission Minimum Data Set (MDS) had not been completed for Resident #214. On 6/26/2023 at 2:54p.m. Resident #214 was observed wearing oxygen via nasal cannula at 3 liters per minute. There was no warning signage observed to communicate oxygen in use outside the room on the door or on the door frame. On 6/29/23 at 3:38p.m. an interview and observation was completed with Nurse #3 who was providing care for Resident #214. Nurse #3 observed Resident #214 to be receiving supplemental oxygen at 3 liters per minute. Nurse #3 confirmed that Resident #214's oxygen order was for 2 liters per minute and explained the flow rate should match Resident #214's order. Nurse #3 stated that it was the responsibility of the nurses to check the flow rate each shift and that he had not checked it that day. In an interview with the Director of Nursing on 6/28/2023 at 10:58a.m., she stated a red magnetic warning sign should had been placed outside the residents' door or door frame to communicate oxygen was in use in the room. She explained the Maintenance Director had the oxygen warnings signs and was responsible for placing on the outside of resident rooms. She stated if nursing was responsible, she would make sure magnetic oxygen in use warning signs were placed on the residents' doors. In an interview with the Maintenance Director on 6/28/2023 at 11:26a.m., he stated he was not responsible for applying oxygen warning signs outside residents' rooms. He explained he had not seen the facility use magnetic oxygen in use warning signs in the facility and he would have to order some magnetic oxygen in use warning signs. He stated the nurse that admitted the residents would have been responsible to apply the oxygen in use warning sign on the door. 4. Resident #25 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease. Resident #25's care plan revised 9/09/2023 included a focus for oxygen therapy due to ineffective gas exchange. Interventions included changing oxygen tubing and nebulizer supplies weekly and providing extension tubing and portable oxygen for ambulation. Use of warning signs for use of oxygen was not included as an intervention. Physician orders dated 9/28/2021 included oxygen at 2 liters continuously by nasal cannula to keep oxygen saturation above 90%. The quarter Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 was cognitively intact and used oxygen. On 6/26/2023 at 12:13p.m. Resident was observed wearing oxygen via nasal cannula at 2 liters per minute. There was no warning signage observed to communicate oxygen in use outside the room on the door or on the door frame. In an interview with the Director of Nursing on 6/28/2023 at 10:58a.m., she stated a red magnetic warning sign should had been placed outside Resident #25's door or door frame to communicate oxygen was in use in the room. She explained the Maintenance Director had the oxygen warnings signs and was responsible for placing on the outside of Resident #25's room. She stated if nursing was responsible, she would make sure magnetic oxygen in use warning signs were placed on the resident's doors. In an interview with the Maintenance Director on 6/28/2023 at 11:26a.m., he stated he was not responsible for applying oxygen warning signs outside residents' rooms. He explained he had not seen the facility use of magnetic oxygen in use warning signs in the facility and he would have to order some magnetic oxygen in use warning signs. He stated the nurse that admitted Resident #25 would have been responsible to apply the oxygen in use warning sign on the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to protect confidential medical information by leaving the Medication Administration Record open during medication pass for 2 of 7 residents observed during medication pass (Resident #11 and #48). The findings included: 1. Resident #11 was admitted on [DATE]. On 4/27/22 at 11:23 AM a medication pass was conducted with Nurse #2. The medication cart was in the hall outside of the nurse ' s station that was at the corner of 2 halls. Nurse #2 was observed to prepare a medication for Resident #11. The computer with the resident ' s medication administration record was on a rack over the medication cart and the screen could be easily seen by anyone that walked by the cart. Nurse #2 left the medication administration record open on the computer screen and walked to the end of the hall and went in the room of Resident #11 to administer the medication and then returned to the medication cart. 2. Resident #48 was admitted to the facility on [DATE]. On 4/27/22 at 11:32 AM Nurse #2 was observed during a medication pass for Resident #48. The medication cart was in the hall outside of the nurse ' s station at the corner of 2 halls. The computer was hanging on a rack over the medication cart and the screen could be easily seen by anyone that walked by the cart. Nurse #2 was observed to leave the medication cart with the medication administration record open and went in the room of Resident #48. Nurse #2 was observed to return to the cart and then left the cart and went into the medication room at the back of the nurse ' s station. Nurse #2 then walked down the hall to another nurse ' s station, returned to the cart and returned to the room of Resident #48 to administer a medication. The medication administration record was observed to be open during the entire observation. Staff and residents were observed walking or wheeling in wheelchairs past the medication cart during the continuous observation. On 4/27/22 at 11:42 AM Nurse #2 stated in an interview that she usually clicked the lock icon to close the screen when she left the cart and she thought she did that. On 4/28/22 at 2:00 PM The Director of Nursing stated in an interview that the nurse was supposed to lock the computer screen when away from the medication cart.

Based on observation, record review, manufacturer's specifications and interviews, the facility failed to have a medication error rate of less than 5 percent as evidenced by 2 medication errors out of 27 opportunities, resulting in a medication error rate of 7.4 percent for 2 of 7 residents observed during medication pass (Resident #46 and #7). The findings included: 1. Review of the manufacturer's package insert for Rybelsus read: Take Rybelsus on an empty stomach when patient first wakes up with a sip of plain water (no more than 4oz (ounces). Take at least 30 minutes before the first food, beverage or other oral medications of the day. Review of the April Medication Administration Record for Resident #46 revealed the following entries: Chewable Aspirin 81 milligrams (mg) 1 tablet in the AM (morning) and was scheduled for 8:00 AM. Lisinopril 10mg 1 tablet one time a day and was scheduled for 8:00 AM. Lasix 40mg 1 tablet one time a day and was scheduled for 8:00 AM. Rybelsus tablet (Antihyperglycemic) 14mg one time a day and was scheduled for 8:00 AM. Clonidine 0.1mg tablet three times a day and was scheduled for 10:00 AM. On 4/28/22 at 9:00 AM, Nurse #1 was observed to prepare medications for Resident #46. Nurse #1 was observed to place the following medications in a medicine cup: Chewable Aspirin 81 milligrams (mg) 1 tablet, Lisinopril 10mg 1 tablet, Rybelsus 14mg 1 tablet and Clonidine 0.1mg 1 tablet. The Nurse stated she did not have any Lasix for him on the cart and would have to give him the Lasix later. Nurse #1 was observed to enter the room of Resident #46 to administer the medications. Resident #46 removed the Rybelsus from the cup and took with a sip of water. Resident #46 stated he was supposed to not take any other medications with the Rybelsus for 45 minutes after taking the Rybelsus and he refused to take the other medications. Nurse #1 removed the rest of the medications from the resident's room and disposed of the medications and stated she would go back later and administer the medications and the Lasix. On 4/28/22 at 9:30 AM, Nurse #1 stated in an interview that at one time the Rybelsus was scheduled to be given at 7:30 AM but Resident #46 did not want to wake up at that time to take the medication, so the time had been changed. Nurse #1 further stated this was done to accommodate the resident's preference but did not know when the change was made. On 4/28/21 at 2:01 PM the Director of Nursing (DON) stated in an interview that Resident #46 could be difficult when taking his medications and thought that the time change was made to accommodate his preferences. The DON further stated it was her expectation that medications be given per physician orders as prescribed and at the correct time. 2. On 4/28/22 at 9:40 AM, Nurse #2 was observed to prepare medications for Resident #7 to administer via a gastric tube. Nurse #2 dispensed Aspirin 81 milligrams (mg) 1 tablet, Lisinopril 5mg 1 tablet, Metformin 500mg 1 tablet and Vimpat 150mg 1 tablet. Nurse #2 then crushed each tablet individually and placed each crushed tablet in a separate medication cup and added 5 milliliters (ml) of water to each of the 4 cups. Nurse #2 also prepared a multi-vitamin liquid 15ml in a cup and mixed 17 grams of Miralax in 4 ounces of water. Nurse #2 was observed to administer the medications via gastric tube per professional standards with no concerns. Upon review of the physician's orders and the Medication Administration Record there was an order for Keppra 1500mg (liquid) via gastric tube scheduled for 8:00 AM. The medication was not signed as given on the Medication Administration Record by Nurse #2 on 4/28/22. On 4/28/22 at 10:45 AM Nurse #2 stated in an interview that she gave the Keppra during the medication pass observation. Nurse #2 was asked if she gave the 8:00 AM dose prior to the medication pass observation and she stated no that she gave the Keppra during the observation of her medication pass at 9:40 AM. Nurse #2 stated the order was for liquid Keppra, but the pharmacy had sent the medication in pill form. Nurse #2 was observed to remove the Keppra tablets for Resident #7 from the medication cart and there were 2 blister packs held together with a rubber band and one package had a large tablet (1000mg) in each blister and the other package had 1/2 tablet (500mg) in each blister. The Nurse stated she gave the 1 ½ tablets during the observation of the medication pass. During the medication pass, Nurse #2 was observed to crush 4 small tablets and did not dispense the large Keppra tablets. On 4/28/22 at 2:04 PM the Director of Nursing stated in an interview that she expected medications to be given per physician's orders as prescribed and at the correct time.

Based on observations, record review and staff interviews, a staff member failed to wash or sanitize their hands after touching objects on the floor and while passing out meal trays to 3 of 3 residents observed the mid-day meal (Resident #3, #15 and #27). The findings included: The facility policy titled Hand Hygiene and dated 11/1/20 read under Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The section titled Policy Explanation and Compliance Guidelines #3 read: Alcohol-based hand rub is the preferred method for cleansing hands in most clinical situations. The Hand Hygiene Table noted to wash hands with either soap or water or alcohol-based hand rub (preferred) between resident contacts and after handling contaminated objects. On 4/25/22 at 12:11 AM an observation was made of the delivery of the mid-day meal to residents on the hall and in the dining room. Nursing Assistant (NA) #1 was observed to deliver a meal tray to the overbed table for Resident #15. The NA left the room without sanitizing her hands and removed a tray off the meal cart and brought to Resident #3 who resided in the same room as Resident #15. The NA sat the tray down on the bedside table and moved the overbed table towards the resident's bed. A phone cord was observed to be wrapped around the wheel of the overbed table and when NA #1 tried to move the table, the table turned over and landed on its side on the floor. NA #1 removed the phone cord from around the wheel and sat the table upright and positioned the table in front of Resident #3 and proceeded to use the utensils on the tray to cut up the resident's food and removed the tops from containers on the tray and placed the utensils in front of the resident so the resident could eat. NA #1 then went over the Resident #15 without sanitizing or washing her hands and touched the utensils on the tray and opened containers on the tray. NA #1 was observed to leave the room without sanitizing or washing her hands. NA #1 returned to the meal cart and removed a tray and carried the tray to the main dining room and placed in front of Resident #27 and touched the utensils on the tray and opened the containers on the tray for the resident to eat. The NA did not wash or sanitize her hands. NA #1 was observed to touch her face mask and her hair with her hands and left the dining room and walked to the linen cart in the hall and removed a blanket from the cart and walked back to the dining room and placed the blanket over another resident. NA #1 then left the dining room and went in a hall bathroom and washed her hands. On 4/25/22 at 12:24 PM, an interview was conducted with NA #1. The NA was asked when she was supposed to wash or sanitize her hands and the NA responded: I do it all day. The observation during the lunch meal was described for the NA and the NA stated that she sanitized her hands all day and did not acknowledge the breaches in infection control practices. On 4/28/22 at 2:02 PM the Director of Nursing stated in an interview that she expected the staff to sanitize or wash their hands between each resident when passing out meal trays.