**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with resident and staff, the facility failed to maintain a wheelchair in good repair for 1 of 1 resident reviewed for safe, clean, comfortable and homelike environment (Resident #18). Resident #18 was admitted to the facility on [DATE]. Review of weekly skin assessments from 06/07/25 through 08/09/25 revealed Resident #18's skin was intact. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #18 with moderate impairment in cognition and her primary mobility device was a wheelchair. During an observation conducted on 08/11/25 at 11:30 AM, Resident #18 was seen sitting in her wheelchair next to her bed in her room. The vinyl cover of the left armrest of her wheelchair was in disrepair with multiple torn spots, ripped edges, and cracked lines approximately size of 2.5 inches by 9 inches. Resident #18 was seen wearing a short-sleeved shirt and her left arm was contacting with the broken armrest during the observation. An interview was conducted with Resident #18 on 08/11/25 at 11:32 AM. She stated that she did not know how long the vinyl cover of the left arm rest had been torn, ripped, and cracked and it bothered her as it irritated her skin at times. She added she used the wheelchair frequently and hoped the staff would fix it soon. During a joint observation conducted on 08/12/25 at 10:36 AM with Nurse #4 and Nurse Aide (NA) #2 in the dining room, the vinyl cover of the left armrest of Resident #18's wheelchair remained in disrepair. Resident #18 was sitting in the wheelchair with her left arm contacting the broken armrest. Nurse #4 assessed Resident #18's left arm immediately and reported that her skin was intact without any redness, rashes or open areas. An interview was conducted on 08/12/25 at 10:41 AM with Nurse #4. She acknowledged that she had provided care for Resident #18 frequently in the past few months, but she did not notice the vinyl cover of the left armrest of Resident #18's wheelchair was broken. She added the broken armrest needed to be fixed immediately to ensure Resident #18's skin integrity. During an interview conducted on 08/12/25 at 10:43 AM, NA #2 stated she noticed the vinyl cover of the left armrest of Resident #18's wheelchair was broken and had reported her findings to the Rehabilitation staff a couple weeks ago. However, she could not recall the name of the rehabilitation staff member. She stated the broken armrest needed to be fixed as soon as possible to avoid skin irritation. An interview was conducted on 08/12/25 at 10:48 AM with the Rehabilitation Director. She stated wheelchair repair was typically handled by the maintenance department. The Rehabilitation Director indicated the department depended on nursing staff to report repair needs for wheelchairs. The Rehabilitation Director explained they would address simple repair issues and notify the maintenance department of complicated repair tasks. She denied she had received any reports related to wheelchair repair from nursing staff in the past couple weeks. An interview was conducted on 08/12/25 at 1:17 PM with the Director of Nursing. She expected the staff to be more attentive to residents' mobility devices when providing care and to report repair needs to the maintenance department in a timely manner. It was her expectation for all the mobility devices to be in good repair all the times. During an interview conducted on 08/12/25 at 1:28 PM, the Maintenance Director acknowledged that the vinyl cover of the left armrest for Resident #18's wheelchair was in disrepair and needed to be fixed immediately. He stated the maintenance department did not perform routine walk throughs in the facility to identify repair needs for wheelchairs. Instead, the maintenance department depended heavily on staff to report repair needs via work order clipboard in each nurse station or verbal notification. He typically checked the work order clipboard at least once daily to ensure all the repair needs were addressed in a timely manner. The Maintenance Director stated he did not know the vinyl cover of the left armrest of Resident #18's wheelchair was broken as he never received any report from the staff. He stated it was important for all the staff to be more attentive to residents' mobility devices and report repair needs as indicated when providing care or performing housekeeping. An interview was conducted with the Administrator on 08/13/25 at 12:06 PM. He expected all the staff, including housekeepers and management staff to be more attentive to residents' repair needs and report the findings to maintenance department in a timely manner. It was his expectation for all the mobility devices including wheelchairs to be in good repair all the times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication, lorazepam (a medication used to relieve anxiety disorder), had a stop date of 14 days for 1 or 5 residents (Resident #3) reviewed for unnecessary medications.Resident #3 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. The care plan for anxiety disorder initiated on 09/22/24 revealed Resident #3 received antianxiety related to anxiety disorder. The goal was to have decreased episodes of anxiety through the next review date. Interventions included administering medications as ordered by the physician. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #3's with severely impaired cognition and indicated she received antianxiety medications during the assessment period. A review of physician's orders dated 07/05/25 revealed Resident #3 had an order to receive one (1) tablet of lorazepam 0.5 milligrams (mg) by mouth once every 4 hours PRN for anxiety disorder. In addition, Resident #3 also had a scheduled order for lorazepam 0.5 mg 4 times daily initiated on 07/05/25. Both orders were entered into the electronic health records by the Medical Director, and there was no stop date for the PRN lorazepam order. A review of Resident #3's July and August 2025 medication administration records (MARs) revealed the PRN lorazepam order that initiated on 07/05/25 remained an active order. Further review of the MARs revealed Resident #3 had not been administered any doses of the PRN lorazepam. An attempt for a phone interview with the Medical Director on 08/12/25 at 12:48 PM was unsuccessful. He did not return the call. During an interview conducted on 08/12/25 at 1:31 PM, Nurse #4 stated she was aware of Resident #3's PRN lorazepam as it remained an active order. She indicated Resident #3 cried frequently in the past and had an order to receive PRN lorazepam 0.5 mg up to 4 times daily. On average, Resident #3 received the PRN lorazepam 2 to 3 times daily in the past. After the physician initiated the scheduled lorazepam 0.5 mg 4 times daily on 07/05/25, the PRN lorazepam had not been administered so far as Resident #3's behavior was under control. Nurse #4 stated she knew all PRN psychotropic drugs were limited to 14 days. Nurses #4 indicated when she saw the PRN lorazepam order for Resident #3 without a stop date, she thought the rules had been changed. An interview was conducted on 08/13/25 at 11:10 AM with the Director of Nursing (DON). She stated it was her expectation for all the physicians to follow the Centers for Medicare and Medicaid Services (CMS) guidelines to set a stop date of 14 days for PRN psychotropic medications. The DON denied this was a system failure but an isolated oversight by the Medical Director and the Consultant Pharmacist. During an interview conducted with the Administrator on 08/13/25 at 12:06 PM, he stated Resident #3's PRN Lorazepam order should have a stop date of 14 days. It was his expectation for all the physicians to follow CMS guidelines when prescribing PRN psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of bladder and bowel, and medications for 2 of 5 residents (Resident #53 and Resident #21) whose MDS were reviewed.The findings included:1.Resident #53 was admitted to the facility on [DATE].A nursing progress note dated 7/20/25 in Resident #53's medical record indicated the nurse discontinued Resident #53's urinary catheter per order without difficulty and without resident complaint.The admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #53 as having an indwelling catheter and was frequently incontinent of urine.An interview with the MDS Coordinator on 8/13/25 at 10:21 AM revealed she should have coded Resident #53's admission MDS as having no indwelling catheter. The MDS Coordinator stated that Resident #53's urinary incontinence status was auto populated based on responses made by the nurse aides and she was frequently incontinent of urine.An interview with the Director of Nursing on 8/13/25 at 2:05 PM revealed the MDS Coordinator should have coded Resident #53's admission MDS accurately. 2.Resident #21 was admitted to the facility on [DATE].The quarterly MDS dated [DATE] coded Resident #21 as taking anticoagulants. An anticoagulant, also known as a blood thinner, is a medication that helps prevent blood clots from forming or growing larger.A review of the Medication Administration Record for Resident #21 for July 2025 indicated she received Apixaban (an anticoagulant) from 7/1/25 to 7/3/25.An interview with the MDS Coordinator on 8/13/25 at 10:17 AM revealed she didn't see that the Apixaban had been discontinued on 7/3/25 for Resident #21. The MDS Coordinator stated she should not have coded Resident #21 as receiving anticoagulants since she did not receive any anticoagulants during the 7-day look back period from 7/25/25.An interview with the Director of Nursing on 8/13/25 at 2:05 PM revealed the MDS Coordinator should have coded Resident #21's quarterly MDS accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews with staff and the Consultant Pharmacist, the Consultant Pharmacist failed to identify a drug irregularity and provide recommendations for 1 of 5 residents reviewed for unnecessary medications (Residents #3). Resident #3 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #3's with severely impaired cognition and indicated she received antianxiety medication during the assessment period. A review of physician orders dated 07/05/25 revealed Resident #3 had an order to receive one (1) tablet of lorazepam 0.5 milligrams (mg) by mouth once every 4 hours as needed (PRN) for anxiety disorder. In addition, Resident #3 also had a scheduled order of lorazepam 0.5 mg 4 times daily initiated on 07/05/25. Both orders were entered into the electronic health records by the Medical Director, and there was no stop date for the PRN lorazepam order. A review of Resident #3's July and August 2025 medication administration records (MARs) revealed the PRN lorazepam order that initiated on 07/05/25 remained an active order. Further review of the MARs revealed Resident #3 had not been administered any doses of the PRN lorazepam. A review of Resident #3's medical record revealed the Consultant Pharmacist had conducted a monthly Medication Regimen Review (MRR) on 08/03/25. Further review of Resident #3's August 2025 MMR revealed no recommendations related to the PRN lorazepam order without a stop date had been made by the Consultant Pharmacist to the facility after completing the MRR on 08/03/25. During a phone interview conducted on 08/12/25 at 10:57 AM, the Consultant Pharmacist confirmed he had completed the monthly MRR for Resident #3 on 08/03/25 but he did not recommend the Medical Director to have a stop date for the PRN lorazepam order. He recalled identifying the PRN lorazepam order that originated on 07/05/25 without a stop date but he could not explain why he did not make a recommendation to the physician. He stated he was familiar with the Centers for Medicare and Medicaid Services (CMS) guidelines and indicated the PRN lorazepam order should have a stop date. He attributed the incident to his oversight. An attempt for a phone interview with the Medical Director on 08/12/25 at 12:48 PM was unsuccessful. He did not return the call. During an interview conducted on 08/12/25 at 1:31 PM, Nurse #4 stated she was aware of Resident #3's PRN lorazepam as it remained an active order. She indicated Resident #3 cried frequently in the past and had an order to receive PRN lorazepam 0.5 mg up to 4 times daily. On average, Resident #3 received the PRN lorazepam 2 to 3 times daily in the past. After the physician initiated the scheduled lorazepam 0.5 mg 4 times daily on 07/05/25, the PRN lorazepam had not been administered so far as Resident #3's behavior was under control. During an interview conducted on 08/13/25 at 11:10 AM, the Director of Nursing (DON) stated she expected the Consultant Pharmacist to identify irregularities related to Resident #3's PRN lorazepam when performing monthly MRRs and report the findings to the facility in a timely manner. The DON further stated it was her expectation that the Consultant Pharmacist followed the CMS guidelines when conducting MRRs. An interview was conducted with the Administrator on 08/13/25 at 12:06 PM. He stated Resident #3's physician order for PRN Lorazepam should have a stop date of 14 days. It was his expectation for the Consultant Pharmacist to identify irregularities when performing monthly MRRs and report the findings to the facility in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions when 3 of 6 staff members (Nurse #2, Nurse #1 and Nurse Aide #1) reviewed for infection control practices failed to wear a gown while performing and assisting with wound care.The findings included: A review of the facility’s undated infection control policy entitled, “Enhanced Barrier Precautions,” indicated enhanced barrier precautions apply when a resident is NOT known to be infected or colonized with any MDRO ([NAME]-drug resistant organism), has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for enhanced barrier precautions (EBP) include dressing, bathing/showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, providing bed mobility, changing linens, prolonged, high-contact with items in the resident’s room, with resident’s equipment, or with resident’s clothing or skin, device care or use and wound care (any skin opening requiring a dressing). 1. An observation of wound care on Resident #8 was conducted on 8/12/25 at 1:42 PM with Nurse #2. Nurse #2 was observed performing hand hygiene using hand sanitizer, donned gloves, and removed the dressing from Resident #8’s pressure ulcer to the right buttock. She removed her gloves, applied hand sanitizer to both hands and donned new gloves. She sprayed the wound with wound cleanser, wiped it with dry gauze, removed her gloves and performed hand hygiene using hand sanitizer. She donned new gloves, applied Silvadene cream to the wound and covered it with a foam dressing. She removed her gloves and performed hand hygiene using hand sanitizer. There was no signage for EBP or personal protective equipment outside of Resident #2’s door. An interview with Nurse #2 on 8/12/25 at 1:50 PM revealed Resident #8’s dressing change was scheduled for the evening shift, and it was normally done by the evening shift nurse. Nurse #2 stated she thought the ordered treatment for Resident #8 was just for protection and that the wound was not open which was why she didn’t put on a gown prior to doing the wound care. Nurse #2 stated Resident #8 probably should have been placed on EBP because of her open stage 2 pressure ulcer to the right buttock. An interview with Nurse #3 on 8/12/25 at 3:32 PM revealed she had been doing Resident #8’s treatment on the evening shift since she observed an open pressure ulcer to her right buttock sometime in July 2025. Nurse #3 stated that she was not aware that she had to place Resident #8 on EBP, and that she thought EBP was just for residents with medical devices or active infections. Nurse #3 stated she had never been told by the facility’s Infection Preventionist that EBP was required for residents with open wounds. An interview with the Infection Preventionist (IP) on 8/13/25 at 3:27 PM revealed she was not aware of Resident #8’s pressure ulcer being open. The IP stated she knew Resident #8 used to have a treatment to her buttocks for protection only. The IP stated that Nurse #3 should have initiated EBP for Resident #8 after she identified Resident #8’s pressure ulcer to her right buttock. The IP stated that Nurse #3 received education on EBP, and she was not sure why Nurse #3 was confused except that she might not have understood the education on EBP. The IP further stated that Nurse #2 received education on EBP and should have worn a gown and gloves while providing wound care to Resident #8. An interview with the Director of Nursing (DON) on 8/13/25 at 2:05 PM revealed she was not sure how EBP got missed for Resident #8. The DON stated Resident #8 should have been placed on EBP as soon as her pressure ulcer was identified, and that the nurses should follow EBP and wear a gown and gloves when providing wound care to Resident #8. 2. An observation of wound care on 08/12/25 at 3:10 PM on Resident #50 was conducted with Nurse #1 and Nurse Aide (NA) #1 assisting. Nurse #1 and NA #1 were observed performing hand hygiene, donned gloves, and while NA #1 held the resident over on her side, Nurse #1 removed the dressing from Resident #50’s pressure area to the sacrum. He removed his gloves, washed his hands with soap and water and donned clean gloves. Nurse #1 cleansed the wound with normal saline soaked gauze and dried with another gauze. He doffed his gloves, sanitized his hands and donned new gloves and applied calcium alginate, and covered the wound with foam dressing. Nurse #1 and NA #1 removed their gloves, sanitized their hands, Nurse #1 gathered his supplies and NA #1 gathered the trash and they both left the room. An interview on 08/12/25 at 3:30 PM with NA #1 revealed her understanding of Enhanced Barrier Precautions (EBP) was that she only had to wear a gown while providing incontinence care to Resident #50. An interview on 08/12/25 at 3:40 PM with Nurse #1 revealed he should have worn a gown to perform Resident #50’s wound care. Nurse #1 stated he was in a hurry to get it done and just forgot to put the gown on but said he knew that he was supposed to wear a gown into Resident #50’s room to perform her wound care. An interview on 08/13/25 at 3:20 PM with the Infection Preventionist (IP) revealed Nurse #1 and NA #1 had received education on EBP, and she was not sure why they had not worn a gown in the room because the sign was on the wall beside her door and the bin filled with personal protective equipment (PPE) right outside her door. The IP stated Nurse #1 and NA #1 should have worn a gown while performing wound care to Resident #50. An interview on 08/13/25 at 2:05 PM with the Director of Nursing (DON) revealed she was not sure why Nurse #1 and NA #1 had not worn a gown into Resident #50’s room to do her wound care since she was on EBP. The DON stated the signage was on the wall beside her door and personal protective equipment (PPE) was in a bin right outside her door and there was no excuse for them not wearing a gown while providing wound care to Resident #50.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure staff implemented their abuse policy and procedure in the areas of reporting, investigation and protection when nursing staff did not immediately inform the Administrator when a resident reported an allegation of abuse. This failure resulted in a delay in reporting the allegation to the State Agency, local law enforcement and Adult Protective Services (APS) and the facility investigating the allegation for 1 of 3 residents reviewed for abuse (Resident #1). Findings included: The facility's undated policy titled Abuse, Neglect, Exploitation, or Misappropriation of Property - Reporting and Investigating revealed in part, all reports of resident abuse including injuries of unknown origin, neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies as required by current regulations and thoroughly investigated by facility management. Findings of all the investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions if any are needed for the protection of residents. Resident #1 was admitted to the facility on [DATE] and discharged home on 6/27/25. A phone interview on 7/2/25 at 3:10 PM with Nurse Aide (NA) #1 revealed that she worked from 7:00 AM to 11:00 PM on 6/21/25. NA #1 stated that she along with NA #2 were the ones who discovered the bruise on Resident #1's right shoulder during her shower on Saturday 6/21/25 at approximately 11:00 AM. NA #1 stated that she asked Resident #1 what happened. Resident #1 stated that she was hit by a large black woman at night. Resident #1 then stated that she was hit by a lady last week. NA #1 stated that Resident #1 changed her story when NA #1 asked her about the bruise on Resident #1's right shoulder. NA #1 stated that she told Nurse #1 immediately after talking with Resident #1. A phone interview on 7/2/25 at 3:21 PM with NA #2 revealed that she worked from 7:00 AM to 11:00 PM on 6/21/25. NA #2 stated that she and NA #1 were giving Resident #1 a shower and they noticed a bruise on Resident #1's right shoulder. NA #2 asked Resident #1 what had happened. Resident #1 stated that that woman had hit her. She asked Resident #1 what woman? Resident #1 would only say that woman hit her. NA #2 stated that she got Nurse #1 immediately. A phone interview on 7/2/25 at 1:11 PM with Nurse #1 revealed that she worked from 7:00 AM to 7:00 PM on 6/21/25. Nurse #1 stated that Nurse Aide #1 found a bruise on Resident #1's right shoulder during her shower on 6/21/25. Nurse #1 asked Resident #1 what happened. Resident #1 stated that woman hit me. Nurse #1 asked what woman? Resident #1 stated that black lady at night. Nurse #1 stated that she told the Nurse Supervisor immediately after talking with Resident #1. Nurse #1 stated she could not remember if she told the Administrator or the Director of Nursing (DON). She stated that their policy was to report to their immediate supervisors and the Director of Nursing (DON) and file an immediate report. She stated that she should have reported the allegation to the DON since Resident #1 stated that someone had hit her. A phone interview on 7/2/25 at 1:33 PM with the Nurse Supervisor revealed that she worked from 7:00 AM to 7:00 PM on 6/21/25. She stated that Nurse #1 told her about the bruise on Resident #1's right shoulder. She stated that she spoke with Resident #1 on Saturday (6/21/25) and Resident #1 told her that a lady hit her. The Nurse Supervisor stated that she waited a few hours later and Resident #1 told her it was that black girl hit me last week. She stated that Resident #1 had habit of changing her story and giving conflicting information during conversations which was why she waited a few hours to ask Resident #1 about the incident a second time. The Nurse Supervisor stated that she told the DON on Saturday 6/21/25 or Sunday 6/22/25 night, but she did not tell her immediately. She stated that she should have told the DON immediately since Resident #1 stated that she had been hit by someone. A joint interview on 7/2/25 at 4:47 PM with the DON and the Administrator revealed they both expected staff to notify them immediately upon discovery of any abuse allegation. The DON did not recall the Nurse Supervisor telling her about Resident #1's abuse allegation on 6/21/25 or 6/22/25. The DON stated that she would have suspended any suspected staff immediately pending an investigation. The Administrator was notified of the abuse allegation by the surveyor on 7/2/25. The Administrator stated that had he been notified immediately he would have reported the allegation to the state, local law enforcement, and APS within 2 hours. The Administrator stated he would have completed a thorough investigation and provided education to the staff. The DON stated that Nurse #1 and the Nurse Supervisor should have told her about the allegation of abuse immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to complete a Significant Change in Status Assessment for a resident who had been discharged from hospice care for 1 of 3 residents reviewed for hospice (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses including heart failure and diabetes. Review of Resident #3's orders revealed he had been admitted to hospice services on 03/03/21 noting he had a life expectancy of less than 6 months and a diagnosis of heart failure. He was discharged from hospice services on 08/09/23. A phone interview was conducted with the Hospice Provider on 07/02/24 at 3:15 PM. The Hospice Provider revealed Resident #3 had been admitted to hospice services on 03/03/21 through 08/09/21 then switched to hospice palliative care 08/09/21 which was discontinued on 01/08/24. No facility physician orders, or facility documentation were discovered indicating hospice palliative care services had been ordered or discontinued. Review of Resident #3's Minimum Data Sets (MDS) revealed the most recent comprehensive assessment, a Significant Change in Status Assessment, dated 09/28/23, and followed by three quarterly assessments dated 12/27/23, 03/27/24, and 06/24/24. These assessments were coded for receiving hospice care. An interview conducted with the MDS Coordinator on 07/03/24 at 12:35 PM revealed it was not communicated to her that Resident #3 had been discharged from hospice and palliative care on 01/08/24. She indicated she usually got her information regarding hospice discharges through the nurses and review of the resident's chart. The MDS Coordinator stated a significant change in status assessment had been completed in September because Resident #3 had a fall with an injury. The MDS Coordinator indicated a significant change in status assessment should have been completed for Resident #3 when the hospice services ended. An interview conducted with the Administrator and Director of Nursing (DON) on 07/03/24 at 1:30 PM revealed they were not aware Resident #3 had been discharged from hospice and palliative care services. It was further revealed they expected the MDS assessments to be coded accurately and was not aware a significant change in status assessment had not been completed when Resident #3 was discharged from hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis included dementia and falls. Review of Resident #40 progress note dated 5/29/24 revealed Resident #40 was readmitted from the hospital on 5/24/24 due to a fall with injury at the facility. Resident #40 readmission diagnosis on 5/29/24 included fracture of neck, not operable, due to fall. Review of 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed no history of falls or falls with major injury. An interview with the MDS Coordinator on 7/03/24 at 1:18 PM revealed Resident #40 had been readmitted to the facility from the hospital on 5/29/24 due to a fall with major injury. She stated Resident #40 should have been coded on his 5-day admission assessment dated [DATE] as having a history of falls and one fall with major injury. She revealed she believed it was just an oversight and human error on her part that she forgot to check the correct boxes under falls. An interview with the Director of Nursing (DON) on 7/03/24 at 1:31 PM revealed Resident #40 5-day admission MDS dated [DATE] should have reflected his previous fall with major injury. She stated MDS assessments should be coded correctly and reflect resident's current orders, changes in conditions, incidents, assessments, and status. 3. Resident # 50 was admitted to the facility on [DATE] and was discharged home on 4/05/24. Review of Resident #50 discharge progress note dated 4/05/24 revealed Resident #50 to discharge home with home health referral completed to evaluate and treat in home and ordered medical equipment received and available at resident home. Resident #50 was wheeled to vehicle and assisted into front seat and her belongings were taken by her husband. Discharge instructions were verbally reviewed in detail with Resident #50 husband, he verbalized understanding, and a written copy was provided. Resident #50 prescriptions were faxed to pharmacy with confirmation received, follow-up appointment made with primary care physician for 4/16/24 at 2:40 PM. Resident #50 had left facility with husband in pleasant mood. The discharge Minimum Data Set (MDS) assessment dated [DATE] indicated under the discharge status, that Resident #50 was an unplanned, return not anticipated discharge to home. An interview with the MDS Coordinator on 7/03/24 at 1:25 PM revealed Resident #50 was a planned discharge and should have been coded as a planned, return not anticipated, discharge to home. She stated she believed it was just an oversight and human error on her part that she forgot to check the correct box under discharge status. An interview with the Director of Nursing on 7/03/24 at 1:40 PM revealed Resident #50 discharge was planned, and she should have been coded on her discharge MDS assessment as a planned discharge to home. She stated MDS assessments should be coded correctly and reflect resident's current orders, changes in condition, admission, and discharge status. Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment for 3 of 6 residents reviewed for hospice, discharge, and falls (Resident #3, Resident #40, and Resident #50). Findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses including heart failure and depression. Review of Resident #3's orders revealed he had been admitted to hospice services on 03/03/21 noting he had a life expectancy of less than 6 months and a diagnosis of heart failure. He was discharged from hospice services on 08/09/23. A phone interview was conducted with the Hospice Provider on 07/02/24 at 3:15 PM. The Hospice Provider revealed Resident #3 had been admitted to hospice services on 03/03/21 through 08/09/21 then switched to hospice palliative care 08/09/21 which was discontinued on 01/08/24. No facility physician orders, or facility documentation were discovered indicating hospice palliative care services had been ordered on 08/09/23 or discontinued on 01/08/24. Review of Resident #3's quarterly Minimum Data Sets (MDS) dated [DATE], and 06/24/24 revealed the resident was coded for receiving hospice care. An interview conducted with the MDS Coordinator on 07/03/24 at 12:35 PM revealed it was not communicated to her that Resident #3 had been discharged from hospice and palliative care on 01/08/24. She indicated she usually got her information regarding hospice discharges through the nurses and review of the resident ' s chart. The MDS Coordinator further revealed Resident #3 should have not been coded for hospice care on the quarterly MDS assessments for 03/27/24 and 06/24/24. An interview conducted with the Administrator and Director of Nursing (DON) on 07/03/24 at 1:30 PM revealed they were not aware Resident #3 had been discharged from hospice and palliative care services. It was further revealed they expected the MDS assessments to be coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to develop personalized comprehensive care plans in the areas of anticoagulation therapy, diuretic therapy, insulin, psychotropic drugs, depression, use of indwelling urinary catheter and respiratory therapy for 2 of 5 residents reviewed (Resident #21, #2). The findings include: 1. Resident #21 was admitted to the facility on [DATE] with a history of deep vein thrombosis (DVT) with pulmonary embolism, diabetes mellitus (DM) type 2, hypertension (HTN), benign prostatic hypertrophy (BPH) with urinary retention, and history of urinary tract infections (UTI), chronic kidney disease. Resident #21's care plan dated 12/08/2022 revealed there was no care plan in place for anticoagulant medication, insulin, or diuretic medication and after 1/26/2023 for indwelling urinary catheter. A review of the most recent Minimum Data Set (MDS) assessment for discharge date d 1/23/2023 revealed Resident #21 independent with decision making and required extensive assistance with bed mobility, transfers, and toilet use. He was frequently incontinent of both bowel and bladder. He returned to the facility from hospital on 1/26/2023. Review of Physician orders dated 01/26/2023 revealed Apixaban 5 mg (an anticoagulant) twice a day. Furosemide (a diuretic) 40 mg daily and insulin 18 units at night. Review of Physician's order dated 01/26/2023 indicated to replace indwelling urinary catheter every 4 weeks and provide catheter care every shift. Interview with MDS Coordinator on 03/02/2023 at 03:30PM revealed she was aware Resident #21 received insulin, anticoagulant and diuretic. She revealed that the anticoagulant and insulin were usually care planned. Diuretics were not usually care planned unless a resident had history of dehydration. She reported the care plans were missed because, Resident #21 was and out of facility and system software did not trigger her to care plan. An interview was conducted on 03/03/23 at 11:20 AM the Director of Nursing (DON) stated she expected to see appliances such as catheters, on a resident care plan and expected to see interventions in place. She stated that care was communicated through conversation. 2. Resident #2 was admitted to the facility on [DATE] with a diagnosis that included anxiety, dementia, Chronic Obstructive Pulmonary Disease (COPD), and psychosis. A review Resident # 2's physician orders revealed on 1/28/22 she was prescribed DuoNeb one treatment every 4 hours as needed for COPD. On 5/30/22 she was prescribed Zoloft 100 mg tablet by mouth daily for depression. On 11/28/22 she was prescribed Geodon 20 milligrams (mg) capsules take one capsule every morning oral every day and Geodon 40 mg by mouth everyday with supper (must be taken with meal) for psychosis. On 2/28/23 she was prescribed Ativan 0.5 mg tablet to take 1/2 tablet (0.25mg) by mouth every 8 hours as needed for agitation for 14 days for anxiety. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #2 was severely cognitively impaired. Resident # 2 was coded for diagnoses of depression, psychotic disorder, COPD, delusional disorder and was on oxygen through a nasal canula. Review of Resident #2's comprehensive care plan dated 2/27/23 revealed there were no care plans in the areas of COPD, or psychosis. An interview with the MDS Coordinator on 3/2/23 at 12:10 PM indicated Resident #2 had received medications that required monitoring. Resident #2 had received medications for psychosis, anxiety, COPD, and depression. Resident #2 was on Geodon for psychosis and was placed on Geodon after having delusions in November 2022. The MDS Coordinator indicated she should have care planned Resident #2's diagnosis of COPD with the use of the DuoNeb medication and the resident's psychotic disorder with the treatment of an antipsychotic medication. She stated the resident was not care planned for anxiety and depression because she had not exhibited behaviors. An interview with Director of Nursing (DON) on 03/03/23 at 1:26 PM revealed that there should have a care plan with diagnoses and medications that require monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility failed to ensure dependent residents received assistance with nail care for 2 of 3 residents reviewed for activities of daily living (ADL). (Residents #8 and #15) The findings included: 1.Resident #8 was admitted to the facility on [DATE] with diagnosis of heart failure, atrial fibrillation, congestive obstructive pulmonary disease (COPD), and contracture of right hand. Resident #8's care plan dated 1/21/2022 included a care plan for ADL care. Intervention included to assist with ADLs as needed. Resident #8's annual Minimum Data Set (MDS) dated [DATE] revealed she was coded as cognitively intact. She required extensive assistance with personal hygiene. Resident #8 was dependent upon staff for bathing and grooming. No refusals of care were coded on the MDS. On 3/01/2023 at 10:21 AM, an observation and interview with Resident #8, revealed she was lying in bed and her fingernails on the left hand were observed to be jagged and approximately ¼ inch past the tip of her fingers. Resident #8's thumb nail and index fingernails on the right hand were approximately ½ inch past the fingertip. Resident #8's fingernails were noted to be dark in color. She had a rolled washcloth in the right hand. Resident #8 reported the washcloth was there because she was not able to open her hand. Resident #8 reported she had asked staff to trim her nails, but they had not been cut. She was not able to remember the last time her nails had been trimmed but did say that her nails were usually trimmed during her shower. Resident #8 reported having a shower earlier in the week, but she could not recall the exact day. Resident #8 reported her fingernails had not been trimmed during her last shower. An interview with NA #1 on 03/02/2023 at 09:48 AM was completed. She revealed fingernails were cut on bath day. NA #1 reported that the Activities Director (AD) also did nail care. Resident #8 was observed sitting in her wheelchair on 03/02/2023 at 09:51 AM. Her fingernails to both hands remained jagged and the same length as the previous day. Resident #8 reported her bath was scheduled for Friday (03/03/2023). Review of care aid papers for the week of 02/28/2023 - 03/05/2023 showed Resident #8 was scheduled for showers on Tuesdays and Fridays. Review of the progress notes for Resident #8 dated 02/28/2022 - 03/03/2023 showed no documentation of refusal of care to include nail care. During an interview with Nurse #1 on 03/02/2023 at 10:26 AM she reported the AD usually trimmed fingernails unless the resident was diabetic then the nurse would do it. Nurse #1 continued to verbalize that NA's were also responsible for nail care. Nurse #1 reported nails should be cleaned during bath time. 2.Resident #15 was admitted to the facility on [DATE] with diagnosis of hypertension and atrial fibrillation. Resident #15's care plan dated 11/30/2022 included a care plan for ADL care. Interventions included assist with ADLs as needed. Resident #15's significant change MDS dated [DATE] revealed Resident #15 was cognitively intact and required extensive assistance with personal hygiene and bathing. During review of MDS no episodes of refusing care was coded. On 3/01/2023 at 11:07 AM Resident #15 was observed sitting in her wheelchair in her room. An observation was completed of her fingernails on both hands. Her nails were observed to be approximately ¼ inch past the fingertip. Resident #15's nails to the left hand were jagged and chipped. Resident #15 reported she preferred to have her nails short. Resident #15 reported her nails were trimmed during her shower and she received showers twice a week. She could not recall the last time her nails had been trimmed. Resident #15 said she had a shower this week but could not recall which day. An observation of Resident #15 on 3/02/2023 at 09:43 AM revealed fingernails on bilateral hands were still the same length as the previous day. There was brown matter noted underneath the thumb and index finger of the right hand. An interview with Nurse Aide (NA) #1 on 3/02/2023 at 09:48 AM revealed Resident #15's fingernails were cut on bath day, NA #1 reported that Activities Director (AD) also did nail care. During an interview with Nurse #1 on 3/02/2023 at 10:26 AM indicated that the nurses trimmed the diabetic resident nails, and the AD and NA trimmed the rest of the nails. Nurse #1 reported nails were cleaned during bath time. Review of care aid papers for the week of 2/28/2023 through 3/05/2023 showed Resident #15 was scheduled for showers on Monday and Thursday on second shift. An observation of Resident #15 on 03/03/2023 at 08:55 AM showed nails on both hands were still approximately ¼ inch past the fingertips. Resident #15 reported her shower was moved from Thursday to the following Monday. Resident #15 had no concerns about having to move her shower from Thursday to Monday. Review of nurse's notes dated 02/28/2023 - 03/03/2023 revealed no episodes of refusal of care to include nail care had been documented. During interview with Activities Director (AD) on 03/03/2023 at 08:58 AM she reported nail care, as an activity was performed on Thursdays. Nails were polished, trimmed, and filed. She went down the different halls to find out if any residents were interested. The AD stated the nurse on the hall or the NA asked the AD to look at resident's nails and if they needed to be trimmed or cleaned, she would do it. Interview on 03/03/2023 at 09:24 AM with NA #2, who was responsible for the care of Resident's #8 and #15 revealed that during baths and daily care, fingernails and toenails were trimmed and cleaned. She indicated nail care was completed in the resident room, and not only on the shower days. NA #2 reported nail care was not completed because it was not high priority. During an observation NA #2 acknowledged that the fingernails required cleaning and trimming. An interview on 03/03/2023 at 11:20 AM with Director of Nursing (DON) revealed nail care was completed on bath or shower day and as needed. The DON reported the AD had a nail activity usually weekly and it was up to the nursing staff to make sure nails were cleaned and trimmed.

Based on observation, record review, staff and Pharmacy interview the facility failed to label and date medications for 1 of 2 storage rooms reviewed for medication storage and labeling. The findings include: During an observation on 03/02/23 at 11:45 AM with Nurse #2 of medication room # 1 revealed an unlabeled plastic bag with 4 unidentified white pills found in an unlocked cabinet inside locked medication room # 1. An interview with Nurse # 2 on 03/02/23 at 11:46 AM indicated that she was unaware of what the 4 pills were in the plastic bag. She further indicated that the plastic bag with the 4 white pills should have been labeled with the type of medication, time due, and name of resident. Nurse # 2 revealed that nursing was responsible for the stocking and checking expiration dates for medications stored in the medication room cabinets. Continued observation in medication room # 1 on 3/02/23 at 11:47 AM revealed 10 prepackaged pills found in the same unlocked cabinet as the plastic bag with 4 unidentified white pills for a resident dated for administration of 12/18/22 and 12/19/22 with no indicated expiration date noted. The prepackaged pills were identified as 1 Metoprolol 25 milligram (MG) tablet, 1 Omeprazole capsule 20 MG, 1 Memantine 10 MG, 1 Buspirone 5 MG tablet, 1 DOK 100 MG tablet, 1 Vitamin D3 25 MG tablet, 1 Sertraline tablet 50 MG, and 3 Furosemide 20 MG tablet. An interview with Nurse # 2 on 03/02/23 at 11:48 AM indicated there should be a clear expiration date on the prepackaged pills. She further indicated the facility doesn't have packaging like that, and it probably came from a hospital. A phone interview with the Pharmacy on 3/3/23 indicated they don't look in the cabinets in the medication rooms. Medications were delivered to the nurses, and they were responsible for storage and management of expirations dates. An interview with the Director of Nursing (DON) 03/03/23 at 1:32 PM revealed the plastic bag with white pills should have been discarded. The prepackaged pills should have been sent home with the resident's family. She was unsure why they were left in the cabinet in medication room # 1.