**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interviews, the facility failed to develop a comprehensive person-centered plan to address anticoagulant, insulin, and antidepressant use for 1 of 15 residents reviewed for comprehensive care plans (Resident # 18). The findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, atrial fibrillation, diabetes mellitus, and major depressive disorder. A review of the physician's orders dated 08/12/24 revealed the following orders: - Insulin Lispro (1 unit dial) Subcutaneous Solution Pen Injector 100 unit/milliliter Inject as per sliding scale subcutaneously four times a day for diabetes mellitus - Insulin Glargine Subcutaneous Solution Inject 10 units subcutaneously in the morning for diabetes mellitus - Sertraline HCL Oral Tablet 50 milligrams Give 1 tablet via PEG Tube one time a day for depression - Apixaban Oral Tablet 5 milligrams Give 1 tablet via PEG Tube two times a day for atrial fibrillation A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively impaired, diagnosed with depression and received antidepressant medication for the seven days of the look back period. The MDS further revealed Resident #18 was diagnosed with diabetes and received insulin six days during the look back period. The MDS also revealed Resident #18 was diagnosed with atrial fibrillation and was marked yes for anticoagulant use during the look back period. A review of the care plan dated 08/18/24 revealed that Resident #18 did not have a person-centered care plan that addressed anticoagulant use, insulin use, and antidepressant use. On 09/27/24 at 12:37 PM an interview was conducted with the MDS Nurse, and she stated the admitting nurse was responsible for initiating a baseline care plan and then the MDS nurse built the comprehensive care plan from the baseline care plan. The MDS Nurse stated a traveling MDS Nurse completed Resident #18's admission MDS assessment. Attempts to reach the traveling MDS Nurse via telephone were unsuccessful. An interview was conducted with the Director of Nursing (DON) and Administrator on 09/27/24 at 12:29 PM and the DON stated the admitting nurse was responsible for the initiation of Resident #18's baseline care plan and then the MDS Nurse built on to the baseline care plan when he/she completed the comprehensive care plan. The DON stated the use of anticoagulant medication, insulin, and antidepressant medication should have been picked up and care planned on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to arrange home health services upon discharge for 1 of 4 sampled residents (Resident #54) reviewed for discharge planning. Findings included: Resident #54 was admitted to the facility on [DATE] with diagnosis of paroxysmal atrial fibrillation, dementia, and congestive heart failure. The admission Minimum Data Set assessment dated [DATE] indicated Resident #54 was severely cognitively impaired. The physician's order dated 5/29/24 documented Resident #54 was to discharge home on 5/31/24. The order revealed the resident would need a hospital bed related to her inability to transfer or lay flat. Resident would need a home health agency (HHA) for ADL (activities of daily living) assistance; home health nursing for medication management; physical therapy (PT) and occupational therapy (OT) to evaluate and treat; and a social worker (SW) for the community. The review of the Discharge Plan Documentation dated 5/30/24 completed by the facility's former Social Worker indicated Resident #54 was to be discharged home with her family, home health services and Hospice starting 5/31/24. A hospital bed was ordered for delivery to resident's home on 5/31/24. The Assessment and Plan included in the physician's Discharge summary dated [DATE] indicated Resident#54's family would assist the HHA with the resident's ADL care at home. If the resident decided to participate with PT, the HHA would also provide PT if the resident was willing to participate. During an interview on 9/25/24 at 3:39 p.m., the Business Office Manager revealed the SW, who conducted the discharge planning at the time of Resident #54's discharge, no longer worked at the facility. She stated that after searching the resident's medical records and the facility's records, there was no documentation available indicating the SW made a referral for home health assistance for Resident #54. She further revealed the facility contacted the two home health providers the facility typically made referrals to and was informed they had no referrals for this resident. On 9/25/24 at 4:51 p.m., a telephone interview was conducted with the former Social Worker who was able to recall completing discharge planning with Resident #54 and her family member. She stated she made the referral for home health for the resident but could not recall if referral was made via email or during an onsite visit. During an interview on 9/27/24 at 4:22 p.m., the Administrator acknowledged the prior Social Worker failed to follow through with home health services for Resident #54.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, the facility failed to determine whether the self-administration of medications was clinically appropriate for 1 of 1 sampled residents (Resident #4) observed to have medications bedside. The findings included: 1. Resident #4 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD). A review of Resident #4's electronic medical record (EMR) revealed physician orders for the following medications; -Albuterol Sulfate HFA (multidose inhaler) aerosol solution 108 MCG (micrograms) to be administered as 2 puffs inhaled orally one time a day for the treatment of asthma with a start date of 9/15/2023. -Breo Ellipta aerosol powder breath activated 100-25 MCG/INH to be administered 1 inhalation a day for treatment of COPD with a start date of 3/11/2021. -Ipratropium Bromide nasal solution 0.03 % to be administered 2 sprays in both nostrils three times a day for allergies with a start date of 10/13/2022. A review of the resident's EMR revealed there was no assessment for self-administration. The resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact. An observation and interview were conducted on 12/12/2023 at 11:00AM of Resident #4 as she prepared to receive wound care treatment. The resident was observed to have a clear plastic bag of medications in the bed next to her. Upon inquiry, Resident #4 reported the nurse left her medications for her to administer and would be back around later to get the medications. Observed in the plastic bag were a multidose inhaler of albuterol, a multidose inhaler of Breo Ellipta, and a bottle of ipratropium bromide nasal spray. On 12/12/2023 at 11:15AM an interview was conducted with Nurse #1, who was assigned to Resident #4. Nurse #1 stated Resident #4 did not have a medication self-administration assessment and should not have medications bedside. She stated the night shift nurse may have left the medications in the resident's room. A second interview was conducted with Resident #4 on 12/12/2023 at 12:00PM. The resident stated Nurse #1 had given her the medications to self-administer. She stated she typically self-administered her inhaled medications. Resident #4's current care plan was last revised 10/15/2023. The resident was not care planned for the self-administration of medications. An interview was conducted on 12/12/2023 at 3:12 PM with the facility's Director of Nursing (DON). During this interview, the DON stated the facility had a process for safe self-administration of medications and that process was not followed. He further stated the medications were removed from Resident #4's bedside, the resident would be evaluated for safe self-administration of those medications per the facility's policy, and the nurse would be provided additional education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and chronic obstructive pulmonary disease (COPD). A review of the active physician orders revealed an order dated 11/7/23, for oxygen at 2 liters via nasal cannula continuously. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 was cognitively intact, had shortness of breath when lying flat and used oxygen. A review of Resident #25's active care plan, last reviewed 11/30/23, included a focus area for exhibited or was at risk for respiratory complications related to COPD and history of acute and chronic respiratory failure. One of the approaches was to provide oxygen as ordered via nasal cannula. On 12/11/23 at 10:00 AM, an observation was made of Resident #25 while she was lying in bed. The oxygen regulator on the concentrator was set at 4 liters flow when viewed horizontally, eye level. An observation occurred on 12/12/23 at 10:06 AM of Resident #25, which revealed the oxygen regulator on the concentrator was set at 4 liters flow by nasal cannula when viewed horizontally at eye level. Resident #25 was observed while lying in bed on 12/13/23 at 10:13 AM. The oxygen regulator on the concentrator was set at 4 liters flow when viewed horizontally at eye level. On 12/13/23 at 10:16 AM, an observation of Resident #25 was completed with Nurse #2, who confirmed the oxygen regulator on the concentrator was set at 4 liters when viewed horizontally at eye level. Nurse #2 adjusted the flow to administer 2 liters of oxygen as ordered. Nurse #2 stated that oxygen rates were checked when she provided medications through out the day. During an interview with the Director of Nursing on 12/13/23 at 12:51 PM, he indicated it was his expectation for oxygen to be delivered at the ordered rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and Medical Director, and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication was time limited in duration for 1 of 5 residents reviewed for unnecessary medications (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was severely cognitively impaired and received hospice services. A review of Resident #2's medical record was completed on 12/12/2023 and revealed Resident #2 had a physician's order dated 10/11/2023 for Lorazepam (a psychotropic used to treat anxiety) 0.5 milligrams (mg) one tablet sublingually every four hours as needed for anxiety. The order for the Lorazepam was entered into the Electronic Medical Record (EMR) by Nurse #3 and did not have a stop date. Additionally, the medical record contained an order for hospice services dated 10/16/2023. A phone interview was conducted with Nurse #3 on 12/13/2023. She stated she was no longer employed by the facility, and she did not recall the resident or the order for lorazepam. Resident #2's progress notes included a monthly medication review by the pharmacy consultant dated 11/24/2023. The consultation report recommended the as needed (PRN) order for lorazepam be discontinued due to the order being greater than 14 days duration without a stop date. A paper copy of the recommendation was provided with the Medical Director's response. The Medical Director responded on 11/29/2023 and declined the recommendation noting the indication for the PRN psychotropic drug was hospice care, the duration of until she passes, with rationale for the extended period as hospice care. An interview occurred with the Medical Director on 12/13/2023 at 11:07 AM, who stated he was aware of the regulation that required all PRN psychotropic medications to be time limited in duration, but he wrote Resident #2's order the way it was because she was on hospice. He wanted the medication to be available if she should need it. He was not aware the regulation extended to residents receiving end of life services.

Based on observations, record review and staff interviews, the facility failed to date multi-use medications per manufacturer's recommendations upon opening and failed to discard expired medications in 1 of 2 medication carts (100 Hall medication cart) reviewed for medication storage and labeling. Findings included: An observation was conducted on 12/12/23 at 11:35 AM of the 100 Hall medication cart in the presence of Nurse #1. The observation revealed no open date on the following multi-dose medications: a. One multi-dose Lantus insulin pen with 60 units out of 100 units left in pen. The manufacturer's recommendation was to discard 28 days after opening. b. One multi-dose Victoza insulin pen with 10mg out of 18mg left in pen. The manufacturer's recommendation was to discard 30 days after opening. c. One multi-dose Glargine insulin pen with 220 units out of 300 units left in pen. The manufacturer's recommendation was to discard 28 days after opening. d. One multi-dose package of Albuterol Sulfate 0.63mg/3ml nebulizer solution, 1 pouch contains 5 vials, 2 vials left in pouch. The manufacturer's recommendation was to discard 7 days after opening. e. One multi-dose package of Albuterol Sulfate 0.63mg/3ml nebulizer solution, 1 pouch contains 5 vials, 3 vials left in pouch. The manufacturer's recommendation was to discard 7 days after opening. Nurse #1 verified the medications were not dated and she removed them from the medication cart and discarded them. She indicated nurses were to write the date on all multi-dose medications upon opening and check dates on all medications prior to administration to make sure they were not expired. She then stated she did not realize the medications were not dated. She further stated that the nurses should be checking the medication carts daily prior to administration. f. The observation also revealed one box of Loperamide Hydrochloride 2mg tablets with 17 of 24 tabs still in box with an expiration date of 08/2023 labeled on box. Nurse #1 verified the Loperamide had expired on 08/2023 and discarded the item. She then stated she did not realize there were expired medications on the cart. An interview was conducted with the Director of Nursing (DON) on 12/13/23 at 1:40 PM. He stated when the items were initially opened for administration the nurse was to write the open date on the medication. The expired medication should have been caught earlier and discarded. The nurses are to check dates prior to administering multi-use medications (insulins, eye drops, nebulizer treatments etc.). He also stated nurses should check dates daily, unit managers check carts weekly, and the pharmacist checks them monthly.

Based on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey conducted on 02/05/21 and annual recertification and complaint survey on 07/11/22. This was for 3 deficiencies that were cited in the areas of Respiratory/Tracheostomy care and Suctioning and Label/Store Drugs & Biologicals which were previously cited on 02/05/21 and Resident Self-Admin Meds-Clinically Appropriate which was previously cited on 07/11/22. The deficient practice area was recited on the current recertification and complaint survey of 12/13/23. The duplicate citations during three federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1. F554-Based on observations, record reviews, resident and staff interviews, the facility failed to determine whether the self-administration of medications was clinically appropriate for 1 of 1 sampled residents observed to have medications bedside. During the facility's recertification and complaint survey of 07/11/22 the facility failed to assess a resident whether the self-administration of medications was clinically appropriate for 1 of 1 sampled resident observed to have medications at bedside. 2. F695- Based on record review, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care. During the facility's recertification survey of 02/05/21, the facility failed to obtain oxygen orders for 1 of 1 residents reviewed for oxygen. 3. F761-Based on observations, record review and staff interviews, the facility failed to date multi-use medications per manufacturer's recommendations upon opening and failed to discard expired medications in 1 of 2 medication carts (100 Hall medication cart) reviewed for medication storage and labeling. During the facility's recertification survey of 02/05/21, the facility failed to remove expired medications from 1 of the 2 medication carts, failed to document open dates of medication in 2 of 2 medication carts, and failed to secure and label unidentified loose pills in 2 of the 2 medication carts. An interview was conducted with the Administrator and facility Nurse Consultant on 12/13/23 at 3:08 PM. The Administrator stated that she felt the repeat citations were due to the facility's leadership turnover and due to the facility currently having an interim DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff and resident interview, the facility failed to assess a resident whether the self-administration of medications was clinically appropriate for 1 of 1 sampled resident observed to have medications at bedside (Resident # 7). Findings included: Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including cellulitis of the left lower extremity. Resident # 7 had doctor's orders dated 6/18/22 for Flonase 1 spray both nostrils daily for allergies, Turmeric 500 milligrams (mgs) 1 tablet by mouth daily for supplementation and B-12 1 tablet by mouth daily for supplementation. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #7's cognition was intact. Resident #7 was observed on 7/5/22 at 10:30 AM and on 7/6/22 at 2:30 PM to have the Flonase nasal spray bottle, Turmeric bottle and B-12 bottle at bedside. When interviewed, Resident #7 stated that her husband had brought these medications from home for her to take. She verified that she had been taking these medications and the nurses knew about it. Review of Resident #7's medical records revealed that she did not have an assessment for self-administration of medication nor a doctor's order to self-administer medications. Nurse # 4 was interviewed on 7/7/22 at 9:20 AM. She stated that she had observed the bottles of Flonase, Turmeric and B-12 at Resident #7's bedside but she indicated that the resident did not have an order to self-administer medications. The Nurse added that she did not know who was responsible to assess the resident for self-administration since she works for an agency. The Director of Nursing (DON) was interviewed on 7/8/22 at 10:10 AM. The DON stated that she started as DON in June 2022. She did not know who was responsible for assessing the resident for self-administration of medication before she was the DON, however the policy stated that the DON was responsible for the assessment. She expected the nurses to inform her of resident's desire to self-administer medications. The DON added that she was not informed that Resident #7 was self-administering medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 2 sampled residents reviewed who were newly admitted (Residents # 58 & # 115). Findings included: 1. Resident # 115 was admitted to the facility on [DATE] with multiple diagnoses including neurogenic bladder. Resident #115 was observed in bed with a suprapubic catheter in place. Review of Resident #115's medical records revealed that she did not have a baseline care plan developed as of 7/7/22. The Minimum Data Set (MDS) Nurse was interviewed on 7/8/22 at 10:25 AM. The MDS Nurse reported that the admitting Nurse was responsible for initiating the baseline care plan and she reviewed the baseline care plan the next day during the clinical meeting. She stated that the baseline care for Resident #115 was missed. The Director of Nursing (DON) and the Administrator were interviewed on 7/8/22 at 11:45 AM. The Administrator stated that the MDS Nurse was responsible for developing the baseline care plan and not the nurses. She added that she would inform the MDS Nurse of this. 2. Resident #58 was readmitted to the facility on [DATE] with multiple diagnoses including end stage renal disease and was receiving hemodialysis. Review of Resident #58's medical records revealed that she did not have a baseline care plan developed as of 7/7/22. The Minimum Data Set (MDS) Nurse was interviewed on 7/8/22 at 10:25 AM. The MDS Nurse stated that Resident #58 was a resident at the facility but was discharged to the hospital. When she was discharged , her care plan was canceled and was never reinstated upon readmission. She reported that the admitting Nurse was responsible for initiating the baseline care plan and she reviewed it the next day during the clinical meeting. She stated that the baseline care for Resident #58 was missed. The Director of Nursing (DON) and the Administrator were interviewed on 7/8/22 at 11:45 AM. The Administrator stated that the MDS Nurse was responsible for developing the baseline care plan and not the nurses. She added that she would inform the MDS Nurse of this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews and record review, the facility failed to develop and implement a comprehensive care plan in the area of hemodialysis (Resident #33). This was for 1 of 2 residents reviewed for dialysis. The findings included: Resident #33 was admitted on [DATE] with a diagnosis of End Stage Renal Disease (ERSD). The admission/5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 was cognitively intact and the MDS was coded for dialysis. Review of Resident #33 admission comprehensive care plan did not include a care area with interventions for her hemodialysis. Review of the care plan revealed it was completed by the Interim Director of Nursing (DON). An interview and observation was completed with Resident #33 on 7/5/22 at 1:00 PM. She stated she went to hemodialysis on Monday, Wednesday and Friday. She presented her left arm for observation. There was a large fistula noted to her upper left arm. She stated she reminded the staff and lab technicians that no blood pressure (B/P) or lab work were to be completed on her left arm. An interview was completed on 7/8/22 at 10:15 AM with the MDS Nurse. She stated she began working at the facility for approximately 6 months ago as the Assistant Director of nursing (ADON) then began training as the MDS Nurse in mid-May 2022. She stated the corporate Clinical Reimbursement Coordinator (CRC) worked remotely and trained her on how to complete a comprehensive care plan. She stated the corporate CRC reviewed all her care plan's s up until her training ended about 2 weeks prior to the Interim DON starting on 6/21/22. She stated Resident #33 should have been comprehensively care planned for her hemodialysis and interventions implemented but it must have been overlooked. An interview was completed on 7/8/22 at 10:49 AM with the Interim DON. She stated she was working remotely for a week or so in June 2022 and she was tasked to do care plan reviews and audits. She stated it was during this time, she completed Resident #33's comprehensive care plan but did not think to care plan her for hemodialysis. The Interim DON stated it was an oversight and she should have care planned the resident for dialysis. An interview was completed on 7/8/22 at 11:42 AM with the Administrator and the Interim DON. The Administrator stated Resident #33 should have been comprehensively care planned to include hemodialysis. She stated there was some transitioning going on then and somehow her comprehensive care plan was not fully completed or implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to ensure fall mats were in place according to the care planned fall safety interventions (Resident #40). This was for 1 of 5 residents reviewed for accidents. The findings included: Resident #40 was admitted to the facility on [DATE] with diagnoses that included dementia and repeated falls with a history of a hip fracture. Resident #40's active care plan, dated 3/21/22, included a focus area for risk for falls due to cognitive loss, lack of safety awareness and impaired mobility. The interventions included fall mats to both sides of the bed that were initiated on 8/26/20. A record review revealed Resident #40 rolled off the bed on 5/9/22. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 had severe cognitive impairment and required limited to extensive assistance for Activities of Daily Living (ADLs). A wheelchair was used for mobility, and she was coded with 1 fall since the last assessment. An observation occurred of Resident #40's bed on 7/5/22 at 2:00 PM. The bed was in the lowest position with a concave mattress present. There were no fall mats located in the room or bathroom. On 7/6/22 at 10:20 AM, an interview occurred with Nurse Aide (NA) #3, who was assigned to Resident #40. She indicated staff monitor for safety as Resident #40 will try to stand on her own from the wheelchair. She further explained when a scoop mattress was present on the bed to prevent her from rolling off the bed and the bed was kept in the lowest position when Resident #40 was in it. When asked about fall mats, she stated she was unsure and hadn't seen any fall mats being used for Resident #40. On 7/7/22 at 2:34 PM, an observation was made of Resident #40 lying in bed with her eyes closed. There were no fall mats present to either side of the bed. An interview occurred with Nurse #1 on 7/7/22 at 3:36 PM, who was assigned to Resident #40. She was unsure if fall mats were to present at bedside and stated that she had just started working that hall and was not familiar with the residents. The interim Director of Nursing (DON) was interviewed on 7/8/22 at 9:15 AM and stated fall mats should be in place to both sides of Resident #40's bed when she is in it. She explained the staff would remove them when she was up in the wheelchair for safety but was unaware they were not being used. She added it was her expectation for fall interventions to be implemented by the staff. The nurse supervisor was interviewed on 7/8/22 at 9:25 AM and stated Resident #40 should have fall mats to both sides of the bed and was unaware they were not being utilized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of restraints and alarms (Residents #17 and #40), skin conditions (Residents #22 and 63) and medications (Residents #6 and #44). This was for 6 of 21 resident records reviewed. The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included dementia. A quarterly MDS assessment dated [DATE] indicated Resident #17 had severe cognitive impairment and was not coded for a wander/elopement alarm. Resident #17's active care plan, last reviewed 5/13/22 included a focus area wanders the facility and talking about leaving to go home. The interventions included a wander-alarm applied to the right ankle that was initiated on 2/3/22. On 7/6/22 at 2:39 PM, an observation occurred of Resident #17 while he was lying in bed watching TV. A wander-alarm bracelet was visible to his right ankle. A phone call was placed to the Clinical Reimbursement Coordinator (CRC) on 7/8/22 at 9:50 AM. A return call was not received during the course of the survey. An interview was conducted with the MDS Nurse on 7/8/22 at 10:14 AM. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarms was not coded. She stated she was not the MDS Nurse at that time and would have been coded by the CRC, however the wander/elopement alarm should have been coded. An interview with the interim Director of Nursing and Administrator occurred on 7/8/22 at 11:41 AM. They both indicated it was their expectation for the MDS assessment to be coded accurately. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses that included dementia. Resident #40's active care plan included a focus area that was initiated on 8/26/20 for risk for elopement related to cognitive loss/dementia and talks about searching for daddy. The interventions included a wander-alarm bracelet to the right ankle. A quarterly MDS assessment dated [DATE] indicated Resident #40 had severe cognitive impairment and was not coded for a wander/elopement alarm. On 7/7/22 at 2:34 PM, an observation was made of Resident #40 while she was lying in bed. A wander-alarm bracelet was visible to her right ankle. A phone call was placed to the CRC on 7/8/22 at 9:50 AM. A return call was not received during the course of the survey. An interview was conducted with the MDS Nurse on 7/8/22 at 10:14 AM. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarms was not coded. She explained at that time she was new to the position and the CRC was checking to ensure her entries were correct before submitting. The MDS Nurse stated it was an oversight not to have coded the wander/elopement alarm for Resident #40. An interview with the interim Director of Nursing and Administrator occurred on 7/8/22 at 11:41 AM. They both indicated it was their expectation for the MDS assessment to be coded accurately. 3. Resident #22 was originally admitted to the facility on [DATE]. Her diagnoses included non-pressure chronic ulcers of the right leg. An Infectious Disease progress note for 1/24/22 indicated Resident #22 had chronic open wounds over the right knee with tunneling and drainage with concern that the right knee prosthetic was infected causing abscesses. A review of a form titled Wound Evaluation and Management Summary completed by the Wound Physician, and dated 5/2/22, revealed the following skin conditions: - A traumatic wound to the right superior knee - A traumatic wound to the right medial knee - A shear wound to the right inferior knee - A wound to the right lateral knee - A wound to the right calf A quarterly MDS assessment dated [DATE] indicated Resident #22 had moderately impaired cognition. She was coded with five venous/arterial ulcers. Resident #22's active care plan, last revised 5/19/22, included a focus area for actual skin breakdown related to right shin and knee wounds due to infected hardware. A phone interview was completed with the VOHRA Wound Physician on 7/8/22 at 8:41 AM and explained Resident #22's wounds to her right knee and shin area were related to infection in her knee prosthetic and not venous/arterial related. A phone call was placed to the CRC on 7/8/22 at 9:50 AM. A return call was not received during the course of the survey. An interview was conducted with the MDS Nurse on 7/8/22 at 10:14 AM. She reviewed the MDS assessment dated [DATE] and verified Resident #22 was coded with 5 arterial/venous ulcers. She explained the entry was completed by the CRC, who should have reviewed the Wound Evaluation and Management Summary as well as physician progress notes to determine how to classify the wounds. An interview with the interim Director of Nursing and Administrator occurred on 7/8/22 at 11:41 AM. They both indicated it was their expectation for the MDS assessment to be coded accurately. 4. Resident #63 was admitted on [DATE] with a diagnosis of Congestive Heart Failure and a pressure ulcer to her right heel. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #63 was cognitively intact and was coded for a stage 4 pressure ulcer acquired at the facility. The MDS assessment dated [DATE] was completed by the corporate Clinical Reimbursement Coordinator (CRC). A wound care observation and resident interview was completed 7/7/22 at 11:50 AM with Resident #63. Resident #63 stated the pressure ulcer to her right heel had been open for 6 years. She continued that the area would improve then re-open and never completely healed. Resident #63 was care planned on 5/9/21 for a stage 2 pressure ulcer to her right heel. This care area was last revised on 5/21/22 The most recent quarterly MDS assessment dated [DATE] was also coded for a stage 4 pressure ulcer acquired at the facility. The MDS assessment dated [DATE] was completed by the MDS Nurse. An interview was completed on 7/6/22 at 3:12 PM with the MDS Nurse. She stated she began working at the facility for approximately 6 months as the Assistant Director of nursing (ADON) then began training as the MDS Nurse in mid-May 2022. She stated the corporate CRC worked remotely and trained her on how to complete a MDS assessment. She stated the corporate CRC reviewed all her MDS assessment's until her training ended about 2 weeks ago. The MDS Nurse stated she completed the 6/4/22 quarterly MDS assessment and copied what the corporate CRC had coded on Resident #63's quarterly MDS assessment dated [DATE]. She stated she was aware that Resident #63 had non-healing right heel pressure ulcer for as long as she had worked at the facility, but thought the corporate CRC knew more about coding the MDS assessment so she coded what the corporate CRC had coded on the quarterly MDS assessment completed 3/4/22. A telephone message was left for the corporate CRC to return surveyor's call on 7/8/22 at 9:50 AM. The Administrator and Interim DON were made aware on 7/8/22 at 11:30 AM that a message was left for the corporate CRC to return the surveyor's call. They suggested letting the facility attempt to contact the corporate CRC but no return phone calls were received. An interview was completed on 7/8/22 at 11:42 AM with the Administrator and the Interim DON. The Administrator stated Resident #63's quarterly MDS assessment dated [DATE] and 6/4/22 should be coded accurately and reflect that her pressure ulcer was present on her admission on [DATE] and not facility acquired. 5. Resident #6 was admitted on [DATE] with a diagnosis of Parkinson's Disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was coded as taking an antipsychotic medication. The MDS assessment was completed by the corporate Clinical Reimbursement Coordinator (CRC). Resident #6's was care planned last revised on 12/1/21 for the use of psychotropic medications related to her psychosis. Review of Resident #6's March, April, May, June and July 2022 Physician orders did not include any orders for an antipsychotic medication. The orders did however include an order dated 3/18/22 for Lamictal (anticonvulsant) for psychosis. An interview was completed on 7/8/22 at 10:15 AM with the MDS Nurse. She stated she began working at the facility for approximately 6 months ago as the Assistant Director of nursing (ADON) then began training as the MDS Nurse in mid-May 2022. She stated her MDS training ended about 2 weeks prior to the Interim DON starting on 6/21/22. The MDS Nurse stated the corporate CRC completed Resident #6's quarterly MDS assessment dated [DATE] and coded her Lamictal as an antipsychotic. She was unable to explain why the MDS assessment was coded inaccurately. A telephone message was left for the corporate CRC to return surveyor's call on 7/8/22 at 9:50 AM. The Administrator and Interim DON were made aware on 7/8/22 at 11:30 AM that a message was left for the corporate CRC to return the surveyor's call. They suggested letting the facility attempt to contact the corporate CRC but no return phone calls were received. An interview was completed on 7/8/22 at 11:42 AM with the Administrator and the Interim DON. The Administrator stated Resident #6's medications should have been coded accurately on the quarterly MDS assessment dated [DATE] and was unable to explain why her Lamictal was coded as an antipsychotic. 6. Resident #44 was admitted to the facility on [DATE]. Resident #44 had a doctor's order dated 5/30/22 for Buspirone (an antianxiety medication) 150 milligrams (mgs) 1 tablet by mouth daily for depression. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #44 had received an antianxiety medication for 3 days during the assessment period. Review of the May and June 2022 Medication Administration Records (MAR) revealed that Resident #44 had received the Buspirone for 7 days during the assessment period (May 31 - June 6, 2022). The MDS Nurse was interviewed on 7/8/22 at 10:25 AM. The MDS Nurse stated that she thought Buspirone was an antidepressant medication and indicated that it was an error on her part. The Director of Nursing (DON) and the Administrator were interviewed on 7/8/22 at 11:45 AM. The Administrator stated that she expected the MDS to be coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, Medical Director, Wound Physician and staff interviews, the facility failed to provide treatments as ordered by the physician to non-pressure related wounds on the lower extremity for 1 of 2 residents reviewed for skin conditions (Resident #22). The findings included: Resident #22 was originally admitted to the facility on [DATE]. Her diagnoses included non-pressure chronic ulcers of the right lower leg and deep incisional surgical site infection. An Infectious Disease progress note dated 1/24/22, revealed Resident #22 had chronic open wounds over the right knee with tunneling and drainage due to right knee prosthetic infection. There were open areas around the right knee and an abscess to the right mid-shin. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #22 had moderately impaired cognition and displayed no behaviors or refusal of care during the look back period. She was coded with 5 venous/arterial ulcers and received application of nonsurgical dressings and ointments other than to her feet. A physician progress note dated 5/27/22 indicated Resident #22 had chronic infection of the right knee prosthetic and has declined surgical intervention. There are several areas on the right leg that drain, and the wound physician monitored weekly. Review of the active care plan, last revised 6/12/22, revealed a focus area for actual skin breakdown of the right shin and knee due to infected hardware. The interventions included to provide wound treatments as ordered and weekly wound assessment by in-house wound doctor to include measurements and description of wound status. a) The active physician orders included an order dated 4/28/22 to pack the right inferior knee wound with Iodoform packing strips (a gauze strip used for open and/or infected wounds), apply Calcium Alginate (a wound dressing used to manage drainage and provide a moist environment for healing), cover with a thick dressing, and wrap with gauze once a day. A review of a Wound Evaluation and Management Summary completed by the Wound Physician and dated 5/2/22 indicated the right inferior knee, shear wound measured 3.8 centimeters (cm) in length and 0.6 cm in width and to continue the current treatment. The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed the right inferior knee wound measured 4 cm in length and 0.8 cm in width. The order was changed to Calcium Alginate to the wound, cover with a dry dressing and wrap with gauze daily. A review of the June 2022 and July 2022 Medication Administration Records (MARs) and Treatment Administration Records (TARs) for Resident #22, did not reveal a change in the treatment order as recommended on 6/20/22 by the Wound Physician. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the packing strip that was present to the right inferior knee wound, cleaned the wound and replaced the packing strip, covered with a dry dressing, and wrapped the extremity in a gauze wrap. Nurse #3 stated the Wound Physician measured the wound weekly. b) The active physician orders included an order dated 4/28/22 to pack with right lateral (side) knee wound with Iodoform packing strips, apply Calcium Alginate, cover with thick dressing, and wrap with gauze once a day. A review of a Wound Evaluation and Management Summary completed by the Wound Physician and dated 5/2/22 indicated the right lateral knee wound measured 1.1 cm in length, 0.6 cm in width and 0.2 cm in depth. The facility was to continue with the current treatment. The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed the wound to the right lateral knee measured 0.8 cm in length, 0.5 cm in width and 0.1 cm in depth. The orders were changed to Calcium Alginate to the wound, cover with a dry dressing and wrap with gauze daily. A review of the June 2022 and July 2022 MARs and TARs for Resident #22, did not reveal a change in the treatment order as recommended on 6/20/22 by the Wound Physician. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the packing strip from the right lateral knee wound, cleaned the wound and replaced the packing strip, covered with a dry dressing, and wrapped the extremity in a gauze wrap. Nurse #3 stated the Wound Physician measured the wound weekly. c) The active physician orders included an order dated 4/28/22 to pack the right superior (upper) knee wound with Iodoform packing strips, apply Calcium Alginate, cover with thick dressing, and wrap with gauze once a day. A review of a Wound Evaluation and Management Summary completed by the Wound Physician and dated 5/2/22 indicated the right superior knee measured 0.6 cm in length, 0.4 cm in width and 0.1 cm in depth. The facility was to continue the current treatment. The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 indicated the wound to the right superior knee measured 1 cm in length, 0.9 cm in width and 0.1 cm in depth. The orders were changed to Calcium Alginate to the wound and wrap with gauze daily. A review of the June 2022 and July 2022 MARs and TARs for Resident #22, did not reveal a change in the treatment order as recommended on 6/20/22 by the Wound Physician. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed to around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the packing strip from the right superior knee wound, cleaned the wound and replaced the packing strip, covered with a dry dressing, and wrapped the extremity in a gauze wrap. Nurse #3 stated the Wound Physician measured the wound weekly. d) The active physician orders included an order dated 4/28/22 to apply a wet to moist gauze with Dakin's solution (a solution used as an antiseptic to clean infected topical wounds) to the right calf wound, cover with dry dressing, and wrap with gauze once a day. A review of a Wound Evaluation and Management Summary completed by the Wound Physician and dated 5/2/22 indicated the right calf wound measured 3.8 cm in length, 3.5 cm in width and 3 cm in depth. The facility was to continue the current treatment. A review of the Wound Evaluation and Management Summary completed by the Wound Physician on 5/16/22 indicated a change in the treatment of the right calf wound. The wound measured 2.9 cm in length, 1.5 cm in width and 2 cm in depth. The facility was to start using Calcium Alginate covered with a dry dressing and wrap with gauze daily. The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed the wound to the right calf measured 2.5 cm in length, 1.8 cm in width and 0.1 cm in depth. The orders remained the same. A review of the June 2022 and July 2022 MARs and TARs for Resident #22, did not reveal a change in the treatment order as recommended on 5/16/22 by the Wound Physician. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed to around the knee area, shin, and calf area. There was no redness or odor present. Nurse #3 removed the dressing, cleaned the wound and reapplied a piece of Calcium Alginate, covered with a dry dressing and wrapped the extremity in a gauze wrap. Nurse #3 stated the Wound Physician measured the wound weekly. When asked about the Dakin's solution she stated that had been discontinued a while back. e) The Wound Evaluation and Management Summary form completed by the Wound Physician on 5/23/22 revealed a wound to the right shin that measured 2.8 cm in length, 2.5 cm in width and 1.5 cm in depth. The orders were to pack with Iodoform gauze, cover with Calcium Alginate and cover with a dry dressing daily. A review of the active physician orders, June 2022 and July 2022 MARs and TARs, for Resident #22, did not reveal an order for the treatment of the right shin wound. The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed the wound to the right shin measured 1.8 cm in length, 1.7 cm in width and 1.1 cm in depth. There were no changes to the order. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the packing strip that was present to the wound, cleaned the wound and replaced the packing strip, covered with a dry dressing, and wrapped the extremity in a gauze wrap. Nurse #3 stated the Wound Physician measured the wound weekly. f) The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed a wound to the right inferior calf that measured 3.4 cm in length and 2 cm in width. The facility was to apply Xeroform gauze (a non-adherent dressing with a mixture containing petroleum jelly) and wrap with gauze daily. A review of the active physician orders, June 2022, and July 2022 MARs and TARs, for Resident #22, did not reveal an order for the treatment of the right inferior calf wound. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the dressing to the wound, cleaned the area and applied a piece of Calcium Alginate, covered with a dry dressing, and wrapped the extremity in gauze. Nurse #3 stated the Wound Physician measured the wound weekly. g) The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed a shear wound to the right superior, lateral (upper and to the side) calf that measured 1.5 cm in length, 0.6 cm in width and 0.1 cm in depth. The facility was to apply Calcium Alginate and a dry dressing daily. A review of the active physician orders, June 2022, and July 2022 MARs and TARs, for Resident #22, did not reveal an order for the treatment of the right superior, lateral calf wound. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the dressing to the wound, cleaned the area and applied a piece of Calcium Alginate, covered with a dry dressing, and wrapped the extremity in gauze. Nurse #3 stated the Wound Physician measured the wound weekly. h) The Wound Evaluation and Management Summary form completed by the Wound Physician on 6/20/22 revealed a wound to the right superior shin that measured 2 cm in length, 1.5 cm in width and 0.1 cm in depth. The facility was to apply Xeroform gauze and wrap with gauze daily A review of the active physician orders, June 2022, and July 2022 MARs and TARs, for Resident #22, did not reveal an order for the treatment of the right superior shin wound. On 7/6/22 at 11:20 AM, wound care observation was completed with Nurse #3. She was observed removing the gauze wrap from Resident #22's right lower leg. Multiple small open areas were observed around the knee, shin, and calf area. There was no redness or odor present. Nurse #3 removed the dressing to the wound, cleaned the area and applied a piece of Calcium Alginate, covered with a dry dressing, and wrapped the extremity in gauze. Nurse #3 stated the Wound Physician measured the wound weekly. An interview occurred with Nurse #3 on 7/6/22 at 12:00 PM, who stated she had followed the orders in the July 2022 MAR and was unaware there were changes or additions to the treatment orders for Resident #22. She added she thought the open areas on her knee and calf were to be covered with Calcium Alginate. She explained she went by what was in the MAR and did not look at the Wound Physician progress notes as someone else rounded with him weekly. On 7/8/22 at 8:41 AM, a phone interview was completed with the Wound Physician. He explained he was at the facility once a week to assess and measure wounds for the residents that were on his caseload. A nurse rounded with him where he relayed the measurements as well as any changes to the treatment orders. He stated he thought the nurse was reviewing the treatment orders for accuracy from week to week and expected the facility to follow his recommendations unless the Medical Director changed them. The Wound Physician stated there would have been no harm to performing treatments according to the April 2022 orders as wound care for Resident #22 was palliative. Her wounds would continue to occur with difficulty healing due to the infected knee prosthetic and her decline for surgical intervention. The interim Director of Nursing (DON) was interviewed on 7/8/22 at 9:15 AM. She reviewed Resident #22's active physician orders, June 2022 and July 2022 MARs and TARs as well as Wound Physician progress notes dated 6/27/22 and verified the orders did not coincide with what was recommended, and a few areas were not present on the active physician orders, June and July 2022 MARs or TARs. She explained she had been rounding with the Wound Physician and would write what he stated about the wounds on a piece of paper, and often stated to keep the treatments the same. The interim DON stated she failed to review the Wound Physician progress notes when they arrived at the facility (within 24 to 48 hours) and just kept Resident #22's treatment orders the same. The Medical Director was interviewed on 7/8/22 at 11:13 AM and stated he left wound care orders to the Wound Physician if he was following the resident for wound care. He added he would expect the facility to follow the wound care orders as recommended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #33 was admitted on [DATE] with a diagnoses of End Stage Renal Disease (ERSD) and a right lower leg fracture. The admission/5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #33 was cognitively intact and the MDS assessment was coded for dialysis. Review of Resident #33's July 2022 Physician orders included an order dated 5/18/22 which read the nurses were to check for a bruit (a loud swishing sound when listening to the fistula using a stethoscope) and thrill (vibrations felt when touching the fistula) every shift. There was an order dated 5/18/22 that read to document dry weights when Resident #33 returned from dialysis on Monday, Wednesday and Friday. Another order dated 5/26/22 was written for fluid restrictions of 1500 milliliters every day. There were no Physician orders for the monitoring of her arterial/vascular (AV) fistula for bleeding, signs and symptoms of infection, removing the dressing to her fistula the following day after dialysis and obtaining vital signs after returning from her dialysis treatments. An interview and observation was completed with Resident #33 on 7/5/22 at 1:00 PM. She stated she went to hemodialysis on Monday, Wednesday and Friday. She presented her left arm for observation. There was a large fistula noted to her upper left arm. She stated she reminded the staff and lab technicians that no blood pressure (B/P) or lab work were to be completed on her left arm. An interview was completed on 7/6/22 at 2:45 PM with the Administrator. She stated all dialysis residents to include Resident #33 took a notebook with the communication forms to each dialysis treatments for the dialysis staff and the facility to document her status pre and post dialysis treatment. She stated she was not aware that Resident #33's Physician orders did not include orders for monitoring her AV fistula for evidence of bleeding or obtaining Resident #33's vital signs upon her return from her dialysis treatments. Another interview was completed on 7/7/22 at 8:50 AM with Resident #33. She stated upon returning from dialysis, the staff transferred her back to bed using a mechanical lift. She stated the staff did not take her vital signs upon her return from dialysis and she monitored her own fistula for bleeding after each dialysis treatment. Resident #33 stated she was given a form to take with her yesterday titled Hemodialysis Communication Record but she had only been given the form maybe one other time since her admission on [DATE]. An interview was completed on 7/7/22 at 9:00 AM with Nursing Assistant (NA) #5. She stated she was not trained on care of dialysis resident but she was aware that a weight needed to be obtained pre and post dialysis treatment. An interview was completed on 7/7/22 at 9:02 AM with the Nursing Supervisor (NS). She stated it was her practice to obtain Resident #33's vital signs before and after her dialysis. The NS was unable to explain why there was no documented evidence that Resident #33's pre and post dialysis vital signs were obtained and entered into the electronic medical record. She stated Resident #33 took a dialysis communication notebook with her to every dialysis treatment for the facility and dialysis staff to communicate regarding the care and monitoring of Resident #33. The NS stated Resident #33's notebook should be located at the nurses station on the split hall. An interview was completed on 7/7/22 at 9:05 AM with Nurse #8. She stated she was very familiar with how to monitor a dialysis resident and it was her practice to check a resident's vital signs following a dialysis treatment because the blood pressure often dropped after a treatment. She stated she also monitored for evidence of bleeding at the dialysis access site and keeping the dialysis site dressing in place for 24 hours. Nurse #8 stated the only Physician orders for Resident #33 were to obtain a pre and post weight and to check Resident #33's AV fistula for a thrill and bruit each shift. An interview was completed on 7/7/22 at 9:10 AM with NA #4. She stated it was her practice to obtain a set of vital signs on all her residents first thing when she got to work but she was not working when Resident #33 returned from dialysis. She stated she was not aware of any additional monitoring that was needed for a dialysis resident. She stated she thought the nurse sent out a notebook with Resident #33 when she went to dialysis. An interview was completed on 7/7/22 at 9:20 AM with Nurse #3 working at the split nurses station assigned Resident #33. She stated on Resident #33's dialysis days, the staff got her up, got her dressed and ensured she ate her breakfast. Nurse #3 stated Resident #33 was always tired when she returned from dialysis and the staff just put her to bed. She stated her AV fistula was checked on every shift to a bruit and thrill and that it was her practice to remove the post dialysis AV fistula dressing around 3 or 4 hours after Resident #33's return. Nurse #3 stated normally Resident #33 took a notebook with communication forms inside for the dialysis staff to document any problems or new orders while she was at dialysis. An observation was completed with Nurse #3 to locate Resident #33's dialysis notebook with her dialysis communication forms inside but Nurse #3 was not able to locate Resident #33's dialysis communication notebook. Observations were completed at the rehabilitation nurses station and the long term care nurses station as well. No dialysis communication notebook was located for Resident #33. An interview was completed on 7/7/22 at 10:07 AM with the interim Director of Nursing (DON). She stated she was under the impression the staff were sending out a notebook with the communication forms inside for the facility and the dialysis clinic staff to document Resident #33's monitoring. The interim DON also stated she was not aware that the facility staff had not obtained Physician orders for the comprehensive care and monitoring of Resident #33. A telephone interview was completed on 7/7/22 at 11:06 AM with the dialysis center's Charge Nurse. She recalled Resident #33's dialysis treatment yesterday because she stated it was the first time the facility had sent the communication form with Resident #33. She stated there was a lack of communication between the facility and the dialysis clinic. An interview was completed on 7/7/22 at 3:05 PM with Nurse #6. She stated when she started working at the facility approximately 3 months ago, she never received any sort of training on the care and monitoring of a dialysis resident. She stated when caring for Resident #33, she only assessed her AV fistula for a bruit and thrill on her shift and did not obtain any vital signs or monitor for bleeding from her AV fistula because there were no orders to do so. An interview was completed on 7/8/22 at 11:00 AM with the Medical Director. He stated as long as Resident #33 remained a resident at the facility, orders should have been obtained for the monitoring of her vital signs, her AV fistula for signs of bleeding or infection and the removal of the post dialysis treatment dressing to her AV fistula. He also stated there must be ongoing communication between the facility and the dialysis clinic. An interview was completed on 7/8/22 at 11:42 AM with the Administrator. She was able to provide dialysis communication forms on Resident #33 dated 6/1/22 and another dated 7/6/22. She stated she expected the facility to obtain Physician orders for the care and monitoring of a dialysis resident. She further stated she expected the facility to ensure there was written communication between the facility and the dialysis center regarding Resident #33. Based on record review, observation and interview from the dialysis center staff, Physician, resident and facility staff, the facility failed to obtain orders for the care and monitoring of a dialysis resident (Resident #33) and failed to utilize the communication sheets to exchange information about resident's treatment and care with the dialysis center for 2 of 2 sampled residents reviewed for dialysis (Residents #33 & # 58). Findings included: 1. Resident #58 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with multiple diagnoses including end stage renal disease (ESRD) and was receiving hemodialysis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #58 had severe cognitive impairment and was on dialysis. Resident #58 did not have a care plan or a baseline care plan for dialysis upon readmission. Review of Resident #58's medical records revealed no on-going communication with the dialysis center regarding resident's care and treatment. There were no pre and post dialysis weights from the dialysis center and there were no laboratory results since readmission. The Nurse Supervisor was interviewed on 7/7/22 at 9:02 AM. She stated that a communication binder was sent with the resident during dialysis days. Review of the dialysis binder, there were only 6 communication sheets (1/12/22, 4/4/22, 4/13/22, 6/8/22, 6/13/22 & 6/20/22) in the binder for Resident #58 for the last 6 months. Nurse #4, assigned to Resident #58, was interviewed on 7/7/22 at 10:40 AM. She stated that she works for an agency and was not familiar with the dialysis communication sheets. The Dialysis Nurse was interviewed on 7/7/22 at 11:06 AM. She stated that the facility was supposed to bring the dialysis communication sheet with the resident during dialysis days. She reported that the dialysis nurse assigned to the resident completes the sheet with the pre and post weights and vital signs and returned the sheet back to the facility. She indicated that she was not sure if the sheets were received at the center or not since the dialysis center was not maintaining copies of the completed sheets. The Administrator was interviewed on 7/8/22 at 11:45 AM. She reported that the facility had just identified 2 dialysis residents including Resident #58 who did not have communication sheets completed during dialysis days. She stated that she would educate all the licensed staff including the agency staff regarding dialysis documentation, policy and procedure and assuring that the dialysis communication sheets were completed and sent with the resident to the dialysis center.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, Medical Director and staff interviews, the facility failed to hold blood pressure medications as ordered by the physician for 2 of 6 residents whose medications were reviewed (Residents #40 and #18). The findings included: 1. Resident #40 was admitted to the facility on [DATE] with diagnoses that included hypertension. Review of Resident #40's physician orders included an order dated 4/26/21 for Tenormin (used to treat hypertension) 12.5 milligrams (mg) 1 tablet by mouth once a day. Call physician if systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 105. Hold if SBP less than 110. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 had severe cognitive impairment. The June 2022 and July 2022 Medication Administration Records (MARs) were reviewed and revealed Resident #40 had received Tenormin, despite the SBP below 110 on the following dates: 6/5/22- SBP was 96 6/23/22- SBP was 100 6/25/22- SBP was 85 6/26/22- SBP was 102 6/27/22- SBP was 102 6/28/22- SBP was 97 6/29/22- SBP was 102 7/4/22- SBP was 100 An interview occurred with Nurse #1 on 7/7/22 at 12:01 PM who was assigned to Resident #40 on 6/25/22, 6/27/22, 6/28/22 and 7/4/22. Nurse #1 indicated she was aware the resident had parameters to hold the Tenormin. She reported she took the blood pressure and recorded on the MAR. Nurse #1 reviewed the June 2022 and July 2022 MARs, verified the Tenormin was administered despite the SBP being below 110 when it should have been held and responded it was an oversight. On 7/7/22 at 1:50 PM, an interview occurred with Nurse #3 who was assigned to Resident #40 on 6/5/22 and 6/23/22. The June 2022 MAR was reviewed with her, and she manually checked Resident #40's blood pressure before administering Tenormin due to the hold parameters ordered. She was unable to recall why the Tenormin was administered outside the parameters other than to say it was an error on her part and the medication should have been withheld. Attempts to contact Nurse #7 were made without success. She was assigned to Resident #40 on 6/26/22 and 6/29/22. The Medical Director (MD) was interviewed on 7/8/22 at 11:13 AM and stated if Resident #40 had received a few dosages of Tenormin outside the parameters it would not have caused any serious harm. The MD added he would have expected the nurses to follow the orders for Tenormin parameters as written. The Administrator and Director of Nursing (DON) was interviewed on 7/8/22 at 11:41 AM and stated she expected the nurses to follow doctor's orders including blood pressure medications with parameters to hold. 2. Resident # 18 was admitted to the facility on [DATE] with multiple diagnoses including hypertension. Resident #18 had a doctor's order dated 4/27/21 for Toprol XL (an antihypertensive medication) 37.5 milligrams (mgs) 1 tablet by mouth daily for hypertension - call the doctor if systolic blood pressure (SBP) is more than 180 or diastolic blood pressure (DBP) is more than 105 and to hold if SBP is less than 110. Review of the May and June 2022 Medication Administration Records (MARs) revealed that Toprol was administered on 5/18/22 with the SBP of 104/68, on 6/5/22 with the SBP of 106/69, on 6/12/22 with the SBP of 108/61, and on 6/13/22 with the SBP of 108/61. Nurse #3, assigned to Resident #58 on 6/13/22, was interviewed on 7/6/22 at 1:40 PM. She stated that she normally checked the BP prior to administering the BP medications. The Nurse added that she was aware that Resident #18 had parameters to hold the BP medication, but she could not remember why the Toprol was not held on 6/13/22 when the SBP was less than 110. Nurse #5, assigned to Resident #18 on 6/5/22 and 6/12/22, was interviewed on 7/6/22 at 2:58 PM. The Nurse stated that she could not remember if Resident #18 had parameters to hold his blood pressure medication. She reported that she normally checked the blood pressure prior to administering the blood pressure medication. Nurse #5 did not have an explanation as to why the Toprol was administered on 6/5/22 and 6/12/22 when the SBP was below 110. The Director of Nursing (DON) and the Administrator were interviewed on 7/8/22 at 11:45 AM. The Administrator stated that the nurses were expected to follow doctor ' s orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the medication manufacturer's instruction, observation and staff interview, the facility failed to have a medication error rate of less than 5 % as evidenced by 5 medication errors of 26 opportunities, resulting in a 19 % error rate for 2 of 3 residents observed during medication pass (Residents # 116 & # 56). Findings included: 1 a. Resident #56 was admitted to the facility on [DATE]. Resident #56 had a doctor's order dated 6/8/22 for Metoprolol extended release (ER) 50 milligrams (mgs) 1 tablet by mouth daily for hypertension. There was no order to crush the medication. The manufacturer's instruction for Metoprolol extended-release tablet indicated tablet should be swallowed whole and not chewed or crushed. Resident #56 was observed during the medication pass on 7/8/22 at 8:30 AM. Nurse #4 was observed to prepare and to crush the resident's medications including the Metoprolol ER 1 tablet and mixed them with apple sauce. Nurse #4 was observed to administer the crushed medication to the resident. b. Resident #56 had a doctor's order dated 6/27/22 for Potassium Chloride (KCL) extended release (ER) 20 milliequivalent (meq) 1 tablet by mouth twice a day for hypokalemia. There was no order to crush the medication. The manufacturer's instruction for KCL ER indicated swallow the tablets or capsules whole. Do not crush or chew extended-release capsules or tablets. Doing so can release all the drug at once, increasing the risk of side effects. Resident #56 was observed during the medication pass on 7/8/22 at 8:30 AM. Nurse #4 was observed to prepare and to crush the resident's medications including the KCL ER 1 tablet and mixed them with apple sauce. Nurse #4 was observed to administer the crushed medication to the resident. c. Resident #56 had a doctor's order dated 6/8/22 for Pantoprazole delayed release 40 milligrams (mgs) 1 tablet by mouth twice a day for gastroesophageal reflux disease (GERD). There was no order to crush the medication. The manufacturer's instruction for Pantoprazole delayed release indicated do not split, chew or crush. Resident #56 was observed during the medication pass on 7/8/22 at 8:30 AM. Nurse #4 was observed to prepare and to crush the resident's medications including the Pantoprazole delayed release 1 tablet and mixed them with apple sauce. Nurse #4 was observed to administer the crushed medication to the resident. d. Resident #56 had a doctor's order dated 6/8/22 for Cymbalta delayed release 60 milligrams (mgs) 2 capsules by mouth daily for depression. There was no order to crush the medication. The manufacturer's instruction for Cymbalta delayed release capsule indicated do not chew or crush and do not open delayed release capsule and sprinkle its contents on food or mix with liquids because these actions might affect the enteric coating. Resident #56 was observed during the medication pass on 7/8/22 at 8:30 AM. Nurse #4 was observed to prepare and to crush the resident's medications and mixed them with apple sauce. The Nurse was also observed to open the 2 capsules of Cymbalta delayed release and mixed them with the crushed medications. Nurse #4 was observed to administer the crushed medication to the resident. Nurse #4 was interviewed on 7/8/22 at 9:40 AM. She stated that she was aware that ER medications were not supposed to be crushed but she was trained at this facility that ER medications could be crushed. She could not remember who provided the orientation training. The Director of Nursing and the Administrator were interviewed on 7/8/22 at 11:45 AM. They both stated that the expectation was ER medications should not be crushed unless there was a doctor's order. 2. Resident # 116 was admitted to the facility on [DATE]. Resident #116 had a doctor's order dated 6/16/22 for Nitroglycerin 0.4 milligrams (mgs)/hour (hr.) 1 patch transdermal daily for angina. Remove at bedtime. Resident #116 was observed during the medication pass on 7/7/22 at 9:02 AM. Nurse #3 was observed to prepare the resident's medications including the Nitroglycerin patch. Before applying the Nitroglycerin patch, Nurse #3 observed the old Nitroglycerin patch on the resident's chest wall. Nurse #3 was interviewed on 7/7/22 at 2:15 PM. The Nurse stated that the previous Director of Nursing (DON) had transcribed the Nitroglycerin order on the Medication Administration Record (MAR) to be given at 9:00 AM and to be removed at 8:59 AM the following day (24 hours), instead of at bedtime (12 hours) as ordered. The Director of Nursing and the Administrator were interviewed on 7/8/22 at 11:45 AM. They both stated that the expectation was for the staff to follow the doctor's order.