**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to provide effective supervision for a cognitively impaired resident when Resident #1 left the facility through the locked main entrance door. The resident was outside without staff knowledge for approximately twenty minutes and the staff found her sitting in her wheelchair between the covered main entrance and the first parked car in the parking lot. Resident #1 was assessed with no injuries noted. This deficient practice was identified for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia with mood disturbance, anxiety disorder, and brain cancer. Review of the significant changes Minimum Data Set (MDS) assessment, dated 1/31/25, revealed Resident #1 had severe cognitive impairment, and wandering behaviors were indicated to occur daily. The MDS also indicated Resident #1 was non-ambulatory and used a wheelchair. Review of the physician's orders for Resident #1, dated 1/4/25, revealed the order to check the wanderguard bracelet is on every shift and a wanderguard battery check every day shift. Review of the recent wandering assessment, dated 4/23/25, revealed that Resident #1 was at high risk for elopement. Review of the plan of care, dated 4/24/25, revealed Resident #1 was a wanderer and at risk for elopement due to wandering and exit-seeking behavior, with a goal to minimize risks for elopement through current interventions over the next 90 days. Interventions included the wanderguard placement to her left ankle, redirection away from exits as needed, and notifying the Director of Nursing (DON) of exit-seeking behaviors. On 5/8/25 at 2:15 PM, during an interview, Nurse Aide #1 indicated that on 5/3/25, approximately at 11:55 AM, she went to her car in the parking lot. She found Resident #1 between the main entrance and the first parked vehicle. The resident was in her wheelchair, in a good mood, smiling, and could not explain why and how she went outside of the facility. Nurse Aide #1 did not observe a wanderguard bracelet on the resident. Nurse Aide #1 pushed the resident in the wheelchair back to the facility and notified Nurse #1. Review of the nurses' notes provided by Nurse #1, dated 5/3/25 at 2:36 PM, revealed that Resident #1 was observed in a front parking lot with no wanderguard bracelet. The resident was returned to the facility immediately, assessed, and no injuries were noted. The resident remained in bed until the new wanderguard applied. Review of the written statement, provided by Nurse #1, dated 5/3/25, indicated that on 5/3/25 (no time was documented), Resident #1 was noted outside the facility and immediately returned to the facility. She did not have her wanderguard on. The new wanderguard was applied and checked for efficiency. The physician on call and family were notified. During a phone interview on 5/7/25 at 11:40 AM Nurse #1 indicated that on 5/3/25, she was assigned to Resident #1 on the 7:00 AM to 7:00 PM shift. Nurse #1 was aware of Resident #1's elopement risk, but became busy and did not check the placement of the wanderguard at the beginning of her shift on 5/3/25. At approximately at 11:40 AM Nurse #1 observed Resident #1 in the middle of the hallway, and the resident was at her baseline behavior, self-propelling in the hallway. At approximately 12:00 PM, Nurse Aide #1 brought Resident #1 in the wheelchair to the nurses' station, and she reported that she found the resident unattended in the parking lot without a wanderguard bracelet. Nurse #1 indicated Resident #1 was assessed and had no injuries, was not in distress, and did not have her wanderguard bracelet on. Resident #1 could not explain how she left the facility or where she went. The interview further revealed Resident #1 remained in her room for about thirty minutes until the new wanderguard was applied to her left ankle and checked for functionality. Nurse #1 stated she notified Nurse 2, Nurse Supervisor, the provider on call, and the family member. An interview with Nurse #2 (Nurse Supervisor) on 5/7/25 at 11:50 AM revealed that after 12:00 PM on 5/3/25 Nurse #1 reported that Resident #1 was found unattended in front of the main entrance. She was not wearing her wanderguard bracelet. Together with Nurse #1, Nurse #2 assessed the resident and did not find injuries. The resident was not in distress and could not explain where she went when leaving the facility. Nurse #2 stated a new wanderguard bracelet was applied to the resident's left ankle. On 5/7/25 at 11:55 AM, during the phone interview, Nurse Aide (NA) #2 indicated that she was assigned to Resident #1 on 5/3/25 for the 7:00 AM to 3:00 PM shift. The resident always wore her wanderguard, but Nurse Aide #2 could not remember if she had the wanderguard on her ankle on 5/3/25. NA #2 indicated at approximately at 11:30 AM she provided incontinence care for Resident #1, placed her in the wheelchair, and observed Resident #1 self-propelling in the hallway. NA #2 stated she was in other residents' rooms and did not witness how Resident #1 left the building. NA #2 indicated she learned about the incident after 2:00 PM. On 5/7/25 at 12:20 PM, during an interview, Nurse Practitioner (NP #1) expected the staff to check the wanderguard placement and functioning according to the order. At the time of the incident with Resident #1, the staff assessed her for injury, placed the new wanderguard, and notified the provider and family. On 5/7/25 at 12:35 PM, during an interview and observation of the facility's wanderguard system, completed with the Maintenance Director, he indicated that the front lobby door was locked automatically every day from 8:00 PM to 7:00 AM, and a code was needed to unlock the keypad and open the door. He continued that during the day, there was a receptionist that monitored the door to keep the residents from wandering outside. He demonstrated that when a person wearing a wanderguard got within approximately 7 feet of the exit door or closer, the alarm would chirp loudly, and it would automatically lock. The Maintenance Director mentioned that the facility and the parking lot are located far from the highway, on a street with no traffic except visitors to the facility. Receptionist #1 was interviewed on 5/7/25 at 1:10 PM and indicated that she was responsible for preventing residents with wanderguards from exiting the building. She worked Monday through Friday, and when Resident #1 left the faciity on Saturday, she was not in the building. Another receptionist worked on weekends from 4:00 PM to 8:00 PM and the main lobby exit door was locked if nobody was at the front desk. Receptionist #1 said she checked the elopement book on the front desk daily to ensure nobody had left or had been added to the list. Receptionist #1 stated Resident #1 was in the elopement book, with her name, room number, serial number of the wanderguard, and an expiration date. Resident #1 was not allowed to go outside without supervision. Receptionist #1 mentioned that she usually tried to distract the residents from setting off the alarm and got them away from the door. On 5/8/25 at 1:15 PM an observation of the parking lot revealed it was enclosed by a fence and a stretch of woods, which separated the facility from the surrounding area. There was one driveway that provided access in and out with slow traffic of occasional vehicles. On the left and right sides of the main entrance, there were several parked cars in designated spaces. An observation and interview with Resident #1 on 5/7/25 at 2:10 AM revealed Resident #1 was in her wheelchair in the middle of the hallway. She had her wanderguard on the left ankle. The resident indicated that she did not leave the facility last weekend. An interview with the Director of Nursing (DON) on 5/8/25 at 10:20 PM revealed that over the last two weeks Resident #1 was in the hospital Emergency Department twice for an evaluation. At the time of the transfer to the hospital, the wanderguard was removed and reapplied at return to the facility. On 4/30/25, since Resident #1 returned from the hospital, the staff observed her with the wanderguard on. The DON indicated it was unclear why Resident #1 was not wearing a wanderguard bracelet on 5/3/25. When this was determined, the nurses immediately replaced it with the new wanderguard bracelet. DON confirmed that all the staff were responsible for monitoring residents with the wanderguard to prevent them from leaving the building unattended. The Administrator indicated during an interview on 5/8/25 at 12:45 PM he expected staff to check the wanderguard placement and functionality as ordered. He indicated that the facility employed a receptionist who worked Monday through Friday from 8:00 AM to 4:30 PM and another who usually worked from 4:30 PM to 8:00 PM. The incident with Resident #1 occurred on the weekend. At the time of the incident, there was no weekend receptionist at the front door. The Administrator mentioned that it was everyone's responsibility to monitor the front door and respond if a wanderguard alarm was going off, preventing residents with wanderguards from exiting the building. The facility provided the following Corrective Action Plan. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 05/03/2025, it was discovered that the Resident #1 exited the facility without staff escort or authorization. Resident #1 was identified as a wander risk and was assigned a wander guard transmitter. The Health Information Manager (HIM) staff previously identified that the wander guard transmitter was in place. Resident #1 was observed by Certified Nursing Assistant (CNA) #1 outside in the parking area adjacent to the front door of the facility at 12:05 PM who immediately assisted Resident #1 to safely return to the facility. Upon return to the facility the wander guard transmitter was not present on the resident. At the time of the event Nurse #1 had not confirmed placement of the wanderguard for her shift and it is unclear whether the resident was wearing her assigned wanderguard transmitter. On 05/03/2025, The Resident #1 was placed on 1:1 monitoring until a wanderguard was placed and staff ensured there were no exit seeking behaviors. Nurse #1 completed a total body assessment to identify any injury and there were no injuries observed. On 05/03/2025, the Director of Nursing (DON) completed a risk assessment that includes a wandering risk scale. The risk assessment identified that Resident #1 as at risk for wandering. On 05/03/2025, the Provider and Responsible Party were both notified of the event by Nurse #1. The DON also talked with the responsible party on 05/03/2025 to discuss the event. The Nurse Consultant reviewed the care plan to ensure it reflected the wandering risk, which it did. The wander guard was placed by the Treatment Nurse on 05/03/2025 to the left ankle. On 05/03/2025, the DON validated that Resident #1's picture was in the facility elopement risk book. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 05/05/2025 a 100% audit/search was initiated and completed by the DON and the Licensed Practical Nurse (LPN) Support Nurse to assure all current residents were present and accounted for on the premises. The results included: All 116 current residents were accounted for. On 05/05/2025, the Nurse Consultant reviewed the current residents admitted since 04/08/2025 to ensure that each resident had a risk assessment that would completed and if the risk assessment indicated risk to wander that a wander guard was placed, and order for wander guard was entered into the Electronic Medical Record, and that a care plan was initiated for wandering risk if not already in place. This was completed on 05/05/2025. The results indicated that 3 residents required a risk assessment to be completed, the risk assessments had previously been started and not finalized. A corrective action was completed on 05/06/2025 when the risk assessments were completed for the 3 residents who required a risk assessment to be completed. None of the 3 residents who required a risk assessment to be completed triggered as being at risk for wandering therefore no interventions were required. On 05/05/2025, the DON, LPN Support Nurse, Nurse Consultant, and Social Services (SS) Director began identification of residents that were potentially impacted by this practice by completing an audit of all current residents at risk for elopement. This was accomplished by reviewing residents' risk assessment scores (9 & above indicating high risk) to ensure a care plan was in place. This was completed on 05/05/2025. The results included: There were 6 care plans that were required to be initiated or updated. On 05/05/2025 a corrective action was initiated by the SS Director to add or update the plan of care to include risk for wandering. On 05/05/2025, the HIM completed a review of all residents with current wander guard orders. This audit consisted of a review to ensure the wander guard was physically in place and functioning by testing each wander guard. The serial numbers and expiration date of each wander guard was reviewed and updated on the facility elopement risk book for each resident. This was completed on: 05/05/2025. The results included: One resident required her wander guard to be replaced due to the battery functioning and reading battery level was low. One resident was added to the wander guard list. Corrective action was completed on 05/05/2025 when wander guards were placed for these residents, orders were validated, and care plan was updated. The DON or designee will be responsible for checking the wander guard and wander guard battery expiration date including updating the elopement risk book with any new residents identified as a wandering risk. On 05/05/2025, the DON, LPN Support Nurse, Nurse Consultant, and SS audited the facility elopement risk book to ensure all moderate and high-risk residents had a current picture/face sheet in the facility elopement risk book identifying their risk for elopement and the serial number and expiration date of the wander guard. This was completed on 05/05/2025. The results included: All current residents with orders for wander guards had a picture and the serial number and expiration date in place. New residents who had wander guards initiated were also added to the facility elopement risk book. On 05/03/2025 and 05/04/2025, the Maintenance Director completed an audit of the wander guard system doors to ensure appropriate functioning. The results included: All wander guard doors were functioning properly. As of 05/05/2025 all of the above areas related to the elopement process were in compliance. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 05/03/2025, the DON or designee began in-servicing of all staff (full time, part time, including agency) from all departments (department directors, nursing, environmental, and dietary) on Elopement Prevention and Management to include: - Elopement Prevention Response - How to identify residents at risk for elopement - What are exit seeking behaviors - What do we do for residents that are high risk for elopement - What else can we do for residents that are high risk - What should we do if the wanderguard system alarm sounds - What to do if a resident is missing During this training staff were educated on the importance of monitoring and supervising residents who may be at risk for elopement or wandering. This monitoring should include the identification of exit seeking behaviors such as sitting for long periods of time at the doors, packing clothes, trying to open the doors/windows and other activities that involve trying to leave the facility and verbalizing that they want to leave or are going to leave. They were also educated on techniques to implement if exit seeking behaviors are identified. This may include 1:1 supervision, monitoring more frequently, redirecting residents, addressing physical causes such as toileting, hunger, thirst, and/or pain, and activities, as well as appropriate functioning of the wander guard system and immediate notification of the Administrator of any concerns related to functioning of the wander guard system. Additionally, the Quality Assurance (QA) Committee whose members include: Administrator, Director of Nursing, MDS Coordinator, Therapy, HIM, and Dietary Manager discussed adding an additional layer of safety by having the department directors to monitor the wander guards for functioning and wander guard doors for functioning at a frequency agreed upon. At this time the frequency will be daily and will be validated in daily stand up meeting. Any changes to the frequency will go through the QA Committee. As of 05/06/2025, the DON will ensure that any of the above identified staff who does not complete the in-service training will not be allowed to work until the training is completed. The DON or designee will ensure this education is reviewed for all new hires during general orientation. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. Beginning on 05/05/2025 the DON or designee will monitor this issue using the Elopement Risk Process Quality Assurance Tools for compliance with the elopement process to include that a risk assessment is completed and if wandering risk is identified that a wander guard is physically in place, that the wanderguard is functioning, that an order for a wanderguard is entered into the Electronic Medical Record (EMR), and that a care plan is in place for the wandering risk. This will be completed weekly times 3 weeks beginning on 05/05/2025 then monthly times 2 months or until resolved by QA Committee. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action was initiated as appropriate. Compliance will be monitored and the ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, Therapy, HIM, and Dietary Manager. Compliance Date: 05/06/2025 The Corrective Action plan was validated onsite on 5/8/25 when staff interviews revealed they had recently received education on Elopement Prevention and Management. In-service reports and sign-in sheets were used to verify this information. The facility provided the audit tools to ensure all current residents were present and accounted for on the premises. The audit tools for all current residents at risk of elopement were reviewed. This audit consisted of a review to ensure the wanderguard was physically in place and functioning by testing each wanderguard. Review of the documents, provided by the facility revealed the audit to make sure the facility elopement risk book to ensure all moderate and high-risk residents have a current picture/face sheet in the facility elopement risk book identifying their risk of elopement and the serial number and expiration date of the wanderguard. The audit, completed by the Maintenance Director, of the wanderguard system doors to ensure appropriate functioning. Multiple staff interviews revealed they could verbalize education training provided in reference to the Elopement Prevention and Management process. The facility's completion date of 5/6/25 for the Corrective Action plan was validated on 5/8/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of skin treatments (Resident #9). This was for 1 of 21 MDS records reviewed. The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnosis that included a stage 3 pressure ulcer. Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated her cognition was intact and she had range of motion limitations to one side of her lower extremity. The area for skin conditions for Resident #9 was coded for 1 stage 3 pressure ulcer that was present upon admission/entry or reentry, and no pressure reducing device for chair was noted. Review of Resident #9's care plan, last revised on 11/11/24, included a focus area that read Resident #9 was at risk for pressure ulcer development related to impaired mobility and her comorbidities. The interventions included pressure reducing mattress on her bed and for staff to encourage her to shift her weight frequently when sitting up in chair. An observation and interview were conducted on 01/23/25 at 10:38 AM with Resident #9. She stated she had a pressure reducing cushion for her wheelchair. She pointed at her wheelchair and stated, That's it right there as she pointed at a cushion in her wheelchair, it's been there since I was admitted to the facility. An observation revealed a pressure reducing cushion in the seat of Resident #9's wheelchair. An Interview was conducted on 01/24/25 at 11:10 AM with the MDS Coordinator. She verified the MDS quarterly dated 11/11/24 was not coded for Resident #9 having a pressure reducing device for her wheelchair. The MDS Nurse indicated it was an oversight that was not coded correctly. An Interview was conducted on 01/24/25 at 12:14 PM with the Administrator. She indicated the MDS assessment should be accurately coded in all care areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interviews, the facility failed to ensure a resident who was dependent on staff assistance for nail care received assistance when needed for 1 of 4 residents (Resident #11) reviewed for activities of daily living (ADL). The findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. Resident #11's annual Minimum Data Set assessment dated [DATE] indicated her cognition was severely impaired. There were no refusals of care, and no behaviors coded. Resident #11 was dependent on staff for oral hygiene, toileting hygiene, shower/bath, dressing, personal hygiene, bed mobility, and transfers. She had range of motion limitations on both sides of her upper and lower extremities. She was coded as receiving hospice services. Resident #11's active care plan, last revised on 11/17/24, included the focus area of an activity of daily living (ADL) self-care deficit and required assistance with ADL. Interventions included she required total assistance with bathing. There were no interventions for nail care. A review of Resident #11's nursing progress notes from 11/26/24 to 01/21/25 revealed no refusals of nail care documented. A review of Resident #11's shower schedule revealed she refused her shower on 12/30/24 and 01/20/25. An observation occurred of Resident #11 on 01/21/25 at 9:50 AM and 12:49 PM. She was lying in bed with her eyes open and was humming a song. Fingernails to both hands were medium in length, past the tips of fingers, and 6 out of 10 fingernails were jagged on the tips with a brown substance under her ring finger and middle finger of the left hand. An interview was conducted on 01/23/25 at 11:15 PM with Nursing Assistant (NA) #6. She stated she provided nail care on resident's shower days and as needed. NA #6 indicated when she provided showers, she tells the residents it's a spa day so she can get the nails as well. Normally she did not have any refusals. She could not recall the last time she provided Resident #11's nail care. She was unable to state why her nail care had not been completed. NA #6 confirmed she was Resident #11's direct care NA on 01/21/24 but she did not remember if she looked at her nails that day. An observation occurred of Resident #11 on 01/23/25 at 11:50 AM and at 2:45 PM. She was still lying in bed with her eyes open, smiling, and was humming a song. Fingernails to both hands were medium in length, past the tips of fingers, and 6 out of 10 fingernails were jagged on the tips with a brown substance under her ring finger and middle finger of the left hand. An observation and interview were conducted on 01/23/25 at 1:20 PM with Nurse #4. She stated Resident #11's fingernails needed to be cut, shaped up, and cleaned. Resident #11 was observed eating pudding with her fingers. An interview was conducted on 01/23/25 at 1:39 PM with NA #7 who was familiar with Resident #11. She stated she tried to look at Resident #11's nails when she worked with her because she would put her hands in her brief at times. She stated she provided nail care on residents' shower days and as needed. An interview was conducted on 01/23/25 at 1:50 PM with NA #8. She was familiar with Resident #11 and was assigned to care for her. She stated it was Resident #11's shower day today which she had not yet provided, and she would provide nail care at that time. An interview was conducted on 01/24/25 at 12:15 PM with the Director of Nursing (DON). She stated nails should be groomed during showers and as needed, to include Hospice residents. The DON indicated the NAs used hand wipes prior to the resident eating meals so Resident #11's jagged and dirty nails should have been discovered.

Based on observations, record review, and staff interviews, the facility failed to maintain a walk-in cooler that was clean and in good repair for 1 of 1 walk-in cooler and failed to store food off the floor in the walk-in cooler. These practices had the potential to affect food served to 100 of 104 residents. The findings included: 1. An observation of the walk-in cooler on 3/26/24 at 11:31 am revealed a black and brown substance on the walls in the form of drip marks that appeared to be dry. There was also dust buildup on the ceiling of the walk-in cooler and to the vents in the walk-in cooler. A vent that contained 3 fans had dust build up. When the ceiling was touched the hanging dust was observed to fall to the cooler floor. The cooler storage rack had dust and had a color of black, white and green. Food items in the walk-in cooler were observed to be covered. An observation and interview with the Dietary Manager on 3/26/24 at 11:34 am revealed it was his second day of employment and he was unaware of any issues involving cleanliness in the walk-in cooler. Upon observation the Dietary Manager indicated the walk-in cooler needed to be cleaned and it appeared to have dust buildup. An observation and interview were conducted with the Administrator and Maintenance Director on 3/26/24 at 11:44 am. The Administrator was observed to rub the ceiling of the walk-in cooler and dust was observed to fall to the ground. Dust was observed to the walk-in cooler vents. The walls were observed to have dried brown and black substance. The Administrator indicated the kitchen had been deep cleaned previously. The Administrator revealed she was aware the walk-in cooler fans created dust per the previous Maintenance Director which indicated the dust was coming from the fans. 2. An observation of the walk-in cooler on 3/26/24 at 11:31 am revealed the floor had 3 tiles not affixed to the floor. The wall to the rear of the walk-in cooler was black, yellow, and brown in color and was crumbling. An observation and interview with the Dietary Manager on 3/26/24 at 11:34 am revealed it was his second day of employment and he was unaware of any issues involving loose tile or moisture in the walk-in cooler. An observation and interview with the Administrator and Maintenance Director on 3/26/24 at 11:44 am revealed they were unaware of the loose tile in the walk-in cooler. Review of maintenance request from January 2024 through March 2024 revealed no maintenance request for the walk-In cooler. An interview with Dietary Staff #2 on 3/27/24 at 1:43 pm indicated the walk-in cooler needed a good cleaning. He indicated he had told the previous Dietary Manager about concerns with cleanliness and needed repairs. He stated the previous Dietary Manager had indicated the walk-in cooler was in the process of being repaired. He stated the substance on the walls was possibly a combination of mold, dust and dirt. He stated a couple of months ago the kitchen had been deep cleaned but not in the walk-in cooler. He stated he believed it was moisture. The previous Dietary Manager had been gone for 2 months. 3. An observation and interview with the Dietary Manager on 3/27/24 at 10:44 am revealed boxes of food items on the floor of the walk-in cooler that included 4 boxes of milk, a bag of onions, a box of lettuce, a box of eggplant and a box of mushrooms. The Dietary Manager stated the food items should not have been stored on the floor. The food items were observed as covered. Interview with the Administrator on 3/27/24 at 3:00 pm revealed there should not be any food items stored on the floor in the walk-in cooler.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #1 was admitted to the facility on [DATE] with diagnoses that included a history of persistent vegetative state, traumatic brain injury, and moderate protein-calorie malnutrition. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was in a persistent vegetative state with limited range of motion present to her bilateral lower and lower extremities. A review of the September 2023 active physician orders included an order to cleanse left lateral neck wound with normal saline, apply collagen sheet with silver (collagen gel wound dressing with silver oxide), hydrofera blue (manages absorption of secretions in the wound) and cover with a super absorbent dressing. Change every 2 days on day shift. Resident #1's active care plan, last reviewed 7/02/23, was reviewed and revealed there was no care plan developed to address the wound to Resident #1 ' s neck. An observation of wound care was completed on 09/13/23 at 11:02 AM with the Wound Physician. Resident #1 was observed to have a wound to the left lateral neck approximately quarter sized. The area was cleaned, measured and a dressing was applied. On 9/13/23 at 2:40 PM, an interview occurred with the MDS Nurse, who reviewed Resident #1's active care plan. She confirmed a care plan was not present for the non-pressure wound to Resident #1 ' s left lateral neck and she stated she thought she had added the wound to the active care plan. She felt it was an oversight. The Administrator was interviewed on 9/13/23 at 3:57 PM and stated the care plan should be person centered and should have included the non-pressure wound to Resident #1 ' s neck. Based on record reviews, observations, resident and staff interviews, the facility failed to develop an individualized and comprehensive care plan for contracture management (Resident #15) and skin impairment (Resident #1). This was for 2 of 19 residents reviewed. The findings included: 1) Resident #15 was admitted to the facility on [DATE] with diagnoses that included a history of traumatic brain injury and muscle spasms. An Occupational Therapy (OT) Evaluation and Plan of Treatment dated 2/3/23 indicated that Resident #15 was being seen due to progressive contracture of the left hand and fingers. She had flexion contractures present to the second to fifth fingers on the left hand. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was cognitively with limited range of motion present to her bilateral lower extremities. A review of the September 2023 active physician orders included an order to place resting hand splint to the left hand for four hours as tolerated every day. Resident #15's active care plan, last reviewed 7/17/23, was reviewed and revealed there was no care plan developed to address the left-hand finger contracture or use of the left-hand splint. An observation and interview occurred on 9/11/23 at 2:30 PM of Resident #15, who was lying in bed. She stated she wore a splint to the left hand on most days for about two to four hours. She was noted with flexion contractures to the second to fifth fingers and had difficulty grasping objects with her left hand. On 9/13/23 at 12:00 PM, an interview occurred with the MDS Nurse, who reviewed Resident #15's active care plan. She confirmed a care plan was not present for the left-hand finger contractures or use of the left-hand splint but should have been developed. She felt it was an oversight. The Administrator was interviewed on 9/13/23 at 3:57 PM, and stated it was her expectation for the care plan to be person centered and should have included Resident #15's left finger contractures and use of the hand splint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.Resident #58 was admitted to the facility 7/24/2020. The resident's annual Minimum Data Set (MDS) dated [DATE] indicated the resident had mild cognitive impairment. The facility provided a paper copy of the Smoking Policy, last revised 1/2023. The policy read in part: Resdients that have been assessed by the interdisciplinary care team as cognitively intact and safe may keep cigarettes and lighters in a locked box in their room. The box must be locked at all times and must not be accessivle to confused residents. The resident's medical record included a smoking assessment was completed 7/6/2023. Resident was evaluated and deemed a safe smoker. The resident's comprehensive care plan was last updated on 7/6/2023 and included a focus for risk of injury related to his preference to smoke. The interventions included storing smoking items (cigarettes, pipes, lighters) in secure locations such as nursing stations, medication carts, or locked in room). The intervention was dated 7/6/2023. On 9/12/2023 at 10:10 AM Resident#59 was observed in his room with 7 lighters and one partial pack of cigarettes on his bedside table. When asked about a lock box, he stated he did not have one. On 9/12/2023 at 10:15 AM writer entered Resident #58's room with the Director of Nursing (DON). The DON asked Resident #58 where his lock box was. He did not answer. The DON looked in the resident's drawers and his closet but did not find a lock box. The DON stated per policy, smoking supplies were to be secured at the nurse station, in the medication cart, or in a lock box in their room. She did not know why the resident did not have a lock box. Nurse Assistant (NA)#6 was interviewed 9/12/2023 at 10:30AM. She stated she had been in Resident #58's room several times that morning and had not noticed the smoking supplies on his bedside table. She further stated the resident was mostly independent and was a safe smoker so she did not spend a lot of time in his room. On 9/13/23 at 3:57 PM the Administrator was interviewed. She stated they have completed regular auditing of smoking supplies at least weekly. The audit was completed by the DON and included checking each resident who smoked for safe storage of smoking supplies. She further stated Resident #58 has a history of borrowing lighters from other residents and not returning them. She did not believe the lighters were functional. It was her expectation that smoking supplies be kept secure. Based on record reviews, observations, staff and resident interviews, the facility failed to ensure fall mats were in place as ordered (Resident #83) and failed to store smoking supplies in a safe manner (Resident #58). This was for 2 of 7 residents reviewed for accidents. The findings included: 1) Resident #83 was admitted to the facility on [DATE] with diagnoses that included dementia and a stroke with ataxia (limited muscle control in extremities). A record review revealed Resident #83 had the following falls by his bed: On 5/31/23 was found between the wheelchair and his bed on the floor. On 6/4/23 was found on the floor by his bed. On 6/7/23 was found lying on the floor of his room. On 6/15/23 was found sitting beside his bed. On 6/25/23 was found at the foot of his bed on the floor. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #83 had severe cognitive impairment and required limited to extensive assistance for Activities of Daily Living (ADLs). A wheelchair was used for mobility, and he was coded with 2 or more falls with no injury and 1 fall with minor injury since the last assessment. A record review revealed Resident #83 was observed lying on the floor by the bed on 8/29/23. A review of the September 2023 active physician orders included an order dated 8/31/23 for nursing to place fall mat beside patient's bed due to recent falls. Resident #83's active care plan, last reviewed 9/6/23, included a focus area for having had an actual fall with risk for further due to poor balance and unsteady gait. The interventions included fall mat at bedside while in bed that was initiated on 8/31/23. A record review revealed Resident #83 was noted on the floor beside his bed on 9/6/23. On 9/7/23 Resident #83 was moved to the 400 hall for increased visibility for safety. An observation occurred of Resident #83's bed on 9/11/23 at 11:20 AM. The bed was in the lowest position with a concave mattress present. There were no fall mats located in the room or bathroom. On 9/11/23 at 12:18 PM, Resident #83 was observed lying in bed. There was no fall mat to the bedside nor in the room or bathroom. Nurse Aide (NA) #4 was interviewed on 9/11/23 at 12:30 PM, who was assigned to Resident #83. She indicated staff monitor for safety as Resident #83 will try to transfer from the bed to the wheelchair on his own, as well as keeping the bed in the lowest position. When asked about fall mats, she stated she was unsure and had not seen any fall mats being used for Resident #83. On 9/12/23 at 10:12 AM, an observation was made of Resident #83 lying in bed. There was no fall mat present to the side of the bed, in the room or the bathroom. An observation was made of Resident #83 on 9/13/23 at 9:20 AM while he was lying in bed. There was no fall mat present to the side of the bed, in the room or bathroom. An interview occurred with Certified Medical Assistant (CMA) #1 on 9/13/23 at 12:06 PM, who was assigned to Resident #83. She was unsure if a fall mat was being used currently but recalled seeing one when Resident #83 was in a different room. The interim Director of Nursing (DON) was interviewed on 9/13/23 at 12:11 PM and stated that Resident #83 was recently moved to the 400 hall as it was a high traffic area and greater visibility for safety. She stated the fall mats were to be discontinued at that time and felt it was an oversight. On 9/13/23 at 3:57 PM, the Administrator was interviewed and stated it was her expectation for the fall mat to be in place if the order was present.

Based on observations, record review, resident and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following recertification surveys dated 5/26/22 and a complaint investigation dated 10/13/21 for two deficiencies in the area of accurate coding the Minimum Data Set (641), comprehensive care planning (656) and in supervision to prevent accidents (F689). The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross referenced to: F641- Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the area of pain assessment for 1 of 1 (Resident #28) resident reviewed for pain. During the recertification survey dated 5/26/22 the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of bowel and bladder and medications. During the complaint investigation dated 10/13/21 the facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of falls for 2 of 3 sampled residents reviewed for accidents. F656-Based on record reviews, observations, resident and staff interviews, the facility failed to develop an individualized and comprehensive care plan for contracture management (Resident #15) and skin impairment (Resident #1). During the recertification survey dated 5/26/22, the facility failed to develop a comprehensive care plan for the use of an as needed psychotropic medication and the use of oxygen. residents reviewed. During the complaint investigation dated 10/13/21, the facility failed to implement the interventions for falls as care planned 2 of 3 sampled residents reviewed for falls. F689- Based on record reviews, observations, staff and resident interviews, the facility failed to ensure fall mats were in place as ordered (Resident #83) and failed to store smoking supplies in a safe manner (Resident #58). During the recertification survey dated 5/26/22 the facility failed to provide wound care in a safe manner that resulted in a resident fall with injury during wound care and sustained a distal femur fracture. In addition, the facility failed to complete an investigation of the fall. The facility also failed to lift a non-ambulatory resident with a mechanical sling lift according to the manufacturer instructions resulting in a distal femur fracture. During the complaint investigation dated 10/13/21, the facility failed to implement the care plan interventions for falls and failed to modify the interventions after each fall to prevent further falls for 2 of 3 sampled residents reviewed for accidents. An interview was completed on 9/13/23 at 3:20 PM with the Administrator. She stated it was obvious that the facility had issues with the MDS coding and care planning and stated she was uncertain why the failure continued but acknowledged it was human error. The Administrator stated the repeat citation for accidents were unrelated but felt the repeat citation for accidents was due to staff turnover.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to date multi-use medications upon opening in 1 of 1 medication storage room and on 2 of 2 medication carts (100 hall and 200 hall medication carts) reviewed. Findings included: A. An observation was conducted on [DATE] at 9:28 AM of the East Wing medication storage room in the presence of Nurse #1. The observation revealed one multi use vial of Tuberculin purified protein with no opened date on vial. The vial appeared to be about less than half full of solution and located in the refrigerator. Nurse #1 confirmed the medication did not have an open date and discarded the vial. B. An observation was conducted on [DATE] at 1:30 PM of the medication cart on 200 Hall in the presence of Nurse #3. The observation revealed no opened date on the following multi-dose medications: 1. One multi-dose package of Ipratropium Bromide and Albuterol Sulfate 0.5mg/3ml inhalation vials. 2. One multi-dose package of Levalbuterol Nebulizer Solution 1.25mg inhalation vials. 3. One multi-dose Advair HFA AER Inhaler. 4. One multi-dose Albuterol AER PFA inhaler. 5. One multi-dose 10ml bottle of Systane Balance 0.6% solution eye drops. 6. One multi-dose 10ml bottle of Bepreve DRO 1.5% solution eye drops. Nurse #3 confirmed 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 multi-dose medications upon opening and check dates prior to administration. She stated she had been off the last two days and did not realize they were not dated. C. An observation was conducted on [DATE] at 1:48 PM of the medication cart on 100 Hall in the presence of Nurse #2. The observation revealed no opened date on the following multi-dose medications: 1. Two multi-dose packages of Retasis Emu 0.05% eye drops. 2. One multi-dose package of Ipratropium Bromide and Albuterol Sulfate 0.5mg/3ml inhalation vials. 3. One multi-dose package of Albuterol Sulfate Nebulizer Treatment 2.5mg/3ml inhalation vials. 4. One multi-dose Symbicort AER 80-4.5 inhaler. 5. One multi-dose albuterol inhaler. 6. One multi-dose Advair HFA AER inhaler. Nurse #2 confirmed 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 multi-dose medications upon opening and check dates prior to administration. She stated she did not realize they were not dated. She also stated that the pharmacy consultant checked medication carts for expired and undated medications although she was unsure how often. An interview was conducted on [DATE] at 2:04 PM with the Director of Nursing (DON). She stated nurses were to date multi-dose medications upon opening and they should be checking for dates daily prior to administration. During an interview with the Administrator on [DATE] at 3:57 PM she stated the nursing staff were to label all multi-use medications upon opening and they should be checking for dates daily prior to administration. Pharmacy consultants checked medication carts and storage rooms every couple of months for expired and undated medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews and record review, the facility failed to assess and obtain Physician orders for the self-administration of a topical cream for 1 (Resident #99) of 2 residents reviewed for the self-administration . The findings included: 1. Resident #99 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident (CVA). Review of Resident #99's active Physician orders included an order dated 5/11/21 for Aspercreme Original Cream 10 % (a topical cream used to treat joint pain) to be applied to his bilateral knees topically every 12 hours for knee pain. Review of Resident #99's care plan last revised on 2/7/22 did not include a care plan for the self-administration of his ordered topical cream. Resident #99's quarterly Minimum Data Set, dated [DATE] indicated he was moderately cognitively intact. Review of Resident #99's electronic medical record did not include any evidence of an order for the self-administration of his Aspercreme and no evidence of a self-administration assessment. A medication administration observation and interview were completed on 5/25/22 at 8:30 AM with Nurse #2. She removed a tube of Aspercreme from the medication cart and put a generous amount of the cream into a plastic medication cup. Nurse #2 stated Resident #99 applied the cream himself. During the administration of Resident #99's medications, she set the medication cup with the Aspercreme on his bedside table and left the room. Resident #99 was interviewed on 5/25/22 at 8:31 AM following the medication administration observation and revealed Nurse #2 always left a cup of Aspercreme for him to apply himself but the other nurses did not. The Administrator stated on 5/25/22 at 2:41 PM, she was unable to find any documented evidence of an order or a self-administration for Resident #99. An interview was completed with Nurse #2 on 5/25/22 at 2:45 PM. She stated she was not aware that Aspercreme required a Physician order and a self-administration assessment had to be completed prior to leaving any prescribed medication at the bedside. An interview was conducted on 5/26/22 at 1:00 PM with the Administrator and Director of Nursing (DON). The DON stated it was her expectation that Nurse #2 not leave topical medications at Resident #99's bedside but rather it be applied by the nurse as ordered every 12 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to submit an admission Minimum Data Set (MDS) within 14 days after admission. This was for 1 (Resident #201) of 21 MDS assessments reviewed for completion. The findings included; Resident #201 was admitted on [DATE]. Resident #201 admission MDS assessment with the Assessment Reference Date (ARD) of 5/12/22 was still in progress on 5/25/22. An interview was completed on 5/26/22 at 12:10 PM with the MDS Nurse. She stated she realized it yesterday and locked the MDS assessment this morning. She stated she had gotten behind and there were other people assisting her with getting caught up and Resident #201's admission MDS assessment was not completed. She stated the assessment should have been completed by the 14th day after his admission. An interview was completed on 5/26/22 at 1:00 PM with the Administrator. She stated it was her expectation that all resident MDS assessment be completed and submitted within the regulated time constraints.

**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 Minimum Data Set (MDS) assessment within 14 days after the resident was discharged from the hospice program for 1 of 2 residents reviewed for hospice (Resident #41). The findings included: Resident #41 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and a stroke. A review of the medical record for Resident #41 revealed a physician's order dated 3/16/22 to discontinue Hospice services. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41 had severe cognitive impairment and was not coded for hospice services. On 5/26/22 at 12:09 PM, an interview was completed with the MDS Nurse who stated she wasn't aware a Significant Change in Status MDS assessment should have been completed within 14 days after Resident #41 was discharged from hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. Resident #44 was admitted on [DATE] with a diagnosis of end stage renal disease. Review of Resident #44's cumulative Physician orders included an order dated 3/9/2022 for her colostomy care every shift. Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had impaired vision and required extensive assistance with all activities of daily living. Resident #44 had a colostomy and was coded as always incontinent of bowel during the assessment period. An interview was completed on 5/26/2022 at 12:22 PM with the MDS Nurse. She stated Resident #44's MDS dated [DATE] was coded inaccurately for always incontinent of bowel. She stated she should have coded it as not rated since the resident had a colostomy. She further stated it was an oversight. An interview was completed on 5/26/22 at 1:00 PM with the Administrator. She stated it was her expectation that all resident MDS assessments be coded accurately. 2b. Resident #44 was admitted on [DATE] with a diagnosis of end stage renal disease. Review of Resident #44's Medication Administration Record (MAR) for March 2022 revealed the resident received heparin, 5000 units per milliliter subcutaneously twice daily for prophylaxis. Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident received antidepressants 5 out of 7 days, opioids 5 out of 7 days, and no anticoagulants during the assessment period. An interview was completed on 5/26/2022 at 12:22 PM with the MDS Nurse. She stated Resident #44's MDS dated [DATE] was coded inaccurately for anticoagulants. The resident had received anticoagulants during the assessment period. She further stated it was an oversight. An interview was completed on 5/26/22 at 1:00 PM with the Administrator. She stated it was her expectation that all resident MDS assessments be coded accurately. Based on record reviews, observations and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of bowel and bladder (Residents #44 and #54), and medications (Resident #44). This was for 2 of 21 residents reviewed. The findings included: 1. Resident #54 was admitted on [DATE] with a diagnosis of Urinary Retention. Review of Resident #54's cumulative Physician orders included an order dated 4/5/22 for her suprapubic catheter. Resident #54's quarterly Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact, coded for a urinary catheter and coded for occasional urinary incontinence. An interview was completed on 5/26/22 at 12:10 PM with the MDS Nurse. She stated Resident #54's MDS dated [DATE] was coded inaccurately for occasional urinary incontinence and that it was an oversight. An interview was completed on 5/26/22 at 1:00 PM with the Administrator. She stated it was her expectation that all resident MDS assessments be coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to develop a comprehensive care plan for the use of an as needed psychotropic medication (Resident #61) and the use of oxygen (Resident #96). This was for 2 of 21 residents reviewed. The findings included: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and seizure disorder. Resident #61's active physician orders revealed an order dated 12/20/21 for Lorazepam (an antianxiety medication) 0.5 milligrams (mg) 1 tablet by mouth every hour as needed for anxiety. A review of the March 2022 Medication Administration Record (MAR) revealed Resident #61 received Lorazepam seven times. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #61 was cognitively intact and received 3 out of 7 days of an antianxiety medication. Resident #61's active care plan, last reviewed 4/15/22, made no reference to the use of antianxiety medications or the associated risks. A review of the April 2022 MAR revealed Resident #61 received Lorazepam 11 times. On 5/26/22 at 12:09 PM, an interview occurred with the MDS Nurse who indicated it was an oversight not to have developed a comprehensive care plan for the use of an as needed psychotropic medication used for anxiety. During an interview with the Administrator and Director of Nursing on 5/26/22 at 1:10 PM they indicated it was their expectation for Resident #61's care plan to be comprehensive and felt it was an oversight not to have included the use of psychotropic medications for anxiety. 2. Resident #96 was originally admitted to the facility on [DATE]. Her diagnoses included congestive heart failure (CHF) and hypertensive heart disease with heart failure. A physician order dated 6/28/21 revealed oxygen at 2 liters via nasal cannula as needed for saturations below 90%. Physician progress notes from 12/28/21 until 4/26/22 indicated Resident #96 had oxygen in place via nasal cannula when she was assessed each time. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #96 had severely impaired decision-making skill and required extensive to total assistance with all Activities of Daily Living. She was not coded for oxygen use. A review of Resident #96's active care plan, last reviewed 5/20/22, revealed no care plan in place for the as needed order for oxygen. Nursing progress notes from 1/1/22 until 5/24/22 indicated Resident #96 used oxygen at 2 liters via nasal cannula. On 5/23/22 at 10:40 AM, Resident #96 was observed lying in bed with oxygen in place via nasal cannula. An interview with Medication Aide (MA) #1 occurred on 5/25/22 at 1:55 PM, who stated she had always known Resident #96 to use oxygen continuously. On 5/26/22 at 12:09 PM, an interview was held with the MDS Nurse who reviewed Resident #96's medical record and care plan. She explained she had always observed Resident #96 with oxygen in place and felt it was an oversight not to have developed a care plan for oxygen use. During an interview with the Director of Nursing, on 5/26/22 at 1:10 PM, she stated it was her expectation for care plans to be an accurate reflection of the resident. She further stated she would have expected a care plan and interventions to be in place to address Resident #96's use of as needed oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #74 was admitted [DATE] with diagnoses that included dementia. Resident #74's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident has severely impaired cognition, required extensive assistance with activities of daily living and required supervision and set up only for eating. Review of Resident #74's comprehensive care plan revised 1/26/2022 included a focus for nutritional problem related to weight loss. The resident's interventions stated the resident could feed herself after tray set up. Review of Resident #74's medical record revealed a progress note dated 3/30/2022 written by the former Director of Nursing (DON). The progress note read; Resident has lost weight. Resident will eat if assisted with meals. New intervention is to have resident assisted with meals. New task put in for resident to be assisted with each meal. The resident's medical record also included a progress note dated 3/30/2022 by the Dietary Manager (DM) that read; put in recommendation to have her assisted with feedings and will continue to monitor her weight. On 5/26/2022 at 11:38 AM a phone interview was conducted with the former DON. She stated the intervention was discussed in the morning interdisciplinary meeting and she did document the resident required assistance with feeding in the resident's progress notes. She made the Minimum Data Set (MDS) nurse aware the resident required assistance with meals and the MDS nurse should have revised the resident's care plan. The former DON stated she did not add assistance with meals to the resident's care task, that would have been the responsibility of the MDS nurse. On 5/26/2022 at 12:25 PM an interview was conducted with the MDS nurse. She stated she did not recall the interdisciplinary meeting in March or being asked to add feeding assistance with each meal to Resident #74's care plan interventions. An interview was completed on 5/26/22 at 1:00 PM with the Administrator. She stated it was her expectation that care plan be revised to reflect the resident's needs. Based on staff interviews and record review the facility failed to revise the comprehensive care plan for contracture management (Resident #60), the development of a pressure ulcer (Resident #3) and for feeding assistance (Resident #74). This was for 3 of 21 residents reviewed for care plan revision. The findings included: 1. Resident #60 was admitted [DATE] with a non-traumatic intercranial hemorrhage with left side hemiplegia. His admission Minimum Data Set (MDS) dated [DATE] indicated he had severe cognitive impairment, coded for total assistance with all of his activities of daily living (ADLs) and coded for impairment to his bilateral upper and lower extremities. Review of a Restorative or Maintenance referral form dated 5/2/22 indicated Resident #60 was to receive passive range of motion (PROM) to his left upper extremities and to wear a wrist-hand orthosis splint to his left hand 3 times per weeks for 3-4 hours for prevention of a left hand contracture. Review of Resident #60's comprehensive care plan 4/22/22 did not include a care plan for contracture management or restorative nursing. An interview was completed on 5/26/22 at 12:10 PM with the MDS Nurse. She stated Resident #60's comprehensive care plan should have been revised to included Resident #60's contracture management for PROM and splinting. An interview was completed on 5/26/22 at 1:00 PM with the Administrator. She stated it was her expectation that Resident #60's revised care plan include the area of contracture management. 2. Resident #3 was on 4/1/8/20 with dementia and osteoarthritis. Review of a nursing noted dated 11/25/21 at 11:06 AM read Resident #3 developed an open area to her left lateral leg under her knee immobilizer. Review of a nursing note dated 12/10/21 read Resident #3's left knee immobilizer was discontinued and new orders were received for the treatment of her left lower lateral pressure ulcer. Review of Resident #3's comprehensive care plan last revised on 2/28/22 did not include a care area with interventions for her stage 4 pressure ulcer. Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] indicated she had severe cognitive impairment and was coded for one stage 4 pressure ulcer. An interview was completed on 5/26/22 at 12:10 PM with the MDS Nurse. She stated Resident #3's comprehensive care plan should have been revised to included Resident #3's pressure ulcer with the onset date of 11/25/21. An interview was completed on 5/26/22 at 1:00 PM with the Administrator. She stated it was her expectation that Resident #3's revised care plan include the pressure ulcer development to her left lower extremity with interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff and resident interviews, the facility failed to identify the correct route of medication administration for 1 of 3 residents (Resident #44) reviewed for medication administration. The findings included: Resident #44 was admitted on [DATE] with a diagnosis of end stage renal disease. Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had moderately impaired vision, required extensive assistance with all activities of daily living, had a percutaneous endoscopic gastric tube (PEG or feeding tube), and received antidepressants and opioids during the assessment period. Resident #44's comprehensive care plan, last updated 3/2/2022, contained a focus for nutritional problem related to weight loss, feeding tube, and dialysis. Resident #44's Medication Administration Record (MAR) for May 2022 revealed he received some medications via oral route while others were ordered to be administered via feeding tube. Resident #44's medical record revealed active physician orders for the following medications to be given through the PEG tube; Aspirin 81milligrams (mg) daily via PEG tube Fish oil 1000mg capsule once daily via PEG tube Fluoxetine 40mg table daily via PEG tube Melatonin 3mg, 2 tablets nightly via PEG tube Nephrovite 1mg tablet via PEG tube daily Probiotic capsule daily via PEG tube. Metoprolol 25mg, half tablet via PEG 2 times daily Midodrine 10mg via PEG tube every 8 hours On 5/24/2022 at 2:00 PM an interview was conducted with Nurse #4. She stated she gave all of Resident #44's medication via oral route. She stated when he first came back from the hospital the orders were written via PEG tube and they were never changed. Nurse #4 stated Resident #44 did not have any difficulty swallowing medications, the PEG was placed for supplemental feedings due to weight loss. She gave all his medication via oral route. Nurse #4 stated it was the nurse's responsibility to change the route of administration if it was incorrect. She had not noticed the route was ordered to be given via PEG and she should have had the order clarified. On 5/25/2022 at 10:49 AM an interview was conducted with Nurse #6. She stated she was an agency/contract nurse and did not work in the facility full time. She confirmed she administered Resident #44's medications. Nurse #6 stated she crushed Resident #44's medication for administration via PEG tube. However, when she entered the room, the resident informed her he did not take his medication via PEG and he had been taking them orally for several months. Nurse #6 stated she did not know; she was following the orders on the MAR. Nurse #6 stated she made the unit manager aware the orders needed clarification. An interview was conducted with Resident #44. He stated all his medication were being administered orally. He further stated he had no difficulty with swallowing and had been taking his medication via oral route for several months. An interview was conducted with the Administrator and the Director of Nursing (DON) on 5/26/2022 at 1:00 PM. The Administrator stated it was her expectation that all medication be given via route ordered. Attempts to interview the facility's medical director were not successful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with Registered Dietician (RD), family, and staff, the facility failed to implement new intervention for a resident identified with weight loss for 1 of 7 residents reviewed for nutrition (Resident #74). The findings included: Resident #74 was admitted [DATE] with diagnoses that included dementia. Resident #74's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident has severely impaired cognition, required extensive assistance with activities of daily living and required supervision and set up only for eating. Review of Resident #74's comprehensive care plan revised 1/26/2022 included a focus for nutritional problem related to weight loss. The resident's interventions stated the resident could feed herself after tray set up. Review of Resident #74's medical record revealed a progress note dated 3/30/2022 written by the former Director of Nursing (DON). The progress note read; Resident has lost weight. Resident will eat if assisted with meals. New intervention is to have resident assisted with meals. New task put in for resident to be assisted with each meal. The resident's medical record also included a progress note dated 3/30/2022 by the Dietary Manager (DM) that read; put in recommendation to have her assisted with feedings and will continue to monitor her weight. A dietary review was conducted by the Registered Dietician (RD) on 3/31/2022. The RD documented Resident #74's meal intake varied between 26-100%. The RD documented feeding assistance was ordered with meals. On 5/23/2022 at 9:10 AM Resident #74 was observed in bed with meal tray. The resident was not receiving assistance with her meal. On 5/23/2022 at 12:55 PM Resident #74 was observed sitting in her wheelchair being assisted with her lunch meal by a family member. The family member stated the facility staff provided assistance with meals when she was not there. The family member further stated she had some concerns assistance was not being provided with meals. On 5/26/2022 at 9:26 AM Resident #74 was observed sitting in her wheelchair with a meal tray set up in front of her. The resident was not receiving assistance with her meal. An interview was conducted with Nurse Assistant (NA) #7 on 5/26/2022 at 10:30 AM. She stated she was assigned to Resident #74. She stated the resident did not get assistance with every meal. The resident's care tasks indicated she was independent with meals but if she noticed the resident was not eating, she would try to assist her. On 5/26/2022 at 9:38 AM a phone interview was conducted with the RD. She stated Resident #74's weight loss was discussed in a multidisciplinary meeting in March. She further stated the former DON was present at the meeting and stated she would put in an intervention for the resident to receive assistance with each meal. On 5/26/2022 at 11:38 AM a phone interview was conducted with the former DON. She stated the intervention was discussed in the morning interdisciplinary meeting and she did document the resident required assistance with feeding in the resident's progress notes. She made the Minimum Data Set (MDS) nurse aware the resident required assistance with meals and the MDS nurse should have revised the resident's care plan. The former DON stated she did not add assistance with meals to the resident's care task, that would have been the responsibility of the MDS nurse. On 5/26/2022 at 12:25 PM an interview was conducted with the MDS nurse. She stated she did not recall the interdisciplinary meeting in March or being asked to add feeding assistance with each meal to Resident #74's care plan interventions or care tasks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, Medical Director and staff interviews, the facility failed to clarify an physician's order for oxygen and administer oxygen as ordered for 1 of 1 resident reviewed for respiratory care (Resident #96). The findings included: Resident #96 was originally admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF) and hypertensive heart disease with heart failure. Review of the active physician orders revealed an order dated 6/28/21 for oxygen at 2 liters via nasal cannula as needed for oxygen saturations below 90% and an order dated 10/15/21 if oxygen saturations are greater than 92% may discontinue use of oxygen. A physician progress note dated 4/26/22 indicated Resident #96 smiles and nods her head when asked a question but was non-verbal. Oxygen was on via nasal cannula and was to continue using at 2 liters as ordered. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #96 has severely impaired decision-making skills and received extensive to total assistance from staff for her Activities of Daily Living (ADLs). She was not coded for oxygen use. A review of the Resident #96's nursing progress notes from 1/1/22 to 5/25/22 indicated she was on 2 liters of oxygen via nasal cannula. A review of the May 2022 Medication Administration Record (MAR) revealed an entry for if oxygen saturations greater than 92% may discontinue use of oxygen at 9:00 AM. The form had a daily check mark and staff initials. In addition, the MAR had an entry for oxygen at 2L as needed for oxygen saturations below 90% and was blank for number of liters of oxygen administered and nursing initials. On 5/23/22 at 10:40 AM, an observation was made of Resident #96 while she was lying in bed listening to the radio. The oxygen regulator on the concentrator was set at 1.5 liters flow when viewed horizontally at eye level. Resident #96 was observed on 5/24/22 at 11:15 AM, while lying in bed listening to music. The oxygen regulator on the concentrator was set at 1.5 liters flow when viewed horizontally, eye level. An observation occurred on 5/25/22 at 9:00 AM of Resident #96, which revealed the oxygen regulator on the concentrator was set at 1.5 liters flow by nasal cannula when viewed horizontally at eye level. On 5/25/22 at 1:55 PM, an interview occurred with Medication Aide (MA) #1 who was familiar with Resident #96 and provided her care. She stated she had been employed at the facility for the past two years and had always known Resident #96 to use oxygen continuously. After reviewing the May 2022 MAR, the MA indicated she checked and initialed the entry that read if oxygen saturations greater than 92% may discontinue use of oxygen at 9:00 AM meaning the resident was using oxygen. Stated the oxygen saturations were checked with the oxygen on. On 5/25/22 at 2:45 PM, an observation of Resident #96 was completed with Nurse #2, who confirmed the oxygen regulator on the concentrator was set at 1.5 liters when viewed horizontally at eye level and looked to be set on 2 liters when standing over the concentrator. Nurse #2 adjusted the flow to administer 2 liters of oxygen as ordered. In addition, Nurse #2 reviewed Resident #96's May 2022 MAR and stated oxygen saturations were checked with oxygen on and that resident utilized oxygen continuously. Nurse #2 stated a clarification order should have been obtained as the orders are very confusing in relation to the oxygen use. Nurse #2 stated the nurse or MA working with Resident #96 would be responsible for ensuring the oxygen was at the right setting. An interview was conducted with the Medical Director on 5/25/22 at 11:37 AM. He reviewed Resident #96's active physician orders and verified the oxygen orders from 6/28/21 and 10/15/21 were confusing. The Medical Director acknowledged Resident #96 used oxygen continuously at 2 liters via nasal cannula and was unaware of the as needed order. The Medical Director stated he would provide a clarification order for resident to receive oxygen at 2 liters via nasal cannula as he intended it to be originally. During an interview with the Administrator and Director of Nursing on 5/26/22 at 1:10 PM, they indicated it was their expectation for oxygen to be delivered at the ordered rate, checked daily by the assigned nurse or MA and obtain clarification orders when there was a question.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #44 was admitted on [DATE] with a diagnosis of end stage renal disease. Resident #44's comprehensive care plan included a care area dated 12/14/2021 with a focus for hemodialysis 3 times weekly. Interventions included checking for at least 24 hours of any bleeding episodes, no blood pressure readings of lab work to the graft arm, keep the dressing on the dialysis access site as ordered, monitor for a thrill (vibrations felt when touching the fistula) and a bruit (a loud swishing sound when placing stethoscope over fistula site) and obtaining her vital signs as ordered. Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had moderately impaired vision and required extensive assistance with all activities of daily living and received dialysis. Review of Resident #44's April and May 2022 Physician orders only included an order dated 3/2/2022 for dialysis every Monday, Wednesday and Friday. Review of Resident #44's April and May 2022 medication administration records (MARs) and treatment administration records (TARs) did not include any documentation related to monitoring resident after dialysis or monitoring the dialysis access site. Review of Resident #44's nursing notes from April 2022 through 5/18/22 did not include any documentation of monitoring post dialysis treatments, monitoring post dialysis vital signs or evidence of monitoring her graft site for a thrill or bruit. An interview was completed with Resident #44 on 5/24/2022 at 11:12 AM. Resident #44 stated he had just returned from dialysis. He stated sometimes the nurses would check on him after he returned from dialysis but most of the time the Nurse Assistants (NA) check on him when he returned to the facility. He further stated the facility staff did not routinely check his vital signs or his graft site after a dialysis treatment. On 5/24/2022 at 2:00 PM an interview was conducted with Nurse #4. She stated she was assigned to Resident #44 and he received dialysis on Tuesdays, Thursdays, and Saturdays. She further stated she did check on the resident when he returned from dialysis, but she did not complete a set of vital signs. Nurse #4 stated in the past, dialysis residents took a form with them to dialysis. The form indicated if the resident had any changes in medications or had any recent change in health status. She did not know why the facility was not using the forms any longer. An interview was completed on 5/24/22 at 4:18 PM with the Administrator. She stated the facility was not completing or sending a dialysis communication forms with Resident #44 to dialysis. She stated she was not certain why the practice stopped. She stated the staff were monitoring vital signs and the graft site but she was unable to find any documentation to support it. An interview was completed on 5/25/22 at 11:35 AM with the MD. He stated he was not aware that the facility was not monitoring Resident #44 after his dialysis treatments and not assessing the dialysis access site. He stated he expected the facility to provide necessary monitoring and care for dialysis residents. An interview was conducted on 5/26/22 at 1:00 PM with the Administrator and Director of Nursing (DON). The Administrator and DON stated they expected the nurses to obtain Physician orders, implement those orders and be knowledgeable regarding the care of a dialysis resident. Based on observations, record review and resident, staff, Medical Director (MD) interviews, the facility failed to obtain and implement Physician orders for the care and monitoring residents on hemodialysis (Resident #30 and Resident 44). This was for 2 of 2 resident reviewed for dialysis. The findings included: 1. Resident #30 was admitted on [DATE] with End Stage Renal Disease. Review of Resident #30's April and May 2022 Physician orders only included an order dated 3/11/22 for dialysis every Monday, Wednesday and Friday. Resident #30's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact and coded as receiving dialysis. Resident #30's comprehensive care plan included a care area dated 5/25/21 that read she was scheduled for hemodialysis 3 times weekly. Interventions included checking for at least 24 hours of any bleeding episodes, no blood pressure readings of lab work to the graft arm, keep the dressing on the dialysis access site as ordered, monitor for a thrill (vibrations felt when touching the fistula) and a bruit (a loud swishing sound when listening to the fistula using a stethoscope) and obtaining her vital signs as ordered. Review of Resident #30's April and May 2022 medication administration records (MARs) and treatment administration records (TARs) did not include any documentation related to dialysis or her dialysis access site. Review of Resident #30's nursing notes from 4/1/22 to 5/18/22 did not include any documentation of monitoring post dialysis treatments, vital signs or evidence of monitoring her graft site for a thrill or bruit. Review of Resident #30's electronic medical record for vital sign following a dialysis treatment did not include any vital signs documentation on 4/8/22, 4/11/22, 4/13/22, 4/15/22, 4/18/22, 4/20/22,4/25/22, 4/29/22, 5/2/22, 5/16/22, 5/20/22 or 5/23/22. An interview was completed on 5/24/22 at 11:30 AM with Resident #30. She stated she had a graft in her left upper arm and was going 5/26/22 to have her graft assessed and opened up to improve the blood flow. Resident #30 stated when she first started dialysis, the facility was giving her a folder to take with her for communication between the facility and the dialysis clinic. She stated that stopped a long time ago because the facility nor the dialysis clinic were documenting anything. She stated the facility staff did not routinely check her graft for a thrill or bruit, assess her vital signs after a dialysis treatment, check her graft for bleeding and did not remove her pressure dressing from her graft. Resident #30 stated she removed her own dressing. An interview was completed on 5/24/22 at 4:18 PM with the Administrator. She stated the facility was not completing or sending a dialysis communication form with Resident #30 to dialysis. She stated she was not certain why the practice stopped. She stated the staff were monitoring her vital signs and her graft site but she was unable to find any documentation to support it. An interview was completed on 5/25/22 at 11:35 AM with the MD. He stated he was not aware that the facility was not monitoring Resident #30 after her dialysis treatments and not assessing her access for a thrill and bruit. He stated he expected the facility to provide necessary monitoring and care for any dialysis resident. An interview was completed with Medication Aide (MA) #1 on 5/25/22 at 2:00 PM. She stated she was not aware of any ongoing monitoring or assessment of Resident #30 and her dialysis site. She stated she recalled there should not be blood pressure or lab work done on her access arm. An interview was completed on 5/25/22 at 2:40 PM with Nursing Assistant (NA) #5. She stated the only thing she did after Resident #30's dialysis treatments was give her food and lay her down in bed. NA #5 stated she did not obtain any vital signs post dialysis because Resident #30 had a folder that she took with her and the dialysis staff obtained her vital after her treatments. NA #5 stated she was not aware that Resident #30's post dialysis site pressure dressing should be monitored for signs of bleeding. She stated she was only aware that no blood pressure or lab work should be done in her left arm because of her graft. An interview was completed with Nurse #2 on 5/25/22 at 2:45 PM. She stated she obtained a post dialysis weight, pulse, temperature, oxygen saturation and occasionally Resident #30's blood pressure. Nurse #2 stated she was not aware that Resident #30's dialysis site pressure dressing should be monitored for bleeding and not removed until the following day. She also stated she was not aware of the need to assess Resident #30's graft site daily for a thrill and bruit because there were no orders to do any of the things. An interview and observation was completed on 5/25/22 at 3:00 PM of Resident #30. She stated she had just returned from her dialysis treatment. Her left arm graft site did not have a pressure dressing in place. She stated she removed it when she got back to the facility. Resident #30 stated nobody had told her that she needed to leave her dialysis site pressure dressing in place until the following day. She stated the facility staff did not obtain her vital signs or check her dressing after each dialysis treatment. An interview was completed on 5/25/22 at 3:46 PM with Unit Manager (UM) #1. She stated Resident #30 left for her dialysis treatments on third shift at approximately 5:45 AM. She stated the nurse was responsible for sending Resident #30's dialysis communication folder with her but apparently it was not happening and hadn't for a while. UM #1 stated she was not aware of the need to obtain Resident #30's vital signs, check her graft dressing for bleeding or the need to leave the dressing in place until the following day after Resident #30's dialysis treatment. She stated the reason she was not aware was because there were no Physician orders to do so. UM #1 the only thing she was aware of was the need to assess her graft for a thrill and bruit and no blood pressures or lab work to her left arm. An interview was conducted on 5/26/22 at 1:00 PM with the Administrator and Director of Nursing (DON). The Administrator and DON stated they expected the nurses to obtain Physician orders, implement those orders and be knowledgeable regarding the care of a dialysis resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews with staff, Pharmacy Consultant and Medical Director, the facility failed to act upon recommendations made by the Pharmacy Consultant for 1 of 6 residents whose medications were reviewed (Resident #61). The findings included: Resident #61 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the brain and anxiety disorder. A review of the active physician orders revealed the following: An order dated 12/20/21 for Lorazepam (Ativan- an antianxiety medication) 0.5 milligrams (mg) 1 tab by mouth every hour as needed for anxiety, nausea, or shortness of breath. An order dated 12/20/21 for Haloperidol (Haldol- an antipsychotic medication) 2 mg, give 2 tablets by mouth every 2 hours as needed for agitation until symptoms are under control. An order dated 12/20/21 for Haloperidol 2 mg, give 2 tablets every 4 hours as needed for agitation. A Pharmacy Medication Regimen Review progress note dated 3/11/22 indicated recommendations were found with a report sent to the Administrator and Director of Nursing (DON). The facility was unable to locate a copy of the recommendation report. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #61 was cognitively intact with no behaviors noted. He was coded with receiving 3 days of an antianxiety medication during the assessment period as well as hospice care. Pharmacy Medication Regimen Review progress notes dated 4/11/22 and 5/10/22, indicated recommendations were found with a report sent to the Administrator and DON. The facility was unable to locate a copy of these recommendation reports. An interview occurred with the Medical Director on 5/25/22 at 11:37 AM, who stated the former DON would provide him with pharmacy recommendations but stated he may have seen a dozen out of 50 plus recommendations that came through each month and was unable to recall if he had viewed the recommendations dated 3/11/22, 4/11/22 or 5/10/22 for Resident #61. A phone interview was completed with the Consulting Pharmacist on 5/26/22 at 8:55 AM who explained the former DON did not respond to pharmacy recommendations consistently to include the ones that required physician responses. The Consulting Pharmacist stated she sent the same recommendations regarding time limited need for the PRN psychotropic medications each month as she had seen no change from month to month. A duplicate recommendation would continue to be made until a response was identified. The pharmacist explained recommendations were sent to the DON via email and the DON would provide to the physician for follow-up if the recommendation required a physician response and signature. On 5/26/22 at 11:34 AM, a phone interview was held with the former DON. She confirmed receiving the pharmacy reports and recommendations each month from the Consulting Pharmacist but stated she didn't always have time to do them since she had 5 other things to do. The Former DON added she left employment with the facility in April 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the Pharmacy Consultant, Medical Director, and staff, the facility failed to ensure an as needed (PRN) psychotropic medications were time limited in duration (Resident #61) and failed to have an adequate clinical indication for the use of an antipsychotic medication (Resident #61). This was for 1 of 6 residents whose medications were reviewed. The findings included: Resident #61 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the brain and anxiety disorder. A review of the active physician orders revealed the following: - An order dated 12/20/21 for Lorazepam (Ativan- an antianxiety medication) 0.5 milligrams (mg) 1 tab by mouth every hour as needed for anxiety, nausea, or shortness of breath. - An order dated 12/20/21 for Haloperidol (Haldol- an antipsychotic medication) 2 mg, give 2 tablets by mouth every 2 hours as needed for agitation until symptoms are under control. - An order dated 12/20/21 for Haloperidol 2 mg, give 2 tablets every 4 hours as needed for agitation. The March 2022 Medication Administration Record (MAR) indicated Resident #61 had received the as needed dosage of Lorazepam seven times and the as needed dosages of Haloperidol eight times. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #61 was cognitively intact. He was coded with receiving 3 days of an antianxiety medication during the assessment period as well as hospice care. Antipsychotic medications were not received during the assessment period. The April 2022 and May 2022 MARs revealed Resident #61 had received the as needed dosage of the Lorazepam 14 times in April and seven times in May. Resident #61 had received the as needed dosages of the Haloperidol nine times in April and four times in May. A review of Resident #61's medical record revealed there was no documented medical justification for the use of PRN Haloperidol. An interview occurred with the Medical Director (MD) on 5/25/22 at 11:37 AM, who stated he was aware of the regulation that required all as needed (PRN) psychotropic medications to be time limited in duration. He indicated he thought hospice residents were exempt from the regulation. In addition, the MD stated he was familiar with Resident #61 who was admitted to the facility with Hospice services in place. He reviewed Resident #61's medical record and indicated agitation was the reason for the use of Haloperidol as well as Lorazepam. The MD was unaware of any psychiatric diagnoses prior to his admission to the facility. On 5/25/22 at 2:45 PM, an interview was conducted with Nurse #2 who was familiar with Resident #61 and was aware he had PRN orders for both Lorazepam and Haloperidol. She reported that when Resident #61 became agitated she utilized either the Haloperidol or Lorazepam since they both relieved his agitation and anxiety. She characterized his agitation as asking for family more frequently, tremors becoming more intense and tearfulness. Nurse #2 stated Resident #61 did not display any aggressive behaviors towards staff or others. She would utilize other interventions such as talking, turning on music or calling his family before medication was utilized. On 5/25/22 at 3:47 PM, an interview was held with Unit Manager #1 who was aware there was a time limited duration for psychotropic medications but thought residents enrolled on hospice care were exempt and allowed to have indefinite PRN psychotropic medications. A phone interview was conducted with the consulting Pharmacist on 5/26/22 at 8:55 AM. She was able to review her monthly DRR's for Resident #61 and stated she had not requested for the physician to provide a qualifying diagnosis for the PRN Haloperidol, as she expected it to be used minimally and on a short-term basis. The consulting Pharmacist stated she had been repetitively asking for the PRN Haloperidol and Lorazepam to have a stop date. The Director of Nursing was interviewed on 5/26/22 at 1:10 PM and indicated she had been employed at the facility for four days. She was aware all PRN psychotropic medications required time limited duration even if enrolled on hospice care, to allow for reassessment of the need for the medication or if any alterations might be needed. The DON also indicated that agitation was not an appropriate clinical indication for the use of PRN Haloperidol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #44 was admitted on [DATE] with a diagnosis of end stage renal disease. Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had moderately impaired vision and required extensive assistance with all activities of daily living. Resident #44's comprehensive care plan had a focus for risk of inability to perform activities of daily living and at risk of self-care deficits related to blindness and end stage renal disease. On 5/23/2022 at 10:50 AM Resident #44 was observed sitting in his wheelchair. His fingernails were long with a black substance under the nails on both hands. Resident #44 stated his family trim his nails when they come to visit. He further stated he had asked the nurse assistants (NA) about trimming his fingernails and they stated they would trim his nails when they had time. He could not identify the NAs he had asked to assist with fingernail care. The resident stated he was aware his nails were long but due to his vision loss, he was not able to see that they were dirty. On 5/24/2022 at 11:13 AM Resident #44 was observed sitting in his wheelchair. His fingernails were long and had a black substance under the nails on both hands. An interview was conducted with NA #7 on 5/24/2022 at 3:05 PM. She stated she was assigned to Resident #44 and was familiar with him. NA #7 observed Resident #44's fingernails and stated the nails were long and dirty. She stated the resident did need nail care. She further stated she was an agency nurse and did not know the facility's policy for nail care. She knew the resident was a diabetic and some facility's do not allow NAs to provide nail care to diabetic residents. An interview was conducted with NA #6 on 5/25/2022 at 11:01 AM. She stated she worked in all areas of the facility and was familiar with Resident#44. She stated nail care is done as needed and NAs were allowed to perform nail care on fingernails but not toenails for diabetic residents. Based on record reviews, observations, resident and staff interviews, the facility failed to trim and clean dependent residents' fingernails (Residents #41, #78, #96 and #44) for 4 of 4 residents reviewed for Activities of Daily Living (ADL). The findings included: 1. Resident #41 was admitted to the facility on [DATE] with a stroke affecting the right dominant side and vascular dementia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41 had severe cognitive impairment and had no behaviors or refusal of care. He required extensive assistance with personal hygiene and bathing tasks and was coded with limited range of motion affecting one upper extremity and both lower extremities. A review of Resident #41's active care plan, last reviewed 4/7/22, included the following focus areas: - Potential for impairment to skin integrity. The interventions included to keep fingernails short. - ADL self-care performance deficit, with an intervention to check nail length, trim and clean as necessary. A review of Resident #41's nursing progress notes from 1/1/22 to 5/24/22 revealed no refusals of nail care documented. On 5/23/22 at 10:25 AM, Resident #41 was observed while lying in bed watching TV. He was noted to have long fingernails on both hands with a dark substance under them. Resident #41 was observed on 5/24/22 at 11:05 AM while lying in bed watching TV. His nails on both hands remained unchanged from previous observations. On 5/24/22 at 3:30 PM, an interview was completed with NA #4, who was familiar with Resident #41, and assigned to care for him that day. She explained nail care would be completed when needed but had not rendered nail care to Resident #41 in a while. An observation of Resident #41's nails occurred with NA #4 who verified they were long with a dark substance under them and stated, well they do need clipping. I'll have to find some clippers. On 5/25/22 at 8:51 AM, an observation was made of Resident #41's hands, which revealed fingernails remained long with a dark substance under them. Resident shook his head no when asked if anyone had offered to complete his nail care. Another observation was made of Resident #41 on 5/25/22 at 1:55 PM. He was lying in bed with his eyes closed and hands resting on top of the covers. His fingernails on both hands were long with a dark substance under them. On 5/26/22 at 9:40 AM, an interview occurred with NA #2 who was assigned to care for Resident #41 on 5/26/22. She stated a group came around to provide nail care to the residents, but she would clean nails if they were dirty. She denied providing recent nail care to Resident #41. An interview was held with NA #6 on 5/25/22 at 11:00 AM and stated she provided nail care when there was a need, unless the resident was a diabetic, then she would let the nurse know. She was unable to state if she had provided nail care to Resident #41. On 5/25/22 at 2:25 PM, an interview was completed with NA #5 and NA #8, who stated nails were to be cleaned and trimmed on shower days or when there was a need. Diabetic fingernails were cared for by the nurse. They were unaware of Resident #41 refusing nail care in the past but had not cared for him in a while. The Administrator and Director of Nursing (DON) were interviewed on 5/26/22 at 1:10 PM and stated they would expect nail care to be rendered during personal care or shower assistance. The DON further added if a NA was unable to complete the task she would expect the nurse to be notified of the need. The Administrator and DON were unable to explain why nail care had not occurred for Resident #41 as there was no documentation to show this had or had not been completed or attempted. 2. Resident #78 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis and seizure disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #78 had moderately impaired cognition and had no behaviors or refusal of care. He required extensive assistance with personal hygiene and bathing tasks. A review of Resident #78's active care plan, last reviewed 5/20/22, included a focus area for ADL self-care performance deficit. One of the interventions was to provide assistance with grooming and personal hygiene. A review of Resident #78's nursing progress notes from 1/19/22 to 5/24/22 revealed no refusals of nail care documented. On 5/23/22 at 10:15 AM, an interview occurred with Resident #78 while he was sitting in a wheelchair in his room. He was noted to have long fingernails with a dark substance under them. Resident #78 stated he didn't like his nails that long and had been a while since they were cut. He added he would bite them, but it would have left them jagged. Resident #78 was observed on 5/24/22 at 11:07 AM while lying in bed watching TV. His nails on both hands remained unchanged from previous observations. On 5/24/22 at 3:30 PM, an interview was completed with NA #4, who was familiar with Resident #78, and assigned to care for him that day. She explained nail care would be completed when needed but she had not rendered nail care to Resident #78 in a while. An observation of Resident #78's nails occurred with NA #4 who verified they were long with a dark substance under them and stated she would care for them. On 5/25/22 at 8:54 AM, an observation was made of Resident #78's hands, which revealed fingernails remained long with a dark substance under them. Resident stated no one had offered to provide nail care to him this week. Another observation was made of Resident #78 on 5/26/22 at 11:00 AM. He was sitting in the wheelchair looking out his window. His fingernails remained long with a dark substance under them. On 5/26/22 at 9:40 AM, an interview occurred with NA #2 who was assigned to care for Resident #78 on 5/26/22. She stated a group came around to provide nail care to the residents, but she would clean nails if they were dirty. She denied providing recent nail care to Resident #78. An interview was held with NA #6 on 5/25/22 at 11:00 AM and stated she provided nail care when there was a need, unless the resident was a diabetic, then she would let the nurse know. She was unable to state if she had provided nail care to Resident #78. On 5/25/22 at 2:25 PM, an interview was completed with NA #5 and NA #8, who stated nails were to be cleaned and trimmed on shower days or when there was a need. Diabetic fingernails were cared for by the nurse. They were unaware of Resident #78 refusing nail care in the past but had not cared for him in a while. The Administrator and Director of Nursing (DON) were interviewed on 5/26/22 at 1:10 PM and stated they would expect nail care to be rendered during personal care or shower assistance. The DON further added if a NA was unable to complete the task she would expect the nurse to be notified of the need. The Administrator and DON were unable to explain why nail care had not occurred for Resident #78 as there was no documentation to show this had or had not been completed or attempted. 3. Resident #96 was originally admitted to the facility on [DATE] with diagnoses that included cerebral palsy, muscle spasms and osteoporosis. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #96 had severely impaired decision-making skills and had no behaviors or refusal of care. She required extensive to total assistance with all ADL and had limited range of motion to all her extremities. A review of Resident #96's active care plan, last reviewed 5/20/22, included a focus area for potential for impairment to skin integrity with an intervention to keep fingernails short. A review of Resident #96's nursing progress notes from 1/19/22 to 5/24/22 revealed no refusals of nail care documented. The nursing progress notes also indicated Resident #96 could nod her head to yes/no questions. On 5/23/22 at 10:40 AM, Resident #96 was observed lying in bed listening to music. She was noted to have contractures to her hands with her fingernails to the right hand long and touching the palm of her hand. Fingernails on her left hand were short in length. There was no skin break down observed. Resident #96 was observed on 5/24/22 at 11:15 AM while lying in bed listening to the radio. Her fingernails to the right hand remained unchanged from previous observations. An interview occurred with Nurse Aide (NA) #7 on 5/24/22 at 3:05 PM. She indicated she was not aware of the facility's policy on nail care and was not sure when nail care would be performed. On 5/24/22 at 3:30 PM, an interview was completed with NA #4, who was familiar with Resident #96, and assigned to care for her that day. She explained nail care would be completed when needed but she had not rendered nail care to Resident #96 in a while. An observation of Resident #96's nails to the right hand occurred with NA #4 who confirmed they needed attention. On 5/25/22 at 9:00 AM, an observation was made of Resident #96's hands, which revealed fingernails to her right hand remained long and touching her palm. Resident #96 shook her head no when asked if anyone offered to provide nail care this week. Another observation was made of Resident #96 on 5/26/22 at 9:34 AM who was lying in bed listening to the radio. Her fingernails to the right hand remained long and she indicated with a nod of her head that no one had offered to trim them. On 5/26/22 at 9:40 AM, an interview occurred with NA #2 who was assigned to care for Resident #96 on 5/26/22. She stated a group came around to provide nail care to the residents, but she would clean nails if they were dirty. She denied providing recent nail care to Resident #96. An interview was held with NA #6 on 5/25/22 at 11:00 AM and stated she provided nail care when there was a need, unless the resident was a diabetic, then she would let the nurse know. She was unable to state if she had provided nail care to Resident #96. On 5/25/22 at 2:25 PM, an interview was completed with NA #5 and NA #8, who stated nails were to be cleaned and trimmed on shower days or when there was a need. Diabetic fingernails were cared for by the nurse. They were unaware of Resident #96 refusing nail care in the past but had not cared for her in a while. The Administrator and Director of Nursing (DON) were interviewed on 5/26/22 at 1:10 PM and stated they would expect nail care to be rendered during personal care or shower assistance. The DON further added if a NA was unable to complete the task she would expect the nurse to be notified of the need. The Administrator and DON were unable to explain why nail care had not occurred for Resident #96 as there was no documentation to show this had or had not been completed or attempted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, staff and Wound Physician interviews, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight (Residents #17, #96, #3 and #30) for 4 of 8 residents reviewed for pressure ulcers. The findings included: 1. Resident #17 was originally admitted to the facility on [DATE] with diagnoses that included a stroke with paralysis, weakness to the dominant (right) side and diabetes type 2. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 and modified independence for daily decision making. He was coded with moisture associated skin damage (MASD) and had a pressure reducing device to the bed. Resident #17's active physician orders included an order dated 3/16/22 for a low air loss mattress to the bed. Check inflation of 75 to 150 per manufacturer guideline. A review of Resident #17's medical record revealed from 4/9/22 until 5/12/22 a foam dressing was applied to his sacrum due to redness every other day. Resident #17's weight on 5/13/22 was 153.4 pounds (lbs.). A review of Resident #17's active care plan, last reviewed 5/20/22, included a focus area for risk for pressure ulcer development due to bowel and bladder incontinence and decreased ability to assist with repositioning. One of the interventions included a pressure reducing mattress to the bed. The May 2022 Treatment Administration Record (TAR) revealed nursing staff had been checking the inflation of the low air loss mattress to Resident #17's bed for the correct weight setting. On 5/23/22 at 10:35 AM, an observation was made of Resident #17. He was sitting up in a wheelchair at bedside. The alternating pressure reducing mattress machine was set at 75 lbs. per weight setting. The machine had settings of 75 lbs., 150 lbs., 175 lbs., 225 lbs., 300 lbs., 375 lbs., 450 lbs., and 500 lbs. and indicated to set according to the resident's weight per pounds. Resident #17 was observed lying in bed watching TV on 5/24/22 at 11:10 AM. The alternating pressure reducing mattress machine was set at 75 lbs. An observation occurred of Resident #17 on 5/25/22 at 9:15 AM while he was lying in bed. The alternating pressure reducing mattress machine was set at 75 lbs. An interview occurred with Medication Aide (MA) #1 on 5/25/22 at 2:00 PM. She stated she checked the functionality of the pressure reducing mattress' making sure the connections were good, the light was on, and the mattress was inflated, but was unaware of a weight setting on the machine. On 5/25/22 at 2:35 PM, an observation was made with the Treatment Nurse of Resident #17's alternating pressure reducing mattress machine, confirming it was set at 75 lbs. The Treatment Nurse stated she checked the functionality of the air mattress' daily during her rounds to make sure the connections were secured, and the mattress was inflated. She indicated she checked the weight settings as well and was unable to explain why Resident #17's mattress was set 75 lbs. unless it had been bumped by staff. The Wound Physician consultant was interviewed on 5/25/22 at 3:10 PM and stated he expected the alternating pressure reducing mattress machines to be checked daily and set according to the resident's weight as stated on the machine. He added large gaps between the resident's weight and the weight on the machine would not be a useful intervention. On 5/26/22 at 1:10 PM, an interview was held with the Administrator and Director of Nursing, who stated they expected the alternating pressure reducing mattress machine to be set according to the resident's weight as stated on the machine. 2. Resident #96 was originally admitted to the facility on [DATE] with diagnoses that included cerebral palsy and osteoporosis. Resident #96's active physician orders included an order dated 10/27/21 for a low air loss mattress to the bed. Check proper inflation range of 75 to 150 per manufacturer weight guidelines. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #96 had severely impaired cognition and had a pressure reducing device to the bed. Resident #96's weight on 5/13/22 was 86.8 pounds (lbs.). A review of Resident #96's active care plan, last reviewed 5/20/22, included a focus area for risk for pressure ulcer development due to history of stage 4 pressure ulcer to the coccyx area and related to bowel and bladder incontinence and decreased ability to assist with repositioning. One of the interventions included a low air loss mattress on the bed. Ensure the mattress is inflated and functioning properly. The May 2022 Treatment Administration Record (TAR) revealed nursing staff had been checking the inflation of the low air loss mattress to Resident #96's bed for the correct weight setting. On 5/23/22 at 10:40 AM, an observation was made of Resident #96, while she was lying in bed listening to the radio. The alternating pressure reducing mattress machine was set at 200 lbs. per weight setting. The machine had settings of 75 lbs., 150 lbs., 175 lbs., 225 lbs., 300 lbs., 375 lbs., 450 lbs., and 500 lbs. and indicated to set according to the resident's weight per pounds. Resident #96 was observed lying in bed listening to the radio on 5/24/22 at 11:15 AM. The alternating pressure reducing mattress machine was set at 200 lbs. An observation occurred of Resident #96 on 5/25/22 at 9:00 AM while she was lying in bed. The alternating pressure reducing mattress machine was set at 200 lbs. An interview occurred with Medication Aide (MA) #1 on 5/25/22 at 2:00 PM. She stated she checked the functionality of the pressure reducing mattress' making sure the connections were good, the light was on, and the mattress was inflated, but was unaware of a weight setting on the machine. On 5/25/22 at 2:35 PM, an observation was made with the Treatment Nurse of Resident #96's alternating pressure reducing mattress machine, confirming it was set at 200 lbs. The Treatment Nurse stated she checked the functionality of the air mattress' daily during her rounds to make sure the connections were secured, and the mattress was inflated. She indicated she checked the weight settings as well and was unable to explain why Resident #96's mattress was set 200 lbs. unless it had been bumped by staff. The Wound Physician consultant was interviewed on 5/25/22 at 3:10 PM and stated he expected the alternating pressure reducing mattress machines to be checked daily and set according to the resident's weight as stated on the machine. He added large gaps between the resident's weight and the weight on the machine would not be a useful intervention. On 5/26/22 at 1:10 PM, an interview was held with the Administrator and Director of Nursing, who stated they expected the alternating pressure reducing mattress machine to be set according to the resident's weight as stated on the machine. 3. Resident #30 was admitted on [DATE] with a stage 4 pressure ulcer. Resident #30's revised care plan dated 5/25/21 read she had a pressure ulcer to her sacrum present on admission [DATE]. Interventions included ensuring her air mattress was inflated and functioning properly. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30 was cognitively intact, coded for a stage 4 pressure ulcer, a pressure reducing device to the bed and for a weight of 248 pounds (lbs). Resident #30's active physician orders included an order dated 4/6/22 for a low air loss mattress to the bed. Check inflation of 225-300 per manufacturer guidelines every shift. A review of Resident #30's April and May 2022 electronic Treatment Administration Record (TAR) revealed nursing staff had documented evidence that they had been checking the inflation of the low air loss mattress to Resident #30's bed for the correct weight setting on all three shifts. Resident #30's last record weight in her electronic medical record dated 5/13/2022 was 271.4 lbs. An observation was completed on 5/23/22 at 3:40 PM. Resident #30's alternating pressure reducing mattress machine weight setting was between 175-225 lbs. An observation was completed on 5/24/22 at 11:30 AM. Resident #30's alternating pressure reducing mattress machine weight setting was between 175-225 lbs. An interview was completed with Medication Aide (MA) #1 on 5/25/22 at 2:00 PM. She stated she checked the functionality of the pressure reducing mattress' making sure the connections were good, the light was on, and the mattress was inflated, but was unaware of a weight setting on the machine. An interview was completed with Nurse #2 on 5/25/22 at 2:45 PM. She stated Treatment Nurse (TN) #1 ensured the alternating pressure reducing mattress machine weight setting were correct on first shift and the floor nurses were responsible to check on all other shifts. She stated she documented her observations on the TAR. An observation was completed on 5/25/22 at 4:30 PM. Resident #30's alternating pressure reducing mattress machine weight setting was between 175-225 lbs. On 5/25/22 at 4:40 PM, an observation was made with TN #1 of Resident #30's alternating pressure reducing mattress machine, confirming it was set between 175-225 lbs. TN #1 stated she checked the functionality of the air mattress daily during her rounds to make sure the connections were secured, and the mattress was inflated. She indicated she checked the weight settings as well and was unable to explain why Resident #30's mattress was set between 175-225 lbs unless it had been bumped by staff. She stated she documented her observations on the TAR for first shift. The Wound Physician consultant was interviewed on 5/25/22 at 3:10 PM and stated he expected the alternating pressure reducing mattress machines to be checked daily and set according to the resident's weight as stated on the machine. He added large gaps between the resident's weight and the weight on the machine would not be a useful intervention. An interview was completed with the Administrator and the Director of Nursing (DON on 5/26/22 at 1:00 PM. The DON stated she expected the alternating pressure reducing mattress machine to be set according to the resident's weight as stated on the machine. 4. Resident #3 was admitted on [DATE]/20 with Dementia and Osteoarthritis. Resident #3's quarterly Minimum Data Set, dated [DATE] indicated she had severe cognitive impairment, coded for one stage 4 pressure ulcer, coded for a pressure reducing device to the bed and her weight was 127 pounds (lbs). Resident #3 comprehensive care plan last revised 2/28/22 did not include a care plan for her stage 4 pressure ulcer. Resident #3's active physician orders included an order dated 10/27/21 for a low air loss mattress to the bed. Check inflation of 75-150 per manufacturer guidelines every shift. Resident #3's last record weight in her electronic medical record was dated 5/11/22 was 127.2 lbs. A review of Resident #3's April and May 2022 electronic Treatment Administration Record (TAR) revealed nursing staff had documented evidence that they had been checking the inflation of the low air loss mattress to Resident #3's bed for the correct weight setting on all three shifts. An observation was completed on 5/23/22 at 11:00 AM. Resident #3's alternating pressure reducing mattress machine weight setting was between 150-175 lbs. An observation was completed on 5/24/22 at 12:05 PM. Resident #3's alternating pressure reducing mattress machine weight setting was between 150-175 lbs. An observation was completed on 5/25/22 at 9:40 AM. Resident #3's alternating pressure reducing mattress machine weight setting was between 150-175 lbs. An interview was completed with Medication Aide (MA) #1 on 5/25/22 at 2:00 PM. She stated she checked the functionality of the pressure reducing mattress' making sure the connections were good, the light was on, and the mattress was inflated, but was unaware of a weight setting on the machine. An interview was completed with Nurse #2 on 5/25/22 at 2:45 PM. She stated TN #1 ensures the alternating pressure reducing mattress machine weight setting were correct on first shift and on the other shifts the floor nurses were responsible to check. She stated she documented her observations on the TAR. On 5/25/22 at 4:40 PM, an observation was made with Treatment Nurse (TN) #1 of Resident #3's alternating pressure reducing mattress machine, confirming it was set between 150-175 lbs. TN #1 stated she checked the functionality of the air mattress' daily during her rounds to make sure the connections were secured, and the mattress was inflated. She indicated she checked the weight settings as well and was unable to explain why Resident #3's mattress was set between 150-175 lbs unless it had been bumped by staff. She stated she documented her observations on the TAR for first shift. The Wound Physician consultant was interviewed on 5/25/22 at 3:10 PM and stated he expected the alternating pressure reducing mattress machines to be checked daily and set according to the resident's weight as stated on the machine. He added large gaps between the resident's weight and the weight on the machine would not be a useful intervention. An interview was completed with the Administrator and the Director of Nursing (DON on 5/26/22 at 1:00 PM. The DON stated she expected the alternating pressure reducing mattress machine to be set according to the resident's weight as stated on the machine.

Based on record review and staff interviews, the facility failed to provide Nursing Assistants (NAs) with annual dementia training for 4 of 5 sampled Nurse Aides reviewed for required in-service training (NAs #1, #2, #3, and #12). The findings included: NA #1's date of hire was 7/26/10. Review of in-service records revealed she was not provided annual dementia training. NA #2's date of hire was 10/21/13. Review of in-service records revealed she was not provided annual dementia training. NA #3's date of hire was 6/17/20. Review of in-service records revealed she was not provided annual dementia training. NA #12's date of hire was 10/23/08. Review of in-service records revealed she was not provided annual dementia training. On 5/26/22 at 10:08 AM, the Administrator stated she reviewed the in-service records for NA's #1, #2, #3 and #12 and could not find documentation that they were provided dementia training annually. She stated the Staff Development Coordinator was no longer employed at the facility for the last few months. The Administrator further stated she had identified a problem with in-service education for the staff, but would expect all NAs to be up to date with dementia training.