**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #3 was admitted to the facility on [DATE] with diagnoses that included Dementia. a. A review of Resident #3's medical record revealed she had a fall on 07/24/24 with no injuries. A quarterly Minimum Data Set (MDS) assessment, dated 07/31/24, indicated Resident #63 had moderate cognitive impairment and was not coded for any falls since the last assessment (quarterly dated 6/15/24). b. A review of Resident #3's medical record revealed she had a fall on 08/05/24 with no injuries. A quarterly MDS assessment, dated 09/15/24, indicated Resident #3 had moderate cognitive impairment and was not coded for any falls since the last assessment (quarterly dated 7/31/24). An interview was conducted with the MDS Coordinator on 12/5/24 at 9:55 AM. The MDS Coordinator reviewed the MDS assessment dated [DATE] as well as Resident #3's medical record. The MDS Coordinator confirmed Resident #3 had a fall since the last assessment on 07/24/24 and should have been coded for a fall with no injury. She then reviewed the MDS assessment dated [DATE] as well as Resident #3 ' s medical record. The MDS Coordinator confirmed Resident #3 had a fall since the last assessment on 08/05/24 and should have been coded for a fall with no injury. She stated it was an oversight. An interview was conducted with the Administrator on 12/5/24 at 10:12 AM and stated it was his expectation for the MDS assessments to be coded accurately in the area of falls. Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of accidents (Residents #63, #64 and #17). This was for 3 of 22 residents whose MDS assessments were reviewed. The findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. A review of Resident #63's medical record revealed he had a fall on 9/20/24 with a minor injury since the quarterly MDS assessment on 8/9/24. The annual MDS assessment, dated 11/9/24, indicated Resident #63 had severe cognitive impairment and was not coded for any falls since the last assessment. On 12/5/24 at 9:50 AM, an interview occurred with the MDS Coordinator, who reviewed the MDS assessment dated [DATE] as well as Resident #63's medical record. The MDS Coordinator confirmed Resident #63 had a fall since the last assessment on 8/9/24 and should have been coded for a fall with minor injury. She stated it was an oversight. An interview was conducted with the Administrator on 12/5/24 at 10:12 AM and stated it was his expectation for the MDS assessments to be coded accurately in the area of falls. 2. Resident #64 was admitted to the facility on [DATE] with diagnoses that included history of a stroke with left sided weakness and repeated falls. A review of Resident #64's medical record revealed he had falls on 7/5/24 with no injury, 7/25/24 with no injury, 8/3/24 with no injury, 8/7/24 with no injury and another fall on 8/7/24 with minor injury since the annual MDS assessment on 6/15/24. The quarterly MDS assessment, dated 9/15/24, indicated Resident #64 had moderately impaired cognition and was coded with one fall with minor injury since the last assessment. On 12/5/24 at 9:50 AM, an interview was completed with the MDS Coordinator, who reviewed the MDS assessment dated [DATE] as well as Resident #64's medical record. The MDS Coordinator confirmed Resident #64 had four falls without injury since the last assessment on 6/15/24 and should have coded the MDS assessment as 2 or more falls with no injury. She stated it was an oversight. An interview was conducted with the Administrator on 12/5/24 at 10:12 AM and stated it was his expectation for the MDS assessments to be coded accurately in the area of falls.

Based on manufacturer's recommendations, observations, record review and staff, and Consultant Pharmacist interviews, the facility failed to discard expired medications in 1 of 2 medication carts (Masters Hall Medication Cart) reviewed for medication storage and labeling. Findings included: An observation was conducted on 12/04/24 at 1:50 PM of the Masters Hall medication cart in the presence of Nurse #1. The observation revealed the following expired medications: a. One opened bottle of Latanoprost eye drops used to treat glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision) with an opened date of 09/10/24. The manufacturer's recommendation was to discard 6 weeks after opening. b. One opened bottle of Latanoprost eye drops used to treat glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision) with an opened date of 10/16/24. The manufacturer's recommendation was to discard 6 weeks after opening. c. One opened bottle of Latanoprost eye drops used to treat glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision) with an opened date of 10/18/24. The manufacturer's recommendation was to discard 6 weeks after opening. An interview was conducted with Nurse #1 on12/04/24 at 1:52 PM. She verified the medications were expired and she removed them from the medication cart and discarded them. She indicated nurses were to check dates on all multi-use medications prior to administration to make sure they were not expired. She then stated she did not realize the medications were expired. She indicated she had not checked the medication cart for expired medications on 12/04/24. An interview was conducted with the Director of Nursing (DON) on 12/05/24 at 10:01 AM. She stated all nurses were responsible for checking dates on multi-use medications prior to administration to verify that they were not expired. She explained that the unit managers could also check the medication carts for expired medications however there was no set days or schedule for them to follow. She then stated the pharmacist should be performing medication cart audits when they were in the building. She expected the nurses to always check dates prior to administration and to remove medications that were expired. A phone interview was conducted with the facility Pharmacist on 12/05/24 at 11:15 AM. She stated she came to the facility every other month and checked the medication carts for dated and expired medications. She explained that she tried to look at all four medication carts while in the facility but that was not always possible, however, she did review at least two of them. She indicated the last time she was at the facility was in October and she checked two medication carts at that time. She did not recall which medication carts that she reviewed in October. The Pharmacist verified the manufacturer's recommendation was to discard Latanoprost eye drops 6 weeks after opening.

Based on record review and staff interview, the facility failed to ensure Nursing Assistants (NAs) received annual Dementia training. This was for 4 (NA #1, NA #2, NA #3 and NA #4) of 5 NAs reviewed for staffing. The findings included: a.NA #1's date of hire was 06/22/10. Review of NA #1's Education/In-services records indicated no record of Dementia training since 06/07/23. b.NA #2's date of hire was 02/02/16. Review of NA #2's Education/In-services records indicated no record of Dementia training since 06/07/23. c.NA #3's date of hire was 12/20/99. Review of NA #3's Education/In-services records indicated no record of Dementia training since 06/06/23. d.NA #4's date of hire was 12/19/22. Review of NA #4's Education/In-services records indicated no record of Dementia training since 06/07/23. An interview was conducted with the Director of Nursing (DON) on12/05/24 at 10:01 AM. She explained the current Staff Development Coordinator (SDC) had been out on medical leave since October 2024 however she had requested to step down from her current position of SDC upon returning. The DON stated Dementia training should be completed yearly, and it was an oversight it wasn't completed within the last year. The DON verified with the previous SDC nurse that it was an oversite that the Dementia training was not completed. An interview was conducted with the Administrator on 12/05/24 at 10:35 AM. He confirmed Dementia training had not been completed since 06/07/23. He stated it was an oversight that the training had not been done. The Administrator stated it was his expectation that the NAs received annual Dementia training.

Based on observations and staff interviews, the facility failed to date leftover food items stored for use in the dry goods storage area and in 1 of 1 walk-in coolers. This practice had the potential to affect food served to residents. The findings included: a. An observation on 12/2/24 at 9:35 AM of the dry goods revealed the following concerns: - an open and undated bag of corn flakes placed in transparent wrapping. - an undated bag of leftover brown sugar stored in a plastic bag that was not sealed. b. An observation of the walk-in cooler on 12/2/24 at 9:45 AM revealed the following concerns: - an undated leftover package of sliced cheese stored in transparent wrapping - an undated leftover package of sliced ham stored in transparent wrapping - a stainless-steel container with cooked mixed vegetables that had not been dated An interview with the Dietary Manager on 12/2/24 at 10:00 AM indicated that she was new in the position. She stated she was responsible for making sure food items were dated and stored properly. An interview with [NAME] #2 on 12/3/24 at 11:10 AM revealed that she knew that refrigerated leftover food had to be used within 3 days. She further indicated that all dry goods should be sealed and labeled with an open date and used within 7 days. If not used in 7 days, the dry foods should be thrown out. An interview with Dietary Aide #1 on 12/3/24 at 11:13 AM indicated that food items should be sealed, dated and the expiration or use by date should be checked daily, and thrown out when indicated. An interview with the Administrator on 12/4/24 at 9:30 AM revealed the Dietary Manager was new on the job. He then said that sanitary and safe food was very important, and he would make sure the Dietary manager would have a system in place to monitor food items for proper wrapping and dating of leftover foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, the facility failed to apply a left lower extremity (LLE) brace as ordered. This was for 1 (Resident #44) of 1 resident reviewed for range of motion (ROM). The findings included: Resident #44 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident (CVA) and multiple contractures. Resident #44's annual Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment, no behaviors, extensive assistance with all of her activities of daily living and she was coded for impairment to both upper and lower extremities. Review of Resident #44 September 2023 Physician orders included an order dated 8/22/23 and reordered on 9/25/23 that read she was to wear a knee brace on her LLE for 4 hours a day, or as tolerated while lying supine in the bed for contracture management. Resident #44 was care-planned for a self-care performance deficit which included the new intervention dated 8/23/23 to wear the knee brace on her LLE for 4 hours a day, or as tolerated while lying supine in bed. A review of the comprehensive care plan did not include any refusals or resistance to wearing her LLE brace. Review of Resident #44's undated electronic Care Guide read the following: Resident was to wear knee brace on LLE for 4 hours or as tolerated daily while lying supine. An observation was completed on 9/25/23 at 12:14 PM of Resident #44. She was lying supine (lying in bed with face upward) in bed with no LLE brace in use. Another observation was completed on 9/26/23 at 11:12 AM of Resident #44. She was lying supine in bed with no LLE brace in use. Resident #44 stated she was supposed to wear the LLE brace everyday but the staff were inconsistent with putting it on her. Observation of Resident #44's closet revealed the LLE brace lying on the bottom of the closet with a pillow on top of it. An interview was completed on 9/27/23 at 9:15 AM with Nursing Assistant (NA) #6, who had worked with Resident #44. She stated she was aware that Resident #44 was ordered an LLE brace and she was not known to refuse the LLE brace. Another observation was completed on 9/27/23 at 9:25 AM of Resident #44. She was lying supine in the bed with no LLE brace in use and observed on top of a nightstand beside her closet was her LLE brace. An interview was completed on 9/27/23 at 9:30 AM with the Therapy Director. He stated Resident #44's LLE brace was a new intervention and was recently put into place on 8/22/23. and she was discharged from Physical Therapy (PT) on 9/14/23. The Therapy Director provided a therapy note dated 9/14/23 which read the following: demonstrated and practiced with the aide donning Resident #44's LLE to reduce her hip and knee flexion contracture. Resident #44 was reminded she was to wear the LLE brace for 4 hours a day while lying supine in bed. The Therapy Director stated when therapy discharged a resident from therapy, they complete written instructions that were provided to nursing department on new interventions implemented. He provided a copy of a form titled Post Discharge Nursing Staff Care Services Communication Form dated 9/15/23 read as follows: Resident #44 had to wear her knee brace on her LLE fir 4 hours or as tolerated daily while supine in bed. The form was not signed by any staff in the nursing department. Review of Resident #44's nursing notes from 8/22/23 to 9/27/23 did not include any documented evidence of her refusing to wear her LLE brace as ordered. Review of the Nurse Aides task documentation for September 2023 did not include any evidence that Resident #44's LLE brace was being applied as ordered. Review of Resident #44's Medication Administration Records (MARs) for August and September 2023 read the following information: Resident #44 was to wear the LLE brace for 4 hours or as tolerated daily while lying supine in bed for contracture management. There was no place for the nurse to document the ordered application and removal of her LLE brace was completed. The Director of Nursing (DON) provided a copy of a nursing note dated 9/26/23 at 3:45 PM as only documented evidence from 8/23/23 to present that the nursing staff were applying Resident #44's LLE brace as ordered. An interview was completed on 9/27/23 at 1:55 PM with Nurse #4. She stated Resident #44 was to wear the LLE brace when supine in bed. Nurse #4 stated the aides put on and remove her LLE brace. Nurse #4 stated she was not aware that the application of Resident #44's LLE brace appeared on the September 2023 MAR. She stated since it was on the MAR, the nurse was responsible for ensuring the aide applied the brace as ordered however that there was no place to document it. She stated it appeared on the MAR as an FYI . Nurse #4 stated none of the aides had reported to her any occasion that Resident #44 refused to wear her LLE brace. An interview was completed on 9/27/23 at 2:00 PM with NA #7 who was assigned to Resident #44. She stated she was unaware that Resident #44's was ordered to wear LLE brace to be worn daily and she had not been applying it. An interview was completed on 9/27/23 at 2:20 PM with the DON. She stated she added the application of Resident #44's LLE brace to the aides daily task list and it would now populate for the aides to document her LLE brace placement, removal and refusals. The DON stated Resident #44's LLE brace should have been applied as ordered for contracture management. An observation was completed on 9/28 at 930 AM of Resident #44. She was lying supine in bed wearing her LLE brace.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and Hospice Aide #1 interviews along with record review, the facility failed to provide care safely which resulted in a fall without injury when Hospice Aide #1 left Resident #68's on his side in bed to retrieve a washcloth and failed to ensure two staff were presence for bed mobility. This was for 1 (Resident #68) of 8 reviewed for accidents. The findings included: Resident #68 was admitted on [DATE] with a diagnosis of cerebral ischemia. Review of Resident #68's Fall Risk assessment dated [DATE] indicated he was a moderate risk for falls, no history of falls and required the presence of 1-2 staff. Review of the incident report read Resident #68 sustained a fall on 7/27/23 when Hospice Aide #1 independently positioned him on his side and stepped away from the bedside to retrieve a washcloth resulting in a fall with no injury. The new intervention implemented was to ensure Resident #68 was repositioned on his back when not providing ADL care. Review of Resident #68's Fall Risk Assessment completed after his fall dated 7/27/23 indicated he was a high risk for falls, no history of falls and required the presence of 1-2 staff. Review of Resident #68's last two quarterly Minimum Data Set (MDS) assessments dated 5/20/23 and 8/20/23 indicated he was coded for extensive assistance with two staff for bed mobility. Resident #68 comprehensive care plan last revised on 9/14/23 read his bed mobility required supervision assistance by one staff to turn and reposition in bed as necessary for his activities of daily living (ADLs). An interview was completed on 9/26/23 at 2:40 PM with the Director of Nursing (DON). She stated she completed one-on-one education with Hospice Aide #1 and the aide notified the hospice agency of the fall. The DON stated Hospice Aide #1 rolled Resident #68 onto his side and then stepped away from the bedside to grab something to provide incontinence care. The DON stated she educated Hospice Aide #1 to return Resident #68 onto his back if she needed to step away from the bedside. An interview was completed on 9/27/23 at 9:20 AM with Nursing Assistance (NA) #7. She stated Hospice Aide #1 came to provide Resident #68's ADL assistance Monday through Friday. She stated Resident #68 did require two staff assistance with turning and repositioning in bed especially with pulling him up in bed. NA #7 stated residents should never be left alone on their side while staff stepped away from the bedside and should always have another staff member present if the residents required two staff assistance with their bed mobility due to increased risk of the resident sustaining a fall. A telephone interview was completed on 9/27/23 at 9:48 AM with Hospice Aide #1. She stated Resident #68 was in his bed. Hospice Aide #1 stated she was washing him up when she rolled Resident #68 onto his side and stepped away from his bedside to grab a washcloth. She stated she tried to grab him to stop the fall but there was nothing to really grab onto. She stated after the fall, she notified her supervisor at the hospice agency and also the DON for the facility. She stated she received re-education from both her hospice supervisor and the facility DON regarding not leaving a resident unattended on their side. She stated at one time, hospice was sending two aides to the facility but then it changed to one due to staffing. Hospice Aide #1 stated about month ago, the agency resumed sending two aides. An interview was completed on 9/27/23 at 11:25 AM with NA #1. She stated Resident #68 always required two staff assistance bed mobility because of how his right side and right leg were contracted and difficult to safely move alone. Another interview was completed with the DON on 9/28/23 at 9:40 AM. She stated she was not aware that Resident #68 was coded for extensive assistance of two staff with his bed mobility until 9/27/23 when she revised his care plan to reflect his bed mobility status to reflect he required to staff present with turning and positioning in the bed. An interview was completed on 9/28/23 at 8:30 AM with the Administrator. She stated it was the responsibility of the facility to ensure Resident #68 not sustain any falls and to ensure there were two hospice aides or the hospice aide to obtain a facility staff member to assist her with Resident #68's bed mobility if the second hospice aide was not available. The Administrator stated there were two hospice aides coming now to provide Resident #68's ADL assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Physician Assistant and staff interviews, the facility failed to transcribe pulse parameters for a heart medication for 1 of 5 residents whose medications were reviewed (Resident #73). The findings included: Resident #73 was initially admitted to the facility on [DATE] with diagnoses of hypertension, presence of a cardiac implant and atrial fibrillation. A physician's progress note dated 7/26/23 indicated that Digoxin 125 micrograms (mcg) was being provided daily for atrial fibrillation and should be held for a pulse rate less than 60. A review of the August 2023 physician orders revealed an order dated 7/26/23 for Digoxin 125 mcg 1 tablet by mouth daily for atrial fibrillation. Hold for pulse less than 60. Review of the August 2023 Medication Administration Record (MAR) from 8/1/23 to 8/21/23 indicated the pulse rate was being monitored when the Digoxin was administered. There were no days that Resident #73's pulse was below 60 and the Digoxin was held. A review of the medical record indicated Resident #73 was admitted to the hospital on [DATE] and was readmitted to the facility on [DATE]. Per the hospital Discharge summary dated [DATE] an order was present for Digoxin 125 mcg 1 tablet by mouth daily in the morning. An interview occurred with Nurse #2 on 9/26/23 at 1:47 PM as she was the nurse who transcribed the Digoxin order when Resident #73 was readmitted to the facility on [DATE]. She reviewed the August 2023 Digoxin orders and confirmed she failed to include when to hold the medication. Nurse #2 stated she should have clarified the order with the Physician's Assistant or Physician when the resident returned back to the facility from the hospital. Review of the August 2023 MAR from 8/29/23 to 8/31/23 indicated the Digoxin 125 mcg was initialed as administered and there were no parameters of when to hold the medication included on the MAR. Review of the September 2023 physician orders revealed an order dated 8/28/23 for Digoxin 125 mcg 1 tablet by mouth daily for atrial fibrillation. The parameters of when to hold the medication were not listed with the order. The September 2023 MAR was reviewed from 9/1/23 through 9/26/23 and revealed the Digoxin 125 mcg was initialed as administered and there were no parameters of when to hold the medication included on the MAR. The Director of Nursing was interviewed on 9/26/23 at 1:29 PM and reviewed the August 2023 and September 2023 MARs and orders. She stated Resident #73 was in the hospital from [DATE] to 8/28/23 and when she returned to the facility the transcribing nurse failed to put the parameters in the order. She felt this was an oversight. The Physician's Assistant (PA) was interviewed on 9/27/23 at 9:58 AM and reviewed Resident #73's Digoxin orders from August 2023 and September 2023. He confirmed the pulse parameter of when to hold the medication was not transcribed when Resident #73 returned to the facility on 8/28/23 and would have expected a pulse be taken prior to giving the medication. He further stated that he felt there was no serious harm caused as he monitored her Digoxin level lab work very closely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the Pharmacy Consultant, Physician's Assistant and staff, the facility failed to have an adequate clinical indication for the use of an antipsychotic medication (Resident #73). This was for 1 of 5 residents whose medications were reviewed. The findings included: Resident #73 was initially admitted to the facility on [DATE] with diagnoses that included dementia with psychotic disturbance, anxiety disorder, and depression. A review of Resident #73's medical record revealed she was hospitalized from [DATE] to 8/28/23. Per the hospital Discharge summary dated [DATE], an order was present for Seroquel 25mg 1 tablet by mouth at bedtime 8:00 PM. A review of the active physician orders included an order dated 8/28/23 for Seroquel 25 mg 1 tab by mouth at bedtime for behaviors. The September 2023 Medication Administration Record (MAR) indicated Resident #73 received Seroquel at bedtime as ordered. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 had moderately impaired cognition and received 7-days of an antipsychotic medication during the assessment period. The Director of Nursing was interviewed on 9/26/23 at 1:29 PM and reviewed Resident #73's active physician orders. She confirmed the diagnosis for Seroquel use was behaviors and stated that was not an appropriate clinical indication. On 9/26/23 at 1:47 PM, an interview occurred with Nurse #2 who was the readmitting nurse for Resident #73 on 8/28/23. She reviewed the order and stated she was unaware a diagnosis of behaviors was not an appropriate clinical indication for the use of Seroquel. An interview occurred with the Physician's Assistant (PA) on 9/27/23 at 9:58 AM. He reviewed Resident #73's medical record and indicated when she returned from the hospital on 8/28/23 and the diagnosis of behaviors was chosen inadvertently. He was aware that a diagnosis of behaviors was not an appropriate clinical indication for the use of Seroquel and stated that the order should have been clarified at the time of readmission. A phone interview was conducted with the consulting Pharmacist on 9/27/23 at 1:20 PM. She was able to review her monthly drug regimen reviews for Resident #73 and stated that on 9/26/23 she requested for the facility to provide a qualifying diagnosis for the Seroquel that was used daily.

Deficiency Text Not Available

Based on record review, observations and interviews with staff, Dishwasher Repairman, and Regional Dietary Director, the facility failed to label opened food items stored in 1 of 1 walk in coolers, 1 of 1 reach in coolers, and 1 of 1 walk in freezers and failed to maintain water temperature during the wash and rinse cycles of the high-temp dishwasher according to manufacturer ' s instructions for 3 of 4 observations. This practice had the potential to affect food served to residents. Findings included: 1. During the initial tour of the kitchen on 09/25/23 at 09:18 AM in the presence of the Dietary Manager (DM) the following were observed: a. Located in the reach-in refrigerator available for use was one ham and cheese sandwich without a label. The DM verified the sandwich did not contain a label and she discarded the item. b. Located in the walk-in refrigerator available for use were two trays containing 64 single serving individual cups with a white substance with no label. The DM identified the white substance as sour cream and stated that it should have been labeled and dated when prepared. On 09/25/23 at 09:24 AM an interview was conducted with Dietary Aide #3. She stated she prepared the cups of sour cream this morning (09/25/23) for today ' s lunch but forgot to label the cups/trays. c. Located in the walk-in freezer available for use were the following items: - One opened box of four ounce Pork Choppette patties that was 1/4 full and undated. The DM stated that the box should have been labeled with the date it was delivered to the facility. -One 30 pound (lb) opened box of cut corn that was 1/4 full, undated and unlabeled. The DM stated that the box should have been labeled with the date it was delivered to the facility. -One 30 lb opened box of sliced zucchini that was 1/4 full, undated and unlabeled. The DM stated that the box should have been labeled with the date it was delivered to the facility. -One 30 lb opened box of cut cauliflower that was 1/2 full, undated and unlabeled. The DM stated that the box should have been labeled with the date it was delivered to the facility. -One 30 lb opened box of sweet peas that was 1/2 full, undated and unlabeled. The DM stated that the box should have been labeled with the date it was delivered to the facility. On 09/25/23 at 9:31 AM an interview was conducted with the Dietary Manager (DM). She stated that it was everyone ' s responsibility for labeling food when it was delivered to the facility, opening and/or preparing the items. She stated per policy, all foods stored in the refrigerator or freezer were to be covered and dated. Received dates (dates of delivery) will be marked on cases. All prepared food in refrigerators should be labeled with the date the item was prepared and with the Use by (expiration) date. 2. During the initial tour of the kitchen on 09/25/23 at 9:46 AM in the presence of the Dietary Manager (DM), racks of dirty dishes were being run through the high temperature dish-machine by Dietary Aide #2. The high temperature dish-machine rinse temperature gauge read 140 degrees Fahrenheit (F) and 145 degrees F during the wash cycle. Dietary Aide #1 was removing the racks of washed meal trays and putting them on a drying rack. The DM stated she thought the dishwasher was a low-temperature dish-machine and she checked the dish-machine temperature and chemical levels daily but had not checked them today. A container located on the wall with hoses connected to the dishwasher was empty. The DM stated the container was the washing detergent for the dishwasher and the shipment had not arrived yet. She reset the heat booster, ran empty racks through the dishwasher for 3 cycles and then used a temperature strip to check the temperature. The strip turned completely orange which indicated the water was at 180 degrees F. The DM implemented that washing/rinsing the dishes using the dishwasher was ceased until the wash detergent arrived at the facility. All lunch meals were served on disposable dinnerware with disposable silverware. The wash detergent arrived at approximately 2:00 PM. On 09/25/23 at 9:52 AM an interview was conducted with Dietary Aide #2. He stated he did not check the water temperature with the temperature strip today. He stated that they have had problems with the heater booster and would have to reset it prior to washing the dishes. He indicated he had reset the heater booster, but he did not realize the temperature gauge read 140 degrees F during the rinse cycle. He was unsure what the manufacturer ' s temperature requirement was. He also stated he did not realize the detergent solution was empty. On 09/25/23 at 9:52 AM an interview was conducted with Dietary Aide #1. He indicated he had not looked at the temperature gauge prior to washing the dishes today and was unsure what the manufacturer ' s temperature requirement was. He stated that they have had problems with the heater booster and would have to reset it prior to washing the dishes. On 09/26/23 at 10:19 AM the Regional Dietary Director was interviewed. He stated the dishwasher was a high temp dishwasher. The rinse temperature of 140 degrees F, and wash temp of 145 degrees yesterday may have been caused by the booster heater tripping. After resetting the booster heater, the temps read within recommended guidelines. He supplied a service call report dated 09/25/23 at 2:38 PM. The service report revealed the overload tripped on booster heater, reset and made sure all temperatures were correct at that time. A follow up kitchen observation was conducted on 09/26/23 at 1:24 PM. Dietary Aide #1 was observed running racks of dirty dishes through the high temperature dish-machine. A second observation at this time revealed the dish-machine temperature gauge read 135 degrees F during the rinse cycle. He stated he did not realize the temperature was at 135 degrees F. On 09/26/23 at 1:25 PM an observation and interview were conducted with the Regional Dietary Director. He verified the temperature gauge read 135 degrees F during the rinse cycle. He immediately educated the dietary aides that they needed to reset the booster heater and to run empty trays through the dishwasher until the gauge read the correct temperature which was 180 degrees F for the finale rinse cycle and 150-165 degrees F for the wash cycle. After the booster heater was reset, the dishwasher temperature gauge read 185 degrees F for the rinse cycle and 150 degrees F for the wash cycle. He also checked the water temperature which read 180 degrees F. The Regional Dietary Director had the Maintenance Director to call the Dishwasher Repairman to come back in to reevaluate the dishwasher. All dishes were rewashed when the appropriate temperatures were reached. On 09/27/23 at 12:47 PM through 1:05 PM an interview was conducted with the Dishwasher Repairman. He reset the booster heater and the temperature gauges went up to 185 degree F for the rinse cycle and 170 degree F for the resting wash temperature. He stated the temperature gauges were working correctly and that it seemed the heater booster was tripping causing the temperatures to drop during the wash/rinse cycle. The Dishwasher Repairman stated the staff needed to monitor the temperature gauges and reset the heater booster if the temperatures start to drop. A follow up kitchen observation was conducted on 09/27/23 at 12:59 PM. Dietary Aide #1 was observed running racks of dirty dishes through the high temperature dish-machine. The third observation revealed the dish-machine temperature gauge read 135 degrees F during the rinse cycle. He stated he did not realize the temperature was at 135 degrees F. The heater booster was reset, and the dishes were rewashed when the appropriate temperature was reached. On 09/27/23 at 1:05 PM an interview was conducted with the Maintenance Director. He stated repairs to the heater booster were conducted on 08/24/23. All terminal connections were checked and tightened, and the power feed contactor was replaced. He indicated they have had problems with the heater booster for a while. On 09/27/23 at 1:22 PM, the Administrator was interviewed. She stated that she expected the Dietary Manager (DM) to inform her and the Maintenance Director immediately when the dish-machine was not working properly. The administrator stated her expectation was that dietary properly label all food items per policy in the coolers and the freezer.

Based on record reviews, observations, Pharmacy Consultant, Hospice Aide, Physician's Assistant, Wound Nurse Practitioner, Dishwasher Repairman, Regional Dietary Director, resident and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following an annual recertification and complaint survey on 9/20/21. This was for five deficiencies that were cited in the areas of Accuracy of Assessments, Treatment/Services to Prevent/Heal Pressure Ulcers, Free of Accident/Hazards/Supervision/Devices, Free from Unnecessary Psychotropic Medications, and Food Procurement/Store/Prepare/Serve-Sanitary. In addition, five additional deficiencies were cited during the annual recertification and complaint survey on 7/20/22 in the areas of Accuracy of Assessments, Treatment/Services to Prevent/Heal Pressure Ulcers, Increase/Prevent Decrease in Range of Motion/Mobility, Residents are Free of Significant Medication Errors and Food Procurement/Store/Prepare/Serve-Sanitary. The duplicate citations during three federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: The citations are cross referenced to: 1) F758- Based on record review and interviews with the Pharmacy Consultant, Physician's Assistant and staff, the facility failed to have an adequate clinical indication for the use of an antipsychotic medication (Resident #73). This was for 1 of 5 residents whose medications were reviewed. During the facility's annual recertification and complaint survey dated 9/20/21, the facility failed to assess residents on antipsychotic medication for abnormal involuntary movement disorders, failed to identify target behavioral symptoms and to monitor those symptoms, failed to evaluate residents on psychotropic medications for gradual dose reductions and failed to ensure PRN (as needed) psychotropic medications were time limited in duration for 7 of 9 residents whose medications were reviewed. An interview was completed with the Administrator and DON on 9/28/23 at 10:30 AM and felt it was an oversight not to have an appropriate clinical indication for the use of a psychotropic medication. 2) F689- Based on staff and Hospice Aide #1 interviews along with record review, the facility failed to provide care safely which resulted in a fall without injury when Hospice Aide #1 left Resident #68's on his side in bed to retrieve a washcloth and failed to ensure two staff were presence for bed mobility. This was for 1 (Resident #68) of 8 reviewed for accidents. During the facility's annual recertification and complaint survey dated 9/20/21, the facility failed to implement a fall intervention for a resident who sustained a fall with the staff present for 1 of 3 residents reviewed for accidents. On 9/28/23 at 10:30 AM, an interview occurred with the Administrator and DON. They both indicated that education was needed for both staff and Hospice providers. A meeting was going to be held with the Hospice providers. 3) F686- Based on record reviews and interviews with staff, Physician Assistant (PA), Wound Nurse Practitioner, and Medical Director (MD), the facility failed to implement preventative measures for a resident assessed to be moderate to high risk for development of pressure ulcers. The resident developed a deep tissue injury to the sacrum, 2 deep tissue injuries to the left lateral foot, as well as a deep tissue injury to the left ankle. Deterioration of the sacral wound was not communicated to the MD or the PA. The resident was admitted to the hospital with septic shock for 1 of 8 residents (Resident #178) reviewed for pressure injuries. During the facility's annual recertification and complaint survey dated 9/20/21, the facility failed to obtain a treatment order when pressure ulcers were first identified for 1 of 4 residents reviewed for pressure ulcers. During the facility's annual recertification and complaint survey dated 7/20/22, the facility failed to complete pressure ulcer treatments as ordered and failed to provide a specialized wheelchair cushion as ordered for 3 of 5 residents reviewed for pressure ulcer care. In an interview with the Administrator and Director of Nursing (DON) on 9/28/23 at 10:30 AM, they indicated there had been turn over with wound care staff as well as wound care providers in the last year. Unit Managers were now responsible for wound care on their units. 4) F812- Based on record review, observations and interviews with staff, Dishwasher Repairman, and Regional Dietary Director, the facility failed to label opened food items stored in 1 of 1 walk in coolers, 1 of 1 reach in coolers, and 1 of 1 walk in freezers and failed to maintain water temperature during the wash and rinse cycles of the high-temp dishwasher according to manufacturer's instructions for 3 of 4 observations. This practice had the potential to affect food served to residents. During the facility's annual recertification and complaint survey dated 9/20/21, the facility failed to label and date food items in a container after opening, failed to date thawed nutritional supplements, and failed to wear hair and beard restraints for 2 of 2 kitchen observations. During the facility's annual recertification and complaint survey dated 7/20/22, the facility failed to ensure food items in the walk-in cooler, that had been opened were labeled and dated for 1 of 1 walk in coolers. During an interview with the Administrator and DON on 9/28/23 at 10:30 AM, they indicated there had been a lot of transition in the kitchen with new staff to include the dietary manager. Duty assignments were going to be put into place for dietary aides. The booster seemed to be an issue on the dishwasher and was going to be replaced with a low temperature dishwasher in two weeks. 5) F641- Based on record reviews, resident and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the area of bathing for 1 of 20 residents reviewed. During the facility's annual recertification and complaint survey dated 9/20/21, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of medications, urinary catheter, weight loss, skin condition, and smoking for 8 of 20 residents reviewed. During the facility's annual recertification and complaint survey dated 7/20/22, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of alarms, Hospice, and falls. This was for 3 of 19 resident records reviewed. An interview occurred with the Administrator and DON on 9/28/23 at 10:30 AM and indicated they felt the repeat citations in MDS accuracy were related to human error as well as turnover in staff. 6) F688- Based on observations, resident and staff interviews, and record review, the facility failed to apply a left lower extremity (LLE) brace as ordered. This was for 1 (Resident #44) of 1 resident reviewed for range of motion (ROM). During the facility's annual recertification and complaint survey dated 7/20/22, the facility failed to follow and implement Physician orders for a left resting hand splint for 1 of 1 resident reviewed for range of motion. During an interview with the Administrator and DON on 9/28/23 at 10:30 AM, they indicated there needed to be a process for when a resident was discharged from therapy services and the need for splint application. 7) F760- Based on record review and interviews with staff, Physician Assistant (PA) and Medical Director (MD), the facility failed to provide scheduled antianxiety medication resulting in multiple missed days of a significant medication for 1 of 5 (Resident #26) reviewed for unnecessary medications. During the facility's annual recertification and complaint survey dated 7/20/22, the facility failed to administer the Keppra (an antiseizure medication) to a resident as ordered from the hospital. This was for 1 of 4 sampled residents who were admitted /readmitted and were reviewed for medication errors. In an interview with the Administrator and Director of Nursing on 9/28/23 at 10:30 AM, they indicated that agency nursing ceased at the facility beginning of July 2023. They felt the use of agency staff could have contributed to this repeat citation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, the facility failed to place a resident's call light within reach for 1 of 1 residents reviewed for accommodation of needs (Resident #7). The findings included: Resident #7 was originally admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and muscle weakness. A significant change in status MDS assessment dated [DATE] indicated Resident #7 had moderately impaired cognition with no behaviors present. She required extensive to total assistance from staff to complete Activities of Daily Living (ADLs) tasks. Resident #7's active care plan, last reviewed 5/23/22, included a focus area for risk for falls related to deconditioning, gait/balance problems, weakness, incontinence and anxiety with a fear of falling. An intervention was to be sure the resident's call light was within reach and encourage her to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 7/17/22 at 2:00 PM, an observation and interview occurred with Resident #7 while she was lying in bed watching TV. The call light was lying on the floor under her bed out of reach. Resident #7 stated, I don't know how long I haven't had it but would like to have it pinned to the bed or something. Stated she would yell out when she needed something. Another observation was made on 7/18/22 at 12:00 PM. Resident #7 was lying in bed watching TV. Her call light remained under the bed out of reach. When asked how she would request assistance, she stated she would use the call light when she could reach it, otherwise she let staff know when they entered the room, when they were passing by or by yelling out for assistance. Resident #7 was observed on 7/19/22 at 9:21 AM, lying in bed with her eyes closed. The call light was observed coiled under the bed not within her reach. Nurse Aide (NA) #3 observed Resident #7's call light on the floor out of reach on 7/19/22 at 2:20 PM. She was assigned to Resident #7 and stated the call light was utilized by Resident #7, but it slid off the bed frequently due to her frequent leg movements. She retrieved the call light and placed it across Resident #7's lap. At the time of the observation there was no clip present on the call light cord. On 7/20/22 at 10:25 AM, Resident #7 was observed lying in bed watching TV. The call light was observed on the floor to the right side of the bed not within reach. The Administrator and Director of Nursing (DON) were interviewed on 7/20/22 at 2:40 PM. The DON stated Resident #7's call light was in the floor frequently due to her sliding her legs around in the bed. They stated it was their expectation for the call light to be within reach at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete an admission Minimum Data Set (MDS) assessment within 14 days of admission for 1 of 4 newly admitted residents whose MDS were reviewed (Resident #121). Findings included: Resident #121 was admitted to the facility on [DATE]. Review of the MDS revealed Resident #121 did not have an admission MDS assessment completed as of 7/19/22. The MDS Nurse was interviewed on 7/19/22 at 12:10 PM. The MDS Nurse reviewed Resident #121's assessments and stated she was working on his admission MDS assessment, but it was not completed and was still in progress. She stated the resident was admitted on [DATE] and should have the admission assessment already completed. She reported that she was behind with her MDS assessments since she did not have any help. The Director of Nursing (DON) was interviewed on 7/20/22 at 2:38 PM. The DON stated she expected the MDS assessments to be completed as required. She added that a new MDS Nurse will be starting this week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of alarms (Resident #32), Hospice (Resident #41) and falls (Resident #70). This was for 3 of 19 resident records reviewed. The findings included: 1. Resident #32 was admitted to the facility on [DATE] with diagnoses that included dementia. The active physician orders for Resident #32 were reviewed and revealed an order dated 5/13/22 for a wander-guard to the ankle to decrease the risk for elopement. Check placement every shift. Resident #32's care plan included a focus area that was initiated on 5/13/22 for elopement risk/wanderer related to cognitive impairment, wandering and exit seeking. The interventions included a wander-guard in place. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 had moderately impaired cognition and was not coded for a wander/elopement alarm. On 7/17/22 at 5:00 PM, Resident #32 was observed while she was lying in bed. A wander-guard bracelet was visible to her ankle. An interview was conducted with the MDS Nurse on 7/20/22 at 1:42 PM. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarm was not coded. She stated it was an oversight not to have coded the wander/elopement alarm for Resident #32 as she was aware one was in place. The Administrator and Director of Nursing were interviewed on 7/20/22 at 2:40 PM and indicated it was their expectation for the MDS assessment to be coded accurately. 2. Resident #41 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of the right upper back and muscle weakness. A physician's order dated 5/29/22 indicated an admission to Hospice care. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was marked yes for a prognosis of less than six months but not coded with receiving Hospice care. An interview was conducted with the MDS Nurse on 7/20/22 at 1:42 PM, she confirmed she was aware Resident #41 received Hospice care and confirmed Hospice was not marked on the MDS assessment dated [DATE]. She stated it was an oversight. The Administrator and Director of Nursing were interviewed on 7/20/22 at 2:40 PM and indicated they were unaware of any coding issues for the MDS assessments. Both further stated, it was their expectation for the MDS assessment to be coded accurately. 3. Resident #70 was admitted to the facility on [DATE] with multiple diagnoses including dementia. Review of the nurse's notes and the incident reports revealed that Resident #70 had falls on 6/22/22 at 6:14 PM, on 6/26/22 at 11:21 PM and on 6/28/22 at 12:18 AM. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #70 had severe cognitive impairment and he had no falls since admission/entry or reentry. The MDS Nurse was interviewed on 7/20/22 at 2:00 PM. The MDS Nurse reviewed the nurse's notes and verified that Resident #70 had falls on 6/22/22, 6/26/22 and 6/28/22. She indicated that the admission MDS assessment dated [DATE] was coded wrong under falls. She stated that she would complete a correction MDS to reflect the 3 falls with no injury under the fall section of the MDS. The Director of Nursing (DON) was interviewed on 7/20/22 at 2:38 PM. The DON stated that she expected the MDS assessment to be coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #176 was admitted on [DATE] with diagnoses that included diabetes type two and end stage renal disease requiring dialysis. The resident's Minimum Data Set (MDS) was in progress and not yet completed. Hospital discharge records included an emergency room encounter dated 6/20/2022. The resident's list of active diagnoses included diabetes and end stage renal disease. The resident's active orders included a physician's order for dialysis on Tuesday, Thursday, and Saturday related to end stage renal disease. The order had a start date of 7/7/2022. The resident's baseline care plan was dated 7/8/2022 and indicated the resident was not a diabetic and did not require dialysis. On 7/19/2022 at 11:37 AM an interview was conducted with the MDS nurse. She stated the baseline care plan was completed on 7/8/2022 by the admitting nurse, Nurse #3. When questioned as to the resident's diagnosis of diabetes and end stage renal requiring dialysis she stated it was an error. She further stated the resident was a diabetic and did receive dialysis. An interview was conducted with Nurse #3 on 7/19/2022 at 12:25 PM. He stated he did not recall if he completed the baseline care plan for Resident #176. There were several admissions on 7/7/2022 and they all came around the same time. He stated if he did complete the baseline care plan, it was an oversight. Resident #176 had a diagnosis of diabetes and received dialysis. An interview was conducted with the Director of Nursing (DON) on 7/20/2022 at 2:40 PM. She stated it was her expectation all baseline care plans are completed and accurate. Based on resident interview, staff interviews and record review, the facility failed to complete a Baseline Care Plan 48 hours after admission for 3 (Resident #171, Resident #121 and Resident #176) of 7 residents reviewed for care planning. The findings included: 1. Resident #171 was admitted on [DATE] for a pelvic fracture. Review of the electronic medical record (EMR) did not include documented evidence of a Baseline Care Plan. An interview was completed on 7/18/22 at 10:50 AM with Resident #171. He stated to date, nobody at the facility had discussed his care or goals with him or his Responsible Party (RP). An interview was completed on 7/20/22 at 10:30 AM with Nurse #1. She stated she completed Resident #171's admission but was not aware that she needed to complete a baseline care plan within 48 hours. An interview was completed on 7/20/22 at 1:42 PM with the Minimum Data Set (MDS) Nurse. She stated it was the responsibility of the floor nurses to complete the baseline care plan for new admissions within 48 hours from admission. The MDS Nurse confirmed Resident #171 did not have a baseline care plan and she did not know if the agency nurse (Nurse #1) was aware of the need to complete the baseline care plan. An interview was completed on 7/20/22 at 2:35 PM with the Director of Nursing (DON). She stated it was her expectation that the admitting nurse start a baseline care plan on admission and the floor nurses to ensure it was completed and reviewed with Resident #171 and his RP within 48 hours. 2. Resident # 121 was admitted to the facility on [DATE]. Review of Resident #121's medical records revealed that there was no baseline care plan developed as of 7/19/22. The MDS Nurse was interviewed on 7/19/22 at 12:10 PM. The MDS Nurse stated that she was not responsible for developing the baseline care plan. She reported that the admitting nurse was responsible for developing the baseline care plan within 48 hours of admission. The MDS Nurse reviewed the resident's medical records and verified that there was no baseline care plan developed for Resident #121. She indicated that the nurse who admitted the resident was an agency nurse, and the agency nurse might not be aware that she has to develop the baseline care plan on admission. The Director of Nursing (DON) was interviewed on 7/20/22 at 2:40 PM. The DON stated the nurses were responsible for developing the baseline care plan on admission. She explained she was not sure if the agency nurses had been educated on baseline care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #41 was admitted to the facility on [DATE]. A physician's order dated 5/29/22 indicated an admission to Hospice care. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was marked yes for a prognosis of less than six months. Resident #41's active care plan, last revised 6/15/22, made no reference to Hospice care. An interview was conducted with the MDS Nurse on 7/20/22 at 1:42 PM, she confirmed being aware Resident #41 received Hospice care and stated it was an oversight. The Administrator and Director of Nursing were interviewed on 7/20/22 at 2:40 PM and indicated it was their expectation for Resident #41's care plan to be comprehensive and felt it was an oversight not to have included Hospice care. Based on observations, staff interviews and record review, the facility failed to develop the comprehensive care plan for 3 (Resident #59, Resident #5 and Resident #3) of 19 residents reviewed for care planning. The findings included: 1. Resident #59 was admitted on [DATE] with diagnoses of Metabolic Encephalopathy, Diabetes and Dysphagia. The 5-day Minimum Data Set, dated [DATE] indicated that Resident #59 had moderate cognitive impairment and required extensive to total assistance with her activities of daily living. She was also coded as incontinent of bladder and bowel. Resident #59's comprehensive care plan included two identified areas of concern: little to no involvement in activities on 6/23/22 and for a nutritional risk on 6/29/22. An interview was completed on 7/20/22 at 1:42 PM with the Minimum Data Set (MDS) Nurse. She confirmed Resident #59 did not have a comprehensive care plan and she stated one should have been completed. The MDS Nurse stated she did not identify that Resident #59 did not have a comprehensive care plan until 7/18/22 when it was identified during the recertification survey. She stated it was an apparent oversight due to her workload. An interview was completed on 7/20/22 at 2:35 PM with the Director of Nursing (DON). She stated the previous Administrator delegated some of the care planning to other staff rather than the MDS Nurse because she reported that she could not complete the scheduled MDS assessments and care planning. The DON stated the MDS Nurse had not identified that Resident #59 did not have a comprehensive care plan until it was identified during the current recertification survey. 2. Resident #5 was admitted on [DATE] with a diagnosis of a left wrist contracture. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #5 had severe cognitive impairment and she was coded for range of movement impairment of one side of her upper extremity. Review of Resident #5's July 2022 Physician orders included an order dated 7/21/20 for the application of a left resting hand splint to be upon waking and removed at bedtime. Observations were completed of Resident #5 on 7/18/22 at 3:20 PM, 7/19/22 at 9:22 AM and 7/20/22 at 8:37 AM. On all occasions her left wrist was contracted and she was not wearing her hand splint. Review of Resident #5's comprehensive care plan last revised 6/13/22 did not include a care plan for her left wrist contracture and the intervention of splinting. Review of the undated Care Guide utilized by the Nursing Assistants also did not include any documentation regarding her contracture or splinting. An interview was completed on 7/20/22 at 1:42 PM with the Minimum Data Set (MDS) Nurse. She stated Resident #5 should be care planned for her left wrist contracture but she obviously missed it. The MDS Nurse stated she did not know if the care plan automatically generated the Care Guide for the aides to follow but then the MDS Nurse went on to say she had to ability to check and enter the information regarding Resident #5's splint orders in so that the aides would know to apply her splint from reading her Care Guide. An interview was completed on 7/20/22 at 2:35 PM with the Director of Nursing (DON). She stated Resident #5's comprehensive care plan should have included the care area for her contractures and splinting. The DON stated MDS Nurse had not identified that Resident #5 did not have a care plan for her contractures until it was identified on 7/20/22 during the current recertification survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to follow and implement Physician orders for a left resting hand splint for 1 (Resident #5) of 1 residents reviewed for range of motion. The findings included: Resident #5 was admitted on [DATE] with a diagnosis of a left wrist contracture. Review of Resident #5's July 2022 Physician orders included an order dated 7/21/20 for the application of a left resting hand splint to be upon waking and removed at bedtime. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #5 had severe cognitive impairment and she was coded for range of movement impairment of one side of her upper extremity. Review of Resident #5's comprehensive care plan last revised 6/13/22 did not include a care plan for her left wrist contracture and the intervention of splinting. An observation was completed on 7/17/22 at 2:00 PM. Resident #5 was sitting up in bed with a left wrist contracture. The left resting hand splint was observed on top of her dresser in her room. Also observed taped to her closet door for the instructions on the application of her hand splint. An observation was completed on 7/18/22 at 3:20 PM. Resident #5 was sitting up in bed without her ordered splint. The left resting hand splint was observed on top of her dresser in her room. An interview was completed on 7/19/22 at 9:10 AM with Nursing Assistant (NA) # 5. She stated she was under the impression that Resident #5's hand splint was applied before bedtime and removed in the morning and she did not recall ever applying it. NA #5 stated Resident #5 was not known to refuse care. An observation was completed on 7/19/22 at 9:22 AM. Resident #5 was sitting up in bed without her ordered splint. The left resting hand splint was observed on top of her dresser in her room. An interview was completed on 7/19/22 at 12:30 PM with NA #3. She stated Resident #5's splint at bedtime so she did not recall ever applying it on her shift. An interview was completed on 7/19/22 at 12:40 PM with NA #2. She stated she was under the impression that her hand splint was only worn at night. An observation was completed on 7/19/22 at 12:42 PM. Resident #5 sitting up in a wheelchair beside her bed. She was not wearing her splint. The left resting hand splint was observed on top of her dresser in her room. An observation was completed on 7/20/22 at 8:37AM. Resident #5 was sitting up in bed without her splint. The left resting hand splint was observed on top of her dresser in her room. An interview was completed on 7/20/22 at 2:04 PM with the Rehabilitation Director. He stated Resident #5 was not on the therapy caseload for splinting. He stated once a splint was provided, fitted and a splinting program was established, the application of the splints was turned over to the floor aides after receiving education and able to correctly apply the splint. The Rehabilitation Director stated Resident #5's left resting hand splint instructions were posted in her room and it was up to the nursing department to determine what shift they assigned the splinting to be completed. An interview was completed on 7/20/22 at 2:35 PM with the Director of Nursing (DON). She stated Resident #5's left resting hand splint was ordered to be worn from when she woke up until she went to bed every day. She stated she was not aware that Resident #5's splint was not being applied but it was her expectation that Resident #5's splinting orders be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview with the resident and staff, the facility failed to obtain an order for the care of the urostomy (surgically created opening in the abdominal wall through which urine passes) and failed to have the urostomy supplies (night drainage bag and pouch) that fit for 1 of 1 sampled resident reviewed for ostomy (Resident # 9). Findings included: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including urinary retention and uterine prolapse. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #9's cognition was intact, and she has an ostomy. Resident #9's care plan dated 5/16/22 was reviewed. The care plan problem was resident has a urostomy related to uterine prolapse and urinary retention. The goal was resident will show no signs/symptoms of urinary infection through review date. The approaches included to monitor for signs/symptoms of discomfort on urination and frequency, monitor and document for pain/discomfort due to urostomy and to monitor/record/report to physician for signs/symptoms of urinary tract infection (UTI). The care plan did not include what, who, how often and how to care for the urostomy. Review of the physician's orders for Resident #9 revealed no order for the care of the urostomy. Review of the treatment administration records (TARS) from 1/2022 through 7/19/22 was conducted. There was no documentation that the urostomy site was cleaned, the wafer or the pouch were changed and emptied. Resident #9 was observed on 7/17/22 at 9:30 AM. She was up in wheelchair in her room. The floor under her wheelchair was wet. The resident stated that her urostomy was leaking between the pouch and the tubing of the drainage bag. Resident #9 was observed on 7/18/22 at 10:05 AM up in wheelchair in her room. Her urostomy pouch was connected to a drainage bag and the drainage bag was in a wash basin under her bed. The resident stated that the connection between the pouch and the drainage bag was leaking. She reported that the tip of the drainage tubing would not fit into the end of the pouch. The resident indicated that the facility knew about the leaking but had not done anything. The Assistant Director of Nursing (ADON) was interviewed on 7/19/22 at 11:10 AM. Th ADON stated that she didn't know why Resident #9 did not have an order for the urostomy including how to care for it. She was not aware that the pouch did not fit the drainage bag and was leaking. Nurse #5, assigned to Resident #9, was interviewed on 7/20/22 at 8:50 AM. The nurse stated that Resident #9 would call if her urostomy wafer or pouch needed to be changed. He added that the resident's husband did most of the urostomy care for the resident when he comes to visit. The nurse did not know why there was no order for the care of the urostomy. He reported that there was no documentation on the TARs about what, who, how often and how to care for the urostomy. Resident #9 was observed on 7/20/22 at 1:30 PM. She was up in wheelchair in her room. Her urostomy pouch was connected to the drainage bag. The tip of the drainage tubing was connected to the pouch with a tape around it. The resident stated that she preferred to use the drainage bag so the nurse's aide would not empty the pouch so often. The resident reported that she used the tape to connect the drainage tubing to the pouch so it would not leak. She indicated that the facility did not have the pouch and drainage bag that fit. The Director of Nursing (DON) was interviewed on 7/20/22 at 2:41 PM. The DON verified that Resident #9 did not have an order for the urostomy including the care. She expected residents with ostomy to have a physician's order including how to care for it. The DON indicated that she was informed that the resident refused to use the urostomy supplies available at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, resident and staff interviews, the facility failed to obtain a Physician's order for a resident's use of continuous oxygen (Resident #62) and failed to administer oxygen as ordered (Resident #7). This was for 2 of 3 residents reviewed for respiratory care. The findings included: 1. Resident #62 was initially admitted to the facility on [DATE]. She returned to the hospital on 6/6/22 until 6/16/22 for a condition unrelated to respiratory. Her diagnoses included chronic obstructive pulmonary disease (COPD) and emphysema. Review of the hospital Discharge summary dated [DATE] revealed Resident #62 was previously on chronic oxygen at home and had been weaned down to 3 liters of oxygen via nasal cannula during the hospitalization. A Physician's progress note dated 6/20/22 read that Resident #62 had COPD and was dependent on oxygen. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was cognitively intact and was coded with the use of oxygen. Resident #62's active care plan included a focus area initiated on 6/30/22 for diagnosis of emphysema/COPD and was at risk for respiratory distress. Review of Resident #62's nursing progress notes from 6/16/22 until 7/18/22 revealed she was using oxygen continuously. A review of Resident #62's June 2022 and July 2022 Physician orders did not include any orders for oxygen. In an observation on 7/17/22 at 2:50 PM, Resident #62 was sitting up in bed watching TV with oxygen running at 3 liters flow via concentrator. She stated she used oxygen at home due to COPD/emphysema. Resident #62 was observed lying in bed watching TV on 7/18/22 at 2:15 PM. Oxygen was being used at 3 liters via a concentrator. In an interview on 7/19/22 at 11:30 AM, the Director of Nursing (DON) stated Resident #62 required continuous oxygen for her COPD. The DON verified there was no order for her continuous oxygen and stated there should have been an order written for it when she was admitted from the hospital. She felt it was an oversight. 2. Resident #7 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Review of Resident #7's active Physician orders included an order dated 4/6/22 for oxygen at 2 liters via nasal cannula continuously. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 had moderately impaired cognition and was coded as using oxygen. Resident #7's active care plan, last reviewed 5/23/22, included a focus area for oxygen therapy. The interventions included oxygen per physician orders. A review of the July 2022 Medication Administration Record (MAR) revealed an entry for oxygen at 2 liters per minute continuously every shift for oxygen therapy. The form had a daily check mark and staff initials. On 7/17/22 at 2:00 PM, Resident #7 was observed lying in bed watching TV with oxygen on via nasal cannula. The oxygen regulator on the concentrator was set at 2.5 liters flow when viewed horizontally, eye level. Resident #7 was observed lying in bed watching TV on 7/18/22 at 12:00 PM and stated she wore oxygen all the time. The oxygen regulator on the concentrator was set at 2.5 liters flow when viewed horizontally, eye level. The oxygen concentrator was noted to not be within Resident #7's reach. On 7/19/22 at 9:21 AM, Resident #7 was observed lying in bed with her eyes closed. The oxygen regular on the concentrator was set at 2.5 liters flow when viewed horizontally at eye level. An observation was made with Nurse #4 of Resident #7's oxygen concentrator on 7/19/22 at 2:31 PM. She stated the oxygen regulator on the concentrator was set at 3 liters when viewed standing and 2.5 liters flow when viewed horizontally at eye level. Nurse #4 verified Resident #7 should be using oxygen at 2 liters and adjusted the flow. Additionally, Nurse #4 stated Resident #7 did not adjust her the oxygen concentrator. During an interview with the Director of Nursing on 7/20/22 at 2:40 PM, she indicated it was her expectation for oxygen to be delivered at the ordered rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to place an unvaccinated newly admitted resident on transmission-based precautions for 1 of 3 (Resident #171) residents reviewed for transmission-based precautions. The findings included: Resident #171 was admitted to the facility on [DATE] diagnosis of pelvic fracture. Resident #171's electronic medical record indicated he was admitted on [DATE]. The resident did not have evidence of COVID-19 vaccination and the electronic medical record indicated he refused COVID-19 vaccnation. There was no documentation of recent COVID-19 infection. During the initial tour of the facility on 7/17/2022 at 1:30 PM, Resident #171 was observed in his room. There was no transmission-based precaution sign on the door. On 7/17/2022 at 5:00 PM staff were observed placing transmission base precaution sign and a personal protective equipment (PPE) caddy on Resident #171's door. An interview was conducted with the Director of Nursing (DON) on 07/17/22 at 5:07 PM. She stated Resident #171 should have been placed on transmission-based precautions on admission, 7/16/2022. She further stated when a resident was admitted , the unit managers got an email with vaccination status and were instructed to place the resident on transmission-based precautions if needed. The unit manager made sure the nurse or nurse assistant placed the sign and PPE caddy on the door. The DON stated she was on vacation last week and 7/17/2022 was the first day she had been in the facility. She stated the weekend supervisor would have been the person responsible for making sure the resident was on precautions, but that person did not work over the weekend. The DON placed the resident on transmission-based precautions when she realized he had not been placed on precautions. On 7/20/2022 at 2:40 PM an interview was conducted with the Administrator. He stated it was his expectation that newly admitted residents without COVID-19 vaccinations be placed on transmission-based precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, Wound Provider and staff interviews, the facility failed to complete pressure ulcer treatments as ordered (Residents #41, #58 and #36) and failed to provide a specialized wheelchair cushion as ordered (Resident #36) for 3 of 5 residents reviewed for pressure ulcer care. The findings included: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses that included a pressure ulcer to the mid back. A review of the Wound Provider's progress note dated 4/19/22 indicated Resident #41's mid back pressure ulcer measured 2 centimeters (cm) in length, 1.4 cm in width and 0.4 cm in depth. The wound stage had changed from unstageable to a Stage 3 due to debridement that had been completed. Resident #41's active care plan, last revised 5/23/22, included a focus area for a pressure ulcer to the mid back and was at risk for further impaired skin integrity/pressure ulcer development related to a history of pressure ulcers, impaired bed mobility, debility, weakness and incontinence. A review of the Wound Provider's progress note dated 5/31/22 indicated Resident #41's mid back pressure ulcer measured 1.8 cm in length, 1.6 cm in width and 0.7 cm in depth. The wound stage had changed to a Stage 4 pressure ulcer. The single wound had improved tissue types but was complicated by known osteomyelitis (an infection of the bone). There would be no aggressive measures of treatment for the osteomyelitis per the responsible party and primary care physician, as the resident was on Hospice care. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41 had severe cognitive impairment and displayed no behaviors or rejection of care during the 7 day look back period. She required extensive to total assistance with Activities of Daily Living (ADLs) and was coded with one Stage 4 pressure ulcer. A review of the Wound Provider's progress note dated 6/28/22 revealed Resident #41's mid back pressure ulcer measured 1.6 cm in length, 1.3 cm in width, 0.7 cm in depth and was classified as a Stage 4. The single wound presented with stable dimensions, overall appearance, and no acute decline. The Wound Provider's progress note dated 7/12/22 indicated Resident #41's mid back stage 4 pressure ulcer measured 2.2 cm in length, 1.6 cm in width, 0.7 cm in depth and no signs of infection. Resident #41's physician orders included the following wound care orders: An order dated 5/10/22 to 7/12/22 that read to cleanse the mid back wound with normal saline/wound cleanser and pat dry. Apply Dakin's (an antiseptic solution with anti-infective properties) 0.5% (full strength) moistened gauze and secure with super absorbent dressing once a day and as needed. An order dated 7/13/22 that read to cleanse the mid back wound with normal saline and pat dry. Apply Dakin's 0.25% (half strength) moistened gauze and secure with a super absorbent dressing once a day and as needed. The nursing progress notes from 5/1/22 until 7/18/22 were reviewed and indicated Resident #41 had no episodes of refusing wound care but did often refuse to turn and reposition for pressure relief. a) The June 2022 Treatment Administration Record (TAR) revealed wound care to Resident #41's mid back pressure ulcer was not initialed as completed on 6/9/22, 6/14/22 and 6/27/22. Multiple phone attempts were made on 7/19/22 and 7/20/22 to reach Nurse #9, which were unsuccessful. She was scheduled to work from 7:00 AM to 7:00 PM with Resident #41 on 6/9/22, 6/14/22 and 6/27/22. b) The July 2022 TAR was reviewed and indicated Resident #41's wound care to her mid back pressure ulcer was not initialed as completed on 7/4/22 and 7/15/22. An interview occurred with Nurse #1 on 7/19/22 at 12:31 PM, who was familiar with Resident #41. She was scheduled for the 7:00 AM to 7:00 PM shift on 7/4/22 and 7/15/22 and explained nursing staff were responsible for completing wound care as ordered. The July 2022 TAR was reviewed and stated if the entry was not initialed it meant she didn't get to the wound care that day. Nurse #1 further stated she had reported this to the oncoming nurse so the wound care could be completed as ordered. Multiple phone calls were made to Nurse #8 on 7/19/22 and 7/20/22 without success. She was scheduled to work with Resident #41 from the 7:00 PM to 7:00 AM shift on 7/4/22. Multiple phone attempts were made on 7/19/22 and 7/20/22 to reach Nurse #7 without success. She was scheduled to work from 7:00 PM to 7:00 AM on 7/15/22 for Resident #41's hall. On 7/18/22 at 11:41 AM, wound care observation occurred with Nurse #4 for Resident #41. A pressure ulcer was noted to the mid back and was the size of a dime. Nurse #4 indicated the Wound Provider measured wounds weekly. There was no drainage or odor present. Nurse #4 cleansed the wound and completed the wound care as ordered. A phone interview was conducted with the Wound Provider on 7/20/22 at 11:45 AM who was familiar with Resident #41. He was unaware wound care had not been completed as ordered for Resident #41 but had not seen a decline in her wound status during his weekly assessments. The Wound Provider added he would expect the facility to provide wound care as prescribed. An interview occurred with the Director of Nursing (DON) on 7/20/22 at 2:40 PM, who stated the former treatment nurse last worked at the facility on 6/14/22 and was unaware Resident #41 had missed several days of wound care to her mid back pressure ulcer. She added it was her expectation for the wound care to be completed as ordered. 2. Resident #58 was admitted to the facility on [DATE] with diagnoses that included an unstageable pressure ulcer to the right hip. A review of the active physician orders revealed an order dated 5/31/22 to cleanse the right hip with wound cleanser or normal saline and pat dry. Apply Santyl (a topical medication used to allow wound healing) and Dakin's (an antiseptic solution with anti-infective properties) moistened gauze. Secure with a super absorbent dressing once a day and as needed. A review of the Wound Provider's progress note dated 6/7/22 indicated Resident #58 was admitted to the facility with an unstageable pressure ulcer to the right hip. On assessment the pressure ulcer measured 9.5 centimeters (cm) in length, 6.2 cm in width and 1.0 cm in depth, with no signs of infection. The Wound Provider's progress note dated 6/21/22 revealed Resident #58's right hip pressure ulcer measured 8 cm in length, 4.1 cm in width and 0.8 cm in depth. There was no signs of acute infection or decline. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #58 had moderately impaired cognition and displayed no behaviors or rejection of care. She required extensive assistance from staff for Activities of Daily Living (ADLs) and was coded with one unstageable pressure ulcer that was present on admission. A review of the Wound Provider's progress note dated 6/28/22 indicated Resident #58's right hip pressure ulcer measured 8 cm in length, 4.6 cm in width and 0.7 cm in depth. The pressure ulcer was classified as a Stage 3. The Wound Provider's progress note dated 7/5/22 indicated Resident #58's right hip pressure ulcer measured 8.5 cm in length, 5 cm in width and 2.8 cm in depth. There was noted deterioration in the size and overall depth and questioned whether it was related to underlying osteomyelitis. Orders for further testing was provided. Resident #58's active care plan, last reviewed 7/11/22, included a focus area for an actual pressure ulcer to the right hip and was at risk for further pressure ulcer development/skin impairment related to impaired bed mobility, weakness and incontinence. A review of the Wound Provider's progress note dated 7/12/22 revealed Resident #58's right hip pressure ulcer measured 8.3 cm in length, 5 cm in width and 2.4 cm in depth. There were no signs of acute infection. The nursing progress notes from 5/19/22 until 7/18/22 were reviewed and indicated Resident #58 had no episodes of refusing wound care. a) The June 2022 and July 2022 Treatment Administration Records (TARs) were reviewed and revealed Resident #58's wound care to her right hip was not initialed as completed on 6/14/22, 6/17/22, 6/22/22, 6/27/22, 6/28/22, 7/1/22, and 7/3/22. A phone interview occurred with Nurse #6 on 7/20/22 at 10:07 AM, who was scheduled for the 7:00 AM to 7:00 PM shift on 6/14/22, 6/17/22, 6/22/22, 6/27/22, 6/28/22, 7/1/22, and 7/3/22 for Resident #58. The June 2022 and July 2022 TARs were reviewed. Nurse #6 stated the Treatment Nurse left unexpectant in early June 2022 and she tried to do the wound care when she was able but thought the managers or the 7:00 PM to 7:00 AM nursing staff would complete them when she didn't. Nurse #6 stated if the wound care was not initialed as completed it meant she didn't get to it that day. b) The June 2022 and July 2022 TARs were reviewed and revealed Resident #58's wound care to her right hip pressure ulcer was not initialed as completed on 6/21/22, 6/29/22, 7/11/22 and 7/15/22. An interview occurred with Nurse #1 on 7/19/22 at 12:31 PM, who was familiar with Resident #58. She was scheduled for the 7:00 AM to 7:00 PM shift on 6/21/22, 6/29/22, 7/11/22 and 7/15/22 and explained nursing staff were responsible for completing wound care as ordered. Nurse #1 reviewed the June 2022 and July 2022 TARs and she stated if the entry was not initialed it meant she didn't get to the wound care that day. Multiple attempts were made to observe Resident #58's wound care on 7/18/22, 7/19/22 and 7/20/22 that were unsuccessful. A phone interview was conducted with the Wound Provider on 7/20/22 at 11:45 AM who was familiar with Resident #58. He was unaware wound care had not been completed as ordered for Resident #58 and had seen no indication to this during his weekly assessments. He added there was a concern for underlying osteomyelitis with tests pending. The Wound Provider added he would expect the facility to provide wound care as prescribed. An interview occurred with the Director of Nursing (DON) on 7/20/22 at 2:40 PM, who stated the former treatment nurse last worked at the facility on 6/14/22 and was unaware Resident #58 had missed wound care to her right hip pressure ulcer. She added it was her expectation for the wound care to be completed as ordered. 3 a. Resident # 36 was admitted to the facility on [DATE] with multiple diagnoses including non-traumatic intracerebral hemorrhage and hemiplegia affecting the right dominant side. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #36's cognition was intact, and he had pressure ulcers. The assessment further indicated that the resident needed extensive assist with bed mobility, and he was totally dependent with transfers. Resident #36's care plan dated 5/16/22 was reviewed. The care plan problem was resident has actual pressure ulcers related to impaired mobility due to hemiplegia. The goal was for the resident's pressure ulcers to show signs of healing. The approaches included to follow facility's protocol for treatment and to monitor/document location, size, and treatment to skin injury/pressure ulcers. Review of the physician's orders for Resident #36 revealed that on 2/1/22 there was an order for a (name of the cushion) cushion (a pressure relief cushion that is made of soft and flexible air cells) to electric wheelchair when up and out of bed. The order was written by the previous treatment nurse, who no longer works at the facility. Resident #36 had a doctor's orders dated 7/13/22, to clean the ulcers on the right and left ischium with Dakin's solution (used to clean the wounds to prevent infection) and to apply crushed Flagyl (an antibiotic used to treat infection) 500 milligrams (mgs) tablet to wound bed and to clean the sacral ulcer with normal saline and to apply collagen powder (helps stimulates tissue growth) and silver alginate (used in treatment of at risk or infected chronic wounds). Resident #36 was observed up in wheelchair on 7/18/22 at 9:40 AM. He was in the smoking area and his wheelchair did not have a cushion on it. Resident #36 was observed during the dressing change on 7/18/22 at 11:30 AM. The resident had 3 pressure ulcers, on the right and left ischium and on the sacrum. The ulcers were deep with necrotic tissue, moderate amount of serous drainage with no odor noted. The Unit Manager (UM) provided the treatment to the resident. She cleaned the right and left ischium pressure ulcers with Dakin's solution and applied crushed Flagyl to the wound bed. She also cleaned the sacral ulcer with normal saline and applied collagen powder and silver alginate. Resident #36 was observed in bed on 7/19/22 at 3:10 PM. He reported that he was paralyzed from waist down and he has pressure ulcers. He stated that he needed a cushion when he was out of bed to help relieved the pressure on his bottom. He stated that he had been asking for a cushion from the therapist, but nothing had been done about it. Nurse #5, assigned to Resident #36, was interviewed on 7/20/22 at 8:50 AM. The nurse reported that Resident #36 preferred to stay out of bed on his wheelchair every day. He went out to smoke most of the time and would not go back to bed. He indicated that the resident had an order for a chair cushion, and he thought the therapist was working on getting him one. Nurse #5 further stated that he had not seen a cushion on his wheelchair. The Rehabilitation (Rehab) Director was interviewed on 7/20/22 at 9:55 AM. He reported that the therapy department was responsible for ordering the chair cushion for the resident. The Rehab Director stated that nobody had informed him that Resident #36 had an order for a chair cushion. He stated that he remembered the resident asking him for the cushion, but he was never informed that he had an order for it. He indicated that he would assess the resident and see what type of cushion fits for him. The Wound Provider was interviewed on 7/20/22 at 11:56 AM. He stated that he had been following Resident #36's pressure ulcers on a weekly basis for quite some time. His ulcers were chronic and were unavoidable due to his medical condition being paralyzed on his lower extremities and his non-compliance with care. He preferred to stay out of bed most of the time and he was educated on the importance of offloading his bottom to help heal his ulcers. The Wound Provider indicated that the resident would benefit using a chair cushion. The Director of Nursing (DON) was interviewed on 7/20/22 at 2:38 PM. The DON stated that Resident #36 had an order for a chair cushion on 2/1/22. The order was written by the previous treatment nurse, who no longer works at the facility. The previous treatment nurse did not inform the therapy department, who was responsible for assessing the resident and for ordering the chair cushion. b. Resident #36 had a physician's order dated 1/26/22 to clean the pressure ulcers on the right ischium and sacrum with normal saline (NS) and to pack with silver alginate and cover with super absorbent dressing. On 6/8/22, the treatment to the right ischium was changed to collagen powder and silver alginate, and to the to the left ischium, the treatment was changed to Santyl (used to remove dead tissue from wounds) and calcium alginate (used on wounds with moderate to heavy exudates). On 7/13/22, the treatment o the left and right ischium was changed to clean with Dakin's solution and to apply crushed Flagyl 500 milligrams (mgs) tablet to wound bed. Resident #36 was observed during the dressing change on 7/18/22 at 11:30 AM. The resident had 3 pressure ulcers, on the right and left ischium and on the sacrum. The ulcers were deep with necrotic tissue, moderate amount of serous drainage with no odor noted. The Unit Manager (UM) provided the treatment to the resident. She cleaned the right and left ischium pressure ulcers with Dakin's solution and applied crushed Flagyl to the wound bed. She also cleaned the sacral ulcer with normal saline and applied collagen powder and silver alginate. Review of the April 2022 Treatment Administration Records (TARs) revealed that on 4/2/22, 4/3/22, 4/16/22, 4/17/22, 4/29/22 and 4/30/22, there were no nurse's initials to indicate that the treatment to the right ischium and sacrum was provided to the resident. There were no notes to indicate that the resident had refused the treatment. Review of the June 2022 TARs revealed that on 6/3/22, 6/6/22, 6/10/22, 6/11/22, 6/12/22, 6/16/22, 6/18/22, 6/20/22 and 6/23/22, there were no nurse's initials to indicate that the treatment to the right and left ischium and sacrum was provided to the resident. There were no notes to indicate that the resident had refused the treatment. Review of the July 2022 TARs revealed that on 7/1/22, 7/3/22, 7/4/22, 7/7/22, 7/8/22, 7/10/22, 7/11/22, 7/12/22 and on 7/14/22, there were no nurse's initials to indicate that the treatment to the left and right ischium and sacrum was provided to the resident. There were no notes to indicate that the resident had refused the treatment. Attempted to call Nurse #10, who was assigned to Resident #36 on 7/8/22, 7/10/22 and 7/14/22 but was unsuccessful. Nurse #5, who was assigned to Resident #36 on 7/7/22, 7/11/22 and 7/12/22, was interviewed on 7/20/22 at 8:50 AM. The nurse reported that at times the treatment was not provided since he did not have the time to do it. He added that at times Resident #36 had refused treatments and at times he assumed that there was a treatment nurse who will provide the treatment to the residents. Nurse #5 indicated that he should have made a note whenever the resident had refused treatment, but he did not. The Wound Provider was interviewed on 7/20/22 at 11:56 AM. He stated that he had been following Resident #36's pressure ulcers on a weekly basis for quite some time. His ulcers were chronic and unavoidable due to his medical condition being paralyzed on his lower extremities and his non-compliance with care. He preferred to stay out of bed most of the time and he was educated on the importance of offloading his bottom to help heal his ulcers. The Wound Provider indicated that he was aware that Resident #36 had refused dressing change, but he expected the nursing staff to try to provide the treatment as ordered and to document if refused. The Director of Nursing (DON) was interviewed on 7/20/22 at 2:39 PM. The DON stated that the previous treatment nurse was not doing her job as treatment nurse. She was not providing the treatments to the residents as ordered. She quit on 6/27/22 but had not been at the facility since 6/14/22. The DON indicated that she expected the nurses to provide the treatment as ordered and to document when the resident refused treatment.

Based on observations and interviews with staff and the Dietary Manager (DM), the facility failed to ensure that food items, in the walk in cooler, that had been opened were labeled and dated. This was for 1 of 1 walk in coolers and had the potential to affect food served to residents. The findings included: On 7/3/2022 at 1:30 PM during an initial tour of the kitchen. 1. The DM identified the following items in the walk-in cooler: One metal container of tuna salad that was not labeled or dated. One metal container of sausage that was not labeled or dated. One metal container of ground pork that was not labeled or dated. One metal container of scrambled eggs that was not labeled or dated. One metal pan of diced tomatoes that was not labeled or dated. One metal pan of shredded lettuce that was not labeled or dated. Four - 8 ounce (oz) cups of orange liquid were not labeled or dated. One large metal bowl with white substance identified by the DM as whip topping, was not labeled or dated. One gallon container of salad dressing was half empty and did not have an open date. One gallon container of relish was half empty with no open date. One gallon container of mustard was observed to be three quarters empty with no open date. 2. In the dry storage room there were two large white plastic four wheeled bins. Neither of the bins were labeled or dated. The DM stated one bin contained sugar and the other bin contained flour. An interview was conducted with the DM after the initial tour of the kitchen on 7/3/2022 at 2:00PM. He stated opened items in the cooler should have been labeled with contents and dated. He further stated the bins in the dry storage room should have been labeled with contents and dated. He stated he did not know why the items were not labeled or dated. An interview was conducted with the Administrator on 7/20/2022. She stated it was her expectation that opened items in the walk in cooler as well as the bins in the dry storage room should be labeled and dated.

Based on observations, staff interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitoring interventions that the committee put into place for the annual recertification surveys dated 3/21/19 and 9/20/21. This was for three recited deficiencies in the areas of Resident Assessments, Comprehensive Resident Centered Care Plan and Pharmacy Services. The continued failure of the facility during three Federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This citation is cross referenced to: F641-Based on record review, observations and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately. F656-Based on observations, staff interviews and record review, the facility failed to develop the comprehensive care plan. F756-Based on record review and interviews with the Pharmacy Consultant and the staff, the facility's Pharmacy Consultant failed to identify and to report drug irregularity. In an interview on 7/20/22 at 2:35 PM, the Administrator stated he was new to the facility and that there had been a large turnover in the nursing department and with nursing management. He stated it was obvious that the monitoring for compliance in the three repeated citations areas was lacking.