Based on observation, interview, medical record review, and policy review, the facility failed to ensure residents who were dependent on staff for assistance received turning and repositioning and transferring to a char as ordered by the physician. This affected one (Resident #59) of two residents reviewed for positioning. The facility census was 96. Findings include: Review of the medical record for Resident #59 revealed an admission date of 12/11/20. Medical diagnoses included cerebral palsy, hydrocephalus, speech disturbances, contractures of muscle, dysphasia, cognitive communication deficit, and congenital deformities of skull, face and jaw. Review of the care plan dated 10/30/23 revealed Resident #59 had activities of daily living self-care performance deficit related to cerebral palsy, cognitive impairment, and an impaired ability to communicate. Listed interventions included placing the resident in a chair from 10 A.M. to 2 P.M. daily and encouraging participation in activities. The care plan also indicated Resident #59 was at risk for impaired skin integrity due to being confined to a chair most of the time, impaired cognition, bladder and bowel incontinence, need for assistance with daily living activities, and preventive tube feed site dressing. Interventions included turning and repositioning as needed, as well as encouraging the resident to reposition himself if able. Review of Resident #59's physician orders revealed an order dated 01/12/24 which stated Resident #59 was to remain in a chair from 10 A.M. to 2 P.M. daily and engage in activities. A follow-up order dated 10/31/24 instructed staff to turn and reposition Resident #59 every two hours. Review of the Minimum Data Set (MDS) 3.0 assessment completed 09/02/24 revealed Resident #59 was severely cognitively impaired, fully dependent on staff for all daily activities, and at high risk for developing pressure ulcers/injuries. Review of the Braden Scale for predicting pressure sore risk, dated 11/19/24, revealed Resident #59 had very limited sensory perception, was occasionally moist, chairfast, completely immobile, with adequate nutritional intake and potential for friction and shear. These factors indicated a moderate risk for skin impairments. Review of the task labeled turn and reposition every two hours and as needed (PRN) revealed on 12/11/24, Resident #59 was documented as being turned at 12:56 A.M., 1:59 P.M., and 8:33 P.M. Observations on 12/11/24 at 11:43 A.M. of Resident #59 revealed the resident was awake and lying in bed. He was positioned with his knees pointed toward the wall, and his legs were bent, with the right leg on top of the left. He was wearing socks on both feet, but his heels were not elevated off the bed. The resident was not covered with a blanket. A specialized chair was present in the resident's room. The specialized chair had a lap tray positioned directly over the top of the seat. The lap tray contained a small amount of clutter on the top of the tray. Observation on 12/11/24 at 1:42 P.M. and 3:01 P.M. revealed Resident #59 remained in the same position in the bed as observed at 11:43 A.M. The specialized chair and lap tray remained in the same location in the resident's room. The clutter on the top of the tray remained unchanged. Observation on 12/11/24 at 4:12 P.M. of Resident #59 revealed both of his socks had been removed, he had been covered up with a blanket, and his legs were propped up on a pillow. His body position remained unchanged from the prior observations at 11:43 A.M, 1:42 P.M., and 3:01 P.M. Interview on 12/11/24 at 4:15 P.M. with Certified Nursing Assistant (CNA) #75 confirmed Resident #59 required assistance with turning and needed to be repositioned every two hours. She explained CNAs were not allowed to perform this task because the resident has a tube feed. CNA #75 clarified the nurse assigned to the resident was responsible for turning him. CNA #75 confirmed she had not transferred Resident #59 to his specialized chair nor had she turned him every two hours during her shift. Interview on 12/11/24 at 4:17 P.M. with Licensed Practical Nurse (LPN) #65 confirmed Resident #59 required assistance with turning, and both CNAs and nursing staff were responsible for repositioning Resident #59 every two hours. LPN #65 stated she had recently entered Resident #59's room to remove the resident's socks and apply lotion but was unable to recall when he was last turned before adjusting his legs. LPN #65 confirmed physician orders specified the resident should be placed in the chair from 10 A.M. to 2 P.M. daily and repositioned every two hours. She noted CNAs do not have direct access to physician orders but can read the care plan. Observation on 12/11/24 at 5:33 P.M. of Resident #59 showed he had been repositioned since the prior observation. Resident #59 was positioned on his left side, with his knees bent and left leg positioned above his right leg. Subsequent review of Resident #59's medical record revealed the task labeled turn and reposition every two hours and PRN on 12/11/24 at 5:35 P.M. revealed the resident's recent repositioning had not been documented in his medical record. Interview on 12/12/24 at 12:36 P.M. with the Administrator and Director of Nursing (DON) confirmed Resident #59's medical record lacked evidence to indicate the resident was regularly repositioned every two hours or placed in his chair between 10 A.M. and 2 P.M.as ordered. Review of the turning and repositioning policy, dated 01/01/22, revealed all residents at risk of pressure injuries should be turned and repositioned every two to four hours. This task is primarily the responsibility of nursing assistants, though all nursing staff are expected to assist. The routine turning schedule involves alternating between side-lying and back positions, rotating between the right side, back, and left side.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy the facility failed to ensure a referral to an ophthalmologist for cataract surgery was made for Resident #17. This affected one resident (#17) of two residents reviewed for communication and sensory. The facility census was 96. Findings include: Review of Resident #17's medical record revealed an admission date of 05/24/23 with diagnoses including type two diabetes mellitus, depression, anxiety, myasthenia gravis, dysphagia, personality disorder, and chronic respiratory failure. Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #17's plan of care dated 10/31/23 revealed the resident was at risk for visual impairment related to age, diabetes, and myasthenia gravis. Interventions included administering medications and treatments as ordered, arranging a consultation with the eye care provider as needed, encouraging the resident to wear glasses, and assist with applying glasses as needed. Review of Resident #17's note dated 07/23/24 from the eye care group revealed the eye doctor's plan for the resident included a recommendation for cataract survey through a ophthalmology consult. Review of Resident #17's medical record from 07/23/24 to 12/09/24 revealed no evidence a referral was made to ophthalmology. Interview on 12/09/24 at 12:38 P.M. with Resident #17 revealed she had seen the eye doctor that morning and he had told her the facility was supposed to have followed up to help her get cataract surgery. Interview on 12/11/24 at 3:00 P.M. with the Director of Nursing (DON) verified there had been a recommendation for a referral that was not completed. Review of the policy 'Hearing and Vision Services' dated 10/30/23 revealed once vision or hearing services have been identified the resident was to be assisted in making appointments and arranging for transportation if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, facility fall investigation reports, and facility policy review, the facility failed to develop and implement timely interventions after a resident fall. This affected one (Resident #1) of three residents reviewed for falls. The facility census was 96. Findings Include: Resident #1 was admitted to the facility on [DATE]. Her diagnoses were conversion disorder, intellectual disabilities, aneurysm of heart, hypertension, hyperparathyroidism, chronic obstructive pulmonary disease, lack of coordination, dysphagia, dementia, major depressive disorder, spondylosis, muscle weakness, cognitive communication deficit, difficulty walking, osteoarthritis, hypothyroidism, osteoporosis, and hypertensive heart disease. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 11/18/24, revealed she had a mild cognitive impairment. Review of Resident #1 fall investigation, dated 09/30/24, revealed she attempted to go to the bathroom independently, and fell between the toilet and the wall. Review of the fall investigation report and summary revealed the interventions put in place were replacing the non-skid strips in the bathroom and continued reminders and education on unassisted transfers and toileting. Review of Resident #1 fall investigation, dated 11/08/24, revealed she attempted to go to the bathroom and fell in between the wall and the toilet. Review of the fall investigation report and summary revealed the intervention put in place was education to Resident #1 to use the call light both before and after using the toilet. Review of Resident #1 fall and incident investigation records and care plans, dated 09/30/24 to 11/15/24, revealed there were no other interventions put in place to reduce the likelihood of Resident #1 going to the bathroom independently or performing tasks in the bathroom without staff assistance. The only intervention to assist with preventing Resident #1 going to the bathroom independently, was educating her about asking for assistance prior to going. Interview with the Director of Nursing (DON) on 12/12/24 at 8:06 A.M. confirmed they have tried to educate Resident #1 about asking for help and educating staff to watch for signs Resident #1 exhibits when she is going to the bathroom. One sign that Resident #1 needs to go to the bathroom is when she wheels her chair into her room; staff should be aware of this. The DON stated Resident #1 spent most of her time in the hall and common areas. Interview with Certified Nursing Aide (CNA) #70 on 12/12/24 at 12:22 P.M. confirmed they are to check on Resident #1 every two hours to see if she needs to go to the bathroom. She confirmed she is aware that Resident #1 will go to the bathroom on her own; they try to catch her before she gets up or remind her to use her call light, but those are the interventions they have in place. Review of the policy Fall Prevention Program, dated 10/26/23, revealed each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness and the plan of care will be revised as needed.

Based on record review, interview, and facility policy review, the facility failed to ensure dietician recommendations were implemented timely and orders were followed. This affected 2 (Residents #12 and #74) of six residents reviewed for nutrition. The facility census was 96. Findings Include: 1. Review of the medical record for Resident #12 revealed an admission date of 08/06/10. Medical diagnoses included chronic kidney disease, dysphasia, muscle weakness, major depressive disorder, cognitive communication deficit, anemia, gastro-esophageal reflux disease (GERD) and unspecified psychosis. Review of Resident #12's care plan dated 10/31/23 revealed the resident was at risk for altered nutritional status related to therapeutic diet, and medical diagnosis that include hypertension, peripheral vascular disease, depression, cognitive communication deficit, anemia, and GERD. A listed goal included for Resident #12 to receive and tolerate his diet, and to maintain weight with no further significant changes. Care planned interventions included to periodically obtain the resident's weight, evaluate, and report to dietician, provider, and responsible party any significant weight changes. Review of Resident #12's Minimum Data Set (MDS) 3.0 quarterly assessment completed 09/19/24 revealed the resident was moderately cognitively impaired, was independent with activities of daily living including eating, was on a mechanically altered and therapeutic diet. Review of Resident #12's physician orders revealed an order dated 10/27/24 for weekly weight to be obtained in the morning every Sunday for weight monitoring. Resident #12 also had an order dated 09/11/24 for a diet of NAS (No Added Salt) diet, Level 3 texture, Regular fluid, thin consistency and fortified pudding with lunch and dinner. Review of Resident #12's weight summary revealed weekly weights were completed on 10/28/24, 11/03/24, 11/30/24, and 12/01/24. There was no recorded weekly weights for 11/10/24, 11/17/24, or 11/24/24, or 12/08/24. Interview on 12/11/24 at 4:03 P.M. with the Director of Nursing (DON) confirmed nursing staff did not obtain Resident #12's weights as ordered. 2. Review of the medical record for Resident #74 revealed an admission date of 04/10/24. Medical diagnoses included schizophrenia, major depressive disorder, anxiety, GERD, dysphasia and chronic kidney disease. Review of Resident #74's MDS 3.0 quarterly assessment completed 10/14/24 revealed the resident was cognitively intact, required setup/clean-up assistance with meal service and was on a therapeutic diet. Review of Standards of Care Meeting dated 11/05/24 revealed the interdisciplinary team met to review Resident #74 weight loss and noted the resident had lost 6.9% of her body weight in one month. Resident #74 received 90 milliliters (ml) Med Pass (liquid nutritional supplement) three times per day, and the note indicated the Med Pass supplement was to be increased to 120 ml three times a day and Resident #74 would be placed on weekly weight monitoring. Review of Resident #74's progress notes dated 11/06/24 revealed the interdisciplinary team met regarding Resident #74's weight loss. The note indicated a new order was received to increase Med Pass supplement to 120 ml three times a day and to obtain weekly weights for four weeks. Review of Resident #74's physician orders revealed an order dated 07/04/24 for Med Pass 90 ml three times a day for nutritional supplement. Resident #74 had an order dated 11/10/24 for weekly weights for four weeks, to be completed on day shift every Sunday. An order dated 12/09/24 indicated Resident #74 required a regular diet with level 3 texture, and thin/regular liquid consistency. Review of Resident #74's weight summary revealed weights were taken on 11/03/24, 11/18/24, 11/24/24, 12/02/24 and 12/08/24 with weight gain. There was no recorded weekly weight for 11/10/24 which created a 15 day gap in weight tracking. Interview on 12/11/24 at 4:03 P.M. with the DON confirmed nursing staff did not obtain Resident #74's weights as ordered on 11/10/24. The DON additionally confirmed staff did not modify the residents order for Med Pass supplement to increase the amount to 120 ml three times a day. Review of the policy Weight Monitoring, dated 10/26/23, revealed a weight monitoring schedule will be created upon admission for all residents, with those experiencing weight loss being monitored on a weekly basis. Interventions will be identified, implemented, and regularly assessed and adjusted based on the resident's assessed needs, preferences, goals, and current professional standards to ensure the maintenance of an acceptable nutritional status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure residents received trauma-informed care that accounted for the resident's experiences and preferences in order to minimize or eliminate triggers that may cause re-traumatization of the residents. This affected two residents (#73 and #43) of two residents reviewed for trauma informed care. The facility census was 96. Findings include: 1. Review of Resident #73's medical record revealed an admission date of 02/28/24. Medical diagnoses included fracture of the left radius, chronic obstructive pulmonary disease, systemic lupus, major depressive disorder, muscle weakness, dysphasia, cognitive communication deficit, and post traumatic stress disorder (PTSD). Interview on 12/09/24 at 10:55 A.M. with Resident #73 confirmed that she had witnessed a family suicide, and was triggered by gun shots and loud noises. Resident #73 stated she had not been involved in care planning related to her PTSD diagnosis, but she used coloring and crafting as non-pharmacological coping methods to manage her mood. Interviews on 12/10/24 at 1:26 P.M. and 1:45 P.M. with Social Services Director (SSD) #48 confirmed upon admission, an initial social service assessment was completed for all residents. If a resident had identified triggers, the care plan was built around those triggers. SSD #48 was unaware of the nature and source of Resident #73's PTSD, and stated that no triggers had been reported or identified. Review of Resident #73's Initial Social Service History assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15 (indicating intact cognition). Resident #73 was documented as having experienced a frightening, horrible, or traumatic event, such as, a loved dying through homicide or suicide. Resident #73 was documented as trying hard not to think about the event, was constantly on guard, and was easily startled. Review of Resident #73's Behavior Management Monthly Note dated 10/01/24, 10/30/24, and 11/27/24 revealed the resident had behavior-related diagnoses of bipolar disorder, major depressive disorder, anxiety, PTSD, and schizoaffective disorder. Resident #73 was documented as having no known triggers on all three documents. Review of Resident #73's PTSD care plan, revised 09/18/24, revealed the resident had impaired mood/psychiatric status related to depression, anxiety, bipolar disorder, PTSD, and schizoaffective disorder. The listed goal was for Resident #73 to remain free of signs and symptoms of depression, anxiety, or sad mood. Care planned interventions included to administer medications and treatments as ordered, assist Resident #73 to cope by discussing possible solutions to conflict, behavioral health consultations as needed, and encourage on-going involvement with family and friends. 2. Review of the medical record for Resident #43 revealed an admission date of 05/23/18. Medical diagnoses included schizophrenia, chronic pain syndrome, bipolar disorder, anxiety, PTSD, and impulsiveness. Review of Resident #43's Minimum Data Set (MDS) 3.0 quarterly assessment completed 11/05/24 revealed Resident #43 was moderately cognitively impaired, exhibited verbal behavioral symptoms towards others, and rejection of care four to six days of the week. Review of diagnoses coded on the assessment revealed psychiatric/mood disorders of anxiety, depression, bipolar disorder, schizophrenia, and PTSD. Review of Resident #43's care plan dated 09/06/23 revealed the resident had impaired mood/psychiatric status related to schizophrenia, depression, anxiety, bipolar disorder, PTSD, and insomnia. Interventions included administering medications and treatments, assisting the resident to cope by discussing possible solutions to conflict, behavioral health consults, observing for and reporting any signs and/or symptoms of changes in mood or acute psychosis from the resident's baseline, and observing mood to determine if problems appear to be related to external causes. Review of Resident #43's progress notes revealed a note dated 08/11/24 which stated the resident was noted to be agitated and yelling at beginning of shift and was medication-seeking. Review of Resident #43's two-week psychiatry follow-up note dated 08/15/24 revealed the provider re-evaluated the patient for a history of schizoaffective disorder, anxiety, PTSD, and dementia. Resident #43 reported situational irritability and was noted to have tolerated medication changes since the last session. Resident #43 remained at baseline for mood and behaviors. Anxiety remained at baseline, with no new or worsening symptoms reported. The note indicated there was no reports of depression, PTSD, aggression, irritability, or agitation. Review of Resident #43's progress notes revealed a note dated 08/28/24 which stated the resident was observed to be yelling at staff that morning. Review of Resident #43's Social Service Progress Review dated 05/08/24 revealed the resident was oriented, had no memory issues, and was independent with daily decision-making. She had a diagnosis of PTSD, with PTSD symptoms noted as being managed effectively, with no mention of any known triggers. Interview on 12/10/24 at 1:50 P.M. with Social Services Director (SSD) #48 confirmed Resident #43 has a current diagnosis of PTSD with no mention of triggers in the care plan or attempts to identify the triggers. SSD #48 confirmed the care plan does not include information pertinent to the treatment of PTSD, and therefore, she is unable to confirm symptoms are being managed effectively if the triggers are not identified. Review of a policy Trauma Informed Care dated 10/24/22 revealed the facility would ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice. The facility will account for residents' experiences, preferences, and cultural differences to eliminate or mitigate triggers that may cause re-traumatization of the resident. The facility care plans will be initiated and updated to address those residents identified. Individualized approaches will be identified, and interventions will be put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure as-needed controlled medications were recorded on the Medication Administration Record (MAR) when administered. This affected one resident (Resident #81) of two residents reviewed for pain management. The facility census was 96. Findings include: Review of Resident #81's medical record revealed an admission date of 03/15/24 with diagnoses including type two diabetes mellitus, neuromuscular dysfunction of the bladder, anxiety disorder, osteomyelitis, cognitive communication deficit, depression, colostomy status, and resistance to vancomycin. Review of Resident #81's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #81's plan of care dated 02/23/24 revealed Resident #81 was at risk for pain related to comorbidities. Interventions included but were not limited to administering medications as ordered, offering non-pharmacological interventions to relieve pain, and observing for effectiveness. Review of Resident #81's physician orders from 11/11/24 to 12/08/24 revealed an order for Oxycodone (a controlled, narcotic analgesic) 5 milligrams (mg), give two tablets by mouth every four hours as needed for pain. The order specified nonpharmacological interventions were to be attempted prior to medication administration. Reconciliation of Resident #81's MAR and Controlled Drug Receipt Record (CDRR) for November 2024 revealed the following discrepancies related to oxycodone: - 11/02/24 - four doses were signed out on the CDRR, and two doses recorded on the MAR - 11/05/24 - four doses were signed out on the CDRR, and two doses were recorded on the MAR - 11/06/24 - three doses were signed out on the CDRR, and two doses were recorded on the MAR - 11/09/24 - six doses were signed out on the CDRR, and three doses were recorded on the MAR - 11/13/24 - five doses were signed out on the CDRR, and three doses were recorded on the MAR - 11/23/24 - four doses were signed out on the CDRR, and two doses were recorded on the MAR - 11/24/24 - four doses were signed out on the CDRR, and three doses were recorded on the MAR - 11/25/24 - four doses were signed out on the CDRR, and two doses were recorded on the MAR - 11/27/24 - four doses were signed out on the CDRR, and three doses were recorded on the MAR Reconciliation of Resident #81's MAR and CDRR from 12/01/24 to 12/08/24 revealed the following discrepancies related to oxycodone: - 12/04/24 - three doses were signed out on the CDRR, and two doses were recorded on the MAR - 12/07/24 - four doses were signed out on the CDRR, and two doses were recorded on the MAR - 12/08/24 - five doses were signed out of the CDRR, and four doses were recorded on the MAR. Interview on 12/11/24 at 3:42 P.M. with the Director of Nursing (DON) verified nursing staff had not documented in the MAR all administrations of Resident #81's Oxycodone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #79 revealed an re-admission date of 06/05/23 with diagnoses of chronic kidney disease, type two diabetes mellitus, atrial fibrillation, essential hypertension, pain and venous insufficiency. Review of Resident #79's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was cognitively intact and had hypertension. Review of Resident #79's care plan dated 10/31/24 revealed he had impaired cardiovascular status related to angina/chest pain, coronary artery disease, hyperlipidemia/hypercholesteremia, hypertension, obesity, and pacemaker placement. Listed interventions include labs/diagnostic testing as ordered, administering medications as ordered, observing for side effects and reporting to the physician, and observing vital signs as needed. Review of Resident #79's physician orders dated 09/06/24 revealed the resident received isosorbide mononitrate (a nitrate used to prevent chest pain and lower blood pressure) extended release 30 mg by mouth in the morning related to hypertension, nifedipine (an antihypertensive) extended release oral tablet 30 mg every morning related to hypertension, and carvedilol 3.125 mg every morning and bedtime related to hypertension. Review of Resident #79's MAR for 12/01/24 to 12/10/24 revealed no hold parameters were in place for the resident's ordered isosorbide mononitrate, nifedipine, and carvedilol. Resident #79 was listed as having received his ordered dose of carvedilol on the evening of 12/02/24 with a blood pressure result of 105/66 mmHg, on the morning of 12/03/24 with a blood pressure result of 108/62 mmHg, on the evening of 12/03/24 with a blood pressure result of 93/53 mmHg, on the morning of 12/04/24 with a blood pressure result of 108/92 mmHg, on the evening of 12/06/24 with a blood pressure result of 96/90 mmHg, on the evening of 12/09/24 with a blood pressure result of 102/72 mmHg, and on the evening of 12/10/24 with a blood pressure result of 107/64 mmHg. Review of Resident #79's progress notes dated 12/02/24 and 12/08/24 revealed carvedilol was held due to low blood pressure, but neither note indicated the physician had been notified. Review of Resident #79's updated physician orders dated 12/12/24 revealed the resident's orders for carvedilol and nifedipine received parameters to hold if the systolic blood pressure reading below 110 mmHg and/or a diastolic blood pressure reading below 60 mmHg. Interview on 12/12/24 at 08:49 AM with Licensed Practical Nurse (LPN) #45 revealed nursing has parameters to hold the medication. The parameter is located in the medical record next to hypertension, stating (I10), which meant to hold the blood pressure medications if the blood pressure is under 110. LPN #45 was asked to clarify what the first digit next to hypertension was, and LPN #45 confirmed it was an I and not a 1 and stated the I must have been an error. LPN #45 confirmed some of the administrations on Resident #79's MAR were not held when the blood pressures were under 110. LPN #45 confirmed the residents' medication orders did not include specific parameters written in or in any additional areas. LPN #45 stated if Resident #79's systolic blood pressure is lower than 110, she is required to hold the medication and notify the physician, which should be documented in the resident's medical record. Interview on 12/12/24 at 09:08 AM with the DON confirmed all residents who receive blood pressure medications should have parameters to hold the medication if the systolic blood pressure is less than 110 mmHg and/or the diastolic blood pressure is less than 60 mmHg. The DON verified the nursing staff is also required to notify the physician of low blood pressure readings and medications which have been held. Based on interview and medical record review the facility failed to ensure medication parameters were in place and followed for Resident #34, #69, and #79, who received blood pressure medication. This affected three residents (#34, #69, and #79) of six residents who were reviewed for medication administration. The facility census was 96. Findings include: 1. Review of the medical record for Resident #69 revealed an admission date of 07/26/24 with diagnoses including cerebral infarction, type two diabetes mellitus, acute respiratory failure, osteomyelitis, cognitive communication deficit, anxiety disorder, osteoarthritis, and hypertension. Review of Resident #69's quarterly Minimum Data Set (MDS) 3.0 dated 11/22/24 revealed he had intact cognition. Review of Resident #69's plan of care dated 07/17/24 revealed the resident had impaired cardiovascular status related to hyperlipidemia and hypertension. Interventions included observing and reporting to the physician any signs of hypertension, administering medications as ordered, and observing vital signs as needed. Review of Resident #69's physician order dated 11/16/24 revealed an order for Metoprolol Tartrate (an antihypertensive) 25 milligrams (mg) one tablet by mouth every morning and at bedtime related to hypertension. There were no parameters for holding the medication Review of Resident #69's Medication Administration Record (MAR) from 12/01/24 to 12/08/24 revealed the resident's Metoprolol medication was held on 12/01/24 for a blood pressure of 94/54 mmHg, twice on 12/02/24 for a blood pressure of 102/59 mmHg and 98/61 mmHg, on 12/05/24 for a blood pressure of 110/57 mmHg and 106/61 mmHg, on 12/06/24 for a blood pressure of 96/54 mmHg, and on 12/08/24 for a blood pressure of 110/48 mmHg. His medication was not held on 12/03/24 for a blood pressure of 106/68 mmHg and on 12/09/24 for a blood pressure of 107/58 mmHg. His blood pressure was not recorded as assessed on 12/03/24, 12/04/24, 12/07/24, and 12/08/24. Review of Resident #69's progress notes dated 12/01/24 to 12/08/24 revealed no indication the physician was notified the medication was held. Interview on 12/12/24 at 9:09 A.M. and 9:12 A.M. with the Director of Nursing (DON) verified nursing was holding Resident #69's blood pressure medications without parameters and without notifying the physician. She reported blood pressure parameters should be in place. The DON indicated the medication should be held for a systolic blood pressure reading below 110 mmHg and/or a diastolic blood pressure reading below 60 mmHg. 2. Review of Resident #34's medical record revealed an admission date of 03/10/23 with diagnoses including end stage renal disease with dependence on renal dialysis, type two diabetes mellitus, chronic obstructive pulmonary disease, psychosis, and cognitive communication deficit. Review of Resident #34's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #34's physician order dated 11/26/24 revealed an order for carvedilol (an antihypertensive) one tablet twice a day for high blood pressure. The medication was to be held prior to dialysis on Monday, Wednesday, and Friday. Review of Resident #34's MAR for 12/02/24 to 12/11/24 revealed carvedilol was not held prior to dialysis on 12/02/24, 12/04/24, 12/06/24, and 12/11/24. Interview on 12/12/24 at 9:09 A.M. with the Director of Nursing (DON) verified Resident #34's carvedilol was not held as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and review of facility policy, the facility failed to complete laboratory testing as ordered by the physician for Resident #81. This affected one resident (#81) of two residents reviewed for hydration. The facility census was 96. Findings include: Review of Resident #81's medical record revealed an admission date of 03/15/24 with diagnoses including type two diabetes mellitus, neuromuscular dysfunction of the bladder, anxiety disorder, osteomyelitis, cognitive communication deficit, depression, colostomy status, and resistance to vancomycin. Review of Resident #81's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #81's laboratory results dated [DATE] revealed her potassium was high at 5.6 milliequivalents (mEq) per liter (L). Review of Resident #81's progress note dated 12/4/24 revealed her potassium was 5.6 mEq/L on her laboratory results. The Certified Nurse Practitioner (CNP) gave an order for Kayexalate (a medication used to lower the amount of potassium in the blood) and to repeat lab orders on 12/05/24. Review of Resident #81's medical record revealed her next labs were drawn on 12/10/24. Interview on 12/11/24 at 8:18 A.M. with the Director of Nursing (DON) verified Resident #81's labs were not redrawn on 12/05/24 as ordered by the CNP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident interview, and staff interview, the facility failed to comprehensively assess Resident #84's dental status. This affected one resident (#84) of 27 sampled residents. The facility census was 88. Findings Include: Review of the medical record for Resident #84 revealed an admission date of 08/04/23 with diagnoses including diabetes, chronic kidney disease, and hemiplegia. Review of a nursing admission assessment dated [DATE] revealed it stated Resident #84 does not use dentures or partials and edentulous was not marked. Review of an initial nutrition assessment dated [DATE] revealed it stated Resident #84 had her own teeth. Review of an admission Minimum Data Set (MDS) assessment completed 08/11/23 revealed Resident #84 was not edentulous and did not have broken or loose dentures. Review of a quarterly MDS assessment completed 11/20/23 revealed Resident #84 had a Brief Interview for Mental Status score of 15, indicating intact cognition. It stated the resident did not have broken or loose dentures. Review of a nutritional assessment dated [DATE] revealed it stated Resident #84 had her own teeth. Interview with Resident #84 on 02/06/24 at 8:42 A.M. revealed she had broken her upper denture when she fell at home prior to admission. She stated she needed a new upper denture and had asked to be put on the list to see the dentist. Observations on 02/07/24 at 9:30 A.M. revealed Resident #84 to have her own bottom teeth but no teeth or denture on top. Interview with Nursing Assistant #506 (providing care on the hall where Resident #84 resided) on 02/07/24 at 9:32 A.M. revealed she did not know the resident's dental status as the resident does her own oral care. Interview with Licensed Practical Nurse (LPN) #429 (nurse for Resident #84) on 02/07/24 at 9:42 A.M. revealed she thought Resident #84 had her own teeth and did not require dentures. Interview with MDS LPN #414 on 02/07/24 at 9:56 A.M. confirmed the nutrition assessments, nursing assessment, and MDS assessments were not accurate since Resident #84 did not have all of her own teeth and had dentures on top, which the resident said were broken. She confirmed a comprehensive assessment of Resident #84's dental status was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and facility policy review, the facility failed to provide showers as scheduled to Resident #46. The deficient practice affected one resident (#46) of two residents reviewed for activities of daily living (ADL). The facility census was 88. Findings Include: Review of the medical record for Resident #46 revealed an admission date on 11/18/23. Medical diagnoses included heart failure, acute and chronic respiratory failure, type II diabetes mellitus, chronic obstructive pulmonary disease (COPD), asthma, morbid obesity, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #46 required partial to moderate assistance from staff for showering or bathing and for tub or shower transfers. Review of shower documentation dated December 2023 revealed Resident #46 was scheduled to receive showers on Mondays and Thursdays during the 2:00 P.M. to 10:00 P.M. shift. Resident #46 did not receive scheduled showers on Monday, 12/11/23, Thursday, 12/14/23, Thursday 12/21/23, or Thursday 12/28/23. Review of shower documentation dated January 2024 revealed Resident #46 did not receive scheduled showers on Monday 01/08/24, Thursday 01/18/24, or Thursday 01/25/24. Review of shower documentation dated February 2024 revealed Resident #46 received showers on 02/01/24 and 02/08/24. Resident #46 was marked as refusing a shower on Monday, 02/05/24. Interview and observation on 02/05/24 at 12:55 P.M. with Resident #46 revealed she did not always receive showers as scheduled. Resident #46 reported she was supposed to receive showers on Mondays and Thursdays. Resident #46 stated she had not been offered a shower yet today, 02/05/24 but typically received showers in the evenings. Resident #46 also reported she had not received a shower for an entire week in January 2024. Resident #46 stated the facility staff may report the resident refused showers, but the resident adamantly denied she had refused any showers at the facility. Interview and observation on 02/07/24 at 10:10 A.M. with Resident #46 revealed she did not receive a shower or bed bath as scheduled on 02/05/24. Again, the resident denied she refused a shower and stated the facility staff had not offered to take her to the shower. Resident #46 stated she was able to complete most of her shower by herself but needed assistance with washing her back and feet and needed staff to stay in the shower room with her for safety. Resident #46 stated her last shower was on Thursday, 02/01/24 (nearly one week ago). Resident #46 stated her next scheduled shower was tomorrow, 02/08/24. Interview and observation on 02/12/24 at 2:37 P.M. with Resident #46 revealed she did not receive a shower on Monday, 02/05/24 or Thursday, 02/08/24. The resident stated she did receive a shower on Saturday, 02/10/24. Resident #46 denied again she had refused any showers. Interview on 02/12/24 at 3:11 P.M. with the Director of Nursing (DON) #533 confirmed Resident #46 did not receive scheduled showers as indicated above in December 2023 or January 2024. Review of the facility policy, Activities of Daily Living (ADL), revised 12/28/23, revealed the policy stated, a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #43 revealed an admission date on 10/27/23 with medical diagnoses including Alzheimer's disease, type II diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease stage three, urinary tract infection, generalized anxiety disorder, psychosis, major depressive disorder, and cognitive communication deficit. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had impaired cognition and scored seven out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #43 required partial to moderate assistance with toileting and toilet transfers. Resident #43 was frequently incontinent of bowel and bladder. Review of the laboratory results from a urinalysis culture and sensitivity (UA C&S) test reported to the facility on [DATE] at 1:36 P.M. revealed Resident #43 had a positive urinalysis with the culture showing an organism of Escherichia coli (e-coli) bacteria growth greater than 100,000 colony-forming units per milliliter (CFU/mL) (a unit which estimates the number of cells viable enough to proliferate and form small colonies). Review of the Medication Administration Record (MAR) dated November 2023 revealed an order for Cephalexin (an antibiotic) 500 milligrams with instructions to give one capsule by mouth three times daily for infection for seven days was ordered to start on 11/28/23 at 1:00 P.M. (two days after the positive urinalysis results were reported to the facility). Review of the laboratory results from a UA C&S test reported to the facility on [DATE] at 3:54 P.M. revealed Resident #43 had a positive urinalysis with the culture showing organisms of e-coli bacteria between 70-99,000 CFU/mL and proteus mirabilis bacteria growth greater than 100,000 CFU/mL. Review of the MAR dated December 2023 revealed an order for Cefdinir (an antibiotic) 300 mg with instructions to give one capsule by mouth every morning and at bedtime for urinary tract infection (UTI) for seven days was ordered to start on 12/17/23 at 8:00 P.M. (approximately 28 hours after results had been reported to the facility.) Review of the laboratory results from a UA C&S test reported to the facility on [DATE] at 4:31 P.M. revealed Resident #43 had a positive urinalysis with the culture showing an organism of e-coli bacteria growth greater than 100,000 CFU/mL. Review of the MAR dated January 2024 revealed there were not any orders for an antibiotic to be started for Resident #43. Review of the MAR dated February 2024 revealed an order for Cephalexin 500 mg with instructions to give one capsule by mouth three times daily for an infection for five days was ordered to start on 02/01/24 at 6:00 A.M. (approximately three and a half days after the results had been reported to the facility). Interview on 02/07/24 at 3:17 P.M. with the DON #533 confirmed there was a delay in starting antibiotic treatment for Resident #43 after positive UA C&S results were reported to the facility on [DATE], 12/16/23, and 01/28/24. DON #533 stated treatment orders should be received immediately after positive lab results were reported. DON #533 stated if results were reported late into the night, the following day would be acceptable but there should not be a longer delay than that to obtain and implement treatment orders. Review of the facility policy, Antibiotic Stewardship Program, revised 12/13/23, revealed the facility would monitor laboratory results when available to determine if an antibiotic was indicated. Review of the facility policy, Antibiotic Prescribing Practices, revised 10/26/23, revealed the purpose of the policy was to implement antibiotic use protocols, including prescribing practices, to optimize the treatment of the infections. The decision to prescribe an antibiotic would be guided by medical knowledge, best practices, and professional guidelines. Based on medical record review, interview, and facility policy review the facility failed to ensure timely treatment was initiated urinary tract infections. This affected two residents (#43 and #84) of six residents reviewed for antibiotic use/urinary tract infections. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #84 revealed an admission date of 08/04/23 with diagnoses including diabetes, chronic kidney disease, and urinary retention. Review of nursing progress notes on 11/13/23 at 11:10 A.M. revealed Resident #84 received the last dose of an antibiotic and stated she feels a little better but not all the way. The resident continued to be slightly confused at times. The nurse updated the nurse practitioner who said it was okay to get another urine culture if needed in the morning. On 11/14/23 at 11:37 P.M. a urine specimen was collected. Review of urine culture results reported on 11/18/23 revealed greater than 100,000 Proteus Mirabilis. The bacteria was not sensitive to any oral antibiotics (only intravenous or intramuscular medications). Resident #84 was started on an antibiotic (Amoxicillin-potassium clavulanate 875-125 milligrams) twice daily for seven days on 11/20/23. This antibiotic was not listed on the urine culture for the bacteria being sensitive to it. Review of the medication administration record revealed the resident received the Amoxicillin-potassium clavulanate from 11/20/23 to 11/27/23 for a total of 14 doses. There was nothing documented to indicate why the antibiotic was not started for two days after the urine culture results were reported. Interview with the Director of Nursing (DON) on 02/07/24 at 2:45 P.M. confirmed Resident #84 was still confused, so another urine culture was obtained on 11/14/23. She confirmed the bacteria was not listed as sensitive to the antibiotic that was used. She stated she did not know why the antibiotic was not started after the results were reported on 11/18/23. She confirmed the antibiotic did not start until 11/20/23 and could have started 11/19/23 in the morning.

Based on observations, resident interview, staff interview, and medical record review, the facility failed to ensure Resident #39 received treatment to maintain vision abilities. This affected one resident (#39) of one resident reviewed for communication/sensory abilities. The facility census was 88. Findings Include: Review of the medical record for Resident #39 revealed an admission date of 03/10/23 with diagnoses including end stage renal disease, diabetes, and psychosis. Record review revealed the resident went out of the facility three times weekly for dialysis. Review of an annual Minimum Data Set (MDS) assessment completed 01/01/24 revealed Resident #39 had a Brief Interview for Mental Status score of 12, indicating moderately impaired cognition (a score of 8-12 = moderately impaired cognition and a score of 13-15 = intact cognition). It stated the resident had impaired vision with no corrective lenses. A quarterly MDS on 10/01/23 also indicated impaired vision with no corrective lenses. Review of a vision consult report dated 04/27/23 revealed Resident #39 was scheduled to be treated, but was out of the building. (The resident had dialysis three days per week outside of the facility). Will attempt to see at next visit. There was no evidence the resident had received a vision exam since admission to the facility. Interview with Resident #39 on 02/05/24 at 9:21 A.M. revealed someone took her glasses a couple months ago. She stated she needed new glasses but had not seen the eye doctor. Observations on 02/05/24 at 9:21 A.M. revealed Resident #39 was not wearing glasses. Interview with Social Service Assistant #551 on 02/08/24 at 1:40 P.M. confirmed Resident #39 could not be seen by the eye doctor on 04/27/23 as she was out of the facility for dialysis. She stated the resident had cataract surgery on 11/20/23 so her daughter took her glasses, so she won't wear them. She stated the resident would need a new eyeglass prescription since having the cataract surgery. She confirmed the facility eye doctor had been to the facility again on 01/08/24 but the resident was at dialysis again. She confirmed a vision exam had not been arranged for Resident #39.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview, and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of a pressure ulcer to Resident #19's nose caused by his glasses. This affected one resident (#19) of four residents reviewed for pressure ulcers. The census was 88. Findings Include: Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, cerebral infarction, anxiety disorder, diverticulitis, major depressive disorder, cognitive communication deficit, hyperlipidemia, contracture of left hand, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 01/01/24, revealed Resident #19 was cognitively intact. The assessment noted the resident was at risk for pressure ulcer development. Review of Resident #19's physician orders, dated 11/27/23, revealed an order for staff to cut about a 2.0-centimeter (cm) strip of DermaFilm Thin hydrocolloid dressing (maintains a moist wound environment) and place across the bridge of Resident #19's nose to protect the corners of the resident's nose from skin irritation/breakdown from resident's glasses. The dressing was to be changed every three days. Within the order, it noted the resident would refuse to take off his glasses to give the areas a rest. Record review revealed this order appeared to be preventative in nature and not as a result of skin breakdown at that time. Review of Resident #19's care plans dated 11/27/23 through 02/06/24 revealed no care plan related to risk of skin breakdown caused by the resident's glasses. Review of Resident #19's Treatment Administration Records (TAR) dated 11/27/23 through 02/06/24 revealed the DermaFilm treatment was not documented as being completed as ordered on 01/05/24 and 01/17/24. On 02/05/24 at 10:00 A.M., 11:44 A.M., and 2:13 P.M., and 02/06/24 at 7:38 A.M., 8:15 A.M., and 2:45 P.M. Resident #19 was observed in his room in bed wearing glasses. The resident was observed to have an open pressure ulcer to the right side of his nose. The nose pad of the glasses was observed to be embedded into the wound. The left side of his nose had a strip of DermaFilm on it. Review of Resident #19's physician orders, dated 02/06/24, revealed the facility obtained an order to cleanse right side of the nose with normal saline and pat dry. Cut about small tear drop shaped DermaFilm Thin hydrocolloid dressing for both sides of the nose, to place under nose pieces of glasses. The treatment order was to be completed every three days and as needed if it comes off. Review of Resident #19's skin assessment, dated 02/06/24, revealed a pressure ulcer to the right and lateral side of the resident's nose measuring 0.85 cm by 0.55 cm with 100% eschar, eschar/scabbed area dark red/black. The pressure ulcer was documented as being in-house acquired. The resident's care plan was updated on 02/07/24 to reflect the development of the pressure ulcer. Interview with Resident #19 on 02/07/24 at 2:43 P.M. and 2:50 P.M. confirmed he had an open area to the right side of his nose. The resident indicated the area was very tender and painful with his glasses on. He indicated he liked to wear his glasses the vast majority of each day because he wanted to be able to see all the time, but stated there were times when the preventative DermaFilm was not across both sides of his nose. The resident denied reporting this to staff for follow-up or to ensure the areas of his nose were being protected to decrease the risk of skin breakdown. Interview with the Administrator on 02/07/24 at 2:50 P.M. confirmed the resident did not have any treatment or barrier across the right side of his nose at the time the ulcer developed. She confirmed there was an open area to the right side of his nose, and the nose piece to the resident's glasses was embedded in the wound. Review of facility Pressure Injury Prevention and Management policy, dated 01/01/22, revealed the facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Interventions would be documented in the care plan and communicated to all relevant staff.

Based on observations, resident interview, staff interview, and medical record review, the facility failed to ensure Resident #85 received services to prevent decrease in range of motion and to maintain or improve mobility. This affected one resident (#85) of three residents reviewed for positioning/mobility. The facility census was 88. Findings Include: Review of the medical record for Resident #85 revealed an admission date of 06/07/23 with diagnoses including cerebral infarction (stroke) with hemiplegia and hemiparesis (muscle weakness/paralysis). Review of a quarterly Minimum Data Set (MDS) assessment completed 12/12/23 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. Resident #85 had impairment in range of motion on one side, upper and lower. The resident was dependent upon staff for transfers. Review of a physical therapy discharge summary revealed Resident #85 received physical therapy from 10/26/23 to 01/16/24. It stated the resident had significant mobility deficits with increased weakness. The resident had resided at home prior to admission and had been able to drive. Physical therapy goals had included walking five to ten feet with left leg brace and walker. Upon discharge from physical therapy, the resident was able to walk 15 feet with brace, rail, and moderate/maximum assistance. Recommendations were made for a restorative nursing program for walking five to ten feet with braces and to use exercise equipment in the therapy gym. Review of an occupational therapy discharge summary revealed Resident #85 received occupational therapy from 11/17/23 to 01/16/24. Occupational therapy goals included tolerating left upper extremity range of motion exercises for 15 minutes for contracture management and to be independent with self-range of motion for left upper extremity to prevent contractures and reduce pain caused by muscle tightening. The goal for tolerating range of motion was met on 01/05/24, and the goal for independence with self-range of motion stated on 01/16/24, the resident was able to complete self-range of motion for affected left hand and wrist but required assistance with left shoulder range of motion. Recommendations were made for a functional maintenance program for staff to assist with range of motion of the left upper extremity with focus on the left shoulder. Review of the plan of care for Resident #85 revealed on 01/31/24 it stated the resident would benefit from a restorative ambulation program related to decreased endurance. The goal was for the resident to ambulate ten-15 feet with hemi walker and bracing daily. The intervention listed was to provide ambulation program daily as tolerated. The plan of care dated 01/31/24 also stated the resident would benefit from a restorative range of motion program related to decreased strength in lower extremities. (The plan of care did not specify the need for range of motion for the left upper extremity). The goal was to use therapy equipment for passive range of motion 15 minutes daily and maintain current level of range of motion. The interventions included to provide range of motion program daily for 15 minutes or as tolerated. Review of the restorative nursing program documentation revealed walking with a hemi walker with assistance of two staff for ten-15 feet and range of motion for 15 minutes using therapy equipment were started on 01/26/24 (10 days after therapy discontinued). Documentation for ambulating revealed between 01/26/24 and 02/10/24 (16 days) the resident walked five times. On nine days it was documented ambulating did not occur (no reason) and on two days the resident was not available. Documentation for therapy equipment for range of motion revealed between 01/26/24 and 02/10/23 (16 days) the resident did range of motion on nine days. On five days it was documented use of therapy equipment did not occur (no reason) and on two days the resident was not available. Interview with Resident #85 on 02/05/24 at 10:35 A.M. revealed she had experienced a stroke and had left sided weakness in her arm and leg. She stated she had been discharged from therapy in mid-January 2024. She stated she was supposed to be assisted to walk in a restorative nursing program but had only been assisted maybe once. She also stated she had weakness in her left arm/hand but did not receive any type of range of motion for this. She stated she wished the staff would assist with this. Observations, at that time, revealed the resident to be seated in a wheelchair and wearing a sling on her left arm. Interview with Rehab Director #611 on 02/12/24 at 9:30 A.M. confirmed Resident #85 was discharged from physical and occupational therapies on 01/16/24. She stated the resident had left sided weakness but met her maximum potential for skilled therapies. She stated the resident was willing to participate in her therapies. She stated upon discharge from therapy the resident was walking ten feet with moderate assistance and a hemi walker. She stated the resident's left arm was flaccid and she used a sling. She stated recommendations were made by physical therapy for a restorative nursing program for walking and use of a leg bike to stretch legs. Interview with Restorative Aide #405 on 02/12/24 at 12:00 P.M. revealed she worked with Resident #85. She stated the resident's restorative programs consisted of taking her to therapy room to use an omni cycle to exercise her legs and to assist the resident to walk when the other restorative aide was available as the resident required two staff to walk. She stated did not occur was documented as there were not enough restorative staff to complete all the programs they are scheduled to do. She stated there are typically two restorative aides during the week unless they got pulled from providing restorative therapy. She stated there were no restorative staff scheduled on Sundays and only one on Saturdays. She stated not available means the resident may have been out for an appointment, etc. She confirmed on those days, there was only one time that restorative therapy was attempted. She confirmed there was no further specific documentation to explain why the restorative programs were not completed daily as per the plan of care. She further confirmed Resident #85 was not provided with any range of motion for her left upper extremity. Interview with the Director of Nursing on 02/12/24 at 12:08 P.M. revealed she did not know why it took ten days to initiate the restorative nursing programs for Resident #85 after her physical and occupational therapies were discontinued. She confirmed the plan of care stated the restorative programs were to be done daily and that they were not being done daily. She confirmed Resident #85 should be receiving range of motion for her left upper extremity and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of fall investigations, and facility policy review, the facility failed to complete neurological checks following unwitnessed falls for Resident #17. The deficient practice affected one resident (#17) of two residents reviewed for falls. The facility census was 88. Findings Include: Review of the medical record for Resident #17 revealed an initial admission date of 08/07/23 and a readmission date of 09/21/23. Medical diagnoses included Alzheimer's disease, history of falling, and type II diabetes mellitus with diabetic chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 was rarely or never understood. Per staff assessment, Resident #17 had moderately impaired cognition. Resident #17 required partial to moderate assistance from staff with transfers and used a walker or a wheelchair for mobility. Review of the fall investigations for Resident #17 revealed the resident had unwitnessed falls on 08/25/23 at 6:10 P.M., 11/20/23 at 3:36 P.M., 12/04/23 at 2:37 P.M., 12/07/23 at 10:45 A.M., and 02/03/24 at 7:49 P.M. Interview on 02/12/24 at 2:24 P.M. with Registered Nurse (RN) #511 revealed neurological checks were to be completed after an unwitnessed fall on every shift for three days. RN #511 stated the neurological checks were documented in the Fall-Follow-up assessments in the medical record. Review of the Fall-Follow-up assessments completed for Resident #17 revealed neurological checks were completed one time on 08/27/23 and 08/28/23, one time on 11/21/23 and 11/22/23, one time on 12/05/23, 12/06/23, and 12/07/23, one time on 12/08/23, not completed at all on 02/04/24, and one time on 02/06/24 following the resident's unwitnessed falls. Interview on 02/12/24 at 3:13 P.M. with the Director of Nursing (DON) #533 confirmed neurological checks should be completed on each shift (twice a day) for three days following an unwitnessed fall. The neurological checks should be documented in the Fall-Follow-up assessment. DON #533 confirmed neurological checks were not completed as required following unwitnessed falls for Resident #17 on 08/25/23, 11/20/23, 12/04/23, 12/07/23, or 02/03/24. Review of the facility policy, Falls-Clinical Protocol, revised 11/02/23, revealed the policy stated, residents who have fallen and have been witnessed to hit their head, suspected to have hit their head, and all un-witnessed falls regardless of the resident's cognitive status should have neurochecks per physician orders or protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility policy and staff interviews, the facility did not ensure all physician ordered nutritional interventions to prevent weight loss were consistently implemented for Resident #53. This affected one resident (Resident #53) of five residents reviewed for nutrition. The facility census was 88. Findings Include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), emphysema, acute respiratory failure, cardiomyopathy, dysphagia, muscle weakness, hypertension, polyneuropathy, anxiety disorder, depression, and hypotension. Review of Resident #53's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/05/23, revealed she had no cognitive impairment, was dependent on staff for eating, had no significant weight changes and received nutrition by mouth with a mechanically altered diet and nutrition through a feeding tube. Review of Resident #53's current care plan revealed she was at risk for altered nutritional status due to COPD, congestive heart failure, anxiety, depression, dysphagia with gastroparesis requiring PEG (percutaneous endoscopic gastrostomy) tube feeding. Interventions included texture modified diet and reliance on enteral nutrition to meet her needs. Review of the physician orders for February 2024 revealed Resident #53 was receiving Remeron 15 milligrams every day for appetite stimulant, Med Pass 2.0 (a liquid, high calorie, high protein supplement) twice a day by mouth and her diet was regular diet, level two texture. Additional diet orders included an order dated 12/19/23 for bolus enteral feeding of 240 milliliters Osmolite 1.5 via PEG tube if the resident consumed less than 50% of lunch or dinner. Review of Resident #53's meal intake logs, dated January 2024 to February 2024, revealed a total of 21 meal entries for lunch and dinner that were left blank. Also, there were 13 entries in which her meal intake for lunch and dinner was less than 50% or she refused her meal. Review of Resident #53's Medication Administration Records (MAR) dated January 2024 to February 2024 revealed good acceptance of the Med Pass 2.0 supplement but varied acceptance and lack of consistent administration of the enteral bolus of Osmolite 1.5. if Resident #53 refused or ate less than 50% of her lunch and dinner. The MAR revealed 16 entries in which she ate less than 50% of her lunch or dinner, or refused either meal, yet her enteral feeding was not offered/provided to her. Review of Resident #53's weights, dated 11/15/23 to 02/07/24, revealed the following weights: 11/15/23 (104.6 pounds), 11/19/23 (106.9 pounds), 11/26/23 (105 pounds), 12/06/23 (101.2 pounds), 12/10/23 (106.4 pounds), 12/11/23 (106.2 pounds), 12/17/24 (101.8 pounds), 01/05/24 (98.8 pounds), 01/22/24 (95.4 pounds), 01/23/24 (96.3 pounds), 01/30/24 (100.6 pounds), 02/07/24 (101.6 pounds). From 12/17/23 to 01/23/24 Resident #53's weight declined 5.5 pounds or 5.4 percent which was a significant weight loss. From 01/23/24 to 02/07/24 Resident #53's weight increased 5.3 pounds for a significant gain of 5.5 percent. Interview was attempted with Resident #53 on 02/07/24 at 2:30 P.M. in her room. Resident #53 presented with a petite stature, weight appropriate for her frame and no observed signs of weakness or malnutrition. When greeted and asked questions, Resident #53 was alert but would not participate in the interview. Interview with Dietitian #500 and Director of Nursing (DON) on 02/12/24 at 2:05 P.M. revealed the facility staff was to offer her the enteral feeding as ordered. Dietitian #500 confirmed she implemented the enteral feeding order to help maintain and stabilize her weight so she would expect this order to be followed. Both confirmed there were both blanks on the MAR and meal intake logs as well as refusals of the enteral bolus. The DON confirmed if Resident #53 was refusing her enteral feeding, the staff should be documenting refusals so Dietitian #500 would have an accurate account of how many times she refused and potentially put another nutritional intervention in place. The DON also confirmed that on the MAR there were multiple NA documented and if the enteral feeding was documented as NA, that would indicate it was not offered. The DON confirmed the number of instances on Resident #53's MAR that were documented as NA and verified the enteral bolus was not being given to Resident #53 according to the physician orders. Review of facility Weight Monitoring policy, dated 10/26/23, revealed interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status.

Based on observations, medical record review, staff interview, and review of the facility list of medications not to be crushed, the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 15% and included four medication errors of 26 medication administration opportunities. This affected one resident (Resident #39) of six residents observed for medication administration. The facility census was 88. Findings include: Review of the medical record for Resident #39 revealed an admission date of 03/10/23 and diagnoses including end stage renal disease and diabetes. The resident received hemodialysis three times weekly. There was no evidence of any physician's orders to crush medications. Observation of medication administration on 02/12/24 at 8:45 A.M. revealed Registered Nurse (RN) #528 preparing medications to administer to Resident #39. The following medications were crushed in applesauce together: Sevelamer 800 milligrams (used to lower phosphorus in the blood of patients receiving kidney dialysis), Ropinirole two milligrams (used for restless leg syndrome), Tamiflu 75 milligrams (used to prevent flu), and Colestipol one gram (used to lower cholesterol). The medications were taken in the room to give to Resident #39. (Crushing and combining medications may result in physical and chemical incompatibilities leading to an altered therapeutic response). On 02/12/24 the Director of Nursing provided a list of medications not to be crushed and included Sevelamer, Ropinirole, and Colestipol. Interview with RN #516 on 02/12/24 at 11:35 A.M. confirmed Tamiflu should not be crushed. Interview with RN #528 on 02/12/24 at 11:35 A.M. confirmed the medications were crushed to give to Resident #39. She stated she thought they were crushed per the resident's preference because some of the pills were big. However, she stated she crushed all of the resident's medications. She confirmed there was no physician's order to crush the medications and no documentation from the physician or pharmacist that it was acceptable to crush the medications that were on the not to be crushed list. A total of 26 opportunities for error were observed during medication administration with a total of four errors (four medications crushed that are not to be crushed) resulting in a 15% medication error rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents were administered medication in accordance with physician orders and prescribing instructions for use of the medications. This affected two residents (Residents #46 and #297) of six residents reviewed for medication administration. The facility census was 88. Findings include: 1. Review of the medical record revealed Resident #297 was admitted to the facility on [DATE] with diagnoses that included arthritis due to other bacteria and left knee bacteremia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #297 was cognitively intact, required moderate assistance for activities of daily living and was receiving intravenous (IV) antibiotics. Review of the discharge information from the hospital dated 12/29/23 for Resident #297 revealed a primary diagnosis of blood stream infection and was ordered to receive intravenous (IV) Vancomycin (medication for infection) every 12 hours until 02/16/24. Review of Resident #297's clinical summary revealed septic shock due to Methicillin-resistant Staphylococcus aureus (MRSA) (a bacteria that causes severe and sometimes life-threatening complications) bacterium resulting in elevated creatinine levels indicating kidney damage. Review of infectious disease sign-off from the hospital for Resident #297 revealed the resident was to receive IV Vancomycin for six weeks with an end date of 02/16/24 due to bacteremia, septic arthritis, MRSA, and left septic knee. Review of the physician orders for January 2024 revealed Resident #297 was ordered Vancomycin 1000 milligrams (mg) to be administered IV every 12 hours for infection related to arthritis due to other bacteria with a start date on 01/29/24 at 9:00 P.M. and end date on 02/16/24. Review of the Medication Administration Record (MAR) for dates 01/30/24 to 02/12/24 revealed the following administration times for Vancomycin HCL IV Solution 1000 MG/200 ML: • On 01/30/24 Resident #297 received his 9:00 A.M. dose at 10:29 A.M. • On 01/31/24 Resident #297 received his 9:00 A.M. dose at 2:05 P.M. • On 02/02/24 Resident #297 received his 9:00 A.M. dose at 11:21 A.M., and his 9:00 P.M. dose at 11:36 P.M. • On 02/04/24 Resident #297 received his 9:00 A.M. dose at 10:38 A.M. • On 02/08/24 Resident #297 received his 9:00 P.M. dose at 11:22 P.M. • On 02/10/24 Resident #297 received his 9:00 P.M. dose at 11:27 P.M. • On 02/12/24 Resident #297 received his 9:00 A.M. dose at 11:16 A.M. Review of Resident #297's progress note dated 01/31/24 at 12:12 P.M. revealed Vancomycin 1000 mg was not available for administration. Interview on 02/08/24 at 5:36 P.M. with Licensed Practical Nurse (LPN) #427 confirmed she was unable to administer the antibiotic due to a shortage of essential fluids to combine the drug. Observation of the emergency drug kit on 02/08/24 at 5:36 P.M. with LPN #427 revealed appropriate fluids were not available for mixing Resident #297's antibiotic if needed. Interview on 02/12/24 at 7:55 A.M. with Director of Nursing (DON) #533 confirmed knowledge of late dose on 01/31/24. DON #533 confirmed medications on 01/30/24, 01/31/24, 02/01/24, 02/02/24, and 02/08/24 were not administered 60 minutes prior to or after scheduled time. Review of the prescribing information for Vancomycin Hydrochloride revised July 2018 revealed Vancomycin Hydrochloride should be taken as directed and skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable. Review of the facility policy, Medication Administration, revised on 01/17/23, revealed medication was to be administered within 60 minutes prior to or after scheduled time. 2. Review of the medical record for Resident #46 revealed an admission date on 11/18/23. Medical diagnoses included heart failure, acute and chronic respiratory failure, type two diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), asthma, morbid obesity, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #46 required assistance from staff which ranged from set up help to maximal assistance to complete Activities of Daily Living (ADLs). Review of progress notes for Resident #46 revealed on 01/19/24 at 11:15 A.M., a new order to discontinue Flovent due to not being available at pharmacy and start Resident #46 on Fluticasone HFA 110 mcg one puff twice daily. On 01/22/24 at 9:33 P.M., Fluticasone Propionate HFA order was noted to be waiting on the pharmacy to deliver the inhaler. On 01/30/24 at 8:59 P.M., Fluticasone Propionate HFA was still waiting to be delivered. On 02/07/24 at 8:57 P.M., Fluticasone Propionate HFA was still waiting for the pharmacy to deliver the medication. Review of physician orders for Resident #46 revealed an order dated 01/22/24 for Levalbuterol Tartrate Inhalation Aerosol 45 mcg/act with instructions to take two puffs inhale orally every four hours as needed for shortness of breath. Review of the MAR dated January 2024 revealed Resident #46 was administered Fluticasone Propionate HFA inhaler at bedtime on 01/19/24, in the morning on 01/20/24, in the morning on 01/22/24, at bedtime on 01/30/24, and both in the morning and at bedtime on 01/23/24, 01/24/24, 01/25/24, 01/26/24, 01/27/24, 01/28/24, 01/29/24, and 01/31/24. Resident #46 was not administered the Levalbuterol Tartrate Inhaler at all in the month of January. Review of the Medication Administration Record (MAR) dated February 2024 revealed Resident #46 had the following orders: Fluticasone Propionate Hydrofluoroalkane (HFA) Inhalation Aerosol 110 micrograms/actuation (mcg/act) with instructions to give one puff inhale orally every morning and at bedtime and rinse and spit after each use with a start date on 01/30/24. Resident #46 was administered Fluticasone Propionate HFA twice daily as ordered and was only administered the Levalbuterol Tartrate Inhaler one time on 02/08/24 and the medication was marked effective. Interview on 02/05/24 at 12:50 P.M. with Resident #46 revealed the resident was not receiving her inhaler in the morning and at night as ordered. Resident #46 stated she discussed her concerns with a nurse (was unsure which nurse) who indicated the inhaler could not be found. Interview on 02/07/24 at 10:10 A.M. with Resident #46 revealed she had been told by a nurse the inhaler should be delivered today, 02/07/24. Observations of the medication cart on 02/08/24 at 9:45 A.M. and 12:21 P.M. with Licensed Practical Nurse (LPN) #543 LPN #543 confirmed the only inhaler available to administer to Resident #46 was the Levalbuterol HFA inhaler. LPN #543 confirmed she had been administering the Levalbuterol HFA inhaler (which was ordered every four hours as needed for shortness of breath) to Resident #46 twice a day and had not been administering the Fluticasone Propionate HFA inhaler (which was ordered to be administered twice daily) to Resident #46 at all due to the inhaler was never received from the pharmacy after several attempts. LPN #543 confirmed the MAR indicated the Fluticasone Propionate HFA inhaler was the one being signed off as administered even though what was actually being given in place of it was the Levalbuterol HFA inhaler which was not being signed off as administered to Resident #46. Interviews on 02/08/24 at 9:45 A.M. and 12:21 P.M. with LPN #543 revealed she discussed Resident #46's medications with Medical Director (MD) #532 this morning and the Fluticasone Propionate HFA inhaler was discontinued effective 02/08/24. LPN #543 confirmed the nursing staff, including herself, marked the wrong inhaler (the Fluticasone Propionate HFA inhaler) as administered in error. LPN #543 stated she thinks she marked the wrong inhaler as being administered because Resident #46 also had an order for scheduled Fluticasone Propionate nasal spray and when she was in a hurry thought she was marking the nasal spray as administered, not the inhaler. LPN #543 could not explain why the Levalbuterol inhaler was not being marked as administered to Resident #46. Review of the Levalbuterol HFA inhaler medication insert revealed the inhaler should not be administered more frequently then the recommended dose which was two inhalations repeated every four to six hours. More frequent administration or a larger number of inhalations is not routinely recommended. Use exactly as your doctor tells you to. Do not change your dose without talking to your doctor first. Review of the facility policy, Medication Administration, revised 01/17/23, revealed the policy stated, medications are administered as ordered by the physician. Review MAR to identify medication to be administered. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time of administration. Administer medication as ordered in accordance with manufacturer specifications. Sign MAR after administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interviews, the facility failed to provide timely dental care and services for one resident (Resident #46). This affected one resident (Resident #46) of one reviewed for dental services. The facility census was 88. Findings Include: Review of the medical record for Resident #46 revealed an admission date on 11/18/23. Medical diagnoses included heart failure, acute and chronic respiratory failure, type two diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), asthma, morbid obesity, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #46 required assistance from staff which ranged from set up help to maximal assistance to complete Activities of Daily Living (ADLs). Resident #46 had missing or broken teeth. Review of the plan of care revised 12/01/23 revealed Resident #46 was at risk for dental problems related to having natural teeth, some in poor condition. Interventions included notify nurse/physician of any pain, open areas, white patches, and/or changes in nutritional status and refer to dental services as needed. Review of the HealthDrive Request for Services dated 01/02/24 revealed Resident #46 requested the HealthDrive Dental Provider examine her for sharp edges or fractured teeth or root tips. The consent was signed by Medical Director (MD) #532, Director of Nursing (DON) #533, and Resident #46. Review of progress notes for Resident #46 revealed on 01/05/24 at 3:43 P.M., the nurse notified Social Service Assistant (SSA) #551 the resident's front tooth fell out. SSA #551 emailed the dentist to let them know and set up a possible course of action. On 01/05/24 at 3:53 P.M., Resident #46 notified the nurse her front left tooth fell out. Upon assessment, the nurse noted front left lateral incisor tooth was missing with some tooth still noted in gum. No bleeding noted. No signs of infection noted. Gums were pink and not swollen. Resident #46 denied pain or discomfort. The physician was notified and no new orders were given. Review of Doctor's Orders for Tooth Concerns, dated 01/09/24, from Dentist #705 for Resident #46 revealed the resident's symptoms included front tooth fell out and two upper front teeth were broken. Please follow the orders below: for tooth pain, request physician prescribe a pain medication for five to seven days and request physician prescribe an antibiotic for seven to ten days. For broken/sharp teeth: apply ortho wax as needed over broken tooth to cover sharp edge until patient is seen by dentist. For gum symptoms (bleeding, swelling, extraction site pain, etc): peridex periodontal solution. Upon authorizing the Doctor Orders listed above: we recommend general observation of the patient's condition. Review of the progress notes dated 01/09/24 at 3:35 P.M., new orders received from Nurse Practitioner #700 for Keflex (an antibiotic) 500 milligrams (mg) twice daily for seven days for tooth and to continue as needed Tramadol order for 50 mg twice daily as needed. Resident #46 was notified. Review of the Medication Administration Record (MAR) dated January 2024 revealed Resident #46 received Cephalexin (an antibiotic) 500 milligrams (mg) every 12 hours for possible tooth infection for 14 administrations. The medication as administered as ordered from 01/09/24 to 01/16/24. On 01/09/24 at 5:01 P.M., a Pertinent Charting-Infections/signs symptoms note revealed Resident #46 was on a preventative antibiotic for broken tooth per the dentist's recommendation. On 01/10/24 at 7:38 A.M., the interdisciplinary team (IDT) met to review the new order for Keflex for possible tooth infection. Resident #46 did not have any redness or edema noted in gums surrounding tooth that fell out. Dentist was contacted by Social Services. Resident #46's pain was currently controlled with current plan of care. On 01/10/24 at 9:14 A.M., no signs or symptoms of an infection were noted for Resident #46. Prophylactic antibiotic for the resident's broken tooth was in place. No pain or discomfort was reported by Resident #46. On 01/12/24 at 5:15 P.M., Resident #46 continued on prophylactic antibiotic for broken front tooth as recommended by the dentist. No signs or symptoms of infection were noted and no complaints of pain or discomfort were reported by Resident #46. On 01/18/24 at 3:09 P.M., antibiotic was completed for Resident #46's front broken tooth. Review of Doctor's Orders for Tooth Concerns, dated 01/23/24, from Dentist #705 for Resident #46 revealed the resident's symptoms included front tooth fell out and two upper front teeth were broken. Please follow the orders below: for tooth pain, request physician prescribe a pain medication for five to seven days and request physician prescribe an antibiotic for seven to ten days. For broken/sharp teeth: apply ortho wax as needed over broken tooth to cover sharp edge until patient is seen by dentist. For gum symptoms (bleeding, swelling, extraction site pain, etc): peridex periodontal solution. Upon authorizing the Doctor Orders listed above: we recommend general observation of the patient's condition. The instructions also stated the office would request Resident #46 complete the Treatment Authorization form for services to be performed. Review of the Treatment Authorization form dated 01/23/24 from Dentist #705 revealed the recommended treatment for Resident #46's tooth concerns was to fill or extract any symptomatic teeth. Resident #46 signed the authorization form. Additional review of the progress notes for Resident #46 revealed there was no evidence of any additional follow up to schedule Resident #46 to be seen by a dentist until 02/01/24 at 12:27 P.M. (two weeks after Resident #46 completed antibiotic treatment for a broken tooth) when Resident #46 signed off agreement to be seen at the next dental visit. On 02/09/24 at 1:43 P.M. (after surveyor had already started questioning about the resident's dental services), Resident #46 notified Social Service Director (SSD) #518 she was experiencing tooth pain. SSD #518 followed up with dentist to request Resident #46 be seen. On 02/12/24 at 1:01 P.M., Resident #46 was seen by the dentist. Interview on 02/05/24 at 1:04 P.M. with Resident #46 revealed she had two broken front teeth and a piece of one of the teeth was still left in the resident's gum. Resident #46 reported it caused pain at times, but not constantly. Resident #46 stated she had requested to see a dentist but was not sure when she would be seen. Interview on 02/06/24 at 9:20 A.M. with the Director of Nursing (DON) #533 revealed a date had not been scheduled for the dentist to visit yet because Social Services Director (SSD) #518 was still gathering consents for treatment from residents and developing a comprehensive list of residents who needed to be seen. Interview on 02/12/24 at 9:56 A.M. with DON #533 confirmed Resident #46 had not been seen by a dentist yet. DON #533 confirmed a referral was sent for the resident to be seen on 01/09/24 (over one month ago) due to broken teeth. A facility policy related to dental care and services was requested at the time of the survey but a policy was not provided.

Based on observation, staff interview, and facility policy review, the facility failed to ensure dietary spreadsheets were followed and all food items on the spreadsheets were offered to the residents according to their needs on a level three dysphagia diet. This affected 14 residents, (Residents #6, #10, #14, #17, #31, #33, #48, #59, #61, #64, #66, #72, #85, and #89) the facility identified as having physician orders for a level three dysphagia diet, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an a level three dysphagia diet should receive ground ham steak with gravy, soft rice pilaf with gravy, chopped soft broccoli and cheese sauce, and pudding. Observation of tray line for the lunch meal on 02/07/24 at 11:55 A.M. with [NAME] #712 revealed the chopped broccoli for the residents on an ordered level three dysphagia diet was plain in water and did not have a cheese sauce. Continuous observation on 02/07/24 from 11:55 A.M. to 12:25 P.M. of lunch tray line service revealed the plain chopped broccoli was served to all residents without a cheese sauce. Interview on 02/07/24 at 12:25 P.M. with Dietary Manager (DM) #710 confirmed the chopped broccoli did not have a cheese sauce. DM #710 confirmed according to the dietary spreadsheet, the chopped broccoli should have had a cheese sauce. Review of the facility policy, Therapeutic Diets, dated 09/01/21, revealed the policy stated, diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care.

Based on observation, staff interview, review of the pureed ham recipe and facility policy, the facility failed to ensure pureed foods were prepared to the appropriate pureed consistency. This affected nine residents, (Residents #2, #22, #27, #29, #41, #49, #50, #76, and #297) the facility identified as having physician orders for pureed diets, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an ordered pureed textured diet should receive pureed ham steak, pureed rice pilaf, pureed broccoli with cheese sauce, pureed cookies, and a beverage. Review of the recipe, Pureed Ham Steak, revealed for preparation, combine chicken base and water to make chicken broth. Place prepared meat in a washed and sanitized food processor. Gradually add broth and blend until smooth. If the product needed thinning, gradually add an appropriate amount of liquid (not water) to achieve a smooth, pudding or soft mashed potato consistency. If the product needed thickening, gradually add a commercial or natural food thickener (potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. Observation of the pureed ham steak preparation on 02/07/24 at 10:30 A.M. with [NAME] #712 revealed the cook used tongs to place several ham steaks into the food processor, added a small amount of chicken broth and proceeded to process the ham. At 10:40 A.M. [NAME] #712 checked the contents of the food processor multiple times. At 10:45 A.M. Corporate Food Manager (CFM) #715 instructed [NAME] #712 to remove some of the pureed ham steaks from the food processor in order to obtain the desired consistency quicker. [NAME] #712 transferred some of the ham from the processor into a container and then continued to process the remaining ham still in the food processor. At 10:53 A.M. CFM #715 stated looks good to [NAME] #712 who then stopped the food processor and proceeded to transfer all of the pureed ham from the food processor into a metal container. The pureed ham appeared lumpy. At 10:55 A.M. [NAME] #712 confirmed she was ready to place the pureed ham on the steam table to be served to residents and had not sampled the texture of the pureed ham. The surveyor intervened due to seeing lumps in the ham and requested to taste the pureed ham. Upon looking into the container, several intact pieces of the ham skin were present in the pureed ham. The surveyor tasted a spoonful of the pureed ham and felt two intact pieces of the skin or rind on the tongue which required chewing to safely swallow it. [NAME] #712 verified the pureed ham was not a smooth, pudding or mashed potato like consistency. At 10:57 A.M. during the observation, interviews conducted with [NAME] #712 and Dietary Manager #710 confirmed the pureed ham was not a safe consistency for residents in need of a pureed diet. Review of the facility policy, Therapeutic Diets, dated 09/01/21, revealed the policy stated, diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care.

Based on observation, staff interview, and facility policy review, the facility failed to follow proper hand hygiene protocols during pureed food preparation. This had the potential to affect all nine residents, (Residents #2, #22, #27, #29, #41, #49, #50, #76, and #297) the facility identified as having physician orders for pureed diets, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an ordered pureed textured diet should receive pureed ham steak, pureed rice pilaf, pureed broccoli with cheese sauce, pureed cookies, and a beverage. Review of the recipe, Pureed Ham Steak, revealed for preparation, combine chicken base and water to make chicken broth. Place prepared meat in a washed and sanitized food processor. Gradually add broth and blend until smooth. If product needs thinning, gradually add an appropriate amount of liquid (not water) to achieve a smooth, pudding or soft mashed potato consistency. If the product needs thickening, gradually add a commercial or natural food thickener (potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. Observation of the pureed ham steak preparation on 02/07/24 at 10:30 A.M. with [NAME] #712 revealed the cook washed her hands at the sink and put on clean gloves. [NAME] #712 turned around to the steamer and grabbed two oven mitts from the top of the steamer and proceeded to put both of them on over her clean gloves. With the oven mitts on, [NAME] #712 retrieved a large covered pan from the steamer and placed it on the preparation counter. [NAME] #712 removed the oven mitts and placed them back on the top of the steamer. Without changing gloves or completing hand hygiene, [NAME] #712 used tongs to remove several ham steaks from the pan and placed them in the food processor. [NAME] #712 added a small amount of chicken broth and turned on the processor. [NAME] #712's glove on her left hand had a hole in the tip of the middle finger which exposed her finger outside of the glove. At 10:40 A.M., [NAME] #712 was observed touching the inside of the food processor lid and bowl with contaminated gloves on. After checking the ham three or four times, at 10:45 A.M., Corporate Food Manager (CFM) #715 instructed [NAME] #712 to remove some of the pureed ham steaks from the food processor in order to obtain the desired consistency quicker. [NAME] #712 grabbed a small metal container already lined with a plastic wrap with the contaminated gloves on. [NAME] #712 used her right gloved hand to press the inside of the plastic wrap down inside the container and then proceeded to transfer some of the ham from the processor into the container on top of the plastic wrap. [NAME] #712 continued processing the remaining ham in the processor. At 10:49 A.M., Dietary Manager (DM) #710 was observed handing [NAME] #712 a clean glove. [NAME] #712 removed her left glove (that had a hole in the middle finger) and donned the clean glove without washing her hands. At 10:50 A.M., [NAME] #712 was observed placing her contaminated gloved fingers inside the food processor and inside the plastic lining of the metal container which held some of the pureed ham mixture. At 10:53 A.M., CFM #715 stated, looks good to [NAME] #712. At that time, [NAME] #712 stopped the processor and proceeded to transfer all of the pureed ham into the metal container. The pureed ham appeared lumpy during the transfer. At 10:55 A.M., [NAME] #712 confirmed she was prepared to place the pureed ham on the steam table to be served to residents. [NAME] #712 removed both gloves and discarded them in a covered trashcan then washed her hands at the sink with soap and water. Interview on 02/07/24 at 10:57 A.M. with [NAME] #712 confirmed she did not change gloves or wash her hands after placing oven mitts over clean gloves and had touched the inside of the food processor lid, bowl, and the plasic wrap on the inside of the metal container with contaminated gloves on. [NAME] #712 also confirmed she did not complete hand hygiene after removing the compromised glove from her left hand and donning a clean glove. Review of the facility policy, Hand Washing, dated 09/01/21, revealed the policy stated, wash your hands as often as possible. It is important to wash your hands: before putting on gloves, after handling soiled utensils or equipment, as often as needed during food preparation and when changing tasks. Gloves, wet-wipes, or hand antiseptics are not substitutes for hand washing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, review of laboratory test results, review of McGreer's criteria for infections, and facility policy review, the facility failed to follow antibiotic stewardship policies and procedures prior to starting antibiotic treatment for two residents (Residents #43, and #84). The facility also failed to ensure laboratory test results were received prior to starting antibiotic treatment for one resident (Resident #11). The deficient practices affected three residents (Residents #11, #43, and #84) of seven residents reviewed for infections and antibiotic use. The facility census was 88. Findings Include: Review of the medical record for Resident #11 revealed an initial admission date on 06/08/21 and a readmission date on 10/23/23. Medical diagnoses included schizoaffective disorder, chronic obstructive pulmonary disorder (COPD), other irritable bowel syndrome, other disorders of urea cycle metabolism, delusional disorders, overactive bladder, urinary tract infection, and severe chronic kidney disease stage four. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had mildly impaired cognition and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #11 required variable assistance from staff to complete Activities of Daily Living ranging from set up help to maximal assistance. Review of progress notes for Resident #11 revealed she was sent to a local hospital on [DATE] to be evaluated for chest pain and have her medications reviewed. She was discharged back to the facility on [DATE] with a diagnosis of UTI and exacerbation of COPD. On 04/25/23 at 4:03 P.M. the progress notes indicated the hospital sent her back to the facility with an order for Cefdiner. There was no indication a urinalysis with culture and sensitivity (UA C&S) had been done for Resident #11 prior to beginning the course of antibiotic treatment with the Cefdiner which did not meet McGreer's criteria. On 04/29/23 at 11:01 A.M., Resident #11 was sent to another emergency room per her request. A complete UA C&S was completed and found the organism was not susceptible to Cefdinir. Review of the Medication Administration Record (MAR) dated April 2023 revealed Resident #11 had an order for Cefidinir (an antibiotic) 300 milligrams (mg) orally every 12 hours for a urinary tract infection (UTI) for 14 days with a start date on 04/25/23 at 9:00 A.M. and an end date on 05/01/23 at 1:20 P.M. Resident #11 was administered eight doses of the antibiotic from 04/25/23 to 04/28/23 then she went on a leave to the hospital beginning on 04/29/24. Review of the MAR dated May 2023 revealed Resident #11 returned to the facility on [DATE] and had an order for Cefidinir 300 mg orally two times a day related to UTI for seven days with a start date on 05/01/23 at 9:00 P.M. and an end date on 05/04/23 at 4:05 P.M. Resident #11 received six doses of the antibiotic from 05/01/23 to 05/04/23. Beginning on 05/04/23 at 9:00 P.M. a new order for Ciprofloxacin Hydrochloride (HCl) 500 mg orally two times a day for UTI for ten days began to be administered to Resident #11 with an end date of 05/14/23. Resident #11 received 20 doses of the Ciprofloxacin HCL from 05/04/23 to 05/14/23. Further review of the medical record revealed there was no evidence a UA C&S had been completed and resulted prior to Resident #11 being started Cefdinir antibiotic. Review of the laboratory test results for a urinalysis with culture and sensitivity (UA C&S) completed while Resident #11 was at the emergency room dated 05/04/23 revealed Resident #11 had a positive result for a urinary tract infection (UTI) and identified pseudomonas aeruginosa as the organism with a greater than 100,000 CFU/mL growth. Interview on 02/07/24 at 4:25 P.M. with the Director of Nursing (DON) #533 confirmed Resident #11 received doses of the Cefdinir antibiotic prior to obtaining any UA C&S lab results or verifying the resident had exhibited signs or symptoms of infection. DON #533 confirmed once UA C&S lab results were received, Resident #11 required antibiotic treatment with a different antibiotic that the organism was susceptible to. Review of the facility policy, Antibiotic Stewardship Program, revised 12/13/23, revealed the policy stated, antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. 2. Review of the medical record for Resident #43 revealed an admission date on 10/27/23. Medical diagnoses included Alzheimer's Disease, Type II Diabetes Mellitus with diabetic chronic kidney disease, chronic kidney disease stage 3, and unspecified psychosis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had impaired cognition and scored a seven out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #43 required varied assistance from staff to complete Activities of Daily Living (ADLs) which ranged from set up help only to substantial/maximal assistance. Resident #43 was frequently incontinent of bowel and bladder. Review of progress notes for Resident #43 revealed on 01/23/24 at 8:49 P.M., the resident continued with increased behaviors. The Nurse Practitioner visited and ordered a urinalysis with culture and sensitivity (UA C&S). On 01/24/24 at 12:54 A.M., an order for a UA C&S one time only for increased confusion and behaviors was administered. Review of the urinalysis with culture and sensitivity (UA C&S) laboratory test results reported to the facility on [DATE] revealed Resident #43 was positive for a urinary tract infection (UTI). The organism identified was Escherichia coli (e-coli) bacteria with a greater than 100,000 CFU/mL. Review of the Medication Administration Record (MAR) dated February 2024 revealed Resident #43 had an order for Cephalexin 500 milligrams (mg) orally three times a day for infection for five days with a start date on 02/01/24 at 6:00 A.M. Resident #43 received 14 doses of the antibiotic. Review of McGreer's Criteria for a UTI without a catheter revealed Resident #43's symptom of increased confusion was not a valid symptom to use in determining a UTI. Interview on 02/07/24 at 4:32 P.M. with the Director of Nursing (DON) #533 confirmed Resident #43 did not meet the McGreer's criteria for an infection and was treated with antibiotics. DON #533 stated the facility had not been using the McGreer's criteria to determine if a resident met the appropriate criteria for an infection and use of antibiotics and had been treating residents with antibiotics only based on a positive UA C&S result. Interview on 02/08/24 at 3:47 P.M. with Physician #703 revealed some of those UTI's (for Resident #43) probably are not really true UTI's. She has had positive urine cultures. Review of the facility policy, Antibiotic Stewardship Program, revised 12/13/23, revealed the policy stated, antibiotic use protocols: the facility uses the McGreer criteria to define infections. 3. Review of the medical record for Resident #84 revealed an admission date of 08/04/23 and diagnoses of diabetes, chronic kidney disease, and urinary retention. Review of nursing progress notes revealed on 09/12/23 at 1:14 A.M. it was documented that a urine specimen was collected for urinalysis and culture and sensitivity. There was nothing documented to indicate why the urine specimen was collected and no symptoms of a urinary tract infection documented. Review of a laboratory report revealed a urine specimen was collected on 09/12/23 and results on 09/15/23 showed >100,000 Proteus Mirabilis and Escherichia Coli. The nurse practitioner was notified on 09/15/23 at 6:09 P.M. and an order was received for an antibiotic (Bactrim DS 800-160 milligrams) twice daily for seven days for a urinary tract infection. Review of the medication administration record revealed the Bactrim was administered from 09/16/23 to 09/22/23 for a total of 13 doses. Review of the facility infection record (McGeer criteria) revealed a resident must meet criteria 1 and 2 for it to be considered a urinary tract infection. (Criteria 1 includes symptoms and Criteria 2 is a urine culture with >100,000 bacteria). The infection record indicated an onset date of 09/11/23 but did not include any symptoms of a urinary tract infection under Criteria 1. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. confirmed there were no symptoms of a urinary tract infection documented for Resident #84 on 09/12/23 when a urine specimen was collected. She confirmed the resident was treated with an antibiotic without meeting the facility guidelines/McGeer criteria for a urinary tract infection. Review of nursing progress notes on 10/31/23 at 1:27 P.M. revealed Resident #84 had a suspected urinary tract infection as the resident was complaining of frequency with episodes of confusion. The note stated a urine sample was to be collected and sent out in the morning and an antibiotic (Cipro 500 milligrams) was ordered twice daily for seven days. The note stated once the final results were received, will have to ensure appropriate antibiotic in place. Review of the medication administration record revealed the resident received Cipro 500 milligrams twice daily from 11/01/23 to 11/05/23 (10 doses). Review of urine culture results reported on 11/05/23 revealed >100,000 Escherichia Coli that was not sensitive to Cipro. Review of nursing progress notes on 11/06/23 at 6:28 A.M. revealed final urine culture sent to physician. New order to discontinue Cipro and start a different antibiotic (Nitrofurantoin) 100 milligrams twice daily for seven days. Review of the medication administration record revealed Nitrofurantoin was administered from 11/06/23 to 11/12/23 for a total of 14 doses. Review of the facility infection record (McGeers criteria) revealed an onset date of 10/30/23 and did not document that any criteria had been met to indicate a urinary tract infection. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. confirmed an antibiotic was started prior to a urinary tract infection being confirmed. She confirmed that the antibiotic the resident received (Cipro) 10 doses of was not an antibiotic that the bacteria was sensitive to so the antibiotic had to be changed. She further confirmed the McGeers form did not indicate criteria was met for a urinary tract infection. Review of nursing progress notes on 11/13/23 at 11:10 A.M. revealed the resident received the last dose of antibiotic and states she feels a little better but not all the way. Continues at times to be slightly confused. Updated nurse practitioner who said ok to get another urine culture if needed in morning. On 11/14/23 at 11:37 P.M. a urine specimen was collected. Review of urine culture results reported on 11/18/23 revealed >100,000 Proteus Mirabilis. The bacteria was not sensitive to any oral antibiotics (only intravenous or intramuscular medications). The resident was started on an antibiotic (Amoxicillin-potassium clavulanate 875-125 milligrams) twice daily for seven days on 11/20/23. This antibiotic was not listed on the urine culture for the bacteria being sensitive to it. Review of the medication administration record revealed the resident received the Amoxicillin-potassium clavulanate from 11/20/23 to 11/27/23 for a total of 14 doses. There was nothing documented to indicate why the antibiotic was not started for two days after the urine culture results were reported. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. confirmed the resident was still confused so another urine culture was obtained on 11/14/23. She confirmed the bacteria was not listed as sensitive to the antibiotic that was used. She stated she did not know why the antibiotic was not started after the results were reported on 11/18/23. She confirmed the antibiotic did not start until 11/20/23 and could have started 11/19/23 in the morning. Review of a text message from the physician on 02/07/24 at 3:21 P.M. revealed regarding antibiotic selection (on 11/20/23) he chose it as the best oral alternative being the most like the IV ampicillin. This was a clinical decision made to try to avoid having to subject the resident to the greater risk of IV and infusion when this oral alternative is likely to be effective. Review of urine culture results on 01/18/24 revealed >100,000 Proteus Mirabilis. Review of nursing progress notes did not indicate why the urine specimen was collected. There were no symptoms of a urinary tract infection documented. The physician was notified on 01/18/24 at 4:22 P.M. and an antibiotic (Augmentin 875 milligrams) was ordered twice daily for seven days. Review of the medication administration record revealed the antibiotic was given from 01/19/24 to 01/25/24 for a total of 14 doses. Review of physician progress notes from September 2023 to January 2024 revealed they were silent to any treatment of urinary tract infections. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. revealed the antibiotic was ordered 01/18/24 due to increased confusion/hallucinations. She confirmed Resident #84 did not meet the McGeer criteria for any of the urinary infections she was treated for. Review of the facility policy titled Antibiotic Stewardship Program dated 10/24/22 and revised 12/13/23 revealed the purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Licensed nurses were to follow protocols as established by the program. Antibiotic use protocols include the use of the McGeer criteria to define infections.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a self reporting incident (SRI), review of the facility's related investigation, staff interview, and policy review, the facility failed to ensure a resident was free from verbal/ emotional abuse. This affected one (Resident #46) of one residents reviewed for abuse. Findings include: A review of SRI #240024 with a date of discover of 10/10/23 revealed an allegation of emotional/ verbal abuse was made known to the facility. The initial source of the allegation was from Resident #46, who was identified as the resident/ victim. The alleged perpetrator was a staff member and was identified as Licensed Practical Nurse (LPN) #22. Witnesses to the alleged emotional/ verbal abuse included the facility's Director of Nursing (DON), LPN #45, and Activity Director #39. A brief description of the allegation revealed Resident #46 came to the nurses' station and requested cough medicine from the oncoming nurse (LPN #22). LPN #22 informed the resident she would be with her in a few and redirected the resident back to her room. The resident didn't want to leave, but kept insisting on the medication to be given immediately. The nurse continued to try to get the resident to understand she would give the medication shortly, but she needed to look up the resident's medications as she was not familiar with them. LPN #22 walked over to another nurse and stated that Resident #46 was acting like a B****. Resident #46 overheard that comment and it led to a shouting episode in the hallway. The incident occurred on 10/10/23 at 8:00 A.M. on the South Short unit. Resident #46 was upset by the incident, but calmed down as the day progressed. A review of the facility's investigation revealed it included an incident report that was completed by the facility's DON. The incident report indicated the DON entered the facility to observe Resident #46 and LPN #22 in a verbal altercation regarding cough syrup. The DON approached the resident and asked what they were yelling about. The resident reported that LPN #22 called her a B****. LPN #22 was sent home, after giving a statement, pending the investigation. A witness statement from Resident #46 for the incident occurring on 10/10/23 at 8:00 A.M. revealed she followed the nurse (LPN #22) up the hallway because she wanted cough syrup. The nurse was just finishing her medication pass and was walking up to the desk. LPN #45 and LPN #22 were at the nurses' station and she asked them to help her get her cough syrup. She told the nurses she was not waiting anymore. LPN #22 said Don't bother me, I don't have time for you. The resident then asked if the other nurse could help her. LPN #45 said she was sorry, but she was not her nurse and that LPN #22 was. LPN #22 then said she was too busy and for her to go back to her room. When LPN #22 asked the resident to go to her room, the resident replied that she would not because she wanted cough medicine and would wait at the cart. LPN #22 then told the resident not to stare at her and that the resident was harassing her. She then allegedly said What the F***, stop being rude to me. The resident told the nurse again that she was not leaving. Resident #46 then heard LPN #22 tell LPN #45 that she (the resident) was being a B****. The resident was asked how that made her feel overhearing the nurse calling her a B**** or being told she was harassing the the nurse. The resident reported she was angry at the time, but had prayed and now felt fine. She denied being angry or sad. She denied feeling fearful of staff when she was interviewed by the DON for her witness statement. A witness statement from LPN #22 for the incident occurring on 10/10/23 at 8:00 A.M. revealed the nurse came on duty at 7:00 A.M. and at 7:30 A.M. Resident #46 came to the medication cart during report. LPN #22 told the resident that she would assist her when they were done with report. The nurse asked the resident to wait in her room because the resident was standing directly over them when she was trying to take report. When the report was finished, the nurse was stocking her medication cart and checking the narcotic supplies. Resident #46 returned and was standing over the nurse. The resident told her that she wanted her pills. The nurse asked her to give her some time, as she did not know her medications, and needed to look them up. The resident then stomped her foot and said she was not moving until the nurse gave her her stuff. The nurse replied that she asked her nicely to please go to her room while she got the resident her stuff. The nurse then indicated in her statement she was carrying a bag of trash to take it to the soiled utility room and walked by LPN #45. LPN #22 thought she was out of earshot of the resident as she was by the soiled utility room at that time. The nurse indicated she said to LPN #45 (under her breath) she's being a B****. When the nurse came out of the soiled utility room, the resident was following the other nurse down the back hallway. At that time the resident was screaming at her (LPN #22) and she was yelling back at the resident. At that time the DON came around the corner and intervened. A witness statement by LPN #45 for the incident occurring on 10/10/23 at 8:00 A.M. revealed she was starting her morning routine and overheard yelling on the South side. Resident #46 was asking for cough medicine and the other nurse (LPN #22) repeated Give me a few minutes, I have this whole side for the love of God! The nurse (LPN #45) told the other nurse (LPN #22) to give her the keys. She would hold them and start the medication pass for the South Short unit. LPN #22 replied no I told you I got this side, she can wait, she needs to stop being a F****** B****, it's a bit much. The resident then asked LPN #22 what did you call me, a F****** B****? The resident told LPN #45 not to let her talk to her like that. At that time, the DON was on the unit. The resident went to her room and LPN #22 went to the medication room. LPN #45 was then asked to take over the South Short unit as LPN #22 was sent home for the day. The witness statement by the DON for the incident occurring on 10/10/23 at 8:00 A.M. revealed she heard Resident #46 and LPN #22 yelling at each other. She could not determine what they were yelling about at the time, but was told LPN #22 called Resident #46 a F****** B****. She approached the nurse as she was gathering her things and reported she was leaving. The DON told LPN #22 that she needed to come to her office. The nurse was crying and was telling her that it was all too much. The DON obtained a statement from LPN #22 before walking her to the time clock before the nurse exited the building through the side door. As a result of the facility's investigation into the allegation of emotional/ verbal abuse that occurred on 10/10/23 at 8:00 A.M. between Resident #46 and LPN #22, the facility substantiated the abuse allegation. LPN #22 was terminated from her employment with the facility as a result of that incident. On 10/23/23 at 11:05 A.M., an interview with the DON confirmed LPN #22 was terminated as a result of the incident that occurred between Resident #46 and LPN #22. The facility substantiated the allegation of abuse based on their investigation. She confirmed Resident #46 did overhear LPN call her a derogatory name and it was upsetting to the resident to hear that, which is why they felt it met the definition of abuse. A review of the facility's abuse policy (revised 10/24/22) revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Abuse was defined as a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which could include staff to resident abuse. Verbal abuse was defined as the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. As a result of the incident, the facility took the following actions to correct the deficient practice by 10/16/23: • Immediately following the incident on 10/10/23, skin and pain assessments were completed on Resident #46 and the resident was seen by psychiatric services that same day. • Psychosocial assessments were completed on Resident #46 on 10/11/23 and 10/12/23 to ensure no negative effects occurred related to the abuse. • LPN #22 was immediately suspended pending the outcome of the investigation. Her employment with the facility was terminated on 10/11/23, as a result of the outcome of the investigation. • On 10/10/23, all alert and oriented residents were interviewed to ensure no abuse had occurred involving those residents. Non-alert and oriented residents had skin sweeps conducted to ensure no evidence of abuse existed for those residents. • On 10/10/23 and by 10/11/23, all facility staff were educated on the facility's abuse policy and procedure with reporting. Education was also provided on how to deal with difficult behaviors. Ongoing training to be provided through Relias on how to deal with residents with difficult behaviors. A post test to be completed to ensure staff competency on the facility's abuse policy and dealing with difficult residents related to behaviors. • Audits to be completed with five residents weekly x 4, then monthly x 1 to ensure residents were free from abuse and felt safe in the facility. Skin sweeps were to be completed on five non-alert and oriented residents weekly x 4, then monthly x 1 to ensure those residents were free of abuse. Five employees weekly x 4, then monthly x 1 would be interviewed to ensure they could identify signs and symptoms of abuse and how to respond appropriately to residents with difficult behaviors. • Results of audits to be reviewed in Ad Hoc QAPI meetings to ensure the plan was appropriate and effective x 2 months. This deficiency is cited as an incidental finding to Complaint Number OH00146747.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a self reporting incident (SRI), review of the facility's related investigation, staff interview, and policy review, the facility failed to ensure residents were free from misappropriation when residents' controlled narcotic pain medication was not misappropriated. This affected 18 residents (#10, #17, #22, #26, #29, #42, #47, #53, #67, #89, #90, #91, #92, #93, #94, #95, #96, and #97) identified by the facility during their investigation into an allegation of misappropriation as having had their controlled narcotic pain medications misappropriated. Findings include: A review of SRI #240119 revealed an allegation of misappropriation was made known to the facility on [DATE]. The initial source of the allegation was a facility nurse and the alleged perpetrator was identified as Licensed Practical Nurse (LPN) #100. The initial resident/ victim was identified as Resident #53. As a result of the facility's investigation, 17 other residents (Resident #10, #17, #22, #26, #29, #42, #47, #67, #89, #90, #91, #92, #93, #94, #95, #96, and #97) were identified and included as resident/ victims. A brief description of the allegation revealed LPN #107 noted Resident #53 was out of her Oxycodone. LPN #107 called the facility's contracted pharmacy for a refill and was told Resident #53 had a quantity of 60 Oxycodone tablets delivered to the facility on [DATE] and should have had enough to last her through 10/14/23. LPN #107 notified the facility's Director of Nursing (DON) and the facility staff began searching for the drug cards and the narcotic count sheet that should have been sent with the controlled narcotic pain medication. It was discovered the drug cards for Resident #53's Oxycodone and it's narcotic count sheet were missing. An investigation began for the misappropriation of the resident's medication. The last nurse in question was identified as the day shift nurse from 10/11/23 (LPN #100). The facility's DON contacted her by phone and LPN #100 confirmed she called the pharmacy to get a refill for Resident #53's Oxycodone. She claimed she placed the empty drug card and the completed narcotic count sheet in the unit manager's box. Those were not found. LPN #100 was suspended pending further investigation. The local law enforcement was notified and a report was opened. A review of the facility's investigation into the allegation of misappropriation was reviewed with the DON. Each of the 18 residents that were identified as being a resident/ victim involved in the misappropriation was reviewed. 1 a.) Resident #89 had the use of Norco (narcotic pain medication) 5/325 milligrams (mg) tablets. The DON reported her investigation determined 30 tablets were suspected as having been misappropriated by LPN #100. The nurse was noted to have documented on the shift to shift sheet that the card containing the Norco tablets and the narcotic count sheet for that controlled medication had been removed from the medication cart and the narcotic count book by LPN #100 on 10/09/23. 1 b.) Resident #10 had the use of Percocet (narcotic pain medication) 5-325 mg tablets. Up to 30 tablets were suspected as having been misappropriated by LPN #100 as a result of the facility's investigation. The DON determined the facility received 30 tablets of Percocet for the resident on 09/26/23. The medication administration record (MAR) did not reflect any doses had been received by the resident. LPN #100 documented on the shift change controlled substance accountability sheet that the resident's card of Percocet and it's narcotic count sheet had been removed on 09/28/23. 1 c.) Resident #90 had the use of Norco 5/325 mg tablets. The DON determined through her investigation that the facility received 30 tablets of Norco from their pharmacy on 07/13/23. The resident's MAR showed five tablets had been given to the resident. 25 tablets of the Norco was believed to have been misappropriated. The card containing the Norco and the narcotic count sheet had been removed by LPN #100 on 07/20/23, after the resident's discharge on [DATE]. The DON stated the resident's discharge was unexpected as his brother just showed up to take him home. The DON denied that the resident would have been given any of the Norco to take home with him, since his discharge was not planned. 1 d.) Resident #17 had the use of Oxycodone (narcotic pain medication) 5 mg tablets. The DON reported the facility received a card of 26 Oxycodone on 09/26/23 from the pharmacy. The card containing the Oxycodone was documented as having been removed from the medication cart along with the narcotic sheet by LPN #100 on 09/28/23, as was indicated on the controlled substance accountability sheet. The DON stated the resident would have had another card of Oxycodone available for use and did not go without any pain medication. 1 e.) Resident #22 had the use of Percocet 5/325 mg tablets. The DON reported the facility had received 30 tablets from their pharmacy for the resident's use on 10/05/23. The facility's investigation determined that medication was not added to the the controlled substance accountability sheet when it was received and the card that contained the controlled narcotic pain medication was not placed in the medication cart. The narcotic count sheet that was to track the use of that controlled medication was not placed in the narcotic control book by LPN #100. The DON reported the nurse was the one that was working when that medication was received. She stated that resident had a previous card that the nurses were pulling from and the resident continued to receive the pain medication when she needed it for pain. 1 f.) Resident #26 had the use of Norco 5/325 mg tablets. A count of 84 Norco's were received by the facility from the pharmacy on 10/06/23. The DON was able to determine the resident had used 10 of those tablets. LPN #100 documented on the controlled substance accountability sheet that she removed three cards containing the Norco from the medication cart and removed one narcotic sheet from their narcotic count book on 10/10/23. The DON stated one card could hold up to 30 tablets and they would have had only one sheet that was supposed to be used to document the 84 doses administered. She could not account for 74 of the 84 tablets and suspected LPN #100 had misappropriated them when the controlled medication was removed from the medication cart. She denied the other nurses would have questioned that nurse removing the card and the narcotic count sheet, as that medication was discontinued it was likely assumed LPN #100 gave the discontinued medication to the DON for destruction as was their policy. 1 g.) Resident #91 had the use of Norco 5/325 mg tablets. The DON reported the facility received 30 tablets from their pharmacy on 08/18/23. The card containing Norco and the narcotic sheet had been removed from their medication cart and the controlled narcotic count book by LPN #100 on 10/06/23. She was able to determine by reviewing the resident's MAR that three doses of the Norco had been used from that 30 tablet supply. She could not account for the 27 tablets of Norco that were missing. She reported the resident was discharged to an assisted living facility, so any remaining balance of the Norco would not have been sent to the assisted living facility with the resident. 1 h.) Resident #29 had the use of Percocet 5-325 mg tablets. A refill was requested from their contracted pharmacy by LPN #100 on 10/09/23. It was determined by the DON that the pharmacy had delivered 12 tablets on that same day. LPN #100 was suspected as having kept the card of Percocet and the narcotic sheet when it was delivered failing to add it to the controlled substance accountability sheet or in the narcotic count book as it should have been. She reported the resident had previous supply of that medication on hand and the medication was available for use if needed. 1 i.) Resident #92 had the use of Percocet 5-325 mg tablets. The DON reported a supply of that medication had been provided by their pharmacy on 09/26/23 to include 30 tablets. The resident used 17 tablets while in the facility per her MAR and was sent home on [DATE] with 12 tablets, as was indicated in her progress notes. She could not account for one of the doses that should have been remaining. She stated it was possible the resident was given the full remaining 13 count, but she could not rule out that LPN #100 took that medication as it was not documented as having been sent with the resident. 1 j.) Resident #93 had the use of Norco 5/325 mg tablets. The DON reported the facility received 30 tablets from their pharmacy on 06/23/23. The resident was discharged home on [DATE]. LPN #100 documented she pulled the card of Norco from the cart and removed the narcotic sheet for that medication from the narcotic count book on 07/20/23. The DON was able to show 19 of the 30 tablets had been signed out for the resident's use, but she could not account for the remaining 11 tablets not accounted for. She suspected LPN #100 had misappropriated those 11 remaining Norco tablets, as they were not turned in to her, after the resident's discharge from the facility, as they should have been. 1 k.) Resident #42 had the use of Tramadol 50 mg tablets. A supply of 30 had been sent from their pharmacy on 05/13/23 according to the DON and her investigation. The resident's MAR showed he received one tablet from that supply. The card containing the medication and the narcotic sheet was removed by LPN #100 on 07/27/23. She determined that 29 tablets could not be accounted for and it was thought the nurse that removed the medication and narcotic sheet misappropriated them. 1 l.) Resident #94 had the use of Norco 5/ 325 mg tablets. The DON reported the pharmacy had delivered 60 tablets of Norco on 07/17/23. The order for Norco was discontinued on 07/31/23. LPN #100 documented on the controlled substance accountability sheet that she removed the card containing the Norco and narcotic count sheet on 08/03/23. The DON was able to show the resident received 24 of those 60 tablets, as was indicated on the MAR's, but 36 tablets could not be accounted for. 1 m.) Resident #47 had the use of Percocet 5/325 mg tablets. The DON stated they received a 30 count from the pharmacy on 07/11/23. She was able to determine that the resident used 16 doses from that 30 count according to doses signed out on the MAR. LPN #100 documented on the controlled substance accountability sheet that she removed the card containing the Percocet and the narcotic sheet on 07/20/23. The DON could not account for the 14 tablets that should have been remaining when the LPN removed them from the cart/ count. She further stated the resident was transferred to the hospital on [DATE] and his return was anticipated. She stated the nurse should have left the Percocet in the cart for him to have upon his return. Resident #47 also had the use of Oxycodone 5 mg tablets. The DON reported the facility received 30 Oxycodone tablets from their pharmacy on 07/31/23. She was able to account for 12 of those 30 tablets being given to the resident based on what was documented on the MAR. LPN #100 documented she removed the card containing the Oxycodone and the narcotic count sheet from their medication cart and count on 08/25/23, as was documented on the controlled substance accountability sheet. She could not account for 18 of the 30 tablets. A further review of the facility's investigation revealed Resident #47 also had a 30 count of Oxycodone 5 mg tablets (30 count) delivered by their pharmacy on 08/25/23. She was able to determine by reviewing the MAR that six of those tablets had been signed out as having been given to the resident. LPN #100 removed the card containing the remaining Oxycodone 5 mg tablets and the narcotic count sheet on 09/14/23, as was documented on the controlled substance accountability sheet. 24 of those 30 tablets could not be accounted for. LPN #100 had also ordered Oxycodone for the resident from their pharmacy on 09/13/23. The nurse signed for receipt of the medication when it was delivered that same day. 30 tablets were reported to have been sent by the pharmacy. The DON indicated the nurse must have taken that card containing the Oxycodone and the narcotic count sheet as it could not be found after it was delivered. 1 n.) Resident #95 had the use of Oxycodone 5 mg tablets. The DON reported the pharmacy delivered 20 tablets on 10/07/23. The order for Oxycodone was given on 10/05/23 before being discontinued on 10/07/23. She reviewed the MAR's and determined the resident was not documented as having received any doses of that medication. LPN #100 documented on the controlled substance accountability sheet that she removed the card and the sheet from their count on 10/09/23. The DON was not able to account for any of the 20 tablets of Oxycodone that was missing. 1 o.) Resident #53 had the use of Oxycodone 10 mg tablets. The DON reported the the facility received a 60 count of Oxycodone from the pharmacy on 10/05/23. The DON was able to account for 35 of the 60 tablets, as that was what was signed out on the MAR. LPN #100 removed the card containing the Oxycodone and the narcotic count sheet on 10/11/23, as was documented on the controlled substance accountability sheet. The DON could not account for the 25 tablets that should have been remaining when the card was removed from the cart on 10/11/23. 1 p.) Resident #96 had the use of Norco 5/325 mg tablets. The DON stated they received 24 tablets from the pharmacy on 09/17/23. The Norco card was not placed in the medication cart and the medication was not added to their shift to shift controlled substance accountability sheet. She reported LPN #100 was the nurse that was working that day and would have been the one to receive the Norco from the pharmacy. She suspected all 24 tablets of the Norco had been diverted by LPN #100 upon their arrival to the facility. The resident also had the use of Percocet 5/ 325 mg tablets. The DON reported they received 30 tablets of Percocet from the pharmacy on 08/21/23. She denied the resident was noted to use any when she looked at the MAR. LPN #100 removed the card and the narcotic sheet on 09/04/23, as was documented on the controlled substance accountability sheet. All 30 tablets of the Percocet was thought to have been misappropriated. The DON indicated her investigation determined another six tablets of Norco had been received by the facility on 07/14/23 for Resident #96. The order was discontinued on 07/17/23 and it was not noted that the resident received any of the 6 doses according to the MAR. LPN #100 had documented on the controlled substance accountability sheet that she removed the card containing the six Norco tablets and the narcotic count sheet from the cart/ count on 07/20/23. All six tablets were thought to have been misappropriated. 1 q.) Resident #97 had the use of Norco 5/325 mg tablets. The DON reported they received 82 tablets of Norco from their pharmacy on 06/11/23. Her investigation showed the resident received 15 of those tablets. LPN #100 documented that she had removed the card containing the Norco and the narcotic count sheet from the medication cart and their count on 06/26/23. She indicated three cards and one sheet had been removed, which the three cards should have still contained 67 tablets of Norco at the time it was removed. 1 r.) Resident #67 had the use of Norco 5/325 mg tablets. The DON reported the facility received 30 tablets from their pharmacy on 10/07/23. She was able to show by reviewing the MAR that six tablets was documented as having been given to the resident since 10/07/23. LPN #100 documented she removed one card and one narcotic sheet from their cart/ count on 10/09/23, as was documented on the controlled substance accountability sheet. The DON could not account for 24 of the 30 Norco tablets and it was suspected that the remaining 24 had been misappropriated by LPN #100. In all, out of the 18 residents that had medications misappropriated, there were 324 tablets of Norco, 117 tablets of Percocet, 143 tablets of Oxycodone, and 29 tablets of Tramadol that the facility could not account for. LPN #100 was directly involved with the ordering, receipt and/ or removal of those controlled medications. As a result of the facility's investigation they substantiated the allegation of misappropriation of residents' medications. LPN #100's employment with the facility had been terminated and she was reported to the local law enforcement agency and the Ohio Board of Nursing. On 10/23/23 at 1:45 P.M., an interview with the DON revealed she did substantiate the allegation of misappropriation of resident medication based on the findings of her investigation. She confirmed 18 residents medications were found to have been misappropriated by LPN #100. The misappropriation had occurred between June 2023 and October 2023 before it was reported on 10/12/23. They were alerted to the possibility of the medication misappropriation when LPN #107 had attempted to get a controlled narcotic pain medication refilled for Resident #53. The pharmacy reported the controlled narcotic pain medication had recently been filled, which the medication and the narcotic count sheet could not be found. They identified the nurse (LPN #100) who was working that day when the controlled narcotic medication had been received. That prompted an investigation that identified 17 other residents to have had their narcotic pain medication misappropriated by LPN #100. She stated the nurse would pull the cards containing to controlled medications from the cart and would remove the count sheet from their controlled medication count book when a resident was discharged or the controlled medications were discontinued. The nurse would also call in for a refill and keep the controlled medication and the count sheets when she received them from the pharmacy. She reported the residents cards/ sheets for controlled medications that were empty and had been used up were to go to the unit managers. If the cards had controlled medication remaining in them, such as at the time of the resident's discharge or when the controlled medication had been discontinued, the cards containing the controlled medication and the narcotic count sheet were supposed to be given to her. If she was not there, they were to remain in their controlled medication storage box and continued to be reconciled every shift until they could be given to her. Her investigation determined concerns with how the facility was keeping track of the controlled medications, as the staff nurses were not completing the shift to shift count correctly. She gave them examples on how the shift to shift count sheet should be completed and how they should look. The count sheets were not being completed neatly and were sloppy. That made it hard to track the controlled medications with how the count sheets/ shift to shift accountability sheets were being filled out. The DON also stated during her investigation, she found pharmacy receipts and narcotic count sheets disposed of in the facility's shredder box for controlled medications LPN #100 received from the pharmacy or pulled from the cart/ count. A review of the facility's policy on policy on Abuse, Neglect, and Exploitation (revised 10/24/22) revealed it was the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings without the resident's consent. A review of the facility's policy on Controlled Substance Administration and Accountability (revised 01/01/22) revealed it was the policy of the facility to promote a safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility would have safeguards in place in order to prevent loss, diversion, or accidental exposure. Controlled medications must be counted upon delivery. The nurse receiving the delivery, along with the person delivering the medication order, must count the controlled substances together. Both individuals must sign the designated narcotic record. If the count was correct on delivery, the medication would be placed in the controlled substance binder for the designated medication cart. Each time a controlled substance and control count sheet was received, it should be added to the shift verification sheet column for the number of control count sheets present. Nursing staff must count controlled drugs at the end of each shift. They must document and report any discrepancies to the DON immediately. When a resident with a controlled substance was discharged from the facility, or the controlled substance was discontinued, the remaining controlled substance and control count sheet would be delivered to the DON as soon as possible. As a result of the incident, the facility took the following actions to correct the deficient practice by 10/16/23: • An investigation into the allegation was initiated by the facility's DON on 10/12/23. A total of 18 residents were identified as having had controlled narcotic pain medication misappropriated by LPN #100 through the facility's investigation. LPN #100 was suspended immediately pending the outcome of the investigation. Her employment with the facility was terminated as a result of the investigation, with local law enforcement and the Ohio Board of Nursing notified of the misappropriation/ diversion of controlled medication. • A whole house audit was completed with a 30 day look back by the DON showing that narcotics have been delivered and added to the narcotic drawer/ count sheet appropriately. A whole house audit was completed of medication carts for the storage of narcotic medications to ensure the counts were correct and the shift to shift sheets were filled out appropriately. The DON completed a review of all narcotics LPN #100 had removed from the cart to ensure they were removed appropriately and either given to the resident at discharge or placed on the destruction log for the DON to destroy. Pain assessments were completed on all residents by the DON/ Designee on 10/12/23 and 10/13/23. Alert and oriented residents were interviewed by 10/13/23 to ensure they were receiving their pain medications as ordered. • All nurses were educated by the DON by 10/15/23 on Controlled Substance Policy to include appropriate narcotic count, ensuring MAR's and narcotic logs would be signed off with all narcotic medication administration and ensure they were counting the narcotics appropriately. All nurses were also educated by the DON/ Designee on the removal of narcotics in a timely manner and to be given to the DON to be added to the destruction log or if given to the residents at discharge must be witnessed by two nurses. When narcotic cards had been emptied, the narcotic card, count sheet, and copy of the shift to shift count would be put in the unit manager's mail box. Unit managers were to compare delivery manifest with the narcotic log daily. When narcotics were discontinued, the floor nurse would alert the DON and the narcotics would be removed from the medication cart at that time during regular business hours for destruction. During off hours, the nurse receiving the order for the narcotics being discontinued, would notify the DON/ on call nurse that the narcotic would need removed from the cart for destruction next business day. Narcotics received would be verified by two nurses at the time of arrival. • DON/ Designee would complete audits on five residents weekly x 4 weeks to ensure MAR's matched the narcotic logs. Any variances would be addressed immediately. The DON/ designee would audit the delivery of narcotics weekly x 4 to ensure narcotics were delivered and added to the medication cart appropriately. The DON/ Designee would audit three nurses weekly x 4 weeks to ensure counting of narcotics were conducted appropriately to include the shift to shift sheet being filled out correctly. The DON/ Designee would audit weekly x 4 the narcotic shift to shift count sheets to ensure any removal of narcotics was removed timely and documented appropriately. • Results of audits to be reviewed in the Ad Hoc QAPI meetings weekly x 4 to ensure the facility's plan was effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, family interview, staff interview, and policy review, the facility failed to ensure residents that were dependent on staff for personal care received the assistance needed to complete oral hygiene care. This affected three residents (#1, #12, and #81) of four residents reviewed for activities of daily living (ADL's). Findings include: 1. A review of Resident #81's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, Parkinson's disease, adult inset diabetes mellitus, and major depressive disorder. A review of Resident #81's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate difficulty with hearing, without the use of a hearing aide, and his speech was clear. He was sometimes able to make himself understood and was sometimes able to understand others. His cognition was severely impaired, but was not known to reject care. He required an extensive assist of two for transfers and personal hygiene. A review of Resident #81's care plans revealed he had a care plan in place for an ADL self-care performance deficit related to Alzheimer's Disease, cognitive impairment, generalized weakness, and Parkinson's disease. The care plan was initiated on 07/27/23 and revised on 07/29/23. His goal was for his ADL needs to be met through the next review. The interventions included a one person assist for personal hygiene. His care plans did not indicate he was known to be non-compliant with oral care. A review of Resident #81's task tab under the electronic health record (EHR) revealed the staff were documenting under an oral care task when that care was being provided. A review of the oral care task report for the past 30 days (07/27/23 thru 08/21/23) revealed the resident was documented as having received oral care once or twice a day on a daily basis since his admission. The times the oral care was documented as having been completed was on the day shift (6a-2p) and the afternoon shift (2p-10p). On 08/21/23 at 10:40 A.M., an interview with Resident #81's family member revealed he had never seen the resident have a toothbrush in his room that was being used to provide him with oral care. He denied his father was capable of communicating much in the way of his needs. He had his own natural teeth and would need the assistance from the staff to provide him with oral care. Up until about a week ago, the resident did not look like he was getting his teeth brushed. He felt the resident's teeth looked a little better now, but he was not sure what toothbrush they were using to provide the resident with oral care. He again stated he had never seen a toothbrush in the resident's room to be used for oral care. On 08/21/23 at 10:50 A.M., an observation of Resident #81 noted him to be in the dining room where he remained after previously participating in an activity. His teeth were noted to be a little discolored and he had a film like coating over them. No halitosis was noted, but the resident did not talk much when spoken to, so it was difficult to assess if halitosis was present. On 08/21/23 at 11:39 A.M., Registered Nurse (RN) #11 was asked to accompany the surveyor to Resident #81's room to check and see what oral care supplies the resident had on hand. She checked a drawer in the nightstand by his bed and located a tube of toothpaste, a toothbrush that was still in the box it was packaged in, and a toothbrush holder that was empty. She verified that was a new toothbrush that had not been used and the tube of toothpaste did not appear to have anything out of it, as it did not appear to have been squeezed. On 08/21/23 at 11:56 A.M., an interview with State Tested Nurse Aide (STNA) #23 revealed Resident #81 required total assist for his personal care, to include oral care. She indicated he allowed oral care at times, but had been non-compliant that morning, despite the task tab documentation for oral care showing that it had been done. She reported the resident would get antsy with care and had his own teeth that they tried to brush the best they could. She denied he had a toothbrush over the weekend and reported she had thrown his previous toothbrush away last Thursday (08/17/23), due to it having bite marks on it. She indicated someone must have brought a toothbrush in since then. She confirmed the toothbrush he had in his room was unused and was still in the box it came in. She also confirmed the tube of toothpaste he had showed no signs of it being previously used. They (aides) were expected to inform the nurses when a resident refused care, such as not allowing oral care to be provided, and it would be documented. She would re-approach a resident if they refused care to see if they would allow it at a later time when the resident was given the opportunity to calm down. She was asked to come get the surveyor, after the resident ate his lunch, to demonstrate his cooperativeness with oral care, when attempted. On 08/21/23 at 2:10 P.M., a follow up observation of Resident #81 noted him to be lying in his bed with his eyes closed. His oral care supplies were checked and the toothbrush had been removed from the box and was now being stored in his toothbrush holder. The toothbrush holder was opened and the toothbrush was noted to be wet and had debris in it. It smelled of mint when the toothbrush holder was opened. The resident's teeth were not visible as he was resting and had mouth closed. On 08/21/23 at 2:36 P.M., an interview with STNA #36 revealed Resident #81 required total assist of one for his personal care. He reported the resident was typically up for his evening meal and they would lie him down in bed soon after. The resident's son was usually there for the evening meal on most days. He indicated personal care would be provided to the resident when they laid him down as needed. He stated if his face and hands were soiled following the evening meal they would wash it off and change his clothes. He believed the resident had his own teeth. Oral care for the resident would be done by the night shift. He denied the afternoon shift provided oral care to the residents, as was being documented under the task tab for oral care. He indicated they had 22 residents on that hall that required a check and change every two hours. They did not have time on the evening shift to do oral care when putting residents in bed. On 08/22/23 at 9:10 A.M., a follow up interview with STNA #23 revealed she was able to get the SR to brush his teeth yesterday afternoon, after he finished his lunch and was taken back to his room. She did not come and get the surveyor, as was requested. She stated she brushed his teeth that morning too, before they took him out for breakfast. She denied he gave her any trouble when brushing his teeth either time. A review of the facility's policy on ADL's revealed a resident, who was unable to carry out activities of daily living, would receive the necessary services to maintain good grooming, personal and oral hygiene. The policy was last reviewed on 01/01/22. 2. A review of Resident #1's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting his right dominant side, contracture of the right hand, abnormalities of gait and mobility, muscle weakness, lack of coordination, and malaise. A review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not noted to reject any care during the seven day assessment period. He was dependent on two for transfers and required an extensive assist of two for personal hygiene (combing hair, brushing teeth, shaving). A review of Resident #1's care plans revealed he had a care plan in place for an ADL self-care performance deficit related to a CVA (stroke) with right sided deficit. The care plan was initiated on 07/28/23. The goal was for the resident's ADL needs to be met. The interventions included providing one person assist for personal hygiene and to encourage participation in daily care and provide positive reinforcement for activities attempted and/ or partially achieved. He also had a care plan for being at risk for dental problems related to needing assistance with oral care. That care plan was initiated on 08/10/23. The goal was for the resident to accept mouth care at least daily. The interventions included encouraging the resident to complete oral hygiene at least daily, provide assistance as needed, and review with the resident the risks of refusing oral care versus the benefits of performing oral care. A review of Resident #1's task tab under the EHR revealed the staff were documenting oral care being provided per the plan of care. The tasks tab for oral care in the past 30 days (07/24/23 thru 08/22/23) revealed the staff documented providing oral care for the resident once or twice a day on a daily basis. The report showed oral care was not provided on one of the two shifts three times that 30 day period and the resident was documented as having refused oral care three times during that same 30 day period. On 08/22/23 at 9:19 A.M., an interview with Resident #1 revealed yesterday (08/21/23) was the first time since he had been there that the staff brought in a bucket with toothpaste, toothbrush, and mouthwash for him to use to perform oral care. He asked them why they were bringing that to him and was told it was because the State was there in the building. He felt he was capable of performing his own oral care, but would be dependent on the staff to set him up with the proper supplies to do so. He denied the staff had ever provided him with set up help to do his own oral care, nor have they asked him if he wanted to do it. 3. A review of Resident #12's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following a CVA affecting her left dominant side, abnormalities of gait and mobility, fatigue, muscle weakness, lack of coordination, and need for assistance with personal care. A review of Resident #12's quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was totally dependent on staff and required the assist of two for transfers and required an extensive assist of two for personal hygiene. A review of Resident #12's active care plans revealed she needed ADL assistance related to a stroke with left side deficits. The care plan was initiated on 01/06/23. The goal was for the resident to maintain her abilities in ADL care. The interventions included providing an extensive assist of one to two staff members for personal hygiene and oral care. The care plan indicated the resident had upper dentures and natural teeth on the bottom. She also had a care plan for being at risk for oral/ dental health problems related to requiring assistance with oral care. That care plan was initiated on 01/06/23. The goal was for the resident to comply with mouth care at least daily. The interventions included providing mouth care as per her ADL personal hygiene care plan. The care plans did not show she had been known to refuse oral care. A review of Resident #12's task tab in the EHR revealed the staff were documenting oral care as having been provided to the resident one to two times daily in the past 30 days (07/24/23- 08/21/23). She was indicated to have refused only once on 07/29/23. On 08/22/23 at 12:20 P.M., an observation of Resident #12 noted her to have some discoloration/ stains on her teeth in her front lower jaw. There was some plaque build-up along the gum line of those front lower teeth. On 08/22/23 at 12:20 P.M., an interview with Resident #12, at the time of the observation, revealed she did not receive the assistance she required with oral care. Her daughter would typically brush her teeth when she visited her in the evenings, but she denied the staff would brush them or even offer. She indicated she had full use of her right arm and felt she may be able to brush them herself, if the staff would help set her oral care supplies up for her. She denied the staff offered to do that as part of the personal care she received in the mornings or at night when going to bed. She would like that to be offered to her twice a day, but hated to ask anyone to do anything for her. She became tearful at that time. This deficiency represents non-compliance investigated under Master Complaint Number OH00145425.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on a closed record review, review of a facility incident report related to a medication error, review of an employee file, and policy review, the facility failed to ensure a resident was free from a significant medication error. This affected one resident (#84) of three residents reviewed for medication administration. Findings include: A review of Resident #84's closed medical record revealed he was admitted to the facility on [DATE] for short respite stay that was to only be over the weekend. He remained in the facility through 07/31/23, when he was transferred to the emergency room directly from his day program set up through the Ohio Department of Developmental Disabilities. He did not return to the facility as he was re-admitted to the hospital on [DATE]. His diagnoses included cerebral palsy, quadriplegia, seizure disorder, neuromuscular scoliosis of the thoracic region, neurogenic bladder, presence of a supra-pubic catheter, and a urinary tract infection (UTI). A review of Resident #84's hospital continuity of care/ after visit summary from the hospital revealed he was to start taking Colace (a stool softener) 100 milligrams (mg) by mouth (po) twice a day, Dulcolax (a laxative) 10 mg suppository one rectally daily, Lactulose (a laxative) 30 milliliters (ml) three times a day as needed (prn) for constipation, and a Fleets enema rectally every day prn for constipation. The continuity of care/ after care visit summary revealed he was to continue to take the following medications: Albuterol 2.5 mg/ 3 ml (0.083%) inhalation solution per nebulizer every six hours prn for wheezing or shortness of breath, Cranberry tablets 400 mg po twice daily, Cymbalta (an anti-depressant) 60 mg po every day, Pepcid (an antacid) 20 mg po twice daily, Allegra (antihistamine)180 mg po every day, Ibuprofen (an anti-inflammatory) 600 mg po every six hours prn for mild pain, Lamictal (an anti-convulsant) 200 mg po twice a day for spastic quadriplegic cerebral palsy, Seroquel (an ant-psychotic) XR 150 mg po every night at at bedtime, Senna (a laxative) 8.6 mg po twice a day, and Zanaflex (a muscle relaxant) 4 mg po three times a day. A review of Resident #84's physician's orders for the date range of 07/27/23 through 07/31/23 revealed ancillary orders were added on 07/28/23. All the medications ordered for the resident upon his admission to the facility as included in the hospital's continuity of care/ after visit summary were not added to his physician's orders until 07/30/23. A review of Resident #84's medication administration record (MAR) for July 2023 revealed he did not receive any medication ordered for him upon his admission until 07/30/23. No medications had been administered to him on 07/28/23 or 07/29/23. The first documented administration of his medications started the morning of 07/30/23. He was not given his Lamictal that was ordered for his seizure disorder until the evening of 07/30/23 and did not receive a dose of Tizanidine (Zanaflex) ordered for his Cerebral Palsy and related diagnoses until the evening of 07/30/23. His MAR's did show the resident had been given a dose of Ibuprofen 600 mg that was ordered every six hours on a prn basis for pain on 07/30/23 at 9:42 A.M. A second dose of the prn Ibuprofen was administered on 07/31/23 at 8:10 A.M. The dose administered on 07/30/23 at 9:42 A.M. was indicated to be effective. The dose given on 07/31/23 at 8:10 A.M. was indicated to be unknown as he was out of the facility at the time a follow up on his pain was required. A review of Resident #84's progress notes revealed a nurse's note dated 07/31/23 at 10:18 A.M. that indicated the facility's Director of Nursing (DON) spoke with the resident's sister regarding the resident's medication error. The resident was indicated to have been sent to the emergency room (ER) from day program due to signs and symptoms of pain. He was admitted to the hospital for a UTI. The resident had been previously hospitalized for a UTI, prior to his admission to the facility. A review of an incident report dated 07/31/23 for a medication error occurring to Resident #84 revealed medication orders were not initiated upon Resident #84's admission to the facility on [DATE]. The person preparing the report was the facility's DON. The error was noticed on 07/31/23 in the morning. Two doses of medications were omitted. The resident was unable to give a description of the incident. Immediate action taken by the facility included entering the medications into the medication administration record (MAR). The physician was notified of the error and no changes were made to the resident's orders. The resident was indicated to be without adverse effects from the error and no change in behavior or seizure activity was noted. A review of Licensed Practical Nurse (LPN) #67's employee file revealed a performance improvement form was completed on 07/31/23. The reason for counseling/ corrective action was the resident (Resident #84) was admitted to the facility on [DATE] in the early afternoon. Medication orders were not entered into the facility's computer software program (PointClickCare/PCC) resulting in medications being omitted x 48 hours. The expected level of performance was for orders to be entered into PCC upon a resident's admission to ensure timely delivery from the pharmacy. The corrective action taken was a written warning. LPN #67 signed the performance improvement form on 07/31/23. On 08/22/23 at 11:07 A.M., an interview with the DON confirmed Resident #84's medications were not ordered upon his admission to the facility on [DATE]. She stated she was doing a random audit at home on Sunday (07/30/23), when she noticed he did not have any medications ordered. She called into the facility and spoke with the nurse that admitted him. It was determined that the nurse had entered the ancillary orders into the computer on 07/28/23, but she forgot to enter his medications, after the resident arrived. They typically entered the ancillary orders ahead of the resident's arrival, but often did not have access to their medication list until the resident's arrival (when the continuity of care form was sent with them). The resident's medications were not entered into the computer until 07/30/23, in which he started to receive his ordered medication on 07/30/23 when they were either pulled from the contingency supply box or after being delivered by the pharmacy. She indicated they completed immediate correction interventions for past non-compliance, since they self identified and addressed the issue. She did a whole house audit for those that had recently been admitted to ensure all residents had medications ordered upon their admission. They disciplined the nurse involved with a written warning (who no longer worked at the facility), educated all nursing staff, and continued to conduct weekly audits of the past weeks admissions to ensure continued compliance. They were reviewing their findings in the weekly Ad hoc QAPI meetings. She denied the resident showed any signs of being in pain or any other discomforts when he left for his day program on 07/31/23. She recalled the resident was smiling, laughing, and waving when he left the facility and was acting his normal self. She stated he was re-admitted to the hospital with a UTI, which he had prior to his admission to the facility on [DATE]. A review of the facility's policy on Medication Reconciliation revised 01/01/22 revealed the facility reconciled medications upon admission and as needed. The definition of medication reconciliation indicated it referred to the process of verifying that the resident's current medication list matched the physician's orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay. Medication reconciliation involved collaboration with the resident/ representative and multiple disciplines, including admission liaisons, licensed nurses, physician's, and pharmacy staff. The pre-admission process was to include obtaining a current medication list from the referral source and to obtain current medication/ admission orders. The admission process was to include verifying the resident information was received, compare the orders to hospital records, follow procedures on the medication reconciliation form, and order medications from the pharmacy in accordance with the facility's procedure for ordering medications. The deficiency was corrected on 07/31/23, after the facility implemented the following corrective actions: • On 07/30/23, Resident #84's medication orders were entered into the computer, when it was discovered by the DON, that he did not have any medications ordered upon his admission to the facility. Resident #84's medications were delivered by the facility's contracted pharmacy later that same day. Resident #84 began receiving his scheduled medications the morning of 07/30/23, after the medication errors were noted, and all were resumed the afternoon of 07/30/23. Resident #84 did not show any adverse effects of not receiving his ordered medication until 07/30/23 at 9:42 A.M., when he was given Ibuprofen as ordered prn for mild pain. • On 07/31/23, LPN #67 received a written warning for failing to enter Resident #84's medications into the computer upon his admission to the facility. She was informed it was expected that all orders would be entered into PCC upon a resident's admission to ensure the timely deliver of the medication from the pharmacy. LPN #67 no longer worked at the facility for an unrelated reason. • On 07/31/23, the facility's DON completed a whole house audit of recent admissions to identify any other residents that could have been affected by the deficient practice. No other issues were noted. • On 07/31/23, the facility's DON provided education to the facility's nurses either in person or via phone regarding the need to enter medications into PCC and ordered from the pharmacy, upon a resident's admission. If they noticed that a resident was not on their MAR, they were to investigate the matter and report accordingly. Failure to initiate/ verify orders upon a resident's admission was a delay of treatment and a medication error that could possibly lead to harm. admission orders must be checked by two nurses on duty upon a resident's admission; 18 nurses received that education. • Ongoing weekly audits were initiated on 08/07/23 and continued to be completed with no issues noted of medications not being ordered for residents upon their admission. Findings of those audits were being reviewed in the facility's weekly Ad hoc QAPI meetings. This deficiency represents non-compliance investigated under Complaint Number OH00145193.

Based on observation, interview, record review and facility policy review, the facility failed to ensure a medication error rate of less than 5%. There were a total of 29 opportunities for error and a total of two errors resulting in a medication error rate of 6.8%. This affected one resident (#50) of three residents observed for medication administration. The facility census was 83. Findings included: Review of Resident #50's medical record revealed an admission date of 07/14/23 with diagnoses including anemia, unspecified, type two diabetes mellitus without complications, peripheral vascular disease and essential hypertension. Review of Resident #50's admission Minimum Data Set (MDS) 3.0 assessment revealed it was not completed due to the recent admission. Review of Resident #50's Skilled Daily - Medically Complex form, dated 07/15/23, revealed the resident was oriented to person, place, date, and time and was a diabetic. Review of Resident #50's physician order, dated 07/15/23, identified he was to receive ferrous sulfate (iron) extended release oral tablet 140 milligrams (mg) by mouth one time a day related to anemia and Insulin Glargine Solostar subcutaneous solution pen-injector 100 units/ml, 30 units subcutaneously in the morning related to type two diabetes mellitus without complications. Observation on 07/17/23 at 8:15 A.M. of Licensed Practical Nurse (LPN) #101 administering medications to Resident #50 revealed Resident #50 was provided one iron tablet 325 mg with his other oral medications. Additional observation revealed LPN #101 dialed Resident #50's Glargine Solostar insulin pen and placed a new needle tip on the pen. She did not prime the pen with two units. Interview following administration of the Resident #50's medications, LPN #101 verified she did not prime the Glargine Solostar insulin pen with two units of insulin resulting in Resident #50 only getting 28 units of insulin and not 30 units. Interview on 07/17/23 at 9:36 A.M. with LPN #101 verified Resident #50 did not receive his Ferrous Sulfate (iron) medication as ordered. She verified she administered 325 mg of ferrous sulfate, and he should have received ferrous sulfate extended release 140 mg. Review of facility policy titled, Medication Administration, dated revised 01/01/22, revealed the licensed nurse or other staff who are legally authorized to administer medications was to review the Medication Administration Record (MAR) to identify medication to be administered. The staff are to compare medication source with the MAR to verify resident name, medication name, form, dose, route, and time of administration. Further review revealed, administer medication as ordered in accordance with manufacturer specifications. This deficiency represents non-compliance investigated under Complaint Number OH00144291.

Based on observation, interview, and facility policy review, the facility failed to ensure insulin pens were dated when opened. This affected nine residents ( #6, #23, #25, #26, #30, #43, #44, #45, and #67) of 83 residents residing in the facility. The facility census was 83. Findings included: Observation on 07/17/23 at 8:30 A.M. of the North Short medication cart revealed the following open insulin pens which had been used and were not dated: Resident #6 an Insulin Glargine Solostar with 120 units remaining out of 260 units, Resident #30 a Lantus Solostar with 180 units remaining out of 260 units Resident #43 an Insulin Glargine Solostar with 140 units remaining out of 260 units and an Insulin Aspart Flex pen with 135 units remaining out of 250 units, Resident #67 an Insulin Glargine Solostar with 245 units remaining out of 260 units. An interview at the time with Licensed Practical Nurse (LPN) #101 verified all insulin pens should be dated when opened. Observation on 07/17/23 at 9:15 A.M. of the South Short medication cart revealed the following open insulin pens which had been used and were not dated: Resident #23 a Tresiba FlexTouch with 230 units remaining out of 250 units, Resident #25 a Lantus Solostar with 180 units remaining out of 260 units, Resident #26 an Insulin Lispro with 200 units remaining out of 220 units and a Lantus Solostar with 120 units remaining out of 260 units, and Resident #45 a Levemir FlexTouch with 140 units remaining out of 250 units. Also observed in the South Short medication cart was a bag labeled for Resident #44 dated 05/19/23 with a Levemir FlexTouch with 190 units remaining out of 250 units. An interview at the time with LPN #103 verified all insulin should be dated when they are opened. She also reported, insulin should be discarded after being open for 28 to 30 days depending on the manufacturer and that Resident #44's insulin pen was definitely over the 30 days. LPN #101 verified that without an open date documented on the pen, a nurse wouldn't know when to dispose of it when it reached to 28 or 30 day time frame. Review of the facility policy titled, Medication Storage, revised 01/01/22, revealed it is the policy of the facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. This deficiency represents an incidental finding investigated under Complaint Number OH00144291.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of self reporting incidents (SRI's), review of the facility's related investigation, record review, staff interview, and policy review, the facility failed to ensure residents were free from being being physically abused or physically abusing other residents. This affected four residents (#24, #29, #44 and #53) from five SRI's reviewed. Findings include: 1. A review of SRI #226839 revealed an allegation of physical abuse was made on 09/15/22. The source of the allegation was from facility staff. The alleged perpetrator was Resident #44 and the alleged victim was Resident #53. The date, time, and location of the occurrence was on 09/15/22 at 8:15 P.M. in the North Long hallway. A narrative summary of the incident revealed Resident #44 was agitated in the hallway and accused Resident #53 of taking his wallet. Resident #53 had not taken Resident #44's wallet and was unaware of the allegation. Resident #44 then hit Resident #53 in the back while Resident #53 was standing in the doorway to his room with his back to Resident #44. Resident #44 was indicated to have a diagnosis of dementia and his cognition was moderately impaired. Resident #53 had Alzheimer's disease, schizophrenia, and schizo-affective disorder. Resident #53 did not sustain any injuries related to the incident and was not known to have any negative effects as a result of the incident. Resident #44 was sent to the emergency room due to the staff not being able to deescalate his behaviors. The facility's investigation included incident reports completed on behalf of Resident #44's and Resident #53's parts they had in the incident. Resident #44's incident report indicated he was a known wanderer as indicated under the predisposing situation factors. He was also indicated to have sundowning behaviors. Witnesses were identified in the incident report and the only staff member who was indicated to have observed the incident was Licensed Practical Nurse (LPN) #57. Her statement was included on the incident report. LPN #57 revealed she was passing medications on the hall when she heard Resident #44 yell where's my wallet ? She looked up and saw Resident #44 punch Resident #53 in the back. She attempted to remove Resident #44 from the area, but he continued to swing, yell, and attempt to bite the nurse. The incident report for Resident #53 revealed the same nurse's description that was provided on Resident #44's incident report. Resident #53 did provide a description of what happened to him. He indicated he was standing in the doorway with his back to the hall. Resident #44 came up behind him and yelled where's my wallet and punched him in the back. The conclusion of the facility's investigation into SRI #226839 revealed they unsubstantiated the allegation of physical abuse. They indicated the evidence indicated abuse did not occur. The facility further indicated the alleged abuse was unsubstantiated due to Resident #44 not having the intent to harm. A review of Resident #44's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia with mood disturbance and restlessness and agitation. A review of Resident #44's active care plans revealed he had a care plan in place for impaired cognitive function/ dementia or impaired thought process. Interventions included supervising the resident as needed. His care plans also included one for socially inappropriate behaviors for going in and out of others' rooms and looking for personal items. That care plan was initiated on 02/15/22. The interventions included providing activities that he enjoyed and psychiatric evaluations as appropriate. It did not include the intervention to provide supervision or redirect the resident when wandering into other residents' rooms. His care plans also indicated that he could be physically aggressive or agitated related to his dementia. He was known to hit others. The interventions included, when the resident became agitated, intervene before agitation escalated, and guide away from source of distress. On 12/06/22 at 11:21 A.M., an interview with the facility's Administrator and DON confirmed the file provided for SRI #226839 was the facility's complete investigation of the alleged incident of physical abuse between Resident #44 and #53. The DON reported the witness statements obtained were documented as given on the incident reports. The Administrator confirmed the nurse on duty, at the time of the incident, contacted her by phone while she was at home to inform her of the incident. She stated she initiated the SRI at that time. She recalled the nurse informing her that Resident #44 was not having a good night and had hit Resident #53. Resident #44 was known to have dementia and was known to have behaviors but those behaviors were usually able to be deescalated. They reported it was the first time he was known to have an incident with another resident where he got physical with them. They confirmed the incident was witnessed by LPN #57 and she did observe Resident #44 punch Resident #53 in the back. The Administrator was asked why the facility unsubstantiated the allegation of physical abuse when they had a staff member witness Resident #44 punching Resident #53. She stated they unsubstantiated it as there was no intent to harm Resident #53. When they discussed it with their legal department, they were told it had to have intent to harm for abuse to have occurred. She was asked to review the facility's abuse policy and read the definition of willful. She read the definition from the abuse policy and indicated the individual must have acted deliberately, not that the individual must have intended inflict injury or harm. A review of the facility's Abuse, Neglect, and Exploitation policy revised 10/24/22 revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse included but was not limited to hitting, slapping, punching, biting and kicking. Under prevention of abuse, neglect and exploitation, identifying, correcting, and intervening in situations in which abuse was more likely to occur with the deployment of trained and qualified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned had knowledge of the individual residents' care needs and behavioral symptoms. 2. A review of SRI #222730 revealed an allegation of physical abuse was made on 06/12/22. A staff member was listed as the initial source of the allegation. The involved residents included Resident #24 and Resident #29. A brief description of the allegation revealed Resident #29 slapped Resident #24 when Resident #24 entered her room. Resident #29 claimed Resident #24 was messing with her belongings. No injuries occurred as a result of the incident. Resident #29 was indicated to have been able to provide meaningful information about the alleged incident, but Resident #24 was not. Resident #24 had vascular dementia with behavioral disturbances and restlessness and agitation. A narrative summary of the incident indicated Resident #29 was in her room when Resident #24 entered. Resident #24 began messing with Resident #29's belongings on her table. Resident #29 then grabbed Resident #24's wrist and proceeded to slap Resident #24 across the face. Resident #29 previously had put her call light on and State Tested Nurse Aide (STNA) #88 entered the room and witnessed Resident #29 yell at Resident #24 telling her to stop bothering her belongings before grabbing her wrist and slapping her across the face. STNA #88 informed Resident #29 she could not put her hands on another resident and Resident #29 replied if she was in her room and was touching her belongings she could lay her hands on her. Resident #29 was indicated to be cognitively intact and Resident #24's cognition was severely impaired. As a result of the facility's investigation into SRI #222730, the facility unsubstantiated the allegation of physical abuse as they indicated the evidence did not indicate abuse occurred. The facility further indicated the incident was unsubstantiated based on Resident #29 not having an intent to physically hurt Resident #24, but only wanted her to stop touching her belongings. This deficiency represents non-compliance investigated under Complaint Number OH00136452.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and policy review, the facility failed to ensure a resident, who was dependent on staff for personal care, received the assistance needed for bathing activities of her choice as scheduled. This affected one (#61) of one resident reviewed for bathing. Findings include: A review of Resident #61's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a frontal lobe and executive function deficit following a stroke, apraxia (difficulty with skilled movements) following a stroke, adult onset diabetes mellitus, end stage renal disease, dependence on renal dialysis, muscle weakness, lack of coordination, abnormalities of gait and mobility, and congestive heart failure. A review of Resident #61's Preferences for Customary Routine and Activities assessment dated [DATE] revealed the resident indicated it was very important to her to choose the type of bathing activity she received. She indicated she would like to receive showers every Tuesday and Thursday on the day shift. A review of Resident #61's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to display any behaviors nor was she known to reject care. She required an extensive assist of one for dressing and personal hygiene. She was totally dependent on one for bathing. A review of Resident #61's active care plans revealed she had a care plan in place for needing assistance with activities of daily living (ADL's) related to her diagnosis of a CVA (stroke). She required an extensive assist of one for bathing and personal hygiene. A review of Resident #61's bathing activities documented as having been provided since her admission on [DATE] revealed there was no documented evidence of the resident being provided a shower or any other type of bathing activity on 11/10/22 (one of her scheduled shower days). Bed baths were documented as having been provided on her scheduled shower days on 10/27/22, 11/03/22, and 11/19/22, when it was known her bathing activity of choice was a shower. On 12/01/22 at 2:53 P.M., an interview with Resident #61 confirmed it was her preference to be showered as her bathing activity on her scheduled shower days. She denied she had requested a bed bath when they were documented as having been provided on 11/03/22 and 11/19/22. She recalled the staff were in a hurry those days and just gave her a bed bath instead. She preferred a shower on those days but was told they had a lot of other residents on the list and did not have time to shower her. She denied any refusals of a shower on 11/10/22, when there was no documentation to support she was given one or at least offered. On 12/01/22 at 3:30 P.M., an interview with the Director of Nursing (DON) confirmed Resident #61's Preferences for Customary Routine and Activities assessment dated [DATE] revealed it was her preference to be showered every Thursday and Saturday on the day shift. She confirmed they had not documented evidence of a shower being given on 11/10/22 or evidence it had been offered and refused. She was asked why the resident was given bed baths on the days indicated above when it was her preference to receive showers. She was not able to explain why bed baths were done on 10/27/22, 11/03/22, or 11/19/22 instead of showers as preferred. A review of the facility's policy on Bathing a Resident revised 12/21/21 revealed it was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent any skin issues. They were to assist the resident to the shower room and assist in the bathing activity as needed. This deficiency represents non-compliance investigated under Master Complaint Number OH00137495.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure a resident received treatments as ordered for the management of edema and cellulitis of the bilateral lower extremities (BLE). This affected one (#61) of one residents reviewed for edema. Findings include: A review of Resident #61's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, end stage renal disease, dependence on hemodialysis, cellulitis of her bilateral lower extremities and edema. A review of Resident #61's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to display any behaviors nor was she known to reject care. She required an extensive assist of one for bed mobility and transfers. She required a limited assist of one for ambulation in her room. An extensive assist of one was needed for dressing and personal hygiene. A review of Resident #61's active care plans revealed she had a care plan in place for having a history cellulitis to her BLE's. Interventions included educating the resident that prevention of cellulitis started with good hygiene. Any breaks in the skin should be reported to staff/physician immediately. They were to monitor/document and report to physician the following symptoms of cellulitis: red, swollen, tender skin, may be accompanied by a fever, reddened area that began to spread, small red spots that appeared on the reddened skin, small blisters which may form and burst, and swollen lymph glands. A review of Resident #61's physician's orders revealed she had an order in place to have Ace wraps applied to her bilateral legs every morning after the application of Atrac- [NAME] (a moisturizing cream that contained Urea and Alpha-hydroxy acid which exfoliated and softened severely dry, cracked, calloused skin) lotion topically to her bilateral legs. The order originated on 10/19/22 and ended on 1028/22. A new order was given on 10/28/22 to perform gentle leg scrubs with Dial soap or a mild soap to remove scales. The treatment was to be performed daily and the order continued until 11/24/22. Her most recent treatment ordered for her BLE's was to cleanse them with normal saline, pat dry, and apply Unna boots (a medicated gauze wrap) wrapping them from the foot to each leg one inch below the knee. The Unna boot was to be covered with Coban (an elastic wrap) on day shift every Tuesdays, Thursdays, and Saturdays. A review of Resident #61's treatment administration record (TAR's) for October and November 2022 revealed the treatment to apply Ace Wraps to the BLE's, after the application of Atrac- [NAME] lotion, was not complete on 10/24/22. The nurse was to initial the box on the TAR to reflect the treatment had been completed. The November 2022 TAR revealed the treatment for gentle leg scrubs with Dial or a mild soap to remove scales was not documented as having been completed on 11/01/22. Again, the nurse failed to initial the box on the TAR to reflect the treatment had been completed. A review of Resident #61's nurses' progress notes revealed there was no documentation to support the above treatments were completed as ordered. There was also no indication of the resident refusing the treatments on those two days. On 12/01/22 at 2:53 P.M., an interview with Resident #61 revealed she did have problems with her legs swelling and was having issues with cellulitis. She did not feel she was getting the proper care for her edema/ cellulitis as her treatments did not always get done and the staff were not good about encouraging her to keep her feet up. She reported she was supposed to get her legs wrapped three times a week and was lucky if they were done twice a week. They scheduled the wrapping of her legs on Tuesdays, Thursdays and Saturdays so they could be done on her shower days. The nurse that was wrapping her legs was the only one that was good about reminding her to keep them elevated. On 12/05/22 at 10:20 A.M., an interview with the Director of Nursing (DON) revealed the floor nurses were the one's who completed Resident #61's treatments to her BLE's. She stated they did have a wound nurse practitioner that visited every Tuesday but she was not sure if she was doing the resident's treatments on Tuesdays. She was asked why they did not have documented evidence of the resident's treatments being completed to her BLE's on 10/24/22 or 11/01/22. She stated she would look to see if she could find any evidence of the treatments being completed or refused by the resident. No additional documentation was received. The DON confirmed, without documentation on the TAR, they did not have evidence the treatments were completed as ordered. This deficiency represents non-compliance investigated under Master Complaint Number OH00137495.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's meal times, resident interview, and staff interview, the facility failed to ensure a resident receiving phosphate bindings medications for end stage renal disease dependent on hemodialysis received those medications before meals as ordered. This affected one (#61) of one residents reviewed for dialysis. Findings include: A review of Resident #61's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease (ESRD) and dependence on hemodialysis. A review of Resident #61's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors nor was she known to reject care. A review of Resident #61's care plans revealed she had a care plan in place for having chronic renal failure related to end stage disease. The interventions included giving medications as ordered by the physician. A review of Resident #61's physician's orders revealed the resident had an order to receive Sevelamer Carbonate (a phosphate binder that prevented the body from absorbing the phosphorus from the food you eat) 800 milligrams (mg) by mouth three times a day. The original order was given on 10/17/22. The order was modified on 10/18/22 to reflect the Sevelamer Carbonate was to be given three times a day before meals. That order continued until 10/27/22. A review of Resident #61's medication administration record (MAR) for October 2022 revealed the Sevelamer Carbonate 800 mg tablets were scheduled to be given three times a day at 7:00 A.M., 11:00 A.M. and 4:00 P.M. A review of the facility's meal times revealed the South Long hall where Resident #61 resided was to receive the breakfast meal at 7:20 A.M., lunch meal at 11:50 A.M. and dinner meal at 5:20 P.M. Meal deliver times may vary by 10 minutes from the posted schedule. A review of a Medication Administration Audit Report for Resident #61 for the period between 10/01/22 and 10/31/22 revealed the resident did not receive her Sevelamer Carbonate prior to her meals on a consistent basis. On 10/21/22, her morning dose of Sevelamer Carbonate was given at 8:08 A.M., after her meal was scheduled to be received. The medication was documented as having been administered after her scheduled lunch meals on 10/23/22 and again on 10/24/22. On 10/23/22, the administration time of that medication was indicated to be at 12:38 P.M. and on 10/24/22 at 12:44 P.M. The medication was also administered after her dinner meals served on 10/22/22 and 10/24/22. On 10/22/22, the medication was not given until 5:43 P.M. and on 10/24/22 at 6:00 P.M. Findings were verified by the Director of Nursing (DON). On 12/01/22 at 10:53 A.M., an interview with Resident #61 confirmed she used to receive phosphate binding medication that she took for her ESRD. She denied she was taking it any longer but did report problems getting it before her meals as ordered. She stated the dialysis center told her it did not do her any good to take the medication after she ate. She reported she no longer needed it, as the dialysis doctor told her she was not eating enough to worry about it. On 12/05/22 at 12:35 P.M., an interview with the DON confirmed the Resident #61's phosphate binding medication (Sevelamer Carbonate) was ordered to be given before meals when it was used between 10/18/22 and 10/27/22. She stated the original order did not specify that, but it was re-ordered on 10/18/22 to include the directive to give the medication before meals. She also confirmed there were five times the nurses documented the Sevelamer Carbonate was administered after scheduled meals times and the medication was not administered in accordance with the physician's orders. This deficiency represents non-compliance investigated under Master Complaint Number OH00137495.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to honor resident's preferences regarding showers and bathing. This affected the two residents (#4 and #63) reviewed for choices. The facility census was 76. Findings include: 1. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] with diagnoses which included type two diabetes mellitus, chronic diastolic heart failure, weakness, reduced mobility, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/24/22 revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility and toileting, extensive assistance from one staff member for transfers, and physical help from one staff member for bathing. Review of the care plan, dated 01/11/22, revealed this resident needed Activities of Daily Living (ADL) assistance. Interventions included to provide extensive assistance with personal hygiene. Review of the facility Preferences for Customary Routine and Activities-Section F Assessment, dated 07/12/21, revealed this resident preferred to have a shower three times a week in the evening and it was very important for the resident to choose her schedule. Review of the State Tested Nursing Assistant (STNA) task bar revealed this resident was scheduled to receive a shower on Monday and Thursday on day shift. Review of the STNA documentation of showers provided from 12/10/21 through 02/10/22 revealed this resident received a shower on Friday 12/10/21, received a shower on Monday 12/13/21, refused a shower on Wednesday 12/15/21, received a shower on Monday 12/20/21, received a shower on Wednesday 12/22/21, received a shower on Wednesday 12/29/21, received a shower on Thursday 01/13/22, received a shower on Wednesday 01/19/22, and received a shower on Wednesday 02/02/22. Interview with Resident #4 on 02/07/22 at 12:20 P.M. revealed the resident was not receiving showers according to her preferred schedule. Interview with the Director of Nursing on 02/10/22 at 2:45 P.M. verified the shower preference for Resident #4 had been documented on 07/12/21 as three times a week in the evening on the Preferences for Customary Routine and Activities-Section F Assessment but the resident was scheduled to receive showers on Mondays and Thursdays during day shift. Interview with Resident #4 on 02/10/22 at 3:00 P.M. verified she had been interviewed regarding her preferences shortly after admission to the facility and had verbalized she wished to receive showers three times a week in the evenings. 2. Review of the medical record for Resident #63 revealed an admission date of 06/03/21 with diagnosis including cellulitis of right lower leg, chronic osteomyelitis of right ankle and foot, type two diabetes mellitus, peripheral vascular disorder and acquired absence of right toes. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had modified cognition with no behaviors. Resident #63 required extensive physical assistance of two persons for bed mobility, toileting and bathing. Review of the admission preference assessment dated [DATE] indicated Resident #63 preferred a shower every day in the mornings. Review of the shower sheets and STNA tasks from 01/10/22 through 02/06/22 revealed Resident #63 was scheduled for showers on Wednesday and Saturday. He received showers on the following dates; 01/12/22, 01/14/22, 01/16/22, 01/19/22, 01/21/22, 01/23/22, 01/30/22, 02/02/22 and 02/05/22. An interview on 02/09/22 at 11:38 A.M. with Resident #63 revealed the resident wanted to have a shower every morning. Resident #63 said he was lucky to have a shower one or two times per week. An interview on 02/09/22 at 3:15 P.M. with the DON confirmed Resident #63 preference assessment on admission indicated he preferred a shower every morning. The DON also confirmed, based on documentation, Resident #63 received one or two showers per week. The facility did not have a policy addressing showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observations, medical record review, facility policy review, and review of the Centers for Medicare & Medicaid Services, the facility failed to assess, obtain Physician orders, and care plan personal alarms. This affected three Residents (#5, #52, #30) of seven residents reviewed for alarms. The facility census was 76. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/03/21. Diagnoses included palliative care, muscle weakness, unspecified fall, abnormalities of gait and mobility, cognitive communication deficit, unsteady on his feet, and Dementia without behavioral disturbance. Review of the physician orders revealed an order dated 11/03/21 for a bed and chair alarm to be in place for 14 days and then to reevaluate the resident. The order was discontinued on 11/16/21. Review of the physician orders revealed an order for a pressure sensor alarm to his wheelchair to alert staff if the resident attempts to transfer unassisted and staff was to check placement and functioning every shift. The order date was 11/04/21, the start date was 02/09/22, and the discontinue date was 02/09/22. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/10/21, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of four out of 15 indicating severe cognitive impairment. He required limited to extensive assistance of one to two staff members for Activities of Daily Living (ADL's). His behaviors included inattention, disorganized thinking, and other behavioral symptoms not directed towards others. Review of the physician orders revealed an order dated 11/16/21 for a bed and chair alarm in place starting 11/16/21. The order was discontinued on 11/29/21 with the reasoning being the resident was not compliant with alarm and therapy agreed the residents safety not at risk in his room. Review of the progress notes for November 2021, December 2021, January 2022, and February 2022 revealed the resident suffered numerous falls but had no noted behaviors. Review of the physician orders revealed an order for a chair alarm to be in place. The start and order dates were 11/29/21 and the discontinue date was 12/21/21. Review of the plan of care dated 01/23/22 revealed the resident was at risk for falls related to history of falls, weakness, poor safety awareness, and unsteady gait. Interventions included fall interventions but did not mention any bed or chair alarms. Interview on 02/09/22 at 10:01 A.M. with Licensed Practical Nurse (LPN) #129 revealed the resident had a chair alarm over the weekend (Saturday and Sunday) but upon her arrival for her shift today, he did not have an alarm. Interview on 02/09/22 at 10:31 A.M. with the Director of Nursing (DON) revealed she was unsure if assessments were completed prior to initiating an alarm. She also stated she knew after 14 days with an alarm the resident was reevaluated in the facility's morning meeting but did not know if it was documented any where. She stated she would provide the facility's policy for review. She also confirmed Resident #5 had a chair alarm intact and functioning on 02/07/22 and 02/08/22. Observation on 02/07/22 at approximately 11:00 A.M. the resident was observed transferring himself from the bed to the wheelchair and then going to the bathroom and setting off his chair alarm. Staff entered the room to assist the resident and turn the alarm off. There were no assessments regarding the need for restraints/alarms. Assessments of the resident's need for the alarms were requested from the DON on 02/09/22 at 3:14 P.M. Interviews on 02/09/22 at 2:12 P.M. and 3:14 P.M. with the DON revealed the facility does not have an alarm policy. She also confirmed she would have to check with corporate to figure out how a resident need for an alarm was assessed. She confirmed she would obtain the appropriate assessments needed prior to the initiation of an alarm. Interview on 02/10/22 at 4:10 P.M. with Regional Nurse #8000 and the DON confirmed there were no assessments completed for Resident #5 prior to initiating the alarm. Review of the webpage titled Restraint/seclusion Interpretive Guidelines and Updated SOM Appendix A on CMS.gov, website for the Centers for Medicare & Medicaid Services, bed and chair alarms, or any position change alarms which make an audible noise near the resident, as a restraint. 2. Review of the medical record for Resident #30 revealed an admission date of 12/29/21 and discharge date of 02/07/22. Diagnoses included unspecified fall, major depressive disorder, anxiety disorder, disorientation, unsteadiness on his feet, cognitive communication deficit, weakness, reduced mobility, muscle weakness, lack of coordination, and insomnia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 01/05/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 out of 15 (cognitively intact). He required extensive assistance of one to two or more staff for Activities of Daily Living (ADL's) and he exhibited other behavioral symptoms not directed towards others. Review of the assessments from 12/01/21 through 02/07/22 revealed there were no assessments regarding the need for a restraint or alarm. Assessments of the resident's need for the alarms were requested from the DON on 02/09/22 at 3:14 P.M. Review of the progress notes for December 2021, January 2022, and February 2022 revealed the resident suffered numerous falls but had no noted behaviors. Review of physician orders dated 12/29/21 revealed an order for a bed alarm to alert staff of unassisted transfers. Review of the plan of care dated 12/29/21 revealed the resident was at risk for falls related to history of falls, weakness, and confusion. Interventions included the resident should wear nonskid footwear when in bed for safety should the resident get out of bed without assistance, the resident uses a bed alarm, and mat to the bedside floor at night. Further review of the care plan revealed the resident used bed and chair alarms. The interventions included discuss and document the risks and benefits, when the personal alarm will be used, routine modifications, and any other concerns or issues related to personal alarm use with the resident/resident representative. Observation and interview on 02/07/22 at 10:22 A.M. revealed Resident #30 was sitting up on the edge of the bed with bilateral bare feet on the floor and an alarm to his motorized wheelchair. Review of the physician orders for February 2022 revealed an order for a bed alarm to the resident bed to alert staff of unassisted transfers every day and night shift for safety starting 12/29/2021. The order was discontinued on 02/07/22 which was also the day the resident was discharged to the community. Review of the Electronic Medical Record/Treatment Administration Record (EMAR/ETAR) for February 2022 revealed all physician's order for a bed alarm to the resident bed to alert staff of unassisted transfers every day and night shift for safety was signed off per orders. Interview on 02/09/22 at 10:01 A.M. with Licensed Practical Nurse (LPN) #129 revealed the resident had a chair alarm over the weekend (Saturday and Sunday) but upon her arrival for her shift today, he did not have an alarm. Interview on 02/09/22 at 10:31 A.M. with the DON revealed she confirmed Resident #30 had a bed alarm intact and functioning on 02/07/22. Interviews on 02/09/22 at 2:12 P.M. and 3:14 P.M. with the DON revealed the facility does not have an alarm policy policy. She also confirmed she would have to check with cooperate to figure out how a resident need for an alarm was assessed. She confirmed she would obtain the appropriate assessments needed prior to the initiation of an alarm. Interview on 02/10/22 at 4:10 P.M. with Regional Nurse #8000 and the DON confirmed there were no assessments completed for Resident #30 prior to initiating the alarm. 3. Review of the medical record for Resident #52 revealed an admission date of 11/05/21 with diagnoses including Alzheimer's disease, adult failure to thrive, chronic obstructive pulmonary disorder, weakness, lack of coordination, anxiety, schizoaffective disorder, Parkinson's disease and need for assistance with personal care. Review of the quarterly MDS dated [DATE] revealed Resident #52 had cognitive impairment with no behaviors. Resident #52 required extensive physical assistance of one person for bed mobility, dressing, toileting and personal hygiene. Resident #52 required limited assistance of one person for transfers. The resident was not coded for a personal alarm. Review of the fall risk assessment dated [DATE] indicated Resident #52 was at high risk for falls. Review of the incident report for Resident #52 fall on 02/05/22 revealed the nurse found Resident #52 seated on the floor beside her bed. There was no injury noted, neurological assessments were initiated and the nurse put a mat to the floor at bedside while in the bed. Review of the nursing progress notes from 02/05/22 through 02/08/22 indicated follow up on Resident #52 post fall revealed no concerns or injury. A progress note dated 02/05/22 at 3:45 P.M. of the initial assessment of the resident fall indicated the intervention was a pull tab alarm to the resident's wheelchair. Review of the physician orders for 02/22 revealed no order for a tab alarm to Resident #52 wheelchair. Review of the medical record of Resident #52 revealed no restraint assessment for the use of a pull tab alarm to her wheelchair. Review of the plan of care for at risk for falls was also silent on the use of a pull tab alarm to Resident #52 wheelchair. An observation on 02/08/22 at 1:42 P.M. and on 02/08/22 at 4:30 P.M. revealed Resident #52 had a pull tab alarm to wheelchair. This was confirmed with STNA #122. An observation on 02/09/22 at 8:53 A.M. revealed the pull tab alarm to Resident #52 wheelchair was removed. An interview on 02/09/22 at 8:56 A.M. with LPN #128 revealed the pull tab alarm to Resident #52 was discontinued on 02/08/22. An interview on 02/09/22 at 9:05 A.M. with the DON confirmed the pull tab alarm to Resident #52 wheelchair was placed on the wheelchair as an intervention to the fall on 02/05/22. Also confirmed there was not a restraint assessment completed on Resident #52 or a physician order written. However, the Interdisciplinary Team (IDT) discussed the alarm and decided it was not an appropriate intervention for the resident's fall and the alarm was discontinued and removed. An interview on 02/09/22 at 2:12 P.M. with the DON revealed the facility did not have a policy on alarms or restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a written Notice of Transfer for one former resident's (Resident #69) hospitalization. The deficient practice affected one resident (Resident #69) out of one reviewed for hospitalization. The facility census was 76. Findings Include: Review of the medical record for former Resident #69 revealed an admission date of 10/28/21 and discharge date of 11/30/21. Medical diagnoses included methicillin resistant staphylococcus aureus infection (MRSA), stage four pressure ulcer of sacral region, cellulitis, presence of left artificial hip joint, and chronic pain. Review of the five day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 had mildly impaired cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Review of the discharge MDS 3.0 assessment dated [DATE] revealed Resident #69 was discharged on 11/30/21 to the hospital with return not anticipated. Review of the nurse's note dated 11/30/21 revealed Resident #69 became unresponsive to verbal commands during a therapy session. The resident also was not able to follow with eyes and was looking off to the right side. Resident #69 became reactive to verbal and tactile stimuli after one to two minutes. The resident's smile was drooping to the left side. Resident #69's husband and the physician were notified. Emergency Medical Services (EMS) was called immediately and the resident was transported to a local hospital. Report was called in to the hospital. There was no evidence in the medical record that a written notice of transfer was provided to Resident #69 or the resident's representative. Interview via email on 02/10/22 at 3:42 P.M. with the Administrator confirmed a written notice of transfer was not completed or provided to Resident #69 or the resident's representative. The Administrator confirmed this was a deficient area that was identified by the facility's corporate team prior to the annual survey but a new process had not been implemented yet. Review of the facility policy, Transfer and Discharge, revised 02/28/20, stated, for emergency transfers, the facility will complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents the resident's status, current diagnoses, allergies, reasons for transfer, contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, current medications, treatments, most recent relevant lab and/or radiological findings, recent immunizations, special instructions or precautions for ongoing care to include precautions such as isolation or contact, special risks such as risk of falls, comprehensive care plan goals, and any other documentation as applicable to ensure a safe and effective transition of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #21 revealed an initial admission date of 08/04/20 and a re-admission date of 04/07/21. Diagnoses included anxiety disorder, Dementia with Behavioral disturbances, bipolar disorder, schizoaffective bipolar disorder, and major depressive disorder. Review of the PASRR dated 08/04/20 revealed it was from the hospital. Review of the PASRR dated 09/09/20 revealed it was completed upon the resident's admission. Review of the plan of care dated 08/05/20 revealed she had the potential to be verbally aggressive, rude, and belligerent. Interventions included administration of medications per orders, monitor/document for side effects and effectiveness, and allow the resident time to express herself and feelings towards the situation. Review of the plan of care dated 08/05/20 revealed the resident was resistive to care and medications at times related to Dementia. Interventions included psychiatric evaluation as needed. Review of the plan of care dated 08/05/20 revealed the resident uses antianxiety medications. Interventions included administration of anti-anxiety medications per orders and monitor/document for side effects and effectiveness. Review of the plan of care dated 08/05/20 revealed the resident used antidepressant medication. Interventions included administration of antidepressant medications as ordered and monitor/document for side effects and effectiveness. Review of the plan of care dated 08/05/20 revealed the resident received antipsychotic medication related to dementia with behavioral disturbances, wandering, crawling on the floor, refusing care, delusions, hallucinations and paranoia. interventions included administration of medications as ordered and monitor/document for side effects and effectiveness. Review of the plan of care dated 08/05/20 revealed the resident used psychotic medications. Interventions included administration of psychotropic medications as ordered by the physician, monitor for side effects/effectiveness every shift, discuss with the Medical Director (MD) and family the ongoing need for the use of the medication, review behaviors/interventions and alternate therapies attempted and their effectiveness as per the facility policy. Review of the medical diagnoses revealed the diagnosis schizoaffective Bipolar disorder was added on 08/06/21. There was no PASRR completed after 09/09/20. Review of a physician order dated 08/06/21 revealed the resident began taking an extended release Brupropion hydrochloride 300 milligram (tablet) by mouth in the morning for depression. She was already ordered to take one 30 mg tablet of abilify (antipsychotic) every morning for dementia with behavioral disturbance and Xanax 0.25 mg tablet three times per day for anxiety disorder prior to the new diagnosis on 08/06/21. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/21, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment and no documented behaviors. She required limited to extensive assistance of one to two staff members for Activities of Daily Living (ADL's). Review of the careplan dated 01/12/22 revealed the resident had the potential to be verbally aggressive, rude, and had belligerent vocalizations. Interventions included administration of medications as ordered, assess and anticipate the resident's needs, assess the resident's understanding of the situation, and allow time for the resident to express herself and her feelings towards the situation. Further review of the careplan revealed the resident was resistive to care/medications at time due to Dementia. Interventions included education, encouragement to participate in her own care, providing opportunities for the resident to self choose, and psychiatric evaluations as needed. Interview on 02/09/22 at 3:06 P.M. with admission Director #7000, revealed she was completing Preadmission Screening and Resident Reviews (PASRR) while the facility did not have a Social Worker. She confirmed Resident #21 should have had completed a new PASRR/trigger a level two when diagnosed with schizoaffective bipolar disorder on 08/06/21. Review of the facility policy titled, PASRR Preadmission Screen and Resident Review dated 10/18/20 revealed a PASRR should be completed with a new diagnosis. Based on interview, record review and review of the facility policy the facility failed to complete an accurate Preadmission Screening and Resident Review (PASRR) including all mental health diagnoses. This affected two of two residents reviewed for PASRR (Resident #21 and #39). The facility census was 76. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 09/29/16 with diagnoses type two diabetes mellitus, morbid obesity, acquired absence of left leg above the knee, depression, anxiety and seizure disorder. On 03/29/17 the diagnosis of personality disorder was added, on 05/08/17 the diagnosis of mood disorder was added and on 05/27/21 the diagnosis of schizophrenia was added. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #39 was cognitively intact with no behaviors noted. Resident #39 expressed symptoms of depression including feeling down, trouble sleeping, feeling tired, feeling bad about self and trouble concentrating. The resident had the following diagnoses; anxiety, depression, schizophrenia and mood disorder. Review of the physician orders for 02/22 revealed Resident #39 received the following medications; Venlafaxine Hydrochloride (HCL) extended release (ER) an antidepressant, Perphenazine an antipsychotic and Bupropion HCL ER an antidepressant. Review of the initial PASRR for Resident #39 dated 06/13/17 revealed no mental health diagnoses and level two assessment was not applicable. On 05/27/21 Resident #39 received the diagnoses of schizophrenia. There was not a new PASRR completed for Resident #39. An interview on 02/09/22 at 3:43 P.M. with the admission Director confirmed the facility did not complete a new PASRR on Resident #39 with new mental health diagnoses. The facility did not provide a policy related to PASRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident #55 revealed this resident was admitted to the facility on [DATE] and had diagnoses including schizophrenia, depression, anxiety, and COVID-19. Review of the quarterly MDS assessment, dated 01/07/22, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 12. This resident was assessed to require supervision for bed mobility, transfers, and toileting. This resident was assessed to have not received oxygen therapy. Review of the active care plans for this resident revealed an absence of a care plan for respiratory care or oxygen use. Review of the active physician's order for Resident #55 revealed an order, dated 02/07/22, for oxygen to be administered at two liters a minute as needed. Observation on 02/07/22 at 10:17 A.M. revealed Resident #55 had an oxygen concentrator in place at bedside. The nasal cannula tubing was observed to be dated 02/01/22. Interview with State Tested Nursing Aide (STNA) #165 on 02/07/22 at 10:17 A.M. verified the oxygen concentrator and tubing belonged to Resident #55 and the resident used oxygen at times. Interview with Resident #55 on 02/07/22 at 10:21 A.M. verified she used the oxygen at times when she was having difficulty breathing. Interview with the Director Of Nursing on 02/10/22 at 3:45 P.M. verified Resident #55 did not have a care plan in place regarding respiratory care or the use of oxygen. Review of the facility policy titled Oxygen Administration, revised on 06/02/21, revealed the resident's care plan should identify the interventions for oxygen therapy. Based on observation, record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for three residents (Residents #12, #55 and #60) in the areas of fluid restriction, behaviors and oxygen. This affected three of 24 sampled residents reviewed. Findings Include: 1. Review of Resident #12's medical record revealed an admission date of 11/21/21. Diagnoses included disruption of wound, right above knee amputation, diabetes mellitus, end stage renal failure with dependence on renal dialysis, atrial fibrillation, history of COVID-19, major depressive disorder, ischemic cardiomyopathy, peripheral vascular disease, hypertension, hyperlipidemia, congestive heart failure and anemia. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a BIMS score of 14. The resident requires supervision with ADL. The assessment indicated the resident received dialysis services. Review of the resident's February 2022 physician's orders identified orders dated 11/26/21 for a 1,000 milliliter (ml) fluid restriction daily with the special instructions for nursing to give 400 ml every shift. Review of the resident's comprehensive plan of cares failed to identify a plan of care addressing the physician ordered fluid restriction. On 02/10/22 at 11:05 A.M. interview with the Director of Nursing (DON) verified the resident lacked of a plan of care addressing the fluid restriction. 2. Review of Resident #60's medical record revealed an initial admission date of 01/07/21 with the latest readmission of 03/21/21. Diagnoses included dementia with behavioral disturbances, anxiety disorders, mood disorder, hypertension, major depressive disorder with psychotic symptoms, pain, restlessness and agitation, history of COVID-19, gastro-esophageal reflux disease, lactose intolerance and insomnia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the mood and behavior revealed the resident had indicators of depression and wandered daily. The assessment indicated the resident received antipsychotic, antianxiety and hypnotic medications on a routine basis. Review of the resident' physician's orders for February 2022 identified an order dated 01/15/22 Zyprexa (a medication used to treat behaviors) 2.5 mg by mouth every day for dementia with behavioral disturbances and 01/19/22 for Zyprexa 5 mg by mouth at bedtime for dementia with behavior disturbances. Review of the resident's comprehensive plan of care failed to identify a plan of care addressing the resident's behavior to support the use of the medication Zyprexa. On 02/10/22 at 11:05 A.M. interview with the Director of Nursing (DON) verified the resident lacked of a plan of care addressing the resident's behavior to support the use of the medication Zyprexa.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and facility policy review, the facility failed to revise care plans in the areas of bruising following a fall and alarms. This affected two Residents (#5 and #52) of 24 residents reviewed for care plans. The facility census was 76. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/03/21. Diagnoses included palliative care, muscle weakness, unspecified fall, abnormalities of gait and mobility, cognitive communication deficit, unsteady on his feet, and Dementia without behavioral disturbance. Review of the physician orders revealed an order dated 11/03/21 for a bed and chair alarm to be in place for 14 days and then to reevaluate the resident. The order was discontinued on 11/16/21. Review of the physician orders revealed an order for a pressure sensor alarm to his wheelchair to alert staff if the resident attempts to transfer unassisted and staff was to check placement and functioning every shift. The order date was 11/04/21, the start date was 02/09/22, and the discontinue date was 02/09/22. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/10/21, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of four out of 15 indicating severe cognitive impairment. He required limited to extensive assistance of one to two staff members for Activities of Daily Living (ADL's). His behaviors included inattention, disorganized thinking, and other behavioral symptoms not directed towards others. Review of the physician orders revealed an order dated 11/16/21 for a bed and chair alarm in place starting 11/16/21. The order was discontinued on 11/29/21 with the reasoning being the resident was not compliant with alarm and therapy agreed the resident's safety not at risk in his room. Review of the physician orders revealed an order for a chair alarm to be in place. The start and order dates were 11/29/21 and the discontinue date was 12/21/21. Review of the Skin assessment dated [DATE] revealed the resident had deep purple bruising on the left hip. The assessment did not have measurements but indicated x-rays were ordered. Review of the progress note dated 12/07/21 at 2:15 P.M. by Registered Nurse (RN) #159 revealed the resident suffered a fall and had deep purple bruising and swelling. Review of the progress note dated 12/07/21 at 9:15 P.M. by Unit Manager (UM) RN #119 revealed the resident's hip was without changes. Review of the progress note dated 12/08/21 at 10:32 A.M. MDS Licensed Practical Nurse (LPN) #999 revealed monitoring of the bruising to the resident's left hip was to occur. Review of the progress note dated 12/08/21 at 5:31 P.M. by RN #159 revealed the resident's daughter was updated on the resident's hip being bruised and swollen. Review of the physician orders revealed an order to monitor bruising to left hip every shift until healed was ordered on 12/08/21. The order was discontinued on 12/26/21. Review of the progress note dated 12/14/21 at 5:08 P.M. revealed the resident's Xarelto was discontinued due to the resident being a fall risk to help with bruising and the hip remained with a quite a bit of bruising. Review of the Skin Assessments dated 12/14/21, 12/25/21, 01/03/22, 01/12/22, 01/19/22, and 01/26/22 revealed the resident did not have any new or existing abnormal skin conditions. Review of the plan of care dated 01/23/22 revealed the resident was at risk for falls related to history of falls, weakness, poor safety awareness, and unsteady gait. Interventions included fall interventions but did not mention any bed or chair alarms or bruise monitoring. Review of the Skin assessment dated [DATE] revealed the resident did not have any new or continued skin conditions. Interview on 02/09/22 at 10:31 A.M. with the DON confirmed Resident #5 had a chair alarm intact and functioning on 02/07/22 and 02/08/22 and a bruise that was to be monitored on his hip following a fall. Interviews on 02/09/22 at 2:12 P.M. and 3:14 P.M. with the DON confirmed Resident #5 did not have an updated careplan to reflect his alarms or bruise monitoring. Review of the facility policy titled, Care Plan Process undated, revealed care plans should be revised with any changes affecting the resident. 2. Review of the medical record for Resident #52 revealed an admission date of 11/05/21 with diagnoses including Alzheimer's disease, adult failure to thrive, chronic obstructive pulmonary disorder, schizoaffective disorder and Parkinson's disease. Review of the quarterly MDS dated [DATE] revealed Resident #52 had cognitive impairment with no behaviors. The resident required extensive assistance of one person for bed mobility, dressing, toileting and personal hygiene. The resident required limited assistance of one person for transfers and supervision for walking in her room. The resident had no recent falls or skin impairments. Review of the physician orders for 02/22 revealed Resident #52 did not have an order to monitor the bruise noted to her left eyebrow and forehead. Review of the fall assessment dated [DATE] indicated Resident #52 was found sitting on the floor beside her bed. The nurse completed an assessment and found no injury. Review of the nursing progress notes from 02/05/22 through 02/08/22 revealed no documentation of the bruise to Resident #52 left eyebrow and forehead. Review of the plan of care revealed the fall and skin care plans were silent on the injury/bruise to Resident #52 left eyebrow/forehead from the fall on 02/05/22. Observations of Resident #52 from 02/07/22 through 02/09/22 revealed the resident had a purple with brown edges bruise to the left eyebrow/forehead area. An interview on 02/09/22 at 8:56 A.M. with Licensed Practical Nurse (LPN) #128 revealed the bruise was being monitored however failed to provide any documentation of the monitoring. An interview on 02/09/22 at 2:12 P.M. with the Director of Nursing (DON) confirmed the bruise to Resident #52 left eyebrow and forehead area was not being monitored and there was no mention of the bruise in the resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #21 revealed an re-admission date of 04/07/21. Diagnoses included cognitive communication deficit, Dementia with behavioral disturbance, schizoaffective bipolar disorder, major depressive disorder, and type two diabetes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/21, revealed Resident #21 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment. She required limited to extensive assistance of one to two staff members for Activities of Daily Living (ADL's). Review of the plan of care dated 08/05/20 revealed she had the potential for nutritional deficits related to Dementia, history of variable feeding assistance needed at times with meals, nutritional supplements, and weight gain in one month. Interventions included provide and serve supplements as ordered (Magic cup twice a day and Med Plus 1.7 every day). Review of the resident's weights were as follows: on 09/27/21 she weighed 144.2 lbs, on 10/06/21 she weighed 136.6 lbs, on 11/09/21 she weighed 142.8, on 12/09/21 she weighed 131.8 lbs, on 01/21/22 she weighed 134.4, on 01/28/22 she weighed 137.0 lbs, on 02/04/22 she weighed 137.8 lbs. There were no documentation of any reweights completed. Review of the Nutrition assessment dated [DATE] revealed the resident was on thin liquids, regular diet, and received a magic cup (600 kcal's,18 gm/pro) supplement twice daily. Further review of the assessment revealed the resident had a 5.3 percent weight loss in the past 30 days and a 15.5 percent decrease in the last 180 days. She usually consumed 50 percent or more of her meals but occasionally ate less. She usually ate 100 percent of her supplements and refused additional supplements. Review of the progress note dated 12/10/21 at 12:18 P.M. revealed a significant weight loss of 5.0% change. She had an average intake of meals 65%, supplement average intake 76%. Interventions included a magic cup twice a day (BID) (600 kcal's, 18 gm/pro). It was recommended that the resident be reweighed to verify weight loss but no reweigh was obtained. It was recommended the resident start Med Plus 1.7 every day to help stabilize her weight. Review of the physician orders for December 2021, January 2022, and February 2022 revealed the resident was ordered to be weighed weekly starting 01/21/22, a Magic Cup (nutritional supplement) twice daily for supplement starting 08/24/21, she was ordered a regular diet, Level 3 texture, regular fluid, and thin consistency starting 09/20/21, and Med Plus Sugar free 1.7 for supplement in the afternoon (there was no amount specified) starting on 12/14/21. Review of the Nutrition assessment dated [DATE] revealed the resident was on thin liquids, regular diet, received a magic cup (600 kcal's,18 gm/pro) supplement twice daily, and Med Plus 1.7 (200 kcal's, 10 gm/pro) 120 milliliters (ml) daily. She had a weight gain of 14 percent (18.4 pounds (lbs)). She usually consumed 50 percent or more of her meals but occasionally ate less. She usually ate 50 percent of her supplements. Interview on 02/08/22 at 5:57 P.M. with the Director of Nursing (DON) confirmed if a resident had significant weight loss then the dietician would make recommendations. If a reweigh was ordered then the weight should have been entered in the resident's medical record. She confirmed a supplement order should have an amount ordered to administer. Interview on 02/09/22 at 3:14 P.M. with the DON confirmed it would be impossible to calculate the amount of Med plus the resident was receiving since the order did not specify the amount to be administered. Review of the Electronic Medication Administration Record (EMAR) for February 2022 revealed the resident was administered the ordered med plus every day in February except 02/03/22 when nothing was documented. It was documented that she drank between 25 and 50 percent of an unknown amount that was administered. It did not reveal the amount of supplement provided to the resident on each administration. Review of the January 2022 EMAR revealed the resident drank between 50 and 100 percent of her med plus supplement every day in January except on 01/20/22 when there was nothing documented. It did not reveal the amount of supplement provided to the resident. Review of the progress note dated 11/30/21 at 2:08 P.M. revealed the resident had a ten percent weight loss (16.9 lbs) from 159.7 lbs on 05/25/21 to 142.9 lbs. Resident #21 consumes 50% or greater of most meals, often 75-100%. She also receives Magic cup BID, which she consumes 100% of on most occasions. She has had a weight loss trend over the past 6 months. This could be related to decreased snacking in between meals. She recently started going to the dining room for meals which appears to be helping intakes as evidenced by a 6 pound weight gain over 1 month. Her current weight is 142.8# and she is 68. Her BMI is 21.7, indicating she is appropriate weight for height. Her needs are 1625-1950 kcal's, 65 gm/pro and ~1950 ml fluid. Continue current diet and supplements as ordered. RD to continue to monitor and make recommendations as needed. Review of the facility policy titled, Medication Administration dated 01/01/21 revealed medication source was to be verified with the Electronic Medication Administration Record (EMAR) to verify the dose. Based on observation, record review, interviews and facility policy review, the facility failed to maintain one resident (#12) dialysis fluid restriction. This affected one of one resident received for dialysis. Additionally, the facility failed to monitor one resident's (#21) supplement intake used to prevent further weight loss. This affected one of four reviewed for nutrition. Findings Include: 1. Review of Resident #12's medical record revealed an admission date of 11/21/21. Diagnoses included disruption of wound, right above knee amputation, diabetes mellitus, end stage renal failure with dependence on renal dialysis, atrial fibrillation, history of COVID-19, major depressive disorder, ischemic cardiomyopathy, peripheral vascular disease, hypertension, hyperlipidemia, congestive heart failure and anemia. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a BIMS score of 14. The resident requires supervision with ADL. The assessment indicated the resident received dialysis services. Review of the resident's February 2022 physician's orders identified orders dated 11/26/21 for a 1,000 milliliters (ml) fluid restriction daily with the special instructions nursing to give 400 ml every shift. Review of the January 2022 Medication Administration Record (MAR) revealed the resident was scheduled to receive 400 ml of fluid every shift (days, evenings and nights) which exceeded the physician ordered 1,000 ml fluid restriction daily. On 02/10/22 at 10:11 A.M. interview with Dietary Aide #145 revealed the resident receives 240 ml of water for breakfast, lunch and supper. On 02/10/22 at 11:05 A.M. interview with the Director of Nursing (DON) verified the resident was scheduled to receive 1,920 ml of fluid which exceeded the resident's physician ordered 1,000 ml fluid restriction daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to obtain physicians orders for the administration of oxygen therapy. This affected the one resident (#55) reviewed for respiratory care. The facility census was 76. Findings include: Record review for Resident #55 revealed this resident was admitted to the facility on [DATE] and had diagnoses including schizophrenia, depression, anxiety, and COVID-19. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/07/22, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 12. This resident was assessed to require supervision for bed mobility, transfers, and toileting. This resident was assessed to have not received oxygen therapy. Review of the active care plans for this resident revealed an absence of a care plan for respiratory care or oxygen use. Review of the active physicians order for Resident #55 revealed an order, dated 02/07/22 and timed 10:47 A.M., for oxygen to administered at two liters a minute as needed. Observation on 02/07/22 at 10:17 A.M. revealed Resident #55 had an oxygen concentrator in place at bedside. The nasal cannula tubing was observed to be dated 02/01/22. Interview with State Tested Nursing Assistant (STNA) #165 on 02/07/22 at 10:17 A.M. verified the oxygen concentrator and tubing belonged to Resident #55 and the resident used oxygen at times. Interview with Resident #55 on 02/07/22 at 10:21 A.M. verified she used the oxygen at times when she was having difficulty breathing. Interview with the DON on 02/10/22 at 3:45 P.M. verified Resident #55 had been receiving oxygen therapy prior to 02/07/22 but could not confirm when it was initiated. The DON verified there had not been a physician's order for the administration of oxygen in place for Resident #55 until 02/07/22 at 10:47 A.M. Review of the facility policy titled Oxygen Administration, revised on 06/02/21, revealed oxygen was to be administered under orders of a physician, except in the case of an emergency. In such case, the oxygen was to be administered and orders for the oxygen were to be obtained as soon as practicable when the situation was under control.

Based on staff interview, observations, medical record review, facility policy review, shift change controlled substance accountability sheets review, procedure review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and the facility failed to remove and dispose of an opioid pain patch. This affected one Residents (#31) of three residents reviewed for medications and had the potential to affect additional residents in the facility who had orders for controlled drugs. The facility census was 76. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 12/18/18. Diagnoses included rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites and age-related osteoporosis without current pathological fracture. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/14/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no cognitive impairment) and no behaviors. The resident required supervision of one staff member for all Activities of Daily Living (ADL's) except personal hygiene where she required the extensive assistance of one staff member. Review of the plan of care dated 07/14/20 revealed the resident was at risk for acute/chronic pain related to arthritis, low back pain, compression fracture, and a history of shingles. Interventions included administration of medications as ordered, evaluate the effectiveness of pain interventions every shift, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Further review of the plan of care dated 07/14/20 revealed the resident was at risk for side effects related to Opioid medication use. Interventions included administration of Opioid medication as ordered by the physician and monitor for side effects and effectiveness every shift. Review of the physician orders revealed an order with a start date of 12/13/21 for Buprenorphine (Butrans) patch (opioid pain patch) five micrograms (mcg) per hour with the instructions to apply one patch every seven days, cover with tegaderm (transparent dressing), and avoid chest where patient may accidentally rub off. A second order with a start date of 10/08/21 revealed an order to check the placement of the residents Butrans patch by examining the resident every shift for proper placement. Review of the progress notes dated 12/27/21 through 02/09/22 revealed no progress note related to the removal of a Butrans patch. Review of the progress note dated 02/09/22 at 5:06 P.M. by Licensed Practical Nurse (LPN) #129 revealed she informed the Physician Assistant (PA) #777 regarding the butrans pain patch found on residents blanket. There were no changes or new orders, the Director of Nursing (DON) was informed and verification of the most recent pain patch was in place was confirmed. Review of the Electronic Medication Administration Record (EMAR) for December 2021 revealed the Butrans patch was placed on 12/20/21 by Registered Nurse (RN) #119 and was replaced on 12/27/21 by RN #159. Further review of the EMAR revealed an order with a start date of 04/19/21 to document the removal and application of the Butrans patch. The order was discontinued on 12/08/21. Observation on 02/09/22 at approximately 4:28 P.M. revealed a labeled Butrans patch dated 12/20 and initialed AS, stuck to the residents blanket. LPN #129 removed the patch from the blanket, informed the Director of Nursing (DON), placed the used patch into a disposal sleeve, and discarded the patch in the sharps/biohazard container. Interview on 02/09/22 at 5:04 P.M. with the DON confirmed she spoke with the nurse who was supposed to have removed the butran patch but she stated there was no patch to remove despite searching the residents body and bedding. The DON confirmed the nurse signed off the order stating she removed the patch but did not document the patch was actually unfound. Interview on 02/10/22 at 4:10 P.M. with the DON confirmed there was no documentation of the Butrans patch removal after 12/08/21. Review of the facility policy titled, Medication-Narcotic Pain Patch revised 06/30/21 revealed patches will be checked for placement by the nurse every shift and documented in the medication administration record and upon the placement of a new patch the old patch will be removed and discarded in a safe and secure method and verified as such by the nurse removing and the nurse verifying the discard of the patch. 2. Review of the Shift Change Controlled Substance Accountability sheet for the controlled substance Emergency Drug Kit (EDK) revealed on 12/27/21 at 7:00 P.M. there was no signature for the oncoming nurse. There was no count documented 12/28/21 or 12/29/21. On 12/30/21 at 7:00 P.M. there was no signature for the off going nurse. There was no count documented on 01/01/22 through 01/12/22. On 01/13/22 at 7:00 P.M. there was no signature for the oncoming nurse. There was no count documented on 01/14/22. On 01/16/22 at 7:00 P.M. there was no signature for the outgoing nurse. There was no count documented on 01/17/22 through 01/23/22. On 01/24/22 at 7:00 A.M. there was no signature for the outgoing nurse. On 01/26/22 at 7:00 A.M. there was no signature for the oncoming nurse. There was no count documented on 01/26/22 evening shift through 02/06/22. On 02/07/22 at 7:00 P.M. there was no oncoming or outgoing nurse signatures indicating the count was completed. There was no count documented on 02/08/22 in the morning or evening and no count completed on 02/09/22 in the morning. On 02/09/22 at 7:00 P.M. there was no signature for the off going nurse. On 02/10/22 at 7:00 A.M. there was no signature for the on coming nurse and no documentation that the count occurred on 02/10/21 evening shift. Interview on 02/10/22 at 11:20 A.M. with Licensed Practical Nurse (LPN) #128 revealed controlled medications were to be counted and documented at the beginning of every shift. Review of the Shift Change Controlled Substance Accountability sheets for the North Long Unit revealed there were no count documented on 01/12/22 night shift through 01/30/22. There was no signature for the on coming nurse on 02/05/22 at 7:00 P.M., 02/06/22 at 7:00 P.M. Interview on 02/10/22 at 3:30 with the Regional Nurse #8000 confirmed the nurses were to count/verify tag numbers and sign the Shift Change Controlled Substance Accountability sheet for the EDK any time a new on coming nurse was starting their shift and every shift for each units medication cart controlled substances. Interview on 02/10/22 at 4:10 P.M. with the Director of Nursing (DON) confirmed the missing counts, missing signatures, and documentation on the Shift Change Controlled Substance Accountability sheets for the North Long Unit and the controlled substance EDK. Review of the facility provided drug information titled, Buprenorphine dated 01/14/22 revealed this drug was a strong pain drug that can increase the risk for addiction, abuse, and misuse, do not take more than what the doctor ordered, taking more than ordered can increase the chances of very bad side effects, take off the old patch prior to placing a new patch, and do not place more than one patch at the same time unless the doctor ordered it. Review of the facility policy titled, Controlled Substance Administration and Accountability dated 10/20/20 revealed nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the DON or his/her designee immediately and documentation should be made on the shift verification sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of pharmacy recommendations, and review of facility policy, the facility failed to implement pharmacy recommendations timely upon approval by the physician for two residents (Resident #3 and Resident #60). The facility also failed to document appropriate justifications for declining a gradual dose reduction (GDR) for two residents (Resident #60 and Resident #67). The deficient practice affected three residents (Residents #3, #60, and #67) out of eight reviewed for unnecessary medications. The facility census was 76. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date on 05/13/21. Medical diagnoses included unspecified mood (affective) disorder, adjustment disorder with mixed anxiety and depressed mood, insomnia, and schizoaffective disorder (Bipolar type). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required supervision with set up help only for most Activities of Daily Living (ADLs). The resident required supervision with one staff assist for bed mobility, dressing, toileting and hygiene. The resident took daily antipsychotics, antianxiety, and antidepressant medications. Review of the physician's orders for February 2022 revealed Resident #3 had an order for Bupropion HCL ER (XL) tablet Extended Release 24 hour 150 milligrams (mg) with instructions to give one tablet by mouth daily for depression for one week and give two tablets daily for depression. The order had a start date of 08/07/21. Resident #3 also had an order for Vilazodone HCL 40 mg with instructions to give one tablet in the morning for depression. The order had a start date of 05/29/21. Review of the plan of care dated 03/30/21 revealed Resident #3 had depression. Interventions included administer medications as ordered and to monitor and document for side effects and effectiveness. Review of the pharmacy recommendation dated 11/17/21 for Resident #3 revealed the resident was prescribed two different antidepressants, Wellbutrin XL (generic brand Bupropion HCL) 300 milligrams (mg) daily and Viibryd (generic brand Vilazodone HCL) 40 mg daily. A trial dose reduction of Wellbutrin from 300 mg to 150 mg daily was recommended. The physician agreed to the trial dose reduction on 12/02/21. Review of the Medication Administration Record (MAR) for December 2021 revealed the only order for Bupropion HCL ER (XL) 150 mg had instructions to give two tablets by mouth one time a day for depression (a total of 300 mg) with a start date of 08/15/21. The medication was administered daily as ordered. Resident #3 also continued to receive Vilazodone HCL 40 mg tablet daily in the morning for depression. Review of the nurse's notes from 11/01/21 to current revealed there was no documentation related to the pharmacy recommendation being implemented. Interview on 02/09/22 at 5:04 PM with the Director of Nursing (DON) confirmed the pharmacy recommendation had not been implemented as indicated by the physician. Review of the facility policy, Unnecessary Drugs-Without Adequate Indication for Use, revised 10/30/20, stated, it is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs. Documentation will be provided in the resident's medical record to show adequate indications for medication's use and the diagnosed condition for which it was prescribed. 2. Review of the medical record for Resident #67 revealed an admission date of 06/08/21 with diagnosis including schizoaffective disorder, mood disorder, unspecified psychosis not due to substance abuse or physiological, major depressive disorder, anxiety and personality disorder. Review of the quarterly MDS dated [DATE] for Resident #67 revealed the resident was cognitively intact with no behaviors. The resident received no psychological treatment and received antidepressant, antianxiety, and sedative/hypnotic medications. Review of the physician orders for 02/22 revealed Resident #67 received Ativan (antianxiety), Buspirone (antianxiety), Hydroxizine (antianxiety), Fluoxetine (antidepressant), Zolpidem (sedative) and Roxerem (sedative). Review of the pharmacy recommendations for Resident #67 dated 06/09/21 revealed the pharmacist recommended discontinuing the Zolpidem because the resident was taking multiple medications for insomnia. Review of the physician progress notes revealed no documentation addressing the recommendations. Interview on 02/10/22 at 9:22 A.M. with the DON confirmed Resident #67 was receiving three medications for sleep, and two were sedative/hypnotics. The DON confirmed the were no gradual dose reductions attempted or physician notes to support the continuation of the medications. Review of the facility policy titled Behavior Management Program dated 01/01/21 indicated the Interdisciplinary team (IDT) would review all residents with behaviors or on psychoactive medications quarterly and assess for a possible gradual dose reduction. 3. Review of Resident #60's medical record revealed an initial admission date of 01/07/21 with the latest readmission of 03/21/21. Diagnoses included dementia with behavioral disturbances, anxiety disorders, mood disorder, hypertension, major depressive disorder with psychotic symptoms, pain, restlessness and agitation, history of COVID-19, gastro-esophageal reflux disease, lactose intolerance and insomnia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the mood and behavior revealed the resident had indicators of depression and wandered daily. The resident required supervision with activities of daily living (ADL). The assessment indicated the resident received antipsychotic, antianxiety, hypnotic medications on a routine basis. The assessment indicated a gradual dose reduction (GDR) had not been attempted and the physician had not documented the GDR was clinically contraindicated. Review of the plan of care dated 01/27/21 revealed the resident receives antipsychotic medications as ordered by physician. Haldol GDR on 02/09/21. Interventions included administer medications as ordered, observe for adverse drug effects and notify MD as needed, observe resident for underlying causes of distress behavior. Review of the resident' physician's orders for February 2022 identified an order dated 01/15/22 Zyprexa 2.5 mg by mouth every day for dementia with behavioral disturbances and 01/19/22 for Zyprexa 5 mg by mouth at bedtime for dementia with behavior disturbances. Review of the pharmacy recommendation dated 03/05/21 revealed the pharmacist recommended an appropriate diagnoses for Zyprexa. The physician addressed the recommendation on 05/05/21. On 02/09/22 at 9:03 A.M. interview with the Director of Nursing (DON) verified the pharmacy recommendation was not addressed in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy, the facility failed to administer opioid pain medication according to the ordered pain level for one resident (Resident #3). The deficient practice affected one resident (Resident #3) of eight residents reviewed for unnecessary medications. The facility census was 76. Findings Include: Review of the medical record for Resident #3 revealed an original admission date on 03/30/21 and a readmission date of 05/13/21. Medical diagnoses included unspecified fractures of unspecified shaft of the radius and patella, Type II Diabetes Mellitus with diabetic neuropathy, mood (affective) disorder, adjustment disorder with mixed anxiety and depressed mood, insomnia, and schizoaffective disorder (Bipolar type). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required supervision with set up help only for most Activities of Daily Living (ADLs). The resident required supervision with one staff assist for bed mobility, dressing, toileting and hygiene. The resident took daily antipsychotics, antianxiety, and antidepressant medications. Review of the physician's orders for February 2022 revealed Resident #3 had an order for Oxycodone HCL (an opioid pain medication) capsule 5 milligrams (mg) with instructions to give one capsule by mouth every four hours as needed for moderate pain. The order had a start date of 05/13/21. Review of the pain evaluation dated 06/29/21 revealed Resident #3 had frequent pain in the last five days that limited her day to day activities and affected the resident's mood. The resident reported her pain management regimen was effective. The resident stated she had moderate pain at a level of five on a pain scale from 0 to 10. Resident #3 stated the pain was aching and throbbing. Resident #3 received as needed pain medication. Review of additional pain evaluations dated 08/23/21 and 08/28/21 revealed Resident #3 reported not having any pain. There were no additional pain evaluations since 08/28/21. Review of the plan of care dated 03/30/21 revealed Resident #3 had chronic pain related to comorbidities and a diagnosis of fracture. Interventions included administer pain medications as ordered. Review of the Medication Administration Record (MAR) for November 2021 revealed Resident #3 was administered Oxycodone HCL on the following dates with the following documented pain levels: 11/02/21 with a pain level of two, 11/01/21, 11/09/21, 11/10/21, and 11/13/21 for a pain level of three, 11/08/21, 11/10/21, 11/11/21, and 11/14/21 for a pain level of four, and 11/04/21, 11/15/21, and 11/16/21 for a pain level of five. Review of the MAR for December 2021 revealed Resident #3 was administered Oxycodone HCL on the following dates with the following documented pain levels: 12/08/21 for a pain level of zero, 12/01/21 for a pain level of five, and 12/02/21, 12/11/21, and 12/12/21 for a pain level of four. Review of the MAR for January 2022 revealed Resident #3 was administered Oxycodone HCL on the following dates for the following pain levels: 01/10/22, 01/11/22, 01/24/22, and 01/27/22 for a pain level of zero, 01/01/22 for a pain level of three, 01/07/22, 01/09/22, and 01/10/22 for a pain level of four, and 01/07/22, 01/14/22, and 01/21/22 for a pain level of five. Review of the MAR for February 2022 revealed Resident #3 was administered Oxycodone HCL on the following dates for the following pain levels: 02/01/22 and 02/09/22 for a pain level of zero, 02/06/22 for a pain level of one, 02/06/22 for a pain level of two, 02/06/22 for a pain level of three, 02/05/22 and 02/06/22 for a pain level of four, and 02/05/22, 02/08/22, and 02/10/22 for a pain level of five. Interviews on 02/09/22 at 3:03 P.M. and 02/10/22 at 2:07 P.M. with the Director of Nursing (DON) confirmed Resident #3 was administered Oxycodone HCL with pain levels not indicative of moderate pain. The DON stated the physician order should have included the pain scale or the nurse should have called the physician to clarify the order. Based on nursing judgement, an order for moderate pain would be considered a pain level of six or higher on a pain scale from zero to ten where ten is the greatest level of pain. Review of the facility policy, Unnecessary Drugs-Without Adequate Indication for Use, revised 10/30/20, stated, it is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #3 revealed an original admission date on 03/30/21 and a readmission date of 05/13/21. Medical diagnoses included unspecified fractures of unspecified shaft of the radius and patella, Type II Diabetes Mellitus with diabetic neuropathy, mood (affective) disorder, adjustment disorder with mixed anxiety and depressed mood, insomnia, and schizoaffective disorder (Bipolar type). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required supervision with set up help only for most Activities of Daily Living (ADLs). The resident required supervision with one staff assist for bed mobility, dressing, toileting and hygiene. The resident took daily antipsychotics, antianxiety, and antidepressant medications. Review of the physician's orders for February 2022 revealed Resident #3 had an order for Buspirone Hydrochloride (HCL) (an antianxiety medication) 5 milligrams (mg) with instructions to give two tablets three times a day related to adjustment disorder with mixed anxiety and depressed mood. The order had a start date of 11/29/21. Resident #3 had an order for Olanzapine (an antipsychotic medication) 2.5 mg with instructions to give one tablet daily related to schizoaffective disorder, Bipolar type. The order had a start date of 09/25/21. Resident #3 had an order for Hydroxyzine Pamoate (an antianxiety medication) 25 mg with instructions to give one capsule by mouth daily for anxiety and give two capsules by mouth at bedtime for anxiety. The order had a start date of 08/06/21. In addition, Resident #3 had an order to monitor for side effects of antidepressant medications with a start date of 05/14/21. There were no orders to monitor for side effects of Resident #3's antipsychotic or antianxiety medications. Review of the Medication Administration Records (MAR) from November 2021 through current revealed side effects of Resident #3's antipsychotic and antianxiety medications were not documented as being monitored. Review of the nurse's notes dated from 11/01/21 through current revealed there were no notes related to monitoring side effects of Resident #3's antipsychotic or antianxiety medications. Review of the plan of care dated 03/30/21 revealed Resident #3 received antipsychotic medication. Interventions included administer medications as ordered and observe for adverse drug effects and notify the physician as needed. In addition, Resident #3 used antianxiety medications. Interventions included administer antianxiety medications as ordered by physician and monitor for side effects and effectiveness every shift. Interview on 02/09/22 at 3:03 P.M. with the Director of Nursing (DON) confirmed there were no physician orders to monitor side effects of Resident #3's antipsychotic or antianxiety medications. Therefore, there was no documentation Resident #3 was being monitored for any side effects of the medications. Review of the facility policy, Unnecessary Drugs-Without Adequate Indication for Use, revised 10/30/20, stated, it is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. Furthermore, the attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: adequate monitoring for efficacy and adverse consequences. Based on interview, record review, and review of facility policy the facility failed to monitor behaviors, ensure appropriate diagnosis for antipsychotic medication use, hypnotic/sedative medication in place over 14 days, and monitor for side effects of antipsychotic and antianxiety medications for Resident #3, #52, #60 and #67. This affected four of eight residents reviewed for unnecessary medications. The facility census was 76. Finding include: 1. Review of the medical record for Resident #52 revealed an admission date of 11/05/21 with diagnoses including Alzheimer's disease, anxiety, schizoaffective disorder and Parkinson's disease. Review of the quarterly MDS dated [DATE] for Resident #52 revealed the resident had moderate cognitive impairment with no behaviors. Review of the physician orders for 02/22 revealed Resident #52 received Risperidone three mg by mouth two times daily for Mood disorder. Review of the Medication Administration Record and the Treatment Administration Record revealed the facility did not monitor or document resident behaviors or interventions. Review of the plan of care for Resident #52 revealed a plan for the inappropriate social behavior of garbled, non sensical repetitive speech. The interventions included offer calm reassuring touch, provide medications as ordered and document efficacy. An interview with the Director of Nursing (DON) on 02/09/22 at 3:13 P.M. confirmed that Mood disorder was not an appropriate diagnosis for the use of Risperidone. The facility did not provide a policy for use of anti psychotic medications. 2. Review of the medical record for Resident #67 revealed an admission date of 06/08/21 with diagnoses including schizoaffective disorder, mood disorder, unspecified psychosis not due to substance abuse or physiological, major depressive disorder, anxiety and personality disorder. Review of the quarterly MDS dated [DATE] for Resident #67 revealed the resident was cognitively intact with no behaviors. The resident received no psychological treatment and received antidepressant, antianxiety, and sedative/hypnotic medications. Review of the physician orders for 02/22 revealed Resident #67 received Zolpidem (sedative) and Roxerem (sedative) with start dates of 06/08/21. Review of the pharmacy recommendations for Resident #67 dated 06/09/21 revealed the pharmacist recommended discontinuing the Zolpidem because the resident was taking multiple medications for insomnia. Review of the physician progress notes revealed no documentation addressing the continued use of a sedative/hypnotic for longer than 14 days. Interview on 02/10/22 at 9:22 A.M. with the DON confirmed Resident #67 was receiving three medications for sleep, and two were sedative/hypnotics. The DON confirmed the were no gradual dose reductions attempted or physician notes to support the continuation of the medications past 14 days, Review of the facility policy titled Behavior Management Program dated 01/01/21 indicated the Interdisciplinary team (IDT) would review all residents with behaviors or on psychoactive medications quarterly and assess for a possible gradual dose reduction. 3. Review of Resident #60's medical record revealed an initial admission date of 01/07/21 with the latest readmission of 03/21/21. Diagnoses included dementia with behavioral disturbances, anxiety disorders, mood disorder, hypertension, major depressive disorder with psychotic symptoms, pain, restlessness and agitation, history of COVID-19, gastro-esophageal reflux disease, lactose intolerance and insomnia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the mood and behavior revealed the resident had indicators of depression and wandered daily. The resident required supervision with activities of daily living (ADL). The assessment indicated the resident received antipsychotic, antianxiety, hypnotic medications on a routine basis. The assessment indicated a gradual dose reduction (GDR) had not been attempted and the physician had not documented the GDR was clinically contraindicated. Review of the plan of care dated 01/08/21 revealed the resident uses anti-anxiety medications related to anxiety. Interventions included administer anti--anxiety medication as order and monitor for side effects and effectiveness every shift. Review of the plan of care dated 01/27/21 revealed the resident receives antipsychotic medications as ordered by physician. Haldol GDR on 02/09/21. Interventions included administer medications as ordered, observe for adverse drug effects and notify MD as needed, observe resident for underlying causes of distress behavior. Review of the plan of care dated 07/27/21 revealed the resident is on sedative/hypnotic therapy related to insomnia. Interventions included to maximize daily activities, encourage socialization, administer sedative/hypnotic medications as ordered by physician, monitor/document/report to nurse/MD/as needed for adverse effects. Review of the resident' physician's orders for February 2022 identified an order dated 01/15/22 for Ambien 5 milligrams (mg) by mouth at bedtime, Zyprexa 2.5 mg by mouth every day for dementia with behavioral disturbances and 01/19/22 for Zyprexa 5 mg by mouth at bedtime for dementia with behavior disturbances. Review of the medical record failed to identify and appropriate diagnoses and identified behaviors to support the use of the medication Zyprexa. Review of the Medication Administration Record (MAR) for January and February 2022 revealed the resident received Ambien 5 mg by mouth daily at bedtime. On 02/08/22 at 3:48 P.M. interview with the Director of Nursing (DON) verified the resident lacked an appropriate diagnosis for the use of the Zyprexa. She also verified the resident received the Ambien for more than 14 days and was not reevaluated for continued use. On 02/09/22 at 9:03 A.M. interview with the DON verified the care plans contained no identified behaviors, no documented behaviors to support the use of the antipsychotropic medications

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observations, medical record review, facility policy review, the facility failed to maintain a medication error rate less than five percent. There were six medication errors out of 26 opportunities, resulting in a 23.08 percent medication error rate. This affected three Residents (#67, #56, #60) of seven residents reviewed for medication administration. The facility census was 76. Findings include: 1. Review of the medical record for the Resident #56 revealed an admission date of [DATE]. Diagnoses included Urinary Tract Infection (UTI) and Dementia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of two out of 15 (severe cognitive impairment). She required extensive assistance of one to two or more staff members for Activities of Daily Living (ADL's). Review of physician orders for [DATE] identified orders for Cranberry 450 milligram (mg) two tablets by mouth in the morning for supplementation to equal 900 mg. The order was stated on [DATE] and changed on [DATE]. She was also ordered Potassium Chloride Extended Release (ER) 20 milliequivalents (MEQ) tablet for supplementation on [DATE]. Observation on [DATE] at 8:36 A.M. with Registered Nurse (RN) #159 revealed she administered two cranberry 425 mg tablets instead of the ordered two tablets of 450 mg of cranberry. RN #159 also crushed the resident's potassium ER and administered it with the other ordered crushed and opened capsule medications in chocolate pudding. Interview on [DATE] at 8:58 A.M. with RN #159 confirmed potassium chloride ER was crushed and the administered cranberry was 425 mg instead of the ordered 450 mg. Review of the facility provided drug information titled, Cranberry dated [DATE] revealed cranberry tablets were available to administer in divided doses. Review of the facility provided drug information titled, Potassium Chloride dated [DATE] revealed tablets were to be swallowed whole, not chewed, crushed, or broken. 2. Review of the medical record for the Resident #67 revealed an admission date of [DATE]. Diagnoses included Allergic Rhinitis and intervertebral disc degeneration. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was not assessed cognitively with a Brief Interview of Mental Status (BIMS) and required extensive assistance of one to two staff members. Review of the BIMS dated [DATE] revealed the resident was cognitively intact with a score of 13 out of 15 (intact cognition). Review of physician orders for [DATE] identified orders to apply a Salonpas Pain Relieving Patch 4% topically to the resident's back one time a day for intervertebral disc degeneration with a start date of [DATE]. The resident also had an order for one spray to each nostril of Fluticasone 50 mcg daily for nasal congestion with a start date of [DATE]. Observation on [DATE] at 9:08 A.M. of the medication administration with Licensed Practical Nurse (LPN) #128 revealed she instructed the resident to spray two sprays of the fluticasone 50 mcg into each nostril. She also did not apply the Salonpas Pain Relieving patch due to the resident's request to apply it at a later date. LPN #128 removed the pain patch from the room and placed in in the medication cart after the medication administration. Interview on [DATE] at 9:15 A.M. with LPN #128 confirmed the pain patch was not applied and was placed back into the medication cart. She also confirmed she instructed the resident to administer two sprays nasally of the fluticasone despite the order stating one spray to each nostril. Interview on [DATE] at 3:47 P.M. with Resident #67 revealed her lidocaine pain patch was never applied. Observation and interview on [DATE] at 3:51 P.M. with the Director of Nursing (DON) and Resident #67 confirmed the resident did not have a pain patch in place per her orders and the application of the pain patch was signed off in the Electronic Medication Administration Record (EMAR). Review of the facility provided drug information titled, Fluticasone dated [DATE] revealed the drug was to be used as ordered by the doctor. Review of the facility provided drug information titled, Lidocaine dated [DATE] revealed the patch was to be placed topically at the same time every day. 3. Review of the medical record for the Resident #60 revealed an initial admission date of [DATE] and a readmission date of [DATE]. Diagnoses included Urinary Tract Infection (UTI) and Dementia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of seven out of 15 (severe cognitive impairment). She required supervision and set up for all Activities of Daily Living (ADL's). Review of physician orders dated [DATE] identified orders to administer two 125 milligram (mg) capsules of Divalproex Sodium Delayed Release (DR) Sprinkle for Dementia with behavioral disturbances. A second order dated [DATE] revealed the resident was to be administered one tablet of Senna plus 8.6-50 mg (stool softener) for constipation. Review of the care plan dated [DATE] revealed the resident had a mood problem related to disease process of anxiety and depression. Interventions included administration of medications per physician orders. There was no care plan for constipation. Observation on [DATE] at 4:35 P.M. of Licensed Practical Nurse (LPN) #129 administering medications to Resident #60 revealed one Senna plus (stool softener) tablet was crushed. Further observation revealed two capsules of divalproex sodium delayed release (DR) 125 milligrams (mg) were opened and the capsule contents were added to the other crushed medications with pudding. Interview on [DATE] at 4:45 P.M. with LPN #129 confirmed the observations. Review of the facility provided drug information titled, Docusate and Senna dated [DATE] revealed other drugs should not be taken within two hours of this drug. Review of the facility provided drug information titled, Valproic Acid and Derivative dated [DATE] revealed the capsules were to be swallowed whole, not chewed, crushed, or broken. Review of the facility policy titled, Medication Administration dated [DATE] revealed medication source was to be verified with the EMAR to verify dose, identify expiration dates and notify the nurse manager if medication was expired, administer medication as ordered in accordance with manufacturer instructions such as do not crush medication with do not crush instructions, sign EMAR after the medication was administered, and correct any discrepancies and report to the nurse manager.

Based on staff interview, observations, facility policy review, the facility failed to ensure expired medications and open medications that were undated were removed from the medication cart. This specifically affected two residents (#370 and #372) but had the potential to affect all residents on the north long hall. The facility census was 76. Findings include: Observation on 02/10/22 at 10:50 A.M. and 1:40 P.M. with Agency Registered Nurse (RN) #3000 of medication storage on the medication cart revealed facility stock medications vitamin B complex with electrolytes dietary supplement, melatonin 5 milligrams (mg), Calcium Carbonate chewable antacid, Cranberry 450 mg extract, Fish oil 1000 mg (300 mg omega-3), Sodium chloride tablets 1 gram, and oyster shell calcium 500 mg plus vitamin D were opened but undated. Further Review of the medication cart revealed Novolog mix 70-30 flex pen (Insulin) for Resident #370 was opened and undated and Flonase for Resident #372 was opened and undated. Further Review of the medication cart revealed Mucus relief guaifenesin 400 mg had an expiration date of 01/22. Interview on 02/10/22 at 11:00 A.M. and 1:49 P.M. with RN #3000 confirmed the findings. After confirming the findings, she then placed the medication back onto the Medication Cart. Observation on 02/10/22 at 11:20 A.M. revealed a sterile water for injection vial with 20 milliliters (ml), opened, but undated in the north medication room. Licensed Practical Nurse (LPN) #160 confirmed the findings at 11:30 A.M. Review of the facility policy titled, Medication Administration dated 01/01/21 revealed medication source was to be verified with the Electronic Medication Administration Record (EMAR) to identify expiration dates and notify the nurse manager if medication was expired and correct any discrepancies and report to the nurse manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to provide ordered laboratory services for residents. This affected two of four sampled residents reviewed for laboratory services (Residents #3 and #60). Findings Include: 1. Review of the medical record for Resident #3 revealed an original admission date on 03/30/21 and a readmission date of 05/13/21. Medical diagnoses included unspecified fractures of unspecified shaft of the radius and patella, Type II Diabetes Mellitus with diabetic neuropathy, mood (affective) disorder, adjustment disorder with mixed anxiety and depressed mood, insomnia, and schizoaffective disorder (Bipolar type). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required supervision with set up help only for most Activities of Daily Living (ADLs). The resident required supervision with one staff assist for bed mobility, dressing, toileting and hygiene. Review of the physician's orders for February 2022 revealed Resident #3 had an order to obtain a hemoglobin A1c (HgbA1c) blood test every three months. The order had a start date on 10/05/21. Review of the Medication Administration Records (MAR) dated from October 2021 and January 2022 revealed on 10/05/21 there was a code of see nurse notes entered. The rest of the month was marked as administered. On 01/05/22, the lab order was marked as administered. Review of the electronic medical record for Resident #3 revealed there were no HgbA1c lab results included in the record. Review of nurse's notes dated from 10/01/21 through current revealed there were no notes related to completion of the HgbA1c lab. Review of the plan of care dated 03/30/21 revealed Resident #3 had Diabetes Mellitus with a history of being non-compliant with taking medications and insulin. Interventions included administer diabetes medication as ordered by physician, monitor and document side effects and effectiveness, and obtain fasting serum blood sugar as ordered by physician. The care plan did not address obtaining labs as ordered by the physician. Interview on 02/09/22 at 2:13 P.M. with the Director of Nursing (DON) confirmed Resident #3 did not have HgbA1c lab drawn as ordered by the physician. The DON stated the staff would be educated related to proper documentation in Resident #3's MAR related to lab orders. 2. Review of Resident #60's medical record revealed an initial admission date of 01/07/21 with the latest readmission of 03/21/21. Diagnoses included dementia with behavioral disturbances, anxiety disorders, mood disorder, hypertension, major depressive disorder with psychotic symptoms, pain, restlessness and agitation, history of COVID-19, gastro-esophageal reflux disease, lactose intolerance and insomnia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the resident' physician's orders for February 2022 identified an order dated 10/28/21 for a Basic Metabolic Panel (BMP) every six months in October and April. Review of the medical record contained no results for the 10/28/21 BMP. On 02/09/22 at 2:16 P.M. interview with Director of Nursing (DON) verified the 10/28/21 ordered BMP was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide mechanically altered foods in the form prescribed by the physician. This affected one resident (#17) of the five residents reviewed for nutrition. The facility census was 76. Findings include: Record review for Resident #17 revealed this resident was admitted to the facility on [DATE] and had diagnoses including epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/25/22, revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require extensive assistance from one staff member for eating. This resident was assessed to have received a mechanically altered diet. Review of the care plan, dated 02/01/22, revealed this resident had the potential for nutritional deficits and received an altered texture diet. Interventions included to assist with meals as needed and provide and serve diet as ordered. Review of the active physicians order, dated 01/25/22, revealed this resident had orders to receive a pureed texture diet with nectar/mildly thick consistency fluids. Observation on 02/07/22 at 12:22 P.M. revealed Resident #17 was being assisted to consume her lunch meal by Activity Director #200. The residents lunch meal tray consisted of a pork chop which had been ground into small chunks and not pureed, mashed potatoes, and spinach was was chopped and also not pureed. The meal ticket lying on the residents tray revealed the resident was to have received pureed pork chops, mashed potatoes, and pureed brussel sprouts. Interview with Activity Director #200 on 02/07/22 at 12:24 P.M. verified the meal ticket for Resident #17 stated the resident was to receive a pureed pork chop, mashed potatoes, and pureed spinach. Activity Worker #200 verified the pork chop and the spinach the resident received had not been pureed. Observation and interview with Licensed Practical Nurse (LPN) #110 on 02/07/22 at 12:28 P.M. verified Resident #17 was ordered to receive pureed foods and the pork chop and spinach on the residents meal tray were ground and not pureed. Review of the facility policy titled Therapeutic Diet Orders, revised 07/31/20, revealed a mechanically altered diet was one in which the texture or consistency of food is altered to facilitate oral intake and dietary and nursing staff were responsible for providing therapeutic diets in the appropriate form as prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain a complete record in the area of psychiatric consults for one resident (#60). This affected one of 24 sampled residents. Findings Include: Review of Resident #60's medical record revealed an initial admission date of 01/07/21 with the latest readmission of 03/21/21. Diagnoses included dementia with behavioral disturbances, anxiety disorders, mood disorder, hypertension, major depressive disorder with psychotic symptoms, pain, restlessness and agitation, history of COVID-19, gastro-esophageal reflux disease, lactose intolerance and insomnia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the resident' physician's orders for February 2022 identified an order dated 01/15/22 for Ambien 5 milligrams (mg) by mouth at bedtime, Zyprexa 2.5 mg by mouth every day for dementia with behavioral disturbances and 01/19/22 for Zyprexa 5 mg by mouth at bedtime for dementia with behavior disturbances. On 02/09/22 at 9:35 A.M. interview with the Director of Nursing (DON) revealed the resident is seen by psychiatry, however the psychiatric consult notes were not available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a clean and sanitary environment in residents rooms. This affected the two residents (#29 and #55). The facility census was 76. Findings include: Observation on 02/07/22 at 10:15 A.M. revealed the trash can in room [ROOM NUMBER] was observed to be filled with garbage which was overflowing onto the floor. The floor, recliner,trash can, and the bottom legs of the bedside stand located in the room were observed to have an excessive amount of a dried, brown, sticky substance covering them. Observation and interview with State Tested Nursing Assistant (STNA) #165 on 02/07/22 at 10:24 A.M. revealed one of the residents in the room had a behavior which included spitting on the floor and items in the room. STNA #165 verified the floor, recliner, and bottom legs of the bedside stand in the room were covered with an excessive amount of a dried, brown, sticky substance which most likely was spit. Observation on 02/08/22 at 7:58 A.M. revealed the trash can and bottom legs of the bedside table in room [ROOM NUMBER] continue to be covered with a dried, brown, sticky substance. Observation and interview with Licensed Practical Nurse (LPN) #110 on 02/08/22 at 8:05 A.M. verified the trash can and bottom legs of the bedside table in room [ROOM NUMBER] were covered in a dried, brown, sticky substance. Observation on 02/09/22 at 3:45 P.M. revealed the trash can and bottom legs of the bedside table in room [ROOM NUMBER] continued to be covered with a dried, brown, sticky substance. Observation and interview with Assistant Director of Nursing (ADON) #700 on 02/09/22 at 3:45 P.M. verified the trash can and bottom legs of the bedside table in room [ROOM NUMBER] were covered in a dried, brown, sticky substance which needed to be cleaned. Review of the facility policy titled Routine Cleaning and Disinfection, revised on 10/17/20, revealed cleaning referred to the removal of visible soil from objects and surfaces and consistent surface cleaning and disinfection would be conducted with a detailed focus on high touch areas to include resident chairs and tray tables. This deficiency substantiates Complaint Number OH00130055.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and facility policy review, the facility failed to monitor bruising following a fall affecting three Residents (#5, #30, and #52) and failed to ensure the hospice notes were available onsite or in the resident's medical record affecting Resident #320 of four residents reviewed for hospice. The facility census was 76. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/03/21. Diagnoses included palliative care, muscle weakness, unspecified fall, abnormalities of gait and mobility, cognitive communication deficit, unsteady on his feet, and Dementia without behavioral disturbance. Review of the physician orders for December, 2021 revealed no orders to monitor bruising. The resident was ordered Xarelto Tablet 20 MG on 11/03/21 for his atrial fibrillation. The Xarelto was discontinued on 12/14/2021. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/10/21, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of four out of 15 indicating severe cognitive impairment. He required limited to extensive assistance of one to two staff members for Activities of Daily Living (ADL's). His behaviors included inattention, disorganized thinking, and other behavioral symptoms not directed towards others. Review of the Electronic Medication Administration Record (EMAR) for November and December, 2021 revealed the resident was administered Xarelto as ordered. Review of the Skin assessment dated [DATE] revealed the resident had deep purple bruising on the left hip. The assessment did not have measurements of the bruising but indicated x-rays were ordered. Review of the progress note dated 12/07/21 at 2:15 P.M. by Registered Nurse (RN) #159 revealed the resident suffered a fall and had deep purple bruising and swelling. Review of the progress note dated 12/07/21 at 9:15 P.M. by Unit Manager (UM) RN #119 revealed the resident's hip was without changes. Review of the progress note dated 12/08/21 at 10:32 A.M. MDS Licensed Practical Nurse (LPN) #999 revealed monitoring of the bruising to the resident's left hip was to occur. Review of the progress note dated 12/08/21 at 5:31 P.M. by RN #159 revealed the resident's daughter was updated on the resident's hip being bruised and swollen. Review of the Skin Assessments dated 12/14/21, 12/25/21, 01/03/22, 01/12/22, 01/19/22, and 01/26/22 revealed the resident did not have any new or existing abnormal skin conditions. Review of the progress note dated 12/14/21 at 5:08 P.M. revealed the resident's Xarelto was discontinued due to the resident being a fall risk to help with bruising and the hip remained with a quite a bit of bruising. Review of the plan of care dated 01/23/22 revealed the resident did not have any care plans related to bruising. Review of the Skin assessment dated [DATE] revealed the resident did not have any new or continued skin conditions. Interview on 02/08/22 at 5:57 P.M. with the Director of Nursing (DON) confirmed bruising should be monitored, an order to monitor bruising should have been placed, and documentation of bruise monitoring should be in the medical record. Interview on 02/09/22 at 10:01 A.M. with LPN #129 revealed the resident had bruising in December following a fall but did not recall an order to monitor the bruising. Interview on 02/09/22 at 10:31 A.M. with the Director of Nursing (DON) confirmed bruising was to be monitored for healing or worsening. Interview on 02/09/22 at 2:12 P.M. with the DON revealed the facility does not have a bruise monitoring policy. She stated the facility's procedure was to monitor bruising each shift and document the findings, and there should have been an order in place to monitor the bruising. Interview on 02/09/22 3:14 P.M. with the DON confirmed there was no documentation of bruise monitoring for the resident. 2. Review of the medical record for Resident #30 revealed an admission date of 12/29/21 and discharge date of 02/07/22. Diagnoses included unspecified fall, major depressive disorder, anxiety disorder, disorientation, unsteadiness on his feet, cognitive communication deficit, weakness, reduced mobility, muscle weakness, lack of coordination, and insomnia. Review of the plan of care dated 12/29/21 revealed the resident did not have any bruise monitoring plan. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 01/05/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 out of 15 (cognitively intact). He required extensive assistance of one to two or more staff for Activities of Daily Living (ADL's) and he exhibited other behavioral symptoms not directed towards others. Interview on 02/07/22 at 10:22 A.M. with Resident #30 revealed he fell last week and his ankle, hip, and knee were painful. He stated he believed the pain was due to the bruising and being sore. Interview on 02/07/22 11:55 A.M. with Registered Nurse (RN) #159 confirmed the resident fell last week but did not suffer from any injuries outside of bruising on his hip/leg. Upon entering the residents room the RN confirmed with the resident that he was experiencing ongoing left side hip pain felt like bruising pain. Interview on 02/09/22 at 2:12 P.M. with the Director of Nursing (DON) revealed the facility does not have an alarm policy or bruise monitoring policy. She stated the facility's procedure was to monitor bruising each shift and document the findings, and there should be an order in place to monitor the bruising. Interview on 02/09/22 at 3:14 P.M. with the DON confirmed there was no documentation of bruise monitoring for the resident. Review of the fall risk assessment dated [DATE] and 02/05/22 revealed the resident was a fall risk and required fall interventions. According to the assessments, the resident's last known fall was 02/05/22. Review of the falls initial charting dated 02/05/22 revealed the resident suffered an unwitnessed fall. The documentation revealed the only noted injury was a laceration to the left outer knee where the resident stated he hit his knee against the toilet paper dispenser. Review of the physician orders for February, 2022 revealed no orders for bruise monitoring. Review of the nurses notes dated 02/05/22 at 7:40 P.M. by Licensed Practical Nurse (LPN) #9000 revealed the resident suffered an unwitnessed fall as a result of increased confusion. He was on an antibiotic for a Urinary Tract Infection (UTI). One laceration was noted to the left knee, but no additional injuries were noted. A sign was placed on the bathroom door to remind the resident to ask for assistance. Review of the nurses notes dated 02/06/22 at 7:40 A.M. by LPN #129 revealed the resident had multiple bruises on his bilateral lower extremities (BLE) and bilateral upper extremities (BUE), as needed (PRN) medication was administered for soreness from his fall on 02/05/22. Review of the nurses notes dated 02/07/22 at 11:58 A.M. by Registered Nurse (RN) #159 revealed the resident reported new left hip pain related to his fall on 02/05/22 to the surveyor. Further review of the progress note revealed the resident described the pain as oh left hip kinda bruise like and he denied left foot pain. The Medical Director (MD) was updated. 3. Review of the medical record for Resident #320 revealed an admission date of 01/25/22. Medical diagnoses included intrahepatic bile duct carcinoma, secondary malignant neoplasm of liver and intrahepatic bile duct, chronic obstructive pulmonary disorder (COPD), and encounter for palliative care. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mildly impaired cognition and scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS). The resident required supervision from one staff to complete Activities of Daily Living (ADLs). The resident received hospice care. Review of the current physician's orders for February 2022 revealed Resident #320 had an order to admit to hospice with a start date of 01/25/22. Review of the nurse's notes from admission to current revealed there were not any notes related to hospice services provided to Resident #320. Review of the plan of care dated 01/26/22 revealed Resident #320 was a Do Not Resuscitate Comfort Care (DNRCC) code status. Interventions included hospice services with a contracted hospice agency. Interview on 02/08/22 at 5:59 P.M. with the Administrator confirmed hospice communication notes were not included as a part of Resident #320's electronic medical record and were not kept onsite. The facility contacted the hospice agency when needed to have communication notes faxed to the facility. Review of the facility hospice agreement dated 01/17/17 revealed the facility shall prepare and maintain complete and detailed records concerning each hospice patient receiving facility services under this agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state laws and regulations and Medicare and Medicaid program guidelines. The facility shall retain such records for a minimum of six years from the date of discharge of each hospice patient or such other time period as required by applicable federal and state law. Review of the facility policy, Hospice Services Facility Agreement, revised 07/28/20, stated, it is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. 4. Review of the medical record for Resident #52 revealed an admission date of 11/05/21 with diagnoses including Alzheimer's disease, adult failure to thrive, chronic obstructive pulmonary disorder, schizoaffective disorder and Parkinson's disease. Review of the quarterly MDS dated [DATE] revealed Resident #52 had cognitive impairment with no behaviors. The resident required extensive assistance of one person for bed mobility, dressing, toileting and personal hygiene. The resident required limited assistance of one person for transfers and supervision for walking in her room. The resident had no recent falls or skin impairments. Review of the physician orders for 02/22 revealed Resident #52 did not have an order to monitor the bruise noted to her left eyebrow and forehead. Review of the fall assessment dated [DATE] indicated Resident #52 was found sitting on the floor beside her bed. The nurse completed an assessment and found no injury. Review of the nursing progress notes from 02/05/22 through 02/08/22 revealed no documentation of the bruise to Resident #52 left eyebrow and forehead. Review of the plan of care revealed the fall and skin care plans were silent on the injury/bruise to Resident #52 left eyebrow/forehead from the fall on 02/05/22. Observations of Resident #52 from 02/07/22 through 02/09/22 revealed the resident had a purple with brown edges bruise to the left eyebrow/forehead area. An interview on 02/09/22 at 8:56 A.M. with Licensed Practical Nurse (LPN) #128 revealed the bruise was being monitored, however failed to provide any documentation of the monitoring. An interview on 02/09/22 at 2:12 P.M. with the Director of Nursing (DON) confirmed the bruise to Resident #52 left eyebrow/forehead was not being monitored or documented in the nursing notes. The DON also stated the facility did not have a policy on monitoring of bruises.