Based on observation, interview, record review, and facility policy review, the facility failed to obtain an order for self-administration of medication and failed to assess the resident's capacity to self-administer medication prior to leaving medication in the room for 1 (Resident #49) of 19 sampled residents. Findings included: A facility policy titled, Self-Administration of medications, dated 10/30/2017, indicated, Each resident who desires to self-administer medication is permitted to do so if the interdisciplinary team has determined that the practice would be safe for the resident and other residents in the facility. An admission Record revealed the facility admitted Resident #49 on 05/08/2024. According to the admission Record, the resident had a medical history that included chronic obstructive pulmonary disease (COPD) and unspecified macular degeneration. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2025, indicated Resident #49 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #49's Care Plan Report, included a focus area initiated 08/29/2024, that indicated the resident had COPD. Interventions directed staff to provide inhalers as ordered. Resident #49's Order Summary Report, with active physician's orders as of 06/02/2025, included an order dated 05/09/2025, for Breo Ellipta inhalation aerosol powder 200-25 milligrams per actuation, with directions to inhale one puff orally one time per day and to rinse the mouth with water and spit after each use. The Order Summary Report revealed no physician orders or instructions to self-administer Breo Ellipta or to keep the medication at the resident's bedside. On 06/01/2025 at 11:15 AM, the surveyor observed a Breo Ellipta inhaler on Resident #49's bedside table. Resident #49 stated Licensed Practical Nurse (LPN) #4 left the inhaler in their room when the LPN left the room to attend to another task. The resident stated they told LPN #4 that they would take the medication. Resident #49 stated that leaving medication in their room was not a common occurrence, and prior to facility admission they had taken their medication independently. Resident #49 stated they were interested in keeping the inhaler at their bedside and self-administering the medication as needed. LPN #4 was interviewed on 06/01/2025 at 12:07 PM. LPN #4 stated the facility policy indicated medications should not be left at a resident's bedside. She stated before staff could leave medication at a resident's bedside, a physician's order had to be obtained, and an assessment for self-administration had to be completed. LPN #4 stated she was unsure whether Resident #49 had been assessed for medication self-administration. Per LPN #4 she forgot that she left the inhaler in Resident #49's room. LPN #4 stated she left Resident #49's room to care for another resident who was calling her name, for a non-emergent situation. The Director of Nursing (DON) was interviewed on 06/02/2025 at 9:00 AM. The DON stated leaving medications at the bedside was not good practice and was not his expectation. The DON stated nurses were expected to watch residents take medications to verify the right medication was taken. The DON stated that prior to self-administration of medications, an assessment had to be completed. The DON further stated that Resident #49 had the capacity to self-administer medications but had not been assessed and did not have a physician's order for self-administration. The Administrator was interviewed on 06/05/2025 at 11:22 AM. The Administrator stated that prior to self-administration of a medication, she expected the nurses to complete an assessment. The Administrator stated she was unaware of Resident #49's cognitive ability or the ability to self-administer medications.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure they maintained an environment as free from accident hazards as possible by ensuring staff did not leave medication at a resident's bedside who was not assessed to administer their own medication. The deficiency affected 1 (Resident #5) of 2 sampled residents reviewed for accident hazards. Findings included: A facility policy titled, Medication Administration, effective 06/21/2017, revealed 11. Administer medication and remain with resident while medication is swallowed. Never leave a medication in a resident's room without orders to do so. Per the policy, 14. Return to the medication cart and document medication administration with initials on the Medication Administration Record (MAR) immediately after administering medication to each resident. An admission Record revealed the facility admitted Resident #5 on 10/05/2021. According to the admission Record, the resident had a medical history that included diagnoses of dementia with mood disturbance, late onset Alzheimer's disease, chronic diastolic congestive heart failure, anemia, recurrent major depressive disorder, essential hypertension, and dorsalgia (back pain). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2025, revealed Resident #5 had Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Resident #5's Care Plan Report included a focus area initiated 10/08/2021, that indicated Resident #5 had altered cognitive/communication related to a diagnosis of dementia as evidenced by confusion related to time and impaired short-term memory. Interventions directed staff to assist the resident with necessary decision making, be consistent with daily routines, and offer verbal reminders and cues, as necessary. The Care Plan Report revealed no indication that the resident self-administered their medication. Resident #5's Order Summary Report, with active orders as of 06/02/2025, included the following orders: - acetaminophen 325 milligrams (mg) two tablets every six hours as needed for pain or elevated temperature. - aspirin 81 mg one tablet daily. - ferrous gluconate (an iron supplement) 324 mg one tablet daily. - midodrine hydrochloride (HCl) (an anti-hypotensive medication) 5 mg twice a day, to be held for a blood pressure exceeding 150/100 millimeters of mercury (mmHg). - potassium chloride (a mineral supplement) extended release (ER) 20 milliequivalents (MEQ) one tablet twice a day. - potassium chloride ER 10 MEQ one tablet two times a day, to be given with the 20 MEQ tablet. - pantoprazole sodium (a medication that relieved symptoms such as heart burn, difficulty swallowing, and persistent cough) 40 mg one tablet twice a day. - senna (a laxative) 8.6 mg one tablet on Mondays, Wednesdays, and Fridays. - sertraline HCl (an anti-depressant medication) 100 mg one tablet a day. - sertraline HCl 25 mg one tablet a day. An observation on 06/02/2025 at 8:43 AM revealed multiple medications on a paper towel on Resident #5's overbed table. Medication observed on the paper towel included a white pill, a grayish white tablet broken into three pieces, a pink pill, an orange pill, a green tablet, a blue pill, a tan pill, and one-half of a white tablet. Resident #5 stated they left the medication every morning in their room for them to take. Resident #5 stated they were unable to name the pills or what the medications were for. Resident #5's MAR for the timeframe 06/01/2025-06/30/2025, revealed Registered Nurse (RN) #1 signed Resident #5's MAR on 06/02/2025, indicating she administered medication to Resident #5. RN #1 was interviewed on 06/02/2025 at 8:47 AM. RN #1 stated the facility's policy indicated medications were not to be left at a resident's bedside. The RN stated she did not leave medication in resident rooms because the resident may throw the medication away instead of taking the medication. RN #1 stated there were residents in the facility that were able to self-administer medications and identified Resident #5 as a resident who was able to self-administer medication. She stated she was unsure if Resident #5 had been assessed for self-administration or had a physician's order to self-administer medication. RN #1 stated she had been trained by multiple staff, and they all told her it was fine to leave medication at Resident #5's bedside. RN #1 checked Resident #5's physician orders and stated the medications she left at the resident's bedside included potassium, ferrous gluconate, aspirin, two tablets of acetaminophen, sertraline, midodrine, pantoprazole, and senna. RN #1 stated she gave the resident the medications around 8:30 AM on 06/02/2025. RN #1 stated she should not have left the medication in the resident's room without knowing if there was an order to leave the medication at the bedside or if the resident had been assessed to self-administer medications. On 06/02/2025 at 8:59 AM, the Registered Nurse (RN) Regional Clinician stated medication was not to be left at a resident's bedside without a physician's order and a completed self-administration assessment. The RN Regional Clinician went to Resident #5's room and heard Resident #5 say the nurse left the medication in the room. The RN Regional Clinician stated she had not reviewed Resident #5's medical record and was unaware if the resident had been assessed to self-administer medication. The Director of Nursing (DON) was interviewed on 06/02/2025 at 9:00 AM. The DON stated it was not good that medications had been left at Resident #5's bedside and he expected nurses not to leave medications at the bedside. He stated that the danger of leaving medication at bedside included the resident not taking the medication. The DON stated the expectation was for nurses to watch residents take medications to verify the medications were taken. The DON stated he felt RN #1 showed poor judgement in not returning to the room after she was notified the medications were at the resident's bedside and RN #1 required more training. The DON stated it was a standard of practice not to leave medication at a resident's bedside, and Resident #5 lacked the capacity for self-administration of medications. The Administrator was interviewed on 06/05/2025 at 11:22 AM. The Administrator stated that prior to a resident self-administering medication, the nurses were expected to complete a self-administration assessment. The Administrator stated she was familiar with Resident #5 and stated she did not think the resident had the ability to self-administer medication. The Administrator stated she would not have expected the nurse to leave the medication at the resident's bedside.

Based on observation, interview, record review, and facility policy review, the facility failed to secure an indwelling urinary catheter for 1 (Resident #39) of 4 sampled residents reviewed for urinary catheters. Findings included: A facility policy titled, Catheter Care/Urinary, revised 07/2006, indicated staff should 12. Secure catheter utilizing a leg band. An admission Record revealed the facility readmitted Resident #39 on 03/28/2025. The admission Record indicated the resident had a medical history that included a diagnosis of urinary retention. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/04/2025, indicated Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #39 required substantial to maximal assistance with toileting hygiene and had an indwelling urinary catheter. Resident #39's Care Plan Report, revealed a focus area initiated 04/17/2025, that indicated the resident had the potential to develop complications due to the use of an indwelling urinary catheter. Interventions directed staff to secure the urinary catheter tubing to prevent accidental dislodgement. Resident #39's Order Summary Report for active physician orders as of 06/03/2025 revealed an order started dated 06/03/2025, for an indwelling urinary catheter. The Order Summary Report also revealed an order dated 03/28/2025, for a urinary catheter securement device to be replaced every seven days and as needed, alternating sites/legs. On 06/02/2025 at 8:31 AM, Resident #39 stated they used an indwelling urinary catheter due to pelvic floor muscle issues. The surveyor noted Resident #39 was in a wheelchair and no device was observed that secured the resident's urinary catheter tubing. An observation on 06/03/2025 beginning at 11:36 AM, revealed State Tested Nurse Aide (STNA) #5 and STNA #6 were providing catheter care for Resident #39. The observation revealed the resident's indwelling urinary catheter tubing was not secured. STNA #6 stated when Resident #39 was initially readmitted to the facility, there was a piece of tape being used to secure the urinary catheter tubing to the resident's leg. At the time of the observation, a piece of tape was observed wrapped and knotted on the catheter tubing but was not connected to the resident's leg to secure the tubing in place. The STNA's stated the facility had other devices to secure urinary catheter tubing but was unsure whether a device had been tried for Resident #39. STNA #2 was interviewed on 06/03/2025 at 12:00 PM. STNA #2 stated she was the resident's primary STNA for 06/03/2025 and had taken care of Resident #39 off and on since admission. She stated the resident had a urinary catheter securement device at times, but she was unsure the last time she had seen the catheter secured. The STNA stated she had been in Resident #39's room on 06/03/2025 but had not paid attention to the resident's indwelling urinary catheter. Licensed Practical Nurse (LPN) #7 was interviewed on 06/03/2025 at 12:07 PM. LPN #7 stated she was assigned to provide care for Resident #39. LPN #7 stated the facility policy was to monitor every shift to ensure a securement device was in place and to replace the device weekly and as needed. LPN #7 stated she had not received any reports about Resident #39's securement device not being in place. She stated having the catheter secured was important to prevent trauma to the resident. The Director of Nursing (DON) was interviewed on 06/03/2025 at 1:46 PM. The DON stated the urinary catheter tubing should be secured to the resident to ensure the catheter did not become displaced. He stated if the device was not in place he expected the STNA to report to the nurse, who should apply a device for the resident. The Administrator was interviewed on 06/05/2025 at 11:20 AM. She stated that she expected staff to secure Resident #39's catheter to prevent the catheter from being pulled and causing the resident trauma.

Based on record review, observation, resident interview, staff interview, and review of manufacturer's specifications, the facility failed to provide a mattress in accordance with a resident's preference and care needs. This affected one (Resident #21) of one resident reviewed for reasonable accomodations of needs and preferences. The census was 66. Findings include: Review of the medical record for Resident #21 revealed an admission date of 04/30/22 with a diagnosis of diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #21 dated 05/07/22 revealed resident was cognitively intact and required extensive assistance with activities of daily living (ADLs). Review of the nurse progress notes for Resident #21 dated 05/31/22 revealed resident was moved into the room she was residing in at the time of the survey. Review of the July 2022 monthly physician orders for Resident #21 revealed there were no orders for the resident to have a scoop mattress. Review of the care plan for Resident #21 revealed no intervention for a scoop mattress. Review of Resident #21's assessment history revealed no assessments completed regarding the risks and benefits of using a scoop mattress for the resident. Observation on 07/25/22 at 9:25 A.M. of Resident #21 revealed the resident's bed had a scoop mattress with raised edges. Interview on 07/25/22 at 9:25 A.M. Resident #21 reported she moved into her room on 05/31/22 and state the mattress was uncomfortable and she requested a new one. The new mattress provided, was softer and more comfortable for sleeping, however it was a scoop mattress. Resident #21 verified she was able to transfer herself from bed to wheelchair and from wheelchair to bed, but it was more difficult to self-transfer due to the raised edges of the scoop mattress. Interview on 07/28/22 at 8:21 A.M. with the Director of Nursing (DON) revealed the scoop mattress had been in place for Resident #21 for approximately two to three weeks. The DON confirmed he interviewed nursing staff who reported Resident #21 complaint about her mattress being too hard, so they provided her with a scoop mattress. The DON reported a scoop mattress was most commonly used as a fall prevention intervention and should be discussed and reviewed by the Interdisciplinary Team (IDT) and should be ordered and care planned prior to use. The DON verified Resident #21 was never evaluated for appropriate use of a scoop mattress. Review of the manufacturer's specifications for the mattress Resident #21 was using, dated 03/20 revealed the mattress came with three inch raised edges around the perimeter.

Based on record review, observation, resident interview, and staff interview, the facility failed to provide a homelike environment for Resident #54. This affected one (Resident #54) of three residents reviewed for homelike environment. The census was 66. Findings include: Review of the medical record for Resident #54 revealed an admission date of 08/17/21 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the MDS for Resident #54 dated 06/07/22 revealed the resident was cognitively intact and required extensive assistance of one staff with hygiene and bathing. Observation on 07/25/22 at 12:31 P.M. of Resident #54's room revealed the resident had three large pictures hung in her room. Two of the pictures were of landscapes and the other picture was some type of fabric/needlework in a wooden frame. Interview on 07/25/22 at 12:31 P.M. Resident #54 confirmed the picture with the fabric was brought from home and Maintenance Director (MD) #31 hung it on the wall for her. Resident #54 further confirmed the two other landscape pictures were hanging on the wall when she moved in, and she asked MD #31 to remove them, but he refused to do so. Interview on 07/27/22 at 4:08 P.M. with MD #31 confirmed Resident #31 asked him to take down the landscape pictures in her room shortly after she moved in. MD #31 confirmed the pictures were in the room when the resident moved in. MD #31 reported he told the resident he would not take the pictures down because he didn't have anywhere to store them, and it would leave a hole in the wall, which he would have to repair. MD #31 confirmed he did not share the resident's request with facility administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interviews, and review of facility policy, the facility staff failed to report an allegation of abuse. This affected one (Resident #68) of one resident reviewed for abuse. The facility's census was 66. Findings include Review of the medical record for the Resident #68 revealed an admission date of 09/13/21. Diagnoses included calculus gallbladder, contusion of the left, lack of coordination, epilepsy, depression, hypoxemia, respiratory failure, and contusion of abdominal wall. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was cognitively intact and required limited assistance with bed mobility and transfers. Review of the plan of care dated 06/29/22 revealed Resident #68 was frequently incontinent of bowel and bladder with an intervention to provide incontinence care as needed. Interview on 07/25/22 at 1:34 P.M. with Resident #68 revealed on 07/24/22 the dayshift State Tested Nurse Aide (STNA) was rough while providing the resident with incontinence care. The resident reported the STNA hurt her, and she felt abused. Resident #68 reported she received Lovenox (anticoagulant) shots in her belly and the area was bruised and sore. The STNA grabbed the resident's incontinence brief without loosening it or disconnecting the side and ripped it from her body. Additionally, the STNA leaned and placed weight on the resident's knee and leg, which had an injury and wound. Resident #68 reported she requested for the STNA to get off her knee as she was hurting her and was told, I am not hurting you, and continued to place pressure and weight on her leg. Resident #68 stated she told another STNA about her concerns. On 07/25/22 at 2:00 P.M. the surveyor notified the Director of Nursing (DON) of Resident #68's abuse allegations. The DON was unaware of the resident's abuse allegation and initiated a Self-Reported Incident (SRI) within an hour of being told. Interview on 07/27/22 at 12:22 P.M. with STNA #57 revealed on 07/24/22 at approximately 9:30 P.M. Resident #68 reported concerns about a dayshift agency STNA being abusive. STNA #57 reported she reported Resident #68's allegations to the nightshift nurse. Interview on 07/27/22 at 12:29 P.M. with Licensed Practical Nurse (LPN) #74 revealed STNA #57 did not inform her of Resident #68's abuse allegations, but overheard staff talking about the resident's complaints regarding how she was treated by the dayshift STNA. LPN #74 reported she did not talk to Resident #68 about her allegations and did not report the concerns to management. Review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16, revealed the facility failed to implement their policy. Facility staff should immediately report allegations of abuse to the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, facility failed to ensure abuse allegations where immediately investigated once reported to staff. This affected one Resident (#68) of one reviewed for abuse. Facility census was 66. Findings include Review of the medical record for the Resident #68 revealed an admission date of 09/13/21. Diagnoses included calculus gallbladder, contusion of the left, lack of coordination, epilepsy, depression, hypoxemia, respiratory failure, and contusion of abdominal wall. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was cognitively intact and required limited assistance with bed mobility and transfers. Review of the plan of care dated 06/29/22 revealed Resident #68 was frequently incontinent of bowel and bladder with an intervention to provide incontinence care as needed. Interview on 07/25/22 at 1:34 P.M. with Resident #68 revealed on 07/24/22 the dayshift State Tested Nurse Aide (STNA) was rough while providing the resident with incontinence care. The resident reported the STNA hurt her, and she felt abused. Resident #68 reported she received Lovenox (anticoagulant) shots in her belly and the area was bruised and sore. The STNA grabbed the resident's incontinence brief without loosening it or disconnecting the side and ripped it from her body. Additionally, the STNA leaned and placed weight on the resident's knee and leg, which had an injury and wound. Resident #68 reported she requested for the STNA to get off her knee as she was hurting her and was told, I am not hurting you, and continued to place pressure and weight on her leg. Resident #68 stated she told another STNA about her concerns. On 07/25/22 at 2:00 P.M. the surveyor notified the Director of Nursing (DON) of Resident #68's abuse allegations. The DON was unaware of the resident's abuse allegation and initiated an investigation. Interview on 07/27/22 at 12:22 P.M. with STNA #57 revealed on 07/24/22 at approximately 9:30 P.M. Resident #68 reported concerns about a dayshift agency STNA being abusive. STNA #57 reported she reported Resident #68's allegations to the nightshift nurse. STNA #57 was unaware if the facility initiated an investigation regarding the abuse allegations. Interview on 07/27/22 at 12:29 P.M. with Licensed Practical Nurse (LPN) #74 revealed STNA #57 did not inform her of Resident #68's abuse allegations, but overheard staff talking about the resident's complaints regarding how she was treated by the dayshift STNA. LPN #74 reported she did not talk to Resident #68 about her allegations and did not report the concerns to management. LPN #74 further verified she never assessed Resident #68 nor was she aware if the facility initiated an investigation regarding the abuse allegations. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16, revealed the facility failed to implement their policy. The policy revealed the facility would investigate all alleged violations involving abuse, neglect, and mistreatment of a resident. If the resident was injured during the suspected incident, staff should immediately report all incidents and allegations to the administrator or designee, the nurse should complete an assessment for possible injuries and the physician should be notified. The policy revealed if the accused, was not an employee, a third party shall be contacted to address the issue and prevent their return during the outcome of the investigation. An investigation should be started immediately and must be finalized and reported to the state survey agency within five business days.

Based on record review, observation, and staff interview, the facility failed to ensure residents received proper nail care and regular showers, including washing of hair. This affected three (Residents #8, #21, and #54) of four residents reviewed for activities of daily living (ADL) care. The census was 66. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 04/17/22 with a diagnosis of diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #8 dated 04/27/22 revealed the resident was cognitively intact and required physical assistance of one staff with bathing and hygiene. Review of the care plan for Resident #8 dated 04/29/22 revealed the resident may require assistance with activities of daily living (ADLs) and may be at risk for developing complications associated with decreased ADL self-performance due to disease process/condition, weakness. Interventions included staff should assist with grooming, including nail care. Observation on 07/25/22 at 11:04 A.M. of Resident #8 revealed the resident's toenails were long and extending approximately one quarter inch past the end of the toe. Interview on 07/25/22 at 11:04 A.M. Resident #8 reported her toenails were too long and the great toenails were somewhat painful and it felt like they were becoming ingrown. Resident #8 further confirmed she had not had her toenails trimmed since admission to the facility. Interview on 07/25/22 at 1:34 P.M. with State Tested Nursing Assistant (STNA) #76 confirmed Resident #8's toenails were long and needed to be trimmed. STNA #76 further confirmed she thought resident needed to have toenails trimmed by a podiatrist because she was a diabetic. Interview on 07/27/22 at 12:13 P.M. with the Director of Nursing (DON) confirmed the facility had no record of podiatry visits for Resident #8 and confirmed the facility had no written policy on nail care. 2. Review of the medical record for Resident #21 revealed an admission date of 04/30/22 with a diagnosis of diabetes mellitus (DM.) Review MDS for Resident #21 revealed the resident was cognitively intact and required extensive assistance of one staff with bathing. Review of the care plan for Resident #21 dated 05/19/22 revealed the resident may require assistance with ADLs and may be at risk for developing complications associated with decreased ADL self-performance related to disease process/condition, recent hospitalization, weakness, vision impairment. Interventions included the following: assistance with bathing, bathing per resident preference, assist with grooming (nails, shaving, hair) Review of the shower sheets for Resident #21 revealed on 06/27/22 the resident had a full shower and on 07/21/22 the resident had a bed bath. Further review of Resident #21's bathing records from 07/15/22 to 07/25/22 revealed no documentation on if the resident received a bed bath or shower and/or refused a bath or shower. Observation on 07/25/22 at 9:20 A.M. revealed Resident #21's long hair appeared greasy and wet as if it had been slicked back. Interview on 07/25/22 at 9:20 A.M. with Resident #21 revealed she had not had a bed bath for the past two weeks and she had not had her hair washed at all in the month of July 2022. Interview on 07/25/22 at 1:37 P.M. with State Tested Nursing Assistant (STNA) #76 confirmed Resident #21 did not refuse care and that staff were supposed to offer to wash the resident's hair at the time of the bath or shower. STNA #76 further confirmed Resident #21's hair appeared greasy. 3. Review of the medical record for Resident #54 revealed an admission date of 08/17/21 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the MDS for Resident #54 dated 06/07/22 revealed the resident was cognitively intact and required extensive assistance of one staff with hygiene and bathing. Review of the care plan for Resident #54 dated 12/22/21 revealed the resident required assistance with ADLs and may be at risk for developing complications associated with decreased ADL self-performance. Interventions included staff should provide assistance with grooming, nail care, and bathing. Review of the shower sheets for Resident #54 for the month of July 2022 revealed the resident received a full bed bath on 07/07/22 and 07/27/22 per the hospice aide. Further review of Resident #54's bathing record in the electronic medical record from 07/15/22 to 07/27/22 revealed the resident was coded as having a bath on 07/27/22 but was not coded for having a bath on any of the other dates. Observation on 07/25/22 at 12:45 P.M. of Resident #54 revealed the resident's fingernails were long (extending approximately one quarter inch behind the end of the fingers) and had dirt under them. Interview on 07/25/22 at 12:45 P.M. Resident #54 verified her fingernails were too long and needed to be cleaned and trimmed. Resident #54 confirmed she usually got a bed bath by the hospice aide but she hadn't had a bath in the past few weeks. Resident #54 reported when she did get a bath earlier in the month, the aide did not trim or clean her nails. Interview on 07/25/22 at 12:50 P.M. STNA #58 verified Resident #54's fingernails were long and needed to be trimmed and cleaned. STNA #58 further confirmed aides usually trimmed fingernails during baths/showers unless the resident was diabetic, in which the nurse had to trim the nails. STNA #58 confirmed Resident #54 received her baths per the hospice aide. Interview on 07/27/22 at 12:13 P.M. with the Director of Nursing (DON) confirmed the facility had no record of bathing for Resident #54 between 07/07/22 and 07/27/22. The DON confirmed Resident #54 had no contraindications to having the aides trim and clean her fingernails as needed. The DON confirmed the facility did not have a policy on bathing. This deficiency substantiates Complaint Number OH00133207.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews and review of facility policy, the facility failed to monitor and treat newly found wounds and skin impairments. This affected one (Resident #68) of two residents reviewed for skin conditions and wounds. The facility census was 66. Findings include: Review of the medical record for Resident #68 revealed an admission date of 09/13/21. Diagnoses included calculus gallbladder, contusion of the left, lack of coordination, epilepsy, depression, hypoxemia, respiratory failure, and contusion of abdominal wall. Review of the MDS assessment dated [DATE] revealed Resident #68 was cognitively intact and required limited assistance with bed mobility and transfers. Review of the plan of care dated 06/29/22 revealed Resident #68 had alteration in skin integrity as evidenced by a surgical wound on the left knee with interventions to assess the area for size, color, and drainage as needed, assess for pain, provide assistance with ADLs and positioning as needed and provide skin care as needed. Review of physician orders for 07/26/22 at 3:19 P.M. identified orders for treatment to cleanse the left elbow with normal saline and pat dry, apply a small piece of adaptic and cover with ABD and secure with kerlix and tape and change daily and as needed. Review of physician order for 07/26/22 at 3:32 P.M. identified order for geri sleeve to left upper extremity at all times as tolerated and to remove the sleeve every shift for hygiene and to inspect skin. No previous orders were found regarding treatments to skin tear on resident's left elbow. Review of the progress note dated 07/26/22 as a late entry from 07/22/22 revealed the resident was found to have a skin tear on the left arm. The area was cleaned and steri-strips were applied. Progress note dated 07/26/22 revealed the resident stated during the night (a few nights ago) she had bumped her left elbow on the side rail. The resident was agreeable to geri-sleeves, as she reported she bumps her arms often. The physician was notified and measurements were taken. The wound was cleaned and treatment was applied. No other progress notes were found regarding the wound. Review of skin assessment dated [DATE] revealed a new wound on the left elbow was found on 07/26/22 (actual date found was 07/22/22). The wound was a skin tear and measured 1.2 cm by 0.2 cm with moderate drainage. The physician and family were notified on 07/26/22. Observation and interview on 07/25/22 at 1:55 P.M. with Resident #68 revealed she had blood on her left elbow with several steri-strips in place. The resident reported she had a skin tear that occurred from reaching between her bed rails to grab something off her end table. She reported the nurse placed the steri-strips but stated she has bled through them and had blood on several spots of her bedding. Observation on 07/26/22 at 12:02 P.M. revealed the resident's elbow had a large Band-Aid covering the skin tear. Interview on 07/26/22 at 3:34 P.M. with the DON revealed the facility had no documentation regarding the resident's skin tear being found, assessed, or treated, but revealed the nurse would place a note today. The DON revealed the wound occurred 07/22/22. Review of the facility policy titled, Skin Assessment, dated 09/2017 revealed areas of alteration in skin that are present, or which develop subsequently to admission, are treated according to medical direction and are conscientiously followed on a weekly basis. An assessment of the area is performed and recorded in the resident's medical record.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to oxygen tubing and handheld nebulizer mask and tubing were maintained in proper and sanitary condition. This affected three (Residents #26, #38, #54) of 13 facility-identified residents with orders for respiratory treatment. The census was 66. Findings include: 1. Review of the medical record for Resident #54 revealed an admission date of 08/17/21 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) for Resident #54 dated 06/07/22 revealed resident was cognitively intact and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the July 2022 monthly physician orders for Resident #54 revealed an order dated 08/17/21 for Albuterol solution per HHN two times per day and an order for oxygen at three liters via nasal canula. Review of July 2022 Medication Administration Record (MAR) for Resident #54 revealed resident received Albuterol per HHN twice daily during the month of July 2022. Review of the July 2022 Treatment Administration Record (TAR) for Resident #54 revealed resident received oxygen at three liters via nasal cannula Review of the care plan for Resident #54 dated 10/07/21 revealed resident had altered health maintenance related to progressive physical and mental status, chronic obstructive pulmonary disease (COPD), emphysema, and seizure disorder. Interventions included the following: administer medications as ordered, administer oxygen per physician order, elevate head of bed per order or as tolerated. Observation on 07/25/22 at 12:52 P.M. of Resident #54's revealed resident's oxygen tubing with nasal canula was dated 07/04/22 and resident was receiving oxygen via concentrator at three liters, and the HHN mask and tubing was undated. Interview on 07/25/22 at 12:52 P.M. of Resident #54 confirmed she was unsure when the tubing for her oxygen and HHN had last been changed. She thought it had a been a few weeks. Interview on 07/25/22 at 07/25/22 at 1:41 P.M. with Registered Nurse (RN) #94 confirmed resident's oxygen tubing dated was dated 07/04/22 and HHN tubing was not dated. RN #94 confirmed oxygen and HHN tubing should be changed weekly and as needed and the nurse should date the tubing at the time of the tubing change. 2. Review of the medical record for Resident #26 revealed an admission date of 12/13/18 with a diagnosis of acute respiratory failure (ARF) with hypoxia. Review of the MDS for Resident #26 dated 05/13/22 revealed resident was cognitively impaired and required extensive assistance with ADLs. Review of the July 2022 TAR for Resident #26 revealed an order for oxygen at two liters per nasal cannula as needed for shortness of breath. Observation on 07/25/22 at 10:28 A.M. of Resident #26 revealed resident's oxygen tubing and nasal cannula was laying directly on the floor and was dated 07/17/22. Interview on 07/25/22 at 10:28 A.M. of Resident #26 confirmed resident's oxygen tubing was laying on the floor. Resident #26 confirmed he did not use oxygen very often and he was unsure when the tubing had been changed last. Observation on 07/25/22 at 1:38 P.M. with Licensed Practical Nurse (LPN) #73 revealed resident's oxygen tubing was laying on the floor and was dated 07/17/22. Interview on 07/25/22 at 1:38 P.M. with LPN #73 confirmed resident's oxygen tubing was laying directly on the floor which was not sanitary and also confirmed the tubing was dated 07/17/22 which was outdated. 3. Review of the medical record for Resident #38 revealed an admission date of 08/24/21 with a diagnosis of end stage renal disease (ESRD.) Review of the MDS for Resident #38 dated 06/05/22 revealed resident was cognitively intact and required extensive assistance of staff with ADLs. Review of the July TAR for Resident #38 revealed an order dated 05/23/22 for oxygen at three liters per nasal cannula as needed for shortness of breath. Interview on 07/25/22 at 1:30 P.M. revealed resident used oxygen at night, and she was unsure how often staff changed the tubing. Observation on 07/25/22 at 1:36 P.M. with LPN #73 revealed Resident #38's oxygen tubing and nasal cannula was laying directly on the floor in resident's room. Oxygen tubing was dated 07/16/22. Interview on 07/25/22 at 1:36 P.M. with LPN #73 confirmed oxygen tubing for Resident #38 was laying directly on the floor and was dated 07/16/22 which was outdated. Interview on 07/27/22 at 12:13 P.M. with the Director of Nursing (DON) confirmed oxygen tubing should not be stored directly on the floor, tubing should be changed once weekly at a minimum, and tubing should be dated when changed. Review of the policy titled Respiratory Equipment Cleaning/Disinfecting dated 09/14/18, revealed tubing/masks/nasal cannula should be changed weekly and as needed. Tubing should be stored clean and dry, in a plastic bag between usages.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure pharmacy recommendations were timely and thoroughly addressed. This affected two residents (#32 and #49) of five reviewed for pharmacy recommendations. Facility census was 66. Findings include 1. Review of the medical record for the Resident #32 revealed an admission date of 10/20/20. Diagnoses included chronic heart failure, hypertension, bipolar disorder, atrial fibrillation, constipation, anxiety, depression and COVID-19. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact and required limited assistance of one for mobility and transfers. Review of the physician orders for 12/18/20 revealed Resident #32 had orders for hydroxyzine (antihistamine) HCl Tablet 10 milligram (mg) for itching, promethazine HCl Tablet 25 mg for nausea. Both medications were discontinued on 10/07/21. A physician order dated 06/29/21 to 05/30/22 for Seroquel (an antipsychotic medication) tablet with instructions to give 50 mg by mouth at bedtime. Review of the pharmacy recommendation dated 08/18/21 revealed Resident #32 was on hydroxyzine HCl Tablet 10 mg and Promethazine HCl Tablet 25 mg both ordered as needed (PRN) and unused for over 60 days with recommendation to discontinue the order. The Nurse Practitioner reviewed the recommendation on 10/05/21 and discontinued the orders on 10/07/21. Review of the pharmacy recommendation dated 09/20/21 revealed Resident #32 received antipsychotic therapy and therefore required an abnormal involuntary movement tests (AIMS) at baseline and every six months. The form was not reviewed, signed and dated by a physician or medical professional and no decision box was checked. A note was written on the page saying an AIMS was completed on 10/04/21. Review of the AIMS assessments revealed they were completed on 10/20/20, 10/04/21, and 06/09/22. Review of the nurse practitioner note dated 10/12/21 revealed no mention of the pharmacy recommendations or a rationale for continuing the medication. Interview on 07/28/22 at 9:19 A.M., with Physician #97 revealed she was provided pharmacy recommendations each time she was at the facility which was twice weekly as well as the nurse practitioner being at the facility twice weekly. Physician #97 acknowledged the pharmacy recommendation dated 08/18/21 was responded to about seven weeks after the recommendation was made. She revealed the recommendation dated 09/20/21 was likely for nursing staff to complete. The physician acknowledged no staff signed or dated the form of when it was reviewed and no decision box was marked and no explanation was provided. Physician #97 would follow up on the AIMS as it had not been completed every 6 months according to the request. 2. Review of the medical record for the Resident #49 revealed an admission date of 01/12/22. Diagnoses included stenosis of left carotid artery, heart failure, muscle weakness, vascular dementia, hyperlipidemia, atrial fibrillation, diabetes, depression, spinal stenosis, and cerebral aneurysm. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively intact with a BIMS of 15 and required limited assistance of one staff member. Review of the physician orders for 01/17/22 identified orders for Memantine HCl Tablet 5 mg with instructions to give one tablet daily for dementia. Review of the physician orders for 06/08/22 identified orders for Memantine HCl Tablet 5 mg with instructions to give one tablet daily for dementia. Review of the physician orders for 07/03/22 identified orders for Memantine HCl Tablet 5 mg with instructions to give one tablet daily for dementia. Review of the pharmacy recommendation dated 03/22/22 revealed resident was receiving medication (memantine). The manufacturer recommends increasing the daily dose by 5 mg every week until maximum dose of 20 mg. Would you consider titrating dose to 10 mg twice daily? The Physician signed the pharmacy recommendation on 04/21/22 and marked other with explanation saying continue. Interview on 07/28/22 at 9:19 A.M. with Physician #97 confirmed no rationale was provided regarding why the physician did not agree with the pharmacy recommendation. During the interview with surveyor, Physician #97 wrote an explanation and dated it for 07/28/22. Review of facility policy titled Medication Monitoring, dated 06/21/17, revealed the facility failed to implement the policy in regards to the allegation. The policy revealed the facility and Physician must address the recommendations in a timely manner tat meets the needs of the residents and no later than their next routine visit. The Provider should also document what irregularity was reviewed and what action was taken to address the issue. If the Physician declines or rejects the recommendation, an explanation as to the rationale for the rejection must be documented in the residents medical record.

Based on record review, resident and staff interview, review of manufacturer's recommendations, and review of facility policy, the facility failed to administer insulin as ordered. This affected one (#21) of 16 facility-identified residents with orders for insulin. The census was 66. Findings include: Review of the medical record for Resident #21 revealed an admission date of 04/30/22, with a diagnosis of diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 05/07/22 revealed resident was cognitively intact and required extensive assistance with activities of daily living (ADLs.) Review of the care plan for Resident #21 dated 05/19/22 revealed resident was at risk for hypo/hyperglycemia episodes related to DM and required daily insulin and sliding scale insulin. Interventions included monitor for signs and symptoms of hypo/hyperglycemia, administer insulin as ordered, monitor blood sugar levels as ordered, report abnormalities to the attending physician. Review of the June 2022 Medication Administration Record (MAR) for Resident #21 revealed an order dated 05/06/22 for resident to receive Lantus insulin 15 units at bedtime. There were not parameters for holding the insulin. Further review of the MAR for Resident #21 revealed insulin was noted as held on 06/10/22 and 06/22/22. Review of nurse progress note for Resident #21 dated 06/10/22 revealed Lantus insulin was held due to resident's blood sugar was 99. The progress note did not include physician notification of the insulin being held. Review of the medical record for Resident #21 revealed the notes did not include an explanation regarding hold insulin for resident on 06/22/22. Review of the July 2022 MAR for Resident #21 revealed an order dated 07/13/22 for resident to receive Lantus insulin 10 units at bedtime. There were no parameters for holding the insulin. Further review of the MAR for Resident #21 revealed insulin was noted as held for 07/16/22. Review of nurse progress note for Resident #21 dated 07/16/22 revealed Lantus insulin was held due to resident's blood sugar was low. The progress note did not include physician notification of the insulin being held. Interview on 07/25/22 at 9:31 A.M., with Resident #21 confirmed staff sometimes told her they were going to hold her insulin at night because her blood sugar was low. Interview on 07/28/22 at 12:12 P.M., with the Director of Nursing (DON) confirmed Lantus insulin orders for Resident #21 had no parameters for withholding and the nurses' notes did not include physician notification of withholding the medication. Review of manufacturer's recommendation for Lantus insulin online resource per Medscape revealed Lantus was a long-acting insulin and it was very important to follow the insulin regimen exactly, and the doctor should be consulted ahead of time regarding what to do it resident missed a dose of insulin. Review of the policy titled Insulin Administration dated 06/21/17 revealed nurses should be familiar with the type of insulin ordered and if the insulin dose is not administered, the prescriber should be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, and review of the hospital continuity of care form, the facility failed to arrange for and provide timely therapy services. This affected one resident (#21) of three residents reviewed for therapy services. The facility census was 66. Findings include: Review of the medical record for Resident #21 revealed an admission date of 04/30/22 with a diagnosis of diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) for Resident #21 dated 05/07/22 revealed the resident was cognitively intact and required extensive assistance of two staff with activities of daily living (ADL). Resident #21 was coded for zero minutes of therapy during the assessment period. Review of the hospital continuity of care form for Resident #21 dated 04/14/22 revealed it included a list of resident's current medications and order for rehabilitation therapies included physical therapy (PT) and occupational therapy (OT). Review of the admission history and physical per the physician for Resident #21 dated 04/29/22 revealed the resident was admitted with generalized weakness and debility and had difficulty caring for herself. Further review of the examination note revealed resident needed PT and OT services. Review of the baseline care plan for Resident #21 dated 05/02/22 revealed the resident was new to the facility and the resident needs would be met and care would be provided based on admission physician orders and professional standards of quality care. Interventions included to provide therapy services as ordered. Review of the nurse progress note for Resident #21 dated 05/01/22 revealed skilled PT services and skilled OT services were required. Review of the therapy records for Resident #21 revealed the resident was not evaluated for PT until 05/17/22 at which time the resident was picked up for PT three times weekly to work on gait training, transfer training, and mobility. Interview on 07/25/22 at 9:31 A.M., with Resident #21 confirmed she had thought she would receive PT and/or OT upon admission to the facility, but she had not started being treated by therapy until 05/17/22. Interview on 07/28/22 at 12:14 P.M. of Physical Therapy Assistant (PTA) #86 confirmed she was the Program Manager for the facility's therapy department. PTA #86 further confirmed all newly admitted residents should be screened for therapy services within one to two days of their admission. PTA #86 confirmed she thought Resident #21 was screened upon admission but could find no record of a screening by therapy. PTA #86 further confirmed the facility admission department told her it was not urgent for Resident #21 to be screened or begin receiving therapy services. PTA #86 confirmed Resident #21 was admitted on [DATE] and was not evaluated and started with PT until 05/17/22. PTA #86 confirmed the facility did not have a written policy regarding screening for therapy services. This deficiency substantiates Complaint OH00133207.

Based on medical record review, observation, staff interviews, and review of facility policy, the facility failed to ensure infection control standards were followed during a blood sugar check for Resident #36. This affected one (Resident #36) of one resident observed for blood sugar checks. The facility's census was 66. Findings include Review of the medical record for Resident #36 revealed an admission date of 05/30/22 with a diagnosis of diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #36 dated 06/06/22 revealed the resident was cognitively impaired and required supervision and set up help of one staff with activities of daily living. Review of the July 2022 monthly physician orders for Resident #36 revealed an order dated 06/28/22 for the resident to receive Humulin insulin 25 units twice daily via injection. Observation on 07/27/22 at 8:08 A.M. of blood sugar check prior to insulin administration for Resident #36 per Registered Nurse (RN) #86 revealed RN #86 used a lancet (small needle) and obtained a large drop of blood from the resident's finger. RN #86 was not wearing gloves when she obtained Resident #36's blood sample and said aloud, I should be wearing gloves right now, shouldn't I? Interview on 07/27/22 at 8:11 A.M. RN #86 confirmed she was not wearing gloves when she obtained Resident #36's blood sample to check the residents blood sugar. RN #86 further confirmed staff should wear gloves whenever having contact with a resident's blood or body fluids is likely. Review of the facility policy titled, Testing Blood Glucose Levels, dated April 2015 revealed staff should apply gloves before obtaining blood samples from the resident and should discard the gloves and perform hand hygiene after the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for the Resident #3 revealed an admission date of 09/09/21. Diagnoses included dementia with behaviors, muscle weakness, lack of coordination, diabetes type two, vascular dementia, and dysphagia. Review of the MDS assessment dated [DATE] revealed Resident #3 was cognitively intact and required supervision set up assistance for mobility and transfers. Review of the progress notes dated 03/20/22 and 07/06/22 revealed the resident was offered a care conference and declined to attend. Review of care conference dated 09/20/21 revealed the resident attended a care conference meeting. Further review of the medical record revealed no documentation or reports of additional care conferences being completed. Interview on 07/25/22 at 10:57 A.M. with Resident #3 revealed she only remembered having one care conference since admission. Interview on 07/27/22 at 1:10 P.M. the Director of Nursing (DON) and Manager of Clinical Services (MCS) #96 confirmed no additional care conference summaries were completed for Resident #3. Interview on 07/28/22 at 10:35 A.M. with SW #63 revealed care conferences were offered every quarter when MDS assessments were updated. SW #63 revealed she was not aware of facility responsibilities and requirements to have a care conference even if the resident declined attendance. SW #63 revealed care conferences were not completed for Resident #3. 4. Review of the medical record for the Resident #7 revealed an admission date of 10/24/18. Diagnoses included schizo affective disorder bipolar type, anxiety, morbid obesity, muscle weakness, lack of coordination, bipolar disorder, and mood disorder. Review of the MDS assessment dated [DATE] revealed Resident #7 was cognitively intact and required limited assistance of one staff member for mobility and transfers. Review of the progress notes dated 04/20/21, 07/20/21, 09/28/21, 01/11/22, 04/05/22, and 07/06/22 revealed the resident was offered a care conference and declined to attend. Further review of medical record found no evidence of care conferences being completed. Interview on 07/25/22 at 1:22 P.M. with Resident #7 revealed the resident had no memory of having care conferences. Interview on 07/27/22 at 1:10 P.M. the DON and Manager of Clinical Services (MCS) #96 confirmed no additional care conference summaries were completed for Resident #7. Interview on 07/28/22 at 10:35 A.M. with SW #63 revealed care conferences were offered every quarter when MDS assessments were updated. SW #63 revealed she was not aware of facility responsibilities and requirements to have a care conference even if the resident declined attendance. SW #63 revealed care conferences were not completed for Resident #7. Review of facility policy titled, Resident and Resident Care Conferences, dated 05/09/18, revealed the facility would hold care conferences upon admission, quarterly, and as needed. Based on medical record reviews, resident interviews, staff interviews, and review of facility policy, the facility failed to conduct care conferences. This affected four (Resident #21, #26, #3, and #7) of four residents reviewed for care conferences. The facility's census was 66. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 04/30/22 with a diagnosis of diabetes mellitus (DM). Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 05/07/22 revealed the resident was cognitively impaired and required extensive assistance of staff with activities of daily living (ADLs). Review of the progress note for Resident #21 dated 05/03/22 revealed staff offered to have a care conference for the resident, but she declined to attend. Further review of the medical record for Resident #21 revealed no documentation or record of care conferences being held for the resident since admission to the facility. Interview on 07/25/22 at 9:27 A.M. Resident #21 reported she had not been invited to a care conference since her admission to the facility and she would like to attend a care conference. Interview on 07/28/22 at 10:25 A.M. with Social Worker (SW) #63 revealed the facility had not conducted a care conference for Resident #21 since her admission on [DATE] because the resident did not want to have a care conference. Further interview with SW #63 revealed it was her understanding that a care conference was not required if the resident declined to attend. 2. Review of the medical record for Resident #26 revealed an admission date of 12/13/18 with a diagnosis of acute respiratory failure (ARF) with hypoxia. Review of the MDS for Resident #26 dated 05/13/22 revealed the resident was cognitively impaired and required extensive assistance with ADLs. Review of the progress notes for Resident #26 dated 08/10/21, 11/10/21, 02/10/22, and 05/10/22 revealed staff offered to have a care conference for the resident, but he declined to attend. Further review of the medical record for Resident #21 revealed no documentation or record of a care conferences being held for the resident in the past 12 months. Interview on 07/25/22 at 10:21 A.M. Resident #26 reported he had not been invited to a care conference in a long time, and he would like to attend a care conference. Interview on 07/28/22 at 10:25 A.M. with Social Worker (SW) #63 revealed the facility had not conducted a care conference for Resident #26 in the past 12 months because the resident did not want to attend. Further interview with SW #63 revealed it was her understanding that a care conference was not required if the resident declined to attend.

Based on observation, staff interview, and policy review, the facility failed to ensure food was labeled, dated, and stored in a safe manner. This had the potential to affect all 66 residents residing in the facility who received their meals from the kitchen. The facility census was 66. Findings include: Observations during the initial tour on 07/25/22 from 9:01 A.M. to 9:28 A.M. revealed the following: Observation on 07/25/22 at 9:05 A.M. revealed one dented can of tropical fruit salad and one dented can of fancy midwest tomato sauce. Observation on 07/25/22 at 9:07 A.M. revealed one unlabeled and undated bag of breadcrumbs. Observation on 07/25/22 at 9:09 A.M. revealed one bag of fried chicken legs, unlabeled and undated, in the freezer. Observation on 07/25/22 at 9:10 A.M. revealed one bag of ribs, unlabeled and undated, in the freezer. Interview on 07/25/22 at 9:15 A.M., with the dietary supervisor #44 verified the above findings and discarded those items. Review of the facility policy titled Food Storage - Labeling and Dating, dated July 2018 revealed all food must have a date that includes month, day, and year on package indicating the date in which it entered the facility. All items removed from its original packaging must be dated. Items must be dated after opening with an open date and use by date unless specified. The use-by-date will be seven days. All foods should be discarded prior to or on day seven. All items considered to be leftovers shall be properly dated and labeled.

Based on record review and staff interview, the facility failed to notify a resident of possible financial liability when Medicare services were discontinued. This affected one (#43) resident of three reviewed for Medicare Part A services and had the potential to affect any residents with Medicare Part A coverage. The facility identified three residents currently on Part A services. Findings include: Review of Resident #43's medical record revealed an admit date of 01/31/19 with diagnoses included diabetes mellitus and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment, dated 02/07/19, revealed the resident's cognition was severely impaired. Review of social worker progress note, dated 02/15/19, revealed a Medicare Notice of Non-coverage was signed 02/15/19 with a last covered day of 02/18/19. Review of the medical record failed to reveal any documentation of a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was provided to the resident's representative. Interview with Social Worker (SW) #12 on 07/08/19 at 3:44 P.M. stated a SNFABN was not provided to Resident #43 since he remained in the facility and was treated with part B services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #15's chart revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia. Review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 04/05/19, revealed the resident was cognitively intact and was reported to have the adequate ability to hear with no hearing aid or other hearing appliance used. Review of Resident #15's care plan revealed the resident to have impaired communication due to her having her hearing deficit. Resident #15 was also reported to have hearing aids listed on the care plan. Interview with the Director of Nursing (DON) on 7/10/19 at 5:00 P.M. revealed the resident did not have hearing aids. Subsequent interview with the DON on 07/11/19 at 10:37 A.M. verified Resident #15's care plan for hearing did not accurately reflect that the resident did not have hearing aids. Based on record review, and interview the facility failed to accurately develop and implement care plans for resident use of diuretics and hearing aids. This affected two (#15 and #20) of 18 residents reviewed for care planning. The facility census was 75. Findings include: 1. Record review for Resident #20 revealed the resident was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/09/19, revealed Resident #20 had severe cognitive deficits. Review of the physician order, dated 07/26/17, revealed the resident was to receive Furosemide (diuretic) 20 milligrams (mg.) once daily. Review of the care plans revealed the electronic health record (EHR) was silent for care plan for the use of a diuretic. Interview on 07/11/19 at 10:48 A.M. with the Director of Nursing (DON) verified that there was no care plan for the use of diuretics for Resident #20.

Based on observation, record review and staff interview, the facility failed to update a fall care plan to include physician ordered alarms. This affected one (#13) of three residents reviewed for accidents. The facility census was 75. Findings include: Review of Resident #13's medical record revealed an admission date of 05/04/15. Diagnoses included schizoaffective disorder and osteoporosis. Review of the annual Minimum Data Set (MDS) assessment, dated 04/4/19, revealed the resident had moderate cognitive impairment and indicated alarms were used daily. Review of the physician orders for July 2019 revealed an order to place an alarm to the resident's bed, check placement and function every shift and place an alarm to the resident's wheelchair, check placement and function every shift. Review of the fall care plan, dated 11/23/18, revealed the resident had a potential risk for falls related to debilitation, weakness, medications, pain, unsteady gait, and disease process. Interventions were locked bed, items (including call light) within reach, clear pathways, education, therapy evaluation, and monitoring for medication side effects. The care plan was silent to use of alarms. Observation of Resident #13 on 07/10/19 at 11:51 A.M. revealed her sitting in a wheelchair with a tab alarm attached to her and the wheelchair. Interview on 07/11/19 at 9:38 A.M. with the Director of Nursing (DON) reported alarms for bed and chair were ordered for Resident #13 after a fall on 03/17/19 to remind her to request for assistance. The DON verified Resident #13's care plan was silent for use of alarms. The DON said the alarms used for residents should be care planned.

Based on observation, record review, and staff interview, the facility failed to maintain infection control procedures when a medication was administered. This affected one (#34) of six residents observed receiving medications and had the potential to affect all 75 residents residing in the facility identified as receiving medications from facility nurses. Findings include: Review of Resident #34's medical record revealed an admit date of 06/18/18. Diagnoses included dementia, congestive heart failure, anxiety, depressive disorder, diabetes, hypertension, and asthma. Review of a quarterly Minimum Data Set (MDS) assessment, dated 05/28/19, indicated the resident had intact cognition. Review of Resident #34's physician orders for July 2019 failed to reveal any mention of a Stiolto inhaler (a medication to relax pulmonary muscles). Observation of Resident #34 receiving medications at 4:32 P.M. on 07/10/19 from Registered Nurse (RN) #3 revealed a Stiolto inhaler provided to Resident #34 who took two puffs through her mouth. Interview on 07/11/19 at 9:30 A.M. with Director of Nursing (DON) reported that RN #3 had administered Resident #70's inhaler to Resident #34. The DON verified it would be an infection control issue since the inhaler was placed in the mouth when administering the medication.