**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #22 was admitted on [DATE]. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, diabetes, rheumatoid arthritis, diabetes, atrial fibrillation, morbid obesity, chronic kidney disease, anxiety, depression, and unsteadiness on her feet. Review of quarterly MDS dated [DATE] revealed Resident #22 was cognitively intact. Review of physician orders for Resident #22 revealed she was prescribed Losartan 100 milligram (mg), Metoprolol 25 mg ER and Diltiazem Extended Release (ER) 180 mg and for high blood pressure, Lipitor 10 mg for high cholesterol, Fluoxetine 40 mg for depression, and Synthroid 125 micrograms (mcg) for low thyroid. Review of the revised care plans, dated 04/28/21, revealed no plan of care for high cholesterol, hypothyroidism, depression and hypertension. During interview on 07/06/21 at 2:11 P.M. , MDS Licensed Practical Nurse (LPN) #54 verified there were no care plans for the use of the above medications. Review of the facility policy titled Care Plans, dated 04/01/09, revealed care plans shall incorporate goals and objectives that lead to the residents highest obtainable level of independence. 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 2. When goals and objectives are not achieved, the residents clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. 3. Care plan goals and objectives are derived from information contained in the residents comprehensive assessment and: a. Are resident oriented; b. Are behaviorally stated; c. Are measurable; and d. Contain timetables to meet the residents needs in accordance with the comprehensive assessment. 4. Goals and objectives are entered on the residents care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 5. Goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition; b. When the desired outcome has not been achieved; c. When the resident has been readmitted to the facility from a hospital/ rehabilitation stay; and d. At least quarterly. 6. The resident has the right to refuse to participate in establishing care plan goals and objectives. When such refusals are made, appropriate documentation will be entered into the residents clinical records in accordance with established policies. Based on record review, interview and policy review, the facility failed to initiate care plans for medication use for two (Residents #18 and #22) of five residents reviewed for unnecessary medication. The facility census was 45. Findings include: 1. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Her diagnoses included suicidal ideations, major depressive disorder, anxiety disorder, bipolar disorder and borderline personality disorder. The quarterly Minimum Data Set (MDS) assessment, completed on 04/17/21, assessed the resident as alert and oriented. Resident #18 was receiving Cymbalta Capsule Delayed Release Particles 20 milligrams (mg) to give two capsules by mouth one time a day for depression, Lorazepam Tablet 0.5 mg to give one half tablet by mouth every eight hours as needed for anxiety, and Seroquel, 100 mg to give 100 mg by mouth at bedtime for bipolar depression. Review of Resident #18's care plans revealed she did not have a care plan addressing psychoactive medications. During interview on 07/01/21 at 3:30 P.M., the Administrator and Director of Nursing (DON) verified the resident did not have a care plan addressing the psychoactive medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident #22 revealed she was admitted on [DATE]. Review of consultation report from the pharmacy issued on 03/02/21 and 05/05/21 revealed a request for Lantus insulin 10 units in the morning and 25 units in the evening to be combined and given in the evening. The recommendation was not reviewed, signed or dated by the physician. During interview on 07/01/21 at 3:30 P.M., the Administrator and Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) had the pharmacy recommendation records offsite and they would try to get the information from the pharmacy. At the time of exit, no policy on pharmacy recommendations and none of the information from the offsite location or the pharmacy had been provided. Based on record review and interview, the facility failed to ensure the physician documented review of pharmacy recommendations. This affected three (Residents #18, #22 and #35) of five residents reviewed for unnecessary medications. The facility census was 45. Findings include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE]. Pharmacy recommendations dated 04/06/21, 05/05/21, and 06/02/21 were not reviewed, signed or dated by the physician. 2. Record review revealed Resident #35 was admitted to the facility on [DATE]. A review of the pharmacy recommendations dated 04/07/21, 04/19/21, and 05/17/21 were not reviewed, signed or dated by the physician.

Based on observation, staff interview and policy review the facility failed to prime insulin needles before administration for one (#26) of one reviewed for insulin injections during the medication administration. The facility identified six residents who received insulin pens. The census was 45. Findings include: Medical record review for Resident #26 revealed an admission date of 05/10/21. Medical diagnoses included type two diabetes. Review of physician orders dated 06/22/21 revealed Humalog KwikPen Solution Pen Injector to inject as per sliding scale, to be given subcutaneously before meals and at bedtime for hyperglycemia. During observation on 07/01/21 at 8:16 A.M., Registered Nurse (RN) #70 drew up four units on the Humalog insulin pen. She did not dial up two units and did not expel the insulin to ensure the pen was working properly. She stated she had primed the needle on the insulin pen when it was first opened and not the beginning of each administration of the pen. She wasn't aware she was supposed to expel two units of the insulin upon every use of the pen. Review of the facility policy titled Medication Safety Alert/Insulin Pen Use, dated 01/01/14, revealed to turn the dose selector to two units and hold the insulin pen with the needle pointing up and tap the cartridge gently a few times to move air bubbles to the top. Press the push button all the way until the dose selector is back to zero. A drop of insulin should appear at the tip of the needle. This must be done before each injection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, the facility failed to ensure a staff member donned appropriate personal protective equipment when caring for a resident on quarantine. This affected one (Resident #9) of three residents identified by the facility as being under quarantine. The facility census was 45. Findings include: Review of the clinical record revealed Resident #9 was admitted to the facility on [DATE]. She was discharged to the hospital on [DATE] and was readmitted on [DATE]. She had an order on 06/25/21 for strict single room isolation with droplet precautions related to readmission from hospital regarding COVID precautions every shift for 14 days. During observation on 06/28/21 at 12:17 P.M., State Tested Nursing Assistant (STNA) #22 set up the resident's lunch tray and sat on the side of the bed to assist the resident with eating. STNA #22 was wearing a surgical mask, but no other personal protective equipment (PPE). During interview on 06/28/21 at 12:20 P.M., Licensed Practical Nurse (LPN) #62 also observed STNA #22 sitting on the side of the resident's bed. She stated the only PPE STNA #22 was wearing was a surgical mask. LPN #62 stated Resident #9 was on quarantine because of her recent hospital admission. LPN #62 stated anyone going into the room would have to wear full PPE, as if the resident had COVID. A review of the facility's policy titled Infection Prevention and Control Program stated to implement appropriate isolation precautions when necessary and follow established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). Review of the CDC Coronavirus Disease 2019 (COVID-19) fact sheet stated the preferred PPE included a face shield or goggles, an N95 or higher respirator, an isolation gown and a pair of clean non-sterile gloves. These are to be used when caring for a patient with confirmed or suspected COVID-19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #24 revealed an admission date of 06/12/07. The last quarterly MDS assessment was dated 05/03/21. Review of care conferences for Resident #24 revealed the last one was held on 11/11/20. Interview with a family member on 06/28/21 at 3:02 P.M. revealed there hasn't been a care conference in several months. The family member stated they do have care conference, but due to their work schedule, they cannot attend. There have been no other arrangements made to attend a care conference. During interview on 07/01/21 at 1:38 P.M., Social Worker Designee (SWD) #26 confirmed the last care conference was on 11/20/20. 3. Record review for Resident #43 revealed an admission date of 01/18/21. The last quarterly MDS assessment was dated 06/13/21. Review of care conferences for Resident #43 revealed a care conference had never been held. During interview on 06/28/21 at 11:42 A.M., Resident #43 stated no care conference had been held since he admitted to the facility. During interview on 07/01/21 at 1:38 P.M., SWD #26 confirmed no care conference had ever been held for Resident #43. Review of the facility policy titled Resident Participation-Assessment/Care Plans, dated 12/01/16, revealed the resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. Based on record review and interview, the facility failed to ensure care conferences were held for residents. This affected three (Residents #18, #24 and #43) of three residents reviewed for care planning. The facility census was 45. Findings include: 1. A review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. She had a quarterly Minimum Data Set (MDS) assessment completed on 04/17/21. There was no evidence a care conference had been held since admission. During interview on 07/01/21 at 3:30 P.M., the Administrator and the Director of Nursing (DON) stated there was no evidence that a care conference had been held for Resident #18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, visitation signage, interview, and review of the Centers for Medicare and Medicaid Services (CMS) guidance, the facility failed to ensure residents were allowed visitation. This affected all of the residents who resided in the facility. The census was 45. Findings include: Review of the coronavirus website for the county positivity rate for Covid-19 revealed as of 06/22/21, the positivity rate in [NAME] county was 1.9%. Review of the list of vaccinated residents in the facility, dated 06/28/21, revealed 22 of 45 residents, or 48 percent, had been vaccinated. Observation of signs on the front door to the entrance of the facility on 06/28/21 at 9:00 A.M. revealed visitation was not allowed unless it was scheduled through the facility. Observation of the Resident Council Meeting conducted on 06/28/21 at 10:57 A.M. by Activities Director (AD) #68 revealed there were questions about visitation and the response was when the residents received more vaccinations the facility would be opening up for more visitation. Interview with Resident #22 on 06/28/21 at 3:30 P.M. revealed the facility was not conducting visitation right now. The families could stand outside the window if they wanted to visit with the residents. There was renovations in the facility and visitors are not allowed in to visit. She revealed she hadn't seen her family in over a year. Interview with AD #68 on 06/29/21 at 7:36 A.M. revealed there were supervised visits in the lobby with the receptionist and it was conducted on Tuesdays and Thursdays due to the low vaccination rate in the facility. The appointments could be made at 1:30, 2:30, or 3:30 P.M. and they lasted 30 minutes. Since the renovations have started in the facility, the visitation is limited to one day a week right now. Interview with the Receptionist #29 on 06/29/21 at 1:11 P.M. revealed the families schedule appointments and make sure one day of the week, when the construction wasn't going on, visitation was set up in the main lobby on Thursdays. She stated visitors could not go to the resident rooms due to the low vaccination rate of the residents. The families and residents are encouraged to receive their vaccinations so the facility could be opened up for visitation. She revealed during the visitation it was kind of supervised to make sure the families don't touch anybody. The visit has to be six feet apart, there could be no hugging or touching, or exchange any items during the visit. Observation of visitation on 07/01/21 at 1:31 P.M. revealed there were four tables with chairs around them placed six feet apart. Scheduler #8 was monitoring the visitation. She was in and out of the room. At 1:57 P.M. the Scheduler told the visitors they had two minutes left for the visit and they had to leave to ensure the next visitation was set up for 2:30 P.M. At 2:00 P.M. the Scheduler told the residents they couldn't touch anything in the room and to go back to their rooms. Interview with Resident #20's family member on 07/01/21 at 1:58 P.M. revealed the families were told they could only visit once a week due to renovations. They were told they couldn't hug or touch the residents or hand them anything on the visit. If the policy had changed the families hadn't been informed of the change. Interview with the Administrator on 07/01/21 at 3:15 P.M. revealed the facility only allowed visits on Tuesdays and Thursdays due to the renovations and the low vaccination rates of the residents. She revealed she was following the guidance from the Department of Aging that was out of date. She stated no one in the building had Covid-19 and no residents were on quarantine. Review of CMS QSO memo 20-39, revised on 04/27/21, stated under Indoor Visitation: Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission (note: compassionate care visits should be permitted at all times). These scenarios include limiting indoor visitation for: · Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated; · Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met two criteria to discontinue Transmission-Based Precautions; or · Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine.

Based on medical record review and staff interview, the facility failed to document provision of care for a urostomy tube. This affected one resident (Resident #23) of 15 resident records reviewed during the annual survey. The facility census was 51. Findings included: Review of the medical record for Resident #23 revealed an admission date of 11/09/18. Diagnoses included cerebral palsy, ileus, other obstructive defects of renal pelvis and ureter and parastomal hernia with obstruction without gangrene. Review of physician orders, dated 11/13/18, revealed to change the urostomy pouch every seven days and as needed. Review of the Treatment Administration Record (TAR) for 12/2018, 01/2019, 02/2019 and 03/2019, revealed there was no documentation for 12/07/18, 12/21/18, 01/18/19, 02/01/19, 02/15/19 and 03/02/19 as to the urostomy bag being changed. Interview on 03/13/19 at 3:55 P.M. with the Assistant Director of Nursing (ADON) revealed she verified there was no charting on 12/07/18, 12/21/18, 01/18/19, 02/01/19, 02/15/19 and 03/01/19. She stated they were changing the bag more frequently due to leakage, and does not know why those times were not charted.