**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and resident interview,the facility failed to protect the resident from abuse by staff. This affected one (Resident #54) of four resident records reviewed for abuse. The census was 105. Findings include: Review of Resident #54's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, morbid obesity, major depression, peripheral vascular disease, anxiety, reduced mobility and anxiety. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact. She required set up or clean up assistance with oral hygiene, she is dependent for toileting, and requires substantial/maximal assistance for shower/bathing, dressing, personal hygiene and turning and repositioning. She is always incontinent of urine and frequently incontinent of bowel. Review of the plan of care she experiences alteration in mood and/or behavior as evidenced by resident has diagnoses of depression feeling bad about self or feeling like a failure, Feeling down/depressed/hopeless, feeling tired or having little energy, feels lonely or isolated, having difficulty concentrating, poor appetite or overeating, showing little interest/pleasure in doing things. Review of the Self Reported Incidents's revealed no reports of abuse. On 5/6/2025 at 10:53 A.M. revealed a progress note that revealed the nurse along with Certified Nurses Aide (CNA) were assisting resident into a sitting position from a lying position in order to utilize sit-to-stand machine. CNA took a hold of residents left hand and skin tear occurred due to residents fragile skin. The nurse immediately assessed residents pain level, resident denied any pain or discomfort upon questioning. The area was measured at 2.5 centimeters (cm) x 0.5 cm. Area was cleansed with normal saline, patted dry and steri-strips were applied and secured with a cover dressing. Intervention; Encourage resident use of geri-sleeves. Treatment in place; top of left hand: Cleanse Skin Tear with Normal Saline, pat dry with gauze. Apply primary dressing: Cover dressing. Allow steri-strips to fall off naturally. Change daily and as needed. Wound nurse to assess on Sunday. Nurse Practioner and daughter was made aware of the same. Review of a statement by CNA #205 revealed on 05/11/25 revealed CNA #10 dropped Resident #54 from the hoyer into the shower chair from at least one foot in the air. CNA #205 told CNA #10 you can't do that and the CNA #10 said sorry, I hope you didn't hurt yourself. Also Resident #54 was was unfamiliar with the hoyer lift and wasn't sure how the hoyer pad was supposed to fit. She asked if it was supposed to be under her neck or behind her head. The CNA #10 without saying a word, reached up and violently yanked the hoyer pad to straighten it out causing the Resident #54's head to snap back. On 06/02/24 at 10:38 A.M., Interview with Resident #54 revealed most staff are very good and kind but there are exceptions. She stated she had been at facility for two and a half years and off the top of her head there had only been one exception, CNA #10. She stated CNA #10 does not take care of her anymore. She stated CNA #10 was not a nice person , she grabbed her by arm when she had a rubber glove on and was helping her turn to get up and caused a skin tear on her arm. She stated she has thin skin. She then stated the aides were putting her in the shower chair with the Hoyer lift (for the first time), they usually use a sit to stand, and she let it down too fast and it scared her. She didn't get hurt. (Resident showed she was about 10 inches from the shower chair) she revealed another staff member was with her. She stated CNA #10 was doing her care once and pulled her hair and stated she didn't know if it was on purpose or an accident. She stated she told on her and she is no longer allowed in her room or to take care of her. She works day shift. On 06/02/25 at 11:12 A.M., interview with the Director of Nursing (DON) revealed one family did ask that the CNA #10 did not take care of their mother any longer. They felt she had an attitude and rough with transfers. There were two CNA's for the transfer. When asked about the skin tear she revealed she had another CNA with her when that happened and it happened when they were getting her up with the sit to stand. Asked about her pulling her hair and she revealed she was never told this. CNA #10 was moved and educated and we have had no other complaints about her. The facility has no hoyer lift policy and procedure. On 06/02/25 at 11:41 A.M., interview with CNA #205 revealed CNA #10 and her were getting Resident #54 up in a shower chair, CNA #205 was holding her back with the hoyer pad so CNA #10 could lower her and she hit the emergency drop button. Resident #54 was about 10 inches from chair. I told her you can't do that. Resident #54 let out a [NAME] but no complaints of injury. Then a couple hours later I was helping to get her back up after CNA #10 had changed her and the Hoyer pad was bunched up under her neck and Resident #54 asked if it was supposed to be like that, she grabbed it and jerked the pad up and her head went back, No complaints of any pain or injury. CNA #10 was very rude and uncaring, not friendly. Felt she was being abusive. The daughter was there at the time. CNA #205 stated she did report it to Registered Nurse (RN) #239 and had to write a statement. Another family also asked for CNA #10 not to take care of their family member Resident #48 because she was rude to her and the family. On 06/02/25 at 12:56 P.M., interview with the Resident #54's daughter revealed she was worried about her mom's safety with CNA #10. The other staff have been tremendous. Wouldn't have her anywhere else. It just feels off with her. Like on mothers day she asked her to get her mom up so we could talk and she said I'm to busy. Everyone bends over backward for mom. I trust them to take care of mom. I feel they have it under control. On 06/02/25 at 1:02 P.M., interview with Resident #54 revealed she was afraid of CNA #10. On 06/02/25 at 1:11 P.M., interview with the DON revealed the Administrator said he did not report the allegation because it was not alleged abuse. This deficiency represents non-compliance investigated under Complaint Number OH00166084.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure residents were provided with necessary transportation to attend outside appointments as scheduled. This affected one (Resident #150) of three residents reviewed for transportation to outside appointments. The facility census was 112 residents. Findings include: Review of the medical record for Resident #150 revealed an admission date of 09/17/20 and a readmission date of 11/30/22 with diagnoses including unspecified injury at T2-T6 level of thoracic spinal cord, morbid obesity due to excess calories, bipolar disorder, anxiety disorder, paraplegia, unspecified mood (affective) disorder, and depression. Review of the care plan for Resident #150 initiated 11/30/22 revealed the care plan did not address the resident's need for transportation to outside appointments. Review of the Minimum Data Set (MDS) assessment for Resident #150 dated 10/09/24 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs). Interview on 12/12/24 at 4:23 P.M. with Resident #150 confirmed she had missed several scheduled outside medical appointments with different physicians due to the facility not making arrangements for needed transportation to the appointments. The resident stated she was supposed to receive Botox injections in her legs every three months to treat leg spasms. Resident #150 stated she last received the injections on 06/12/24. The resident missed her scheduled appointment in September 2024 due to the facility not being able to secure bariatric transportation. Resident #150 stated her neurologist had ordered outpatient neurological rehabilitation for the resident back in June or July 2024. The resident had not been able to attend any scheduled therapy appointments due to not having transportation. Resident #150 stated the outpatient rehabilitation facility dropped her as a patient due to excessively missing appointments. Resident #150 also reported she had missed two scheduled gynecologist appointments as well due to not having transportation. Resident #150 stated her legs hurt badly because she hadn't had the Botox injections. Interview on 12/12/24 at 4:37 P.M. with Scheduler #455 confirmed Resident #150 had missed multiple scheduled outside medical appointments due to not being able to secure needed transportation for the resident. Interview on 12/12/24 at 4:45 P.M. with the Administrator confirmed Resident #150 had missed multiple scheduled outside medical appointments due to not being able to secure the transportation needed for the resident. The Administrator stated he had been trying to find another provider who was able to accommodate Resident #150's need for bariatric transportation as well as the ability to provide additional people to assist the resident but had not been able to find a provider yet. A facility policy was requested at the time of the survey. The Director of Nursing (DON) confirmed the facility did not have a policy that addressed providing transportation for outside appointments when needed. This deficiency represents noncompliance investigated under Complaint Number OH00160217.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review the facility failed to report an allegation of resident-to-resident sexual abuse. This affected one (Resident #12) of three residents reviewed for abuse. The facility census was 112. Findings include: Review of the medical record for Resident #12 revealed an admission date of 01/24/2021. Diagnoses included dementia, unspecified sequelae of cerebral infarction, and moderate protein calorie malnutrition. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a memory problem and had severe cognitive impairment. Review of Resident #12's nursing progress noted from 04/2024 revealed nothing related to inappropriate resident contact. Review of Resident #16's medical record revealed an admission date 07/01/23. Diagnoses included dementia, hypertension, and primary open-angled glaucoma. His April 2024 orders revealed an order for a Wandergaurd to is right ankle. Review of his quarterly MDS assessment dated [DATE] revealed a moderate cognitive impairment. Review of his care plan revealed no evidence of the resident having sexual behavior. Review of Resident #16's nursing progress notes revealed a note dated 04/22/24 at 5:04 P.M. which stated, Resident was seen by one of the aides fondling one of the resident's breasts. This nurse notified the unit manager and redirected resident. Interview on 05/02/24 at 11:07 A.M. State Tested Nurses Aide (STNA) #203 revealed Resident #16 wanders around the unit quite a bit. He will go into other rooms. STNA #203 stated she has witnessed the resident fondling Resident #12 in the past. She went on to say she does have to frequently redirect him away from Resident #12. STNA #203 revealed she has never been required to provide statements or receive formal training on how to appropriately treat his behaviors. Interview on 05/02/24 at 11:18 A.M. with STNA #204 revealed she was told by the nurses to try to keep Resident #16 away from Resident #12 because he was observed inappropriately touching her. She reported, at times, it takes constant redirection to keep him separated from her. She stated she has witnessed him inappropriately touching residents in the facility and has told the nurse before. She stated she has never been required to provide statements or received formal training on how to appropriately treat his behaviors. Interview on 05/02/24 at 2:44 P.M. with the facility Director of Nursing (DON) reported that on 04/22/24 she received a report that an STNA witnessed Resident #16 fondle Resident #12's breasts. She reported both residents are cognitively impaired. She stated a skin assessment was completed and no injuries were noted. She stated that if the incident does not cause physical harm or change in psychosocial status the facility does not notify the state agency. Review of the facility's, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated 11/21/16 revealed it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, and Misappropriation of Resident Property. Additionally, the facility should immediately report all such allegations to the administrator and to the state survey agency. The policy went on to identify sexual abuse is nonconsensual sexual contact of any type with a resident. This deficiency represents non-compliance investigated under Complaint Number OH00153480.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review the facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse. This affected one (Resident #12) of three residents reviewed for abuse. The facility census was 112. Findings include: Review of the medical record for Resident #12 revealed admission date of 01/24/2021. Diagnoses include dementia, unspecified sequelae of cerebral infarction, and moderate protein calorie malnutrition. Review of Resident #12's quarterly Minimum Data Set assessment dated [DATE] revealed she had a memory problem and had severe cognitive impairment. Review of Resident #12's nursing progress noted from 04/2024 revealed nothing related to inappropriate resident contact. Review of Resident #16's medical record revealed an admission date 07/01/23. Diagnoses included dementia, hypertension, and primary open-angled glaucoma. His April 2024 orders revealed an order for a Wandergaurd to is right ankle. Review of his quarterly MDS assessment dated [DATE] revealed a moderate cognitive impairment. Review of his care plan revealed no evidence of the resident having sexual behavior. Review of Resident #16's nursing progress notes revealed a note dated 04/22/24 at 5:04 P.M. which stated, Resident was seen by one of the aides fondling one of the resident breasts. This nurse notified the unit manager and redirected resident. Interview on 05/02/24 at 11:07 A.M. with State Tested Nurses Aide (STNA) #203 revealed Resident #16 wanders around the unit quite a bit. He will go into other rooms. STNA #203 stated she has witnessed the resident fondling Resident #12 in the past. She went on to say she does have to frequently redirect him away from Resident #12. STNA #203 revealed she has never been required to provide statements or received formal training on how to appropriately treat his behaviors. Interview on 05/02/24 at 11:18 A.M. with STNA #204 revealed she was told by the nurses to try to keep Resident #16 away from Resident #12 because he was observed inappropriately touching her. She reported, at times, it takes constant redirection to keep him separated from her. She stated she has witnessed him inappropriately touching residents in the facility and has told the nurse before. She stated she has never been required to provide statements or received formal training on how to appropriately treat his behaviors. Interview on 05/02/24 at 2:44 P.M. with the facility Director of Nursing (DON) reported that on 04/22/24 she received a report that an STNA witnessed Resident #16 fondle Resident #12's breasts. She reported both residents are cognitively impaired. She stated a skin assessment was completed and no injuries were noted. She confirmed a formal investigation was not completed, interviews were not conducted, other residents were not assessed, and Resident #16's care plan was not updated to address his new sexual behaviors. Review of the facility's, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated 11/21/16 revealed it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, and Misappropriation of Resident Property. Additionally, the facility should immediately report all such allegations to the administrator and to the Ohio Department of Health. The policy went on to identify sexual abuse is nonconsensual sexual contact of any type with a resident. This deficiency represents non-compliance investigated under Complaint Number OH00153480.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an investigation and appropriate corrective action was implemented after staff used a mechanical lift incorrectly. This affected one (Resident #13) of three residents reviewed for accidents. The facility census was 112. Findings include: Review of the medical record for Resident #13 revealed an admission date of 11/05/2022. Diagnosis included hemiplegia and hemiparesis following a cerebral infarction, stiffness of the left hip, ataxia, and Moyamoya. Review of Resident #13's physician orders revealed an order dated 02/28/23 that stated the facility may utilize Hoyer lift for transfers as needed for weakness/difficulty transferring. Review of Resident #13's progress notes from 03/01/24 through 03/31/24 revealed no notes related to the incident. A note on 03/11/2024 at 10:18 P.M. revealed that neurological (Neuro) checks continue as ordered. Review of her Quarterly Minimum Data Set (MDS) dated [DATE] revealed she has intact cognition and required staff assist for transfers. Interview on 05/02/24 at 10:25 A.M. with Resident #13 revealed a few weeks ago, a State Tested Nurses Aide (STNA) #100 was transferring her in a Hoyer lift independently when the Hoyer lift tipped and fell on top of the resident and hit her in the head. She reported two staff members are supposed to use the lift when transferring her but sometimes only one staff will do it. She stated that her head hurt for a little while, but the pain did not last long. Review of Review of Registered Nurse (RN) #200 witness statement dated 03/11/24, revealed 11:30 A.M. this morning STNA #100 approached her and informed her that the Hoyer lift fell on Resident #13. RN #200 quickly rushed to the resident's room to help. RN #200 and STNA #100 were not able to get the Hoyer lift from the resident, so she called one more STNA to help. RN #200 stated she saw the resident sitting in her wheelchair and the Hoyer was on top of her, they were able to get the Hoyer off the resident. RN #200 stated she notified the unit manager RN #201 and also informed the resident's Power of Attorney about the incident. A head-to-toe assessment was done with no injury noted. Acetaminophen was administered due to the resident's complaint of a headache. Neuro checks are in progress and this report has been passed to the night shift nurse to continue to monitor on resident. Interview on 05/02/24 at 2:24 P.M. with Human Resources Manager (HRM) #202 revealed on 03/11/24 she wrote up and suspended STNA #100 for using a Hoyer lift by herself and for being insubordinate at her inquiry into the incident. She stated STNA #100 refused to sign the discipline. She continued that she was suspended for one day and then permitted to come back to work. HRM #202 went on to say STNA #100 was not retrained on the proper use of a Hoyer lift to her knowledge before returning to work but did report that she had previous training upon hire. Interview on 05/02/24 at 12:20 P.M. with the facility's Director of Nursing (DON) stated on 03/11/24 STNA #100 transferred Resident #13 by herself using a Hoyer lift. She reported that Hoyer transfers always require two staff to transfer the resident safely. The DON went on to say while transferring the resident the Hoyer lift fell on the resident hitting her in the head. She stated she was assessed, and no injury was noted so she did not complete an incident report or investigation including interviews with staff present, interview with the resident, or retraining of proper Hoyer lift techniques. She stated STNA #100 was disciplined but was permitted back to the facility without reeducation on the proper use of a Hoyer lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation of wound care, and facility policy review, the facility failed to ensure resident room door and window blind was closed during wound care. This affected one (Resident #6) of one resident reviewed for privacy during wound care. The facility census was 108. Findings include: Review of the medical record review for Resident #6 revealed an admission date of 05/19/23. Diagnoses included heart failure, peripheral vascular disease (PVD), and primary osteoarthritis. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating the resident had a severely impaired cognition for daily decision making abilities. Resident #6 was noted to have one unstageable pressure ulcer, one stage II pressure ulcer, and three venous and arterial ulcers. Review of Resident #6's treatment orders dated 01/07/24 revealed the following treatment to be completed, Right upper thigh, cleanse wound with Vashe wound cleanser, pat dry with gauze, apply primary dressing , honey wound gel and cover with secondary dressings, clean dry dressing every night shift for healing and as needed. Observation on 01/25/24 02:01 P.M. of Registered Nurse (RN) #226 completing wound care with the assistance from RN #30 revealed concerns regarding privacy. While dressing change was completed to Resident #6's right upper thigh, her room door remained opened and a housekeeping staff member was visible from the residents beside. Resident #6's room window faced the facility main parking lot and was noted to have a blind which was open during this same wound care. Interview on 01/25/24 with RN #226 and #30 confirmed the window blind and room door was left open during Resident #6's wound care and they also confirmed Resident #6's bed was visible from the hallway. Review of the facility policy titled Dressing Changes, dated 09/29/2017 revealed under section titled Procedures: 2. Greet the Resident, explain the procedure and provide privacy.

Based on record review, resident representative and staff interviews, review of laboratory test results, and facility policy review, the facility failed to notify one resident's representative (Resident #7) of laboratory test results. The facility also failed to notify one resident's (Resident #7) physician/nurse practitioner/physician assistant or resident representative a lab was not completed as ordered. This affected one (Resident #7) of one reviewed for notification of change. The facility census was 108. Findings Include: Review of the medical record for Resident #7 revealed an admission date on 11/16/21. Medical diagnoses included spinal stenosis, chronic obstructive pulmonary disease (COPD), chronic kidney disease Stage 3, and dysphagia (difficulty swallowing) oropharyngeal phase. Review of the emergency contacts for Resident #7 revealed the resident's daughter (Daughter #301) was the resident's primary emergency contact and the resident's Durable Power of Attorney (DPOA). Review of the annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #7 had impaired cognition and scored a seven out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #7 required assistance ranging from partial assistance to dependence on staff to complete Activities of Daily Living (ADLs). Review of the Medication Administration Record (MAR) dated November 2023 revealed Resident #7 had an order for a Complete Blood Count (CBC), Basic Metabolic Panel (BMP), and B-Type Natriuretic Peptide (BNP) Test one time only for edema, hypertension, and weakness for three days dated 11/22/23 at 12:45 P.M. The lab tests were marked completed on 11/24/23 at 5:24 A.M. An additional order for Resident #7 to check BMP, check potassium level one time only for two days was dated 11/28/23 at 7:00 P.M. The lab order was marked as other see notes on 11/28/23 at 11:32 P.M. Review of the progress notes dated from 11/01/23 through 01/24/24 revealed on 11/22/23 at 2:10 P.M., the Physician Assistant (PA) was in for rounds and ordered Lasix 20 milligrams (mg) orally daily for three days and lab work. Daughter #301 was notified. There was no follow up note related to the results of the lab work or that Daughter #301 was notified of the results. On 11/28/23 at 8:27 P.M., a new order to recheck Basic Metabolic Panel (BMP), check potassium level was received. Daughter #301 was notified. There was no follow up note related to the results from the lab work or that the physician/nurse practitioner/physician assistant or Daughter #301 was notified of the results. Review of the care plan revised 01/11/24 for Resident #7 revealed the resident had altered health maintenance related to progressive physical and mental status. Interventions included monitor labs as ordered and report results to the physician. Review of the BMP, CBC, and BNP lab results reported on 11/25/23 revealed Resident #7 had a high potassium level of 5.3 (normal levels ranged from 3.5 to 5.1 mmol/L). The Physician Assistant was notified. Review of the BNP lab results reported on 11/27/23 at 9:12 A.M. revealed Resident #7 had a high BNP value of 108 pcg/mL (normal levels ranged from 0-100 pcg/mL). The Physician Assistant was notified. There was no BMP lab results provided for the lab ordered on 11/28/23. Interview on 01/22/24 at 2:44 P.M. with Daughter #301 revealed the facility did not always notify her of changes related to Resident #7. Daughter #301 stated the facility had completed blood work for Resident #7 recently but had not followed up with her since to notify her of the results of the blood work. Interview on 01/25/24 at 7:52 A.M. with the Director of Nursing (DON) and Regional Nurse (RGN) #292 confirmed there was no evidence Daughter #301 was notified of the results of the lab results dated 11/25/23. The DON and RGN #292 confirmed the BMP lab ordered on 11/28/23 had not been completed as ordered and there was no evidence the physician/nurse practitioner/physician assistant or Daughter #301 had been notified the lab was not completed as ordered. Review of the facility policy, Change of Condition, revised 04/2013, revealed the policy stated, A change of condition is defined as deterioration in the health, mental, or psychosocial status of a resident related to a life-threatening condition, a significant alteration of treatment, or a significant change in the resident's clinical condition or status. A significant alteration in treatment is defined as a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new treatment, or the decision to transfer a resident to a hospital. The Unit Supervisor or Charge Nurse will notify the resident, physician, and guardian/interested family member of all changes as stated above and of any other situations requiring notification. The person doing the notification may document all notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to implement preventative skin interventions to prevent repeated skin infections for Resident #85. Additionally, the facility failed to timely assess a bruise for one resident (Resident #4) and failed to implement physician order for a back brace for one resident (Resident #96). This affected two residents (Resident #4 and #85) out of four residents reviewed for skin integrity and one resident (Resident #96) out of three residents reviewed for positioning devices. The facility census was 108. Findings Include: 1. Review of the medical record for Resident #85 revealed Resident #85 was admitted to the facility on [DATE] with admitting diagnoses including Huntington's Disease, depressive disorder, disorders of the bladder, overactive bladder, impaired communication, and anxiety. Resident #85 required assistance from staff for activities of daily living (ADL) tasks. Review of Resident #85's quarterly [NAME] Data Set (MDS) dated [DATE] revealed resident had rejection of care for one to three days and was frequently incontinent of bladder. Review of Resident #85's care plan dated 11/10/21 revealed alteration in elimination of bladder and bowel incontinence. Resident #85 may require assistance with ADLs and may be at risk for developing complications associated with decreased self-performance. Resident #85 is at risk for alteration in skin integrity with interventions including provide skin care as needed, provide assistance with ADLs, and complete skin assessments per facility policy. Review of Resident #85's physician orders revealed a signed order dated 10/13/23 for antibiotic Bactrim DS 800/160 milligrams two times daily for seven days for skin infection. Further review revealed a signed order dated 01/16/24 for antibiotic Bactrim DS 800/160 milligrams two times daily for seven days for skin infection. Observation on 01/23/24 at 2:23 P.M. revealed Resident #85 lying in bed on a blue uncovered mattress. There was no covering or fitted sheet on the mattress. Resident #85 was dressed in a short sleeved short and lounge pants with slip-on shoes and no socks. Resident #85's upper extremities were uncovered with elbows and forearms in direct contact with the uncovered mattress. Observation on 01/24/24 at 8:58 A.M. revealed Resident #85 lying in bed with a blanket covering from the waist to feet. Resident #85's upper body and arms are uncovered with elbows and forearms in direct contact with the uncovered mattress. Observation on 01/25/24 at 8:07 A.M. revealed Resident #85 lying in bed wearing a short sleeve short and a blanket is covering from the chest down to lower legs. Resident #85 is wearing soft slip-on shows with no socks. Resident #85's uncovered elbows and forearms are in direct contact with the uncovered mattress. Interview on 01/24/24 at 10:37 A.M. with Physician Assistant (PA) #294 revealed Resident #85 had developed atypical areas to both elbows due to spending majority of time lying in bed and using elbows to move around in bed. Assessment of both elbows revealed there was excoriation (worn off skin resulting in an abrasion) and redness in color. Interview on 01/25/24 at 8:07 A.M. with State Tested Nursing Assistant (STNA) #182 revealed Resident #85 will refuse incontinence care and cleaning of the mattress due to urine incontinence. Resident #85 prefers no sheets or coverings on the mattress. When the mattress does have a sheet or covering Resident #85 will either remove or will become entangled in the sheets due to increased body movements related to disease process. STNA #182 stated, We don't do anything other than incontinence care to decrease the friction and moisture from her movements in bed. Interview on 01/25/24 at 12:22 P.M. with PA #294 confirmed Resident #85's areas could be prevented. PA #294 stated Resident #85 had an area to the right elbow a couple of months ago and these current areas were new but have developed like the previous areas to Resident #85's lower legs due to the friction from continuous movements and the moisture from incontinence. PA #294 was not aware of any skin prevention interventions for Resident #85 since ordering the antibiotic. 2. Review of Resident #4's medial record revealed resident was readmitted to the facility on [DATE] with the admitting diagnoses including major depression, anxiety, bipolar disorder, Chronic Obstructive Pulmonary Disorder (COPD), and seizures. Further review revealed Resident #4 required assistance with activities of daily living (ADL) tasks and had intact cognition. Review of Resident #4's care plan dated 03/22/19 revealed Resident #4 was at risk for alteration in skin integrity. Further review revealed Resident #4 had skin integrity interventions in place including weekly and as needed body checks, complete skin assessments per facility policy, and provide skin care as needed. Review of Resident #4's recent laboratory results revealed Resident #4 had blood collected on 01/17/24 for a Complete Blood Count (CBC) laboratory test. Review of Resident #4's shower documentation dated 01/17/24 to 01/19/24 revealed no new skin areas were observed. Observation on 01/22/24 at 4:05 P.M. revealed Resident #4 with a moderate bruise located on the top and thumb joint area of the left hand. The bruise was dark purple in color and was circular in size, covering approximately one quarter of Resident #4's top of left hand including the first joint of the left thumb. Review of Resident #4's assessments and progress notes date ranges from 01/17/24 to 01/23/24 revealed no evidence of an assessment of skin impairment of the bruise located on top of Resident #4's left hand. Interview on 01/25/24 at 8:00 A.M. with State Tested Nursing Assistant (STNA) #22 revealed if during personal care or bathing tasks, skin impairments including bruises are observed and then reported to the nurse or the Unit Manager. Interview on 01/25/24 at 8:20 A.M. with Registered Nurse (RN) #30 confirmed RN #30 was not aware of Resident #4's bruise to the left hand. RN #30 stated, Usually the STNA's will report any type of skin impairments and/or bruises to myself or the floor nurse. Once the skin impairment has been reported then an assessment is completed, and ongoing monitoring is completed in the progress notes until the area has been resolved. Review of the facility policy titled Skin Assessment revised 09/2017 revealed, Daily, skin is checked during activities of daily living (ADL) care. 3. Review of the medical record for Resident #96 revealed an admission date of 03/01/23 with cognitive deficits. Diagnoses included dementia, unspecified glaucoma, constipation, and chronic pain. Review of Resident #96 nurse's progress notes revealed on 12/19/23 Resident #96 fell out of her wheelchair when leaning over to pick something off the floor. She was diagnosed with a compression fracture to L1&L2. When she returned to the facility, she received physical and occupational therapy. Observation and interview on 01/22/24 10:15 A.M. with Resident #96 revealed she was in her bed wearing a back brace over her clothes. She denied any concerns. Observation and interview on 01/24/24 04:24 P.M. with Resident #96 revealed she was wearing a back brace and had no concerns. Observation and Interview on 01/25/24 at 07:55 A.M. with Resident #96 revealed she was wearing a back brace over her pajamas and a robe. She complained of no pain. Interview on 01/24/24 at 4:30 P.M. with STNA's #210 and #234 confirmed Resident #96 wears the back brace daily. Interview on 01/25/24 at 7:50 A.M. with Physical Therapist # 116 confirmed Resident #96 wears the back brace daily for comfort and pain control. She verified Resident #96 does not have a physician order to wear the back brace since receiving it on 12/20/23. She denied educating the staff on how the resident should wear the brace and how to place the brace on the resident. Interview on 01/25/24 at 8:52 A.M. with STNA # 252 confirmed she does not put the back brace on Resident #96, she believes the physical therapist places it on. She denied being educated on when Resident #96 should wear the back brace or how to place the brace on Resident #96. Review of Resident #96 physician orders dated 01/01/24 to 01/31/24 revealed no order for a back brace. Review of the Resident #96 Plan of Care last updated on 01/08/24 revealed no plan for Resident #96 to wear a back brace. Review of Resident #96 Treatment Administration Records from 01/01/24 to 01/31/24 revealed no instruction for using a back brace. Review of the Physician Orders-Telephone and Verbal Policy dated 08/16/10 revealed the facility must receive and transcribe physician orders in accordance with professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observations, and facility's fall policy, the facility failed to ensure ordered fall interventions were in place. This affected one (Resident #86) of the eight residents reviewed for falls. The facility census was 108. Findings include: Review of the medical record for Resident #86 revealed an admission date of 04/06/21. Diagnoses included Parkinson, hypokalemia, aphasia, seizures, vitamin B 12 deficiency anemia, and hypertension. Review of the plan of care dated 04/22/21 and revised 05/02/23 revealed Resident #86 was at risk for falls due to unsteady gait, Parkinson's, seizures, the use of psychotropic medication, incontinence, needing assistance with activities of daily living (ADL)'s. Interventions include to educate the resident on the use of the call light, keep call light is in reach, extend strips to the shower floor, commonly used articles in reach, keep trash can within reach, non-skid material to top of chair, to toilet, chair near window closet door, shower floor, left side of bed, pull tab to wheelchair, personal sensor alarm to bed, replace alarm box and pad, and shorten string to alarm. Review of Resident #86's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating a moderately impaired cognition for daily decision making abilities. Resident #86 was noted to be free from any bilateral upper or lower extremity impairment and required the use of a walker and/or wheelchair for mobility. Resident #86 required partial to moderate assistance for toilet hygiene, dressing, bed mobility, and transfers, and was noted to be frequently incontinent of bowel and bladder function. Review of orders for Resident #86 revealed the following fall interventions: -Secure a small basket for personal items on bedside table -Non skid material to bed under sheets -PSA to bed -Non skid strops to floor from chair to chair -Ensure bedside table is in reach -Keep trash can in reach -Shortened cord to pull tab alarm -Pull tab alarm to chair, check placement and function every shift -Non skin strips to floor from chair to toilet -May use reacher to obtain items easily -non skid material to chair -visual reminder to wall in room for resident to ask for assistance -partial assist bar to right side of bed -non skin strip to shower floor -non skid strips in from of chair near window, in front of closet door Review of Resident #86's fall risk assessment dated [DATE] revealed a score of 12.5 indicating the resident was at risk for falls. Review of Resident #86's progress note dated 01/19/24 at 3:24 P.M. created by Social Worker (SW) #86 revealed resident and family was notified that they will be changing rooms temporarily for renovations. Phone call made to family. Resident and family were in agreement and voiced understanding and no care concerns was voiced. Observation on 01/23/24 at 9:57 A.M. of Resident #86 revealed the resident laying sideways in bed with his head hanging over one side and this bilateral lower extremities hanging over the other side of the bed. Resident #86 claimedWe can't eat like this. No personal sensor alarm was noted to the residents bed at this time. Observation on 01/24/24 at 8:42 A.M. revealed non-skin strips were not installed in Resident #86's new room he was currently in due to a recent room change for renovations. Interview on 01/24/24 at 8:50 A.M. with Registered Nurse (RN) #212 confirmed the non-skid strips had not been installed in Resident #86's room yet due to a recent room change. Communication was being completed with the Unit Manager to have this completed. RN #212 confirmed Resident #86 has switched room on 01/19/24 and that the interventions should have been implemented immediately. Review of facility policy titled Fall Management dated 10/17/16 revealed under section titled Follow-Up for Falls: a. Appropriate follow-up will occur as directed by physician orders, facility practice, and the resident's plan of care. c. The need for further evaluation of the resident's health condition, the environment, equipment, medication, staff, resident practices, or other factors will be determined by members of the interdisciplinary team in order to promote a comprehensive plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observations, and facility policy review, the facility failed to assist residents with eating and implementing nutritional interventions with a noted significant weight loss. This affected two (Resident #2 and #70) of the three residents reviewed for nutritional support. The facility census was 108. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 11/09/22. Diagnoses included dementia, metabolic encephalopathy, encounter for palliative care, and dysphasia. Review of Resident #70's documented weights revealed on 04/06/23 resident weighed 155.4 pounds and then on 04/25/23 the resident weighted 138.4 pounds. This is a noted loss of 17 pounds in less than 30 days. Continued weights after 04/25/23 revealed weights at 138.4 or less. Review of Resident #70's dietary charting revealed no documentation noted to address the sudden 17 pound weigh loss or implementation of interventions to prevent further weight loss. Review of Resident #70's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05 out of 15 indicating the resident had a severely impaired cognition for daily decision making abilities. Resident #70 displayed altered level of consciousness and delusions. Resident #70 required partial to moderate assistance from staff for eating. Resident #70 was noted to be 67 inches tall and weighted 128 pounds with a significant weight loss noted. Interview 01/25/24 at 3:00 P.M. with Dietary Tech #170 revealed there was another Registered Dietitian who was here prior to her coming in and did not follow the appropriate documentation or implementation of interventions for significant weight loss for this resident. There was no charting or documentation noted regarding the noted weight loss. After a significant weight loss there was not follow up weight requested. 2. Review of the medical record for Resident #2 revealed an admission date on 05/23/23. Medical diagnoses included cerebral infarction, mild protein-calorie malnutrition, dysphagia oropharyngeal phase, gastro-esophageal reflux disease without esophagitis, dementia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had impaired cognition. Resident #2 required substantial/maximal assistance from staff with eating. Resident #2 had a significant weight loss of 5 percent in the last month or a loss of 10 percent or more in the last six months while not on a prescribed weight loss regimen. Resident #2 was 63 inches tall and weighed 97 pounds (lbs). Review of the physician orders dated January 2024 revealed Resident #2 had the following orders in place: Mighty Shakes two times a day with lunch and dinner for supplement dated 01/09/24, Regular pureed textured diet with thin liquids in Blue Provale 5 cc cups with no straws: single sips; upright for meals and for 45 mins following the meal dated 11/15/23, and house supplement three times a day for supplement dated 11/02/23. Review of the weights dated from 05/23/23 through 01/17/24 revealed Resident #2 weighed 121 lbs on 05/23/23, 114 lbs on 07/06/23, 103 lbs on 08/07/23, 101 lbs on 11/08/23, 100 lbs on 12/07/23, 98 lbs on 01/17/24. Review of speech therapy treatment note dated 12/19/23 revealed speech therapist would recommend Provale 5 cc cup to be used at meals for thin liquids. Close supervision recommended during meals. Review of the care plan revised 01/02/24 revealed Resident #2 was non-compliant with eating. Interventions included document educational attempts made with resident in relation to compliance, educated resident and family on negative outcomes related to non-compliance, and notify the physician of non-compliance. Resident #2 had potential for alteration in nutrition and hydration. Significant weight loss times 180 days was noted effective 01/05/24 with a non-significant weight loss noted times 30 and 90 days with poor oral intakes and supplements being received. Interventions included adaptive equipment as ordered, assistance with meals as necessary, dysphagia guidelines as ordered, provide diet as ordered/modified, provide supplement as ordered, speech therapist referral as needed, registered dietitian referral as needed, and weights as ordered. Review of the Nutritional assessment dated [DATE] revealed Resident #2 received a pureed diet with intakes 0-25% at meals with occasional meals at 50%. Resident #2 needed fed at meals and received Blue Provale 5 cc cup to assist self-feeding, resident able to use. Significant weight loss of 17 lbs or 15 percent over 180 days. Question accuracy of July weight (no re-weight was completed). Non-significant weight loss of 4.5 percent over 30 days. Current body mass index of 17.1 indicated underweight for height. Resident was at high risk for decline in nutritional status per Nutrition Risk Tool. Observation and interview on 01/24/24 at 5:30 P.M. with Resident #2 and State Tested Nurse Aide (STNA) #234 of resident's dinner meal tray. STNA #234 confirmed there was not a Blue Provale 5 cc cup on the resident's meal tray. Observation on 01/25/24 from 11:55 A.M. to 12:25 P.M. (30 minutes continuously) during lunch meal service for Resident #2. At 11:55 A.M., Resident #2 was observed laying in bed with her lunch meal tray sitting on the bed side table next to the bed. The bed side table was not pulled in front of the resident and the resident's tray was not set up for Resident #2. The resident's entrée remained covered, her silverware was still rolled up, the lids were not taken off her cup of water or apple juice. No staff were observed assisting Resident #2 with eating. At 12:02 P.M., a staff person was observed pushing another male resident in a wheelchair past Resident #2's room. The staff person looked into Resident #2's room but did not say anything to the resident from the hallway. At 12:05 P.M., this surveyor entered Resident #2's room and with the resident's permission sat in a chair in the corner of the resident's room. Resident #2 had a two-handled empty sippy cup, empty Mighty Shake carton, opened chocolate milk carton with approximately 10% of the carton empty, and another cup with a small amount of chocolate milk in it that was not within Resident #2's reach. There were three signs posted behind the resident's bed that stated, no straws, one sip at a time, and seated completely upright for meals and drinks. Resident #2 was observed to have her head of bed slightly elevated at approximately 30 degrees but was not sitting completely upright during the observation. Resident #2 was observed attempting to take drinks from the sippy cups on several occasions but only able to get a few drops that were left in the cup. Resident #2 did not attempt to eat anything. There was not a Blue Provale 5 cc cup observed on her meal tray. No staff came to check on Resident #2, encourage Resident #2 with eating or drinking, provide supervision or offer assistance with eating or drinking until this surveyor intervened at 12:25 P.M. (30 minutes). Review of Resident #2's meal ticket dated 01/25/24 revealed Resident #2 should have a 5 cc Provale Cup and no straws. Observation and interview on 01/25/24 at 12:26 P.M. with Licensed Practical Nurse (LPN) #226 of Resident #2 in her room confirmed no staff was assisting Resident #2 with eating or drinking or providing any supervision of the resident. LPN #226 confirmed there was no Blue Provale 5 cc cup on the resident's meal tray, only a clear sippy cup. LPN #226 moved the resident's bed side table in front of the resident. Resident #2 attempted to take the lid off the cup of water but was unable to do so. LPN #226 assisted with removing the lid. LPN #226 did not raise Resident #2's head of bed so the resident was sitting upright. LPN #226 offered Resident #2 a straw for her water and unwrapped a straw on the resident's tray. At that time, this surveyor intervened and showed LPN #226 the sign that indicated Resident #2 was not to use straws. LPN #226 stated, oh, that is my fault. I did not look. At 12:28 P.M., LPN #226 stated, I would love to be able to feed her but I have to start medication pass. I will have to find someone else to help her. LPN #226 left Resident #2's room at that time unsupervised. This surveyor remained in the resident's room and observed Resident #2 taking several large gulps of water from the uncovered cup followed by coughing. Resident #2 drank approximately 90% of the cup of water by 12:30 P.M. (two minutes) when another STNA arrived. Observation and interview on 01/25/24 at 12:30 P.M. with STNA #246 of Resident #2. STNA #246 also confirmed there was no blue Provale 5 cc cup on the resident's meal tray. STNA #246 confirmed Resident #2 required assistance with eating and drinking. STNA #246 raised the resident's head of bed up until Resident #2 was sitting nearly upright. STNA #246 uncovered the resident's entrée and opened the resident's cup of applesauce. STNA #246 offered Resident #2 a bite of food and the resident accepted it. STNA #246 stated she did not know no one had come to feed Resident #2. This surveyor left Resident #2's room at this time. Review of the facility policy, Medical Nutrition Therapy Best Practices For High Risk Areas-Weight Loss, undated, revealed the policy stated, evaluate the effectiveness of current interventions, assess the resident's ability to eat independently and adequacy of total nutrient intake. Put new intervention in place. Risk factors to consider include functional problems such as swallowing problems, contractures, limited range of motion, difficulty with performing ADLs, positioning problems, and difficulty communicating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility failed to post safety signs indicating the use of oxygen outside of oxygen-dependent residents' rooms as required. This affected one resident (Resident #20) who receives oxygen. The facility census was 108. Findings Include: Review of the medical record for Resident #20 revealed the resident was admitted on [DATE] for Urinary Tract Infection, Respiratory disorder, and Acute Respiratory Failure. Review of the Care Plan dated 12/23/23 for Resident #20 indicated the resident receives oxygen therapy. Resident #20 suffers from respiratory deficits caused by a history of Coronavirus disease 19, which includes persistent shortness of breath, pneumonia, and respiratory failure. Review of Resident #20 orders dated 12/24/23 revealed resident is to receive oxygen continuous per nasal cannula to maintain saturation above 90% every shift for hypoxia. Observation on 01/22/24 at 2:47 P.M. revealed the absence of safety signs indicating the use of oxygen outside of Resident #20 room. Observation on 01/23/24 at 7:53 A.M. and 2:57 revealed the absence of safety signs indicating the use of oxygen outside of Resident #20 room. Observation on 01/24/24 at 7:50 A.M. revealed the absence of safety signs indicating the use of oxygen outside of Resident #20 room. Interview on 01/24/23 at 10:05 A.M. with Registered Nurse (RN) #282 stated the resident is currently on oxygen, and Resident #20 does not have a safety signs indicating the use of oxygen outside of the door. RN #282 stated they should be on the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to administer blood pressure medication according to the physician's order for one resident (Resident #75). This affected one (Resident #75) of five reviewed for unnecessary medications. The facility census was 108. Findings Include: Review of the medical record for Resident #75 revealed an initial admission date on 03/03/20 and a readmission date on 03/30/23. Medical diagnoses included cerebral palsy, chronic atrial fibrillation, presence of cardiac pacemaker, and hypotension (low blood pressure). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #75 had mildly impaired cognition and scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #75 was independent with completing bed mobility, toileting, and dressing and required supervision or set up help from staff to complete transfers, hygiene, showering/bathing, and eating tasks. Review of the Medication Administration Record (MAR) dated December 2023 revealed Resident #75 had an order for Midodrine Hydrochloride (HCl) 10 milligrams (mg) with instructions to give one tablet by mouth three times daily for hypotension. Hold Midodrine if Systolic Blood Pressure (SBP) was over 130 or Diastolic Blood Pressure (DBP) was over 80 with a start date 06/16/23. The medication was administered on the following dates with the following blood pressure readings: 12/03/23 138/90, 12/08/23 126/87, 12/19/23 132/86, and 12/29/23 132/78. In addition, the medication was held on the following dates with the following blood pressure readings: 12/04/23 116/80 and 12/10/23 124/80. Review of the MAR dated January 2024 revealed Resident #75 received Midodrine HCl 10 mg medication on the following dates with the following blood pressure readings: 01/15/24 143/78 and 01/20/24 124/83. In addition, the medication was held on the following date with the following reading: 01/22/24 120/80. Interview on 01/25/24 at 3:03 P.M. with Regional Nurse (RGN) #292 confirmed Resident #75 received Midodrine HCl medication when his blood pressure was outside the provided parameters. RGN #292 also confirmed Resident #75's medication was held when his blood pressure readings were within the provided parameters and the medication should have been administered. Review of the facility policy, Physician Orders-Telephone and Verbal, revised 08/16/10, revealed the policy stated, physician orders will be received by licensed nurses, pharmacists, therapists and other persons authorized by state law to do so, and will be confirmed in writing by the prescriber with their dated signature. Record the actual order(s) received from the physician in the electronic medical record. Once the order is written, the nurse takes steps to transcribe and note the order. The policy did not address properly following physician orders.

Based on record review, staff interviews, and facility policy review, the facility failed to obtain a laboratory test as ordered by a physician for one resident (Resident #7). This affected one (Resident #7) of one reviewed for laboratory tests. The facility census was 108. Findings Include: Review of the medical record for Resident #7 revealed an admission date on 11/16/21. Medical diagnoses included spinal stenosis, chronic obstructive pulmonary disease (COPD), chronic kidney disease Stage 3, and dysphagia (difficulty swallowing) oropharyngeal phase. Review of the annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #7 had impaired cognition and scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #7 required assistance ranging from partial assistance to dependence on staff to complete Activities of Daily Living (ADLs). Review of the Medication Administration Record (MAR) dated November 2023 revealed an order for Resident #7 to check Basic Metabolic Panel (BMP), check potassium level one time only for two days was dated 11/28/23 at 7:00 P.M. The lab order was marked as other see notes on 11/28/23 at 11:32 P.M. Review of the progress notes dated from 11/01/23 through 01/24/24 revealed on 11/28/23 at 8:27 P.M., a new order to recheck Basic Metabolic Panel (BMP), check potassium level was received. Daughter #301 was notified. There were no additional notes related to the results from the lab test. Review of the care plan revised 01/11/24 for Resident #7 revealed the resident had altered health maintenance related to progressive physical and mental status. Interventions included monitor labs as ordered and report results to the physician. Review of the laboratory test results for Resident #7 dated from 01/01/2023 through 01/24/24 revealed there was no BMP lab result provided for the lab ordered on 11/28/23 or after. Interview on 01/25/24 at 7:52 A.M. with the Director of Nursing (DON) and Regional Nurse (RGN) #292 confirmed the BMP lab ordered on 11/28/23 had not been completed as ordered. Review of the facility policy, Physician Orders-Telephone and Verbal, revised 08/16/10, revealed the policy stated, physician orders will be received by licensed nurses, pharmacists, therapists and other persons authorized by state law to do so, and will be confirmed in writing by the prescriber with their dated signature. Record the actual order(s) received from the physician in the electronic medical record. Once the order is written, the nurse takes steps to transcribe and note the order. The policy did not address properly following physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to implement infection control measures for the cleaning of glucometers (blood sugar meters) and proper hand hygiene during wound dressing change procedures. This affected two residents (Residents #26 and #108) out of eleven residents requiring blood sugar checks on Units 200 and 300, and one resident (Resident #6) out of three residents reviewed for skin pressure injuries. The facility census was 108. Findings Include: 1. Review of Resident #108's medical record revealed Resident #108 was admitted to the facility on [DATE] with the admitting diagnoses including Diabetes Mellitus type two, high blood pressure, hypothyroidism, and weakness. Resident #108 required limited assistance from staff for activities of daily living (ADL) tasks. Review of Resident #108 signed physician orders revealed an order dated 11/01/23 for Novolog Insulin 100 unit per milliliter administered four times daily per blood sugar check results. Observation on 01/24/24 at 8:10 A.M. revealed Registered Nurse (RN) #282 during morning medication administration for the 200 unit performing blood sugar check for Resident #108. RN #282 sanitized hands and removed the glucometer, several alcohol wipes, lancet, and a bottle of test strips from the medication cart and entered Resident #108's room. RN #282 placed a paper towel for a barrier and then placed the supplies on the barrier. RN #282 donned gloves and performed the finger stick and blood sugar check for Resident #108. RN #282 removed the gloves, washed hands and gathered the remaining supplies and left Resident #108's room. #282 placed the glucometer and the bottle of test strips on the top of the medication cart and disposed of the other supplies. RN #282 washed her hands and then documented the blood sugar results. RN #282 continued the morning medication administration without cleansing the glucometer. Interview on 01/24/23 at 8:25 A.M. with RN #282 confirmed following Resident #108's blood sugar check the glucometer should have been cleaned using disinfectant wipes and following the manufacturer guidelines, and then stored in the medication cart. 2. Review of Resident #26 medical record revealed Resident #26 was admitted to the facility on [DATE] with the admitting diagnoses including history of stroke, high blood pressure, Diabetes Mellites type two, and hyperlipidemia. Resident #26 requires the use of a walker for ambulation assistance and limited assistance from staff for activities of daily living (ADL) tasks. Review of Resident #26's signed physician orders revealed an order dated 02/01/23 for Insulin Aspart 100 units per milliliter administered four times daily per results of blood sugar check. Observation on 01/24/23 at 10:53 A.M. revealed Licensed Practical Nurse (LPN) #144 during noon medication administration for 300 unit performing blood sugar check for Resident #26. LPN #144 donned gloves and removed two alcohol wipes from the medication cart and began wiping the glucometer with the alcohol wipes. After wiping the glucometer, LPN #144 placed the glucometer on a paper towel on top of the medication cart, removed the gloves and sanitized hands. LPN #144 then gathered the rest of the supplies including a finger stick lancet, a test strip, and several alcohol wipes. LPN #144 placed these supplies into two empty plastic cups and entered Resident #26's room. LPN #144 placed a paper towel on the bedside table, placed the supplies on the barrier, washed hands and donned gloves. LPN #144 obtained Resident #26's blood sugar check, removed gloves, washed hands, gathered the remaining supplies, and left the room. LPN #144 placed the glucometer on the barrier on top of the medication cart and disposed of the rest of the supplies. LPN #144 donned gloves and wiped the glucometer with several alcohol wipes, and then stored the glucometer in the medication cart. Interview on 01/24/23 at 1:30 P.M. with LPN #144 confirmed the glucometer should be cleansed with disinfectant wipes per the manufacturer guidelines instead of using alcohol wipes. Review of the facility's policy titled, Cleaning and Disinfection of Capillary-blood sampling devices revised 04/2015 revealed, Cleanse the glucometer with the disinfectant wipe. Allow surfaces to remain wet based on the manufacturer guidelines. 3. Review of the medical record review for Resident #6 revealed an admission date of 05/19/23. Diagnoses included heart failure, peripheral vascular disease (PVD), and primary osteoarthritis. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating the resident had a severely impaired cognition for daily decision making abilities. Resident #6 was noted to have one unstageable pressure ulcer, one stage II pressure ulcer, and three venous and arterial ulcers. Review of Resident #6's treatment orders dated 01/07/24 revealed the following treatment to be completed, Right upper thigh, cleanse wound with Vashe wound cleanser, pat dry with gauze, apply primary dressing , honey wound gel and cover with secondary dressings, clean dry dressing every night shift for healing and as needed. Observation on 01/25/24 02:01 P.M. of RN #226 completing wound care with the assistance from RN #30 revealed concerns regarding infection control. RN #212 was observed using hand sanitizer upon enter the residents room to completed wound care. Gloves were put on and the old dressing was removed and the wound was cleansed. RN #212 removed the old dirty gloves and put on a pair of new gloves with out completing hand hygiene in between the removal of the soiled gloves and placement of the clean gloves. Interview on 01/25/2024 with RN #226 and #30 confirmed hand hygiene was not completed in between glove changes. Interview on 01/25/2024 at 3:30 P.M. with the Director of Nursing (DON) revealed when a dressing is to be changed hand hygiene should be completed prior and after gloves are changed, if the hands are not visibly soiled, they can use hand sanitizer, if soiled, need to wash with soap and water. Review of facility policy titled Hand Hygiene, dated 11/28/2017 revealed, 6. Staff perform hand hygiene (even if gloves are used) in the following situations: c. after removing personal protective equipment (e.g. gloves, gown, facemask).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of manufacture guidelines the facility failed to remove five expired tuberculin (TB) solution vials from circulation. This had the potential to affect all 108 residents residing in the facility. The facility census was 108. Findings Include: Observation on [DATE] at 1:20 P.M. of unit 400 medication storage refrigerator revealed an opened Aplisol tuberculin (TB) solution vial received from pharmacy on [DATE] with an opened date of [DATE]. Registered Nurse (RN) #212 confirmed the expired opened Aplisol TB solution vial. Observation on [DATE] at 1:30 P.M. of unit 200 medication storage refrigerator revealed an opened Aplisol TB solution vial received from the pharmacy on [DATE] with no opened date. Further observation revealed another opened Aplisol TB solution vial received from the pharmacy on [DATE] with no opened date. Registered Nurse (RN) #282 confirmed the two opened expired Aplisol TB solution vials. Observation on [DATE] at 1:42 P.M. of unit 300 medication storage refrigerator revealed an opened Aplisol TB solution vial received from the pharmacy on [DATE] with an opened of date [DATE]. Further observation revealed an opened Aplisol TB solution vial received from the pharmacy on [DATE] with no opened date. Licensed Practical Nurse (LPN) #144 confirmed the two opened expired Aplisol TB solution vials. Review of the Aplisol TB solution manufacturer guidelines revealed, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

Based on record review, facility policy and procedure review and interview the facility failed to obtain written authorization to manage personal funds and failed to ensure funds were maintained in an interest-bearing account for a Medicaid recipient. This affected one resident (#38) of nine residents reviewed for resident funds. Findings include: Review of the medical record for Resident #38 revealed an admission date of 03/02/21 with diagnoses including diabetes, diabetic neuropathy, right left below knee amputation and urine retention. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 03/23/22 revealed Resident #38 was cognitively intact with a Brief Interview for Mental Score (BIMS) of 14. The assessment revealed the resident required extensive assistance with staff for transfers and mobility. On 04/14/22 at 10:20 A.M. interview with Business Office Manager (BOM) #228 revealed Resident #38 provided the business office manager an envelope of money. BOM #228 revealed the envelope initially had $450.00. BOM #228 counted out the remaining money in the envelope to determine the remaining balance in front of surveyor and revealed $301.62 remained in the envelope. On 04/19/22 at 5:50 P.M. interview with BOM #228 revealed Resident #38 gave money to the BOM in 03/2022. BOM #228 confirmed the resident was not able to access the account without assistance from her or her staff. BOM#228 acknowledged this would constitute the facility holding and managing the resident's money. Review of resident fund balance totals, dated 04/11/22, revealed Resident #38 did not have a personal funds account open with the facility. Review of an undated consent form revealed resident does not give consent to open an account for facility funds and revealed resident or another entity other than the facility to manage resident money while in the facility. Review of facility undated policy titled Management of Personal Funds revealed upon written authorization the facility would hold and manage an account for the personal funds the resident deposited with the facility. The policy revealed funds would be placed in an interest bearing account separate from facility accounts that credit's interest earned.

Based on observation, record review, facility policy and procedure review and interview the facility failed to establish a system that assures the full, complete and separate accounting, according to generally accepted accounting principles related to funds being held by the facility for Resident #38. This affected one resident (#38) of nine residents reviewed for resident funds. Findings include: Review of the medical record for Resident #38 revealed an admission date of 03/02/21 with diagnoses including diabetes, diabetic neuropathy, right left below knee amputation and urine retention. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 03/23/22 revealed Resident #38 was cognitively intact with a Brief Interview for Mental Score (BIMS) of 14. The assessment revealed the resident required extensive assistance with staff for transfers and mobility. On 04/14/22 at 10:20 A.M. interview with Business Office Manager (BOM) #228 revealed Resident #38 provided the business office manager an envelope of money. BOM #228 revealed the envelope initially had $450.00. BOM #228 counted out the remaining money in the envelope to determine the remaining balance in front of surveyor and revealed $301.62 remained in the envelope. On 04/19/22 at 5:50 P.M. interview with BOM #228 revealed Resident #38 gave money to the BOM in 03/2022. BOM #228 confirmed the resident was not able to access the account without assistance from her or her staff. BOM#228 acknowledged this would constitute the facility holding and managing the resident's money. Review of an undated consent form revealed resident does not give consent to open an account for facility funds and revealed resident or another entity other than the facility to manage resident money while in the facility. Review of facility undated policy titled Management of Personal Funds revealed upon written authorization the facility would hold and manage an account for the personal funds the resident deposited with the facility. The policy revealed accounting statements would be provided to residents quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, and staff interview, the facility failed to ensure a resident was provided with personal privacy. This affected one resident (#17) of one resident reviewed for privacy. Findings include: Review of the medical record for Resident #17 revealed an admission date of 01/20/22. She had resided in the same room since admission. A Minimum Data Set assessment completed on 01/27/22 stated the resident required extensive assistance from staff with transfers and locomotion. Interview with Resident #17 on 04/12/22 at 9:43 A.M. revealed the sliding door to the bathroom in her room does not close all the way. (room [ROOM NUMBER]). She stated that if the main door to her room does not get shut by staff, she feels like the people in the hallway can see her using the bathroom. (The bathroom is located right beside the main door to the room). She stated sometimes she does not like to go to the bathroom because of this. She stated the door had been this way since she was admitted . Observations on 04/12/22 at 9:56 A.M. revealed the sliding door to the bathroom in room [ROOM NUMBER] was located right beside the main door to the room. The sliding bathroom door had magnets on it that were supposed to attach to the door casing to keep the door closed. However, the magnets did not hold and the door would not close completely, leaving a gap. Interview with Maintenance Director #94 on 04/13/22 at 8:02 A.M. confirmed the sliding bathroom door would not latch to keep it closed. He stated he was not aware the door would not latch and did not know how to fix it. He stated all they could do was try to get the door to relax more so the magnets would stick (the door was a folding type door). He stated maintenance routinely checks the bathroom doors by visualizing them for issues, not actually closing them to see if they latch. He stated those type of doors were typically off the track at the top. Interview with Corporate Registered Nurse #290 on 04/13/22 at 2:00 P.M. revealed the facility did not have a policy on privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #95 revealed an admission date of 08/17/17. Diagnosis included major depressive disorder recurrent, anxiety disorder, hallucinations, schizoaffective disorder, and dementia without behavioral disturbances. Review of Resident #95's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05 indicating Resident #95 had a severely impaired cognition related to daily decision making abilities and was noted to display behaviors including inattention. Resident #95 required extensive assistance from two staff members for bed mobility, and transfers, and extensive assistance from one staff member for dressing, eating, toilet use, and personal hygiene. Resident #95 was noted to be free of impairments to the bilateral upper and lower extremities and required the assistance of a wheelchair for mobility. Review of Resident #95's plan of care dated 08/08/20 revealed Resident #95 was at risk for adverse effects related to the use of psychoactive medication use for anxiety and a history of hallucinations and the use of antidepressants for depression and antipsychotic medications for schizoaffective. Interventions included to assess behaviors for which drugs were being used for, administer medication as ordered, and monitor for side effects. Review of the plan of care dated 08/08/17 revealed Resident #95 experiences alteration in mood and/or behavior as evidenced by feeling tired or having little energy, and trouble falling or staying asleep. Interventions include to allow resident to vent feelings, explain procedures before beginning them, and administering medications as ordered. Review of Resident #95's physician's orders for April 2022 revealed the following: • Sertraline Hydrochloride (hcl) (a selective serontonin reuptake inhibitor), 50 milligram (mg) tablet, give three tablets via peg tube (a long tube that enters the stomach through an artificial external opening) for depression. • Exelon Patch 24 hours (a acetylcholinesterase inhibitor, used to treat symptoms of dementia), 4.6 mg / 24 hours, apply one patch transdermal (application of patch directly to the skin) daily for dementia and remove per schedule. • Seroquel (a antipsychotic), 25 mg, give two tablet at nighttime for schizoaffective disorder. Review of Resident #95's Preadmission Screening and Resident Review (PASARR) which is a requirement to help ensure individuals are not inappropriately placed in a nursing home for long term care, dated 03/13/18 revealed the following diagnosis under Section D: Indication of Serious Mental Illness, No diagnosis of any of the listed serious mental illness. Specific diagnosis listed under this sections for selection inlcuded, Schizophrenia, Mood Disorder, Delusional Disorder, Panic and or other severe Anxiety Disorder, Somatoform Disorder, Personality Disorder, Other Psychotic Disorder, Another Mental Disorder other than MR (mental retardation) that may lead to a chronic disability. Review of Resident #95's PASARR determination letter dated 03/14/18 revealed, You have been ruled out and do not require further review. Review of Resident #95's PASARR Summary Report dated 03/14/18 revealed under the section indication why the individual had been ruled out of needing further review, Outcome/Disposition the question, Has a serious mental illness, was answered no. Interview on 04/14/22 at 11:12 A.M. with the Director of Nursing (DON) confirmed Resident #95 had diagnosis that was not indicated on the completed PASARR assessment that should have been to ensure a thorough PASARR review was completed. A facility policy related to accurately completing PASARR screenings was requested during the survey. The DON stated the facility did not have a policy. Based on record review and staff interview the facility failed to update and submit Preadmission Screening and Resident Reviews (PASARR) for Resident #95 and Resident #104 to include all mental health diagnoses. The affected two residents (#95 and #104) of four residents reviewed for PASARR screenings. Findings Include: 1. Review of the medical record for Resident #104 revealed an original admission date on 02/20/18 and a recent readmission date on 02/20/22. Medical mental health diagnoses included generalized anxiety disorder (04/30/18), schizoaffective disorder (09/14/18), major depressive disorder (03/02/18), and unspecified psychosis not due to a substance or known physiological condition (02/20/18). Review of the PASARR screening for Resident #104 dated 03/15/18 revealed mood disorder and psychotic disorder were included on the PASARR. The resident received new mental health diagnoses on 04/30/18 and 09/14/18. There were no updated PASARR screenings included in Resident #104's medical record that included the new mental health diagnoses. Interview on 04/12/22 at 6:26 P.M. with the Administrator and the Director of Nursing (DON) confirmed the PASARR dated 03/15/18 was the only screening completed for Resident #104 since admission. The Administrator and DON confirmed the PASARR screening did not include Resident #104's diagnoses of anxiety disorder or schizoaffective disorder and a new PASARR had not been completed or submitted. The Administrator and DON provided a significant change PASARR completed on 04/12/22 due to Resident #104's admission to hospice services on 04/08/22. However, the updated PASARR failed to include the resident's diagnosis of schizoaffective disorder. The Administrator and DON confirmed the updated PASARR did not include all of Resident #104's mental health diagnoses.

Based on observation, record review and interview facility failed to ensure Resident #36's plan of care was implemented and updated to reflect the resident's dental care needs. This affected one resident (#36) of 27 residents whose care plans were reviewed. Findings include: Review of the medical record for Resident #36 revealed an admission date of 02/10/21. Resident #36 had diagnoses including cerebral infarction, diabetes mellitus type two, respiratory disorder, hemiplegia, seizure disorder, hypertension, anxiety, depression, atrial fibrillation, chronic pain and polyneuropathy. Review of the plan of care, dated 09/20/21 revealed Resident #36 had impaired dentition and was at risk for oral problems including pain, chewing and swallowing difficulty and had upper and lower dentures. Interventions on the care plan included if dentures were ill fitting, contact social services to make arrangements to get dentures examined for repairs, complete an oral assessment per schedule, dentures to be worn for meals, monitor and report to the physician any reports of pain or poor fitting dentures and monitor resident for any signs and symptoms of chewing and swallowing difficulty during meals. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/11/22 revealed Resident #36 was cognitively intact with a Brief Interview for Mental Status Score (BIMS) of 13. The MDS assessment revealed the resident required extensive assistance from two staff members for transfers and mobility, had no pain in mouth or difficulty chewing. On 04/11/22 at 10:02 A.M. interview with Resident #36 revealed she got new dentures a few months ago and reported the bottom denture rubbed on the right-side causing pain. The resident revealed the dentures did not fit right, staff had placed her dentures in the bathroom drawer over two months ago and she was having trouble chewing especially meat due to not having access to her bottom teeth (dentures). Review of an oral assessment, dated 04/13/22 revealed resident had dentures she wore the majority of the time and no oral health concerns or pain. The assessment did not mention the resident's lower dentures had been placed in bathroom drawer by staff several months earlier which made chewing difficult or the dentures were painful when she did have access to them. Review of the progress notes revealed no documentation of the resident not utilizing her bottom denture, having pain with her dentures or staff placing the dentures in bathroom drawer. In addition, review of the plan of care revealed no evidence it was updated to reflect the resident's trouble chewing and inability to use her bottom denture. Review of the medical record revealed no evidence social services or the administrator were notified regarding the resident's ill-fitting dentures and/or getting an appointment with the dentist as per the resident's plan of care. On 04/13/22 at 9:47 A.M. interview with Registered Nurse (RN) #268 revealed if a resident reported a concern about their teeth or dentures, they would be placed on the list to see the dentist on the next dentist visit or the resident could be scheduled to go out for an emergency dental appointment if they needed to be seen sooner. RN #268 denied knowledge of any residents on her unit having any issues with their teeth or dentures and revealed she was not familiar with Resident #36 having any dental needs or concerns. On 04/13/22 at 12:40 P.M. observation and interview with RN #268 revealed Resident #36 had a hard time chewing and swallowing and had started to choke on her food (pork roast). RN #268 was nearby and assessed the resident promptly. The resident was coughing and reported she couldn't swallow and was short of breath when asked by RN #268. The resident reported to RN #268 she had difficulty chewing the food. The RN asked the resident if the food was too tough and Resident #36 responded yes. The resident then reported staff took her bottom teeth (dentures) about two months ago and put them in her bathroom drawer due to them causing her pain. The resident again reported she had a hard time eating meats due to the size and toughness of the food and revealed she had previous choking incidents. At the time of the observation/interview the resident was observed eating with her top dentures only. Review of a nursing progress note, dated 04/13/22 and authored by Registered Nurse (RN) #268 revealed this nurse answered the resident's call light and the resident appeared short of breath and stated she felt short of breath. The RN assessed the resident's lungs which were clear at this time and the resident's oxygen saturation and pulse rate were within normal limits. The note revealed the RN made the resident a peanut butter and jelly sandwich and coffee as requested. The resident stated she was feeling better and the physician assistant (PA) was made aware of the same. On 04/14/22 at 12:40 P.M. interview with Resident #36 revealed her lunch meal consisted of noodles and beef and she had a hard time chewing the beef. Resident #36 revealed staff did not provide her her bottom denture for use during the meal and it remained in the bathroom drawer. On 04/14/22 at 4:07 P.M. interview with RN #268 revealed since the choking incident that occurred on 04/13/22 she had spoken with the medical team regarding the resident's diet orders and they did not want to change her diet to a mechanical soft or pureed diet due to resident previously refusing to eat foods in these textures. The RN revealed she spoke with the kitchen staff and requested staff put gravy on resident's meats to help them go down easier as the dryness of the food was a possible cause for her choking. The RN revealed she had the resident try on her lower dentures and the resident revealed they caused her pain. Resident #36 was also then placed on the list to see the dentist. The RN verified her progress note, dated 04/13/22 did not give a full picture of the event from the previous day and did not include any interventions or communication the RN had with the interdisciplinary team. RN #268 acknowledged her note did not mention eating had anything to do with the incident. The RN revealed she would update her note to reflect the concern for food and chewing to make her note more accurately reflect the event that occurred and interventions that had been done. On 04/14/22 at 4:17 P.M. interview with MDS Licensed Practical Nurse (LPN) #64 revealed the dental assessment completed on 04/13/22 was done through chart review of admission paperwork, dental visit notes and medical team progress notes. MDS LPN #64 revealed she does not meet with residents to physically look at their teeth during the assessment. MDS LPN #64 revealed she was not informed of the choking incident on 04/13/22. On 04/14/22 at 4:32 P.M. during a follow up interview with RN #268, the RN revealed she changed her mind and felt she did not need to change and update her note to better reflect the above incident on 04/13/22. Review of the dental visit lists dated 11/03/21, 12/17/21, 01/27/22 and 04/01/22 revealed Resident #36 was not listed on any of the lists and was not scheduled to see the dentist on any of these visits. Resident #36 last saw the dentist on 10/2021. Review of facility policy titled Dental Services, dated 11/14/17 revealed dental needs were identified through the resident assessment process and were addressed in the residents' plan of care. The facility would assist the resident with making dental appointments and arrange transportation to and from those services.

Based on closed record review, facility policy and procedure review and interview facility failed to provide a safe discharge for Resident #111. This affected one resident (#111) of one resident reviewed for discharge. Findings include Review of the medical record for the Resident #111 revealed an admission date of 01/28/22 with discharge date of 02/12/22. Resident #111 had diagnoses including dementia without behaviors, diabetes type one, asthma legal blindness, heart failure, peripheral vascular disease, and history of falls. Review of the Minimum Data Set (MDS) assessment, dated 02/04/22 revealed Resident #111 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required extensive assistance of two staff members for bed mobility and extensive assist of one staff for transfers. Review of the progress notes dated 02/12/22 at 5:20 P.M. revealed resident left facility with family and all belongings. The nurse was unsuccessful in contacting listed phone numbers on resident's profile. The nurse left message for resident's wife and attempted to contact resident's son and granddaughter. A progress note, dated 02/13/22 at 9:49 P.M. revealed the nurse called the resident's wife to discuss his admission and ask if resident would be returning. The resident's wife informed the nurse she did not think resident would be returning to the facility. The resident's wife revealed she would be calling the next day (02/14/22) to talk with staff about discharge and nurse informed her resident cannot be discharged properly since he left Against Medical Advice (AMA). Review of the medical record revealed no evidence resident or family were informed of the risks of leaving AMA. Neither the resident and/or the resident's family were offered or provided an AMA form to sign at the time the resident left the facility. On 04/14/22 at 4:51 P.M. interview with the Director of Nursing (DON) revealed staff reported to the DON that the resident left with family and belongings. The DON revealed she was later informed Resident #111 was not returning to the facility. The DON revealed she was unsure if staff reached out to discuss the risks of leaving AMA and was also unsure if staff reached out to provide any discharge assistance and inform the resident of limits for discharge due to leaving AMA. The DON confirmed the progress note stating, family reported they will call in tomorrow for discharge plans and family was told resident cannot be properly discharged due to leaving AMA. The DON revealed she did not contact the resident or resident's family. On 04/18/22 at 11:53 A.M. interview with Regional Clinical Care Coordinator (RCCC) #290 revealed the resident had left AMA when he walked out of the facility with his family and the facility had no responsibility to provide or offer any discharge supports and services. However, the facility was unable to provide evidence an AMA form was signed and resident and/or family were educated related to the risks of leaving AMA. RCCC #290 revealed no evidence staff reached out or spoke with resident or resident's family after resident's wife planned to reach out about discharge planning. RCCC #290 acknowledged during the nurses conversation with the resident's family on 02/13/22, the resident could have returned to the facility as he had not been discharged or confirmed an AMA discharge. RCCC #290 revealed all AMA discharges were considered not-applicable to get discharge services even though the facility policy does not report this and the facility had a policy specific to AMA discharges. The policy titled Discharge Against Medical Advice - AMA, dated 05/2012 revealed residents and family may be informed of the possible risks and consequences when requesting discharge from the facility without a physician's order. Residents and family pursuing AMA discharges may be counseled by staff regarding reasons why departure was against medical advice and provide education of the inability of the facility to provide proper discharge planning including medications, arranging equipment and making social service referrals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure residents dependent on staff received assistance with hygiene including shaving, and nail care. This affected one resident (#15) of the four residents reviewed for activities of daily living (ADL) care. Findings include: Review of the medical record for Resident #15 revealed an admission date of [DATE]. Diagnosis included fracture of part of the neck of the right femur, orthopedic aftercare, non-displaced type II dens fracture (dens is also known as the odontoid bone, an upward extension of the Cervical 2 (C2) vertebrae up into the C1), trochanteric fracture of the left femur, abnormalities of gait and mobility, and legal blindness as defined in the United States. Review of Resident #15's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15's cognition had not been assessed. Resident #15 was noted to required extensive assistance from two staff members for bed mobility, transfers, and toilet use, and extensive assistance from one staff member for dressing. Limited assistance was required from one staff member for personal hygiene and physical help from one staff member was required for bathing. Resident #15 was noted to be free of bilateral upper and lower extremity impairments and required a wheelchair and/or walker for mobility. Resident #15 was noted to required an indwelling Foley catheter for bladder elimination and was noted to be occasionally incontinent of bowel function. Review of the plan of care dated [DATE] revealed Resident #15 was noted to experience alteration in mood and/or behavior as evidenced by feeling down, depressed, hopeless, feeling tired or having little energy, showing little interest pleasure in doing things, trouble falling or staying asleep. Interventions inlcuded to allow the resident to vent feelings, validate feelings as needed, decrease stimulation as needed, and to distract and redirect as needed. Review of the plan of care dated [DATE] revealed Resident #15 may require assistance with Activities of Daily Living (ADL)s and may be at risk for developing complications associated with deceased ADL self performance due to right femur fracture, being legally blind, and having a dens fracture. Interventions inlcuded to provide diabetic nail care, elevate head of bed as needed for shortness of breath, and Resident #15 is noted to be able to groom self with one staff assistance. Review of Resident #15's ADLs care provided task completed by direct care staff from [DATE] through [DATE] revealed Resident received a bath or shower on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the facility's bath/shower schedule revealed Resident #15 was to receive a bath or shower on Monday and Thursday nights. A look back from [DATE] through [DATE], Resident #15 as per schedule should have received a bath or shower on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Observation on [DATE] at 11:47 A.M. of Resident #15 revealed resident with long nails with noted brown substance under each nail. Resident #15 was also noted to have short to medium length facial hair stubble. Interview on [DATE] at 11:48 A.M. with Resident #15 revealed he prefers to be clean shaved. Residents #15 denied receiving any nail care when he was receive a shower, which Resident #15 was unable to provide the day he last receive a shower, nor was he offered to be shaved. Observation on [DATE] at 12:57 P.M., on [DATE] at 11:23 A.M., and on [DATE] at 3:13 P.M., of Resident #15 revealed the resident still had not received nail care and nails continued to appear long with dark brown substance under each nail and continued to have not medium length facility hair stubble. During observations made on [DATE] at 12:57 P.M. and on [DATE] at 11:23 A.M. and 3:13 P.M., Resident #15 was noted to be wearing the same clothing on both days. Resident #15 was noted to be wearing a white t-shirt with noted yellow stains and light brown stains on it. Interview on [DATE] at 3:13 P.M. with Resident #15 revealed he received a shower that previous Monday night which was [DATE] but had not been shaved and nail care was not completed. When asked if staff assisted him with dressing daily, Resident #15 claimed that he did not have much clothing so he wore the same clothing over and over again. Resident #15 claimed he was not aware of any stains or issues with the t-shirt he was currently wearing. Interview on [DATE] at 3:18 P.M. with Licensed Practical Nurse (LPN) #190 verified Resident #15 required staff assistance for personal hygiene and bathing. When asked if Resident #15 had ever refused to receive personal hygiene including nail care or being shaved, LPN #190 claimed that Resident #15 is scheduled to receive bathing on night shift so she could not say for certain but he had never refused any care for her nor had she received reports from any of the direct care staff that Resident #15 had refused care. When asked what Diabetic Nail Care was, LPN #190 claimed diabetic nail care was nail care that was provide by the nurse due to the resident having a diagnosis of being a diabetic and there was extra care that needed to be taken when providing nail care. LPN #190 observed Resident #15 and verified the resident required nail care and needed to have his facility hair shaved and his t-shirt was soiled and needed to be changed. Review of the facility policy titled Bathing: Shower, dated 04/2002 revealed under Purpose, To provide cleanliness and comfort, stimulate circulation, and observe condition of resident. Review of the facility policies provided revealed the facility did not provide a policy and/or procedure related to nail care and shaving of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #47 revealed an admission date of [DATE] with diagnoses including cerebral infarction, unsteadiness on feet, hyperlipidemia, healed femur fracture and depression. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #47's cognition was not assessed and the resident required extensive assistance of two staff members for bed mobility and transfers. Review of care plan dated [DATE] revealed the resident was at risk for impaired skin integrity with interventions for daily skin checks. Review of a progress note, dated [DATE] revealed resident had a fall from her bed. The facility placed a sign for visual cues to encourage resident to call don't fall. On [DATE] staff noticed a bruise on resident's arm from fall the previous day. The care plan was not updated after the bruise was discovered on [DATE]. Review of a skin assessment, dated [DATE] revealed a bruise was found under the resident's left upper arm that measured nine centimeters (cm) long by five cm wide. Review of physician's orders revealed an order, dated [DATE] to monitor bruising to the underside of the left upper arm each shift until healed. Review of the skin grid non-pressure assessment form, dated [DATE] revealed a bruise was acquired from a fall on [DATE] that measured nine cm in length by five cm wide. Review of the Treatment Administration Record (TAR) dated 04/2022 revealed no documentation of monitoring of the bruise each shift. The TAR revealed weekly skin assessments were checked off on [DATE] and [DATE]. Review of shower sheets dated [DATE] and [DATE] revealed no assessment of a bruise or injury or how the injury looked including a description of the area. The sheets only contained a circle around the left arm of the diagram with no mention of an injury or bruise to that area. Review of medical record revealed no evidence of facility monitoring of the bruise either through a check off method or through detailed descriptions of the healing status. On [DATE] at 11:10 A.M. observation of Resident #47 revealed resident still had a bruise on her left upper arm measuring about the size of a quarter. The bruise appeared reddish purple and looked to be in the healing stages. On [DATE] at 1:05 P.M. interview with Licensed Practical Nurse (LPN) #138 revealed if a resident had an order for injury of bruise monitoring, the order would be on the TAR for sign off by nursing staff to reflect the monitoring was being completed. On [DATE] at 1:24 P.M. interview with DON confirmed bruising should be monitored and confirmed the physician requested monitored each shift according to the order. The DON was not aware of where evidence of wound/injury monitoring was located in the medical record. On [DATE] interviews between 1:45 P.M. and 5:00 P.M. with Regional Clinical Care Coordinator (RCCC) #290 revealed the facility policy which referenced monitoring skin weekly would suffice for the monitoring requested by physician order for every shift. RCCC #290 then reported the plan of care and policy about skin checks by the STNA staff would cover the request by the physician for monitoring every shift. RCCC #290 confirmed there was no written documentation in the resident's medical record after [DATE] in relation to bruise monitoring. Review of skin and wound best practice policy revealed skin checks should be completed weekly for every resident. The facility did not have a policy specific to monitor bruising or following physician orders. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and/or the residents' choices. The facility failed to ensure Hospice communication documentation was kept readily available for review at the facility or in the resident's medical record for Resident #16 and failed to ensure the Hospice provider was notified timely of changes in the resident's condition. The facility failed to monitor bruising following a fall for Resident #47. The facility failed to schedule and complete an ordered Magnetic Resonance Image (MRI) timely for Resident #104. This affected three residents (Residents #16, #47 and #104) of four residents reviewed for quality of care. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date on [DATE] with diagnoses including moderate protein-calorie malnutrition, essential hypertension (high blood pressure), cataract (lens) fragments in eye following cataract surgery and underweight. Review of the current physician's orders revealed Resident #16 had an order dated [DATE] to admit to Hospice care with a terminal diagnosis of moderate protein calorie malnutrition. Review of the plan of care revealed Resident #16 received Hospice services for end stage diagnosis of moderate protein calorie malnutrition. Interventions included Hospice to collaborate care with facility staff, contact Hospice for changes in resident condition and Hospice services as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The assessment revealed the resident required limited to extensive assistance from one staff person to complete activities of daily living (ADL) care and received Hospice services. Review of a progress note, dated [DATE] at 1:00 P.M. revealed Resident #16 was found on sitting on the floor in front of the bedroom chair. The note revealed the Unit Manager (UM), Physician Assistant (PA) and family were made aware of the fall. The note did not indicate hospice had been notified. On [DATE] at 7:15 P.M. Resident #16 was found lying on the floor on her right side by the bed. The resident was noted to have a medium size hematoma (bruise) on the right side of her head toward the front of her head. The note indicated the PA and family were notified of the resident's fall. The note did not indicate the Hospice provider was notified. There were no Hospice communication notes found in Resident #16's electronic medical record. On [DATE] at 10:26 A.M. interview with Resident #16's nephew revealed the Hospice provider had not been in regular contact with him regarding Resident #16's status. Resident #16's nephew stated he was contacted approximately once a month but was not sure how often Hospice services were provided for Resident #16 at the facility. On [DATE] at 12:58 P.M. information from the Director of Nursing (DON) revealed Hospice communication notes were located in binders on each unit of the facility. On [DATE] at 3:46 P.M. the Hospice provider binder located on Resident #16's unit was reviewed and revealed there were limited Hospice communication notes dated only from [DATE] to [DATE]. There were not any notes prior to [DATE] included in the binder. On [DATE] at 4:25 P.M. interview with the DON confirmed Hospice communication notes included in the binder were dated from [DATE] to current and there were not any notes prior to [DATE] included in the binder. The DON stated additional Hospice communication notes may be in medical records waiting to be uploaded to Resident #16's electronic health record or she could contact the Hospice provider to request additional communication notes be sent to the facility. On [DATE] at 5:04 P.M. review of the Hospice contract revealed hospice and the facility shall communicate with each other regarding the Hospice patient's condition through telephone, in person verbal communication and if appropriate written communication in the Hospice patient's medical record to ensure the hospice patient's needs were met 24 hours every day. The contract also stated both parties would immediately notify the other if there was a significant change in condition, clinical complications appear that suggested a need to alter the plan of care (POC), there was a need to transfer the resident from the facility or the resident died. On [DATE] at 10:30 A.M. interview with the DON confirmed there was no evidence the Hospice provider had been invited to participate in care conferences routinely for Resident #16 since her admission to Hospice services on [DATE]. On [DATE] at 2:41 P.M. the DON provided additional hospice communication notes. Each note was labeled Interdisciplinary Group Meeting. The notes were typed and followed the same format for each note. The Hospice communication notes reviewed from the binder on-site at the facility were hand-written communication notes from the Hospice staff. Review of the IDT Group Meeting notes from the hospice provider dated [DATE], [DATE], [DATE], and [DATE] revealed the Registered Nurse Case Manager (RNCM) visited Resident #16 on [DATE] and noted there had not been any changes during the past two weeks. Resident #16 had a fall on [DATE]. The RNCM's note dated [DATE] also noted no changes in the past two weeks. Resident #16 had another fall on [DATE]. On [DATE] at 2:47 P.M. an email was received from the DON which included an attached letter from the Hospice provider related to the collaboration between the Hospice provider and the facility. The letter revealed the Hospice provider's staff documented communication within their visit notes and interdisciplinary team (IDT) notes. The facility communication logs kept in the binders on-site were often thinned and were not a part of the resident's medical record. On [DATE] at 4:07 P.M. an email was received from the DON that confirmed the Hospice provider staff documented their communication with Resident #16 in their visit notes and IDT notes. The facility requested notes from the Hospice provider as needed via email. Review of the facility policy titled Hospice Care in Nursing Home, dated [DATE] revealed the facility would meet the physical, emotional, and spiritual needs of patients and their families facing life ending illnesses by working collaboratively with the Hospice provider to enhance the quality of life for both the patient and the family. The facility would designate and notify the Hospice of the identity of an IDT member to be responsible for working with Hospice representatives to coordinate the care of the Hospice patients provided by the facility staff and the Hospice staff. The facility designated IDT member would be responsible for: collaborating with Hospice representatives and coordinating facility staff participation in the Hospice care planning process, communicating with Hospice representatives and other healthcare providers participating in the provision of care for the Hospice patient's condition to ensure quality of care, obtaining information from Hospice, including, but not limited to, the most recent Hospice plan of care, the Hospice election form and hospice medication information specific to each Hospice patient, and ensuring that the facility provides orientation to the Hospice staff in the policies of the facility, including resident rights, appropriate forms, and record keeping requirements. The facility would notify the Hospice provider if there was a significant change in a Hospice patient's physical, mental, social, or emotional status or there are clinical complications suggesting a need to alter the plans of care. 2. Review of the medical record for Resident #104 revealed an original admission date on [DATE] and most recent readmission on [DATE] with diagnoses including moyamoya disease (a chronic and progressive condition of the arteries in the brain), Type II diabetes mellitus with diabetic neuropathy, schizoaffective disorder, generalized anxiety disorder, major depressive disorder, unspecified psychosis not due to a substance or known physiological condition and displaced intertrochanteric fracture of left femur. Review of the physician orders revealed Resident #104 had an order dated [DATE] at 2:43 P.M. to obtain a MRI of the left lower extremity (LLE) to rule out osteomyelitis. Resident #104 also had an order for the antibiotic, Vancomycin HCL Solution Use 1000 milligrams (mg) intravenously (IV) every 12 hours for osteomyelitis with a start date on [DATE] and a completion date on [DATE]. Review of the weekly Pressure Skin Grid assessments revealed on [DATE], Resident #104 had a Stage III pressure ulcer to her left heel. The pressure ulcer had been present since [DATE] and the wound had declined at the time of the assessment. The weekly skin grid assessments dated from [DATE] to [DATE] noted the wound to be improving. The skin assessment dated [DATE] noted the wound to be declining again. The skin assessment dated [DATE] noted the wound to be improving again. The skin assessment dated [DATE] noted the wound to be unchanged. The skin grid assessment dated [DATE] noted the wound to be declining again. The pressure ulcer remained a Stage III from [DATE] to [DATE]. Review of progress notes dated from [DATE] to [DATE] revealed Resident #104 was on an antibiotic for a left heel infection on [DATE]. On [DATE], Resident #104 went to a scheduled appointment at a wound clinic but was not able to be seen due to short staffing. The resident returned to the facility and wound treatments was completed as ordered. On [DATE], Resident #104's left heel was noted to be red and swollen around the wound. The Certified Nurse Practitioner (CNP) ordered another, different, antibiotic for treatment of the resident's left heel. Review of the progress note dated [DATE] at 10:57 A.M. revealed Resident #104 was seen by the CNP for a wound assessment. The problem was reported by the nursing staff and was described as chronic and worsening and was located on the left heel. Nursing requested follow up due to the wound declining and showed signs of cellulitis. Resident #104 also reported an increase in pain. The CNP noted the pressure ulcer of the left heel to be chronic and worsening with an increase in area, pain, and drainage. The CNP noted and order for the wound treatment and to continue offloading boot at all times while Resident #104 was in bed. Resident #104 would continue on the same antibiotic for treatment of cellulitis. The CNP recommended a MRI of her left foot to rule out osteomyelitis due to recurrent infections and delayed wound healing. Review of progress notes dated [DATE] to [DATE] (nearly one month) revealed no documentation related to scheduling an MRI for Resident #104. Review of fax cover sheets dated [DATE] and [DATE] revealed the facility faxed the order to central scheduling at the local hospital. The MRI was scheduled for [DATE] at 3:30 P.M. originally but transportation did not arrive and the appointment had to be rescheduled. Review of progress notes dated [DATE] at 2:35 P.M. revealed Registered Nurse (RN) #268 called central scheduling regarding scheduling the MRI for Resident #104. Central scheduling agreed to follow up with the facility to schedule the MRI. Review of progress notes dated from [DATE] to [DATE] (nearly two months after the MRI was ordered) revealed no further documentation related to Resident #104's MRI being scheduled or completed. Review of the progress note dated [DATE] at 9:31 A.M. revealed Resident #104's results from the MRI were compromised due to motion degradation but report was forwarded to the wound nurse as ordered. The wound nurse advised no new orders at this time and would re-evaluate at the next visit with the resident to determine if another MRI should be scheduled. Review of the MRI results dated [DATE] revealed an MRI of Resident #104's lower extremity was completed on [DATE]. The results were severely compromised and a repeat MRI with sedation was recommended. The results were compatible with localized acute osteomyelitis as well as cellulitis. Review of the progress noted dated [DATE] at 12:54 P.M. revealed Resident #104 received initial dose of Vancomycin (an antibiotic) intravenously (IV) as ordered by PA #500. On [DATE] at 12:46 P.M., the facility notified Resident #104's son the resident would be receiving antibiotic therapy for osteomyelitis for 28 days until [DATE]. Review of the care plan dated [DATE] revealed Resident #104 was at risk for infection related to heel wound infection. Interventions included to give antibiotics as ordered, assess for signs and symptoms of infection and report to a physician, culture areas if it is clinically suspicious, labs as ordered and informed physician of abnormal results, complete treatments as ordered, and notify physician if course of treatment appears to be ineffective. Resident #104 had an alteration in skin integrity as evidenced by pressure ulcer present at left heel. Interventions included assess area for size, color, drainage weekly and as needed, assess for pain and provide treatment per physician order, elevate heels in bed as tolerated, encourage and assist with repositioning and turning, encourage off loading boot to the left foot, and provide treatments per physician orders. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #104 had impaired cognition and with a score of seven out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The assessment revealed the resident required extensive assistance from one to two staff to complete activities of daily living (ADL) care. The resident had one unhealed Stage IV facility acquired pressure ulcer. On [DATE] at 10:00 A.M. interview with Registered Nurse (RN) #268 (the facility wound nurse) confirmed there was a delay in scheduling the ordered MRI for Resident #104. RN #268 confirmed the MRI was ordered by the CNP on [DATE] but it was not completed until [DATE] (nearly two months later). RN #268 confirmed the results were compromised but the new physician assistant (PA) who started following Resident #104 after MRI results were received wanted to address the results that indicated an osteomyelitis infection and ordered intravenous (IV) antibiotics without completing another MRI. On [DATE] at 12:45 P.M. interview with Central Scheduling (CS) #300 revealed patients were able to be scheduled within 24 hours once a physician's order was received. CS #300 could not find any evidence of communication with the facility regarding Resident #104. On [DATE] at 12:52 P.M. interview with Intake #301 revealed no any evidence of communication with the facility regarding Resident #104. A facility policy was requested related to the deficiency during the survey period. However, none was provided for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #38, who developed a pressure ulcer in the facility received the necessary treatment and services to promote healing and prevent new ulcers from developing. This affected one resident (#38) of five residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #38 revealed an admission date of 03/02/21 with diagnoses including diabetes with neuropathy and right below the knee amputation. The resident was admitted with an unstageable pressure ulcer to the bottom of his left foot. On 03/02/21 the resident was assessed as not being at risk for pressure ulcers with a score of 19. The rating system used by the facility was a score of 15-18 was at risk, 13-14 moderate risk, 10-12 high risk, 9 or below very high risk. A Minimum Data Set (MDS) 3.0 assessment, dated 03/09/21 indicated the resident had an unstageable pressure ulcer on admission. An MDS 3.0 assessment, dated 02/11/22 indicated the resident had no pressure ulcers (all were healed). Review of the skin grids revealed on 10/19/21 Resident #38 was noted to have a new pressure ulcer on the left heel documented to be a Stage II pressure ulcer measuring three centimeters (cm) long by 4.5 cm wide with no depth. It was described as an intact fluid filled blister. (A Stage II pressure ulcer is defined as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage). A physician's order, dated 10/19/21 was obtained for an off loading boot to the left foot at all times. Record review revealed a plan of care related to alteration in skin integrity evidence by pressure ulcer on left heel. The plan of care indicated to encourage resident to reposition left foot frequently when in wheelchair and offloading boot to left foot per orders (in bed only). The plan of care did not include any type of pressure relieving boot to be worn when up in the wheelchair. Resident #38 was seen by the podiatrist on 10/27/21 for evaluation of left heel ulcer. The podiatrist described the area as a circular blister site with a centralized ulcer/blister measuring three cm in diameter with the ulcer measuring one cm in diameter. There was no associated erythema, edema, or drainage and no signs of infection. The ulcer extended to subcutaneous tissue. There was no visible or probable ligament, tendon or bone. The physician revealed moon boots (padded pressure relieving boots) were to be worn at all times. The pressure ulcer on the left heel was documented as healed on 12/07/21. On 12/09/21 the podiatrist assessed the left heel with no ulcer. He did note a hyperkeratotic site sub-fifth metatarsal without any opening or ulcer. He stated new order written for a moon boot to the left foot when in bed and in wheelchair. (An off loading boot was already ordered on 10/19/21). The resident was to be seen again in two months. On 02/15/22 a new Stage II pressure ulcer was noted on the left heel measuring three cm long by 3.2 cm wide by 0.1 cm deep. On 02/17/22 Resident #38 was seen by the podiatrist who noted he was wearing a wedge shoe offloading the forefoot. He noted the heel ulcer had reopened within the past couple weeks. The podiatrist assessed the ulcer to be three cm extending to the subcutaneous tissue in the heel. He also noted a one cm ulcer of the sub-fifth metatarsal as well. The podiatrist discussed the importance of blood sugar control and the need for continued offloading of both the heel and the left forefoot. The podiatrist recommended following through with the exact same orders that were currently in place including the moon boot for offloading. Record review revealed no evidence there was ever a physician's order for any type of wedge shoe for offloading the forefoot. On 03/01/22 the pressure ulcer on the left heel was still noted as a Stage II and measured four cm long by 4.5 cm wide by 0.1 cm deep. On 03/08/22 the left heel was noted to be a black unstageable ulcer measuring five cm long by five cm wide with depth unable to be determined. The physician was notified of the decline and the resident was transferred to the hospital for evaluation. Review of hospital records revealed Resident #38 was hospitalized from [DATE] to 03/16/22. During the hospital stay, the left fifth toe was amputated and the left heel was incised. The resident was referred to the wound center after the hospitalization. Upon return to the facility 03/16/22, the left heel was noted to be a Stage IV pressure ulcer measuring 4.5 cm long by 3.5 cm wide by four cm deep. On 03/16/22 physician's orders were obtained for off loading boot to left lower extremity when in bed as tolerated and non weight bearing on left lower extremity. There was no evidence of any orders for any type of pressure relief for the left heel when up in the chair. Review of the MDS 3.0 assessment, dated 03/23/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment revealed the resident required extensive assistance from two staff for bed mobility and transfers and had a Stage IV pressure ulcer. (A Stage IV pressure ulcer had full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location). Review of wound center notes revealed on 03/28/22 the resident was noted with a Stage IV pressure injury to left heel measuring 4.3 cm long by 3.2 cm wide by 1.2 cm deep. Instructions included wear heel guards to keep pressure off heels while in bed or in a chair. Record review revealed the order for off loading boot for just in bed continued after the wound centers instructions to wear heel guards in bed and in a chair. Review of wound center notes on 04/11/22 revealed the same instructions to wear heel guards to keep pressure off heels while in bed or in a chair. Record review revealed the order for off loading boot for just in bed continued after the wound centers instructions to wear heel guards in bed and in a chair. On 04/11/22 at 2:25 P.M. Resident #38 was observed up in a wheelchair with a black open toed shoe on his left foot. The resident's foot was resting on the wheelchair foot rest. On 04/13/22 at 8:41 A.M. Resident #38 was observed to be in bed eating breakfast. The resident had no pressure relieving device on the left foot. Interview with the resident at the time of the observation revealed staff did not put it on last night and does not know why. On 04/13/22 at 10:09 A.M. Resident#38 was observed up in a wheelchair in the activity room. The resident's left foot was wrapped with an ace wrap, the resident had no pressure relieving device on his foot and his foot was resting on the wheelchair foot rest. On 04/13/22 at 1:04 P.M. the resident was observed sitting in the wheelchair in his room with his left foot wrapped with an ace wrap. The resident had pressure relieving device on his foot and his foot was resting on the wheelchair foot rest. On 04/14/22 at 7:55 A.M. Resident #38 was observed sitting in the wheelchair in the hallway with his left foot wrapped with an ace wrap. The resident had no pressure relieving device on his foot and his foot was resting on the wheelchair foot rest. On 04/14/22 between 9:45 A.M. and 10:45 A.M. Resident #38 was observed to have an open hole in his left heel measuring 3.6 centimeters (cm) long by 3.4 cm wide by 0.8 cm deep. The pressure ulcer (a healing Stage IV) was noted with 80% beefy red tissue and 20% white slough in the center (Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). The ulcer had bloody drainage. After the area was cleansed, a wound vac was attached to the wound. (A wound vac is a vacuum-assisted closure of a wound that decreases air pressure on the wound helping it to heal). Resident #38 had a physician's order for a treatment to the left heel pressure ulcer including a wound vac three times per week. On 04/14/22 at 10:55 A.M. interview with Registered Nurse #268 revealed she would have to clarify if Resident #38 should be wearing a pressure relieving boot at all times. She stated the order was for just when he was in bed. She stated the resident should not be wearing the black open toed shoe when up as it did not provide pressure relief for his left heel. She provided manufacturer information on the black open toed shoe that indicated it was a Darco Ortho-wedge Off-loading shoe that provided pressure offloading of the forefoot, not the heel. On 04/14/22 at 7:35 A.M. interview with State Tested Nursing Assistant (STNA) #146 revealed Resident #38 wore a heel boot in bed but wears the black ortho wedge shoe when up. On 04/18/22 at 2:44 P.M. interview with Registered Nurse (RN) #268 on 04/18/22 at 2:44 P.M. confirmed pressure relieving boots had been ordered for both in bed and when up until the resident went to the hospital on [DATE]. When he returned, the pressure relieving boots were only ordered for in bed, even though the podiatrist had stated to wear them at all times and the wound center had stated to wear heel guards when up in chair. At 3:45 P.M. RN #268 revealed the Darco black open toed shoe had been provided by the podiatrist at an undetermined time. She confirmed there was no order for Resident #38 to wear the Darco shoe, even though he was currently wearing it. On 04/19/22 at 8:00 A.M. Resident #38 was observed up in a wheelchair in the hall. The resident's left foot was wrapped with an ace type bandage and the resident had no pressure relieving device on his left foot. Registered Nurse #268 confirmed the resident did not have a pressure relieving boot on his left foot at that time. She asked STNA #212 if the resident had said anything about the boot that morning and STNA #212 responded that he had not said anything about it. On 04/19/22 at 9:25 A.M. interview with Physician Assistant (PA) #500 revealed she had not seen the pressure ulcer on Resident #38's heel since he returned from the hospital. She stated the facility should be following the recommendations from the wound center that included heel guards for pressure relief when in bed or in the chair. She also confirmed that the facility should have had a physician's order for the use of the Darco ortho shoe if the resident wore it. On 04/19/22 at 12:55 P.M. interview with RN #501 from the wound center confirmed Resident #38 should be wearing a pressure relieving boot for pressure relief for the left heel when up and in bed. She stated she was not aware of any recommendation for the Darco off loading shoe.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure fall interventions were in place for residents at risk for falls and/or with history of falling. This affected two residents (#16 and #73) of four residents reviewed for accidents. Findings include: 1. Review of the medical record for Resident #73 revealed an admission date of 08/21/20 with diagnoses including insomnia, recurrent major depressive disorder and heart failure. Review of the plan of care, dated 01/05/21 revealed Resident #73 was at risk for falls due to a history of a cerebral vascular accident (CVA), impaired balance and personal history of falls. Interventions included to ensure brakes to wheelchair were fixed, encourage and remind to ask for assistance, ensure call light was within reach, ensure environment was free of clutter, commonly used articles were in reach, pull tab alarm was attached to bed and wheelchair, non-skid strips to the right side of the bed and visual reminders on bathroom wall to ask for help. A plan of care, dated 07/07/21 revealed Resident #73 was non-compliant with medications, showers, bowel protocols, personal care and transfers self, along with non-compliance with asking for assistance with meals. Interventions included to document attempts made with resident in related to compliance and notify the medical director of non-compliance. Review of Resident #73's fall risk evaluation completed 12/31/21 revealed a score of 9.5 indicating the resident was a risk for experiencing falls. A quarterly fall risk evaluation completed on 02/21/22 revealed the same score of 9.5 and quarterly fall risk evaluation completed on 03/10/22 revealed a score of 9.0 which still indicated Resident #73 was at risk for experiencing a fall. Review of Resident #73's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/11/22 revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident had an intact cognition for daily decision making ability. Resident #73 was noted to experience delusions and to display verbal behaviors towards others and to reject care. Resident #73 required extensive assistance from one staff member for bed mobility, transfers, locomotion on the unit and toilet use. Resident #73 had impairment to one lower extremity and required a wheelchair for mobility. Resident #73 was assessed to be frequently incontinent of bowel and bladder function. Review of Resident #73's physician orders for April 2022 revealed the resident had current fall intervention orders to apply bilateral assist bars to enhance bed mobility, floor mats to both sides of the bed, non-skid strips to the floor on the right side of the bed and pull tab alarm to bed and wheelchair every shift. On 04/12/22 at 12:50 P.M. Resident #73 was observed sitting up in her recliner chair watching television. Resident #73 was observed to have a tab alarm attached to the back of her shirt and the alarm was noted to be secured to the bedside stand. Non-skid strips were noted to be on the floor on the right side of the residents bed. No other fall interventions were observed in Resident #73's room including fall mats. On 04/12/22 at 12:52 P.M. interview with Resident #73 revealed most of the time the staff do not attached the tab alarm but stated they did today because surveyors were in the building. The resident indicated the staff knew she had enough sense to ask for help. Resident #73 also revealed when she asked for help, and if was not received in a timely manner, she would get up and transfer herself to the bathroom, like she did yesterday. On 04/13/22 at 12:51 P.M. Resident #73 was observed in bed lying on her right side with her eyes closed. Floor fall mats were not noted to be in place on either sides of the resident's bed. On 04/13/22 at 2:15 P.M. interview with Licensed Practical Nurse (LPN) #190 verified Resident #73 was a fall risk and verified one of Resident #73's fall intervention was to place a fall mat on each side of the resident's bed on the floor while in bed. LPN #190 confirmed Resident #73's fall mats were not in place at this time. LPN #190 also confirmed fall mats were not noted in Resident #73 room, closet or bathroom at that time. LPN #190 claimed she would go obtain some fall mats for Resident #73 and put them in place right away. Review of the facility policy titled Fall Management, dated 10/17/16 revealed residents who experience a fall would receive prompt medical attention. Immediate needs would be quickly assessed and responded to. A plan would be identified and implemented as necessary to protect the resident and/or others from recurrences. An interdisciplinary care plan was developed as necessary to reflect the resident's safety status, needs and interventions. 2. Review of the medical record for Resident #16 revealed an admission date on 07/02/21 with diagnoses including moderate protein-calorie malnutrition, essential hypertension (high blood pressure) and cataract fragments in eye following cataract surgery. Review of the plan of care, dated 07/02/21 revealed Resident #16 was at risk for falls due to an unsteady gait and decreased mobility. Interventions included have commonly used articles within easy reach and pull tab to chair or pull tab when up in chair. Review of the quarterly MDS 3.0 assessment, dated 10/25/21 revealed Resident #16 had impaired cognition with a score of six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #16 required extensive assistance from one staff to complete bed mobility, transfers, locomotion and toileting. Resident #16 required limited assistance from one staff to ambulate in her room and for dressing, eating and personal hygiene. The resident had not had any falls since admission and received Hospice services. Review of the physician's orders revealed Resident #16 had a verbal order (dated 01/10/22) for a pull tab to chair with instructions to check placement and function every shift for safety intervention. Review of the Fall Risk Evaluations dated 01/07/22 and 04/07/22 revealed Resident #16 was at risk for falls with scores of 14 and 12 respectively. The resident had a history of one to two falls in the previous 90 days on each evaluation. Resident #16 had cognitive impairment and impaired vision. Resident #16 saw only light, colors, or no vision. Resident #16 required assistance with mobility and was not steady on her feet. The resident needed assistance from staff to assist with stabilizing her when transitioning from seated to standing as well as with ambulation. The resident had multiple chronic medical conditions and took several medications. Review of the progress notes revealed Resident #16 sustained falls on 01/07/22 and 04/07/22. On 01/07/22 at 1:00 P.M. Resident #16 was found on the floor sitting upright in front of bedroom chair. The resident was alert and oriented to self and situation and vitals were within normal limits. Resident #16 stated, I was trying to move in my chair and slid, I did not fall. Notifications were completed. Review of the Fall Investigation Report, dated 01/07/22 revealed current fall prevention interventions included verbal reminders to call for help, non-skid socks, a clutter free environment, a well lit environment, and call light to be kept within reach. A new fall intervention initiated as a result of the fall for Resident #16 was a pull tab alarm when Resident #16 was in her chair. Resident #16 was noted to wait for the call light to be answered. Review of an incident note, dated 01/11/22 revealed the Interdisciplinary Team reviewed Resident #16's falls. On 01/11/22 at 3:07 P.M. a new fall intervention of a pull tab alarm to chair was initiated. On 04/07/22 at 7:15 P.M. Resident #16 was found laying on the floor on her right side by the bed. The resident's head was toward the top of the bed and her legs were bent and arms at her side. Resident #16 stated, I was trying to put my cup on water on my table but could not find it. Resident's bedside table was pushed away from her bed and looked like she had been reaching out too far and fell out of bed. Resident #16 sustained a medium sized hematoma (bruise) to the middle of her forehead. Notifications were completed. A new intervention of non skid strips by the right side of bed to help the bedside table to stay by bed was initiated. Review of the Fall Investigation Report, dated 04/07/22 revealed current fall prevention interventions included to maintain a clear pathway, pull tab to chair, non slip material to resident's room chair, ensure call light was within reach, commonly used articles were kept within reach, and verbal reminders to ask for assistance. A new fall intervention of non skid strips to the floor to help keep bedside table in place was initiated for Resident #16. Resident #16 was noted to wait for the call light to be answered. Review of an incident note, dated 04/12/22 revealed the Interdisciplinary Team reviewed Resident #16's falls. On 04/12/22 at 10:48 A.M. a new fall intervention of non skid strips to the floor on the right side of the resident's bed was initiated. On 04/12/22 at 5:08 P.M. Resident #16 was observed in her room sitting up in her chair eating dinner meal. No pull tab alarm was observed in the resident's chair. The resident's touch pad call light was observed draped over the right side of the bed and not within reach from the resident's chair. Resident #16 would have had to stretch out from chair and reach for the call light in order to reach it. Resident #16 was observed to be extremely visually impaired and needed assistance to find where foods were located on her meal tray in front of her. On 04/13/22 at 5:28 P.M. Resident #16 was observed lying in bed with her dinner meal tray on the bed side table. The resident was observed to have a large bruise in the middle of the forehead that appeared light green and yellowish in color and appeared to be healing. The resident's touch pad call light was observed hanging over the bed rail on the right side of the bed and not within resident's reach due to visual impairment. Resident #16's bed side table was observed not be placed directly in front of her and was out away from the bed at a slightly diagonal angle. When the resident was asked how she would get help if she needed it, Resident #16 was observed feeling around the bed but was not able to find what she was feeling for. The resident stated, I don't know where it is, referring to her call light. On 04/13/22 at 5:45 P.M. observation with Licensed Practical Nurse (LPN) #138 confirmed Resident #16's touch pad call light was not within reach of the resident and confirmed due to the resident's visual impairment, she would not be able to find it hanging over the right side of the resident's bed railing. LPN #138 revealed Resident #16 did not use her call light very often but to her knowledge, the resident was cognitively and physically able to use the call light for assistance. LPN #138 confirmed Resident #16's bed side table did not lock in place and was easily pushed away or moved out of place. LPN #138 confirmed the intervention of using non skid strips on the floor was ineffective in keeping the resident's bed side table (a commonly used item) in place for the resident. On 04/18/22 at 5:10 P.M. observation of Resident #16's room revealed the resident was lying in bed with her dinner tray in front of her on the bed side table. The resident's call lights were not observed to be within the resident's reach. The resident was asked if she was able to find her call light in case she needed assistance. Resident #16 proceeded to feel all around her on the bed on top of the covers but was not able to find a call light. The resident was observed to have two push button call lights in place instead of the touch pad call light. One of the call lights was observed hanging over the left bed rail below the bed, nearly touching the floor. The second call light was observed laying across the resident's lap but sandwiched and covered up with the quilt on her bed. Resident #16 continued to try to feel for a call light but was not able to find either of them. No pull tab alarm was observed anywhere in resident's room or by the resident's chair. When asked what the call light was for, Resident #16 stated, I press it to get help. Resident #16's bed side table was observed not to be locked in place and resident was able to move it easily while trying to feel around in the bed. On 04/18/22 at 5:17 P.M. observation with LPN #138 confirmed Resident #16's bed side table still did not lock into place. The nurse stated maintenance did change out the table but it was still easily rolled around and moved out of the reach of the resident. LPN #138 confirmed Resident #16's call lights were not within the resident's reach or easily located in the resident's bed due to be being tucked in the quilt. LPN #138 stated she was not sure why the resident's call lights were changed back to a push button call light because that would be even more difficult for Resident #16 to operate to call for assistance due to her visual impairment. LPN #138 confirmed there was no pull tab alarm on Resident #16's chair or used when the resident was up in her chair. The nurse stated to her knowledge the resident had never had one in place. Review of the facility policy titled Fall Management, dated 10/17/16 revealed an interdisciplinary plan of care would be developed, implemented, reviewed and updated, as necessary to reflect each resident's current safety needs and fall reduction interventions. For a resident who experiences a fall, a plan would be identified and implemented as necessary to protect the resident and/or others from recurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure laboratory testing to rule out a possible urinary tract infection was completed timely and as ordered for Resident #362 who had a history of urinary tract infections. This affected one resident (#362) of four residents reviewed for quality of care. Findings include: Review of the medical record for Resident #362 revealed an admission date of 03/29/22 with diagnoses including unspecified fracture of shaft of humerus in right arm, Type II diabetes mellitus, urinary tract infection (UTI) and unspecified atrial fibrillation. Review of the admission Bowel and Bladder Assessment, dated 03/29/22 revealed Resident #362 had an indwelling catheter at the time of admission. The remaining sections of the assessment were not completed. Review of the plan of care, dated 03/29/22 revealed Resident #362 had an alteration in elimination related to recently having recently having a Foley catheter. Interventions included to monitor for signs and symptoms of UTI including hematuria (blood in the urine), report to the physician to seek diagnosis and treatment promptly. Resident #362 was also at risk for infection related to a history of UTI. Interventions included to report signs and symptoms of infection including decreased output, sediment, cloudy urine, and foul smelling urine and obtain labs as ordered. Review of progress notes revealed the resident was admitted to the facility on [DATE] with an indwelling urinary catheter. Resident #362 was noted to be cognitively intact. Resident #362 was taking an antibiotic for a diagnosis of urinary tract infection (UTI). On 03/31/22 at 11:34 P.M. the progress note revealed Resident #362 continued to take antibiotic for UTI. Review of the Medicare 5-day Minimum Data Set (MDS) 3.0 assessment, dated 04/04/22 revealed Resident #362's cognition was not assessed. The assessment revealed the resident required extensive assistance from one to two staff to complete activities of daily living (ADL) care. Resident #362 had an indwelling catheter. On 04/04/22 notes entered at 8:01 A.M. and 6:30 P.M. revealed Resident #362's physician agreed to have the indwelling catheter removed due to the resident being ambulatory. The Foley catheter was removed without any issues. On 04/05/22 at 6:30 A.M. and 1:46 P.M. progress notes revealed Resident #362 had not had any urine output since the Foley catheter had been removed. Resident #362 was straight cathed with urine output. The urine was noted as dark yellow. The note revealed the Foley catheter was placed again due to urinary retention after removal of catheter the day before. On 04/09/22 at 10:44 A.M. Resident #362 was noted with slightly bloody urine. The note indicated the nurse practitioner (NP) was aware. On 04/10/22 at 10:29 A.M. Resident #362 was noted with clear pale yellow urine in catheter tubing and pink tinged urine noted in the urine collection bag. Review of Resident #362's physician orders revealed Resident #362 had an order (dated 04/12/22) for a STAT (immediate) Complete Blood Count (CBC) for monitoring. The order was dated 04/12/22 at 3:05 A.M. with a start date on 04/12/22. The order was marked as completed with an end date on 04/12/22. On 04/12/22 at 9:12 A.M. Resident #362 was noted with dark urine. On 04/12/22 at 6:20 P.M. (15 hours after the STAT lab order was made), the lab tech arrived to draw labs but was not able to obtain. The NP was notified and agreed to have lab drawn on 04/13/22. On 04/13/22 at 1:50 A.M. a medication administration note revealed CBC STAT for monitoring. New order put in. On 04/13/22 at 4:07 P.M. Resident #362's spouse visited and inquired about the color of the resident's urine. The note revealed Registered Nurse (RN) #70 educated Resident #362's spouse related potential causes of discoloration. On 04/14/22 at 11:23 A.M. final lab results were sent to NP #501. A new order was given to redraw CBC in one week. Review of lab results collected on 04/13/22 at 4:30 P.M. (37 hours after the STAT lab was originally ordered for Resident #362) and results reported on 04/14/22 at 8:36 A.M. revealed Resident #362 white blood cell count was within normal limits. Review of Laboratory Services Agreement, dated 06/09/17 revealed the agreement indicated the laboratory would provide medically necessary scheduled and emergency clinical laboratory services upon the receipt of a physician's order from a resident's attending physician, 24 hours a day, seven days a week. The parties agree to comply with the terms ad conditions set forth in Exhibit C (STAT Eligible Test Menu. The lab shall provide emergency laboratory test results within five hours. All tests described in Exhibit C (STAT Eligible Test Menu) shall be available on an emergency basis. Exhibit C (STAT Eligible Test Menu) included a Complete Blood Count (CBC) with or without platelets. On 04/13/22 at 10:30 A.M. interview with Resident #362 revealed the resident reported a laboratory technician arrived last evening to complete blood work but was not able to find a vein to complete the blood draw. Resident #362 stated the technician was scheduled to return again today. At the time of the interview, white sediment was observed in the resident's catheter tubing. The urine appeared pale yellow in color, however, a foul urine odor was noted. On 04/13/22 at 5:53 P.M. interview with Resident #362 revealed the laboratory technician did complete the blood work today at approximately 4:00 P.M. Resident #362 reported her urine turned dark brown again in the catheter tubing and there was also white stuff (sediment) that was in the tubing as well. A small amount of white sediment was observed in the resident's catheter tubing. On 04/13/22 at 6:05 P.M. interview with Registered Nurse (RN) #52 revealed the laboratory services the facility utilized did not respond timely to physician ordered labs. RN #52 confirmed NP #501 ordered a STAT (immediate) CBC for Resident #362 on 04/12/22. RN #52 explained the lab's scheduled days to be at the facility were Wednesdays and Fridays so any labs ordered to be completed on a non-scheduled day had to be ordered as a STAT lab. RN #52 confirmed the STAT lab order was entered at approximately 3:00 A.M. on 04/12/22 because NP #501 did not want to wait until the next scheduled lab day (the following day on 04/13/22) due to the resident having blood in her urine. RN #52 stated per her nursing judgement, she would expect a STAT lab to be responded to within three to four hours. RN #52 confirmed Resident #362 has had blood in her urine and her urine has been dark brown at times off and on. RN #52 revealed Resident #362 was asymptomatic of any infection but NP #501 wanted to check the resident's white blood count cell count to rule an infection out. RN #52 confirmed the laboratory technician did not arrive to obtain the blood draw until approximately 6:00 P.M. on 04/12/22 but was not able to obtain any blood from the resident. RN #52 stated she notified NP #501 of the issues with the lab not being able to be obtained. RN #52 stated NP #501 was frustrated but agreed to make another order to have the CBC completed as a routine lab on 04/13/22. RN #52 confirmed the laboratory technician did return on 04/13/22 at approximately 4:30 P.M. and obtained the needed blood work to complete the CBC lab. RN #52 stated results should be reported to the facility either the same night or the next morning. On 04/14/22 at 10:06 A.M. interview with the Director of Nursing (DON) revealed the facility had started a new agreement with a new lab company due to the current lab continued to have staffing issues. The lab had been scheduled at the facility five days a week when the agreement was first put in place, then the lab reduced to three days a week and recently reduced again to two days a week. The DON revealed the current lab company was not able to meet the needs of the residents. The DON stated for a STAT lab order, the best case scenario would be for it to be responded to within three to four hours. The DON confirmed Resident #362 had a STAT CBC order entered at approximately 3:00 A.M. on 04/12/22 and the lab was not actually completed until 04/13/22 at approximately 4:30 P.M. (approximately 37 hours later). Review of an email received from the DON on 04/20/22 at 4:41 P.M. revealed the current contracted lab notified the facility via an email on 12/03/21 at 12:51 P.M. due to short staffing, the lab would only be able to provide STAT lab services three days a week on Tuesday, Wednesday, and Friday during the hours of 6:00 P.M. to 2:00 A.M. and any STAT lab requests outside of these hours would need to be evaluated by the facility to determine if the lab can be drawn on the next routine lab day or if other measures needed to be taken on behalf of the resident. On 04/19/22 at 5:50 P.M. interview with NP #501 confirmed she ordered a STAT CBC lab for Resident #362 on 04/12/22 in the morning because she had concerns related the resident having blood in her urine and did not want to wait until the next routine lab day to have it completed. NP #501 confirmed she placed the order in the morning and was aware the lab technician did not arrive at the facility until that same evening (approximately 15 hours later) and could not obtain the blood work. Therefore, NP #501 confirmed the STAT lab that was ordered was not completed until NP #501 agreed to make a new routine lab order on 04/13/22 which was not completed until the afternoon on 04/13/22. On 04/21/22 at 11:35 A.M. interview with Lab Coordinator (LC) #502 revealed notification of a STAT lab order from the facility was received by the lab on 04/12/22 at 3:33 P.M. (12 hours after NP #501 ordered the lab). LC #502 confirmed the lab technician informed the lab she was not unable to obtain the lab and a nurse from the facility canceled the order on 04/12/22 at 5:53 P.M. LC #502 confirmed the lab's goal was to complete STAT lab orders and report results within five hours of receiving the physician's order, however, with the current short staffing situation, the lab was not able to meet this goal currently. A facility policy was requested related to obtaining physician ordered labs but none was provided at the time of the survey.

Based on record review, facility policy and procedure review and interview the facility failed to ensure adequate monitoring was completed related to the administration of cardiac medication for Resident #36 to ensure the medication was necessary and administered at the most effective dosage. The facility also failed to ensure adequate justification for the use of Tagamet prescribed to treat sexual behaviors for Resident #100 and failed to ensure staff documented and monitored for target behaviors to ensure the justification of the continued use of the medication. This affected two residents (#36 and #100) of four residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 02/10/21. Resident #36 had diagnoses including cerebral infarction, diabetes mellitus type two, respiratory disorder, hemiplegia, seizure disorder, hypertension, anxiety, depression, atrial fibrillation, chronic pain and polyneuropathy. Review of the care plan, dated 09/20/21 revealed resident had cardiac symptoms with interventions to provide medications as ordered, give medication for hypertension and monitor the effectiveness of the interventions. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/11/22 revealed Resident #36 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. The assessment revealed the resident required extensive assistance from two staff members for transfers and mobility. Review of physician's orders, revealed on 02/24/21 an order for the cardiac medication Carvedilol 25 milligrams (mg) one table by mouth twice daily for hypertension and hold for heart rate under 65 (beats per minute). Review of a pharmacy recommendation, dated 07/27/21 revealed Resident #36 was on a Carvedilol (Coreg) medication with instructions to hold for heart rate (HR) under 65. The pharmacist made notation, please ensure heart rate was being monitored and documented before doses were given. Review of medical record revealed last heart rate was documented in May 2021. On 11/03/21 the order was changed to give Carvedilol 12.5 mg one tablet twice daily for hypertension and hold for heart rate under 65 (beats per minute). Review of the resident's medical record progress notes (from 11/01/21 to 04/13/22) revealed on 11/01/21, 11/02/21, 11/03/21, 11/28/21 and 04/03/22 staff documented the resident's heart rate was assessed and the Carvedilol was held. There was no other documentation of heart rate assessments for any dates from 11/01/21 to 04/13/22. Review of medication administration record (MAR), dated 11/01/2021 to 04/13/2022 revealed no documentation of the resident's heart rate when staff documented the medication was administered. On 04/18/22 at 3:00 P.M. interview with Regional Clinical Care Coordinator (RCCC) #290 confirmed Resident #100's heart rate was not documented on the administration records related to the administration of the Carvedilol medication. RCCC #290 verified the few progress notes had documentation when the Carvedilol medication was held for a low heart rate but was unable to provide evidence heart rates were documented twice daily in the medical record for each administration of the medication to ensure adequate monitoring of the medication for the resident. Review of the facility policy titled Unnecessary Drugs, dated 06/27/15 revealed unnecessary drugs were any drugs when used in excessive dose (including duplicate drug therapy), for excessive duration, without adequate monitoring, without adequate indications for its use or if the presence of adverse consequences which indicate the dose should be reduced or discontinued. The policy also included the requirement of documentation of ineffective non-pharmacological interventions. 2. Review of the medical record for Resident #100 revealed an admission date of 09/14/21. Resident #100 had diagnoses including repeated falls, insomnia, dementia without behavioral disturbances, Parkinson's disease, recurrent major depressive disorder and anxiety. Review of a psychiatric note, for Resident #100 dated 10/2021 revealed a new order for Tagamet 300 mg due to staff reporting sexual behaviors. Review of the resident's physician ordered medications revealed on 10/21/21 an order was obtained for Tagamet 300 milligrams (mg) one tablet daily for sexual behaviors. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/20/22 revealed a Brief Interview for Mental Status (BIMS) score of 07 which reflected the resident had severely impaired cognition for daily decision making ability. The assessment revealed the resident displayed verbal behavior towards others four to six times a week. The assessment also indicated the resident required supervision with set up assist from staff for bed mobility, ambulation in room and on unit. The resident was assessed to require extensive assistance from two staff members for transfers and one staff assistance for toilet use, limited assistance from one staff member for dressing and personal hygiene and bathing. Resident #100 was noted to be free of impairment to the bilateral upper and lower extremity and required the use of a walker or wheelchair for mobility. Review of the plan of care, dated 04/01/22 revealed Resident #100 was at risk for adverse effects related to psychoactive medication use, anxiety and insomnia and was currently on anti-anxiety, anti-psychotic and anti-depressant medications. Interventions included to assess behaviors for which drugs were being given, assess for adverse effects, assess for non-drug approaches to deal with problem, give medications as ordered and report changes in behavior or mood state. Review of the plan of care, dated 04/01/22 revealed Resident #100 was experiencing alteration in mood and/or behavior as evidenced by feeling tired or having little energy, showing little interest pleasure in doing things, trouble falling or staying asleep and displaying inappropriate sexual behaviors at times. Interventions included to allow resident to vent, administer medication as ordered, talk with resident about setting realistic self expectation goals and provide activities of interest. Review of Resident #100's progress notes from 09/14/21 through 04/11/22 revealed no documentation of sexual behavior reported by staff or other residents. Review of Resident #100's behavior monitoring from 09/14/21 through 04/17/22 revealed no documented evidence of sexual behavior being displayed. Resident #100 was noted to yell out or scream, display repeated movements and occasional pacing/wandering and disruptive sounds (grunting chanting). On 04/17/22 at 10:30 A.M. interview with Regional Clinical Care Coordinator #290 confirmed Resident #100's behavior monitoring did not note sexual behaviors as being a behaviors displayed by the resident. Regional Clinical Care Coordinator #290 claimed disruptive behavior noted on 09/29/21 was noted by the staff to be a sexual behaviors due to Resident #100 making moaning sounds at them. Regional Clinical Care Coordinator #290 confirmed this behavior was only displayed once or only documented once. Review of the facility policy titled Unnecessary Drugs, dated 06/27/15 revealed unnecessary drugs were any drugs when used in excessive dose (including duplicate drug therapy), for excessive duration, without adequate monitoring, without adequate indications for its use or if the presence of adverse consequences which indicate the dose should be reduced or discontinued. The policy also included the requirement of documentation of ineffective non-pharmacological interventions.

Based on record review, facility policy and procedure review and interview the facility failed to ensure adequate justification for the use of Tagament prescribed to treat sexual behaviors for Resident #100 and failed to ensure staff documented and monitored for target behaviors to ensure the justification of the continued use of the medication. This affected one resident (#100) of four residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #100 revealed an admission date of 09/14/21. Resident #100 had diagnoses including repeated falls, insomnia, dementia without behavioral disturbances, Parkinson's disease, recurrent major depressive disorder and anxiety. Review of a psychiatric note, for Resident #100 dated 10/2021 revealed a new order for Tagament 300 mg due to staff reporting sexual behaviors. Review of the resident's physician ordered medications revealed on 10/21/21 an order was obtained for Tagament 300 milligrams (mg) one tablet daily for sexual behaviors. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/20/22 revealed a Brief Interview for Mental Status (BIMS) score of 07 which reflected the resident had severely impaired cognition for daily decision making ability. The assessment revealed the resident displayed verbal behavior towards others four to six times a week. The assessment also indicated the resident required supervision with set up assist from staff for bed mobility, ambulation in room and on unit. The resident was assessed to require extensive assistance from two staff members for transfers and one staff assistance for toilet use, limited assistance from one staff member for dressing and personal hygiene and bathing. Resident #100 was noted to be free of impairment to the bilateral upper and lower extremity and required the use of a walker or wheelchair for mobility. Review of the plan of care, dated 04/01/22 revealed Resident #100 was at risk for adverse effects related to psychoactive medication use, anxiety and insomnia and was currently on anti-anxiety, anti-psychotic and anti-depressant medications. Interventions included to assess behaviors for which drugs were being given, assess for adverse effects, assess for non-drug approaches to deal with problem, give medications as ordered and report changes in behavior or mood state. Review of the plan of care, dated 04/01/22 revealed Resident #100 was experiencing alteration in mood and/or behavior as evidenced by feeling tired or having little energy, showing little interest pleasure in doing things, trouble falling or staying asleep and displaying inappropriate sexual behaviors at times. Interventions included to allow resident to vent, administer medication as ordered, talk with resident about setting realistic self expectation goals and provide activities of interest. Review of Resident #100's progress notes from 09/14/21 through 04/11/22 revealed no documentation of sexual behavior reported by staff or other residents. Review of Resident #100's behavior monitoring from 09/14/21 through 04/17/22 revealed no documented evidence of sexual behavior being displayed. Resident #100 was noted to yell out or scream, display repeated movements and occasional pacing/wandering and disruptive sounds (grunting chanting). On 04/17/22 at 10:30 A.M. interview with Regional Clinical Care Coordinator #290 confirmed Resident #100's behavior monitoring did not note sexual behaviors as being a behaviors displayed by the resident. Regional Clinical Care Coordinator #290 claimed disruptive behavior noted on 09/29/21 was noted by the staff to be a sexual behaviors due to Resident #100 making moaning sounds at them. Regional Clinical Care Coordinator #290 confirmed this behavior was only displayed once or only documented once. Review of the facility policy titled Unnecessary Drugs, dated 06/27/15 revealed unnecessary drugs were any drugs when used in excessive dose (including duplicate drug therapy), for excessive duration, without adequate monitoring, without adequate indications for its use or if the presence of adverse consequences which indicate the dose should be reduced or discontinued. The policy also included the requirement of documentation of ineffective non-pharmacological interventions.

2. Review of the medical record for Resident #36 revealed an admission date of 02/10/21. Resident #36 had diagnoses including cerebral infarction, diabetes mellitus type two, respiratory disorder, hemiplegia, seizure disorder, hypertension, anxiety, depression, atrial fibrillation, chronic pain and polyneuropathy. Review of the plan of care, dated 09/20/21 revealed Resident #36 had impaired dentition and was at risk for oral problems including pain, chewing and swallowing difficulty and had upper and lower dentures. Interventions on the care plan included if dentures were ill fitting, contact social services to make arrangements to get dentures examined for repairs, complete an oral assessment per schedule, dentures to be worn for meals, monitor and report to the physician any reports of pain or poor fitting dentures and monitor resident for any signs and symptoms of chewing and swallowing difficulty during meals. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/11/22 revealed Resident #36 was cognitively intact with a Brief Interview for Mental Status Score (BIMS) of 13. The MDS assessment revealed the resident required extensive assistance from two staff members for transfers and mobility, had no pain in mouth or difficulty chewing. On 04/11/22 at 10:02 A.M. interview with Resident #36 revealed she got new dentures a few months ago and reported the bottom denture rubbed on the right-side causing pain. The resident revealed the dentures did not fit right, staff had placed her dentures in the bathroom drawer over two months ago and she was having trouble chewing especially meat due to not having access to her bottom teeth (dentures). Review of an oral assessment, dated 04/13/22 revealed resident had dentures she wore the majority of the time and no oral health concerns or pain. The assessment did not mention the resident's lower dentures had been placed in bathroom drawer by staff several months earlier which made chewing difficult or the dentures were painful when she did have access to them. Review of the progress notes revealed no documentation of the resident not utilizing her bottom denture, having pain with her dentures or staff placing the dentures in bathroom drawer. On 04/13/22 at 9:47 A.M. interview with Registered Nurse (RN) #268 revealed if a resident reported a concern about their teeth or dentures, they would be placed on the list to see the dentist on the next dentist visit or the resident could be scheduled to go out for an emergency dental appointment if they needed to be seen sooner. RN #268 denied knowledge of any residents on her unit having any issues with their teeth or dentures and revealed she was not familiar with Resident #36 having any dental needs or concerns. On 04/13/22 at 12:40 P.M. observation and interview with RN #268 revealed Resident #36 had a hard time chewing and swallowing and had started to choke on her food (pork roast). RN #268 was nearby and assessed the resident promptly. The resident was coughing and reported she couldn't swallow and was short of breath when asked by RN #268. The resident reported to RN #268 she had difficulty chewing the food. The RN asked the resident if the food was too tough and Resident #36 responded yes. The resident then reported staff took her bottom teeth (dentures) about two months ago and put them in her bathroom drawer due to them causing her pain. The resident again reported she had a hard time eating meats due to the size and toughness of the food and revealed she had previous choking incidents. At the time of the observation/interview the resident was observed eating with her top dentures only. Review of a nursing progress note, dated 04/13/22 and authored by Registered Nurse (RN) #268 revealed this nurse answered the resident's call light and the resident appeared short of breath and stated she felt short of breath. The RN assessed the resident's lungs which were clear at this time and the resident's oxygen saturation and pulse rate were within normal limits. The note revealed the RN made the resident a peanut butter and jelly sandwich and coffee as requested. The resident stated she was feeling better and the physician assistant (PA) was made aware of the same. On 04/14/22 at 12:40 P.M. interview with Resident #36 revealed her lunch meal consisted of noodles and beef and she had a hard time chewing the beef. Resident #36 revealed staff did not provide her her bottom denture for use during the meal and it remained in the bathroom drawer. On 04/14/22 at 4:07 P.M. interview with RN #268 revealed since the choking incident that occurred on 04/13/22 she had spoken with the medical team regarding the resident's diet orders and they did not want to change her diet to a mechanical soft or pureed diet due to resident previously refusing to eat foods in these textures. The RN revealed she spoke with the kitchen staff and requested staff put gravy on resident's meats to help them go down easier as the dryness of the food was a possible cause for her choking. The RN revealed she had the resident try on her lower dentures and the resident revealed they caused her pain. Resident #36 was also then placed on the list to see the dentist. The RN verified her progress note, dated 04/13/22 did not give a full picture of the event from the previous day and did not include any interventions or communication the RN had with the interdisciplinary team. RN #268 acknowledged her note did not mention eating had anything to do with the incident. The RN revealed she would update her note to reflect the concern for food and chewing to make her note more accurately reflect the event that occurred and interventions that had been done. On 04/14/22 at 4:17 P.M. interview with MDS Licensed Practical Nurse (LPN) #64 revealed the dental assessment completed on 04/13/22 was done through chart review of admission paperwork, dental visit notes and medical team progress notes. MDS LPN #64 revealed she does not meet with residents to physically look at their teeth during the assessment. MDS LPN #64 revealed she was not informed of the choking incident on 04/13/22. On 04/14/22 at 4:32 P.M. during a follow up interview with RN #268, the RN revealed she changed her mind and felt she did not need to change and update her note to better reflect the above incident on 04/13/22. Review of the dental visit lists dated 11/03/21, 12/17/21, 01/27/22 and 04/01/22 revealed Resident #36 was not listed on any of the lists and was not scheduled to see the dentist on any of these visits. Resident #36 last saw the dentist on 10/2021. Review of facility policy titled Dental Services, dated 11/14/17 revealed dental needs were identified through the resident assessment process and were addressed in the residents' plan of care. The facility would assist the resident with making dental appointments and arrange transportation to and from those services. Based on observation, record review, facility policy and procedure review and interview the facility failed to obtain or provide timely dental services to meet the needs of each resident. This affected two residents (#36 and #55) of four residents reviewed for dental services. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 12/05/21. Record review revealed the resident had a physician's order for a low concentrated sweets diet (no texture modifications). An oral assessment, dated 12/05/21 revealed the resident was edentulous (no teeth) and had no dentures. Review of an admission Minimum Data Set (MDS) 3.0 assessment, completed 12/12/21 revealed the resident was edentulous. The MDS care area assessment (CAA) dental status revealed the resident was noted with impaired dentition. It did not mention if the resident had dentures. An oral assessment, dated 03/30/22 indicated the resident was edentulous with no dentures. A quarterly MDS 3.0 assessment, completed 04/03/22 did not indicate any issues related to dental status. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the comprehensive plan of care revealed the resident had impaired dentition and was at risk for oral problems (i.e. pain, infection, difficulty chewing/swallowing, poor self image) related to missing some natural teeth or edentulous. The interventions included dental consult/follow up as ordered and as needed. ON 04/12/22 at 9:21 A.M. interview with Resident #55 revealed he had no teeth and had not had dentures since he was admitted . The resident stated he would like to have dentures. On 04/13/22 at 8:49 A.M. Resident #55 was observed in the lounge eating breakfast. The resident was not observed to have any teeth. On 04/13/22 at 2:40 P.M. interview with State Tested Nursing Assistant #146 (working on the unit where Resident #55 resided) revealed Resident #55 had his own teeth. On 04/13/22 at 2:42 P.M. interview with Registered Nurse (RN) #264 (working on the unit where Resident #55 resided) revealed she did not know if Resident #55 had teeth or not. On 04/14/22 at 12:00 P.M. interview with the Administrator revealed Resident #55 had not seen the dentist since admission. On 04/14/22 at 1:50 P.M. interview with Corporate Registered Nurse (RN) #290 revealed he did not know why Resident #55 had not seen a dentist since being admitted . RN #290 revealed he did not know if the resident had given consent to see the dentist or not. However, no documentation was provided the resident had refused to see the dentist since admission.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #36's medical record was maintained in a complete and accurate manner. This affected one resident (#36) of 27 residents whose medical records were reviewed. Findings include: Review of the medical record for Resident #36 revealed an admission date of 02/10/21. Resident #36 had diagnoses including cerebral infarction, diabetes mellitus type two, respiratory disorder, hemiplegia, seizure disorder, hypertension, anxiety, depression, atrial fibrillation, chronic pain and polyneuropathy. Review of the plan of care, dated 09/20/21 revealed Resident #36 had impaired dentition and was at risk for oral problems including pain, chewing and swallowing difficulty and had upper and lower dentures. Interventions on the care plan included if dentures were ill fitting, contact social services to make arrangements to get dentures examined for repairs, complete an oral assessment per schedule, dentures to be worn for meals, monitor and report to the physician any reports of pain or poor fitting dentures and monitor resident for any signs and symptoms of chewing and swallowing difficulty during meals. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/11/22 revealed Resident #36 was cognitively intact with a Brief Interview for Mental Status Score (BIMS) of 13. The MDS assessment revealed the resident required extensive assistance from two staff members for transfers and mobility, had no pain in mouth or difficulty chewing. On 04/11/22 at 10:02 A.M. interview with Resident #36 revealed she got new dentures a few months ago and reported the bottom denture rubbed on the right-side causing pain. The resident revealed the dentures did not fit right, staff had placed her dentures in the bathroom drawer over two months ago and she was having trouble chewing especially meat due to not having access to her bottom teeth (dentures). Review of an oral assessment, dated 04/13/22 revealed resident had dentures she wore the majority of the time and no oral health concerns or pain. The assessment did not mention the resident's lower dentures had been placed in bathroom drawer by staff several months earlier which made chewing difficult or the dentures were painful when she did have access to them. On 04/13/22 at 12:40 P.M. observation and interview with RN #268 revealed Resident #36 had a hard time chewing and swallowing and had started to choke on her food (pork roast). RN #268 was nearby and assessed the resident promptly. The resident was coughing and reported she couldn't swallow and was short of breath when asked by RN #268. The resident reported to RN #268 she had difficulty chewing the food. The RN asked the resident if the food was too tough and Resident #36 responded yes. The resident then reported staff took her bottom teeth (dentures) about two months ago and put them in her bathroom drawer due to them causing her pain. The resident again reported she had a hard time eating meats due to the size and toughness of the food and revealed she had previous choking incidents. At the time of the observation/interview the resident was observed eating with her top dentures only. Review of a nursing progress note, dated 04/13/22 and authored by Registered Nurse (RN) #268 revealed this nurse answered the resident's call light and the resident appeared short of breath and stated she felt short of breath. The RN assessed the resident's lungs which were clear at this time and the resident's oxygen saturation and pulse rate were within normal limits. The note revealed the RN made the resident a peanut butter and jelly sandwich and coffee as requested. The resident stated she was feeling better and the physician assistant (PA) was made aware of the same. On 04/14/22 at 4:07 P.M. interview with RN #268 revealed since the choking incident that occurred on 04/13/22 she had spoken with the medical team regarding the resident's diet orders and they did not want to change her diet to a mechanical soft or pureed diet due to resident previously refusing to eat foods in these textures. The RN revealed she spoke with the kitchen staff and requested staff put gravy on resident's meats to help them go down easier as the dryness of the food was a possible cause for her choking. The RN revealed she had the resident try on her lower dentures and the resident revealed they caused her pain. Resident #36 was also then placed on the list to see the dentist. The RN verified her progress note, dated 04/13/22 did not give a full picture of the event from the previous day and did not include any interventions or communication the RN had with the interdisciplinary team. RN #268 acknowledged her note did not mention eating had anything to do with the incident. The RN revealed she would update her note to reflect the concern for food and chewing to make her note more accurately reflect the event that occurred and interventions that had been done. On 04/14/22 at 4:32 P.M. during a follow up interview with RN #268, the RN revealed she changed her mind and felt she did not need to change and update her note to better reflect the above incident on 04/13/22. Review of facility policy titled Documentation charting, dated 09/16/19 revealed each resident's medical record shall contain an accurate representation of the resident. The policy revealed staff shall document assessments and observations in the medical record in accordance with facility policy. Principles of documentation include documentation should be factual, objective and complete. The policy revealed corrections to a medical record shall be made to clarify inaccurate information.

Based on record review, facility policy and procedure review and interview the facility failed to implement an effective antibiotic stewardship program to ensure the appropriate use of antibiotics to reduce the development of antibiotic-resistant infections/organisms. This affected one resident (#38) of five residents reviewed for urinary tract infections. Findings include: Review of the medical record for Resident #38 revealed an admission date of 03/02/21 and a diagnosis of urinary retention. Record review revealed Resident #38 had a physician's order for an indwelling urinary catheter. Review of a nurse's progress note, dated 11/01/21 at 1:13 P.M. revealed a new order was obtained to complete a urinalysis and culture and sensitivity related to Resident #38 being febrile. Review of temperature records revealed on 10/31/21 at 12:53 P.M. a temperature of 101.1 degrees Fahrenheit (F). On 10/31/21 at 3:45 P.M. his temperature was 100.1 degrees F. On 11/01/21 at 12:07 A.M. his temperature was 99.8 degrees F. On 11/01/21 at 7:32 A.M. his temperature was 98.8 degrees F. and at 1:47 P.M. was 98.9 degrees F. There were no other symptoms documented related to a possible urinary tract infection at that time. Review of a urine culture report revealed a urine specimen was collected on 11/02/21 with results reported on 11/06/21. The results of the urine culture were 50-60,00 CFU/ml of proteus mirabilis that was resistant to six of the ten antibiotics listed. Keflex (Cefalexin) was not listed on the antibiotic sensitivity list. Record review revealed Resident #38 was started on the antibiotic Keflex 500 milligrams every 12 hours for seven days for a urinary tract infection on 11/07/21. He received 14 doses of the antibiotic from 11/07/21 to 11/13/21. Review of the facility infection tracking log for November 2021 revealed Resident #38 was not listed as having any infection in that month. Review of the Minimum Data Set (3.0) assessment, completed 03/23/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. On 04/11/22 at 2:09 P.M. interview with Resident #38 revealed he had been treated for six or seven urinary tract infections (UTI) in the past year. (Record review revealed he had been treated for four UTIs in the past seven months). On 04/14/22 at 7:35 A.M. observation of Resident #38 revealed the resident had an indwelling urinary catheter. On 04/18/22 at 10:50 A.M. interview with the Director of Nursing revealed the facility used the Loeb Minimum Criteria for initiation of antibiotics. However, nothing was documented to indicate the criteria was met for the use of antibiotics. On 04/18/22 at 12:00 P.M. interview with Corporate Registered Nurse #290 revealed the facility also used the McGeer Criteria for determining appropriate antibiotic use. Review of the facility policy titled Antibiotic Stewardship Program, dated 11/28/17 revealed the purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The program included antibiotic use protocols and a system to monitor antibiotic use. Antibiotic use protocols included: Nursing staff shall assess residents who were suspected to have an infection for symptoms, laboratory testing shall be in accordance with current standards of practice, McGeer Criteria were used to define infections and the Loeb Minimum Criteria were used to determine whether or not to treat an infection with antibiotics. Review of the McGeer Criteria provided by the facility revealed for a resident with a catheter, a UTI should be diagnosed when there were localizing genitourinary signs and symptoms and a positive urine culture result. The criteria revealed at least one of the subcriteria (fever, change in mental status, new onset of suprapubic pain or purulent discharge around catheter) must be present and the resident must have a urinary catheter specimen culture with at least 10 to the fifth power (100,000) CFU/ml of any organism. On 04/18/22 at 12:00 P.M. interview with Corporate Registered Nurse (RN) #290 confirmed Resident #38's urine culture results on 11/06/21 did not meet the criteria for 100,000 CFU/ml of any organism. On 04/18/22 at 2:15 P.M. RN #290 confirmed the use of the antibiotic in November 2021 for Resident #38 was not included in the facility infection tracking logs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview facility failed to ensure the flu vaccine was offered and provided to Resident #72. This affected one resident (#72) of five residents reviewed for vaccines. Findings include Review of the medical record for the Resident #72 revealed an admission date of 09/30/21 with diagnoses including Waldenstrom macroglobulinemia, depression, psychosis, dementia with behavioral disturbances, constipation and anxiety. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 03/11/22 revealed Resident #72 was cognitively intact with a Brief Interview for Mental Status Score (BIMS) of 8. Review of Section O of the MDS assessment, revealed the flu vaccine was not offered or provided. Review of Resident #72's hard chart medical record contained a flu vaccination consent form that only contained the resident's name printed at the top and the date of admission [DATE]). The form did not have a selection marked regarding the vaccination and consent for the vaccine had not been obtained from the resident's power of attorney. On 04/13/22 at 9:30 A.M. interview with Registered Nurse (RN) #22 verified the lack of information related to whether Resident #72 and/or the resident's POA were provided education/offered a flu vaccine following the resident's admission. On 04/13/22 at 9:35 A.M. interview with Licensed Practical Nurse (LPN) #138 revealed if a resident received a flu vaccine during admission it would be documented in the resident's electronic medical record. LPN #138 confirmed Resident #72 did not have the flu vaccine documented as a provided vaccine. On 04/13/22 between 9:00 A.M. and 3:00 P.M. interviews with Regional Clinical Care Coordinator (RCCC) #290 and the Director of Nursing (DON) revealed Resident #72 had not been offered the flu vaccine as they believed the resident had received it in the hospital prior to admission. On 04/13/22 at 4:40 P.M. during a follow up interview with the DON, the DON revealed the resident had actually not received a flu vaccine in the hospital prior to admission. The DON was unable to provide any evidence the resident and/or the resident's POA was informed, educated and offered the flu vaccine following admission to the facility on [DATE]. Review of facility policy titled Immunization of Residents, dated 04/2022 revealed the facility would offer the flu vaccine from October to March. Physicians would place an order for the flu vaccine. Education would be provided to the resident or resident representative regarding benefits and side effects or risks of the vaccines. The resident or resident representative would document consent to receive or not receive the vaccine. The resident should be assessed for contraindication for the vaccine and if contraindications were found the physician should be notified. If no contraindications were found and consent was obtained the vaccine should be provided.

Based on review of facility infection control logs and infection control documentation, staff training records and interview the facility failed to develop and implement a comprehensive and effective infection control program to timely identify and implement corrective measures when trends and increased numbers of infection were identified to prevent the spread of infection including COVID-19. This had the potential to affect all 105 residents residing in the facility. Findings include Review of the infection control log for November 2021 revealed 34 of the 102 residents in the facility were on antibiotics (33%) during the month. This included 13 residents treated for urinary tract infections (UTIs), 12 residents with skin or wound infections, six residents with respiratory infections and six residents with eye infections, C Diff, or other infections. Review of the infection control log for December 2021 revealed 32 of the 107 residents in the facility were on antibiotics (30%). This included 12 residents treated for UTIs, six residents with skin or wound infections, eight residents with respiratory infections, 17 residents with COVID-19 and seven residents with C Diff, or other infections. Review of a staff training log, dated 12/09/21 revealed staff education on the topic of COVID-19 which included hand hygiene and how to apply (donn) and remove (doff) personal protective equipment (PPE). The training did not include any information about UTIs or hands on resident care and the prevention of infections. The sign in sheet included one assessment (MDS) nurse, six Licensed Practical Nurses (LPNs, three Registered Nurses (RNs) and 15 State Tested Nursing Assistants (STNAs). The facility had no documentation of any additional trainings completed for staff related to infection control during this time period. Review of the infection control log for January 2022 revealed 26 of the 106 residents in the facility were on antibiotics (25%). This included six residents treated for UTIs, five residents with skin or wound infections, two residents with respiratory infections and one resident had another infection. Review of the infection control log for February 2022 revealed 26 of the 113 residents in the facility were on antibiotics (23%). This included 13 residents treated for UTIs, one resident with a skin or wound infection and seven residents with eye infections, C Diff or other infections. Review of a training log, dated 02/04/22 revealed staff education on the topic of masks, hand hygiene and glucometers and included how to wash hands and the use hand sanitizer. The training did not include any information about UTIs or hands on resident care and the prevention of infections. The sign in sheet included one MDS nurse, seven LPNs, three RNs and 13 STNAs. The facility had no documentation of any additional trainings completed for staff related to infection control during this time period. Review of the infection control log for March 2022 revealed 26 of the 117 residents in the facility were on antibiotics (22%). This included 15 residents treated for UTIs, five residents with skin or wound infections, one resident with a respiratory infection and seven residents with eye infections, C Diff, or other infections. Review of the staff roster revealed facility had approximately 30 nurses and 55 nursing assistants/aides who were considered direct care staff. This resulted in less than one-third of the direct care facility staff attending each of the two trainings (12/2021 and 02/2022) with many of the same staff attending both trainings. On 04/14/22 at 2:41 P.M. interview with the Director of Nursing (DON) revealed the previous DON completed the infection control logs through 01/2022 and she started them in 02/2022. The DON revealed unit managers on each hall tracked infections and she compiled them onto the monthly log report each month. The DON revealed infection trends were to be reviewed in the risk management meetings weekly. The DON reviewed the monthly log from 11/2021 and acknowledged noticing a pattern of many UTI's and wound/skin infections. The DON revealed the facility would have completed training on infection control practices for these areas of concern. The DON reviewed the monthly log from 02/2022 and acknowledged noticing a pattern of many UTI's and wound/skin infections. The DON revealed the facility would have completed training on infection control practices for these areas of concern. On 04/19/22 at 3:40 P.M. interview with the DON revealed she would expect all direct care staff to have been trained on infection control after the concerns were noted in the infection control logs. The DON confirmed sign in sheets did not match the staffing list and the DON was unable to provide any additional trainings and sign in sheets. The DON also confirmed the training topics did not address the concerns for urinary tract infections and skin and wound infections she named as being concerned. Review of facility undated documentation related to their understanding of compliance with infection control logs and antibiotic stewardship revealed the facility reviewed 08/2021 through 02/2022 infection control logs for concerns of the high number of urinary tract infections (UTIs) and large percentage of residents on antibiotics. The facility reported the following nosocomial, or facility acquired urinary tract infections. In 08/2021 the facility had ten facility acquired UTIs. In 09/2021 the facility had ten facility acquired UTIs. In 10/2021 the facility had 12 facility acquired UTIs. In 11/2021 the facility had nine facility acquired UTIs. In 12/2021 the facility had five facility acquired UTIs. In 01/2022 the facility had five facility acquired UTIs. In 02/2022 the facility had 11 facility acquired UTIs. In 03/2022 the facility had 13 facility acquired UTIs. The document contained a note that the high percentages might be skewed due to an abnormally low average monthly census of 102. Current census was 105. On 04/20/22 at 1:39 P.M. during a follow up interview with the DON, the DON indicated if the facility typically had 10 to 12 nosocomial UTIs in a month (which was the case) and one month there were 20 or more then the DON indicated she may consider that a trend because those findings would be abnormally higher, which would prompt intervention of education and auditing at that time. During an interview with the DON on 04/20/22 at 2:36 P.M. the DON revealed in her opinion, 10% of residents having urinary tract infections each month was not concerning to her and does not require further review or intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to ensure quarterly comprehensive assessments were accurate. This affected one (Resident #30) of two residents reviewed for restraints. The census was 120. Findings include: Medical record review revealed Resident #30 was admitted on [DATE] with diagnoses including dementia and anxiety disorder. Review of the quarterly Minimum Data Set 3.0 (MDS) assessments dated 03/29/19 and 04/02/19 revealed Resident #30 did not use a bed alarm. Review of the Restraint Enabler Decision Tree assessment dated [DATE] revealed Resident #30 had a pressure sensor alarm (PSA) to the bed to assist the resident's functional status and safety. Review of the monthly Physician Orders dated June 2019 revealed Resident #30 had a PSA to the bed for safety since 10/11/17. On 06/03/19 at 9:54 A.M., observation revealed a PSA alarm to the resident's bed. On 06/06/19 at 12:20 P.M., observation and interview with Housekeeping Staff #41 verified Resident #30 had a PSA bed alarm. On 06/06/19 at 12:33 P.M., interview with the Director of Nursing verified Resident #30's quarterly MDS assessments dated 03/29/19 and 04/02/19 were inaccurate for bed alarm use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to refer residents for Pre-admission Screening and Resident Review (PASRR) level two services after a significant mental health change. This affected one (Resident #2) of three residents reviewed for PASRR. The census was 120. Findings Include: Resident #2 was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, unspecified psychosis not due to a substance or known physiological condition, bipolar disorder, anxiety disorder, and schizoaffective disorder. Her Brief Interview for Mental Status (BIMS) score was 12, which indicated she was cognitively intact. This assessment was completed on 05/19/19. Review of Resident #2 medical records revealed an added the following mental health diagnoses after admission to the facility: unspecified psychosis not due to a substance or known physiological condition (02/06/18), bipolar disorder (07/10/18), anxiety disorder (07/10/18), and schizoaffective disorder (09/10/18). Review of Resident #2's PASRR application/form (completed on 01/08/14) revealed she had Section D, titled indications of serious mental illness indicated as no, which indicated she did not have a mental illness at the time the form was completed. In review of Resident #2 medical records, there was no other PASRR application/form completed after 01/08/14. Finally, in review of Resident #2 physician orders, she was prescribed routine/daily doses of Sertraline (antidepressant) 50 milligrams (mg) and Olanzapine (antipsychotic) 1.25 mg and 7.5 mg for her mental health diagnoses. Interview with Licensed Social Worker #31 on 06/04/19 at 1:40 P.M. confirmed the facility would send in a new PASRR application if there was a significant change to the residents health/mental health. She confirmed that she did not complete a significant change PASRR and send it to the state mental health agency for review to determine if the newly identified and treated mental health diagnoses would have resulted in additional services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to ensure comprehensive care plans were developed. This affected one (Resident #29) of three residents reviewed for urinary catheters/urinary tract infection (UTI) and one (Resident #62) of three residents reviewed for respiratory care. The census was 120. Findings include: 1. Medical record review revealed Resident #29 was admitted on [DATE] with diagnoses including Parkinson's disease and unspecified dementia without behavioral disturbance. Review of the Progress Note dated 06/02/19 revealed an order to administer Bactrim DS (antibiotic) for seven days for a UTI. On 06/03/19, the resident started on Bactrim DS twice a day. Review of the Medication Administration Record dated June 2019 revealed Resident #29 was administered Bactrim DS since 06/03/19. Review of the medical record revealed no documented evidence of a UTI care plan for Resident #29. On 06/06/19 at 3:56 P.M., interview with Minimum Data Set (MDS) Consultant #550 verified no UTI care plan had been developed for Resident #29 until the surveyor inquired about one. 2. Medical record review revealed Resident #62 was admitted on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure and stroke. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #62 was severely impaired for daily decision-making and received oxygen. Review of the Treatment Administration Record dated June 2019 revealed continuous oxygen per nasal cannula to maintain saturation above 90% was administered on 06/05/19 and there was no evidence of a prescribed flow rate to be administered. Review of the record revealed no oxygen care plan. On 06/03/19 at 11:11 A.M. and 06/05/19 at 9:16 A.M., observation revealed Resident #62 was receiving oxygen via nasal cannula. On 06/05/19 at 9:18 A.M., interview with Licensed Practical Nurse #92 verified there was no care plan for Resident #62's oxygen use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to ensure personal hygiene was provided to dependent residents. This affected one (Resident #29) of three residents reviewed for ADL (activities of daily living). The facility census was 120. Findings include: Medical record review revealed Resident #29 was admitted on [DATE] with diagnoses including Parkinson's disease and functional quadriplegia. Review of the care plan: Self-Care Deficit revised 04/12/18 revealed interventions included to assist with ADL as needed. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #29 was cognitively intact for daily decision-making and was totally dependent on staff for personal hygiene and bathing. Review of the Monthly Nursing Summary - V3 assessment dated [DATE] revealed Resident #29 was dependent on staff for personal hygiene. On 06/03/19 at 3:22 P.M., Resident #29 was observed in bed with dried food all over her face, nails and shirt, her hair was greasy and not combed. Assistant Director of Nursing #52 verified the above at the time of the observation. On 06/04/19 at 2:42 P.M., Resident #29 was observed in bed with dried food on her lips and her hair was not combed. The resident was only wearing a shirt and an incontinence product. Licensed Practical Nurse #92 verified the resident's hair was not combed, she looked disheveled and was partially covered with blanket; however, the incontinent product could be seen. On 06/04/19 at 2:50 P.M., interview with Licensed Practical Nurse #92 stated Resident #29 required assistance with ADL and staff was to check the resident at least every two hours. On 06/06/19 at 3:45 P.M., interview with the Director of Nursing (DON) verified the above and stated staff was responsible to ensure residents were clean and personal hygiene provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident interview, staff interview, family interview, and facility policy review, the facility failed to provide the necessary communication tools for the resident to be able to effectively communicate with others. This affected one (Resident #19) of two residents reviewed for communication. The census was 120. Findings Include: Observations on 06/03/19 at 4:25 P.M., 06/04/19 at 3:23 P.M., and 06/05/19 at 9:12 A.M. and 2:25 P.M. revealed Resident #19 sitting in her room by herself with no music or television on. An interview was attempted on 06/03/19 at 4:25 P.M., which was unsuccessful because she did not speak English. Resident #19 was admitted to the facility on [DATE]. Her diagnoses were osteoporosis, atrial fibrillation, chronic pain, major depressive disorder, Alzheimer's disease, osteoarthritis, congestive heart failure, anemia, chronic kidney disease, hypertension, and history of falling. Her Brief Interview for Mental Status (BIMS) score was not calculated due to the facility staff's inability to communicate with her at the time of the assessment. It was attempted on 03/21/19. Review of Resident #19 medical records revealed a psychosocial assessment (dated 03/21/19) that stated, resident needs/wants interpreter to communicate with doctor or healthcare staff. Resident has unclear speech, rarely/never understood or understands. Resident is Romanian, does not speak English. Son is her translator. According to her plan of care, one of the focus areas was potential for alteration in activities due to resident being Romanian and English is a second language. She had some familiarity and acceptance with being amidst English speaking crowds. The interventions for this focus area were: Offer activity program directed toward specific interests/ needs of resident, seek and coordinate a plan for on going translation as needed and utilize Romanian speaking family member to obtain interest, review calendar and to explain specific program contents. Even though there was an intervention to seek and coordinate a plan for on-going translation, the facility did not devise a plan to obtain these translation services if/when Resident #19 son is not available to translate. Review of her activity assessment (dated 03/19/19) revealed her documented favorite activities were family visits, music, television/movies, bird watching and reading magazines. But according to her comprehensive assessment (dated 03/21/19), neither her nor her family were a part of the information provided for the assessment. Finally, review of her activity logs (dated March 2019 to May 2019) revealed the vast majority of her documented activities were socialization, music, television, public interaction, phone calls, and family visits. There were multiple refusals documented for group and interactive activities. There were no documented or attempted activities that were related to her Romanian culture and/or language other than family visits and phone calls. Interview with State Tested Nursing Aide (STNA) #81, Registered Nurse (RN) #43, STNA #13, and STNA #50 on 06/05/19 at 2:40 P.M. revealed it is very difficult to communicate with Resident #19. They stated she understood a few words, but they typically called her son to translate for them. They stated she did not like activities; she preferred to stay in her room. They confirmed again she did not know much English, so they needed to call the son to be able to translate. They also stated hospice had a translator, but they did not need to use it due to the son always answering when they called. They would ask Resident #19 if she wanted to go to an activity, but she would typically refuse to go. Interview with Licensed Social Worker (LSW) #31 on 06/06/19 at 10:22 A.M. confirmed that she had not gathered information for the comprehensive assessment from the family or Resident #19 in over a year. She confirmed she would call the family on the day she was doing the assessment and ask if they were coming into the facility to help translate. They would say they weren't so she would fill out the information based on interviews from the staff. When asked if they could use the translator from hospice, she stated, well, I guess we could have done that. She confirmed that activities section in the comprehensive assessment had no feedback from Resident #19 or her family. Interview with Resident #19 family on 06/06/19 at 10:36 A.M. revealed that Resident #19 would do more activities, but she got intimidated and anxious when she did not understand the language. They confirmed that Resident #19 primarily speaks Romanian, and no one in the facility does. They confirmed she would do more activities if she understood English. She tends to stay in her room, by herself instead of engaging in activities. Interview with Activities Director #3 on 06/06/19 at 10:45 A.M. revealed Resident #19 liked to stay in her room, listen to folk/country music, and watch movies. They would also do hand massages, look at picture books together, and socialize with the few English words that she knew. She would be asked if she wanted to attend church services, but she would refuse. She confirmed that no one in the facility spoke Romanian, so if they needed to communicate with Resident #19, they would contact her son. She confirmed the activities assessment (dated 03/19/19) was not fully completed due to the inability to communicate with Resident #19 and her family not being available to answer the questions. Review of facility Foreign Speaking Residents policy (dated April 2002) revealed, If a resident who only understands a foreign language is admitted , a list will be posted at the time clock with the names and departments of staff who may be called on to interpret. Social Services will work with the family in developing an effective communication method.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, hospice notes, and hospice contract review, the facility failed to adequately monitor and assess Resident #20 and failed to ensure Resident #62's care plans and assessments were part of the medical record. This affected two (Resident #20 and #62) of 25 residents reviewed. Facility census was 120. Findings include: 1. Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnosis that included dementia. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Review of a health status note dated 04/03/19 at 2:45 P.M. revealed hospice wrote an order for Cipro (antibiotic) 500 milligrams (mg) twice a day for ten days for aspiration pneumonia. Review of hospice notes (provided to surveyor on 06/05/19), revealed on 04/03/19, Resident #20 had expiratory wheezing (high-pitched noise with breathing) and rhonchi (course rattling respiratory sounds usually caused by secretions) noted throughout all lung fields. Resident #20 also had a low-grade fever of 99.1 degrees Fahrenheit (F), a heart rate of 101 beats per minute, respirations of 24 breaths per minute, and increased fatigue. Resident #20's oxygen saturation was 86 percent (under 90 percent is considered low) on three liters of continuous oxygen. Review of Resident #20's temperatures by the facility staff revealed on 04/04/19 a temperature of 98 degrees F, 04/09/19 a temperature of 98.4 degrees F, on 04/11/19 a temperature of 97.8 degrees F. Further review of the provided hospice notes revealed on 04/11/19, Resident #20's oxygen saturation was 84 percent on two liters of oxygen. Oxygen was increased by the hospice nurse to 3 liters. Review of facility health status note dated 04/11/19 at 11:43 A.M. revealed Resident #20 continued with antibiotic for pneumonia without adverse reactions. Fluids were encouraged and the resident accepted the fluids. Resident #20's temperature on 04/25/19 was 97.7 degrees F. A hospice note dated 05/21/19 revealed Resident #20 had expiratory wheezes audible throughout posterior and anterior lung fields. Crackles (clicking, rattling, or crackling noise) were often heard. Review of facility medical record for April and May 2019 revealed no documentation of the resident's respiratory condition or signs and symptoms of pneumonia other than Resident #20 received an antibiotic for aspiration pneumonia. Interview on 06/05/19 at 12:31 P.M. with Director of Nursing (DON) verified if a resident was on an antibiotic, the nurses should chart every shift the residents temperature and any signs and symptoms that exist. Interview on 06/05/19 at 1:29 P.M. Hospice Registered Nurse (RN) #800 verified Resident #20 had wheezing and a fever. Hospice RN #800 also verified the hospice notes were not available at the facility, but she would contact her supervisor to obtain hospice notes for surveyor. Interview on 06/05/19 at 1:30 P.M. with Regional Director #501 verified there was no documentation in the medical record by the facility nurses of Resident #20's signs and symptoms of pneumonia. Review of the Hospice Contract signed 01/25/18 revealed a written plan established by the hospice medical director, the attending physician and the hospice interdisciplinary group was to be maintained for each hospice resident. The hospice plan of care was to include, but not limited to, an assessment of the resident's needs, the appropriateness of hospice care, a medical history, identification of services to be provided and a detailed description of the scope and frequency of services needed to meet the hospice resident and family's needs. The hospice plan of care must also identify the care and services needed and specifically identify what services the hospice and what services the facility was responsible to perform. Hospice was to keep accurate records of services provided at the facility in accordance with the facility record keeping policy and such records were to be located at the facility. 2. Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnosis that included dementia. The quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Review of hospice notes (provided on 06/05/19) revealed on 04/03/19 Resident #20 had increased yellow/green drainage to bilateral eyes. Review of Resident #20's temperatures by the facility staff revealed on 04/04/19 a temperature of 98 degrees F. Review of the Certified Nurse Practitioner (CNP) note dated 04/08/19 (no time) revealed Resident #20 had bilateral eye redness with purulent drainage from the right eye. The CNP further indicated Resident #20 had bilateral conjunctivitis (pink eye). A health status note dated 04/08/19 at 2:28 P.M. revealed an order was received on 04/08/19 for Resident #20 to have Cipro (antibiotic) eye drops every two hours for two days and then every four hours for five days. The facility record revealed Resident #20's temperature on 04/09/19 was 98.4 degrees F. and on 04/11/19 the resident's temperature was 97.8 degrees F. Review of facility medical record for April 2019 revealed no documentation of the resident's eye infection other than Resident #20 received an antibiotic for conjunctivitis. Interview on 06/05/19 at 12:31 P.M. with the DON verified if a resident was on an antibiotic, the nurses should chart every shift the resident's temperature and any signs and symptoms that exist. Interview on 06/05/19 at 1:29 P.M. Hospice Registered Nurse (RN) #800 verified hospice notes were not at the facility and she would contact her supervisor to obtain hospice notes for surveyor. Interview on 06/05/19 at 1:30 P.M. with Regional Director #501 verified there was no documentation in the medical record by the facility nurses of Resident #20's signs and symptoms of conjunctivitis. Review of the Hospice Contract signed 01/25/18 revealed a written plan established by the hospice medical director, the attending physician and the hospice interdisciplinary group was to be maintained for each hospice resident. The hospice plan of care was to include, but not limited to, an assessment of the resident's needs, the appropriateness of hospice care, a medical history, identification of services to be provided and a detailed description of the scope and frequency of services needed to meet the hospice resident and family's needs. The hospice plan of care must also identify the care and services needed and specifically identify what services the hospice and what services the facility was responsible to perform. Hospice was to keep accurate records of services provided at the facility in accordance with the facility record keeping policy and such records were to be located at the facility. 3. Medical record review revealed Resident #62 was admitted on [DATE] with diagnoses including seizure disorder, encephalopathy, acute respiratory failure and stroke. Review of the Physician Orders dated 05/23/19 revealed the resident was admitted with hospice services. Review of the medical record revealed no documented evidence of the hospice certification, hospice orders, comprehensive care plans or assessment of services by hospice. There was no written hospice plan of care or identification of services received from the hospice provider during the survey for review. On 06/05/19 at 11:00 A.M., interview with the DON verified Resident #62's hospice certification, prognosis, comprehensive nurse notes, plan of care and identification of services to provide were not on the premises. The DON stated she did not know the information was not at the facility and had to call the hospice provider to have the information faxed. On 06/05/19 at 11:58 A.M., interview with the DON verified the facility had still not received the plan of care or identification of services from the hospice provider. Review of the Hospice Contract signed 01/25/18 revealed a written plan established by the hospice medical director, the attending physician and the hospice interdisciplinary group was to be maintained for each hospice resident. The hospice plan of care was to include, but not limited to, an assessment of the resident's needs, the appropriateness of hospice care, a medical history, identification of services to be provided and a detailed description of the scope and frequency of services needed to meet the hospice resident and family's needs. The hospice plan of care must also identify the care and services needed and specifically identify what services the hospice and what services the facility was responsible to perform. Hospice was to keep accurate records of services provided at the facility in accordance with the facility record keeping policy and such records were to be located at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and facility policy and procedure review, the facility failed to follow care planned fall interventions. This affected one (Resident #55) of two (Residents #55 and #78) reviewed for accidents. The census was 120. Findings Include: A review of Resident #55's medical record review revealed an admission date of 10/22/18 (readmitted on [DATE]) with diagnoses including unsteadiness on feet, muscle weakness, Parkinson's disease, vascular dementia, generalized anxiety disorder, psychosis, disorientation, cataracts, depression, high blood pressure (HTN), and lack of coordination. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/12/19, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The resident required assistance of two staff for transfers and was independent with set-up only with locomotion via wheelchair. A fall risk assessment, completed 05/26/19, revealed the resident was at risk for falls. A care plan, created 01/16/19, revealed the resident was at risk for falls with potential for injury related to history of falls, multiple fall risk factors, debilitation, weakness, dementia, and impaired balance. Interventions included bed in lowest position, maintain a clear pathway, and non-skid socks. Resident #55 had physician orders to keep the bed in the lowest position. A review of Resident #55's falls from November 2018 through 06/06/19 revealed he had fallen 15 times. A review of the fall investigation, dated 05/27/19, revealed Resident #55 fell from his bed when he attempted to get to his wheel chair to look for his daughter. A new intervention was created to keep the bed in the lowest position at all times. An observation on 06/06/19 at 11:45 A.M. revealed Resident #55's bed at a medium height and his call light on. State Tested Nurse Assistant (STNA) #51 was observed responding to the residents call light. An interview on 06/06/19 at 11:45 A.M. with STNA #51 revealed the staff keeps the bed up higher so his bedside table can fit under it when he eats. STNA #51 confirmed there was no meal tray on the bed side table, the resident wasn't eating, and the bedside table was next to the bed, not underneath the bed or over the resident. Review of the policy titled, Fall Management, dated 10/17/16, revealed an interdisciplinary plan of care will be developed, implemented, reviewed, and updated to reflect the residents current safety needs and fall reduction interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #9's medical record revealed an admission date of 12/14/07 with diagnoses including cerebrovascular disease, anxiety, high blood pressure (HTN), peripheral vascular disease (PVD), hemiplegia, hemiparesis, neuromuscular dysfunction of bladder, heart failure, depression, anemia, constipation, kyphosis, vascular dementia. Review of the MDS 3.0 assessment, dated 03/11/19, revealed a Brief Interview for Mental Status (BIMS) of 00, indicating severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, the resident did not transfer and was not mobile. A bowel and bladder assessment, dated 03/11/19, revealed the resident was incontinent of bowel and bladder. A care plan, created 12/14/18, revealed Resident #9 had an alteration in elimination and was completely incontinent of bowel and bladder. Interventions included: monitor for signs and symptoms of urinary tract infection (elevated temperature, dysuria, flank pain, hematuria, and foul smelling urine), report signs of infection to the physician to seek diagnoses and treatment promptly, and provide incontinence care as needed. A review of Resident #9's May 2019 through June 2019 physician orders revealed orders for Macrobid (antibiotic) 100 milligrams (mg) twice daily for ten days for urinary tract infection (started on 05/18/19 through 05/27/19). There was no documented evidence of Macrobid 100 mg twice daily for seven days on the May 2019 through June 2019 Medication Administration Record (MAR). Resident #9 also had physician orders for a urinalysis (UA) with culture and sensitivity to be completed on 05/16/19 and 05/23/19. A review of the UA, documented as completed on 05/16/19, revealed the specimen was not collected and new orders for Macrobid 100 mg twice daily for 10 days were received. The UA completed on 05/24/19 revealed the resident had multiple abnormal readings, indicating a UTI. An attachment page read that a UA was ran before a culture could be done, with instructions to recollect the urine. There was hand written documentation on the lab for new orders of Macrobid 100 mg twice daily for seven days. An interview on 06/06/19 at 11:35 A.M. with the DON revealed the 05/24/19 culture was not completed because the resident was still on Macrobid from the previous UTI, indicating the UTI from 05/16/19. The DON showed the surveyor a 05/24/19 lab with no hand written physician order on it and stated there were no new orders from the 05/24/19 UA. Surveyor showed the DON the hand written physician order documentation on the lab from 05/24/19, reading Macrobid 100 mg twice daily for seven days. An interview on 06/06/19 at 11:55 A.M. with the DON revealed the 05/16/19 UA specimen was not collected per hospice and the physician was notified and gave the new orders for Macrobid 100 mg twice daily for 10 days. The DON further stated the physician meant to write continue Macrobid 100 mg twice daily for 10 days on the 05/24/19 UA lab orders, but instead wrote new orders for Macrobid 100 mg twice daily for seven days. Based on medical record review and interview, the facility failed to ensure interventions were implemented to restore or maintain bladder function after a decline in urinary continence for Resident #115 and failed to follow physician orders to treat a urinary tract infection for Resident #9. This affected one (Resident #115) of one resident reviewed for bladder incontinence and one (Resident #9) of three residents reviewed urinary tract infections. The facility census was 120. Findings include: 1. Medical record review revealed Resident #115 was admitted on [DATE] with diagnoses including Alzheimer's disease, cerebral infarction, schizoaffective disorder and generalized anxiety disorder. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] and the MDS assessment dated [DATE] revealed Resident #115 declined in urinary continence from being continent of urine to occasionally incontinent of urine with no toileting program. Review of the record revealed no evidence interventions were implemented to attempt to restore Resident #115's bladder function when a decline was noted on the MDS assessment dated [DATE]. Review of the Progress Note dated 11/14/18 revealed an occupational therapy (OT) screen was completed, and the resident did not require OT services at the time. Physical therapy was addressing a recent decline in transfers. Review of the MDS assessment dated [DATE] revealed Resident #115 was moderately impaired for daily decision-making and required extensive assist of two staff for toilet use. The resident was occasionally incontinent of urine with no toileting program. Review of the MDS assessment dated [DATE] revealed Resident #115 was frequently incontinent with no toileting program. Review of the care plan: Alteration in Elimination reviewed 02/27/19, revealed Resident #115 was frequently incontinent of urine. Interventions included: monitor for infection and provide incontinence care as needed. There was no evidence of a program to restore urinary continence. Review of the Task: Bladder Elimination dated 05/07/19 to 06/04/19, revealed Resident #115 had daily episodes of urinary incontinence. Review of the quarterly Bowel and Bladder Assessment 3.0 dated 05/21/19, revealed Resident #115 was frequently incontinent of urine, was moderately cognitively impaired, frequently confused and made poor decisions. The resident required moderate assistance with ambulation and transfer to the toilet. The type of urinary incontinence was assessed to include the following: urge, overflow and functional incontinence. The impression of incontinence was functional incontinence with the plan being an incontinence care program. Review of the Physician Orders dated June 2019 revealed no evidence of a toileting program to restore bladder function. On 06/04/19 at 1:35 P.M., interview with Regional Director #501 stated the facility did not have a policy or procedure regarding urinary incontinence or restoring bladder function. On 06/06/19 at 4:29 P.M., interview with the Director of Nursing (DON) verified the above MDS assessments were accurate and Resident #115 had declined from being continent of urine to frequently incontinent of urine without interventions to restore bladder function. The DON stated she provided oversight of the restorative and toileting programs; however, no interventions had been implemented and somehow the resident fell through the cracks. The DON stated the only intervention implemented was an OT screen on 11/14/18, but no services were needed at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospice contract review, policy review and interview, the facility failed to ensure oxygen was provided at the ordered flow rate. This affected one (Resident #62) of three residents reviewed for respiratory care. The census was 120. Findings include: Medical record review revealed Resident #62 was admitted on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure and stroke. Review of the care plan: Cardiac Symptoms revised 07/13/17 revealed interventions including to administer medications as ordered. Review of the Hospice Contract signed 01/25/18 revealed all physician orders communicated to the facility on behalf of hospice were to be in writing and signed by the hospice patients attending physician or the hospice medical director. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #62 was severely impaired for daily decision-making and received oxygen. Review of the Hospice Visit Note Report dated 05/23/19 at 6:14 P.M., revealed review of medication changes including the administration of oxygen at 2 liters per minute (L/min). Review of the Physician Orders dated June 2019 revealed oxygen per nasal cannula to maintain saturation above 90%. Review of the facility orders revealed no ordered flow rate. Review of the Treatment Administration Record (TAR) dated June 2019 revealed continuous oxygen per nasal cannula to maintain saturation above 90%. Further review of the TAR revealed the resident required oxygen on 06/05/19 and there was no evidence of the flow rate administered. Review of the record revealed no oxygen care plan. On 06/03/19 at 11:11 A.M., observation revealed Resident #62 was receiving oxygen via nasal cannula at 1.5 L/min. There was no date observed on the tubing or humidification bottle. On 06/05/19 at 9:16 A.M., observation revealed Resident #62 was receiving oxygen via nasal cannula at 1.5 L/min. On 06/05/19 at 9:18 A.M., interview with Licensed Practical Nurse (LPN) #92 stated the resident was ordered oxygen at 2 L/min and was to be titrated as needed to keep his oxygen saturation above 90%. LPN #92 verified the resident was not receiving the correct flow rate and increased the resident's flow rate to 2 L/min. The surveyor asked LPN #92 to check the resident's oxygen saturation and at 9:22 A.M., after several minutes, LPN #92 obtained an oxygen saturation of 91% on 2 L/min of oxygen. LPN #92 verified there was no flow rate order or care plan for oxygen use. Review of the policy Respiratory: Oxygen Administration via Nasal Cannula revised 08/25/12 revealed a physician order was required to be obtained prior to the administration of oxygen via nasal cannula. Procedures included to verify the physician's order and set the prescribed flow rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure adequate justification for the use of anti-psychotic medications. This affected two (Resident #68 and Resident #98) of five residents reviewed for unnecessary medications. The census was 120. Findings Include: 1. Resident #68 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, muscle weakness, lack of coordination, dementia with Lewy bodies, atrial fibrillation., type II diabetes, hypertension, hyperlipidemia, restlessness and agitation, generalized anxiety disorder, and persistent mood disorder. Her Brief Interview for Mental Status (BIMS) score was not calculated due to her inability to answer the questions effectively. The assessment was attempted on 04/23/19. Review of Resident #68 medical records revealed she had the following medications and justifications for the medications listed: Seroquel 25 milligrams (mg) three times daily for agitation. In review of her progress notes and behavior logs, there was no other justification listed for the use of Seroquel (anti-psychotic) other than agitation, which is not an appropriate use for an anti-psychotic. When reviewing her behavior logs, the following behaviors were documented (March 2019 to May 2019): yelling and screaming, throwing things, seeing/hearing things not there, expressing false beliefs, grabbing, kicking/hitting, disruptive noises, and cursing at others. The justification for Seroquel (agitation) was never defined or described as specific behaviors in which the facility was to monitor. 2. Resident #98 was admitted to the facility on [DATE] with diagnoses including ischemic cardiomyopathy, congestive heart failure, unspecified psychosis, history of falling, hypertension, visual loss, hyperlipidemia, type II diabetes, dementia, major depressive disorder, Parkinson's disease, anxiety disorder, hallucinations, and peripheral vascular disease. Her BIMS score was 14, which indicated she was cognitively intact. This assessment was completed on 05/18/19. In review of Resident #98 medical records revealed the diagnoses of anxiety disorder (02/22/19), hallucinations (03/15/19), and unspecified psychosis (03/01/19) were added after she was admitted to the facility. According to her physician orders, she has the current medications and justifications prescribed: Haldol 0.25 milliliters (mL) for 14 days for anxiety/nausea, Haldol 0.25 mL every six hours as needed for anxiety/nausea, Seroquel 25 mg at bed time for psychosis, Sertraline 100 mg for depression, and buspirone 15 mg twice daily for anxiety. According to her behavior logs (dated March 2019 to May 2019) revealed two total behaviors documented (one for repeated movements and one for seeing/hearing things not there). Within her nursing/progress notes, there were three notes that stated the resident felt anxious and asked for her as needed anxiety medication, and two instances of refusing medications. Another nursing note (dated 03/01/19) stated the psychiatrist as Resident #98 that day and increased her psychotropic medications (Zoloft, Seroquel, and Ativan). There was no documentation provided by the facility to justify the increase of the psychotropic medications. The facility did not provide justification for the current use of psychotropic medications. Finally, the pharmacy wrote a note (dated 03/22/19) that stated, please ensure behaviors are charted in electronic records. Many psychotropic medications recently added and only one instance of 'Hallucinations.' This hallucination is also surrounded a newly diagnosed urinary tract infection. Thanks! Interview with State Tested Nursing Aide (STNA) #14 and Licensed Practical Nurse (LPN) #92 06/05/19 at 2:01 P.M. confirmed that if a resident had a behavior, they would document that in the electronic record through a progress note or on the behavior log. With Resident #68, she did not display behaviors. They stated she may cry a little if she had to go to the bathroom, but they would immediately take her and she would stop crying. She was easily redirectable. She did not have hallucinations, and she did not physically act out toward others. Interview with Director of Nursing (DON) and Regional Director #501 on 06/06/19 at 8:49 A.M. stated they understood the justification for the use of psychotropic medications was a double edged [NAME]. They understood that they had to have a proper justification for the use of the medication, but they also wanted to treat the symptoms that were shown by the resident (rejection of care, yelling/screaming, etc.) They confirmed the lack of documentation to support the use of psychotropic medications for both Resident #68 and Resident #98, but they saw a psychiatrist who reviewed their documentation and reports from facility staff to prescribe the medications. Interview with LPN #77 on 06/06/19 at 9:22 A.M. revealed Resident #98 was calm for the most part. She stated the resident would yell out and scream at times, but she also confirmed that these were typical behaviors for her; something that they knew she always did, and they tried to re-direct her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of facility policy and procedure for infection control, and review of the McGeer criteria for infections the facility failed to ensure the criteria was met before Resident #20 was given an antibiotic for pneumonia. This affected one (Resident #20) out of three residents reviewed for infections. Facility census was 120. Findings include: Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, and seasonal allergic rhinitis. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severely impaired cognition. A health status note dated 04/03/19 at 8:25 P.M. revealed Resident #20 was started on Ciprofloxacin (antibiotic) 500 milligram (mg) twice a day for ten days for aspiration pneumonia. Review of hospice communication notes (no date) revealed Resident #20 would have a chest x-ray three days after Ciprofloxacin was completed. Review of chest x-ray dated 04/17/19 revealed there was central pulmonary venous congestion without overt pulmonary edema and no focal pneumonia was evident. Review of the health status notes for March and April revealed no mention of Resident #20 with any respiratory symptoms. Interview on 06/05/19 at 9:47 A.M. with Licensed Practical Nurse (LPN) #64 revealed an x-ray was not completed before starting the antibiotic for pneumonia because Resident #20 was on Hospice. LPN #64 stated Hospice usually did not order any labs or x-rays on their residents. Interview on 06/05/19 at 12:31 P.M. the Director of Nursing (DON) verified Resident #20 did not have an x-ray before an antibiotic was started for pneumonia. The DON also verified the facility followed McGeer criteria for antibiotic use. Review of the facility policy and procedure for infection control/antibiotic stewardship dated 11/28/17 revealed laboratory testing should be done in accordance with standards of practice and the McGeer criteria was used to define infections. Review of the McGeer criteria for long term care surveillance definitions for infections updated 2012, provided by the facility, revealed the criteria for pneumonia included there must be a chest x-ray that demonstrated pneumonia, probable pneumonia, or a new infiltrate. In addition to the x-ray, there must also be one of the following: new or increased cough, oxygen saturation below 94%, pleuritic chest pain, fever, new or increased sputum production, or new or changed lung exam abnormalities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to maintain a clean and sanitary environment. This affected one (Resident #29) of three residents reviewed for activities of daily living. The census was 120. Findings include: Medical record review revealed Resident #29 was admitted on [DATE] with diagnoses including Parkinson's disease. Review of the care plan: At Risk for Falls with Potential for Injury dated 08/30/17 revealed interventions including floor mattresses to the left side of the bed. On 06/03/19 at 3:22 P.M., observation revealed Resident #29's lunch tray was on top of two stacked mattresses on the floor next to the resident's bed with dried brown/white food on the mattress. There was also dried food on the resident's bed, bed sheet and foot board of the bed. Resident #29's lunch tray arrived on the unit at 11:55 A.M. on 06/03/19. Interview with Assistant Director of Nursing #56 verified the above at the time of the observation. On 06/04/19 at 2:42 P.M., observation revealed two stacked mattresses next to Resident #29's bed with dried brown and white food/liquid on the mattress. Interview with Licensed Practical Nurse #92 verified the above at the time of the observation. On 06/05/19 at 9:25 A.M., observation revealed a mattress next to Resident #29's bed with dried food on it.