**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and policy review the facility failed to assess and monitor a resident's edema while having a sling and brace in place for a humerus fracture. This affected one resident (#249) of 24 resident records reviewed for assessments. Findings include: Review of record revealed Resident #249 was admitted to the facility on [DATE] with diagnoses including left humerus fracture, hypertension (HTN) atrial fibrillation, generalize anxiety disorder, major depressive disorder, Gastrointestinal reflux disease (GERD), type 2 diabetes, heart failure, cerebrovascular disease, hyperlipidemia, anemia, mitral stenosis, lymphedema, atherosclerotic heart disease, abnormal weight loss, Transient ischemic attack (TIA), breast cancer, hypothyroid, dry eyes, cataracts, polyarthritis, hyponatremia, diverticulitis left breast lumpectomy with lymph node sampling, lumpectomy of right breast. Review of baseline care plan completed 03/25/25 revealed Resident #249 required two assist with ambulation and transfers, one assist with bathing and hygiene, and a one assist with dressing and grooming. Resident #249 needed assistance with setup for meals, two assist for toileting, and used a wheel chair. Goals included observing pain and report as indicated, administer pain medication as ordered, and attempt non-medication interventions. Resident is able to communicate wants and needs. Visual ability indicates Resident #249 used glasses and will have adequate vision. Resident was alert to person, place, and time. Resident has anxiety and depression and will have a safe comfortable environment, social service visit and encouraged to ventilate feelings, provide redirection for episode behavior, monitor for medication effectiveness and side effects, and provide emotional support. Consult physical therapy (PT) and occupational therapy (OT) as ordered, evaluate for unsteady gate, ambulation devices as necessary, call bell within reach, observe footwear and non-skid socks. Prevent pressure ulcer and skin break down by following facility skin protocol, turn and position PRN, weekly skin evaluation, report any redness to medical director (MD), keep linens dry and wrinkle free, do prescribed treatment as ordered, notify MD is treatment is ineffective. Record review of Emergency department physician notes dated 03/23/25 revealed Resident #249 arrived from home due to a fall from ground level from standing position onto her left side, states she has left shoulder pain. Left arm x-ray revealed an acute humerus fracture. Left humeral sugar-tong splint placed to left humerus for stabilization. Record review of progress notes revealed a note on 03/25/25 at 6:00 P.M. by Licensed Practical Nurse (LPN) that identified Resident #249 had a brace and sling to left upper extremity (LUE) with pitting +2 edema to left hand. States brace/ sling can be removed for care. Resident is in good spirits with pain upon movements. Record Review of a comprehensive nursing note written on 03/26/25 by Registered Nurse (RN) #123 at 5:47 P.M. revealed nonpitting edema to LUE due to lymphedema. Sling in place per order to LUE. Record review of comprehensive nursing notes revealed no documentation of Resident #249's edema to the LUE on comprehensive nursing notes completed on 03/25/25, 03/27/25, 03/28/25, 03/29/25, 03/30/25, 03/31/25, 04/01/25, and 04/02/25. Record review revealed no documentation of monitoring or evaluation of Resident #249's LUE edema. Record review revealed no documentation of interventions ordered or being implemented for Resident #249 LUE edema. Observation on 03/31/25 at 11:10 A.M. revealed Resident #249's arm in a brace and sling, only able to visualize Resident #249's hand with swelling to the left hand. Observation on 4/01/25 at 11:21 A.M. revealed Resident #249 moving herself down the hallway in her wheelchair with a brace and sling applied to the LUE. Unable to visualize LUE from the wrist up. Swelling noted to the left hand of Resident #249. Observation on 04/02/25 at 9:05 A.M. revealed Resident #249 and RN #123 speaking. Observed sling and brace to Resident #249's LUE. Unable to visualize Resident #249's LUE from wrist up. Resident #249 had swelling to the left hand. Interview on 04/02/25 at 10:26 A.M. with Registered Nurse (RN) #123 revealed that Resident #249's arm had been swollen due to her lymphedema and was swollen on previous admissions. RN#123 stated before they were able to elevate her arm, but therapy has Resident #249 limited on what she can do with her left arm and they are only able to take the brace off for care. RN #123 stated the edema should be documented in the comprehensive nursing assessment. Interview on 04/02/25 at 10:13 A.M. with Occupational Therapy Assistant (OTA) #555 revealed Resident #249 is coming to therapy 3-5 times a week, they've had a few sessions and are working on exercises Resident #249 can do while seated, improving range of motioning to her left upper extremity, and hand exercises to help with the edema in that arm. Interview with RN #111 on 04/02/25 at 2:20 P.M. stated that the edema on the arm should be documented. RN #111 stated she understands it is necessary to evaluate the swelling to monitor for any changes especially with the sling and the fracture to the extremity. Review of policy Charting and Documentation (revised July 2017) revealed treatments or services performed must be documented in the medical record, documentation will be objective (not opinionated or speculative), complete, and accurate. Documentation will include care specific details including the assessment data and any unusual findings obtained during the procedure/treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, restorative master log, review of the therapy log, and interview the facility failed to ensure a newly admitted resident was accurately assessed for range of motion (ROM) and failed to ensure an individualized restorative program was implemented to ensure the resident maintained range of motion. This affected one resident (#399) of three reviewed for ROM. Findings included: Medical record review revealed Resident #399 was transferred to the facility on [DATE] from another skilled nursing facility located in another state. The resident diagnoses included stiffness of unspecified joint, absence of right leg above knee, diabetes type two, hemiplegia and hemiparesis following cerebral infarction affecting right dominating side, lack of coordination, weakness, and difficulty walking. Review of Resident #399's base line care plan dated 03/01/25 revealed the resident's bilateral hands the fingers (last two) only opened 50-75%. There were no goals or interventions documented. Review of Resident #399's comprehensive plan of care revealed no evidence of a plan of care for limited ROM/contractures. Review of admission Minimum Data Set (MDS) dated [DATE] revealed the resident had no impairment of the upper extremity and impairment one side of the lower extremity. Review of Resident #399's mobility evaluation dated 03/07/25 revealed the resident had full range of motion of right and left fingers. Review of Resident #399's orders and task (CNA documentation) revealed no evidence the resident had orders for splints, braces, or restorative therapy. Review of restorative master log sheet dated 04/2025 revealed no evidence Resident #399 was receiving restorative services. Review of the Therapy log dated 04/2025 revealed no evidence Resident #399 was receiving therapy services. Interview and observation with Resident #399 on 03/31/25 at 10:29 A.M. and 04/01/25 at 8:25 A.M., revealed the resident had contractures noted right pinky and left ring finger and pinky. The resident confirmed he had not received therapy, splints, or any type of treatment to prevent contractors in his fingers from getting worse since he had been admitted to the facility a month ago. The resident reported he was in a skilled nursing home in another state and was not receiving good care which resulted in his fingers being contracted. The resident reported he was hoping to have therapy and they would put something in place but he has not seen therapy yet. Interview and observation on 04/01/25 at 1:25 P.M. of Resident #399 with Licensed Practical Nurse (LPN) #110 and Certified Nursing Assistant (CNA) #148 confirmed Resident #399's right pinky and left ring finger and pinky were contracted. The LPN attempted to straighten out the resident fingers, however, was not able due to the extent of the contractures and the resident was experiencing pain. The LPN was not able to open fingers more than halfway on the right and less than halfway one the left. The CNA (who was related to Resident #399) and resident confirmed the contractures had not worsened in the last 30 days. Interview on 04/01/25 at 1:42 P.M., with LPN/Restorative Nurse #300 confirmed Resident #399's admission MDS and mobility evaluation were inaccurate due to the resident having limited ROM/contracture with his fingers on admission per the baseline plan of care and resident interview. The LPN confirmed the resident did not have a comprehensive plan of care for the limited range of motion/contractors nor was in a restorative program/therapy initiated, however a program should have been initiated. LPN #300 confirmed the resident was not receiving therapy services. Review of Resident #399's MDS note dated 04/01/25 (after surveyor confirming findings with staff) revealed the resident stated he would enjoy having exercise to his joints. The resident stated his ROM had not declined since admission. The resident had noted limitation to his pink finger on the right hand and last two fingers on the left hand. The resident reported the limitation happened at the place he was prior to coming to the facility. Will add ROM program.

Based on record review, staff interview and policy review, the facility failed to identify, monitor and measure targeted behaviors with the use of antipsychotic medication. This affected one resident (#14) of five residents reviewed for unnecessary medication. The facility census was 50 residents. Findings include: Review of Resident #14's medical record revealed a 08/21/23 admission with diagnoses including severe protein calorie malnutrition, magnesium deficiency, hypo-osmolality an hyponatremia, age related physical disability, pain, lack of coordination, muscle wasting and atrophy, peripheral vascular disease, Vitamin D deficiency, neuropathy, bipolar disorder, major depressive disorder, Vitamin B 12 deficiency anemia, dizziness and giddiness, gastroesophageal reflux disease, insomnia, dysphagia, anxiety disorder, hypokalemia, hypothyroidism, hypertension, orthostatic hypotension, and diverticulosis, Review of the Quarterly 01/02/25 Minimum Data Set assessment revealed the resident was independent for daily decision making with little interest or pleasure in doing things, feeling down, depressed, or hopeless. The resident was feeling tired or having little energy, having trouble falling or staying asleep, or sleeping too much, She had a poor appetite. She had trouble concentrating on things, such as reading the newspaper or watching television. She was on antipsychotics, antianxiety, opioid, antiplatelet, and anticonvulsant mediations. She had not started on hospice yet. A review of physician orders included Ativan, antianxiety medication, 0.5 milligram (mg) tablet TID, three times a day for anxiety ordered 08/24/23. Remeron, an antidepressant, 15 mg daily for major depressive disorder since 01/23/24. Lamictal, an antipsychotic, 150 mg tablet at bedtime for bipolar disorder current episode manic severe with psychosis, Risperdal 1 mg daily ordered 06/07/22. Abilify, an antidepressant, 5 mg at bedtime was ordered 08/28/24 for depression. Review of the 06/06/19 psychotropic drug care plans included an anti-depressant plan of care revealed the resident would remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood. The goal was the resident will be free of signs and symptoms of depression, anxiety or sad mood. The plan did not identify what behaviors the resident exhibited while depressed. There were no behaviors identified to monitor for the use of antidepressants. Review of the 11/03/22 plan of care for psychotropic drug use included the resident was at risk for adverse consequences related to receive an antipsychotic medication for psychosis. The long-term goal was the resident will not exhibit signs and drug related side effects or adverse drug reaction. The plan did not identify what behaviors the resident exhibited while psychotic. There were no behaviors identified to monitor for the use of antidepressants. Review of the Certified Nurse Aide TASK documentation revealed there was not a behavior section included in their documentation. Review of the Medication Administration Record (MAR) and the Treatment Record (TAR) revealed there were no sections related to the documentation of targeted behaviors for the use of psychotropic medication. Interview on 04/01/25 on 11:59 A.M. with the Director of Nursing verified the resident had no identified targeted behaviors being monitored and measured for the use of psychotropic medications. Further verified behavior monitoring would assist with the justification to increase or titrate medications. Review of the facility 08/30/24 Psychotropic Medication policy included if behaviors are displayed to document the behaviors in the Nurse Notes and interventions used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review the facility failed to ensure laboratory testing was completed per physician order. This affected one resident (#28) of five residents reviewed for medication review. Findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including history of hypertension, grade I diastolic dysfunction, and dementia. Review of Resident #28's orders dated 03/2025 revealed on 10/28/22 the physician ordered lipid profile to be obtained every six months (April/October). Review of laboratory results dated [DATE] to 04/01/25 revealed no evidence a lipid profile was obtained per orders in October 2024. Further review of laboratory results revealed the last lipid profile was obtained on 04/05/24. The resident's cholesterol was 250 (high) (normal less than 200 milligram (mg) / deciliters (dL), triglyceride 234 high (normal less 150 mg/dl), HDL 36.0 low (higher than desirable 40 mg/dl), LDL 167 high (less than 100 if desirable if clinical atherosclerotic disease or diabetes had been diagnosed). Review of the facility policy titled Lab Draw dated 01/2025 revealed labs would be drawn as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and staff interview the facility failed to ensure residents had appropriate indications for use of antibiotics. This affected one resident (#20) of five residents reviewed for antibiotic use. The facility census was 50. Findings include: Review of Resident #20's medical record revealed an admission date of 12/13/22 with diagnoses that included diabetes mellitus, hypertension and peripheral vascular disease. Review of Resident #20's nursing notes revealed on 11/01/24 the resident sustained a fall and was sent to the local emergency department for evaluation. Upon return to the facility on [DATE], Resident #20 was diagnosed at the emergency department with a urinary tract infection (UTI) and prescribed Cephalexin (antibiotic) 500 milligrams (mg) every six hours for five days due to a UTI. Nursing staff advised Resident #20's physician of the returning diagnosis and antibiotic order. Nursing staff also advised the physician the resident's urinalysis was negative and resident asymptomatic for a UTI. Resident #20's physician advised staff to continue the antibiotic. On 11/04/24, after receiving the final urinalysis results, the physician was notified Resident #20 did not meet criteria and advised to continue the antibiotic as ordered. Review of the physician's medication orders revealed on 11/02/24 Resident #20 was prescribed the use of Cephalexin (antibiotic) 500 milligrams (mg) every six hours for five days due to a urinary tract infection (UTI). Review of the antibiotic assessment completed on 11/02/24 revealed Resident #20 did not meet McGeer's criteria for appropriate indication for antibiotic use. The assessment indicated Resident #20 had a urinalysis and culture that final results returned on 11/03/24 which indicated a bacteria growth of proteus mirabilis of >100,000 colonies per million (cfu/ml). The resident had no additional symptoms of a UTI. Review of facility policy titled Antibiotic Stewardship with a reviewed date of December 2016 revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Additional policy review titled Infection Prevention and Control; Antibiotic Stewardship with a review date of June 2024 revealed the facility administration and medical director should ensure that current standards of practices based on recognized guidelines are incorporated in the residents care policies and procedures. Interview with the Director of Nursing on 04/02/25 at 2:25 P.M. verified the antibiotic for Resident #20 on 11/02/25 did not meet criteria for appropriate indication for use.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #31 was provided a dignified dining experience. This affected one resident (#31) of thirteen residents observed for dining. Findings include: Review of Resident #31's medical record revealed an admission date of 01/26/21 with diagnoses including arthritis, cervical spinal stenosis and dysphagia (difficulty swallowing). Review of the physician's orders revealed the resident had a current order for a puree consistency diet. Review of the annual Minimum Data Assessment (MDS) 3.0 assessment, dated 08/30/22 revealed the resident had severe cognitive impairment and required extensive assistance of one staff member with eating. On 10/11/22 at 8:22 A.M. Resident #31 was observed seated in her chair while State Tested Nursing Assistant (STNA) #44 was observed standing next to Resident #31, feeding the resident her breakfast meal. The STNA continued to stand through completion of the meal at 8:40 A.M. On 10/11/22 at 8:35 A.M. the Director of Nursing (DON) entered the dining room and spoke with residents eating as well as STNA #44. No mention was made to the STNA regarding her standing while assisting the resident with her breakfast meal. On 10/11/22 at 8:42 A.M. STNA #44 was observed to remove Resident #31 from the dining room. On 10/11/22 at 8:47 A.M. interview with STNA #44 verified she stood while feeding Resident #31 her breakfast. The STNA acknowledged she should be seated next to the resident while assisting the resident with her meal and this was not a dignified dining experience for the resident. On 10/11/22 at 10:30 A.M. interview with the DON verified the STNA should have been seated next to the resident while assisting the resident with her meal. Review of the Quality of Life- Dignity Policy, dated 2001 and revised 11/2017 revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident would be assisted in maintaining and enhancing his or her self-esteem and self-worth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertrophy of kidney, obstructive and reflux uropathy, Vitamin D deficiency, constipation, heart disease, diabetic, hyperlipidemia, morbid obesity and chronic kidney disease requiring dialysis. Review of Resident #11's nutritional note, dated 07/21/22 revealed the resident was ordered a no OJ, tomatoes or fried foods diet. The resident was currently not on any supplements, had no significant weight changes, meal intakes were 76% to 100% and fluid intakes were good. The resident was alert, and able to feed self. Nutritional needs were 1832-2290 calories, protein 92-110 and fluids were 1832-2290. The nutritional summary indicated the resident tolerated diet as ordered with meal intakes averaging 95% and no chewing or swallowing difficulties noted. His current weight was 290.4 pounds with a body mass index (BMI) of 40.5, indicating resident was morbidly obese. There were no significant weight changes triggering at present. The resident had no pressure wounds. The note revealed for registered dietician to follow and address nutritional concerns as appropriate. Review of Resident #11's meal intakes on hemodialysis days (M-W-F) from 09/02/22 to 10/03/22 revealed the resident had zero intakes for breakfast on the 7th, 9th, 12th, 14th, 19th, 21st, 23rd, 26th, 28th, 30th of September and 10/03/22. Review of Resident #11's nutritional plan of care revealed the resident's goal was to maintain meal intakes of 66% or greater. Interventions included to honor food preferences and offer meal replacement for poor intakes or upon request. Review of Resident #11's current orders for 10/2022 revealed orders for hemodialysis days Monday, Wednesday, and Friday at 7:00 A.M. and a diet order was for a non-gastric irritating (no OJ, tomatoes or fried foods) regular texture diet with thin (regular) liquids. Interview on 10/03/22 at 2:42 P.M., with Resident #11 revealed he only received two meals (lunch and dinner) on dialysis days. The resident revealed the dialysis center does not permit food in the center so he could not even take snack to eat, and the nursing home kitchen was not open early enough to make him a breakfast before he left for dialysis. The resident reported he would like something to eat besides cold cereal and peanut butter sandwiches, which was all the staff had access to in the morning before he left to offer him. The resident verified he was not offered any other choices of breakfast items to eat prior to go to dialysis. Interview on 10/04/22 at 2:32 P.M. and 3:09 P.M., with the Dietary Manager (DM) #4 and Resident #11 revealed the DM was not aware the resident was not eating breakfast on dialysis days. The direct care staff had never reported to her he was not eating breakfast on those days. The DM confirmed the kitchen staff do not come in early enough to make him a hot breakfast. The resident reported staff were getting him up and ready around 5:30 A.M. and he leaves between 6-6:30 A.M. for his 7:00 A.M., chair time. The DM confirmed residents were not permitted to eat at dialysis center and the dialysis center had called her reported to remind the resident not to bring food to the dialysis center. Interview on 10/04/22 at 3:02 P.M., with STNA #28 confirmed Resident #11 doesn't get a breakfast meal or eat anything in the mornings prior to going to dialysis. The STNA reported one of the reasons was the kitchen was not open until 6:00 A.M. and the second reason was they used to offer him a peanut butter sandwich in the morning, but he was declining them. The STNA reported the only breakfast items they have to offer him in the mornings were cold cereal and peanut butter sandwiches. Interview on 10/05/22 at 2:44 P.M., with Dietician #80 revealed she was not aware the resident was not eating breakfast on dialysis days, but stated she was not too worried because he had snacks in his room, however if a resident was not eating, she would inquire into why they were not eating. Based on record review, shower schedule review and interview the facility failed to ensure residents were provided the opportunity to choose their shower schedule and/or failed to ensure residents were offered choices related to meals. This affected one resident (#32) of one resident reviewed for choices and one resident (#11) of one resident reviewed for dialysis. Findings include: 1. Review of Resident #32's medical record revealed an admission date of 08/27/22 with diagnoses including nondisplaced fracture of the surgical neck of the left humerus, hypertension and heart disease. Review of the physician's orders revealed an order, dated 08/27/22 to maintain sling to the left arm and may remove for hygiene. Review of the undated document titled MDS Information and Resident History revealed the resident preferred a shower and the preferred time of day was 9:00 A.M. to 10:00 A.M. Review of the resident preferences plan of care, initiated on 08/29/22 revealed interventions including make sure she gets a shower between 9-10:00 A.M. as per their request Review of the five day admission Minimum Data Set (MDS) 3.0 assessment, dated 09/03/22 revealed the resident was cognitively intact and required extensive assistance from one staff member with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the shower documentation from 09/13/22 through 10/05/22 revealed the resident received a shower on 09/20/22, 09/27/22, 10/04/22 and 10/05/22. Review of the undated document titled Shower Schedule (Hall Name) Night Shift revealed the schedule was based off resident preferences, do not change). The document reflected Resident #32 was to receive a shower three days a week on Monday, Wednesday and Friday on night shift (6:00 P.M. to 6:30 A.M.) On 10/03/22 at 12:07 P.M. interview with Resident #32 revealed she doesn't get showered as often as she would like and she would like to receive showers more often. A follow-up interview on 10/05/22 at 11:00 A.M. revealed the resident received showers on night shift which she does not like because then she goes to bed with wet hair and her hair was a mess the following morning. On 10/04/22 at 4:10 P.M. interview with State Tested Nursing Assistant (STNA) #32 verified the resident was to be showered three times a week on night shift and the showers were documented in the facility electronic/computer system. The STNA revealed the facility did not utilize shower sheets or other paper documentation for showers. On 10/05/22 at 1:59 P.M. interview with the Director of Nursing (DON) verified the resident was not provided showers per her preference as she was scheduled on night shift and the resident's MDS information, which was asked on admission and her plan of care both indicated the resident wanted showered between 9-10:00 A.M. The DON also verified the resident had only received four showers in the last 30 days and she was scheduled to received showers three times a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure resident health concerns were timely reported to the physician. This affected one resident (#32) of five residents reviewed for range of motion. Findings include: Review of Resident #32's hospital history and physical, dated 08/22/22 revealed the resident had a past medical history of thyroid disease. Review of Resident #32's medical record revealed an admission date of 08/27/22 with diagnoses including nondisplaced fracture of the surgical neck of the left humerus, hypertension and heart disease. Review of the physician's orders revealed an order, dated 08/27/22 to maintain sling to the left arm and may remove for hygiene. There were no orders for thyroid medication or thyroid laboratory monitoring. Review of the five day admission Minimum Data Set (MDS) 3.0 assessment, dated 09/03/22 revealed the resident was cognitively intact and required extensive assistance from one staff member with bed mobility, transfers, dressing, toilet use and personal hygiene. Further review revealed the resident did not have thyroid disease coded on the MDS as a diagnosis. On 10/03/22 at 11:47 A.M. interview with Resident #32 revealed she had been feeling nervous, had been crying and unable to sleep. The resident shared she had a history of low thyroid and had since she was [AGE] years old. The resident stated she had taken medication prior to COVID but then COVID affected getting her medications refilled and she had not taken the medication for some time. The resident also revealed she informed the nurse at the facility she needed checked as she thought her thyroid was out of whack and the reason she had been having issues. As the interview was occurring, Licensed Practical Nurse (LPN) #53 was walking in the hall and stopped to ask the resident what she needed. The resident informed the nurse she thought her thyroid was off and the nurse informed the resident she would call and update the resident's physician. Further review of the medical record as of 10/05/22 revealed no evidence LPN #53 notified the physician of the resident's concern. On 10/05/22 at 2:13 P.M. telephone interview with LPN #53 verified she did not notify Resident #32's physician regarding her concerns with her thyroid levels. The LPN stated she should have notified the physician on 10/03/22, when the resident reported to her the concerns she was having regarding her thyroid. On 10/05/22 at 3:03 P.M. interview with the Director of Nursing (DON) verified LPN #53 should have contacted the resident's physician about her concerns regarding her thyroid. The DON stated she spoke with the resident's medical care provider and she ordered lab studies to be completed for the resident. On 10/05/22 at 3:03 P.M. interview with Registered Nurse (RN) #57 verified the MDS assessment did not accurately reflect the resident's thyroid disease and verified the hospital documentation listed thyroid disease as part of the resident's medical history. Review of the undated Physician Notification of Changes in Resident Status Policy revealed specific signs, symptoms and laboratory values suggestive of acute illness needing immediate medical assessment should be reported to the attending physician by the staff as soon as possible after they were identified. All acute changes in resident status reported to the medical staff on an immediate basis would be assessed and documented in the medical record by the nursing staff. Specific signs/symptoms and lab values suggestive of sub-acute illness shall be reported to the attending physician but not on an immediate basis. All subacute changes in resident status reported to the physician on a non-immediate basis would be assessed and documented in the medical record. If a physician does not respond by the end of the shift, the information would be given to the oncoming shift who would be responsible for follow-up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility investigation, facility policy and procedure review and interview the facility failed to prevent an incident of misappropriation of personal property involving Resident #11. This affected one resident (#11) of five residents reviewed for misappropriation. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertrophy of kidney, obstructive and reflux uropathy, Vitamin D deficiency, constipation, heart disease, diabetic, hyperlipidemia, morbid obesity, chronic kidney disease requiring dialysis. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of 15). Interview on 10/03/22 at 2:32 P.M., with Resident #11 revealed in April the resident's wallet came up missing out of his locked cabinet. The facility replaced the wallet and helped him obtain a new social security card. The resident stated he canceled his debit card himself, however the facility would not replace the $63.00 that was in his wallet. Review of the facility investigation revealed: A lost or missing article report form, dated 02/28/22 indicated Resident #11 reported to Social Service (SS) #43 his wallet containing $42.00 and social security card were missing. The resolution was to replace the wallet and order a new social security card. The report indicated the money would not be replaced due to facility policy. Review of a grievance/concern form, dated 02/28/22 revealed Resident #11 reported his wallet was missing. The writer and Resident #11 went through the resident's drawers and they were not able to find the wallet. The writer asked if maybe the resident's niece might have taken it to keep the wallet safe. The resident reported she (the niece) didn't have it. Action taken was to replace the wallet if not found and replacement social security card ordered. The author signed the resident was satisfied with the outcome. The form was not signed by the Director of Nursing (DON) or administrator in the spaces provided at the end of the form, nor was the form signed by the resident. The investigation also noted a review of a nursing note, dated 12/24/21 revealed the resident's niece picked up the resident's laptop, charger, wallet, money, phone, and glasses. Review of a signed consent, dated 12/24/21 from Resident #11's niece revealed she took the resident's laptop, charger, wallet, money (no amount noted), phone, and glasses. Review of SS #43's statement, dated 02/28/22 revealed Resident #11 had reported that his wallet and money were missing. The SS and resident looked through the locked drawer and could not find the wallet. The resident confirmed his niece did not have his wallet. SS #43 called the niece and she reported he had returned the resident's laptop and everything to him. Staff who worked on the resident's hall were interviewed and no one had seen the wallet aside from the nurse who gave it to his niece in December 2021. She notified the resident she would replace the wallet and help him get a new social security card. Review of State Tested Nursing Assistant (STNA) #28's undated statement revealed he had never seen the resident's wallet nor was aware the wallet was missing. Review of STNA #81's statement, dated 03/01/22 revealed she had never seen Resident #11's wallet. Review of Licensed Practical Nurse (LPN) #59's statement, dated 02/28/22 revealed she was present when the resident's niece had signed out the resident's belongings on 12/24/21. Further review of the investigation revealed no evidence of any additional staff, family or resident interviews conducted. Review of the February 2022 schedule revealed on 02/27/22 and 02/28/22 nine additional STNAs who worked on 02/27/22, three housekeepers, one activities staff and four nurses. On 02/28/22 there were seven additional STNAs, five housekeepers, and five additional nurses. There was no evidence STNA #81 was on the schedule on 02/27/22 or 02/28/22 and LPN #59 only worked 02/28/22. Interview on 10/05/22 at 10:09 A.M., with Resident #11's niece revealed she had picked up some items for her uncle on 12/24/21, however returned all the items around the end of December. The niece reported the resident had two bank envelopes containing cash. One envelope had 13 one-dollar bills and the other one had $40 with $5 bills. The niece stated she had the resident count the money when she returned it to him. She did not open his wallet, so she did not know what items he had in it. The resident had kept his money and wallet locked in the dresser; however, the key was in his room when he was out to the hospital. Interview on 10/05/22 at 8:35 A.M. with SS #43 and the Director of Nursing (DON) revealed they had not reported the allegation of misappropriation to the State agency because they did not feel they could prove the resident's niece had returned the resident's wallet/money that she signed out two months prior when Resident #11 was in the hospital, even though when they called the niece on 02/28/22 she had reported she had already returned all his items. The DON reported no one had seen the wallet and she thought the family still had it. The SS confirmed she did ask the niece originally the date she had returned the items. The SS reported she had called the niece yesterday; however, it had been so long the niece could not remember the date when she returned the items. The facility was not aware of any credit/debit card the resident had in his wallet. The SS confirmed the resident had the wallet in a locked cabinet when it had come up missing. She did not know when the resident had last seen his wallet to determine when it had come up missing. Interview on 10/05/22 at 11:44 A.M., with the Director of Nursing (DON) revealed the investigation was not through or complete and the misappropriation of the wallet and belongings were not reported to the State agency, and should have been reported no matter who took the wallet. There was no evidence in the investigation when the resident last saw the wallet or when the niece returned the items taken in December while the resident was in the hospital. The DON was not sure why the wallet was replaced and not the money. Interview on 10/05/22 at 12:30 PM with Resident #11 and DON revealed the resident reported he had counted the money the day before the wallet had come up missing and he had $63 in his wallet. He only had one card which was debit card and he canceled it right away and no transactions were made on it. He kept his wallet locked in the cabinet but at that time he left the key on the bed rail. Review of the facility undated admission agreement revealed the facility could not guarantee that items would not be lost or stolen. The agreement revealed should an item become missing, please notify the nursing staff immediately so the nursing staff could notify administration. The facility would follow their policies for items reported missing or stolen. Our facility would make every effort to keep track of (resident) belongings. Review of the mistreatment, neglect, abuse, and misappropriation policy, dated 06/09/22 revealed the facility would not tolerate misappropriation of resident's funds or property by anyone. The facility shall report an incident or suspicion of misappropriation of property immediately. The Administrator or designee would report the incident to the State agency. An investigation shall be completed, whenever possible, within five days after the Administrator or DON have knowledge of the incident. The investigation should include interviews with the resident and all witnesses. Obtain written statements from the resident and witness. In the case of alleged or suspected misappropriation, a physical audit of funds or other property was performed. Collect, review, and retain all pertinent facility documentation which may have a bearing on a full and proper investigation (schedule, work assignment, policies, and procedures). If a third party (including family member) have stolen from a resident, the Administrator or designee should report the incident immediately to the State agency or refer the matter for appropriate professional interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility investigation, facility policy and procedure review and interview the facility failed to implement their abuse/misappropriation policy and procedure to prevent an incident of misappropriation, to ensure the incident was thoroughly investigated and to ensure the incident was reported to the State agency. This affected one resident (#11) of five residents reviewed for misappropriation. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertrophy of kidney, obstructive and reflux uropathy, Vitamin D deficiency, constipation, heart disease, diabetic, hyperlipidemia, morbid obesity, chronic kidney disease requiring dialysis. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of 15). Interview on 10/03/22 at 2:32 P.M., with Resident #11 revealed in April the resident's wallet came up missing out of his locked cabinet. The facility replaced the wallet and helped him obtain a new social security card. The resident stated he canceled his debit card himself, however the facility would not replace the $63.00 that was in his wallet. Review of the facility investigation revealed: A lost or missing article report form, dated 02/28/22 indicated Resident #11 reported to Social Service (SS) #43 his wallet containing $42.00 and social security card were missing. The resolution was to replace the wallet and order a new social security card. The report indicated the money would not be replaced due to facility policy. Review of a grievance/concern form, dated 02/28/22 revealed Resident #11 reported his wallet was missing. The writer and Resident #11 went through the resident's drawers and they were not able to find the wallet. The writer asked if maybe the resident's niece might have taken it to keep the wallet safe. The resident reported she (the niece) didn't have it. Action taken was to replace the wallet if not found and replacement social security card ordered. The author signed the resident was satisfied with the outcome. The form was not signed by the Director of Nursing (DON) or administrator in the spaces provided at the end of the form, nor was the form signed by the resident. The investigation also noted a review of a nursing note, dated 12/24/21 revealed the resident's niece picked up the resident's laptop, charger, wallet, money, phone, and glasses. Review of a signed consent, dated 12/24/21 from Resident #11's niece revealed she took the resident's laptop, charger, wallet, money (no amount noted), phone, and glasses. Review of SS #43's statement, dated 02/28/22 revealed Resident #11 had reported that his wallet and money were missing. The SS and resident looked through the locked drawer and could not find the wallet. The resident confirmed his niece did not have his wallet. SS #43 called the niece and she reported he had returned the resident's laptop and everything to him. Staff who worked on the resident's hall were interviewed and no one had seen the wallet aside from the nurse who gave it to his niece in December 2021. She notified the resident she would replace the wallet and help him get a new social security card. Review of State Tested Nursing Assistant (STNA) #28's undated statement revealed he had never seen the resident's wallet nor was aware the wallet was missing. Review of STNA #81's statement, dated 03/01/22 revealed she had never seen Resident #11's wallet. Review of Licensed Practical Nurse (LPN) #59's statement, dated 02/28/22 revealed she was present when the resident's niece had signed out the resident's belongings on 12/24/21. Further review of the investigation revealed no evidence of any additional staff, family or resident interviews conducted. Review of the February 2022 schedule revealed on 02/27/22 and 02/28/22 nine additional STNAs who worked on 02/27/22, three housekeepers, one activities staff and four nurses. On 02/28/22 there were seven additional STNAs, five housekeepers, and five additional nurses. There was no evidence STNA #81 was on the schedule on 02/27/22 or 02/28/22 and LPN #59 only worked 02/28/22. Interview on 10/05/22 at 10:09 A.M., with Resident #11's niece revealed she had picked up some items for her uncle on 12/24/21, however returned all the items around the end of December. The niece reported the resident had two bank envelopes containing cash. One envelope had 13 one-dollar bills and the other one had $40 with $5 bills. The niece stated she had the resident count the money when she returned it to him. She did not open his wallet, so she did not know what items he had in it. The resident had kept his money and wallet locked in the dresser; however, the key was in his room when he was out to the hospital. Interview on 10/05/22 at 8:35 A.M. with SS #43 and the Director of Nursing (DON) revealed they had not reported the allegation of misappropriation to the State agency because they did not feel they could prove the resident's niece had returned the resident's wallet/money that she signed out two months prior when Resident #11 was in the hospital, even though when they called the niece on 02/28/22 she had reported she had already returned all his items. The DON reported no one had seen the wallet and she thought the family still had it. The SS confirmed she did ask the niece originally the date she had returned the items. The SS reported she had called the niece yesterday; however, it had been so long the niece could not remember the date when she returned the items. The facility was not aware of any credit/debit card the resident had in his wallet. The SS confirmed the resident had the wallet in a locked cabinet when it had come up missing. She did not know when the resident had last seen his wallet to determine when it had come up missing. Interview on 10/05/22 at 11:44 A.M., with the Director of Nursing (DON) revealed the investigation was not through or complete and the misappropriation of the wallet and belongings were not reported to the State agency, and should have been reported no matter who took the wallet. There was no evidence in the investigation when the resident last saw the wallet or when the niece returned the items taken in December while the resident was in the hospital. The DON was not sure why the wallet was replaced and not the money. Interview on 10/05/22 at 12:30 PM with Resident #11 and DON revealed the resident reported he had counted the money the day before the wallet had come up missing and he had $63 in his wallet. He only had one card which was debit card and he canceled it right away and no transactions were made on it. He kept his wallet locked in the cabinet but at that time he left the key on the bed rail. Review of the facility undated admission agreement revealed the facility could not guarantee that items would not be lost or stolen. The agreement revealed should an item become missing, please notify the nursing staff immediately so the nursing staff could notify administration. The facility would follow their policies for items reported missing or stolen. Our facility would make every effort to keep track of (resident) belongings. Review of the mistreatment, neglect, abuse, and misappropriation policy, dated 06/09/22 revealed the facility would not tolerate misappropriation of resident's funds or property by anyone. The facility shall report an incident or suspicion of misappropriation of property immediately. The Administrator or designee would report the incident to the State agency. An investigation shall be completed, whenever possible, within five days after the Administrator or DON have knowledge of the incident. The investigation should include interviews with the resident and all witnesses. Obtain written statements from the resident and witness. In the case of alleged or suspected misappropriation, a physical audit of funds or other property was performed. Collect, review, and retain all pertinent facility documentation which may have a bearing on a full and proper investigation (schedule, work assignment, policies, and procedures). If a third party (including family member) have stolen from a resident, the Administrator or designee should report the incident immediately to the State agency or refer the matter for appropriate professional interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility investigation, facility policy and procedure review and interview the facility failed to report an allegation of misappropriation of personal property involving Resident #11 to the State agency as required. This affected one resident (#11) of five residents reviewed for misappropriation. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertrophy of kidney, obstructive and reflux uropathy, Vitamin D deficiency, constipation, heart disease, diabetic, hyperlipidemia, morbid obesity, chronic kidney disease requiring dialysis. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of 15). Interview on 10/03/22 at 2:32 P.M., with Resident #11 revealed in April the resident's wallet came up missing out of his locked cabinet. The facility replaced the wallet and helped him obtain a new social security card. The resident stated he canceled his debit card himself, however the facility would not replace the $63.00 that was in his wallet. Review of the facility investigation revealed: A lost or missing article report form, dated 02/28/22 indicated Resident #11 reported to Social Service (SS) #43 his wallet containing $42.00 and social security card were missing. The resolution was to replace the wallet and order a new social security card. The report indicated the money would not be replaced due to facility policy. Review of a grievance/concern form, dated 02/28/22 revealed Resident #11 reported his wallet was missing. The writer and Resident #11 went through the resident's drawers and they were not able to find the wallet. The writer asked if maybe the resident's niece might have taken it to keep the wallet safe. The resident reported she (the niece) didn't have it. Action taken was to replace the wallet if not found and replacement social security card ordered. The author signed the resident was satisfied with the outcome. The form was not signed by the Director of Nursing (DON) or administrator in the spaces provided at the end of the form, nor was the form signed by the resident. The investigation also noted a review of a nursing note, dated 12/24/21 revealed the resident's niece picked up the resident's laptop, charger, wallet, money, phone, and glasses. Review of a signed consent, dated 12/24/21 from Resident #11's niece revealed she took the resident's laptop, charger, wallet, money (no amount noted), phone, and glasses. Review of SS #43's statement, dated 02/28/22 revealed Resident #11 had reported that his wallet and money were missing. The SS and resident looked through the locked drawer and could not find the wallet. The resident confirmed his niece did not have his wallet. SS #43 called the niece and she reported he had returned the resident's laptop and everything to him. Staff who worked on the resident's hall were interviewed and no one had seen the wallet aside from the nurse who gave it to his niece in December 2021. She notified the resident she would replace the wallet and help him get a new social security card. Review of State Tested Nursing Assistant (STNA) #28's undated statement revealed he had never seen the resident's wallet nor was aware the wallet was missing. Review of STNA #81's statement, dated 03/01/22 revealed she had never seen Resident #11's wallet. Review of Licensed Practical Nurse (LPN) #59's statement, dated 02/28/22 revealed she was present when the resident's niece had signed out the resident's belongings on 12/24/21. Further review of the investigation revealed no evidence of any additional staff, family or resident interviews conducted. Review of the February 2022 schedule revealed on 02/27/22 and 02/28/22 nine additional STNAs who worked on 02/27/22, three housekeepers, one activities staff and four nurses. On 02/28/22 there were seven additional STNAs, five housekeepers, and five additional nurses. There was no evidence STNA #81 was on the schedule on 02/27/22 or 02/28/22 and LPN #59 only worked 02/28/22. Interview on 10/05/22 at 10:09 A.M., with Resident #11's niece revealed she had picked up some items for her uncle on 12/24/21, however returned all the items around the end of December. The niece reported the resident had two bank envelopes containing cash. One envelope had 13 one-dollar bills and the other one had $40 with $5 bills. The niece stated she had the resident count the money when she returned it to him. She did not open his wallet, so she did not know what items he had in it. The resident had kept his money and wallet locked in the dresser; however, the key was in his room when he was out to the hospital. Interview on 10/05/22 at 8:35 A.M. with SS #43 and the Director of Nursing (DON) revealed they had not reported the allegation of misappropriation to the State agency because they did not feel they could prove the resident's niece had returned the resident's wallet/money that she signed out two months prior when Resident #11 was in the hospital, even though when they called the niece on 02/28/22 she had reported she had already returned all his items. The DON reported no one had seen the wallet and she thought the family still had it. The SS confirmed she did ask the niece originally the date she had returned the items. The SS reported she had called the niece yesterday; however, it had been so long the niece could not remember the date when she returned the items. The facility was not aware of any credit/debit card the resident had in his wallet. The SS confirmed the resident had the wallet in a locked cabinet when it had come up missing. She did not know when the resident had last seen his wallet to determine when it had come up missing. Interview on 10/05/22 at 11:44 A.M., with the Director of Nursing (DON) revealed the investigation was not through or complete and the misappropriation of the wallet and belongings were not reported to the State agency, and should have been reported no matter who took the wallet. There was no evidence in the investigation when the resident last saw the wallet or when the niece returned the items taken in December while the resident was in the hospital. The DON was not sure why the wallet was replaced and not the money. Interview on 10/05/22 at 12:30 PM with Resident #11 and DON revealed the resident reported he had counted the money the day before the wallet had come up missing and he had $63 in his wallet. He only had one card which was debit card and he canceled it right away and no transactions were made on it. He kept his wallet locked in the cabinet but at that time he left the key on the bed rail. Review of the facility undated admission agreement revealed the facility could not guarantee that items would not be lost or stolen. The agreement revealed should an item become missing, please notify the nursing staff immediately so the nursing staff could notify administration. The facility would follow their policies for items reported missing or stolen. Our facility would make every effort to keep track of (resident) belongings. Review of the mistreatment, neglect, abuse, and misappropriation policy, dated 06/09/22 revealed the facility would not tolerate misappropriation of resident's funds or property by anyone. The facility shall report an incident or suspicion of misappropriation of property immediately. The Administrator or designee would report the incident to the State agency. An investigation shall be completed, whenever possible, within five days after the Administrator or DON have knowledge of the incident. The investigation should include interviews with the resident and all witnesses. Obtain written statements from the resident and witness. In the case of alleged or suspected misappropriation, a physical audit of funds or other property was performed. Collect, review, and retain all pertinent facility documentation which may have a bearing on a full and proper investigation (schedule, work assignment, policies, and procedures). If a third party (including family member) have stolen from a resident, the Administrator or designee should report the incident immediately to the State agency or refer the matter for appropriate professional interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #18, who was dependent on staff for activities of daily living (ADL) care received proper and adequate oral care. This affected one resident (#18) of one resident reviewed for activities of daily living (ADL). Findings include: Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, cerebrovascular disease, multiple sclerosis, mood affective disorder, osteoporosis, dysphagia and Alzheimer's Disease. Review of Resident #18's last dental note, dated 01/23/18 revealed the resident had lots of debris and inflammation. The note revealed the resident needed assistance with brushing teeth and gums. Patient was uncooperative; unable to clean teeth today and would try with next visit. Review of Resident #18's Minimum Data Set (MDS) 3.0 assessment, dated 07/26/22 revealed the resident had severe cognitive impairment, had no behaviors or rejection of care. The resident was assessed to be total dependent on one staff member for personal hygiene including brushing her teeth. The resident had obvious or likely cavity or broken natural teeth. Review of Resident #18's personal hygiene plan of care revealed staff were to brush the resident's teeth every morning and night and as needed. Further review of Resident #18's plan of care revealed the resident refused medication at times and spits them out. However, there was no evidence the resident refused oral care. Review of the nurse aide tracking documentation for personal hygiene, dated 09/03/22 to 10/03/22 revealed the resident was mostly dependent of staff for hygiene care. Observation on 10/03/22 at 3:16 P.M., revealed Resident #18 had plaque build-up noted on the teeth, The resident's teeth were also discolored with one tooth missing on the top. There was no evidence of oral hygiene products visible in the resident's room or bathroom. Observation of Resident #18 and interview on 10/06/22 at 2:27 PM with Licensed Practical Nurse (LPN) #51 and State Tested Nursing Assistant (STNA) #28 confirmed the resident had no oral care supplies (toothbrushes, swabs, mouth wash, toothpaste) in the room. Both staff members confirmed the resident's teeth were in poor condition with plaque buildup. The STNA reported he thought one of the Hospice aides brought her own oral hygiene supplies to do mouth care but was not sure if the rest of the Hospice aides did. The Hospice aides visit three times a week per LPN #51. STNA #51 reported he only used mouth wash on a swab when he provided mouth care to Resident #18 even though she had her own natural teeth. STNA #28 reported the resident would often tell you no if you asked her any questions and then she would play possum, (acting like she is asleep). An additional observation on 10/11/22 at 10:11 PM with STNA #44 revealed the STNA reported she had not provided mouth care to the resident in the past but was told to use a mouth swab with mouth wash on it to clean the resident's teeth. The aide reported she should be using tooth paste in addition since the resident had her natural teeth. The STNA reported she would not just use mouth wash to clean her own natural teeth. The STNA #44 then removed an unopened box of tooth paste from the dresser and applied it to the swab. The STNA asked the resident if she could provide oral care and the resident responded no. The STNA did not encourage the resident to participate or help with her own oral care. Interview on 10/11/22 at 11:04 A.M., with LPN #51 revealed the resident refused to open her mouth for the dentist in 2018 and she had not been seen by the dentist since. The resident had consented to see the dentist and she should have been seen in 2021 and 2022. The dentist did not visit in 2020 due to COVID-19. The LPN reported she would make sure the resident was on the list to be seen at the next visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to develop and implement comprehensive and individualized restorative nursing service plans to ensure interventions and treatments were provided to residents to prevent a decline in range of motion (ROM) or maintain current ROM function. This affected two residents (#1 and #11) of five residents reviewed for mobility. Findings include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's Disease and limited range of motion. Review of Resident #1's annual Minimum Date Set (MDS) 3.0 assessment, dated 09/20/22 revealed the resident had limited range of motion to one side of the upper extremity. Review of Resident #1's current orders, dated 10/2022 revealed an order (dated 02/04/22) to gently perform passive range of motion to the right hand and place rolled wash cloth after range of motion was performed. The order indicated to keep wash cloth in place as tolerated throughout the day and at night. Review of Resident #1's risk for skin breakdown and risk for impaired functional range of motion care plans revealed the resident was to wear a rolled cloth to the right hand and if not able to tolerate, let therapy know and to gently perform passive range of motion to the right hand and place rolled wash cloth after range of motion was performed, keep wash cloth in place as tolerated throughout the day and at night. Review of the nursing task list dated 09/11/22 to 10/11/22 revealed to gentle perform passive range of motion to the right hand and place rolled wash cloth after range of motion was performed, keep wash cloth in place as tolerated throughout the day and at night. Further review revealed on 10/11/22 staff documented at 2:25 P.M. the washcloth was in-place. Observation on 10/11/22 at 2:48 P.M., with Licensed Practical Nurse (LPN) #51 revealed the resident was resting in bed and no washcloth was noted in the right hand or bed. The resident would not let the LPN touch her hand and kept pulling it way. The hand was noted to be contracted. Interview on 10/11/22 at 2:51 P.M., with LPN #51 revealed she had spoken to the resident's aide, and she reported the resident had gotten ketchup on the washcloth at lunch and she removed it and forgot to replace it. Interview on 10/11/22 at 3:05 P.M., interview with the Director of Nursing (DON) revealed she had just helped the aide place a new washcloth in the right hand it was difficult, but they were able to slide the washcloth in her hand. The DON verified staff had documented at 2:25 P.M., the washcloth was in-place, however the observation at 2:51 P.M., revealed the washcloth was not in-place, and the staff reported to LPN #51 she had removed it after lunch and forgot to replace it. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including respiratory failure, heart failure, osteoarthritis of knee, diabetes, and difficulty walking. Review of Resident #11's quarterly MDS 3.0 assessment, dated 07/12/22 revealed the resident's cognition was intact. The assessment revealed the resident had behaviors or refusal of care and had had impairment to his bilateral lower extremities. Review of a therapy referral to restorative form, dated 05/25/22 revealed Resident #1 was referred for active range of motion (AROM) to the right and left upper and lower extremities, two sets and ten repetitions. The number of times per day was blank. Review of Resident #11's task documentation, dated 05/26/22 revealed AROM to bilateral upper and lower extremities. There was no indication on how many repetitions or sets or how many times a week to complete. Record review revealed the resident had a current limited mobility plan of care. The plan revealed the resident would receive AROM to the bilateral upper and lower extremities, two sets of ten repetitions for at least 15 minutes daily. Interview on 10/03/22 at 2:35 P.M., with Resident #11 revealed staff were not assisting him with range of motion exercises and he had limitations to his lower extremities. Interview on 10/04/22 at 3:02 P.M., with STNA #28 revealed floor staff were responsible for restorative therapy and ROM. STNA #28 reported Resident #11 would allow staff to do ROM with his upper extremities, however he would not allow you to touch his legs. The resident would scream out in pain even before you touched him. Interview on 10/05/22 at 12:30 P.M., with Resident #11 and the DON revealed he would like to have therapy, but was concerned his insurance would not cover it. The resident revealed he had been taking pain medication three times a day and had seen a doctor for steroid injections at one time. Interview on 10/05/22 at 2:51 P.M., with Registered Nurse (RN) #57 revealed she was new to the program and was not aware resident was not participating in the lower leg AROM program. The RN confirmed the program under the task section for the aides to document did not include the number of repetitions, sets, time, or frequency to complete each upper and lower extremity exercise. The RN reported under the task section, the upper extremity and lower extremities had been separated and should have included two sets of 10 reps for 15 minutes; six to seven times a week. The RN reported she would update therapy on the resident's refusal to perform AROM to the lower extremity and update the task order for the aide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of dialysis dietary notes, facility policy and procedure review and interview the facility failed to ensure residents were assessed and timely identified related to continued significant weight loss. The facility also failed to ensure residents receiving hemodialysis had accurate diet and fluid restriction orders. This affected two residents (#11 and #21) of three residents reviewed for nutrition. Findings include: 1. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertrophy of kidney, obstructive and reflux uropathy, Vitamin D deficiency, constipation, heart disease, diabetic, hyperlipidemia, morbid obesity, chronic kidney disease requiring dialysis. Review of Resident #11's nutritional note, dated 07/21/22 revealed the resident was ordered a no OJ, tomatoes or fried foods diet. The resident was currently not on any supplements, had no significant weight changes, meal intakes were 76% to 100% and fluid intakes were good. The resident was alert, and able to feed self. Nutritional needs were 1832-2290 calories, protein 92-110 and fluids were 1832-2290. The nutritional summary indicated the resident tolerated diet as ordered with meal intakes averaging 95% and no chewing or swallowing difficulties noted. The resident's current weight was 290.4 pounds with a body mass index (BMI) of 40.5, indicating resident was morbidly obese. There were no significant weight changes triggering at present. The resident had no pressure wounds. The note indicated registered dietician to follow and address nutritional concerns as appropriate. Review of a dialysis dietary note, (requested by surveyor), dated 09/26/22 revealed to reinforce one liter fluid restriction, limit salt use, and encourage oral nutrition supplements in the facility with high protein food choices. Further review of the dialysis dietary note, dated 08/04/22 revealed the dialysis registered dietician noted to encourage resident to eat meats and or eggs with each meal three times daily. There were multiple documentation entries from 02/01/22 to present to work with the facility to stabilize fluid intake and encourage high protein diet. One note, on 05/27/22 revealed the registered dietician called the nursing home to encourage a fluid restriction for the resident due to him being a dialysis patient. Review of Resident #11's current orders for 10/2022 revealed the resident received hemodialysis every Monday, Wednesday, and Friday at 7:00 A.M. The resident had an order for a non-gastric irritating (no OJ, tomatoes or fried foods) regular texture diet with thin (regular) liquids. There was no evidence the resident was on fluid restriction or a renal diet. Interview on 10/03/22 at 2:42 P.M., with Resident #11 revealed he was not aware of any fluid or diet restrictions at the facility. Interview on 10/06/22 at 10:47 AM with Registered Nurse (RN) #50 revealed Resident #11 was not on a fluid restriction or renal diet. Interview on 10/06/22 at 11:00 A.M., with Dietary Aide #8 revealed Resident #11 had been on a fluid restriction but it was discontinued a long time ago. Interview on 10/05/22 at 2:44 P.M., 10/06/22 11:50 A.M. and 10/11/22 at 10:25 A.M. with Dietician #80 revealed the resident's fluid restriction was not reordered upon his return from a hospital visit in December 2021. Dietician #80 revealed she was not aware of the dialysis dietician recommendation for diet and fluids until the surveyor had requested notes from the dialysis centers dietician during the survey. The resident was in and out of the hospital multiple times in the past year and his diet and fluid restriction orders were not reordered. The dietician reported she was able to write dietary orders, however the facility policies was she was not permitted to write orders. She had not talked to the dialysis dietician probably since spring regarding this resident. Dietician #80 revealed she was not aware the dietician from the dialysis center had called the facility in May 2022 to discuss the resident's fluid restrictions. Dietician #80 revealed she called and spoke to the dialysis dietician on 10/06/22 after reviewing the notes and verified orders for a 1500 cubic centimeter (cc) fluid restriction, however she did not verify the diet order for the resident. The dietician currently reported the resident's diet order was for GI issues and not his renal failure. 2. Review of Resident #21's medical record revealed an admission date of 04/08/20 with diagnoses including depression, Alzheimer's Disease and schizoaffective disorder. The diagnosis of Parkinson's disease was added to the resident's medical record in July 2022. Review of the resident requires a therapeutic nutrition intervention plan of care dated 12/10/20 revealed interventions including honor food preferences, offer a meal replacement for poor intakes or upon request, offer a nourishing bedtime snack daily, provide diet as ordered and record intakes every meal and provide supplements as order- Mighty Shakes twice a day. Review of Resident #21's weights revealed: On 05/04/22 216 pounds On 06/10/22 216 pounds On 07/07/22 210 pounds On 08/05/22 202 pounds On 09/11/22 194 pounds a 7.8% weight loss (16 pounds) since 07/07/22. No additional weight monitoring was noted in the medical record. Review of the resident requires a pureed diet with nectar thick liquids plan of care, dated 07/28/22 revealed interventions including consult speech as needed and follow recommendations provided, observe for difficulty swallowing, holding food in mouth, prolonged swallowing time. repeated swallows ER bite, coughing, throat clearing, drooling, pocketing food in mouth and excessive chewing, provide diet texture as ordered. Review of the quarterly MDS 3.0 assessment, dated 08/15/22 revealed the resident had modified cognitive impairment and the resident was dependent on two staff members for bed mobility, transfers, dressing and toilet use. The resident required supervision while eating and had not experienced a significant weight loss in the last three to six months per the MDS assessment. Review of the physician's orders revealed a pureed diet with honey thickened liquids, dated 09/07/22 (following safe swallowing instructions from a modified barium swallow), a magic cup with meals dated 09/16/22 and to eat all meals in the dining room dated 09/26/22. The resident was receiving mighty shakes (supplement) two times a day from 07/29/22 through 09/16/22. Review of the resident's supplement intakes for September and October 2022 revealed the nurse documented with a check mark indicating the resident received his nutritional supplement but did not document the percentage consumed. Review of the nutrition progress note dated 09/15/22 revealed the physician was notified of the weight loss of 22.2 pounds (10.3 % in three months). Current weight 193.8 pounds with a body mass index of 25.6. Meal intakes average 68% yet ongoing weight loss was noted. Resident's diet texture was downgraded to puree with honey thickened liquids. Mighty shakes ordered twice a day. The registered dietician (RD #80) recommended to discontinue mighty shakes twice a day and provide magic cups three times a day. On 10/05/22 at 12:28 P.M. Resident #21 was observed seated in his wheelchair in the dining room. The resident was being assisted with his meal by a family member. On 10/05/22 at 5:25 P.M. Resident #21 was observed seated in his wheel chair in the dining room. The resident was feeding himself and was being provided verbal cues from staff in the dining room. The resident was observed to eat his magic cup during the meal and was provided the appropriate diet and fluid consistency. On 10/06/22 at 10:42 A.M. interview with RD #80 revealed the resident had experienced significant weight loss and recently had a change in his fluid consistency from nectar to honey thickened and his diet changed to puree texture in July 2022. The RD stated speech therapy was working with the resident and verified she had not observed the resident eating since she was not always in the facility during meal times. The RD stated she did not recommend changing the resident from monthly weights to weekly weights despite the resident's identified significant weight loss of 10.3 % or 22.2 pounds in three months. On 10/06/22 at 11:15 A.M. LPN #51 and State Tested Nursing Assistant (STNA) #26 were observed to weigh Resident #21 while in his wheelchair. The resident and chair weighed 242.4 pounds and this was verified by LPN #51. At 11:20 A.M. LPN #51 weighed only the resident's wheelchair and it weighed 52.8 pounds. This indicated the resident now weighed 189.6 pounds, a 4.2 pound weight loss since 09/11/22. This was verified with LPN #51 at the time of the observation. On 10/06/22 at 11:40 A.M. a follow-up interview was completed with RD #80. The RD verified the resident's additional weight loss and felt all hope is not lost and the resident's weight loss could have been worse. The stated she would consider the resident nutritionally complex and would need to re-evaluate him. She indicated she used information such as observing the resident eat, weights and labs to determine if the facility was meeting the resident's nutritional needs. On 10/11/22 at 10:50 A.M. a follow-up interview was completed with RD #80 which revealed she spoke to someone (she was unable to recall the staff member) regarding the resident's weight fluctuations and felt this may be due to excess fluid but had no additional information to support her thought of excess fluid volume. The RD stated the resident was weighed over the weekend but the weight was not documented. Lastly, the RD stated more frequent weights may be upsetting to residents and some don't like seeing the scale and being weighed so she didn't want to upset the residents by weighing them more often than monthly. On 10/06/22 at 12:35 P.M. telephone interview with the Speech Therapist (ST) #75 revealed she wasn't seeing the resident any longer and discharged him about two weeks ago with recommendations for him including to be up at 90 degrees, go to the dining room for meals, close supervision while eating, feed only when alert, small bites and sips while eating and alternate liquids and solids. She stated she felt his Parkinson's disease may be progressing and this caused a lot of his nutritional issues and his participation varied greatly related to his fatigue level and how tired he was. If the resident was fatigued and needed assistance he could go to bed and have the head of the bed elevated 90 degrees. ST #75 revealed the resident does very well but how well he does depends on him and his day. The ST did not feel the resident had any additional therapy needs such as occupational therapy at the time of discharge from ST. On 10/06/22 at 6:00 P.M. interview with the DON verified the resident had experienced significant weight loss and diet changes as well as the addition of some nutritional interventions. The DON verified the resident's weight loss should have been identified timely and monitored more closely due to his complex issues such as dysphagia, diet changes and co-morbidities. The DON stated she planned to discuss the resident with the dietician and place the resident on weekly weights to ensure his needs were being met. A follow-up interview on 10/11/22 at 11:04 A.M. verified the resident's nutrition care plan was not updated to reflect the resident's supplement change or consistency of his liquids being changed from nectar thick to honey thick. The DON also verified there was no indication the resident was experiencing any fluid overload as he was not experiencing any shortness of breath, edema or adventitious lung sounds. Review of the Weight Policy, reviewed and revised 07/13/16 revealed residents would be weighed upon admission within 48 hours and then once a month or as ordered by the physician. Available information would be reviewed for possible reasons for weight loss. Physicians would be notified of any weight change of five percent or more in a month, seven and a half percent in three months and 10 % in six months and all necessary interventions would be implemented as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure parameters were noted when to administer analgesic verses narcotic pain medication. The facility also failed to ensure nonpharmacological intervention were attempted prior to administration of narcotics. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including renal dialysis, osteoarthritis of the knee, and unspecified pain. Review of Resident #11's orders, dated 09/01/22 to 10/06/22 revealed the resident was ordered Acetaminophen 325 milligrams (mg) two tablets every four hours as needed for pain and Oxycodone 10 mg one tablet every six hours as needed for pain. Review of Resident #11's medication administration records (MAR) dated 09/2022 and 10/2022 revealed Acetaminophen was administered for a pain level of four to six as well as Oxycodone being administered for pain rated a level of zero to nine. Review of Resident #11's progress notes dated 09/01/22 to 10/06/22 revealed resident received 35 doses of Oxycodone without evidence a nonpharmacological interventions being considered or attempted first. Interview on 10/06/22 at 10:17 A.M. with the Director of Nursing (DON) confirmed there were no parameters as to when staff were to administer the Acetaminophen versus Oxycodone for the same pain level. The DON also verified there were several times nonpharmacological interventions were not attempted prior to administering the as need narcotic medication. The DON reported nurses should try a nonpharmacological intervention prior to administering Oxycodone.

Based on record review, facility policy and procedure review and interview the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of as needed psychotropic medications. This affected one resident (#21) of five residents reviewed for unnecessary medications use. Findings include: Review of Resident #21's medical record revealed an admission date of 04/08/20 with diagnoses including depression, Alzheimer's Disease and schizoaffective disorder. The diagnosis of Parkinson's Disease was added to the resident's medical record in December of 2021. Review of the resident uses anti-anxiety medications related to anxiety disorder plan of care, dated 07/07/21 revealed interventions including administer medications per orders and observe for side effects and effectiveness. Review of the physician's orders revealed an order for Vistaril (anti-anxiety medication) 50 milligrams tablet one tablet by mouth twice a day for anxiety disorder (initiated 07/24/22) and one 50 mg tablet daily as needed for restlessness for 14 days only (dated 09/23/22) and discontinued on 10/07/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/15/22 revealed the resident had modified cognitive impairment and was dependent on two staff members for bed mobility, transfers, dressing and toilet use. The resident required supervision while eating and had not experienced a significant weight loss in the last three to six months. Review of the Medication Administration Record (MAR) for September 2022 revealed the resident received as needed Vistaril on 09/24/22 at 2:17 P.M., 09/25/22 at 3:43 P.M. and 09/27/22 at 10:00 P.M. All doses were marked as effective. Review of the nursing progress notes revealed the following: On 09/25/22 at 3:41 P.M. the resident continued to wander around the facility in his wheelchair looking for family, tried to transfer self and appeared anxious. As needed Vistaril given. On 09/25/22 at 4:06 P.M. the resident's fingernails were cleaned and trimmed. On 09/27/22 at 10:36 P.M. no adverse reactions from increase to Vistaril. Received one dose this shift for insomnia/agitation. Further review of the medical record revealed no evidence non-pharmacological interventions were attempted prior to administration of the Vistaril on 09/25/22 and 09/27/22. On 10/06/22 at 2:00 P.M. interview with the Director of Nursing verified non-pharmacological interventions were not attempted prior to the administration of the as needed Vistaril. The DON stated the interventions attempted should be documented in the medical record and the progress notes should contain documentation describing the resident's behaviors that warrant the use of the as needed medication. The DON verified the care plan did not inform the staff to attempt non-pharmacological interventions or the specific interventions to try for the resident prior to administering the as needed medication. Review of an untitled policy, dated 04/24/18 revealed when giving as needed medications the following steps would be completed including attempt non-pharmacological interventions prior to giving the medication and document in the progress notes what non-pharmacological interventions were attempted. Give as needed medication if non-pharmacological interventions were not effective.

Based on record review, infection control log review, McGeer's Criteria review, facility policy and procedure review and interview the facility failed to ensure antibiotic use was appropriate and/or met antibiotic stewardship criteria. This affected two residents (#3 and #21) of five residents reviewed for unnecessary medications and one resident (#40) of one resident reviewed for antibiotic stewardship. Findings include: 1. Review of Resident #3's medical record revealed an admission date of 05/30/19 with diagnoses including overactive bladder, dementia and constipation. Review of the June 2022 Infection Control Log revealed a urine culture was obtained due to increased behaviors and urgency on 06/17/22 and contained greater than 100,000 colony count of escherichia coli and this met McGeer's Criteria for treatment due to the colony count and increased urgency. The resident was treated with the antibiotic, Keflex for a urinary tract infection. Review of the urine culture obtained on 06/17/22 and verified on 06/19/22 revealed the resident did have E coli in her urine, however Keflex was not listed as a treatment option. Review of the physician's orders revealed Keflex 500 milligrams twice a day for seven days was ordered on 06/17/22 and initiated on 06/18/22. The resident received the entire course of antibiotics. Review of the nursing progress note, dated 06/17/22 at 3:20 P.M. revealed the resident was transported to the emergency room due to suicidal ideations. The resident returned to the facility at 9:01 P.M. with orders for Keflex 500 mg twice a day for seven days to treat a urinary tract infection. Further review revealed on 06/20/22 at 9:17 P.M. revealed the urinalysis and culture was received and showed greater than 100,000 E. coli. The nurse practitioner was notified and ordered to continue Keflex as ordered from the emergency room. On 10/11/22 at 3:55 P.M. interview with the Director of Nursing (DON) verified the resident met criteria for treatment of a urinary tract infection, however the antibiotic used was not indicated for treatment of the organism the resident had in her urine. The DON verified the facility utilized McGeer's Criteria for the definition of infections and antibiotic stewardship. 2. Review of Resident #21's medical record revealed an admission date of 04/08/20 with diagnoses including Alzheimer's Disease, acute respiratory failure with hypoxia and hypotension. Review of the June 2022 Infection Control Log revealed Resident #21 presented with a cough and hoarseness on 06/24/22 and a chest x-ray was obtained. The resident's chest x-ray was negative for acute cardiopulmonary disease but due to the resident having two symptoms, the resident met McGeer's criteria for treatment of an upper respiratory infection. The resident received Zithromax 500 mg the first day and 250 mg three days following the loading dose beginning 06/24/22. Review of the physician's orders revealed Zithromax 500 mg the first day and 250 mg each day following for three days, dated 06/24/22, Review of the nursing progress notes, from 06/24/22 through 06/28/22 revealed the resident had a non-productive cough but no other symptoms were documented. Review of the McGeer's Criteria revealed the resident must present with at least two symptoms to meet criteria for treatment. On 10/11/22 at 3:58 P.M. interview with the DON verified the medical record only indicated the resident had a non-productive cough with no other symptoms were documented. The DON verified the resident did not meet criteria for treatment of an upper respiratory infection due to lack of symptoms present. 3. Review of Resident #40's medical record revealed an admission date of 10/11/21 with diagnoses including Alzheimer's Disease, mild chronic kidney disease and hypertension. Review of the July 2022 Infection Control Log revealed the resident had increased falls and a urinalysis was completed on 07/21/22. The urinalysis did not contain abnormalities to require a urine culture. The resident did not meet McGeer's Criteria for treatment due to not meeting criteria for a urine culture. However, the resident was ordered the antibiotic, Keflex and received the entire course of treatment. Review of the nursing progress note, dated 07/21/22 at 6:41 P.M. revealed the resident was sent to the emergency room due to somnolence, increased falls and disequilibrium. The resident returned with orders for antibiotic, Keflex 500 mg every six hours for UTI for seven days. Review of the physician's orders, dated 07/22/22 revealed orders for Keflex 500 mg every six hours for seven days. Review of the July 2022 MAR revealed the resident received the Keflex from 07/22/22 through 07/29/22. Review of the nursing progress notes revealed the facility received the urinalysis results on 07/25/22 and reported the results to the physician with orders to continue Keflex as ordered in the emergency room. On 10/11/22 at 4:00 P.M. interview with the DON verified the resident's urinalysis did not indicate the resident had a UTI and therefore did not meet McGeer's Criteria for treatment. The DON verified the resident was treated with Keflex without appropriate justification and the physician did not provide rationale as to why treatment should continue. Review of the Infection Prevention and Control: Antibiotic Stewardship Policy, dated 02/20/20 revealed the facility had developed and implemented written policies and procedures for the provision of infection prevention and control. The facility administration and medical director should ensure that current standards of practices based on recognized guidelines were incorporated in the residents' care policies and procedures. Nursing would obtain labs, cultures, chest x-rays etc as ordered and fax or call results to the physician. Nursing would follow orders as given by the physician, nursing would complete the criteria checklist as related to symptoms, educate nursing staff on what to monitor of criteria if not met and continue to inform the physician when criteria not met for antibiotic stewardship protocol.

Based on record review, facility policy and procedure review and interview the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 42 residents residing in the facility. Findings include: Review of the facility assessment, dated 02/02/22 revealed no evidence of RN requirements, however the assessment revealed nursing was available 24 hours a day. Review of the staffing schedule, daily posting, and timecards dated 08/29/22 to 09/25/22 revealed there was no consecutive RN coverage for eight hours as required on 09/03/2, 09/10/22, or 09/11/22. Interview on 10/05/22 at 9:23 A.M. with Human Resource (HR)/Scheduler #42 verified there was only six hours RN coverage on 09/03/22 and there was no RN coverage on 09/10/22 or 09/11/22 due to call offs and no RNs to cover the shifts. Interview on 10/05/22 at 10:57 A.M. with the Director of Nursing (DON) confirmed there was not eight hours of consecutive RN coverage on 09/03/22, 09/10/22, or 09/11/22. Review of the Staffing policy, dated 2017 revealed the facility would provide enough staff with the skills and competency necessary to provide care services for all residents in accordance with resident care plans and the facility assessment.

Based on record review and interview the facility failed to ensure Advanced Directive were clearly and accurately represented on all resident's charts. This affected two residents (Resident #35 and Resident #42) out of three reviewed for Advanced Directives. The facility census was 51. Findings include: 1. Review of Resident #35 revealed an admission date of 01/07/19 with diagnoses that included dysphasia (difficulty swallowing) and hypertension (high blood pressure). Review of current physician's orders revealed an order dated 01/16/19 for a code status of Do Not Resuscitate-Comfort Care (DNR-CC). This means a person will receive any care that eases pain and suffering, but no resuscitative measures to save or sustain life will be provided. Review of Resident #35's medical chart revealed that the DNR-CC was missing from the advanced directives tab in the resident's chart. Review of the facility policy, Advanced Directives, dated 12/2016, revealed information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. Interview on 01/21/20 at 2:55 P.M. with the Director of Nursing confirmed Resident 35's advanced directive was missing from their medical chart. 2. Review of Resident #42 revealed an admission date of 08/28/18 with diagnoses that included heart failure, Parkinson's disease, and hypertension. Review of Resident #42's January 2020 monthly physician's orders revealed the resident had an order indicating she had a Full Code status. This means the person will receive care and treatment for all health issues and will receive all life saving measures in the event of cardiac or respirator arrest. Review of Resident #42's medical chart revealed an undated DNR-CC form signed by the resident and the resident's physician. Interview on 01/21/20 at 2:50 P.M. Registered Nurse #68 confirmed that the Full code order was incorrect and that the resident's code status was changed to DNR-CC in October 2019. Review of the facility policy, Advanced Directives dated 12/2016, stated copies of guardianship, durable power of attorney and/or living will must be in the resident's chart, and information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record.

Based on record review and interview the facility failed to ensure two residents remaining in the facility received completed liability notices once skilled Medicare Part A services ended. This affected two residents (Resident #32 and Resident #36) of three residents reviewed for liability notices. The facility's census was 51. Findings include: 1. Review of Resident #32's medical record revealed an admission date of 07/25/19 with diagnoses including Parkinson's disease, high blood pressure, and arthritis. Review of the Notice of Medicare Non-Coverage (NOMNC) revealed the resident's skilled services would end on 09/17/19, and the resident would remain in the facility. It was further revealed that the facility had not completed a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN). Interview on 01/22/20 at 9:15 A.M. with Social Service Director #17 confirmed the facility failed to complete and provide a SNFABN to the resident or her representative. 2. Review of Resident #36's medical record revealed an admission date of 08/29/19 with diagnoses including muscle weakness, high blood pressure, and gout. Review of the Notice of Medicare Non-Coverage (NOMNC) revealed the resident's skilled services would end on 09/25/19 and the resident would resident in the facility. It was further revealed that the facility had not completed a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN). Interview on 01/22/20 at 9:15 A.M. with Social Service Director #17 confirmed the facility failed to complete and provide a SNFABN to the resident or his representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure restorative programs were implemented per the resident's plan of care. This affected two (Resident #2 and Resident #5) of three reviewed for range of motion. Findings included: 1. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome, osteoarthritis, acute embolism and thrombosis (blood clots) of superficial veins of left upper extremity, diabetes, cerebral infarction (stroke), and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the right dominant side. Review of Resident #2's current at risk for impaired functional range of motion (ROM) plan of care revealed the resident was at risk for impaired functional ROM related to hemiplegia, hemiparesis, dementia, depression, cerebral infarction and history of deep vein thrombosis to left upper extremity. His interventions included active assist range of motion (AAROM) to left upper extremity and passive range of motion (PROM) to right upper extremity, three sets of 10 repetitions daily for at least 15 minutes a day. Staff were to cue and prompt the resident to perform exercises. Review of Resident #2's ROM documentation located in the electronic medical record under the task tab dated 12/23/19 to 01/21/20 revealed no evidence PROM was performed to the right upper extremity. Interview on 01/21/20 at 3:23 P.M., with Licensed Practical Nurse (LPN) #39 verified there was no documented evidence Resident #2's restorative program for PROM to the right upper extremity was performed per the resident's plan of care. The LPN reported when she was entering the restorative program into the task tab in the electronic medical record, she must have missed the PROM. Interview on 01/22/20 at 10:02 A.M., with State Tested Nurse's Aide (STNA) #37 revealed the floor staff were responsible for ensuring the restorative programs were implemented. STNA #37 reported she did not know the difference between AROM and PROM. The STNA reported she did not believe Resident #2 was on a restorative program and would have to ask the nurse to find out. The STNA verified she had access to the resident's tasks and plan of care. 2. Review of Resident #5's medical record revealed an admission date of 06/11/18 with diagnoses including lupus and dementia without behavioral disturbance. Review of the current impaired functional range of motion (ROM) to both upper and lower extremities related to dementia and weakness initiated 08/13/18 revealed staff were to provide assisted active ROM/active ROM to both upper and lower extremities for 15 minutes twice a day. Review of the Quarterly Minimum Data Set (MDS) 3.0 dated 10/22/19 revealed the resident required extensive assistance of two staff members with bed mobility, transfers, dressing and toilet use. The resident required extensive assistance of one staff member with personal hygiene. Further review revealed the resident had functional ROM limitations to both upper and lower extremities. The resident received ROM to both upper and lower extremities daily for the last 30 days. Review of the STNA task documentation from 12/24/19 through 01/22/20 revealed ROM documentation once a day except 12/25/19 and 01/15/20 when the program was provided twice on those dates per the documentation. On 01/21/20 at 2:56 P.M. interview with the Director of Nursing (DON) verified the ROM program was not provided per the plan of care. On 01/21/20 at 3:00 P.M. interview with Licensed Practical Nurse (LPN) #39 verified the program was to be provided twice a day, 15 minutes each time for a total of 30 minutes per day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to implement fall interventions/physician orders for one (Resident #8) of two residents reviewed for accidents. Findings include: Review of Resident #8's medical record revealed diagnoses including Alzheimer's disease, dementia, vitamin B12 deficiency anemia, insomnia, dizziness and giddiness, and polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain). A care plan initiated 03/11/19 indicated Resident #8 had potential for falls related to Alzheimer's, confusion, and gait/balance problems. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was rarely/never understood and rarely/never understood others. Resident #8 was assessed with short and long term memory problems and moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #8 required limited assistance for transfers and walking in the room and corridor. Resident #8's balance while moving from a seated to standing position, walking and during surface to surface transfer was unsteady with Resident #8 only able to stabilize with staff assistance. On 11/12/19, a physician order was written for dycem (a non-slip material) to the wheelchair to aid in positioning. On 12/06/19, a physician order was written for a pull tab alarm to the wheelchair to alert staff of unassisted ambulation. The order instructed staff to check for the placement and function of the alarm to be monitored every shift. A fall risk evaluation dated 01/21/20 indicated Resident #8 continued to have fall risks including loss of balance while standing. On 01/22/20 at 7:44 A.M., Resident #8 was sitting in a wheelchair in the dining room watching television and conversing with another resident. An alarm box was positioned on the back of the wheelchair with a cord extending toward the seat of the wheelchair. None of the LED indicator lights were lit to indicate it was on and functioning. At 8:55 A.M., Resident #8 was observed propelling herself back to her room leaning forward in the wheelchair. Resident #8 leaned forward, getting items from the bottom drawer of a stand in her room before sitting back. The alarm did not sound. At 9:01 A.M., Resident #8 propelled herself to the nursing station where she stopped to speak. Resident #8 was confused and sometimes struggled for words. The LED indicators of the alarm box remained dark. On 01/22/20 at 9:06 A.M., State Tested Nursing Assistant (STNA) #40 verified the indicator lights on the alarm box should be lit. STNA #40 removed the alarm box from the wheelchair and verified it was in the on position. STNA #40 proceeded to push the clip from the wire into the box and it beeped. The lights lit up. STNA #40 had Resident #8 stand and the pressure alarm sounded. STNA #40 verified Resident #8 did not have a dycem in the wheelchair. On 01/22/20 at 9:47 A.M., the Director of Nursing verified Resident #8 did not have the type of alarm on which was ordered. Resident #8 had a pressure alarm applied instead of the ordered clip alarm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy reviews the facility failed to ensure Resident #31 was provided an effective pain management regimen. This affected one of three residents reviewed for pain management. Findings include: Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome and paraplegia. Review of Resident #31's pain evaluation dated 12/18/19 revealed he had no pain therefor the rest of the evaluation was not completed (description of pain, what makes pain worse, medications, non-pharmalogical interventions, and if pain medication was effective). Review of Resident #31's comprehensive assessment dated [DATE] to 01/09/20 revealed the resident had no pain. Review of Resident #31's quarterly minimum data set (MDS) assessment dated [DATE] revealed he had pain or hurting in the last five days. The pain/hurting was almost constantly. The assessment indicated the pain did not affect his sleeping or activities of daily living. Review of Resident #31's current chronic pain plan of care revealed the resident had chronic pain related to paraplegia and autonomic dysreflexia (a syndrome with a sudden onset of excessively high blood pressure). The interventions included for staff to assess pain control preferences and attempt to adhere to them, monitor/record pain characteristics, location, onsets, aggravating factors, and relieving factors. Interview on 01/21/20 at 10:19 A.M., with Resident #31 revealed he had constant pain and the Tylenol was not really helping his pain. He said he had reported his concerns to staff. Review of Resident #31's medication administration records dated 12/2019 and 01/2020 revealed the resident had not received the Tylenol. He had physician orders for Tylenol 1,000 milligrams (mg) every eight hours for pain. Interview on 01/22/20 at 9:15 A.M., with Resident #31 and Licensed Practical Nurse (LPN) #24 revealed the resident reported he had pain all over, all the time, especially in his shoulders. He rated the pain a 6-7 out of 10, which was now tolerable for him. The pain at the worst was 9-10 out of 10. The pain scale is zero with no pain and 10 as the worst pain ever. He said the Tylenol was not effective, and he had reported to staff it was not effective, however the doctor did not prescribe anything different, so he just deals with it. The staff or physician have not provided a rational why he could not have anything other than Tylenol. He said he usually doesn't request the Tylenol as it was not effective. The resident reported certain nurses will give him an itching pill and the Tylenol at night. He verified the night nurse gave him Tylenol last night. Interview on 01/22/20 at 10:23 A.M., with LPN #24 verified Resident #31 was admitted to the facility with a diagnosis of chronic pain and his MDS assessment indicated he had constant pain, however his pain assessments and plan of care did not address the resident's location of pain, characteristics, aggravation factors, or relieving factors. Review of the pain management policy dated 11/2019 revealed all residents shall be evaluated upon admission and at regular intervals for the presence of pain. Residents shall be asked to classify their pain level on a pain assessment scale. Assessment of pain would include location, duration, radiation, and precipitating all alleviating factors. Attempts to control the pain would be employed until the residents reaches acceptable comfortable levels. The physician and responsible party shall be notified of any adverse reactions and the pain management plan shall be revised to better suit the needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview the facility failed to ensure pharmacy recommendations were timely addressed. This affected one resident (Resident #27) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #27's medical record revealed an admission date of 09/17/19 with diagnoses including atrial fibrillation (irregular heartbeat), peripheral vascular disease, hypertensive heart disease and diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was dependent on staff members for assistance with activities of daily living. The assessment revealed Resident #27 received an anticoagulant for seven days during the assessment period. Lastly, the resident had pain during the assessment period and required the use of as needed pain medication. Review of the physician orders revealed an order for Eliquis (a blood thinner used to treat and prevent blood clots for individuals with a known history of blood clots or atrial fibrillation) 2.5 milligrams (mg) twice a day (ordered on 11/11/19) and Ultram, also known as Tramadol, a narcotic pain reliever, 100 mg every six hours as needed for pain (ordered on 11/14/19). Review of the pharmacy recommendation dated 11/15/19 revealed the resident was taking Eliquis for atrial fibrillation at 2.5 mg twice a day. A dose of 5 mg twice a day is recommended because the resident weighed more than 60 kilograms (the resident weighed 85 kilograms) and had a serum creatinine level of less than 1.5 milligrams per deciliter (the resident's level was 0.94 mg per deciliter). As of 01/20/20, the recommendation had not been addressed. Review of the pharmacy recommendation dated 12/20/19 revealed in patients over [AGE] years of age (the resident was [AGE] years old), the maximum recommended dose of Tramadol is 300 mg per day. The resident had an order for 100 mg every six hours which allowed the resident 400 mg per day. The pharmacist suggested adding a physician order for staff to do not exceed 300 mg per day to the as needed order. As of 01/21/20, the recommendation had not been addressed. On 01/21/20 at 9:56 A.M. interview with the Director of Nursing (DON) verified the recommendation for Eliquis had not been addressed. An additional interview on 01/23/20 at 12:45 P.M. verified the recommendation for Ultram had also not been addressed and placed the resident at risk for receiving more than the daily recommended dose. The DON stated the facility planned to revise their policy and address recommendations more timely when related to medication dosages to prevent residents receiving too much or too little of prescribed medication. Review of the policy for Drug Regimen Review, dated 06/19, revealed any noted/identified medication related issues or concerns will be noted by the pharmacist via drug review recommendations. These recommendations will be made available to the physician in a timely manner and not longer than 60 days from the date of the recommendation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure Resident #5 was provided routine dental services. This affected one of three residents reviewed for dental services. Findings include: Review of Resident #5's medical record revealed an admission of 06/11/18 with diagnoses including lupus, dementia without behavioral disturbance and hypertension. The resident's current payer source is Medicaid. Review of the dental consent dated 06/11/18 revealed the resident/responsible party consented to emergency and preventative dental services. Review of the plan of care for potential oral/dental health problems related to having her own teeth, initiated 12/12/18, revealed interventions including for staff to coordinate arrangements for dental care as needed and observe/document/report to the medical doctor, as needed, oral/dental problems needing attention such as loose, broken or decayed teeth. Review of the dental assessment dated [DATE] revealed the resident had two to three decayed or broken teeth without pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance from one staff member with personal hygiene. Review of the medical record revealed no evidence of a dental evaluation since admission in 2018. On 01/21/20 at 3:30 P.M., Resident #5 was observed in her room, seated in a wheel chair. A build-up of a white material was observed on the resident's lower teeth, near the gum line. On 01/22/20 at 10:36 A.M., interview with the Director of Nursing verified Resident #5 had been in the facility since June of 2018 and had not received any dental services despite the resident consenting to dental services including preventative and emergency services. The Director of Nursing verified the resident had a white substance on her lower teeth near the gum line and the dental assessment from 10/22/19 indicated the resident had broken or decayed teeth. On 01/22/20 at 1:30 P.M. interview with Social Services Designee #17 verified she was responsible to ensure resident's were seen by the dentist for preventative dental care of they consented for services. Social Services Designee #17 verified Resident #5 had not received any dental services and would be seen by the dentist during the next visit scheduled in February, 2020.

Based on review of infection control surveillance logs and interview, the facility failed to complete comprehensive infection control records for infection surveillance, failed to investigate an increase in urinary tract infections, and failed to educate staff regarding infection control practices. This had the potential to affect all 51 residents residing in the facility. Findings include: Review of infection control surveillance logs with Licensed Practical Nurse (LPN) #39 revealed a spike in recorded urinary tract infections(UTI), which developed in the facility, in October 2019. The October 2019 log indicated there were four UTI with catheters and seven non-catheter associated UTIs. However, one of the residents with a catheter associated infection was listed twice, having to be treated a second time. The log indicated three of the residents with recorded UTIs had cultures completed with no results recorded. LPN #39 stated she monitored for occurrence of infections and if/when she noticed a concern it was addressed with the Director of Nursing (DON) and they worked together to provide education for staff. During this interview on 01/21/20 at 5:26 P.M., LPN #39 verified the October 2019 log revealed an increase in the number of UTI. And on 01/21/20 at 6:28 P.M., LPN #39 verified there was no evidence the facility attempted to determine the reason for the increase in UTIs and no education was provided to staff when the increase was noted in October 2019 to try and decrease the infection rate. On 01/22/20 at 5:00 P.M., Registered Nurse (RN) #68 verified determining the root cause of the increases was important in preventing further infections and determining if education was needed and, if so, what type of education. On 01/23/20 at 9:40 A.M., LPN #39 was interviewed regarding the infection surveillance logs not revealing culture results. LPN #39 verified the logs were incomplete although she had the culture results.

Based on record reviews, interviews, review of infection control/antibiotic stewardship log, and policy review the facility failed to implement a comprehensive antibiotic stewardship program to monitor and prevent unnecessary/inappropriate use of antibiotics. This affected one resident, Resident #32, however it had the potential to affect all 51 residents residing at the facility. Findings included: Record review revealed Resident #32 was admitted to facility on 07/25/19 with diagnoses including Parkinson's disease and diabetes. Review of Resident #32's record revealed a fax to the resident's doctor dated 01/07/20 which indicated the resident had complaints of a sore throat and nasal congestion. The physician responded on 01/07/20 and a Z-pak (antibiotic) was ordered. Review of Resident #32's orders and medication administration records (MARs) dated 01/07/20 to 01/11/20 revealed Resident #32 received 500 milligrams (mg) of Z-pak on 01/07/20 and 250 mg on days 01/08/20 through 01/11/20. Review of Resident #32's infection report dated 01/07/20 revealed the resident had congestion, nonproductive cough, and was afebrile (no fever). The resident was ordered a Z-pak. There was no evidence the resident met criteria for antibiotic treatment. Review of the infection control log/antibiotic stewardship log dated 01/2020 revealed no evidence the facility had criteria established to ensure residents met criteria for antibiotic treatment. There was documented evidence if the resident met or did not met criteria. Review of the infection prevention and control: antibiotic stewardship, undated, revealed no evidence what criteria was to be used, however staff was to inform the physician/staff when the criteria were not met. Interview on 01/23/20 at 11:38 A.M. and 11:49 A.M., with Licensed Practical Nurse (LPN) #39 and Registered Nurse (RN) #68 revealed the facility had not been utilizing any criteria to ensure antibiotics were used appropriately. The nurses reported the facility should have been using the McGeer criteria. After reviewing the McGeer criteria with LPN #39 she confirmed Resident #32 would have not met criteria for antibiotic treatment. 2. On 01/21/20 starting at 5:26 P.M., infection control logs from July 2019 to January 2020 were reviewed with Licensed Practical Nurse (LPN) #39. LPN #39 was asked to describe the process she utilized in monitoring infections. LPN #39 stated if residents exhibited signs/symptoms of infection the physician was updated and tests were ordered. LPN #39 stated some of the physicians were ordering antibiotics before culture results were obtained and/or ordering antibiotics without obtaining cultures. When this happened, staff asked the physician if he/she was sure they wanted to continue the antibiotic use. LPN #39 stated it was mainly the same two physicians who did this, one being the medical director. When asked if the problem with getting the physicians to comply with the antibiotic stewardship program was discussed with the Director of Nursing (DON) or Administrator to increase compliance, LPN #39 stated she had not discussed the issue with the Administrator. LPN #39 stated every resident who was ordered an antibiotic had an infection report done. When asked what criteria was used in determining if residents had true infections, an immediate response was not provided. Then LPN #39 indicated McGeer's criteria was used. The forms provided did not have sufficient information to determine if the residents met the criteria. On 01/23/20 at 9:17 A.M., LPN #39 stated when physicians gave orders for antibiotics before chest x-ray or culture results were received, she or LPN #24 called the physician and asked if they wanted to discontinue the order. When asked if physicians had been educated regarding the antibiotic stewardship program, LPN #39 stated she assumed the hospital would do that. On 01/23/20 at 9:40 A.M., LPN #39, in the presence of Registered Nurse (RN) #68, was interviewed. LPN #39 provided a copy of an undated letter which RN #68 stated was sent to the physicians in 2017 when the antibiotic stewardship regulations came out informing the physicians of the an antimicrobial stewardship program which addressed the appropriate use of antibiotics, using them only when truly needed and using the right antibiotic for each infection. RN #68 stated she was not aware the physicians were not following the antibiotic stewardship program but had found that a lot of times she just had to remind the doctors or suggest that they needed to wait for results prior to initiating antibiotics. On 01/23/20 at 10:04 A.M., RN #68 stated she and the Administrator just had a teleconference with the medical director and his nurse practitioner and they agreed to be more cognizant about ordering antibiotics without test results. On 01/23/20 at 11:44 A.M., RN #68 verified the antibiotic stewardship policy was vague. Review of the facility's Infection Prevention and Control, Antibiotic Stewardship policy (not dated) indicated nursing would complete criteria checklist as related to symptoms, educate nursing staff on what to monitor if criteria were not met, and continue to inform the physician when criteria was not met of the antibiotic stewardship protocol. The policy did not indicate what criteria was being used to determine if residents had infections or needed antibiotics. On 01/23/20 at 11:44 A.M., RN #68 verified LPN #39 was utilizing the correct form provided by the facility but the form did not provide the criteria in an organized manner to aid in determining if residents met the criteria for antibiotic use.