**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident care conferences were offered and provided routinely as required. This affected two (#6 and #7) of two residents reviewed for care conferences. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #6 was admitted on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, chronic kidney disease stage, type two diabetes mellitus, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Review of the care plan conference documentation revealed Resident #6's last date of documented care conferences was 05/14/21. Interview on 04/29/25 at 4:07 P.M. with Social Services #134 verified Resident #6 has not had a formal care conference in quite a while. Social Services #134 stated care conferences were an open invitation or upon request at the frequency requested of the resident or resident representative. Social Services #134 stated the facility does not schedule regular care conferences. 2. Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease, schizophrenia, type two diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, primary osteoarthritis, and depression. Review of the Minimum Data Set (MDS) assessment, dated 02/16/25, revealed Resident #7 was cognitively intact. Review of the care plan conference documentation revealed Resident #7 did have not have any care conferences since admission. Interview on 04/29/25 at 4:07 P.M. with Social Services #134 verified Resident #7 did not have any formal care conference. Social Services #134 stated care conferences were an open invitation or upon request at the frequency requested of the resident or resident representative. Social Services #134 stated the facility does not schedule regular care conferences. Review of the policy titled Comprehensive Person-Centered Care Plans dated March 2022 revealed the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the quarterly MDS assessment. The resident is informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences.

Based on observation, record review, family and staff interview, and review of the policy, the facility failed to ensure residents who were dependent on staff with activities of daily living were offered and fed their meals. This affected one (#45) resident observed during meal service. The facility census was 70. Findings include: Review of the medical record for Resident #45 revealed an admission date of 08/01/24 with diagnoses adult failure to thrive and dementia. Resident #45 was admitted to hospice care on 12/30/24. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/22/25, revealed Resident #45 had impaired cognition and was dependent on staff for eating. Resident #45 had no significant unplanned weight loss. Review of the current physician order, dated 12/26/24, revealed Resident #45 received a diet of no added salt/no concentrated sweets, pureed texture and nectar thick liquids. Observation on 04/28/25 at 11:06 A.M. revealed Hospice Aide (HA) #274 giving report to Licensed Practical Nurse (LPN) #114 regarding Resident #45. Observation on 04/28/25 at 11:16 A.M. revealed noon meal trays were delivered to Resident #45's hall. Concurrent observation revealed Resident #45 alone in her room, lying in bed sleeping. Continuous observations on 04/28/25 at 11:23 A.M. revealed Certified Nursing Assistant (CNA) #133 passing meal trays on the hall. Interview on 04/28/25 at 11:44 A.M. with CNA #133 confirmed one meal tray remained on the cart. CNA #133 stated the tray was for Resident #45. CNA #133 stated she did not pass the tray for Resident #45 because the hospice aide was working with Resident #45. Observation on 04/28/25 at 12:07 P.M. revealed Resident #45's noon meal tray remained on the tray cart. Concurrent interview with CNA #133 revealed she had no plans to offer Resident #45's meal tray because HA #274 told CNA #133 that Resident #45 was not very responsive that morning. Interview on 04/28/25 at 12:08 P.M. with LPN #114 confirmed she received report from HA #274 regarding Resident #45 and confirmed HA #274 had completed providing care for Resident #45 at the time of the report (11:06 A.M.). LPN #114 further stated HA #274 asked LPN #114 to have the facility CNA arouse Resident #45 and attempt to feed her when the noon meal tray arrived. LPN #114 stated she advised CNA #133 of the request. Interview on 04/30/25 at 3:56 P.M. with Resident #45's daughter revealed Resident #45's daughter did not want Resident #45 awoken for meals. However, Resident #45's daughter stated she would like staff to offer each meal. Follow-up interview on 05/01/25 at 11:17 A.M. with CNA #133 revealed LPN #114 did not tell her to offer the meal tray to Resident #45 on 04/28/25. Review of the policy titled Assistance with Meals, revised 03/2022, revealed facility staff will serve resident trays and will help residents who require assistance with eating.

Based on observation, record review, and resident and staff interview, the facility failed to ensure wound treatments were completed per physician order. This affected one (#13) of two residents reviewed for wounds. The facility census was 70. Findings include: Review of the medical record for Resident #13 revealed an admission date of 06/13/23 with diagnoses including peripheral vascular disease and type II diabetes mellitus. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/01/25, revealed Resident #13 had intact cognition. Review of the physician order initiated 04/12/25 revealed Resident #13 received betadine to the right great toe three times daily. Review of the Treatment Administration Record (TAR) dated April 2025 revealed Resident #13's right great toe treatment was provided once daily between 04/12/25 and 04/28/25. Review of the Weekly Wound & Skin Assessment Documentation revealed Resident #13's wound was identified 04/12/25 and initially assessed on 04/15/25. Weekly skin assessments, with measurements and description, revealed the wound was decreasing in size and the skin was pink and wound edges were intact. Measurements completed 04/29/25 revealed the wound was 1.5 centimeters (cm) in length, 2.4 cm in width, and 0.1 cm in depth. Interview on 04/28/25 at 10:47 A.M. with Resident #13 stated he had a sore on his right toe and he was supposed to receive daily treatment with a cream, but not a bandage. Resident #13 stated he had not received care for his toe yet that morning. Interview on 04/29/25 at 1:10 P.M. with Registered Nurse (RN) #126 confirmed Resident #13's right great toe treatment order indicated it should be completed three times daily, but was only scheduled once daily. RN #126 stated the wound looked like dry skin, and was improving. Interview on 04/29/25 at 2:00 P.M. with RN #182, who completed weekly wound care assessments, stated Resident #13's wound was considered an abrasion. Concurrent observation of Resident #13's right great toe revealed pink granulation tissue surrounded by intact skin. RN #182 stated the wound was improving. Follow-up interview and observation on 05/01/25 at 12:44 P.M. with RN #182 of Resident #13's right great toe revealed the wound bed had dark red granulation, was blanchable, had good blood flow and the surrounding tissue was pink with a healthy appearance. RN #182 further confirmed Resident #13's treatments were not completed three times daily as ordered between 04/12/25 and 04/29/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interview, the facility failed to ensure medications were not left at the bedside. This affected one resident (#50) of four residents reviewed for medication administration. The facility census was 70. Findings include: Record review for Resident #50 revealed admission date of 04/01/25 with diagnoses including fracture of right fibula, osteoporosis of left foot and ankle, effusion of right ankle, anxiety, and major depression. There was no self-administration of medication assessment. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively intact. Observation on 04/29/25 at 7:24 A.M. revealed Resident #50's was lying in her bed watching television with a bedside tray at her side. There were several unidentified medications in a small plastic medication cup placed on Resident #50's bedside tray. When Resident #50 was asked about the pills, Resident #50 did not respond, but picked them up and spilled the pills on her bed and then started to take medication one at time. Interview on 04/29/24 at 7:47 A.M. with Resident #50 stated she saw a nurse place medications on bedside tray and walk away. Resident #50 stated she liked to take her time taking her pills sometimes because there was a big pill in there in the morning and she chokes. Interview on 04/29/24 at 7:47 A.M. with Registered Nurse (RN) #137 verified she left Resident #50's morning medication on Resident #50's bedside tray and verified she should not have done that. However, RN #137 stated she normally does set her medications on her bedside tray for her to take them when she wakes up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the activity calendar, record review, resident and staff interview, and policy review, the facility failed to offer a variety of activities to the residents which meet the resident's needs and preferences. This affected five (#18, #38, #43, #56, and #63) of five residents reviewed for activities. The facility identified 34 residents who regularly attended activities. The facility census was 70. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 06/24/24 with diagnoses including congestive heart failure, sciatica right side, chronic kidney disease, and weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had preferences that were very important to the resident which included having books, newspapers, and magazines to read, listen to music she likes, keep up with the news, do things with groups of people, do favorite activities, and participate in religious services or practices. The quarterly MDS assessment dated [DATE] revealed Resident #18 was cognitively intact. Review of the Activity Participation Quarterly assessment dated [DATE] revealed Resident #18 previously stated she never felt socially isolated and currently continues to never feel socially isolated. Activities will encourage time spent outside of room with others. Activities will monitor activity levels and make changes as needed. Review of the care plan dated 02/12/25 revealed Resident #18 was pleasant and cooperative. Alert and oriented times three. Resident #18 did not want to participate in activities. Resident #18 never feels socially isolated. Interventions included activities will monitor and encourage her current activity level. Activities will continue to encourage daily self-initiated activities and current therapy goals to return home. The Activity Participation Quarterly assessment dated [DATE] revealed Resident #18 previously stated she never felt socially isolated and currently continues to never feel socially isolated. Activities will encourage time spent outside of room with others. Activities will monitor activity levels and make changes as needed. Interview on 04/30/25 at 1:32 P.M. with Resident #18 revealed the resident did not go to any activities. Resident #18 stated she does like to go outside when it was nice. Resident #18 stated she likes music type activities. Resident #18 verified the facility did not offer any activities in the evening. Resident #18 verified they offer two activities a day according to the activity calendar. Resident stated she plays cards on her I-pad in her room and watches her television shows in the evening. 2. Review of the medical record for Resident #38 revealed an admission date of 04/09/25 with diagnoses including spinal stenosis lumbar region, wedge compression fracture, dementia, anxiety, depression, hallucinations, and delusional disorders. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact. Preferences which were very important to the resident included listening to music they like, keeping up with the news, doing things with groups of people, doing favorite activities, and going outside to get fresh air when the weather is good. Review of the care plan dated 04/09/25 revealed Resident #38 was pleasant and cooperative. Resident #38 did not want to participate in activities. Resident's goal was to return to Assisted Living. Interventions included activities will ensure the resident has a positive rehabilitation experience. Activities will encourage daily self-initiated activities. Activities will monitor and encourage her current activity level. Activities will continue to encourage daily self-initiated activities. Interview on 04/30/25 at 2:15 P.M. with Resident #38 revealed the resident came to rehab from the assisted living part of the facility. Resident #38 stated they had not received an activity calendar. Resident #38 stated that no one from activities comes into her room to tell her about what activities were going on. The family member in room at the time confirmed the resident had no calendar for activities. 3. Review of the medical record for Resident #43 revealed admission date of 02/09/25 with diagnoses including osteoporosis without current pathological fracture and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively intact. Preferences which were very important to the resident included having books, magazines, and newspapers to read, do things with groups of people, do favorite activities, and go outside to get fresh air when the weather is good. Observation on 04/28/25 at 10:17 A.M. of the activity calendar posted on the resident's bathroom door revealed only two activities scheduled for the day. One-on-one visits at 10:00 A.M. and Bingo at 2:00 P.M. There were only two activities scheduled on most weekdays with one of the activities being one-on-one visits at 10:00 A.M. and another activity at 2:00 P.M. One activity was scheduled for Saturdays and Sundays. Interview on 04/29/25 at 11:58 A.M. with Resident #43 revealed the resident stated they did not go to activities. Resident #43 denied any activities staff coming to her room for any activity. Resident #43 denied any activity staff asking her to go to an activity. 4. Review of the medical record for Resident #56 revealed an admission date of 02/22/24 with diagnoses including fracture of lower end of right tibia, displaced fracture of lateral malleolus of right fibula, generalized anxiety disorder, foot drop right foot (11/26/24), and major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed preferences that were very important for Resident #65 included doing favorite activities. The quarterly MDS assessment dated [DATE] revealed Resident #65 was cognitively intact. Review of the care plan dated 03/31/25 revealed Resident #56 was alert and oriented times three. Resident #56 prefers to structure day independently. Resident #56 continues to refuse out of room activities. Interventions included activities will encourage more time out of room daily. Activities will continue to encourage any activity involvement too. Activities will continue to encourage self-initiated activities as well as some out-of-room activities. Review of Activity Participation Quarterly assessment dated [DATE] revealed Resident #45 never felt socially isolated. Activities will encourage the resident to participate in activities they were interested in. Activities will offer assistance to and from activities. Activities will monitor the residents' activity levels for social isolation. Interview on 04/28/25 at 10:59 A.M. with Resident #56 revealed the resident did not feel the facility has enough activities and activities that they were interested in. 5. Review of the medical record revealed Resident #63 was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was cognitively intact. Preferences that were very important to Resident #63 included going outside when the weather is good, and participating in religious services or practices. Review of the care plan dated 04/21/25 revealed Resident #63 was pleasant and cooperative. Resident #63 was alert and oriented times three. Her goal was to return home. Resident #63 stated he often feels socially isolated. Interventions included activities will begin one-on-one support three times weekly to offer extra support and sensory stimulation. Activities will encourage more time out of her room either around others in a social environment or at activities large or small group as appropriate for her. Activities will support her goals to return home. Review of the Activity Participation Note dated 04/21/25 revealed Resident #63 was admitted facility on 04/18/25 and activities will support her goals. Interview on 04/30/25 at 2:20 P.M. with Resident #63 revealed the resident stated that they have not received an activity calendar and no one from activities lets them know about activities or offered to go to an activity. Observation on 04/30/25 at 1:50 P.M. of the activities room revealed no residents in the room. The 2:00 P.M. activity scheduled for that day (04/30/25) revealed it was Can It In the activity room. At 1:54 P.M., activities staff were observed wheeling one resident into the activity room. At 2:08 P.M., two residents observed in the activity room doing the activity. Interview on 04/30/25 at 2:45 P.M. with Activities Director (AD #269) revealed they had been at facility for 26 years. AD #269 verified they only hold the two activities each day normally. AD #269 stated that since COVID, the activity staff has seen a lower number of residents attending activities. AD #269 stated the one-on-one visits were for the residents who state they were always or almost always feeling socially isolated. AD #269 verified they only have one activity on the weekends. Review of the policy titled Activity Programs, revised June 2018, revealed the activities program is provided to support the well-being of residents and to encourage both independence and community interaction. The activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Activities are scheduled seven days a week and residents are given the opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the program. Individual and group activities are provided that reflect the schedules, choices, and rights of the residents, are offered at hours convenient to the residents, including weekends, evenings, and holidays, and reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents.

Based on review of the nursing staffing schedules and staff interviews, the facility failed to have Registered Nurse coverage for eight consecutive hours on two days as required. This had the potential to affect all 69 residents residing in the facility. Facility census was 69. Findings include: Review of the nursing staffing schedules dated 11/14/23 to 11/20/23 revealed there was no Registered Nurse present in the facility on 11/18/23 or 11/19/23. Interview on 12/06/23 at 11:06 A.M. with Director of Nursing revealed the facility did not have Registered Nurse coverage in the facility as required on 11/18/23 or on 11/19/23. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, resident and staff interview, the facility failed to ensure residents had access to the call light. This affected two residents (#18 and #52) and had the potential to affect all 57 residents residing in the facility. Findings include: Observation on 10/03/22 at 10:37 A.M. revealed Resident #18's call light was hanging from the bed, out of her reach. Interview at the time with Resident #18 revealed she could not find her call light and would like to be repositioned. Interview on 10/03/22 at 10:45 A.M., with the Administrator verified the call light was not within her reach and he ensured it was clipped to her bed sheet. Observation on 10/04/22 at 1:37 P.M. revealed Resident #52's call light was not within her reach. Interview at the time with Licensed Practical Nurse #117 verified the call light not within Resident #52's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. There was no further documentation of skin conditions. Review of the progress notes of the admission skin assessment for Resident #259 revealed her buttocks was red and non-blanchable, the left great toe wound measured 3.5 centimeters (cm) by 4.5 cm by unable to determine the depth due to black eschar tissue, a second left toe measurement of 2.5 cm by 2.0 cm by unable to determine the depth due to black eschar tissue, the third left toe measurement of 1.0 cm by 1.3 cm by unable to determine the depth due to black eschar tissue, the right great toe measurement of 2.0 cm by 1.5 cm scarring, the second right toe amputation with black tissue scarring, three scabs noted to the third right toe, the fifth right toe amputation noted, and bilateral heels were soft and mushy. It was also documented Resident #259 was followed by the physician for bilateral feet due to the peripheral vascular disease and the next visit was scheduled 09/29/22. Interview on 10/11/22 at 1:51 P.M., with the Licensed Practical Nurse (LPN) #252 verified the only documentation of the skin concerns on Resident #259's admission MDS were of three stage one pressure ulcers. Based on medical record review and staff interview, the facility failed to ensure accuracy of the minimum data assessment. This affected two residents (#16 and #259) out 16 residents reviewed. The facility census was 57. Findings include: 1. Review of the medical record of Resident #16 revealed an admission date of 07/11/22. Diagnoses included orthopedic aftercare, fracture of unspecified part of neck of left femur (07/06/22), cognitive communication deficit, difficulty in walking, type II diabetes mellitus without complications, major depressive disorder, anemia and sleep apnea. Review of the admission Minimum data set (MDS) assessment dated [DATE] revealed Resident #16 had moderate impaired cognition. The resident required extensive assistance of two staff for bed mobility, and extensive assistance of one staff for transfers, walking in the room, for locomotion on unit, dressing, toilet use and for personal hygiene. Resident #16 required limited assistance of one staff for locomotion in the corridor. The assessment indicated the resident had fallen in the month prior to admission but indicated no fracture in the six months prior to admission. Interview on 10/06/22 at 1:30 P.M. with Licensed Practical Nurse #159 provided verification of the inaccuracy of the MDS assessment with no fracture identified upon admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the baseline care plan was accurately completed. This affected one resident (#259) out of 24 resident reviewed. The facility census was 57. Finding include: Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. There was no further documentation of skin conditions. Review of the progress notes of the admission skin assessment for Resident #259 revealed her buttocks was red and non-blanchable, the left great toe wound measured 3.5 centimeters (cm) by 4.5 cm by unable to determine the depth due to black eschar tissue, a second left toe measurement of 2.5 cm by 2.0 cm by unable to determine the depth due to black eschar tissue, the third left toe measurement of 1.0 cm by 1.3 cm by unable to determine the depth due to black eschar tissue, the right great toe measurement of 2.0 cm by 1.5 cm scarring, the second right toe amputation with black tissue scarring, three scabs noted to the third right toe, the fifth right toe amputation noted, and bilateral heels were soft and mushy. It was also documented Resident #259 was followed by the physician for bilateral feet due to the peripheral vascular disease and the next visit was scheduled 09/29/22. Review of the baseline care plan for Resident #259 revealed only a potential for alteration in skin integrity related to debility and decreased self-mobility. Interventions included to encourage food and fluid, keep the skin dry and clean and turn and reposition frequently. Interview on 10/11/22 at 1:51 P.M., with the Licensed Practical Nurse (LPN) #252 verified there was no care plan for Resident #259's actual wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff and resident interview, the facility failed to ensure the care plan was accurately developed and implemented. This affected two residents (#259 and #07) out of 24 residents reviewed. The facility census was 57. 1. Review of the medical record for Resident #07 revealed an admission date of 06/10/19. Diagnoses included congested heart failure (CHF), hypertension (HTN), and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #07 had intact cognition and required extensive one person assistance for bed mobility, transfers, and toilet use. Review of the care plan for potential for impairment of skin integrity listed betadine to the right ear for proactive skin health and scabs to bilateral feet. Interventions included assess areas over bony prominences, encourage to remove shoes when resting in the chair and betadine as per order and monitor for effectiveness (03/30/22). Review of subsequent care plans dated 05/07/22 and 07/14/22 revealed no change regarding the intervention for the right ear to apply betadine and monitor for its effectiveness. Observation on 10/04/22 at 2:31 P.M. of Resident #07's right ear revealed an approximate one inch grey colored dry scabbing area to the superior helix (the top of the ear). Interview at the time of the observation revealed Resident #07 said the scab had been on her ear for some time. Review of the weekly skin assessment dated [DATE] for Resident #07 revealed a reddened area to the right ear. Further skin assessment revealed no new areas however no further assessments of the area were noted aside from on 07/27/22 which documented scab continued, no signs or symptoms of infection and resident denied pain; on 08/02/22 two small scabs noted no signs or symptoms of infection, the resident denied pain and the area showed signs of healing. Observation and interview on 10/06/22 at 2:20 P.M. with the Director of Nursing (DON) of Resident #07's ear revealed she believed the scab may be larger than she remembered. Interview on 10/11/22 at 1:51 P.M., with the Licensed Practical Nurse (LPN) #252 regarding the care plan for Resident #07's right ear revealed she had not assessed the resident or completed the previous care plans. She verified the wound was on going from the original date of 03/30/22 with no documentation the effectiveness of the intervention had been monitored nor had it been updated. 2. Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. There was no further documentation of skin conditions. Review of the progress notes of the admission skin assessment for Resident #259 revealed her buttocks was red and non-blanchable, the left great toe wound measured 3.5 centimeters (cm) by 4.5 cm by unable to determine the depth due to black eschar tissue, a second left toe measurement of 2.5 cm by 2.0 cm by unable to determine the depth due to black eschar tissue, the third left toe measurement of 1.0 cm by 1.3 cm by unable to determine the depth due to black eschar tissue, the right great toe measurement of 2.0 cm by 1.5 cm scarring, the second right toe amputation with black tissue scarring, three scabs noted to the third right toe, the fifth right toe amputation noted, and bilateral heels were soft and mushy. It was also documented Resident #259 was followed by the physician for bilateral feet due to the peripheral vascular disease and the next visit was scheduled 09/29/22. Review of the baseline care plan for Resident #259 revealed only a potential for alteration in skin integrity related to debility and decreased self-mobility. Interventions included to encourage food and fluid, keep the skin dry and clean and turn and reposition frequently. Review of the comprehensive care plan for Resident #259 revealed an added focus for pressure ulcer or potential for pressure ulcer related to decreased mobility and extensive assistance with bed mobility with interventions which included but were not limited to, bilateral heel boots on at all times while in bed, skin prep to bilateral heels and buttocks and administer treatments as ordered and monitor for effectiveness. No additional focus was made for the actual non pressure wounds present on admission. Interview on 10/11/22 at 1:51 P.M., with the LPN #252 verified there was no care plan for Resident #259's actual non pressure wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #07 revealed an admission date of 06/10/19. Diagnoses included congested heart failure (CHF), hypertension (HTN), and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #07 had intact cognition and required extensive one person assistance for bed mobility, transfers, and toilet use. Review of the care plan for potential for impairment of skin integrity listed betadine to the right ear for proactive skin health and scabs to bilateral feet. Interventions included assess areas over bony prominences, encourage to remove shoes when resting in the chair and betadine as per order and monitor for effectiveness (03/30/22). Review of subsequent care plans dated 05/07/22 and 07/14/22 revealed no change regarding the intervention for the right ear to apply betadine and monitor for its effectiveness. Observation on 10/04/22 at 2:31 P.M. of Resident #07's right ear revealed an approximate one inch grey colored dry scabbing area to the superior helix (the top of the ear). Interview at the time of the observation revealed Resident #07 said the scab had been on her ear for some time. Interview on 10/04/22 at 3:01 P.M., with the Licensed Practical Nurse (LPN) #113 revealed Resident #07's right ear wound began as a scratch and they had applied triple antibiotic ointment to it, then the physician decided it needed to dry and changed the order to betadine in May 2022. The scab then falls off and reappears, and she was unsure if a physician has looked at it. Review of the weekly skin assessment dated [DATE] for Resident #07 revealed a reddened area to the right ear. Further skin assessment revealed no new areas however no further assessments of the area were noted aside from on 07/27/22 which documented scab continued, no signs or symptoms of infection and resident denied pain; on 08/02/22 two small scabs noted no signs or symptoms of infection, the resident denied pain and the area showed signs of healing. Observation and interview on 10/06/22 at 2:20 P.M. with the Director of Nursing (DON) of Resident #07's ear revealed she believed the scab may be larger than she remembered. Interview on 10/11/22 at 1:51 P.M., with the Licensed Practical Nurse (LPN) #252 regarding the care plan for Resident #07's right ear revealed she had not assessed the resident or completed the previous care plans. She verified the wound was on going from the original date of 03/30/22 with no documentation the effectiveness of the intervention had been monitored nor had it been updated. 3. Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. There was no further documentation of skin conditions. Review of the progress notes of the admission skin assessment for Resident #259 revealed her buttocks was red and non-blanchable, the left great toe wound measured 3.5 centimeters (cm) by 4.5 cm by unable to determine the depth due to black eschar tissue, a second left toe measurement of 2.5 cm by 2.0 cm by unable to determine the depth due to black eschar tissue, the third left toe measurement of 1.0 cm by 1.3 cm by unable to determine the depth due to black eschar tissue, the right great toe measurement of 2.0 cm by 1.5 cm scarring, the second right toe amputation with black tissue scarring, three scabs noted to the third right toe, the fifth right toe amputation noted, and bilateral heels were soft and mushy. It was also documented Resident #259 was followed by the physician for bilateral feet due to the peripheral vascular disease and the next visit was scheduled 09/29/22. Review of the baseline care plan for Resident #259 revealed only a potential for alteration in skin integrity related to debility and decreased self-mobility. Interventions included to encourage food and fluid, keep the skin dry and clean and turn and reposition frequently. Review of the comprehensive care plan for Resident #259 revealed an added focus for pressure ulcer or potential for pressure ulcer related to decreased mobility and extensive assistance with bed mobility with interventions which included but were not limited to, bilateral heel boots on at all times while in bed, skin prep to bilateral heels and buttocks and administer treatments as ordered and monitor for effectiveness. No additional focus was made for the actual non pressure wounds present on admission. Interview on 10/11/22 at 1:51 P.M., with the LPN #252 verified there was no care plan for Resident #259's actual non pressure wounds. Based on medical record review, observation and staff and resident interview, the facility failed to ensure interventions were reviewed and revised after a fall. This affected one resident (#16) out of two residents reviewed for falls. In addition, the facility failed to ensure resident skin care plans were reassessed, reviewed, and revised This affected two (#259 and #07) of three residents reviewed for skin alterations. The facility census was 57. Findings include: 1. Review of the medical record of Resident #16 revealed an admission date of 07/11/22. Diagnoses included orthopedic aftercare, fracture of unspecified part of neck of left femur, cognitive communication deficit, difficulty in walking, type II diabetes mellitus without complications, major depressive disorder, anemia, and sleep apnea. Review of the admission Minimum data set (MDS) assessment dated [DATE] revealed Resident #16 had moderate impaired cognition. The resident required extensive assistance of two staff for bed mobility, and extensive assistance of one staff for transfers, walking in the room, locomotion on the unit, dressing, toilet use and for personal hygiene. Resident #16 required limited assistance of one staff for locomotion in the corridor. The assessment indicated she had fallen in the month prior to admission but indicated no fractures in the six months prior to admission. Review of the fall risk assessment dated [DATE] revealed Resident #16 was a low risk for falls however, all sections of the assessment were not completed as the section titled Systolic Blood Pressure was unmarked. Fall risk assessments dated 08/10/22 and 09/19/22 revealed Resident #16 was a high risk for falls. Review of the initial care plan dated 07/12/22 revealed a potential for/at risk for injuries/falls related to unsteadiness with various transfers, and a fall history. No interventions were initiated until 07/22/22, and the intervention was to instruct the resident not to get up without assistance. Interventions initiated on 07/26/22 included half assist rail/transfer enabler to both sides of the bed to enhance independent bed mobility, assist in positioning for comfort as needed, anticipate needs as able, maintain uncluttered environment, monitor safety/preventative devices for application, instruct on the use of adaptive equipment as needed, observe for signs and symptoms of pain, medicate per physician orders, pharmacy medication review as needed, refer to therapy services as needed, physical and occupational therapy evaluation and treat as ordered or as needed. No new interventions were added after the fall on 08/04/22 or on 08/08/22. Interview on 10/05/22 at 2:30 P.M. with Licensed Practical Nurse (LPN) #159 provided verification of the lack of interventions for fall precautions in the initial care plan, and no new interventions following falls on 08/04/22 or 08/08/22. Review of the progress note dated 07/22/22 timed 9:34 P.M. revealed a temporary nurse (agency) was alerted at 8:40 P.M. Resident #16 was on the floor, face down. Resident stated she hit her head, a hematoma was noted on her left face. The resident complained of pain in her left wrist upon palpation and movement. She was sent to the emergency room and returned approximately three hours later with a diagnosis of a left wrist fracture. Review of the emergency department notes dated 07/22/22 revealed a splint was applied to the left wrist. Review of the progress note dated 07/23/22 at 12:47 A.M. revealed Resident #16 returned to the facility with a splint to the left wrist. Review of the progress note dated 08/04/22 at 10:55 A.M. revealed Resident #16 was found on the floor on her belly with her left arm tucked under her body and her left leg slightly under her right leg. The left side of her head was lying flat on the floor. She had non-skid socks on both feet and the call light was attached to the bed rail. Resident #16 was complaining of pain to the left side of her head and the left hip and was asked to remain still until the emergency squad arrived. No visual injuries were observed. Resident #16 returned from the emergency department as 2:15 P.M. with diagnosis of contusion to the knee and the hip. Review of the progress note dated 08/08/22 at 3:49 A.M. revealed Resident #16 was found on the floor, sitting next to her bed with her left leg crossed under her right leg. She had complaints of pain to the left leg. Resident was sent to the emergency department. A follow-up progress note dated 08/08/22 at 6:54 A.M. revealed the emergency department called to inform facility Resident #16 was being admitted with a left lower femur fracture and surgical repair would be initiated. Interview on 10/06/22 at 1:45 P.M., with Licensed Practical Nurse #159 verified the care plan had not been updated timely after a fall on 07/22/22, 08/04/22, and on 08/08/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #07 revealed an admission date of 06/10/19. Diagnoses included congested heart failure (CHF), hypertension (HTN), and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #07 had intact cognition and required extensive one person assistance for bed mobility, transfers, and toilet use. Review of the care plan for potential for impairment of skin integrity listed betadine to the right ear for proactive skin health and scabs to bilateral feet. Interventions included assess areas over bony prominences, encourage to remove shoes when resting in the chair and betadine as per order and monitor for effectiveness (03/30/22). Review of subsequent care plans dated 05/07/22 and 07/14/22 revealed no change regarding the intervention for the right ear to apply betadine and monitor for its effectiveness. Observation and interview on 10/06/22 at 2:20 P.M., with the Director of Nursing (DON) of Resident #07's ear revealed the DON believed the scab may be larger than she remembered. She further shared Resident #07 had been seen by the wound nurse for her feet and was unsure if she saw her for her ear, or if any follow-up assessments of the area were completed by the nurses of the area. Resident #07 said she had not been seen by the wound nurse for her chronic right ear skin condition. Review of the physician orders for Resident #07 revealed weekly skin assessments were ordered with a start date of 11/08/21. Review of the audiology appointment dated 08/30/22 for Resident #7 revealed the physician addressed the scab to the right ear as being present on the 04/2022 appointment and recommended a referral to a dermatologist due to the chronic non-healing nature of the scab. Interview on 10/11/22 at 10:20 A.M., the DON revealed she was unaware of a referral to the dermatologist, and later set the appointment for 12/20/22. She then acknowledged staff had been documenting no new areas on the skin assessments and not assessing the current wound to the right ear, and it would be her expectation to do so. 3. Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. Review of the physician orders for Resident #259 revealed weekly skin assessments were ordered with a start date of 09/26/22. Review of the care plan for Resident #259 revealed pressure ulcer or potential for pressure ulcer related to decreased mobility and extensive assistance with bed mobility with interventions including bilateral heel boots on at all times while in bed, skin prep to bilateral heels and buttocks and administer treatments as ordered and monitor for effectiveness. Interview on 10/11/22 at 11:05 A.M., with the DON revealed Resident #259 was admitted to the facility with documented wounds, followed by an outside physician and had an appointment previously scheduled for 09/29/22. However, due to the steady decline of Resident #259, her family opted for hospice care. She was admitted to hospice on 10/1/22 and the family no longer wanted the resident followed by the outside physician and opted for the facility wound nurse to follow the resident. The DON further shared the wound nurse saw residents weekly on Thursdays and was unable to verify if Resident #259 had been seen yet. The DON also verified there had not been any further assessments or measurements of the wounds since admission. Record review of the policy titled Managing Skin Integrity, undated revealed nursing, in collaboration with the interdisciplinary team, will assess and manage skin integrity for all residents throughout the stay and provide close monitoring of the response to treatment and a referral to additional resources when indicated. The plan of care will be developed to consider the current state of skin integrity. Based on medical record review, staff, resident, and hospital staff interview, observation, and policy review, the facility failed to ensure a resident was prepared for a colonoscopy and endoscopy as scheduled. This affected one resident (#26) out of one resident reviewed for medical appointments. In addition, the facility failed to ensure existing skin conditions were assessed, measured and referrals were made. This affected two (#07 and #259) out of 24 Residents reviewed. The facility census was 57. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 06/24/22. Diagnoses included muscle weakness, difficulty walking, major depression, diabetes mellitus type II, essential hypertension, chronic kidney disease, and unspecified intellectual disabilities. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was assessed with intact cognition. Review of a physician order dated 08/12/22 revealed Resident #26 was scheduled for an appointment with a physician for a possible colonoscopy (examination of the large bowel and the distal part of the small bowel with a camera on a flexible tube passed through the anus) due to anemia. Review of a physician visit dated 08/12/22 revealed Resident #26 visited with the physician to discuss a colonoscopy. Resident #26 was assessed during the physician visit to have iron deficiency anemia and given the nature of the anemia the physician would perform a colonoscopy and esophagogastroduodenoscopy (EGD, which is using a flexible camera to view the upper part of the gastrointestinal tract). The procedure was explained in detail per the physician visit note and orders were placed for diagnostic colonoscopy and diagnostic upper endoscopy. Review of a monthly physician visit note dated 09/06/22 revealed the practitioner noted in Resident #26's assessment and plan that Resident #26 was getting scopes due to anemia. Review of a physician order dated 09/26/22 revealed Resident #26 had an appointment for the colonoscopy and upper endoscopy on 09/26/22 at 1:00 P.M. Further review of the physician orders between 09/25/22 and 09/26/22 revealed no orders for Resident #26 to prepare for the colonoscopy or upper endoscopy. There was no documentation in the medical record of Resident #26's colonoscopy or upper endoscopy being completed on 09/26/22 as scheduled. Review of a nursing progress note dated 09/27/22 revealed Resident #26's colonoscopy and upper endoscopy were rescheduled for 11/14/22. Interview on 10/06/22 at 12:46 P.M. with Licensed Practical Nurse (LPN) #118 stated Resident #26 received orders for the colonoscopy and upper endoscopy when she was on the rehabilitation hall of the facility and was later transferred to the long-term care hall were LPN #118 worked. LPN #118 stated Resident #26 before coming to the long-term care hall Resident #26 never had orders for preparation for the colonoscopy and upper endoscopy and no one caught it. LPN #118 stated when Resident #26 left for her appointment on 09/26/22 no one knew it was for an actual procedure and verified Resident #26 was not properly prepared for the colonoscopy and upper endoscopy, so it was not done on the scheduled day and needed to be rescheduled. A telephone interview was completed on 10/06/22 at 12:55 P.M. with Hospital Medical Records Clerk #163. Hospital Medical Records Clerk #163 verified Resident #26 was scheduled for a colonoscopy and upper endoscopy on 09/26/22 but the procedures were canceled due to Resident #26 not being prepared for them. Hospital Medical Records Clerk #163 could not provide any additional information related to Resident #26's appointment on 09/26/22. Hospital Medical Records Clerk #163 verified Resident #26's procedures were rescheduled for 11/14/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interview, the facility failed to ensure pressure ulcer care planned and ordered interventions were implemented. This affected one resident (#259) out of 24 residents reviewed. The facility census was 57. Findings include: Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. There was no further documentation of skin conditions. Review of the progress notes of the admission skin assessment for Resident #259 revealed her buttocks was red and non-blanchable, the left great toe wound measured 3.5 centimeters (cm) by 4.5 cm by unable to determine the depth due to black eschar tissue, a second left toe measurement of 2.5 cm by 2.0 cm by unable to determine the depth due to black eschar tissue, the third left toe measurement of 1.0 cm by 1.3 cm by unable to determine the depth due to black eschar tissue, the right great toe measurement of 2.0 cm by 1.5 cm scarring, the second right toe amputation with black tissue scarring, three scabs noted to the third right toe, the fifth right toe amputation noted, and bilateral heels were soft and mushy. It was also documented Resident #259 was followed by the physician for bilateral feet due to the peripheral vascular disease and the next visit was scheduled 09/29/22. Review of the comprehensive care plan for Resident #259 revealed an added focus for pressure ulcer or potential for pressure ulcer related to decreased mobility and extensive assistance with bed mobility with interventions which included but were not limited to, bilateral heel boots on at all times while in bed, skin prep to bilateral heels and buttocks and administer treatments as ordered and monitor for effectiveness. No additional focus was made for the actual non pressure wounds present on admission. Review of the physician orders for Resident #259 revealed an order for bilateral heel protectors on at all times while in bed, with a start date of 09/29/22. Observation on 10/04/22 at 9:05 A.M. revealed Resident #259 was lying in bed with her left heel boot off. At the time of the observation the State Tested Nursing Assistant (STNA) #125 verified the boot was off and retrieved the boot from the chair beside the bed and applied it to Resident #259's left foot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure residents with orders for as needed psychotropic medications had not extended the order beyond 14 days without physician rationale. This affected one resident (#26) out of five residents reviewed for unnecessary medications. The facility census was 57. Findings include: Review of Resident #26's medical record revealed an admission date of 06/24/22. Diagnoses included muscle weakness, difficulty walking, major depression, diabetes mellitus type II, essential hypertension, chronic kidney disease, and unspecified intellectual disabilities. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was assessed with intact cognition. Review of a nursing communication document dated 07/22/22 revealed Resident #26 had increased anxiety with behaviors from being in COVID-19 quarantine as evidence by hitting bed rails, yelling out, refusing therapy, and attempting to harm the therapy staff. Review of a physician order dated 07/22/22 revealed Resident #26 was ordered the anti-anxiety medication Ativan 0.5 milligrams (mg) by mouth every six hours as needed. Further review of the physician order gave no indication of a stop date or rationale for continued use beyond 14 days. Review of the July and August 2022 medication administration records (MARs) revealed Resident #26 received as needed Ativan on 07/27/22, 08/04/22, 08/05/22, and 08/11/22 with each dose documented as effective. Review of the September and October 2022 MARs revealed Resident #26 received no doses of Ativan in either month. Review of a physician order dated 10/05/22 revealed Resident #26's as needed Ativan was discontinued. Review of a nursing progress note dated 10/05/22 revealed Resident #26's order for as needed Ativan was discontinued due to non-use. Interview on 10/06/22 at 2:55 P.M., with the Director of Nursing (DON) #100 verified Resident #26 was ordered as needed Ativan on 07/22/22 and the order continued beyond 14 days without a documented rationale for continued use. Review of the facility policy titled Antipsychotic Medication Use, revised December 2016 revealed the need to continue as needed orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the as needed order will be indicated in the order.

Based on observation, medical record review, staff interview, and policy review the facility failed to ensure medications were administered without error. There were three errors out of 34 opportunities for a calculated medication error rate of 8.82 percent. This affected one resident (#03) out of three residents observed for medication administration. The facility census was 57. Findings include: Observation on 10/05/22 at 7:44 A.M. with Licensed Practical Nurse (LPN) #110 revealed he prepared and administered 12 medications for Resident #03, which included isosorbide mononitrate (anti angina medication) extended release tablet 30 milligrams (mg), Lasix (a diuretic medication) 40 mg, and Xarelto (an anticoagulant medication) tablet 15 mg. Review of the current physician orders revealed there was no order for the isosorbide mononitrate, Lasix, or Xarelto. The medications had been discontinued on 07/24/22. Interview on 10/05/22 at 9:14 A.M., with LPN #110 verified the medication error. LPN #110 added he normally removes those three medications when administering to Resident #03, but forgot to remove them today. Review of the facility policy titled Administering Medications, dated 12/2012 revealed medications must be administered as ordered. The individual administering must check the label three times to verify the right resident, right medication, right dosage, right time and right method before giving the medication.

Based on observation, staff and resident interview, and policy review, the facility failed to ensure infection control procedures were implemented. This affected two residents (#24 and #57) out of two residents reviewed for transmission based precaution. The facility census was 57. Findings include: 1. Observation on 10/03/22 at 11:55 A.M. revealed State Tested Nursing Assistant (STNA) #124 entering Resident #24's room after donning a cloth gown that had been hanging on the outside of his door, an N95 mask, with only one strap that had been stored in a cloth pocket of a hanging organizer, and gloves. STNA #124 entered the room with a lunch tray with Styrofoam containers, and exited a short time later. STNA #124 removed the gown, inside out, and hung it back on the hook on the outside of the door, removed the N95 mask and replaced it in the pocket of the organizer and proceeded down hall. The gown was touching items in a yellow pocket organizer, hanging slightly to the right of the gown. No disinfectant wipes were observed in the organizer. Interview at 11:57 A.M., with the STNA #124 verified she had not donned any eye protection, performed hand hygiene, and the N95 had broken one strap off. She added she wore the same gown all day long, turning it right side out before donning it and not performing hand hygiene after doing so. She added Resident #24 had been in isolation for a long time related to COVID but was supposed to come out tomorrow (10/04/22). Observation on 10/04/22 at 7:00 A.M. revealed a green cloth gown hanging on the outside of door of Resident #24's room, and the resident was in isolation for COVID. The yellow pocket organizer was hanging slightly to the right of the gown and the gown was touching the organizer. 2. Observation and interview on 10/04/22 at 9:45 A.M., with Licensed Practical Nurse (LPN) #117 revealed Resident #57 was in contact isolation for extended spectrum beta-lactamase (ESBL) and if not touching her or soiled clothing, there was no need for gown or gloves. Observation of the yellow pocket organizer hanging from the door of Resident #57's room revealed no gowns were present. Observation and interview on 10/04/22 at 9:50 A.M., with Resident #57 revealed she had been incontinent of urine since before breakfast and had been told she had to wait. She would not name the person who told her that. Her call light had been activated and her pants were darker between her legs where she had soiled herself. Observation and interview on 10/04/22 at 10:02 A.M. revealed STNA #128 preparing to enter the room of Resident #57, STNA #128 had on a surgical mask and gloves. The STNA #128 stated she was preparing to assist the resident with perineal care. STNA #128, when questioned about a gown, she said she did not have to wear a gown and proceeded into the room. Interview on 10/04/22 at 10:05 A.M., with LPN #158 revealed when providing direct care to Resident #57, staff should wear a gown. Review of the facility policy titled Isolation - Categories of Transmission-Based Precautions revised 01/2012, revealed when a resident is in contact isolation a disposable gown was to be worn when entering the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, policy review, the facility failed to accurately assess residents and obtain consent for assist rails/transfer enablers. This affected 10 residents (#02, #06, #10, #18, #24, #30, #34. #37, #50, and #52) and had the potential to affect all residents in the facility. The facility census was 57. Findings include: Observation on 10/04/22 at 10:20 A.M. with State Tested Nursing Assistant (STNA) #124 revealed the side rails on the beds of seven residents (#02, #06, #18, #34, #37, #50, and #52) were in the raised position and extended approximately two foot from the head board to two foot from the foot board on both sides of the bed. Interviews from 10:20 A.M. to 10:30 A.M. with Resident #10, Resident #30, and Resident #34 revealed they did not use the side rails and would like them removed. 1. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #02 had severe cognitive impairment and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #02 was not ambulatory, had no history of falls, no decrease of consciousness, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated without any indication. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown, promoting independence and sense of accomplishment and independent function. Safety risks without use included reduced bed mobility, anxiety/fear, fall from bed, and decreased functional ability. The assessment was not signed by the resident or a representative. 2. Review of the annual MDS assessment dated [DATE] revealed Resident #06 had severe cognitive impairment and required extensive assistance of one staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #06 was not ambulatory, no decrease of consciousness, had history of falls, and did have poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated without any indication. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown, promoting independence and sense of accomplishment and independent function. Safety risks without use included reduced bed mobility, anxiety/fear, fall from bed, total dependence on staff for bed mobility, and decreased functional ability. The assessment was not signed by the resident or a representative. 3. Review of the quarterly MDS assessment dated [DATE] revealed Resident #10 had intact cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #10 was not ambulatory, no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received medications that impaired safety and did not use the rails for positioning. The assessment indicated two rails were indicated without any indication. No benefit of use was indicated. Safety risks without use included anxiety/fear, and fall from the bed. The assessment was not signed by the resident or a representative 4. Review of the quarterly MDS assessment dated [DATE] revealed Resident #18 had moderate impaired cognition and required extensive assistance of one staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #18 was ambulatory, had no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated without any indication. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown, promoting independence and sense of accomplishment and independent function. Safety risks without use included reduced bed mobility, anxiety/fear, and decreased functional ability. The assessment was not signed by the resident or a representative 5. Review of the quarterly MDS assessment dated [DATE] revealed Resident #24 had moderate impaired cognition and required extensive assistance of one staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #24 was not ambulatory, no decrease of consciousness, had no history of falls, and did not have poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated one transfer enabler was indicated to enhance independent bed mobility. The benefits of use included improved independent bed mobility, promoting independence and sense of accomplishment and independent function. Safety risks without use included reduced bed mobility and decreased functional ability. The assessment was not signed by the resident or a representative. 6. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 had intact cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #30 was not ambulatory, had no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated with an indication to allow the resident to participate in turning and repositioning. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown promoting independence and sense of accomplishment and independent function. No safety risks without or with use were indicated. The assessment was not signed by the resident or a representative. 7. Review of the quarterly MDS assessment dated [DATE] revealed Resident #34 had intact cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #34 was not ambulatory, had no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated with an indication to allow resident to participate in turning and repositioning. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown, promoting independence and sense of accomplishment and independent function. No safety risks without or with use were indicated. The assessment was not signed by the resident or a representative. 8. Review of the quarterly MDS assessment dated [DATE] revealed Resident #37 had intact cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #37 was not ambulatory, had no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received no medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated with an indication to allow resident to participate in turning and repositioning. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown promoting independence and sense of accomplishment. No safety risks without or with use were indicated. The assessment was not signed by the resident or a representative. 9. Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 had intact cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #50 was not ambulatory, had no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated with no indication for use. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown, promoting independence and sense of accomplishment and independent function. Safety risks without use were reduced bed mobility, total dependence on staff for bed mobility and decreased functional ability. The assessment was not signed by the resident or a representative. 10. Review of the quarterly MDS assessment dated [DATE] revealed Resident #52 had moderate impaired cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #52 was not ambulatory, had no history of falls, no decrease of consciousness, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated to allow resident to participate with turning and repositioning. The benefits of use included improved independent bed mobility, decreased risk of sin breakdown, promoting independence and sense of accomplishment and independent function. No safety risks were indicated with or without use. The assessment was not signed by the resident or a representative. Interview on 10/05/22 at 10:00 A.M., with the Director of Nursing verified the incomplete assist rail/transfer enablers forms for the above residents. Review of the facility policy titled Bed Safety, dated 12/07 revealed resident sleeping environment shall be assessed by an interdisciplinary team, considering a resident's safety, medical conditions, comfort, and freedom of movement and will get input from resident and family. The facility shall obtain consent for the use of side rails from the resident or their representative prior to use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, policy review and review of information from on infection from McGreer's, the facility failed to timely notify the physician for a resident with a urinary tract infection (UTI). This affected one (#8) out of four residents reviewed for hospitalization. The facility census was 79. Findings included: Review of Resident #8's medical record revealed resident was admitted to facility on 04/03/2018. Diagnosis include atherosclerotic heart disease, coronary artery disease with angina, muscle weakness, type two diabetes mellitus with diabetic neuropathy, essential hypertension, hyperlipidemia, chronic obstructive pulmonary disease, diabetic chronic kidney disease, gastro esophageal reflux disease with out esophagitis, major depressive disorder, sleep apnea, retention of urine, hypothyroidism, anemia, old myocardial infraction, chronic kidney disease. Review of the Quarterly Minimum Data Sheet, (MDS) dated [DATE] revealed Resident #8 was assessed as cognitively intact with no deficits. Resident #8 was also assessed as requiring extensive assist plus two for toileting. She was also assessed as occasionally incontinent and did not have an urinary catheter during the assessment period. Review of Resident #8 comprehensive care plan documented she had recurrent UTI's with interventions including nursing staff to monitor, document, and report all signs and symptoms of UTIs to the medical doctor as needed. Record review of nursing progress notes dated on 07/27/18 revealed Resident #8 was seen by Medical Doctor, (MD) #320 on 07/27/18 and returned with Foley Catheter in place and appointment card only. The nursing progress notes indicated the facility called MD #320 office for progress notes and documentation of the appointment. Record review of nursing progress notes dated on 07/28/18 revealed facility received a call from Hospital #1 indicating MD #320 had ordered a CT of abdomen and pelvis without contrast to be completed there on 08/06/19. Record review of nursing progress notes dated on 07/30/2018 revealed a urine specimen had been ordered Microalbumin was added to the order. Record review from a urinary analysis with culture and sensitivity (U/A, C&S), laboratory result for Resident #8 revealed a final status report on 08/01/18. The U/A C&S result revealed greater than 100,000 Escherichia Coli (E. Coli). Record review of nursing progress notes dated on 08/01/18 revealed a call was placed to MD #310 office in regards to the UA results and indicated his nurse stated MD #310 would address the results that day. Record review of a nursing progress note dated 08/02/19 revealed a follow-up call was made to MD #310 indicating again the facility nursing staff was seeking a response on the UA results. MD #310's nurse indicated the doctor would address the results after he finished with his patients he was seeing in the office. Record review of MD #300 progress note dated 08/06/18 revealed Resident #8 had been seen for a monthly visit. MD #300 documented that MD #310, nephrologist, had ordered a UA on 07/30/18. MD #300 documented the U/A was greater than 100,000 E. Coli and sensitive to Cipro antibiotic. MD #300 documented Resident #8 was symptomatic with belly pain, low grade fever, and nausea. The assessment and plan revealed MD #300 was prescribing Cipro 500 milligrams (mg) two times a day for seven days to treat the UTI. Review of physician order revealed MD #300 ordered Cipro 500 mg two times a day for seven days to treat the UTI. Review of Emergency Ebox use form verified Cipro 250 mg, quantity two was taken out of inventory on 08/07/19 at 4:15 P.M.; nurses signature was not legible. Record review of Medication Administration Record, (MAR) revealed the Cipro 500 mg two times per day prescribed by MD #300 on 08/06/18 was not administered until the evening of 08/07/19. Record review of consultation dated 08/08/18 for Resident #8 with MD #310 revealed he was evaluating and treating for decreased renal function. MD #310 documented Resident # 8 had decreased renal function, a distended abdomen, nausea and a Foley catheter in place for one week. There was no documentation of the Resident # 8 being treated by MD # 300 for UTI or that he had been notified that week of the U/A C&S results. Interview on 07/09/19 at 02:33 P.M. with the Director of Nursing, (DON) verified that when C/S results are returned with more than 100,000 organisms of E-Coli what are the expectations of your nursing staff. The DON revealed the expectation is to notify the in-house physician or specialist. When the DON had been given the scenario of the specialist not returning the notification for several days. The DON revealed there is an in-house physician group at the facility three days a week and the nurse could put the results in front of them and see if the in house group would order and antibiotic. Interview via telephone on 07/09/19 at 3:54 P.M. with MD #300 and the Medical Director of the facility. MD # 300 verified it would be his expectation for the nursing staff to contact him if they could not get a response for an order from a specialist. When given the scenario of what had taken place 07/27/18 through 08/09/18 by the, MD #300 revealed it was a problem the nursing staff did not contact him sooner. MD #300 further revealed as a medical director his primary problem is the nursing staff doesn't always notify him when needed. MD #300 verified he would have treated the Resident #8 sooner if he would have been notified. Interview on 07/09/19 at 6:20 P.M. with the DON was not able to explain a reason as to why the nurse waited until the evening of 08/07/18 to administer the antibiotic ordered on 08/06/18 for Resident #8 . The DON then verified this resulted in the Resident # 8 not receiving treatment for seven days for a UTI. The DON revealed she could not get in touch with the nurse who should have administered the antibiotic sooner. Policy review of the facilities undated, Change in Condition Policy, revealed the facility was to notify the attending physician or physicians on call within 24 hours for a non-emergency significant change in condition. In addition the facility is to continue to monitor and document the status of the resident. Policy review of the facilities Urinary Tract Infections/Bacteruria-Clinical Protocol, revealed the facility refers to the current guidelines of McGeer's for criteria that define a UTI. Review of information from McGreer Criteria for Long-Term Care Surveillance Definitions for infections updated 2012, revealed criteria of a diagnosis of a UTI with a catheter documents a resident must have signs and symptoms for a UTI and have a culture specimen greater than 100,000 of units of any organism.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure Resident #32, who required staff assistance with activities of daily living, received adequate and timely care to maintain good personal hygiene including facial shaving. This affected one (#32) out of three residents reviewed for assistance with personal hygiene. The facility census was 79. Finding include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses including Alzheimer's disease, abnormal weight loss, restlessness and agitation, dementia with behavioral disturbance, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, heart failure, delusional disorders, chronic ischemic heart disease, anxiety disorder, hyperlipidemia, diabetes mellitus type two, iron deficiency anemia, hypertension, depressive disorder, unspecified psychosis, atherosclerotic heart disease, coronary artery disease without angina, cardiac pacemaker. Record review of Minimal Data Sheet, (MDS), Quarterly assessment dated [DATE], Brief Interview of Mental Status, (BIMS) score of two indicating severe cognitive impairment. Further review of the MDS revealed the residents required extensive assistance with activities daily living (ADL). Record review of comprehensive care plan for Resident # 32 revealed an ADL Self Care Performance Deficit related to impaired cognition, impaired range of motion, (ROM), Limited Mobility, short of breathe, (SOB) with exertion, becomes agitated and combative with staff assist at times. Record review of progress notes revealed no documentation for Resident # 32 regarding being shaved with ADL's. Record review of Resident #32 for showers and personal hygiene look back report from 06/26/19 through 7/09/19 reveled no documentation for shaving. Observation on 07/09/19 at 11:22 A.M. of Resident #32 revealed she had chin hairs. At the time of the observation State Tested Nursing Assistant (STNA) #150 verified she did not attempt to shave Resident #32 when she saw her/provided care today. She further verified Resident #32 needs shaved and she will attempt it today. STNA #150 revealed she didn't know the last time Resident #32 was shaved. STNA #150 also verified the STNA's and/or facility doesn't document when residents are shaved so there no way to know when she was shaved last. Interview on 07/09/19 at 11:38 AM with the Director of Nursing (DON) verified she would expect a STNA to shave any resident who needs shaved. The DON revealed the expectation for STNA's is to attempt more than once to shave a combative resident and to get assistance with staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, policy review and review of information from on infection from McGreer's, the facility failed to ensure treatment was provided to a resident timely for the treatment of a urinary tract infection (UTI). This affected one (#8) out of four residents reviewed for hospitalization. The facility census was 79. Findings included: Review of Resident #8's medical record revealed resident was admitted to facility on 04/03/2018. Diagnosis include atherosclerotic heart disease, coronary artery disease with angina, muscle weakness, type two diabetes mellitus with diabetic neuropathy, essential hypertension, hyperlipidemia, chronic obstructive pulmonary disease, diabetic chronic kidney disease, gastro esophageal reflux disease with out esophagitis, major depressive disorder, sleep apnea, retention of urine, hypothyroidism, anemia, old myocardial infraction, chronic kidney disease. Review of the Quarterly Minimum Data Sheet, (MDS) dated [DATE] revealed Resident #8 was assessed as cognitively intact with no deficits. Resident #8 was also assessed as requiring extensive assist plus two for toileting. She was also assessed as occasionally incontinent and did not have an urinary catheter during the assessment period. Review of Resident #8 comprehensive care plan documented she had recurrent UTI's with interventions including nursing staff to monitor, document, and report all signs and symptoms of UTIs to the medical doctor as needed. Record review of nursing progress notes dated on 07/27/18 revealed Resident #8 was seen by Medical Doctor, (MD) #320 on 07/27/18 and returned with Foley Catheter in place and appointment card only. The nursing progress notes indicated the facility called MD #320 office for progress notes and documentation of the appointment. Record review of nursing progress notes dated on 07/28/18 revealed facility received a call from Hospital #1 indicating MD #320 had ordered a CT of abdomen and pelvis without contrast to be completed there on 08/06/19. Record review of nursing progress notes dated on 07/30/2018 revealed a urine specimen had been ordered Microalbumin was added to the order. Record review from a urinary analysis with culture and sensitivity (U/A, C&S), laboratory result for Resident #8 revealed a final status report on 08/01/18. The U/A C&S result revealed greater than 100,000 Escherichia Coli (E. Coli). Record review of nursing progress notes dated on 08/01/18 revealed a call was placed to MD #310 office in regards to the UA results and indicated his nurse stated MD #310 would address the results that day. Record review of a nursing progress note dated 08/02/19 revealed a follow-up call was made to MD #310 indicating again the facility nursing staff was seeking a response on the UA results. MD #310's nurse indicated the doctor would address the results after he finished with his patients he was seeing in the office. Record review of MD #300 progress note dated 08/06/18 revealed Resident #8 had been seen for a monthly visit. MD #300 documented that MD #310, nephrologist, had ordered a UA on 07/30/18. MD #300 documented the U/A was greater than 100,000 E. Coli and sensitive to Cipro antibiotic. MD #300 documented Resident #8 was symptomatic with belly pain, low grade fever, and nausea. The assessment and plan revealed MD #300 was prescribing Cipro 500 milligrams (mg) two times a day for seven days to treat the UTI. Review of physician order revealed MD #300 ordered Cipro 500 mg two times a day for seven days to treat the UTI. Review of Emergency Ebox use form verified Cipro 250 mg, quantity two was taken out of inventory on 08/07/19 at 4:15 P.M.; nurses signature was not legible. Record review of Medication Administration Record, (MAR) revealed the Cipro 500 mg two times per day prescribed by MD #300 on 08/06/18 was not administered until the evening of 08/07/19. Record review of consultation dated 08/08/18 for Resident #8 with MD #310 revealed he was evaluating and treating for decreased renal function. MD #310 documented Resident # 8 had decreased renal function, a distended abdomen, nausea and a Foley catheter in place for one week. There was no documentation of the Resident # 8 being treated by MD # 300 for UTI or that he had been notified that week of the U/A C&S results. Interview on 07/09/19 at 02:33 P.M. with the Director of Nursing, (DON) verified that when C/S results are returned with more than 100,000 organisms of E-Coli what are the expectations of your nursing staff. The DON revealed the expectation is to notify the in-house physician or specialist. When the DON had been given the scenario of the specialist not returning the notification for several days. The DON revealed there is an in-house physician group at the facility three days a week and the nurse could put the results in front of them and see if the in house group would order and antibiotic. Interview via telephone on 07/09/19 at 3:54 P.M. with MD #300 and the Medical Director of the facility. MD # 300 verified it would be his expectation for the nursing staff to contact him if they could not get a response for an order from a specialist. When given the scenario of what had taken place 07/27/18 through 08/09/18 by the, MD #300 revealed it was a problem the nursing staff did not contact him sooner. MD #300 further revealed as a medical director his primary problem is the nursing staff doesn't always notify him when needed. MD #300 verified he would have treated the Resident #8 sooner if he would have been notified. Interview on 07/09/19 at 6:20 P.M. with the DON was not able to explain a reason as to why the nurse waited until the evening of 08/07/18 to administer the antibiotic ordered on 08/06/18 for Resident #8 . The DON then verified this resulted in the Resident # 8 not receiving treatment for seven days for a UTI. The DON revealed she could not get in touch with the nurse who should have administered the antibiotic sooner. Policy review of the facilities undated, Change in Condition Policy, revealed the facility was to notify the attending physician or physicians on call within 24 hours for a non-emergency significant change in condition. In addition the facility is to continue to monitor and document the status of the resident. Policy review of the facilities Urinary Tract Infections/Bacteruria-Clinical Protocol, revealed the facility refers to the current guidelines of McGeer's for criteria that define a UTI. Review of information from McGreer Criteria for Long-Term Care Surveillance Definitions for infections updated 2012, revealed criteria of a diagnosis of a UTI with a catheter documents a resident must have signs and symptoms for a UTI and have a culture specimen greater than 100,000 of units of any organism.

Based on observation and staff interview, the facility failed to ensure personal items including attends, wash basins and bed pans were appropriately stored to prevent cross contamination. This affected five (#8, #20, #32, #33, and #63) out of 24 residents observed during the initial pool sample. The facility census was 79. Findings include: On 07/08/19 11:25 A.M. an observation was made of Residents (#8, #33 and #32) shared bathroom. During the observation two packs of attends, a bed pan and a wash basin were observed laying inside the bed pan. All the items were observed lying on the floor of the bathroom without any bags or barriers over the personal items to ensure proper infection control was maintained. On 07/08/19 at 11:29 A.M. an observation was made of Resident #20 and Resident #63 shared bathroom. During the observation a bed pan and a wash basin was observed laying inside of the bed pan. All the items were observed lying on the floor of the bathroom without any bags or barriers over the personal items to ensure proper infection control was maintained. On 07/09/19 11:23 A.M. interview with State Tested Nurse Aide (STNA) #150 verified items including the attends, bad pans, and wash basin were being to be stored on the floor of the bathrooms. She further verified the attends should be stored in the closets on the self and the bed pan and wash basins should be stored in a bag and placed in the residents nigh stand. She then verified she will be throwing all the observed personal items away. She also verified Resident (#8, #33 and #32) shared a bathroom and Resident #20 and Resident #36 shared a bathroom. On 07/09/19 11:30 A.M. interview with the Director of Nursing (DON) verified all personal items including attends wash basins and bed should not be stored on the floor or not bagged. She verified attends should be stored in a closet on the shelf and wash basins and bed pans should be placed in a bag stored on a self or in a drawer of the residents night stand. She verified the facility has no policy for storing all personal items in a sanitary manner.