**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure informed consent was obtained for the use of an psychotropic medication for one (#29) of five sampled residents reviewed for unnecessary medications. The DON identified 27 residents were prescribed psychotropic medication. Findings: The facilty's Initiation of a Psychotropic Drug policy policy, dated 11/21/22, read in part, The family is to be notified .Explain our effects and inquire about their feeling toward the use if a psychotropic medication and explain the risk involved. Resident #29 was admitted on [DATE] with diagnoses which included major depressive disorder and dementia unspecified with other behavioral disturbances. A physician order, dated 12/26/23, documented Resident #29 was prescribed buspirone HCI oral tablet 15 mg .Give one tablet by mouth two times a day .Citalopram Hydrobromide Oral Tablet 10 mg. Give one tablet in the morning. A quarterly assessment, dated 4/9/24 documented Resident #29's cognition was significantly impaired. The clinical health record did not contain documentation an informed consent had been signed for the use of buspirone and citalopram. On 07/09/24 at 2:26 p.m., the IP was asked if they could provided consents for psychotropic medications for Resident #29. The IP stated they had a form they previously used, cant locate consents and education in the clinical health record. On 07/09/24 at 2:27 p.m., the DON was asked what psychotropic medications Resident #29 was prescribed. The DON stated the Resident#29 was prescribed buspirone and citalopram. The DON was asked to provide the consents and education for the prescribed psychotropics. The DON stated, No, I cant find them at this time. I don't think they had been doing them.

Based on observation, record review, and interview, the facility failed to ensure a resident who was physically restrained has a physician order, was assessed, and monitored for one (#1) of one sampled resident reviewed for the use of physical restraints. The Administrator identified 35 residents resided in the facility. Findings: An undated facility policy titled Restraint Policy, read in part, All residents will have an assessment performed to determine the safety and protective needs of the resident prior to the application of the restraints. The policy also read, .restraints may be applied only on a physician's written order and shall identify the type and reason for the restraint .A restrained resident shall have their restraints released every two hours for at least ten minutes. Resident #1 had diagnoses which included cerebral palsy and dystonia. An annual resident assessment, dated 05/06/24, documented Resident #1 had severe cognitive impairment and required extensive assistance with ADL's. On 07/09/24 at 8:51 a.m., Resident #1 was observed in their wheelchair. There was a black belt around their waist with a quick release buckle. On 07/10/24 at 9:56 a.m., Resident #1 was observed sitting in the common area. There was a black belt around their waist with a quick release buckle. On 07/10/24 at 9:57 a.m., RN #1 stated Resident #1 has a lap belt on their wheelchair because they moved a lot and they were fidgety. On 07/10/24 at 10:01 a.m., RN #1 stated there was no physician order for the use of the lap belt and no documentation Resident #1's wheelchair lap belt use was monitored. On 07/10/24 at 10:05 a.m., Admin stated Resident #1 can undo the wheelchair seat belt on their own. On 07/10/24 at 10:06 a.m., the DON and Infection Preventionist instructed Resident #1 to undo the seat belt. Resident #1 was unresponsive to the instructions given. On 07/10/24 at 10:16 a.m., the DON was unable to locate a resident assessment for the use of the wheelchair seat belt.

Based on observation, record review, and interview, the facility failed to ensure physical restraints were coded accurately on MDS assessments for one (#1) of one sampled resident reviewed for the use of physical restraints. The Administrator identified 35 residents resided in the facility. Findings: Resident #1 had diagnoses which included cerebral palsy and dystonia. An annual resident assessment, dated 05/06/24, did not document Resident #1's use of chair restraint. On 07/09/24 at 8:51 a.m., Resident #1 was observed in their wheelchair. There was a black belt around their waist with a quick release buckle. On 07/10/24 at 9:56 a.m., Resident #1 was observed their wheelchair in the common area. There was a black belt around their waist with a quick release buckle. On 07/10/24 at 10:06 a.m., the DON and Infection Preventionist instructed Resident #1 to undo the seat belt. Resident #1 was unresponsive to the instructions given. On 07/10/24 at 10:20 a.m., MDS Coordinator #1 stated it was considered a restraint if a resident is not able to undo their wheelchair seat belt. On 07/10/24 at 10:23 a.m., the DON stated the use of the wheelchair seat belt was not coded in Resident #1's annual resident assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was labeled and dated, per the facility policy and professional standards of care, for one (#20) of one resident sampled for respiratory care. The DON identified one resident used supplemental oxygen. Findings: The facility's OXYGEN THERAPY policy, undated, read in part, Change device tubing every 30 days on the 15 th of the month on night shift and store the tubing in a bag when not in use. Tubing is to be dated. Resident #20 was admitted on [DATE] with diagnoses which included acute respiratory failure and major depressive disorder. A annual assessment, dated 04/01/24, documented Resident #20's cognition was intact. A physician order, dated 05/07/24, read in part, O2 via nasal cannula PRN to keep sats above 89% every shift. On 07/08/24 at 2:17 p.m., Resident #20 observed in bed wearing O2 with a nasal annual. There was no date observed on the O2 tubing or O2 saturator. On 07/10/24 at 1:39 p.m., CNA #1 went in Resident #20's room. They were asked to observe the date the O2 tubing was changed. They stated there was no date on the tubing or saturator. On 07/10/24 at 1:42 p.m., RN#1 was asked to look at the Resident #20s O2 tubing and saturator. They stated there was no date and have an order to change it monthly. They stated the tubing should be labeled with date. On 07/10/24 at 1:50 p.m., the DON was aked what the policy was when changing O2 tubing and humidifier on the O2 saturator. The DON stated the O2 tubing needed to be labeled with the date it was changed and put in a bag when not in use.

Based on record review and interview, the facility failed to ensure a medication regimen review gradual dose reduction was responded to timely for one (#35) of five sampled residents reviewed for unnecessary medications. The administrator identified 35 residents resided in the facility and received medication. Findings: The facility's Drug Regimen Review policy, dated 11/21/22, read in part, The consultant pharmacist documents potential or actual medication therapy problems, and communicates them to the primary physician and the Director of nursing. A written report is provided to the physician within seven working days. Resident #35 had diagnoses which included major depressive disorder and peripheral vascular disease. A physician order, dated 05/17/24, documented to administer tramadol 50 mg HCI oral tablet every 6 hours as needed for pain. A monthly medication review, dated 05/22/24, documented the pharmacist request to attempt a gradual dose reduction of the residents tramadol 50 mg every six hours as needed. The medication review was not documented as sent to the physician or responded to by the physician in the clinical health record. On 07/10/24 at 10:40 a.m., the Medical records personal was shown the GDR attempt dated 05/22/24 and asked to locate the physician response. They stated it was never sent to the physician due to finding it in a stack of paperwork. They were asked what the policy was when a GDR from a monthly medication regimen review was received . They stated the staff give them to me and I send them to the doctor. When they come back signed, we review and update chart. On 07/10/24 at 11:22 a.m., the DON was asked what the policy was when a monthly medication pharmacy review GDR was requested. The DON stated the GDR should of been sent sent to the physician within 7 days and nursing personnel should of provided a response within two weeks. The DON stated the physician should of provided a report to the facility within one month after the report was sent. The DON was asked if the policy was followed. They stated the policy was not followed.

The facility failed to ensure resident assessments accurately reflected the residents status for two (#5 and #6) of three sampled residents. The administrator stated the facility census was 35. Findings: 1. Resident #5 had diagnosis to include Alzheimer's disease. A physician order, dated 03/15/23, documented Resident #5 was to be provided a regular diet with a mechanical soft texture. A quarterly assessment, dated 01/14/24, documented Resident #5's proportion of total calories received through a parenteral or tube feeding was 25% or less; and the average fluid intake per day by tube feeding was 500 cc or less during seven days of the assessment. On 01/30/24 at 12:15 p.m., Resident #5 was observed in the dining room for the noon meal. Resident #5 had been served a mechanically soft diet and a family member was assisting with the meal intake. 2. Resident #6 had a diagnosis to include Barrett's esophagus and abnormal weight loss. A physician order, dated 05/12/22, documented Resident #6 was to be provided a regular diet with pureed texture and pudding thickened liquids. A quarterly assessment, dated 12/27/23, documented Resident #6's proportion of total calories received through a parenteral or tube feeding was 25% or less; and the average fluid intake per day by tube feeding was 500 cc or less during seven days of the assessment. On 01/30/31 at 12:15 p.m., Resident #6 was observed to have been served a pureed diet and staff assist with the meal intake. On 01/31/24 at 12:35 p.m., the MDS coordinator was asked if Residents #5 and #6 had tube feedings or other alternates for nutritional intake. They stated Residents #5 and #6 had never had tubes. They stated the assessments were not accurate.

Based on observation, record review and interviews, it was determined the facility failed to ensure residents were resting in their bed in a dignified manner for one (#25) of one sampled resident. The Resident Census and Condition of Residents identified seven residents that required total assistance in dressing. Findings: 1. Resident #25 had diagnosis to include traumatic subdural hemorrhage; dementia; anxiety disorder; major depressive disorder; and delusional disorder. A quarterly assessment, dated 04/19/21, documented the resident had severe cognitive impairment for daily decision making, was rarely/never understood, and required extensive assistance with dressing and bed mobility/transfers. On 06/01/21 at 02:25 p.m., resident #25 was observed in his bed. The door from his room into the hallway was opened. The resident was dressed in an adult diaper and shirt. He was uncovered, and exposed to hallway. Several residents, staff and surveyors were in the hallway. On 06/09/21 at 8:56 a.m., the DON was informed of the observation of the resident exposed from his room into the hallway. She stated, The resident sometimes kicks the covers off but he should not have been left that way.

Based on observation, record review, and interview, it was determined the facility failed to ensure residents were educated in reporting information to Ombudsman and OSDH and the information were readily accessible. This affected five of five residents who attended the group interview. It had the potential to affect 33 residents and the family representatives. Findings: On 06/02/21 at 10:00 a.m., five alert/oriented attended the resident interview. The residents were asked if they knew how to file a grievance. They reported they would talk to the activities/social services director or the facility administrator. The residents were asked if they knew where the Ombudsman contact information was posted. They stated they did not know. The residents were asked if they knew how to report a complaint to the Oklahoma State Department of Health. They stated they were not sure but if they could find out from the activities/social services director or the facility administrator. Following the group interview, the signage for Ombudsman information and OSDH reporting was observed on the bulletin board near the 300 hall. The information for both, were approximately 5 feet from floor level. On 06/09/21 at 11:05 a.m., the administrator was asked to observe the bulletin board containing the signage of Ombudsman contact information and OSDH reporting information. The administrator was asked if the Ombudsman contact information was posted in a manner that was readily accessible to the residents. She stated, Its a little high. The administrator was asked if the information to file a complaint to OSDH was readily accessible to the residents. She stated, We will need to get it moved down.

Based on observation and interview, it was determined the facility failed to make survey results readily accessible/available to residents. The facility census was 33. Findings: On 06/02/21 at 10:00 a.m., five alert/oriented residents attended the resident council interview. The residents were asked if they could review the results of the state inspection without having to request to see the report. They stated the administrator would have the reports. Directly after the meeting, the bulletin board near the 300 hall was observed to have a small binder clip which contained multiple documents: ~The top document was labeled .Fire Department - Fire Procedure; ~Behind the Fire Department document, were reports of a COVID focus survey completed on 10/21/20; and desk audit for a follow up for the COVID focus survey, dated 01/25/21. The re-certification/re-licensure survey reports were not located. On 06/09/21 at 11:05 a.m., the administrator was asked to review the items on the bulletin board. While observing the signage and posting of reports, the administrator was asked if the state survey results were readily available with easy access for residents. She stated a resident has been taking the survey results from the bulletin board and the reports are now in a different place and not easy to find.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility failed to include documentation an Advance Directive had been formulated or that information had been provided to formulate an Advance Directive in the clinical record for three (#7, 11 and #36) of three sampled residents reviewed for Advance Directive. The census and condition, dated 06/01/21, identified 33 residents who resided in the facility. Findings: 1. Resident #7 was readmitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, sleep related hypoventilation, other specified disease of upper respiratory tract, and tremor. A quarterly assessment, dated 03/04/21, documented the resident was severely impaired in cognition and required no assistance with most activity of daily living. The care plan, last updated 03/11/21, documented, .I have advance directive .guardian and DNR (do not resuscitate) . The current physician order documented, DNR. No further orders or instructions were provided. The clinical record did not include documentation an Advance Directive had been formulated or that information had been provided to formulate an Advance Directive. 2. Resident #11 was readmitted to the facility on [DATE] from skilled to long term care. Her diagnoses included: edema; diabetes mellitus - type 2; dysphagia; and encounter for attention to gastrostomy. An Annual assessment, dated 03/16/21, documented the resident to have severe cognitive impairment for daily decision making; was rarely/never understood; required limited to extensive assistance for ADLs; and received nutrition via parenteral tube feedings. The care plan, last updated 04/02/21 documented .Special Instructions: Code Status --DNR [Do Not Resuscitate] . The care plan did not address any details of the DNR or if an Advance Directive had been initiated or offered. The current physician orders documented, Do Not Resuscitate . No further orders or instructions were provided. The clinical record did not include documentation an Advance Directive had been formulated or that information had been provided to formulate an Advance Directive. 3. Resident #36 was readmitted on [DATE] with diagnoses that included hypertension, pain, major depressive disorder and unspecified osteoarthritis. An annual assessment, dated 05/26/21, documented the resident was severely impaired in cognition and required total assistance with most activity of daily living. The care plan, last updated 06/03/21, documented, I have signed a DNR and it is on my chart . The current physician order documented, DNR. No further orders or instructions were provided. On 06/02/21 at 9:41 a.m., the DON was asked if advance directives was discussed with residents on admission. She said, Yes. She further stated the social worker reviews all the advance directives with residents on admission, the documents are scanned into the electronic medical records and a copy placed in the resident's chart. At 9:52 a.m., the social service director was asked to show the where the documentation advance directive was reviewed with residents on admission. She said, There is not one. She was asked if advance directive should be discussed with each resident on admission. She said, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews it was determined the facility failed to notify the physician and/or the resident representative for four (#2, #14, #25, and #35) of 16 sampled residents. This had the potential to affect 33 residents who resided in the facility. Findings: 1. Resident #2 had diagnoses to include: Alzheimer's Disease; atrial fibrillation; major depressive disorder; and heart failure. A nurse's note, dated 02/05/2021 at 9:01 p.m., documented, .while transferring with sit to stand res'd [resident's] knees bent and he began to slide down, lowered easily to floor by staff without difficulty or injury. Alert, denies pain/discomfort. VSS [vital signs] staff instructed to use full body lift for transfers . A nurse's Monthly Summery report for February 2021, dated 03/26/2021 at 00:29 a.m., documented, .on 02/05/21 resident had a fall in his room (slid out of Sit-to-Stand.) . The clinical record did not contain documentation the physician or the resident's representative was notified of the fall. On 06/08/21 at 3:23 p.m., the DON was asked if the physician or family representative had been notified of the resident's fall from the sit-to-stand lift as documented on 02/05/21. She stated she would have to look but had not considered it a fall so an incident report was not completed. No further information was provided. 2. Resident #25 had diagnoses to include: dementia; anxiety; major depressive disorder; delusional disorder; peripheral vascular disease; and cellulitis. A nurse's note, dated 03/25/21 at 1:24 p.m., documented, .right thumb is purple in color and 'boggie' He denies pain . A nurse note, dated 03/26/21 at 2:08 p.m., documented, .he was kicking his feet. CNAs noted that he had kicked a toenail off .Triple antibiotic applied with band aid. A quarterly assessment, dated 04/19/21, documented the resident had severe cognitive impairment for daily decision making; required extensive assist for bed mobility, transfers and dressing; was totally dependant of staff for locomotion; did not walk; and had not experienced any falls. The care plan, last updated on 05/19/21, documented the resident had a diagnosis of Peripheral Vascular Disease. Interventions included to monitor extremities for sign/symptoms of injury, infections or ulcers. The current physician orders documented weekly skin evaluations every Wednesday had been initiated on 10/09/19. There was no physician's order documented for the treatment of the toe after the toenail had fallen off. On 06/09/21 at 8:50 a.m., the DON was asked if the physician and/or family representative had been notified of the change of condition. She stated, No. 3. Resident #14 had diagnosis to include: dementia; vitamin deficiency; toxic affect of spider venom; and hypertension. A nurse's note, dated 04/19/2021 4:10 a.m., documented, Open area on coccyx measures 2cm [centimeters]x 2.5cm. Protective cream applied . There was no documentation the family and/or physician had been notified of the open area to the coccyx and an order was obtained for the protective cream. On 06/07/21 at 4:28 p.m., the assistant director of nursing (ADON) was asked if the resident's physician and family were notified of the open area to the coccyx and an order obtained for treatment. She stated, She didn't write that, no. 4. Resident #35 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, dizziness, dementia without behavior, auditory hallucination and chronic pain. A progress note, dated 01/15/21 at 5:00 a.m., documented the resident had a FSBS (finger stick blood sugar) of 58 a peanut butter and jelly sandwich was given and consumed. A progress note, dated 01/18/21 at 1:24 a.m., documented the resident had blood glucose reading of 44 and consumed milk, peanut butter and jelly sandwich and a cup of juice. The blood sugar was rechecked with a result of 53. A progress note, dated 01/20/21 at 5:50 a.m., documented the resident had a finger stick blood sugar reading of 50 and a snack was provided. A progress note, dated 01/22/21 at 6:18 a.m., documented the resident FSBS was 47. There was no documentation the physician had been notified of the low FSBS. A progress note, dated 05/07/21 at 1:38 p.m., documented staff alerted the charge nurse resident right pinky toe was bleeding .resident had ripped off .toe nail .area cleansed and bandaged. A progress note, dated 05/23/21 at 12:33 a.m., documented the resident was observed with an injury to the back of his head and the area was treated with triple antibiotic. There was no documentation the physician was notified of the right toe and/or the injury to the back of head. A progress note, dated 05/24/21 at 5:21 a.m., documented the resident had a FSBS reading of 52 at 4:00 a.m. and consumed a protein shake. There was not documentation the physician was notified. A progress note, dated 05/24/21 at 9:02 p.m., documented the resident was confused and had a FSBS of 403 at 3:30 p.m. and a FSBS of 483 at 6:00 p.m. There was no documentation the physician was notified of the elevated FSBS. A care plan, last updated 05/27/21, documented .FOCUS .Diabetes .Goal .I want my FSBS (finger stick blood sugar) level to be WNL (within normal limits) throughout this review .Interventions .Notify my PCP (primary care physician) of any abnormal FSBS .or s/s (sign/symptom) of high/low blood sugars and follow through . A facility document, titled weights and vitals summary, documented a blood sugar reading on 05/29/21 at 6:50 a.m. of 51. There is no documentation physician was notified. On 06/08/21 at 3:39 p.m., the DON was asked what was the facility's policy for notification of a resident change in condition. She stated the facility did not have one. She was asked to review the progress notes of abnormal finger stick blood sugar reading for the dates 01/15/21, 01/18/21, 01/20/21, 01/22/21 and 05/24/21. She was asked if physician was notified of change in condition. She said, No. In reference to the progress note dated 05/07/21 of an injury to resident right pinky toe nail ripped off and bleeding. The DON was asked if the physician and family was notified. She said, No. In reference to the progress note dated 05/23/21 of an injury to resident head which required a treatment, the DON was asked if the physician and family was notified. She said, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined the facility failed to ensure a significant change of status assessment was completed as required for one (#11) of 16 sampled residents whose records were reviewed for accuracy. The facility census was 33. Findings: Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis to include: dysphagia; and encounter for attention to gastrostomy. An annual assessment, dated 03/16/21, documented the resident to have severe cognitive impairment in daily decision making; required limited assistance for eating; and a percutaneous endoscopic gastrostomy (PEG) tube for 25% or less of nutritional intake and 500 cc or less for hydration intake The care plan, last updated 04/02/21, documented: ~Self-care performance deficit. On 01/14/21, resident returned from the hospital with orders to have nothing by mouth and PEG tube feedings for nutritional/hydration intake was initiated ~Diet order for Glucerna 1.2 to run continuous at 65 cc/hr to begin on 01/15/21. The current physician orders documented: ~Glucerna 1.2 to run continuously at 40 cubic centimeter per hour (cc/hr) to begin on 1/28/21; and ~Regular diet, pureed texture, nectar consistency related to encounter for attention to gastrostomy, to begin on 03/02/21. On 06/07/21 at 4:20 p.m., certified nurse aides (CNA) #1 and #2 were observed to check resident #11 for incontinent care. The resident was clean and dry. The resident's skin was clean, dry and intact. A small round scar was noted on the upper left abdomen. There was not a PEG tube present. The CNAs were asked if the resident had ever had a PEG tube. They stated she had but has not had one for a period of time. The CNAs were unable to provide information regarding the PEG tube being discontinued. On 06/09/21 at 9:50 a.m., the DON was asked if the resident had a PEG tube and received nutrition/hydration via PEG tube only. She stated the resident went to the hospital and a PEG tube was placed at that time. The DON stated the resident later pulled the PEG tube out and it remained out. The DON was asked if a significant change of assessment was completed when the PEG tube was removed and the diet orders were changed for nutrition/hydration to be received orally. She stated a significant change of assessment should have been completed and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility failed to complete an accurate Minimum Data Set (MDS) assessment to reflect the residents toiling needs at the time the assessment for three (#11, #14, and #25) of 16 sampled residents. This had the potential to affect 33 residents who resided in the facility. Findings: 1. Resident #11 had diagnosis to include mood disorder; schizophrenia; and dementia An annual assessment, dated 03/16/21 documented toileting had not occurred; the resident was frequently incontinent of bowel and bladder: and currently on a toileting plan for urination with results to decrease wetness. The assessment documented the resident had a significant weight loss and a significant weight gain. The care plan, last updated 04/02/21, documented the resident required assistance with self-care and staff were to complete toileting and do proper care for cleansing. 2. Resident #25 had diagnosis to include: urine retention, benign prostatic hyperplasia (BPH), and dementia. A quarterly assessment dated [DATE] documented the resident toileting had not occurred; was always incontinent of bowel and bladder; and had moisture associated skin damage. The care plan, last updated 05/19/21, documented the resident was incontinent, wore disposable briefs, required staff to provide peri-care after each incontinent episode, and staff would assess the resident every two hours for incontinence/toileting needs. 3. Resident #14 had diagnosis to include: dementia and chronic kidney disease. A quarterly assessment, dated 03/27/21, documented toileting did not occur; was always incontinent of bowel and bladder.; and had moisture associated skin damage. The care plan, last updated 04/02/21, documented the resident required staff to assist with incontinent care after each episode of incontinence. On 06/07/21 at 2:50 p.m., the DON and MDS coordinator were asked to clarify the accuracy of the assessments for residents #11, #25, and #14, regarding toileting had not occurred. The MDS coordinator stated, it should have been coded they required extensive assistance for toileting, the assessments are not correct. On 06/08/21 at 9:50 a.m., the DON was asked to review the annual assessment for resident #11. The DON was asked if the resident had actually experienced a significant weight loss and a significant weight gain, and not on a prescribed diet for either. The DON stated the resident did have a significant weight loss but had not experienced a significant weight gain. She stated the assessment was not accurately coded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility failed to ensure a comprehensive care plan was completed at the time of a comprehensive assessment to accurately reflect the needs of the residents. This affected four (#7, #11, #16, and #27) of 16 sampled residents whose care plans were reviewed. This had the potential to affect 33 residents who resided in the facility. Findings: 1. Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis to include: dysphagia; and encounter for attention to gastrostomy. An annual assessment, dated 03/16/21, documented the resident to have severe cognitive impairment in daily decision making; required limited assistance for eating; and a percutaneous endoscopic gastrostomy (PEG) tube for 25% or less of nutritional intake and 500 cc or less for hydration intake. The care plan, last updated 04/02/21, documented: ~Self-care performance deficit. On 01/14/21, resident returned from the hospital with orders to have nothing by mouth and PEG tube feedings for nutritional/hydration intake was initiated. ~Diet order for Glucerna 1.2 to run continuous at 65 cc/hr to begin on 01/15/21. The care plan had not been updated to reflect the resident's change in nutritional intake from PEG tube to oral intake. The current physician orders documented: ~Glucerna 1.2 to run continuously at 40 cubic centimeter per hour (cc/hr) to begin on 1/28/21; and ~Regular diet, pureed texture, nectar consistency related to encounter for attention to gastrostomy, to begin on 03/02/21. On 06/09/21 at 9:50 a.m., the DON was asked if the resident had a PEG tube and received nutrition/hydration via PEG tube only. She stated the resident went to the hospital and a PEG tube was placed at that time. The DON stated the resident later pulled the PEG tube out and it remained out. The DON was asked if a significant change of assessment completed and/or the care plan updated when the PEG tube was removed and the diet orders were changed for nutrition/hydration to be received orally. She stated a significant change of assessment and the care plan update were not completed and should have been. 2. A current physician order, dated 12/27/20, documented resident had order for Oxygen at 2L per N/C (nasal cannula) to keep oxygen saturation above 89% every shift. Resident #7 was readmitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, sleep related hypoventilation, other specified disease of upper respiratory tract, and tremor. A quarterly assessment, dated 03/04/21, documented the resident was severely impaired in cognition and required no assistance with most activity of daily living. There was no documentation resident was on oxygen therapy in the assessment. A physician order, dated 04/14/21, documented the resident had a current order for Ventolin HFA aerosol sol 108 (albuterol sulfate) - 2 puff inhale orally every 6 hours as needed for Dyspnea. A physician order, dated 04/12/21, documented resident wore a Cpap at bedtime every night shift for sleep related hypoventilation. The resident's care plan was not developed to address the respiratory therapy and Cpap at bedtime. On 06/09/21 at 10:25 a.m., the DON was asked to show where oxygen and C-pap was documented in the resident care plan. She was observed to review the resident's care plan and said, There is not one. 3. Resident #16 was admitted [DATE] with diagnoses which included Alzheimer's disease, macular degeneration bilateral, atrial fibrillation, diabetes mellitus, arthritis, hypertension and anxiety. A quarterly assessment, dated 04/01/21, documented the resident was severely impaired in cognition and required limited assistance with most activity of daily living. The assessment documented the resident had no wandering behaviors. A progress note, dated 01/28/21 at 7:07 p.m., documented the charge nurse was informed by dietary staff the resident had pushed the north hall exit door open and had front wheels of the wheel chair across the door frame before resident was assisted back into the facility. A care plan, last revised on 04/08/21, documented, Focus .wandering .I have been noted to be wandering in the halls going into and out of other residents rooms .Goal .I want to safely be able to go where I want in the facility without getting into other residents rooms .Intervention . I have not attempted to elope - I am comfortable with my home . Please explain to other residents that I get confused at times, and I don't mean to go into their room to cause any harm .Please redirect me when I go into other residents room. I usually go into the same residents rooms, which are located on the other hall in approximately the same location as my own .Show me where my room is - be patient with me- this is very upsetting for me . A progress note, dated 05/26/2021 at 8:37 p.m., documented resident was exit seeking out the door near the laundry room. Resident had got outside and staff had gotten her back in On 06/07/21 at 10:30 a.m., resident was observed unzipping entrance to the isolation area at the end of hall 200 into 100. At 12:40 p.m., resident was observed at the end of hall 200 near the activity office sitting in her wheel chair. No staff was present. At 2:47 p.m., resident remained at the end of hall 200 and staff observed walking by resident with no attempts to redirect or assist resident. At 3: 12 p.m., resident observed to propelling self towards nurse's station and up hall 300. At 3:39 p.m., resident observed entering room [ROOM NUMBER] and was assisted by staff out of room. Staff assisted resident back to her room. On 06/08/21 at 12:03 p.m., the DON was asked to review the progress note dated 05/26/21 where it documented resident had exited the building unaccompanied by staff. She was asked if the resident care plan indicated resident was exit seeking and had eloped the building without staff knowledge. She said, No. 4. Resident #27 was admitted on [DATE] with diagnoses which included chronic obstructed pulmonary disease, congestive heart failure, Parkinson and moderates intellectual disabilities. A physician order, dated 04/19/21, documented resident had order for DNR (do not resuscitate). A physician order, dated 04/19/21, documented resident was on tramadol 50 mg two tablets twice daily by peg tube for chronic pain. A physician order dated 04/28/21, documented, Admit to Hospice. There is no additional information in the current physician orders. A progress note, dated 04/28/21, documented, order to place resident on hospice care .She had previously been on hospice at prior facility [named hospice] .was notified. A progress note, dated 04/28/21, documented, [named] hospice has been called for hospice Care and will be here this afternoon to assess. A hospice evaluation document located in a hospice chart, dated 04/28/21, documented resident as a new admission with terminal illness as Alzheimer's and certification start date of 04/28/21. There is no documentation in the resident's electronic record of a current diagnosis of Alzheimer's disease. A care plan, initiated 04/28/21, documented, Focus .Hospice .Goal .I require hospice services .Intervention .A hospice nurse comes to check me over every week .hospice CNA's give me a bath twice a week .I receive spiritual services from hospice .I use [named] hospice services .please work with the hospice of my choice so my care can be the best possible. An admission assessment, dated 05/02/21, documented the resident was severely impaired in cognition and required total assistance in all activities of daily living. The assessment documented resident was on hospice services prior to admission. A physician order, dated 05/26/21, documented resident was on Ativan 1mg (milligram) three times daily by peg tube for anxiety. The care plan did not include advance directive, symptom management for pain/agitation or anxiety/pressure ulcer prevention, and psychosocial intervention. On 06/08/21 at 3:51 p.m., the DON was asked what the basis was for the determination that the resident is approaching the end of life and requires hospice. She stated resident was previously on hospice and had a mental decline since admission. She was asked what was the terminal illness or diagnosis which certified the need for hospice for the resident. She reviewed the resident medical record and stated she did not know. She was informed the diagnosis utilized as the resident terminal illness was Alzheimer's. She stated she could not find a diagnosis of Alzheimer's in resident's medical records. At 3:53 p.m., the DON was asked who coordinated the resident's care with hospice. She stated she was the one who coordinated care with hospice. She was asked if advance directive, cardiac status, symptom management for pain/agitation, respiratory and pressure ulcer prevention was care planned. She reviewed resident's care plan and said, No.

Based on record review and interviews, it was determined the facility failed to update/revise resident care plans to reflect their current status for two (#2, and #16) of 16 sampled residents. This had the potential to affect 33 residents who resided in the facility. Findings: 1. Resident #2 had diagnosis to include: Alzheimer's Disease; bilateral osteoarthritis of the hip; atrial fibrillation; hypokalemia; heart failure; and hypertension. A nurse's note, dated 02/05/21 at 9:01 p.m., documented, .while transferring with sit to stand res'd [resident's] knees bent and he began to slide down, lowered easily to floor by staff .staff instructed to use full body lift for transfers . A monthly summaries report for February 2021, dated 03/26/2021 at 12:29 a.m., documented, .on 02/05/21 resident had a fall in his room (slid out of the sit-to-stand.) . The care plan, last updated on 04/02/21, documented: ~Resident was unable to ambulate unassisted; ~Resident was a high risk for falls. Interventions included staff were to anticipate needs; review information from past fall to determine root causes and remove any potential causes if possible; and ~Resident experienced an actual fall while trying to get of the recliner, slid to the end of the recliner and fell. The intervention included to check on resident frequently and anticipate his needs. The care plan did not address the safest mode of transfers, or review further interventions regarding lift chair/recliner as continued increase for falls. A quarterly assessment, dated 05/28/21, documented the resident had severe cognitive impairment for daily decision making; required limited assistance for bed mobility; required extensive assistance for transfers and toileting; was frequently incontinent of bowel and bladder; and had experienced two or more falls, without injury, since the prior assessment. The current physician's orders documented the resident was to use a high/low bed for fall precautions and a wheelchair for mobility. On 06/03/21 at 10:18 a.m., Resident #2 was seated in a wheelchair near the nurse's desk. Observations made in the resident's room. A lift chair/recliner is in the room, in a normal seated position. On 06/07/21 at 10:29 a.m., and 2:22 p.m., the resident is observed to be seated in a wheelchair in the in common area. The room was observed with a lift chair/recliner in an seated position, with an incontinent pad in the seat of the chair. On 06/08/21 at 10:54 a.m., the resident was observed in a wheelchair in the common area. The residents room was again observed with a lift chair/recliner with an elevated/standing position with an incontinent pad in the chair. At 3:00 p.m., the resident was being assisted into activities. The resident's room was again observed with the lift chair/recliner was again in an elevated/standing position with an incontinent pad in the chair. On 06/08/21 at 3:23 p.m., the DON was asked if the resident's care plan addressed the mode of transfer to ensure safe transfers. She reviewed the care plan and stated she did not see it in the care plan. At 4:29 p.m., CNAs #1 and #2 were asked how the resident was transferred. They stated they use the sit-to-stand lift due to they were not feel comfortable to use the tranport lift. They stated the transfer lift does not have the safety straps for secure transfers. The CNAs showed the transfer lift to the surveyor. The lift has platform for positioning feet to transport; a handlebar but not grab bars, no safety harness/belts or attachments. CNAs stated that is why we do not like to put him it is.

Based on observation, record review and resident and staff interview, it was determined the facility failed to ensure assistance was provided for nail care for one (#24) of three sampled residents reviewed for activities of daily living. The Resident Census and Conditions of Resident's report documented 33 residents resided in the facility. Findings: Resident #24 had diagnoses which included adult failure to thrive and macular degeneration. On 06/02/21 at 11:12 a.m., the resident was observed to have long, jagged toenails. A bath sheet documented the resident had been bathed on 06/02/21. On 06/03/21 at 10:16 a.m., the resident was asked if she had her toenails trimmed during her bath yesterday. She stated, No, I need to ask the nurse to do it. At 10:18 a.m., certified medication aide (CMA) #2 was asked how frequently residents received nail care. She stated they received nail care on bath days. She was asked to observed the resident's toenails. The resident's left great toenail was observed to be long and jagged and the right second and third toenails were observed to be long and curling over the ends of her toes. She was asked if her toenails should've been trimmed. She stated yes during bath unless the resident refused due to them hurting. The resident was asked if they were hurting. She stated, No. The CMA was asked if her toenails needed trimmed. She stated, Yes. On 06/08/21 at 3:48 p.m., CMA #1 was asked if the resident was independent for nail care. She stated, She uses the podiatrist. She was asked how frequently the podiatrist came to the facility. She stated the podiatrist was in the facility on 04/23/21. She was asked if that was the only visit made to the facility this year. She stated, Yes. She was asked who was responsible for nail care between podiatry visits. She stated, We are.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, it was determined the facility failed to provide timely meal assistance for dependent residents. This affected four (#2, #5, #20, and #25) of 24 dependent residents observed during meal service. The Residents Census and Condition of Residents documented 19 residents required staff assistance for meals and five residents were totally dependant for meal intake. Findings: 1. Resident #2 was admitted to the facility on [DATE] with diagnosis to include: Alzheimer's Disease; vitamin deficiency; and abnormal weight loss. The care plan, last updated 04/02/21, documented physician ordered diet of regular with ground meat/gravy. Nursing interventions included to provide the amount of assistance required, reminders to continue eating, and total assistance if required. A quarterly assessment, dated 05/28/21, documented the resident had severe cognitive impairment for daily decision making; required limited assistance for eating; and received a mechanically altered diet. Current physician orders, documented the resident was to receive a regular diet with ground meat/gravy, and a house supplement with meals for weight loss. On 06/01/21 at 11:35 a.m., the meal service was observed in the dining room. Resident #2 was seated at a table with three other residents. Resident #2 had been provided fluids that were within reach. Dietary staff served resident #2 a plate and utensils. The fluids remained directly in front of the resident, the plate was placed to his right side and utensils were placed on the right side of the plate, out of reach/sight. A small dessert bowl was placed above/left of the plate, near the glasses of fluids. Nursing staff provided assistance to the three other residents at the table. At 12:16 p.m., resident #2 continued to drink the fluids directly in front of him. He placed his fingers in a bowl of pudding consistency dessert, licked his fingers and returned to the fluids. Staff did not provide assistance or cueing. At 12:25 p.m., Resident #2 propelled his wheelchair from the table. He continued to drink from a glass of fluids. The plate of food and the house supplement remained untouched. At 12:27 p.m., certified nurse aide #4 stood from assisting another resident at the table, repositioned resident #2 in order for his wheelchair to the original place setting. She placed the plate of food in front of him. provided verbal encouragement and handed him eating utensils. The resident began to eat the food in the plate. Resident #2 had not been provided appropriate meal set up, cue or reminders from 11:35 a.m., until 12:27 p.m. 2. Resident #25 had diagnosis to include: abnormal weight loss, and dementia. A quarterly assessment, dated 4/19/21, documented the resident had severe cognitive impairment for daily decision making; required limited assistance for eating; received a mechanically altered diet: and received nutritional/hydration interventions. The care plan, last updated on 05/19/21, documented the resident's diet orders were to be followed. Nursing interventions included the resident was to receive pureed diet and he could eat fingerboards without assistance at times but needed to be fed all other foods as he was unable to use silverware. The current physician orders documented the resident was to receive a regular diet with pureed texture and a house supplement with meals for weight loss. On 06/01/21 at 11:35 a.m., the meal service was observed in the dining room. Resident #25 was observed to be seated at a table with three female residents. The three female residents were provided assistance with food/fluid intake. Resident #25 had been provided fluids but the glasses were out of his reach. No plate/food was served to resident #25. At 12:25 p.m., a plate of food and a small dessert bowl were served to resident #25. Staff began to assist him with meal intake. Resident #25 had not been offered assistance with the available fluids or provided food from 11:35 a.m., until 12:25 p.m 3. Resident #5 had diagnosis to include: anxiety; dementia; vitamin deficiency; dehydration; and abnormal weight loss. A quarterly assessment, dated 03/04/21, documented the resident had moderate cognitive impairment for daily decision making; required set-up assistance and supervision for meals; and was on a prescribed weight gain regimen. The care plan, last updated 06/05/221, documented: ~The resident had self-care performance deficit for eating related to dementia. Nursing interventions included the resident would be provided encouragement, and reminders at times to finish meals. ~The resident had potential nutritional issues due to poor appetite at times. Nursing interventions included the resident was to receive a supplement with every meal and she would be encouraged to socially interact at meal times. The current physician orders documented the resident was to receive a regular diet and a house supplement with meals for weight loss. 4. Resident #20 had diagnosis to include: narcolepsy; vitamin deficiency; cutaneous abscess of left foot. An annual assessment, dated 04/03/21, documented the resident had severe cognitive impairment for daily decision making and required limited assistance with eating. The care plan, last updated on 05/16/21, documented: ~Concerns for nutritional status. Interventions included for the meal plate to be within reach and within sight due to poor vision; and staff were to provide encouragement to drink fluids due to the high risk for dehydration. ~A deficit in self-care performance with eating was identified. Interventions included the resident required assistance at times at meal. Staff were to monitor meal intake for the potential of aspiration. The current physician orders documented the resident was to be served a regular diet with pureed texture. On 06/08/21 at 11:44 AM resident's #5 and #20 were observed to be seated together at a dining table for the noon meal. Resident #5 was seated in a wheelchair with both eyes closed. A plate of food was in front of her. The food has been untouched. Several glasses of fluids remained untouched. Resident #20 was seated with a plate of pureed food in front of him. Nosey cups were directly above the plate. The cups were placed in a backward position with the opening for the nose closer to the resident. His utensils remained wrapped within the napkin. At 11:57 a.m., dietary aide #1 approach resident #20 and and asked if he was hungry. The resident shook his head 'yes.' The staff opened the napkin and handed the resident utensils. The food had been served in a divided plate and he began to eat from the larger compartment next to him. The nosey cups remained in a backward position. Resident #5 remains with both eyes closed and not moving. She is not prompted or provided cues to begin eating her meal. At 12:05 p.m., resident #20 has eaten the food from the larger compartment of his plate and stopped eating. Resident #5 remained with her eyes closed and food/fluids untouched. At 12:07 p.m., CNA #3 approached/prompted resident #5 to waken and eat. At 12:15 p.m., dietary staff removed a half eaten tray from the table where residents #5 and #20 remain seated. Resident #5 continued to eat. Resident #20 remained with only the larger portioned plate consumed, leaving the remainder of the food and fluids untouched. Resident #20 was not provided assistance, cues/prompting or encouragement to eat his meal. At 12:23 p.m., the DON approached resident #20 and asked if he wanted help eating. The resident readily accepted and took large bites of food offered to him. On 06/09/21 at 9:40 a.m., the DON and DM were informed of the observations in the dining room during meal service. The DM stated resident #2 requires staff to provide directions at meals for him to eat. The DON stated if fluids were left in front of resident #25, he would reach and spill the drinks. They were asked if the resident should have been served at the time others at his table were served. They stated, the resident should have been left in the television room until there were enough staff to assist him with his meal. They were informed of the observations regarding residents #5 and #20. The DM stated resident #20 is a good eater but requires for staff to rotate his plate. Asked the DON and DM if the residents were provided meal service with encouragement, cues and assistance as required. They stated, We need to work on this together.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #27 was admitted on [DATE] with diagnoses which included chronic obstructed pulmonary disease, congestive heart failure, Parkinson and moderates intellectual disabilities. A physician order, dated 04/19/21, documented resident had order for DNR (do not resuscitate). A physician order, dated 04/19/21, documented resident was on tramadol 50 mg two tablets twice daily by peg tube for chronic pain. A physician order dated 04/28/21, documented, Admit to Hospice. There was no additional information in the current physician orders regarding the hospice provider. A progress note, dated 04/28/21, documented, order to place resident on hospice care .She had previously been on hospice at prior facility [named hospice] .was notified. A progress note, dated 04/28/21, documented, [named] hospice has been called for hospice Care and will be here this afternoon to assess. A hospice evaluation dated 04/28/21, documented the resident was a new admission with terminal illness of Alzheimer's. The admission date was documented as 04/28/21. There was no documentation in the resident's electronic record of a current diagnosis of Alzheimer's disease. A care plan, initiated 04/28/21, documented, Focus .Hospice .Goal .I require hospice services .Intervention .A hospice nurse comes to check me over every week .hospice CNA's give me a bath twice a week .I receive spiritual services from hospice .I use [named] hospice services .please work with the hospice of my choice so my care can be the best possible. An admission assessment, dated 05/02/21, documented the resident was severely impaired in cognition and required total assistance in all activities of daily living. The assessment documented resident was on hospice services prior to admission. A physician order, dated 05/26/21, documented resident was on Ativan 1mg (milligram) three times daily by peg tube for anxiety. The care plan did not include advance directive, symptom management for pain/agitation or anxiety/pressure ulcer prevention, and psychosocial intervention. On 06/08/21 at 3:51 p.m., the DON was asked what the basis was for the determination that the resident is approaching the end of life and required hospice. She stated the resident was previously on hospice and had a mental decline since admission. She was asked what the terminal illness or diagnosis which certified the need for hospice. She reviewed the resident medical record and stated she did not know. She was informed the diagnosis utilized as the resident terminal illness was Alzheimer's. She stated she could not find a diagnosis of Alzheimer's in resident's medical records. At 3:53 p.m., the DON was asked who coordinated the resident's care with hospice. She stated she was the one who coordinated care with hospice. She was asked if advance directive, cardiac status, symptom management for pain/agitation, respiratory and pressure ulcer prevention was care planned. She reviewed resident's care plan and said, No. At 3:58 p.m., the DON said, Hospice never discuss with us. 3. Resident #35 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, dizziness, dementia without behavior, auditory hallucination and chronic pain. A progress note, dated 01/15/21 at 5:00 a.m., documented the resident had a FSBS (finger stick blood sugar) of 58, a peanut butter and jelly sandwich was given and consumed. There was no documentation the physician was notified. There was no documentation the resident was reassessed. A progress note, dated 01/18/21 at 1:24 a.m., documented the resident had blood glucose reading of 44 and consumed milk, peanut butter and jelly sandwich and a cup of juice. The blood sugar was rechecked with a result of 53. There was no documentation of any additional intervention. There was no documentation the physician was notified. A progress note, dated 01/20/21 at 5:50 a.m., documented the resident had a finger stick blood sugar reading of 50 and a snack was provided. There was no documentation the physician was notified. There was no documentation the resident was reassessed. There was no documentation of any additional intervention. A progress note, dated 01/22/21 at 6:18 a.m., documented the resident FSBS was 47. There was no documentation the resident was assessed, monitored or any additional intervention by staff were implemented. There was no documentation the physician was notified. A progress note, dated 05/07/21 at 1:38 p.m., documented staff alerted the charge nurse resident right pinky toe was bleeding .resident had ripped off .toe nail .area cleansed and bandaged. There was no documentation the physician was notified. There was no documentation the injury was monitored. A significant change assessment, dated 05/22/21, documented the resident was severely impaired in cognition and required limited assistance with most activity of daily living. A progress note, dated 05/23/21 at 12:33 a.m., documented the resident was observed with an injury to the back of his head and the area was treated with triple antibiotic cream. There was no documentation the physician was notified and an order was obtained for the triple antibiotic cream. There was no documentation in the resident's medical record that indicated triple antibiotic was ordered and dispensed by pharmacy for the injury to the back of his head. A progress note, dated 05/24/21 at 5:21 a.m., documented the resident had an fsbs reading of 52 at 4:00 a.m. and consumed a protein shake. The physician was notified of the abnormal reading an hour and nineteen minutes after initial reading. There is no documentation the resident FSBS was rechecked. A progress note, dated 05/24/21 at 9:02 p.m., documented the resident was confused and had a FSBS of 403 at 3:330 p.m. and a FSBS of 483 at 6:00 p.m. There was no documentation the physician was notified. A care plan, last updated 05/27/21, documented .FOCUS .Diabetes .Goal .I want my FSBS (finger stick blood sugar) level to be WNL (within normal limits) throughout this review .Interventions .Notify my PCP (primary care physician) of any abnormal FSBS .or s/s (sign/symptom) of high/low blood sugars and follow through . A facility document, titled weights and vitals summary, documented a blood sugar reading on 05/29/21 at 6:50 a.m. of 51. There was no documentation the physician was notified. There was no documentation staff had assessed, monitored or intervened for resident's change in condition. On 06/08/21 at 3:30 p.m., the DON was asked what the facility's protocol was for a resident who exhibited an abnormal low or high blood sugar reading. She stated the facility did not have one. She was asked if the physician had parameters for a resident who had an order for insulin. She stated the resident should have physician recommended parameters in the body of their orders. The DON was observed looking in the electronic medical records and stated she did not locate parameters. She was asked when the physician should be notified of abnormal blood sugar reading. She stated an abnormal blood sugar reading would be below 60 or above 250. She further stated the physician would only be notified if intervention for low blood sugar reading was not effective. She was asked to review the progress notes of abnormal finger stick blood sugar reading for the dates 01/15/21, 01/18/21, 01/20/21, 01/22/21 and 05/24/21. She was asked if the facility staff had reassessed, monitored or provided additional intervention for abnormal blood sugar readings. She said, No. At 3:39 p.m., the DON was asked if there was an incident report for the documented injury to resident toe which occurred on 05/07/21. She said, No. She was asked if the resident injury had been monitored. She stated she could not find further monitoring in the resident's medical record. She further stated she would only notify physician and family and complete and incident report if bleeding occurred and would do nothing if it just needed a band aid. At 3:50 p.m., the DON was asked to review the progress note dated 05/23/21 which indicated resident had an injury to the head and was treated with triple antibiotic. She reviewed the document and stated physician and family was not notified, no incident report done and no continued monitoring or further treatment was conducted. She stated the nurse treated the injury and acknowledge the medical record had no order for the triple antibiotic. Based on observations, record reviews and interviews, it was determined the facility failed to: ~obtain a treatment order prior to a treatment being administered; ~assess and monitor finger stick blood sugar (FSBS) results that were below the accepted standard of practice; and ~coordinate care with hospice services. This affected three (#25, #27, and #35) of 16 sampled residents. This had the potential to affect 33 residents who resided in the facility. Findings: 1. Resident #25 had diagnoses to include: dementia; anxiety; major depressive disorder; delusional disorder; peripheral vascular disease; and cellulitis. A nurse's note, dated 03/25/21 at 1:24 p.m., documented, .right thumb is purple in color and 'boggie' He denies pain . A nurse note, dated 03/26/21 at 2:08 p.m., documented, .he was kicking his feet. CNAs noted that he had kicked a toenail off .Triple antibiotic applied with band aid. A quarterly assessment, dated 04/19/21, documented the resident had severe cognitive impairment for daily decision making; required extensive assist for bed mobility, transfers and dressing; was totally dependant of staff for locomotion; did not walk; and had not experienced any falls. The care plan, last updated on 05/19/21, documented the resident had a diagnosis of Peripheral Vascular Disease. Interventions included to monitor extremities for sign/symptoms of injury, infections or ulcers. The current physician orders documented weekly skin evaluations every Wednesday had been initiated on 10/09/19. There was no physician's order documented for the treatment of the toe after the toenail had fallen off. On 06/09/21 at 8:50 a.m., the DON was asked if an order was obtained for the treatment applied to the toe after the nail had fallen off. She stated, I didn't think an order was needed since it was an over the counter medication.

Based on observation, record reviews and interviews, it was determined the facility failed to identify, notify physician/family representative, obtain appropriate treatment orders and monitor pressure wounds for one (#14) of four sampled residents reviewed for pressure wounds/injury. This had the potential to affect all residents that resided in the facility. The Resident's Census and Condition of Residents, documented there were no pressure ulcers/wounds in the facility and had a census of 33. Findings: Resident #14 had diagnosis to include: dementia; vitamin deficiency; toxic affect of spider venom; and hypertension. A quarterly assessment, dated 03/27/21, documented the resident had severe cognitive impairment for daily decision making; poor appetite; required total assistance for bed mobility, transfers, dressing, and bathing; always incontinent of bowel and bladder; at risk for pressure ulcers; did not have unhealed pressure ulcers/injuries; had open lesions other than ulcers; had moisture associated skim damage; and was on a program for turning/repositioning. A nurse's note, dated 04/19/21 4:10 a.m., documented, Open area on coccyx measures 2cm [centimeters]x 2.5cm. Protective cream applied . A nurse's note, dated 04/21/21 at 5:46 a.m., documented, .OPEN AREA ON COCCYX CLEANSED AND CREAM APPLIED . A nurse's note, dated 05/16/21 at 5:26 a.m., documented, .RESIDENT CONTINUES TO HAVE OPEN AREA TO COCCYX. PERI CARE PROVIDED WITH EACH INCONTINENT EPISODE AND CREAM APPLIED . A nurse's note, dated 05/16/21 at 7:58 p.m., documented, .RES [resident] CONT [continues] TO HAVE OPEN AREA TO COCCYX AREA IS CLEANED AND CREAM APPLIED . The care plan, last updated on 05/19/21, documented: ~Resident is at risk for skin breakdown. Interventions include to apply barrier cream to protect skin after incontinent care; ~Self-care deficit for bed mobility had been identifies. Interventions include for staff to assist in turning/repositioning every two hours; and ~Resident had a potential for skin breakdown related to decreased mobility. Interventions include: keep skin clean/dry; remind to reposition frequently; monitor skin condition closely during care and whirlpools. Notify charge nurse of any changes so that she can check on the changes and notify the physician. A nurse's note, dated 05/21/21 at 5:50 a.m., documented, .RESIDENT CONTINUES TO HAVE AN OPEN AREA ON COCCYX, AREA CLEANSED AND CREAM APPLIED AFTER EVERY INCONTINENT EPISODE . A nurse's note, dated 05/27/21 at 4:07 a.m., documented, .RESIDENT CONTINUES TO HAVE AN OPEN AREA TO HER COCCYX, AREA IS SUPERFICIAL AT THIS TIME. NO S/S [signs and symptoms] OF PAIN OR DISCOMFORT NOTED. AREA CLEANSED AND CREAM APPLIED AFTER EACH INCONTINENT EPISODE . On 06/01/21 at 3:20 p.m., the current physician orders documented: ~ A dressing change to be completed daily and as needed for excessive drainage, clean wound with NS, place collagen on packing strip, pack loosely and cover with non-adherent pad, use brief to hold dressing in place; and ~Skin tear to front right hand, clean with normal saline, prepped with skin prep, dress with steristrip and foam border; ~Conduct weekly skin assessments every Thursday for documentation only. On 06/03/21 at 10:18 a.m., on 06/07/21 at 10:26 a.m., and at 2:19 p.m., the resident was observed in bed with her eyes closed. She was positioned on her back. The resident only was observed out of bed for meals in the dining room. A nurse's note, dated 06/03/2021 at 5:42 a.m., documented, .RESIDENT CONTINUES TO HAVE OPEN AREA ON COCCYX THAT APPEARS TO BE HEALING SINCE THE LAST TIME THIS NURSE SAW IT. AREA CLEANSED DURING EVERY INCONTINENT EPISODE AND CREAM APPLIED . A nurse's note, dated 06/04/2021 at 11:32 a.m., documented, .RES CONT TO HAVE OPEN AREA TO COCCYX. AREA CLEANSED AND CREAM APPLLIED . On 06/07/21 at 4:28 p.m., the assistant director of nursing (ADON) was asked if the resident had any skin issues. She stated the resident had a spider bite to the left buttocks approximately two years ago, but the area was healed. An observation of the resident's skin was made with the ADON. The resident was observed in bed laying on her back. She was assisted by three staff to turn to her left side. The resident was observed to have a whitish cream to the buttocks/coccyx area. The ADON stated it is peri guard barrier that they use on the residents after incontinent episodes. An open area was observed to the resident's coccyx approximately 2.5cm around with pink tissue. The ADON was asked when the coccyx wound had developed. Stated she would have to look in the resident's medical records. She looked at medical records, and was asked where staff documented skin issues. She stated nurses chart in nurse's notes and aides document on bath sheets. She stated there was a nurse's note on 04/14/21 and that's the first time it looks like its noted. She was asked if there was documentation of physician and family notification. She stated, She didn't write that, no. She was asked when skin assessments were conducted. She stated they were conducted weekly by the nurses. She was asked what information went on a skin assessment when a resident had a wound. She stated, drainage, size, if it's healing or not, odor, redness, granulated tissue. The ADON was asked if the resident's wound was a pressure ulcer. She stated her best guess would be yes, since it's over a bony prominence. She was asked to locate the weekly skin assessments since 4/14/21. She stated there was one on 04/19/21. She was asked if 04/19/21 was the last time the wound had been measured. She stated, Yes. She was asked what the current treatment order was for the pressure area. She stated, She doesn't have one. She was asked if she should have one. She stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, it was determined the facility failed to ensure residents were free from hazards regarding: ~Safe mode of transfers, and appropriate seating for one (#2) of three sampled residents reviewed for falls. The facility identified 10 residents that required mechanical lifts for transfers. ~Elopement/wandering for one (#16) of one sampled resident reviewed for elopement/wandering; and The facility census was 33. Findings: 1. Resident #2 had diagnosis to include: Alzheimer's Disease; bilateral osteoarthritis of the hip; atrial fibrillation; hypokalemia; heart failure; and hypertension. A nurse's note, dated 02/05/21 at 9:01 p.m., documented, .while transferring with sit to stand res'd [resident's] knees bent and he began to slide down, lowered easily to floor by staff .staff instructed to use full body lift for transfers . A monthly summaries report for February 2021, dated 03/26/2021 at 12:29 a.m., documented, .on 02/05/21 resident had a fall in his room (slid out of the sit-to-stand.) . The care plan, last updated on 04/02/21, documented: ~Resident was unable to ambulate unassisted; ~Resident was a high risk for falls. Interventions included staff were to anticipate needs; review information from past fall to determine root causes and remove any potential causes if possible; and ~Resident experienced an actual fall while trying to get of the recliner, slid to the end of the recliner and fell. The intervention included to check on resident frequently and anticipate his needs. The care plan did not address the safest mode of transfers, or review further interventions regarding lift chair/recliner as continued increase for falls. A nurse's note, dated 04/10/21 at 4:17 p.m., documented, .resident had slipped out of recliner in his room and onto the floor . A nurse's note, dated 05/03/21 at 2:45 p.m., documented, .Resident observed sitting on floor in front of recliner with back leaning against recliner .Answers yes when asked if he slid out of recliner. Chair pad underneath resident on floor . A quarterly assessment, dated 05/28/21, documented the resident had severe cognitive impairment for daily decision making; required limited assistance for bed mobility; required extensive assistance for transfers and toileting; was frequently incontinent of bowel and bladder; and had experienced two or more falls, without injury, since the prior assessment. The current physician's orders documented the resident was to use a high/low bed for fall precautions and a wheelchair for mobility. On 06/03/21 at 10:18 a.m., Resident #2 was seated in a wheelchair near the nurse's desk. Observations made in the resident's room. A lift chair/recliner is in the room, in a normal seated position. On 06/07/21 at 10:29 a.m., and 2:22 p.m., the resident is observed to be seated in a wheelchair in the in common area. The room was observed with a lift chair/recliner in an seated position, with an incontinent pad in the seat of the chair. On 06/08/21 at 10:54 a.m., the resident was observed in a wheelchair in the common area. The residents room was again observed with a lift chair/recliner with an elevated/standing position with an incontinent pad in the chair. At 3:00 p.m., the resident was being assisted into activities. The resident's room was again observed with the lift chair/recliner was again in an elevated/standing position with an incontinent pad in the chair. At 3:23 p.m., the DON was asked if the resident's use of the recliner had been assessed as a restraint due to the falls related to the lift chair/recliner in reference to the incidents on 04/10/21 and 05/03/21. The DON stated the resident had not been assessed for the recliner to be a restraint due to it did not prevent his movement. She stated, It would be an increased fall risk. The DON was asked if the lift chair/recliner was still used for the resident. She stated not as much as it used to be. The resident will sit in the recliner for a while then forgets he cannot put the feet down and climbs out enough the chair tips forward. The DON was asked if the resident had been assessed for the safest mode of transfers. She stated the transfer depends on the resident's mood and the staff would use a sit-to-stand or a transport. She was asked who would determine the mode of transfer. She stated the nurse aides determine the mode of transfer. At 4:29 p.m., certified nurse aides (CNA) #1 and #2 were asked if they ever allowed resident #2 the opportunity to be in the recliner. CNA #2 stated not very often. The resident might take a short nap and then he is restless and tries to climb out of the recliner and falls. The CNAs were asked how the resident was transferred. They stated they use the sit-to-stand lift. They pointed to two lifts in the hallway to show the surveyor. The transport has a platform to position the feet and a small cross bar for the resident to hold. There were no grab bars/handles, safety harness/belts, or attachments to assist the resident to remain standing/balanced during the transfer. The CNAs were asked if the resident was transferred with the sit-to-stand or the transporter when he slide out of the sit-to-stand. They acknowledged they did not know. 2. Resident #16 was admitted [DATE] with diagnoses which included Alzheimer's disease, macular degeneration bilateral, atrial fibrillation, diabetes mellitus, arthritis, hypertension and anxiety. A quarterly assessment, dated 04/01/21, documented the resident was severely impaired in cognition and required limited assistance with most activity of daily living. The assessment documented the resident had no wandering behaviors. A progress note, dated 01/28/21 at 7:07 p.m., documented the charge nurse was informed by dietary staff the resident had pushed the north hall exit door open and had front wheels of the wheel chair across the door frame before resident was assisted back into the facility. A care plan, last revised on 04/08/21, documented, Focus .wandering .I have been noted to be wandering in the halls going into and out of other residents rooms .Goal .I want to safely be able to go where I want in the facility without getting into other residents rooms .Intervention . I have not attempted to elope - I am comfortable with my home . Please explain to other residents that I get confused at times, and I don't mean to go into their room to cause any harm .Please redirect me when I go into other residents room. I usually go into the same residents rooms, which are located on the other hall in approximately the same location as my own .Show me where my room is - be patient with me- this is very upsetting for me . A progress note, dated 05/26/2021 at 8:37 p.m., documented resident was exit seeking out the door near the laundry room. Resident had got outside and staff had gotten her back in. On 06/07/21 at 10:30 a.m., the resident was observed unzipping the entrance to the isolation area at the end of hall 200 into 100. At 12:40 p.m., resident was observed at the end of hall 200 near the activity office sitting in her wheel chair. No staff was present. At 2:47 p.m., resident remained at the end of hall 200 and staff observed walking by resident with no attempts to redirect or assist resident. At 3: 12 p.m., the resident was observed propelling self towards nurse's station and up hall 300. At 3:39 p.m., resident observed entering room [ROOM NUMBER] and was assisted by staff out of room. Staff assisted resident back to her room. On 06/08/21 at 12:03 p.m., the DON was asked to review the progress note dated 05/26/21 where it documented resident had exited the building unaccompanied by staff. She was asked if the resident care plan indicated resident was exit seeking and had eloped the building without staff knowledge. She said, No. She further stated she had no knowledge resident had exited the building. At 1:55 p.m., the DON stated she was informed by the nurse who made the entry on 05/26/21 that the resident had attempted to follow a staff who exited the facility to smoke and was outside the building for two seconds. She was asked about the documented two occurrence of resident attempting to leave (elope) the building and the safety concern of her unknowingly exiting the building. She stated the staff depended on the door alarming. She was informed that the doors alarmed and the alarm was not heard at the far end of 200 hall. She was informed of observation of resident unzipping entrance to the isolation area at the end of hall 200 into 100. She said, She always does that.

Based on observation and staff interviews, it was determined the facility failed to ensure staff were properly trained to be competent to use a suction machine for one (licensed practical nurse [LPN] #1) of one staff member observed demonstrating the use of a suction machine. Findings: On 06/03/21 at 9:19 a.m., during a medication storage task, certified medication aide #1 was asked asked where the suction machine was located. She stated it was in a locked oxygen room. At 9:31 a.m., LPN #1 was asked to show this surveyor the suction machine. The suction machine was observed to have a piece of tubing connected from the canister to a piece of suction tubing. There was no tubing connected the canister to suction machine which would create the suction. She was asked to plug the machine in and show how it worked. She plugged it in and turned it on. She was observed to put the tip of the suction tubing to her hand and stated, It's not suctioning. She stated, I think I need to put some water in there. She was pointing to the canister. The assistant director of nursing (ADON) was standing near by and came and attached the appropriate tubing and showed LPN #1 how it worked. She stated, She's a new graduate. LPN #1 stated this was the first time she had seen this suction machine. At 9:37 a.m., the ADON was asked how long LPN #1 had been here as a nurse. She stated, Almost a year. She was asked what type of training she had received upon hire. She stated she had trained three days on day shift, two days on evenings and two on nights. She was asked if staff were trained on how to use suction machines. She stated, Yes, that's a new one though and not everyone has been in-serviced on it. She was asked how long the facility has had the new suction machine. She stated, Less than 6 months. She was asked if staff should be in-serviced on the new machine. She stated, You would think she would've learned on the newer machines in school.

Based on record review and interview, it was determined the facility failed to ensure a medication regimen review was thoroughly conducted to ensure irregularities were identified and reported. This affected two (#2 and #14) of five sampled residents whose records were reviewed for unnecessary medications. The facility census was 33. Findings: 1. Resident #2 had diagnosis to include Alzheimer's Disease, and major depressive disorder. A quarterly assessment, dated 02/25/21, documented the resident had severe cognitive impairment for daily decision making; had not displayed mood or behaviors; had been administered an anti-depressant seven of seven days of the assessment. The care plan, last updated 04/02/21, documented the resident had a diagnosis of depression. Interventions included for staff to monitor/document/report as needed of any signs/symptoms of depression. The care plan did not address the resident was taking an anti-depressant or the side effects that should be monitored. The current physician's orders documented the resident was to be administered Sertraline 150 mg every morning. Monthly Medication Regimen reviews for 3 months were reviewed. There was no documentation of irregularities regarding the resident was not being monitored/documented for signs/symptoms of depression or side effects of an anti-depressant. On 06/07/21 at 2:40 p.m., the assistant director of nurse's (ADON) was asked to provide information the Sertraline/antidepressant was being monitored for effectiveness and/or side effects. She reviewed the record and stated, It does not have one. At 3:53 p.m., the DON was informed of the above findings. She acknowledged the resident had not been monitored for effectiveness that would require the need for an anti-depressant or for the potential side affects of taking an anti-depressant. She was asked if the pharmacy consultant had identified, in the monthly review, that the resident should have been monitored for behaviors and/or side effects. She stated she did not know and would look in the information provided by the pharmacy consultant. No further information was provided 2. Resident #14 had diagnosis to include dementia, and major depressive disorder. A quarterly assessment, dated 03/27/21, documented the resident had severe cognitive impairment for daily decision making; experienced sleep disturbance, alterations in appetite and slow or restless during the 14 day assessment; and had been administered an antidepressant 7 of 7 days of the assessment. The care plan, last updated on 05/19/21, documented the resident had a diagnosis of major depressive disorder. Interventions included for staff to monitor side effects of the anti-depressant and notify the physician for increases signs of depression. The current physician orders documented the resident was to receive Citalopram, an antidepressant, 20 mg daily for major depressive disorder. The clinical record did not contain documentation the resident was being monitored for signs/symptoms of depression or for side effects caused by the administration of an anti-depressant. Monthly Medication Regimen by the consultant pharmacists were reviewed for the past 3 months. There was no documentation the consultant pharmacists had identified the resident had not been monitored for signs/symptoms of depression and/or the potential for side effects due to the administration of an anti-depressant. On 06/07/21 at 2:43 p.m., the assistant director of nurses (ADON) was asked if the if resident had been monitored for behaviors of depression and/or side effect of taking an anti-depressant. She reviewed the record and stated there was no monitoring. At 2;50 p.m., DON and MDS #1 were asked if resident had been monitored, for behaviors of depression or side effects of an anti-depressant. After they reviewed the record, The DON stated, No. The DON was asked if the pharmacy consultant had identified the resident was taking an anti-depressant without behavior or side effect monitoring. The DON stated she would look. No further information was provided.

Based on record review and interviews, it was determined the facility failed to ensure a residents who received anti-depressant medications were monitored for the effectiveness and/or side effects from an anti-depressant medication. This affected two (#2 and #14) of five sampled residents whose records were reviewed for unnecessary medications. The facility facility identified 21 residents who received anti-depressant medications. Findings: 1. Resident #2 had diagnosis to include Alzheimer's Disease, and major depressive disorder. A quarterly assessment, dated 02/25/21, documented the resident had severe cognitive impairment for daily decision making; had not displayed mood or behaviors; had been administered an anti-depressant seven of seven days of the assessment. The care plan, last updated 04/02/21, documented the resident had a diagnosis of depression. Interventions included for staff to monitor/document/report as needed of any signs/symptoms of depression. The care plan did not address the resident was taking an anti-depressant or the side effects that should be monitored. The current physician's orders documented the resident was to be administered Sertraline 150 mg every morning. Monthly Medication Regimen reviews for 3 months were reviewed. There was no documentation of irregularities regarding the resident was not being monitored/documented for signs/symptoms of depression or side effects of an anti-depressant. On 06/07/21 at 2:40 p.m., the assistant director of nurse's (ADON) was asked to provide information the Sertraline/antidepressant was being monitored for effectiveness and/or side effects. She reviewed the record and stated, It does not have one. At 3:53 p.m., the DON was informed of the above findings. She acknowledged the resident had not been monitored for effectiveness that would require the need for an anti-depressant or for the potential side affects of taking an anti-depressant. 2. Resident #14 had diagnosis to include dementia, and major depressive disorder. A quarterly assessment, dated 03/27/21, documented the resident had severe cognitive impairment for daily decision making; experienced sleep disturbance, alterations in appetite and slow or restless during the 14 day assessment; and had been administered an antidepressant 7 of 7 days of the assessment. The care plan, last updated on 05/19/21, documented the resident had a diagnosis of major depressive disorder. Interventions included for staff to monitor side effects of the anti-depressant and notify the physician for increases signs of depression. The current physician orders documented the resident was to receive Citalopram, an antidepressant, 20 mg daily for major depressive disorder. The clinical record did not contain documentation the resident was being monitored for signs/symptoms of depression or for side effects caused by the administration of an anti-depressant. Monthly Medication Regimen by the consultant pharmacists were reviewed for the past 3 months. There was no documentation the consultant pharmacists had identified the resident had not been monitored for signs/symptoms of depression and/or the potential for side effects due to the administration of an anti-depressant. On 06/07/21 at 2:43 p.m., the ADON was asked if the if resident had been monitored for behaviors of depression and/or side effect of taking an anti-depressant. She reviewed the record and stated there was no monitoring. At 2;50 p.m., DON and MDS #1 were asked if resident had been monitored, for behaviors of depression or side effects of an anti-depressant. After they reviewed the record, The DON stated, No.

Based on observation, record review, and interview, it was determined the facility failed to: ~ensure menu was followed for residents who received a puree diet; The DM identified seven residents who had a physician prescribed pureed diet. ~ensure substitute of meal item was approved. The DM identified 31 residents who resided in the facility and received nutrition from the kitchen. Findings: A facility menu, signed by the registered dietician, date signed 03/25/21, documented, week 5 day 3 .menu item .lunch .Pork chops, garlic potatoes, peas and carrots (carrots marked out) and dinner roll . .week 6 day 2 .menu item .lunch .chicken strips, mac n (and) cheese, corn, and roll . On 06/01/21 at 11:44 a.m., lunch meal was observed. [NAME] #1 was observed to plate pureed pork chop, pureed potatoes and pureed green peas for seven residents with order for pureed texture. No pureed roll was observed. On 06/02/21 at 10:00 a.m., the DM was asked to provide a detailed/ extended menu. She stated the facility did not have a detailed menu and could go type one up. She stated a menu book was utilized which was approved by the dietician. She stated the menus were daily menu with the week listed. The DM provided copies of the daily menus requested. The facility had no expanded/detailed menu to provide to the surveyor when requested. On 06/07/21 at 11:05 a.m., cook #2 was observed preparing the pureed meal and was assisted by the DM. The following was observed: ~seven serving of green peas was pureed, ~when pureeing seven servings of chicken, she added undisclosed amount of chicken paste with an undisclosed amount of hot water, ~ when pureeing seven servings of macaroni and cheese, she added an undisclosed amount mixture of chicken paste and hot water, ~ no rolls were observed to be pureed. At 11:35 a.m., the DM was observed to plate pureed chicken, pureed macaroni and cheese, and pureed peas for three residents. No pureed roll was observed being provided to the residents. At 11:44 a.m., the DM was observed to plate an additional three pureed plates with no pureed roll offered. At 11:46 a.m., the DM was asked if roll was served to residents who had a physician diet order for pureed texture. She said, We never serve roll/bread because it would just be milk and bread. At 11:50 a.m., the DM was asked if the green peas served for lunch was on the daily menu signed by the registered dietician. She stated corn was on the signed menu and was substituted with peas. She was asked to provide a signed document the registered dietician approved substitution of meal item. During the time of survey no additional information was received.

Based on observation and interview, it was determined the facility failed to ensure the recommended final internal cooking temperature for food was monitored and recorded documented for safe consumption. The facility identified 31 residents who received nutrition from the kitchen. Findings: On 06/01/21 at 12:11 p.m., cook #1 was asked how often internal temperature was monitored and documented to determine the internal food cooking temperatures for safe consumption. She stated she had been instructed to check the temperature and document the reading only once before food is served from hot tray line. She stated the internal temperature of all hot cooked food should be no less than 141 degrees. On 06/03/21 at 12:16 p.m., the DM was asked what the policy was for checking and recording the internal temperature of food after cooking. She stated she was unsure when the temperature should be monitored and documented. She stated she was able to check and after verification will have the staff to monitor and record cooking temperature and serving temperature.

Based on observation, interview, and record review, it was determined the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The facility failed to: ~ Ensure thermometer were cleaned and sanitized by staff after each use; ~ Ensure staff performed hand hygiene during meal service; and ~ Ensure tracking and trending were conducted. This had the potential to affect all 33 residents who resided in the facility. Findings: 1. On 06/08/21 at 11:03 a.m., cook #2 was observed at nurse's station. She was observed picking up the thermal thermometer, placed it directly to forehead pressed the button. She then removed from forehead, placed the thermometer back on the nurse's station and wrote on the clipboard. She was not observed to clean and sanitized the thermometer after use. At 11:04 a.m., certified nurse aide/mediation aide #2 was observed at the nurse's station. She was observed picking up the thermal thermometer, placed it directly to forehead pressed the button. She removed from forehead, looked at the thermometer, placed the thermometer back on the nurse's station and wrote on the clipboard. She was not observed to clean and sanitize the thermometer after use. At 11:22 a.m., housekeeper #1 was observed at nurse's station. He was observed picking up the thermal thermometer, placed it on his forehead and took his temperature. He removed from forehead, looked at the thermometer, placed the thermometer back on the nurse's station and wrote on the clipboard. He was not observed to clean and sanitize the thermometer after use. At 11:24 a.m., ADON/IP was asked about screening and monitoring of staff. She stated the staff self- screened by taking their own temperature at start of shift, after break and at the end of their shift. At 11:54 a.m., ADON/IP was asked how the facility ensured thermometers were sanitized between each use. She stated the thermometer was a thermal thermometer and did not require sanitizing. She replied, It is no touch to skin. She was informed of observation of improper use of thermal thermometer and not cleaning/sanitizing after use. She acknowledge and observed to sanitize the thermal thermometer and placed back on the nurse's station. 2. On 06/01/21 at 11:35 a.m., the noon meal service was observed. Residents #2, #36 and #13 were seated together at an assisted table. CNA #4 was seated next to resident #36 while she provided assistance with her meal. Resident #13 was feeding herself while conversing with others. Resident #2 had been provided fluids and was drinking fluids which were positioned directly in front of him. Dietary staff provided a meal/plate to the right of the resident. Utensils were placed further right. At 12:15 p.m., resident #2 continued to drink fluids, placed his fingers in a dessert bowl, licked his fingers, and continued with drinking fluids. At 12:25 p.m., resident #2, propelled his wheelchair from the table while he continued to drink fluids. He remained near the table. At 12:27 p.m., CNA #4 got up from her chair where she assisted resident #36, moved resident #2 back to his original place setting, placed his plate of food in front of him, unwrapped the utensils and handed to resident #2. She then returned to her seat next to resident #36 and continued to assist #36 with her meal. The CNA did not wash/clean her hands at any time during the change of resident #36 to resident #2, back to resident #36. On 06/08/21 at 3:23 p.m., the DON was asked when staff are to sanitize/clean hands in regards to resident care. She stated they should clean/wash hands between residents. She was informed her of the observations in dining room with staff leaving a resident to assist another resident, return to first resident without cleaning hands. She stated they should have used alcohol between residents. The DON was asked if the facility had a policy for hand cleaning/sanitation. She stated yes and would look for one. She acknowledged there was a problem with the staff not cleaning hands between residents. No further information was provided. 3. Infection control logs documented the following: ~ January 2021- two urinary tract infections (UTIs), one upper respiratory infection and two wound/skin infections, five started on antibiotic therapy (ABT), ~ February 2021- two wound/skin infections, two started on ABT and four required COVID precautions, ~ March 2021- one wound/skin infection, two other infections, three started on ABT, and ~ April 2021- two UTIs, 23 gastro-intestinal, one other, three started on ABT. The logs documented symptom on-set dates, ABT dates and resolution dates. There was no documentation in the infection control logs to indicate the facility had been tracking and trending infections for the month of May 2021. On 06/09/21 at 9:43 a.m., the director of nursing was asked for May 2021 infection control logs and any trending and in-service related to the above findings. She stated the assistant director of nursing handled the infection control and was not in the facility at the time. She stated as far as trending and education, they talked about it, but it's not documented. She was informed of the lack of trending and in-service. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain an effective pest control program in the kitchen. The facility identified 31 residents who received meals prepare in the kitchen. Findings: On 06/01/21 at 11:58 a.m., live roaches were observed crawling on the floor in the kitchen during meal service. There were two roaches observed. [NAME] #1 observed stepping on one of the roaches killing it and stated the facility was having trouble with roaches. On 06/02/21 at 12:20 p.m., dietary manager was asked if there was a pest control problem in the kitchen. She stated the exterminator had been four times in the past two to three months and the administrative staff and maintenance were aware. At 12:40 p.m., the administrator was asked what the policy was to ensure the facility was free of pests. She stated pest control comes monthly and when requested. She stated she was aware of issues with roaches and spiders.

Based on observation, record review and staff and resident interviews, it was determined the facility failed to ensure residents had the right to unrestricted visitation. The Resident Census and Conditions of Residents report, documented 33 residents resided in the facility. Findings: The Centers for Medicare and Medicaid Services (CMS) guidance titled In-Person Nursing Home Visitation, dated 03/16/21, documented , .visitation should be allowed at all times .regardless of vaccination status .visitors should be able to adhere to core principles .if fully vaccinated, a resident may choose close contact (including touch) with their visitor while wearing a well-fitting face mask and performing hand hygiene before and after . On 06/01/21 at 10:31 a.m., during the entrance conference, the administrator was asked how visitation was being conducted. She stated they used a visitation room. She was asked how visits were scheduled. She stated family called the facility and got put on the calendar for the day they requested to come visit. She was asked how long they were allowed to visit. She stated they scheduled visits for an hour they they could stay longer if another family member was not waiting. The ADM was asked if only one resident could have a visitor at a time. She stated, Yes, inside. She stated they also had outdoor visitation.

Based on observation, record review and staff and resident interviews, it was determined the facility failed to ensure residents had informed of their right to receive visitors. The Resident Census and Conditions of Residents report, documented 33 residents resided in the facility. Findings: The Centers for Medicare and Medicaid Services (CMS) guidance titled In-Person Nursing Home Visitation, dated 03/16/21, documented , .visitation should be allowed at all times .regardless of vaccination status .visitors should be able to adhere to core principles .if fully vaccinated, a resident may choose close contact (including touch) with their visitor while wearing a well-fitting face mask and performing hand hygiene before and after . On 06/01/21 at 10:31 a.m., during the entrance conference, the administrator was asked how visitation was being conducted. She stated they used a visitation room. She was asked how visits were scheduled. She stated family called the facility and got put on the calendar for the day they requested to come visit. She was asked how long they were allowed to visit. She stated they scheduled visits for an hour they they could stay longer if another family member was not waiting. The ADM was asked if only one resident could have a visitor at a time. She stated, Yes, inside. She stated they also had outdoor visitation.

Based on record review and staff interview, it was determined the facility failed to ensure grievances made by residents/family representatives were documented, investigated and resolved and the documentation was maintained. The Resident Census and Condition of Residents report, documented 33 residents resided in the facility. Findings: A grievance policy, dated 10/24/18, documented, .that each resident has the right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal .will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The facility grievance process will be overseen by a designated Grievance Official who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations, maintaining the confidentiality of all information associated with grievances, communicate with the residents throughout the process to resolution .objective of the grievance policy is to ensure .prompt efforts to resolve grievances a resident may have .to support each resident's right to voice grievances .and to assure that after receiving a grievance .actively seeks a resolution . A grievance log documented three grievances had been made in 2018 and 2019. There was no documentation of grievances for 2020 or 2021. On 06/02/21 at 8:50 a.m., the administrator (ADM) was asked who was responsible for handling grievances. She stated, Usually [social service director] or whoever they come to. She was asked how residents and family representatives put in a grievance. She stated, They just come up and talk to you. She stated several came to her or the social service director. The ADM was asked if the grievance log they had provided contained all the grievances since the past recertification survey. She did not respond. She was asked if staff documented grievances on a grievance form or log. She stated, Not always. She stated, We just try to fix the problem. The ADM was asked what she would consider a grievance. She stated if a resident was missing clothes they would just go through closets and the laundry room, find the items and return them. She stated the nurses sometimes documented a nursing communication in the electronic medical record (EMR) if a resident had something missing. At 9:56 a.m., the assistant director of nursing informed the ADM that there was no documentation of grievances in the nurses communication in the EMR. She stated the social service director did not have any documentation of grievances.

Based on observation, interview, and record review, it was determined the facility failed to: ~ ensure the ice machine was cleaned and ~ensure dishes and utensils were cleaned under sanitary conditions. The administrator identified 33 residents who received their meals from the kitchen. Findings: 1. On 06/3/21 at 11:10 a.m., the dietary manager (DM) was asked to unlock the ice machine located in the dining room. The ice machine drop was wiped with a clean white cloth in the presence of the dietary manager. Pink slime substance was observed on the cloth. The DM stated the ice machine was cleaned twice a year by maintenance. She stated maintenance would be notified and the ice machine would not be utilized. At 11:15 a.m., dietary aide #2 was stopped by this surveyor from serving residents prefilled ice water to residents seated in the dining room for lunch. At 11:20 a.m., the DM stated the ice machine was last cleaned March 2021. At 12:40 a.m., the administrator was notified and acknowledged the findings. A request was made for the ice machine cleaning logs. On 06/07/21 at 10:35 a.m , a hand written document titled Ice machine/ cleaned and sanitized, documented 03/29/21 was the last date the ice machine was cleaned. At 10:36 a.m., the administrator reported bagged ice would be utilized to replace use of the ice machine. She stated maintenance could not clean ice machine. 2. On 6/03/21 at 12:27 p.m., Dietary aide #1 was asked to perform the dish machine sanitizing check. The DM was observe to run the dish machine and dietary aide #1 placed test strip with no reading observed. The DM changed the heavy duty rinse additive and the concentrated dish machine detergent. The DM was observed to make three more attempts to test the chemical reading of the dish machine. All three test strips observed with no indication the dish machine was functioning properly. At 12:34 p.m., the DM stated the test strip utilized not good. The test strip was observed with expiration date of September 2022. At 12:36 p.m., the DM was asked if the dishes and utensils were cleaned under sanitary conditions. The DM stated she could observe the chemicals dispensing into the dish machine. She was asked how she could verify the proper chemical sanitization since the test strips had no readings after four separate attempts. She stated she would notify [named company] to report concern.