Based on interview and record review it was determined the facility failed to ensure call lights were in reach for 1 of 3 sampled residents (#287) reviewed for environment. This placed residents at risk for unaddressed individual needs. Findings include: Resident 287 was admitted to the facility in 8/2024 with diagnoses including palliative care and diabetes. A 8/5/24 care plan indicated staff were to respond immediately to Resident 287's need for pain relief. On 8/13/24 at 1:45 PM Resident 287 was observed in bed and her/his call light was not within reach. On 8/13/24 at 2:11 PM Staff 35 (CNA) stated she neglected to ensure Resident 287's call light was within reach after she provided her/his care around noon. On 8/14/24 11:37 AM Staff 4 (RNCM) stated Resident 287 was able to use her/his call light and expected the resident's call light would be within reach when she/he was alone in her/his room. Staff 4 stated staff would be re-educated to ensure Resident 287's call light was within reach. On 8/15/24 at 2:09 PM Resident 287 was observed in bed and her/his call light was not within reach. On 8/15/24 at 2:10 PM Staff 4 was notified Resident 287 did not have her/his call light within reach and confirmed her/his call light should be within her/his reach.

Based on interview and record review it was determined the facility failed to address a grievance for 1 of 4 sampled residents (#20) reviewed for ADLs. This placed residents at risk for unresolved grievances. Findings include: Resident 20 admitted to the facility in 6/2021 with a diagnosis of a stroke. A 11/20/23 Interdisciplinary Conference form revealed Resident 20 reported she/he requested assistance from a CNA and the CNA refused to assist. The form indicated the resident care manager was to follow up with the concern. On 8/15/24 at 8:35 AM Staff 9 (Social Services Director) stated if a resident voiced a concern at a care conference staff were to follow-up with the concern. Staff 9 stated Staff 28 (Staffing) was to review the schedule and determine the CNA who worked with the resident. Staff 9 stated she maintained all the grievances and she did not have a grievance for Resident 20's 11/20/23 concern. On 8/15/24 at 9:47 AM Staff 28 stated if a resident voiced a concern a grievance was to be initiated. Depending on the situation, she or nursing staff would address the resident concern and follow-up with the resident. Staff 28 stated she did not recall Resident 20's grievance. On 8/16/24 at 9:23 AM Staff 4 (RNCM) stated she did not recall the 11/20/23 grievance.

Based on interview and record review it was determined the facility failed to ensure allegations of abuse were reported to administration for 1 of 5 sampled residents (#85) reviewed for accidents. This placed residents at risk for abuse. Findings include: Resident 85 admitted to the facility in 1/2013 with a diagnosis of stroke. A 7/31/23 Progress Noted by Staff 20 (Agency LPN) revealed the nurse on the previous shift (not identified) reported she may have placed the suction tip too far into the resident's throat to suction secretions and blood was observed in the suction tubing. On 9/23/24 Witness 2 (Complainant) reported to the state agency facility staff were aware of an incident when a CNA held Resident 85's hands down in order for the nurse to suction the resident's secretions. On 8/13/24 at 5:40 PM Staff 32 (Former CNA) stated she heard another CNA held down Resident 85's hand while the nurse suctioned the resident. On 8/13/24 at 6:07 PM Witness 4 (Anonymous Staff) stated she was aware of a situation when the night nurse had a CNA hold down Resident 85's hand so the nurse could suction the resident. Witness 4 stated she reported to Witness 3 (Anonymous Staff) On 8/13/24 at 7:51 PM Witness 3 stated a CNA reported to her, during Resident 85's care, another CNA held the resident's hands down. Witness 3 directed the CNA to report the concern to administration. On 8/14/24 at 3:12 PM Staff 16 (Regional Nurse) stated if staff had any concern that another staff member held down a resident's hands during care, it was to be reported and an investigation would be initiated. On 8/14/24 at 3:30 PM Staff 1 (Administer) stated she was just made aware of the allegation a CNA held down Resident 85's hands therefore a FRI was not submitted at the time of the 7/31/23 incident.

Based on interview and record review it was determined the facility failed to develop a person-centered care plan for 1 of 1 sampled resident (#30) reviewed for tube feeding. This placed residents at risk for lack of identified needs. Findings include: Resident 30 admitted to the facility in 3/15/24 with diagnoses including brain damage, quadriplegia (paralysis of all four extremities), and a feeding tube. An 3/15/24 Care Plan indicated the following for Resident 30: -Toilet use: the resident was independent or had toileting deficits due to quadriplegia and brain damage. The interventions included toilet use, dependant on one staff. Resident 30 was incontinent and did not use the toilet. -Bowel incontinence: the resident will have less than two episodes of incontinence per day. Assess pattern of incontinence and indicate toileting schedule if indicated. -Transfers: the resident was independent or had transferring performance deficits due to quadriplegia and brain damage. Interventions were three or more staff assistance with slide transfer to bed and wheelchair. Resident 30 used a mechanical lift for transferring. -Eating: The resident was independent or had eating performance deficits due to quadriplegia and brain damage. The goal included the resident will be able to eat in the highest practical level for their current condition. Resident 30 received nourishment and medications through her/his feeding tube. -Dressing: the resident was independent or had dressing performance deficits due to quadriplegia and brain damage. Interventions included to assist the resident to choose simple comfortable clothing that enhanced the resident's ability to dress her/himself, and to make sure shoes were comfortable and not slippery. On 8/15/24 at 11:57 AM Staff 7 (RNCM) acknowledged Resident 30's care plan was not individualized or person-centered and should have been.

Based on interview and record review it was determined the facility failed to suction a resident safely, and failed to follow diabetic orders for 2 of 9 sampled residents (#s 7 and 85) reviewed for accidents and medications. This placed residents at risk for injury and delayed treatment. Findings include: 1. Resident 7 admitted to the facility in 7/2020 with a diagnosis of diabetes. A 7/2024 Diabetic Administration Record (DAR) revealed staff were to implement the hypoglycemic protocol (provide juice, sugar or medication to increase a resident's low blood sugar level) if Resident 7's CBG level was less than 60. The DAR revealed on 7/16/24 at 7:00 AM Resident 7's CBG was 48. The Diabetic Administration Record did not indicate the hypoglycemic protocol was implemented. A 7/16/23 Progress Note contained no information staff provided interventions when Resident 7's CBG level was 48. On 8/1/24 at 9:09 AM Staff 4 (RNCM) stated if a CBG level was less than 60 staff should have provided interventions, re-checked the CBG level after interventions were provided, and documented in the resident's clinical record. Staff 4 verified the resident's record did not indicate the hypoglycemic protocol was followed. 2. Resident 85 admitted to the facility in 1/2013 with a diagnosis of stroke. A Care Plan initiated 12/2014 revealed Resident 85 was at times resistive to care and had a communication deficit due to a stroke. If the resident bats away staff or pushes them away it indicated Resident 85 did not want to participate in something. Staff were to allow Resident 85 to make choices. A Progress Note by Staff 20 (Agency LPN) dated 7/31/23 revealed the nurse on the previous shift reported she may have inserted the suction tip too far into Resident 85's throat to suction secretions and blood was observed in the suction tubing. A 7/31/23 hospice Staff Progress Notes revealed facility staff reported Resident 85 was suctioned too deep by facility staff and she/he had dried blood in her/his mouth. The note indicated Resident 26 did not appear to be actively bleeding. On 8/13/24 at 6:07 PM Witness 4 (Anonymous Staff) stated she heard the nurse give report that a CNA held Resident 85's hands down while a nurse suctioned the resident and the resident bled. On 8/13/24 at 3:25 PM Staff 2 (Assistant DNS) stated she did not recall an incident related to Resident 85's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 27 admitted to the facility on 12/2023 with diagnoses including stroke and diabetes. A 12/19/23 admission Profile assessment indicated Resident 27 had pressure to the coccyx (tailbone). The pressure area was described as purple, non-blanchable, and not currently open. Calazime (a skin protectant) cream was to be applied during skin checks. No wound measurements were obtained. A 12/29/23 Pressure Ulcer CAA indicated resident 27 was at risk for skin breakdown and pressure injury due to decreased mobility and the need for extensive assistance with toileting. Staff were to provide prompt peri-care for toileting and to notify a nurse of any skin breakdowns or injuries. The CAA did not include any information regarding the pressure to Resident 27's tailbone. A review of Resident 27's clinical record from 12/30/23 through 4/3/24 (106 days), revealed the following: -No weekly wound round assessments were initiated. -The Weekly Skin Check Body Diagram and the TARs had no information or monitoring of Resident 27's coccyx pressure ulcer. An 4/3/24 Pressure Injury investigation revealed Resident 27 reported pain and discomfort to his/her buttock region. The resident exhibited dark purple discoloration on both bilateral buttocks and tailbone; wound measurements were completed. Staff 3 (LPN) notified Staff 30 (LPN Resident Care Manager) the wound nurse. An 4/3/24 Initial Skin Ulcer/Injury Measurement and Evaluation completed by Staff 30 revealed the resident had a facility-acquired DTPI (deep tissue pressure injury [persistent non-blanchable deep red, maroon or purple discoloration]) to the bilateral buttocks. The suspected DTPI had multiple, purple/maroon localized areas of discolored intact skin from pressure and/or shearing with repositioning or transfers. Wound measurements were obtained and treatment was initiated. Weekly wounds rounds and treatments were implemented on 4/4/24. On 7/6/24 a Wound Evaluation assessment indicated Resident 27 had a Stage 2 (partial-thickness loss with exposed dermis) pressure ulcer. The pressure ulcer measured 2.8 cm in length x 1.95 cm in width, with an overall area of 3.68 cm, and no signs or symptoms of infection. The assessment did not identify the location of the wound and indicated it was present on admission. A physician order with a start date of 7/10/24 and discontinued on 7/23/24 instructed staff to cleanse with wound Dakins (a solution to treat wound infections), pat to dry, apply Santyl ointment (helps remove dead tissue) to the wound bed, sprinkle Flagyl (an antibiotic) on the wound bed for odor control, pack with Maxorb AG ribbon (a calcium alginate to treat moderate to heavy draining wounds), apply calazime ointment, cover with a dressing and keep clean and dry every day and evening shift for wound care to left buttocks. A 7/13/24 and 7/20/24 Wound Evaluation assessment indicated Resident 27 had a Stage 3 (full-thickness skin loss) pressure ulcer. The pressure ulcer measured 2.68 cm in length x 1.38 cm in width, with an overall area of 2.41 cm. The assessment indicated the resident's wound had a suspected infection but was improving. A 7/23/24 Wound Clinic document revealed Resident 27 had a Stage 4 (full-thickness skin and tissue loss, undermining and/or tunneling often occur) pressure injury over the left iliac crest (hip bone) as well as the following: -The resident's left iliac crest foam dressing was 100% saturated, and the drainage was purulent (thick milky fluid which oozes from a wound that is not healing properly) and yellow with no odor. -The wound measured 2.8 cm in length x 1.6 cm in width x 2.4 cm in depth with a wound surface of 4.48 cm. The wound had significant depth/tunneling, extending to 7.5 cm. -During the wound debridement three pieces of packing were found in the wound and subsequently removed. -A new order directed staff to change the dressing PRN for saturation of the foam dressing at three to four corners of the foam dressing, remove the packing and heavily irrigate the wound using wound cleanser spray or pressure nozzle wound cleanser, pat the wound dry and fill the wound with ONE continuous piece of silver hydrofiber (soft sterile wound care product) packing. -It was emphasized to ensure ALL packing was removed from the wound before filling the wound with one continuous piece of packing, leaving a three-inch tail for retrieval. In an interview on 8/12/24 at 11:23 AM and 8/14/24 at 11:10 AM Resident 27 stated she/he had a sore on her/his buttocks and was receiving treatment in the facility. Resident 27 stated she/he recently was sent to a wound clinic due to the wound not improving. The resident stated during the wound clinic appointment, the wound nurse discovered old packing deep within the wound, which she had to remove before cleaning and packing the wound. Resident 27 stated this caused her/him extreme pain. In an observation and interview on 8/15/24 at 9:40 AM Staff 3 (LPN) was observed performing wound care for Resident 27. Staff 3 removed the dressing from the resident's left buttock, removed the packing from the wound, discarded her gloves, sanitized her hands, and donned clean gloves. Staff 3 cleansed the wound with a spray, changed her gloves, and applied packing to the inside of the wound. Staff 3 stated the tunneling extended all the way up the left buttock, close to the lower back. Staff 3 placed a dressing over the wound and applied ointment to reddened area around the buttocks. Staff 3 stated she was aware of the wound when it was a stage 2, and staff applied Flagyl due to the wound developing an odor. Staff 3 stated she heard about the wound clinic discovering packing left in Resident 27's wound. Staff 3 stated she did not apply packing into the wound until after the wound clinic appointment. Staff 3 indicated Resident 27 stated it was the worst pain she/he ever had. In an interview on 8/15/24 at 12:44 PM Staff 3 stated the weekly Skin Body Diagram was completed by Staff 30. These diagrams involved a full body scan to ensure no skin breakdown occurred. Staff 3 stated recently the weekly skin checks were reassigned to nurses on the floor. Staff 3 stated she recalled first noticing the wound on Resident 27's buttocks approximately three months ago during a weekly skin check, but she could not recall to whom she reported the concern. The wound care orders directed staff to pack the wound, treat the wound with Santyl ointment, place AG rope on top of the resident's wound, and apply Flagyl for odor control. Staff 3 stated she placed the AG rope on top of the wound because she/he was unaware of any tunneling and indicated she never packed the wound. Staff 3 stated packing a wound meant folding the dressing in half and placing it on top of the wound. Staff 3 stated she only began packing the wound after Resident 27 was seen by the wound specialist on 7/23/24. In an interview on 8/15/24 at 3:34 PM Staff 8 (LPN) stated weekly skin checks were conducted by Staff 30 which involved an entire head-to-toe body check to identify any skin breakdown or wounds. Staff 8 stated recently the weekly skin checks were reassigned to nurses on the floor. Staff 8 did not recall any reports of Resident 27's buttocks until a few months ago. During that time the wound was not open, but resembled a discolored scab without any signs or symptoms of infection. Staff 8 confirmed the wound care orders prior to Resident 27's wound clinic visit instructed staff to pack the wound. Staff 8 explained the term packing referred to covering the site to facilitate absorption, as there was no tunneling to the wound to Staff 8's knowledge. Staff 8 denied packing Resident 27's wound. Staff 8 stated Resident 27 was seen by a wound specialist in 7/2024 and packing was found inside the wound, possibly remaining from previous dressing changes. Staff 8 stated Staff 30 completed weekly wound assessments which involved measurements and a description of the wound, including measuring the length, width, and depth. Interviews conducted on 8/16/24 at 9:28 AM revealed the following: -Staff 4 (RNCM) stated she completed the admission Profile assessment for Resident 27 on 12/19/23 but did not identify the stage of the wound to the tailbone region. Staff 4 sated she was supposed to report her finding to Staff 30 to initiate wound care orders and treatment for Resident 27's pressure to the tailbone. -Staff 30 stated she completed the MDS and the 12/29/23 Pressure Ulcer CAA for Resident 27. Staff 30 stated she reviewed hospital records and spoke with the resident. Staff 30 stated she intended to review the admission Profile Skin assessment, which Staff 4 completed, however Staff 30 acknowledged there was no information about the resident's pressure ulcer on the CAA because she missed reviewing the admission Profile Skin assessment on 12/19/23. Staff 30 stated when she reviewed the 12/30/23 Skin Check Body Diagram there was no information regarding Resident 27's wound to the buttocks, leading her to assume the wound was resolved. - Staff 16 (Regional Nurse) stated Resident 27 had a DTPI, and weekly wound assessments should have been initiated along with monitoring of the wound. Staff 16 acknowledged the three-month delay for monitoring of the DTPI. -Staff 16 and Staff 30 stated Resident 27 showed no signs or symptoms of infection until 7/8/24. The wound culture was negative, and Staff 30 stated to her knowledge there was no noticeable tunneling. On 7/23/24 Resident 27 was sent to the wound specialist where the wound was debrided, tunneling was noted, and old packing was found in the wound. Staff 16 acknowledged the wound orders for Resident 27 instructed staff to pack the wound. Staff 16 explained packing a wound referred to laying a pad across the wound, even if the wound was crater-like, to assist with granulation (development of new tissue). -Staff 30 stated she completed weekly wound assessment and used a sterile cotton swab to measure the deepest point, and monitored the tunneling of the wound. Staff 30 and Staff 16 acknowledged there was no documentation regarding Staff 30 measuring the wound for tunneling. -When asked about current wound care orders for Resident 27, Staff 16 confirmed the order instructed staff to heavily irrigate the wound with cleanser. Staff 16 stated the method of heavy irrigation could vary depending on the specific order. When asked if spraying a wound with wound cleanser constituted heavily irrigated, Staff 16 stated she would clarify the wound order. Staff 16 acknowledged there were significant issues and concerns with wound care. -No information was provided if the wound care order was clarified. Based on observation, interview and record review it was determined the facility failed to accurately assess, investigate, and care plan pressure ulcers for 3 of 4 sampled residents (#s 15, 27 and 28) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: A Skin at Risk Program Overview Policy revised on 4/2018 revealed the following: -Residents who enter the facility without a significant wound do not develop wounds unless their clinical condition demonstrates the wound was unavoidable. -The initial ulcer assessment will be initiated for each new ulcer (pressure, venous stasis, arterial or diabetic) identified, and wound monitoring order added to the resident treatment record as appropriate. -Pressure ulcers will be reviewed weekly during wound rounds. -Weekly measurements for pressure ulcers will be documented on the weekly ulcer evaluation following completion of the initial ulcer assessment. Documentation includes length, width, depth, undermining, tunneling, pain, amount and type of drainage, condition of the wound bed and wound edges. -Development of a stage 2 (partial-thickness loss of skin with exposed dermis) or greater pressure ulcer will be documented on an incident report and investigated per protocol. 1. Resident 15 admitted to the facility in 12/2023 with diagnoses including depression and diabetes. A 12/23/23 admission MDS and Pressure Ulcer and Injury CAA indicated Resident 15 was at risk for skin breakdown due to decreased mobility and her/his need for extensive assistance with toileting. Resident 15 did not have any pressure ulcers and staff were to notify nursing with any signs of skin breakdown. An 4/28/24 Skin Check and Body Diagram revealed there was a scab on the right ankle prominence boney area fell off, float heel and off load to relieve any pressure to avoid skin break down, No new skin issues. The 5/2024 TAR indicated on 5/31/24 Resident 15 started to receive wound treatments with iodine to both of her/his outer ankles every shift and a foam dressing was to be applied for protection. A 6/8/24 Skin and Wound Evaluation (first wound evaluation) indicated Resident 15 had a Stage 2 pressure ulcer on her/his left [NAME] (ankle) on her/his amputation site (Resident 15 did not have an amputation site) and the wound was in the middle. The form indicated the wound was new. A 6/11/24 SOAP (Subjective, Objective, Assessment, Plan) provider note indicated an air mattress for Resident 15 was discussed becaused the resident laid in her/his bed frequently on her/his sides which caused pressure ulcers on the outside of Resident 15's ankles. A 7/13/24 Skin and Wound Evaluation indicated Resident 15 had a Stage 2 pressure ulcer to her/his right Lateral Malleolus (boney joint on the outside of the ankle) and the origin was unknown. A 7/24/24 revised care plan included Resident 15 had the potential for skin breakdown, encourage the resident to float heels and reposition and she/he used body positioning pillows to decrease pressure. On 8/12/24 11:30 AM and 1:18 PM Resident 15 was observed in bed sleeping and no body pillow was used or heels floated to protect her/his ankles. On 8/13/24 at 2:25 PM Resident 15 was observed sitting in her/his wheelchair with foam dressing attached to both of her/his outer ankles. Staff 34 (NA) stated she often assisted Resident 15 and was not aware the resident had any pressure ulcers or what care was necessary to address the needs of her/his ankles. On 8/14/24 at 10:06 AM and 10:49 AM Staff 16 (Regional Nurse) and Staff 30 (LPN-Resident Care Manager) stated when the wounds on Resident 15's ankles were first discovered the wounds were believed to be skin tears. The 6/8/24 wound assessment first identified the wounds as Stage 2 pressure ulcers based on a physician's observation and recommendation. Staff 30 stated she believed Resident 15's ankle wounds were caused when Resident 15 hit her/his ankles against her/his wheelchair foot rests. On 8/14/24 at 1:29 PM Staff 16 acknowledged, based on the data presented and available documentation, there was no initial investigation and appropriate follow-up of the wounds to Resident 15's ankles as expected to understand the root cause of the wounds and the wound assessments were inaccurate once the wounds were identified as pressure ulcers. 3a. Resident 28 admitted to the facility in 2/2024 with diagnoses including bilateral aka (above the knee) amputations and pressure ulcers. The 6/2/24 admission MDS indicated Resident 28 required assistance with bed mobility and was at risk for pressure ulcers to deteriorate and to develop more. Resident 28's skin was monitored for signs of newly developing skin issues. The care plan dated 7/28/24 indicated Resident 28 had excoriation and an open area to the right buttock. An 8/2/24 Skin Ulcer/Injury Measurement and Evaluation Note indicated Resident 38 had a Stage 3 (full-thickness skin loss) pressure ulcer to her/his left buttocks. An 8/12/24 Skin and Wound Evaluation Note indicated Resident 28 had a Stage 2 (partial-thickness skin loss) pressure ulcer to her/his left buttocks. On 8/15/24 at 4:33 PM Staff 16 (Regional Nurse) acknowledged staff assessed the wound inaccurately; Resident 28 had a Stage 2 pressure ulcer not a Stage 3. b. On 8/9/24 a Skin Monitoring Comprehensive CNA Shower Review indicated the resident had no skin issues. The 8/2024 Documentation Survey Report indicated Resident 28 had a skin observations performed on 8/12/24 and 8/13/24 on all shifts, and no skin concerns were observed. On 8/12/24 at 1:27 PM Resident 28 was is observed to have an open area approximately the size of a nickel on the right stump underneath the leg prosthesis and a small scab. Resident 28 stated she/he had open areas to the right thigh, but staff did not place dressings over the wounds. On 8/14/24 at 1:39 PM Staff 16 (Regional Nurse) observed multiple blisters (Stage 2 pressure ulcers) to Resident 28's right thigh and acknowledged there was no documentation in Resident 28's medical record to identify the blisters to the resident's right thigh.

2. Resident 10 admitted to the facility on 3/2021 with diagnoses including Parkinson's disease and repeated falls. A care plan initiated on 7/1/21 revealed Resident 10 was a fall risk and required a one-person assist with toileting. A revision dated 5/6/22 revealed Resident 10 was not to be left alone when using the restroom. A FRI dated 1/25/24 revealed the following: - Resident 10 was found on the floor in the north common bathroom by Staff 18 (Former CNA) and Staff 26 (Former CNA) after they heard a thud. - Staff 4 (RNCM) assessed Resident 10 who was unable to describe the incident due to being non-verbal, but was able to shake her/his head yes or no. The resident denied pain. Staff 4 indicated the resident sustained a hematoma (an abnormal collection of blood outside of a blood vessel or body space) measuring approximately three inches. - Staff 17 (Former CNA) indicated she placed Resident 10 on the toilet and left the restroom to allow her/him privacy. Staff 17 indicated during shift change she reported to Staff 18 Resident 10 was on the toilet. Staff 17 assumed Staff 18 was going to assist Resident 10 off of the toilet, so Staff 17 left the facility. - Staff 18 indicated she received report during shift change from Staff 17 and was informed Resident 10 was on the toilet, but assumed Staff 17 was going to complete caring for Resident 10 and assist her/him off of the toilet. However, Staff 17 left the facility after shift change. -The miscommunication resulted in Resident 10 being left on the toilet unattended in the bathroom and she/he subsequently fell off the toilet. -It was determined there was poor communication between Staff 17 and Staff 18 during shift change and Staff 17 did not follow the care plan, which indicated Resident 10 was not to be left alone when using the toilet. On 8/12/24 and 8/13/24 attempts to contact Staff 17 were unsuccessful. On 8/13/24 at 12:54 PM and 3:09 PM Staff 23 (CNA) and Staff 19 (CNA) stated on 1/25/24, during shift change, Staff 17 was assigned to Resident 10 and indicated she placed the resident on the toilet in the bathroom, after which Staff 17 left the facility. Staff 23 stated she entered the bathroom after hearing a loud noise and found Resident 10 on the floor. Staff 23 stated she ran for additional help because other staff were already in the bathroom. Staff 23 and Staff 19 stated Resident 10 was a fall risk and was not to be left alone when she/he was in the bathroom. On 8/15/24 at 9:13 AM Staff 18 stated on 1/25/24, during shift change, Staff 17 told Staff 18 she placed Resident 10 on the toilet but then left the facility. Staff 18 stated she thought Staff 17 was going to assist the resident off of the toilet before she left the facility after her shift ended, but that did not occur. Staff 18 stated she heard a thud and found Resident 10 on the floor in the bathroom unattended. The resident looked bewildered but was smiling. Staff 18 stated Resident 10 was not to be left unattended in the bathroom and there was a miscommunication between her and Staff 17. On 8/15/24 at 1:51 PM Staff 4 stated the 1/25/24 incident occurred during shift change and there was poor communication between staff. Additionally, Resident 10 was not to be left alone when she/he was placed on the toilet. Staff 4 stated Staff 17 did not follow the care plan which resulted in Resident 10 falling off of the toilet. Staff 4 stated Resident 10 obtained a hematoma with pain to the head, but once back in her/his wheelchair the resident was back to her/his baseline. On 8/15/24 at 2:10 PM Staff 2 (acting DNS) stated she was aware of the incident on 1/25/24, acknowledged Staff 17 did not follow the care plan, and there was poor communication during shift change. Staff 2 stated Resident 10 was not sent out to the hospital because she/he was comfort care measures only. Staff 2 stated staff initiated neurological checks and monitored her/him appropriately for pain and discomfort after the fall. Based on interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety and ascertain post-fall injuries for 2 of 4 sampled residents (#s 10 and 26) reviewed for accidents. This placed resident placed at risk for lack of supervision and falls. Findings include: 1. Resident 26 admitted to the facility in 9/2022 with a diagnosis of a stroke. a. A Fall investigation dated 5/14/24 revealed Resident 26 had an unwitnessed fall on 5/14/24 at 12:35 AM. Progress Notes from 5/14/24 to 6/4/24 revealed the following: -5/14/24 Resident 26 fell and neurological assessments were initiated. -5/15/24 Resident 26 was assessed to not have an injury from her/his fall. There were no additional post fall assessments after 5/15/24. A Neurological Check form (assessment for head injury) initiated 5/14/24 revealed staff were to assess Resident 26 every 15 minutes for one hour, every one hour for four hours, every four hours for 16 hours, and every eight hours for 24 hours, a total of 19 assessments. The assessment included vital signs, pupil size, and strength of arms and legs. A complete neurological assessment was not completed for any of the scheduled times. On 8/15/24 at 8:30 AM Staff 4 (RNCM) stated staff were to assess and document in the Progress Notes for 72 hours after a resident fall. Staff 4 acknowledged the neurological assessments and charting was not done for Resident 26's 5/14/24 fall. b. A Fall investigation dated 6/4/24 revealed Resident 26 had an unwitnessed fall on 6/4/25 at 6:13 AM. The investigation indicated neurological assessments were completed. Review of Resident 26's clinical record revealed no Neurological Check form (assessment for head injury). Progress notes from 6/4/24 to 6/7/24 revealed no notes related to Resident 26's fall. On 8/15/24 at 8:30 AM Staff 4 (RNCM) stated staff were to assess and document in the Progress Notes for 72 hours after a fall. On 8/15/24 at 9:51 AM Staff 33 (LPN) stated neurological assessments were to be completed at scheduled times for unwitnessed falls. On 8/15/24 at 12:24 PM and 8/15/24 at 12:45 PM a request was made to Staff 16 (Regional Nurse) for assessments after Resident 26's 6/4/24 fall. No additional information was provided. c. A Fall investigation dated 6/26/24 revealed Resident 26 had an unwitnessed fall on 6/26/24 at 4:39 AM. Resident 26 sustained a hematoma (collection of blood under the skin) and was sent to the emergency room for evaluation. Resident 26 was assessed to not have a head injury. The investigation also indicated neurological assessments were completed. A Neurological Check form (assessment for head injury) initiated 6/26/24 revealed staff were to assess Resident 26 every 15 minutes for one hour, every one hour for four hours, every four hours for 16 hours, and every eight hours for 24 hours, a total of 19 assessments. The assessment included vital signs, pupil size, and strength of arms and legs. Complete neurological assessments were completed six times in the first 24 hours. Assessments were not completed for the remaining 32 hours. On 8/15/24 at 9:51 AM Staff 33 (LPN) stated neurological assessments were to be completed at scheduled times for unwitnessed falls. On 8/15/24 at 8:30 AM Staff 4 (RNCM) acknowledged the neurological assessments and charting was not completed after Resident 26's 6/26/24 fall.

Based on observation, interview and record review it was determined the facility failed to assess and implement trauma informed care interventions for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for re-traumatization. Findings include: Resident 15 admitted to the facility in 12/2023 with diagnoses including PTSD (Post Traumatic Stress Disorder) and anxiety. A 12/22/23 Psychosocial History and Discharge Plan assessment indicated Resident 15 had no trauma, mood or behavior issues. A 7/18/24 revised care plan indicated staff were to notify Staff 9 (Social Services Director) with changes in mood or behaviors and Resident 15's psychosocial well-being problem was related to a recent hospitalization (in 2023). No focus or interventions related to Resident 15's PTSD were found. On 8/12/24 11:30 AM and 1:18 PM Resident 15 was observed in bed sleeping with the door open and no blankets or clothing were observed to cover her/him. On 8/13/24 at 9:34 AM Resident 15 was observed in bed sleeping. Staff 6 (RN) stated Resident 15 usually was awake most of the night and woke for the day by 3:00 PM. On 8/14/24 at 11:17 AM Staff 6 stated she was only aware of Resident 15's PTSD because she spoke with the resident and believed her/his withdrawn behavior and anxiety at night was also related to her/his PTSD. Staff 6 stated other staff would benefit to know how to approach Resident 15 because she/he only accepted or spoke with select staff. Staff 6 expressed concerns there were no monitors in place related to Resident 15's PTSD. On 8/14/24 at 11:41 AM and 12:48 PM Staff 9 stated she was recently informed of issues at night for Resident 15 and stated her/his baseline behavior was long hours of sleep and ignoring people. Staff 9 acknowledged Resident 15's psychosocial assessment was inaccurate because she was not aware of her/his PTSD diagnosis at admission. Staff 9 also acknowledged Resident 15's care plan was not specific to her/his behaviors and interventions for her/his PTSD were needed.

Based on interview and record review it was determined the facility failed to monitor side effects of psychotropic medications for 1 of 5 sampled residents (#7) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 7 was admitted to the facility in 5/2017 with chronic mental health diagnoses. Resident 7's 7/2024 and 8/2024 MARs and TARs revealed she/he was administered scheduled olanzapine (antipsychotic), valproic acid (mood stabilizer), and clonazepam (treats anxiety). There was no indication the side effects of the psychotropic medications were monitored. On 8/14/24 at 10:01 AM Staff 3 (LPN) stated staff were to document on the TAR if a resident had side effects of psychotropic medications. If there were side effects staff were also to document in the Progress Notes. On 8/14/24 at 2:15 PM Staff 4 (RNCM) stated the psychotropic medication side effects were to be entered as a scheduled nursing task. Staff 4 stated the order was entered as PRN and therefore the system did not alert staff to monitor and document if the resident had any medication side effects.

Based on interview and record review it was determined the facility failed to ensure flu and pneumonia vaccines were provided for 2 of 5 sampled residents (#s 7 and 15) reviewed for immunizations. This placed residents at risk for respiratory infections. Findings include: 1. Resident 7 admitted to the facility in 4/2017 with a diagnosis of diabetes. A Consent For Annual Flu, Pneumonia, and Covid Vaccines form revealed on 5/4/24 Resident 7 consented to have a pneumonia vaccine administered. Resident 7's record did not have documentation to indicate she/he received the vaccine. On 8/14/24 at 2:33 PM Staff 30 (IP) verified Resident 7 consented to the pneumonia vaccine but staff did not administer it. 2. Resident 15 admitted to the facility in 12/19/23 with a diagnosis of diabetes. A Consent For Annual Flu, Pneumonia, and Covid Vaccines form revealed on 12/19/23 Resident 15 consented to have a flu vaccine administered. Resident 15's record did not have documentation to indicate she/he received the vaccine. On 8/14/24 at 2:33 PM Staff 30 (IP) verified Resident 15 consented to the flu vaccine but staff did not administer it.

Based on observation, interview and record review it was determined the facility failed to staff a registered nurse for eight consecutive hours per day seven days per week for nine out of 60 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: A review of the Direct Care Staff Daily Reports and payroll records dated 2/1/24 through 3/31/24 revealed nine days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period. On 8/15/24 at 12:04 PM and 8/16/24 at 10:32 AM Staff 1 (Administrator) confirmed on the dates of 2/3/24, 2/10/24, 2/17/24, 2/24/24, 3/2/24, 3/9/24, 3/16/24, 3/23/24 and 3/30/24 there were no RNs in the building as required and a corrective action plan was in place since 4/1/24 to address RN staffing. On 8/19/24 at 3:24 PM Staff 1 provided the following written documentation of the corrective action: an 4/1/24 short-term action plan was implemented to ensure RNs reallocated their hours to ensure the requirements for RN coverage was met until new RNs were hired and trained. The committee members met quarterly to evaluate progress which included the use of hosting nursing clinics and increased recruitment. The facility's implementation of corrective actions were verified through the survey process. Observations of RN coverage from 8/12/24 through 8/16/24 and record review of Direct Care Staffing Report from 7/14/24 through 8/12/24 revealed no concerns with RN coverage for eight consecutive hours in a 24 hour period for any of these shifts .

Based on observation and interview review it was determined the facility failed to follow therapeutic diets for 1 of 1 kitchen. This placed residents at risk for lack of nutritional interventions. Findings include: On 8/15/24 at 11:06 AM Staff 14 (Cook) was observed to prepare lunch for residents and did not utilize recipes or therapeutic diet spread sheets for portion control or meal substitution for any resident who received a therapeutic diet. Staff 14 stated she had no training on the use of diet spread sheets since she was hired almost a year ago. Staff 14 also stated when a NEM (Nutritionally Enhanced Meal) was ordered for a resident, their foods were not nutritionally enhanced but rather nutritional supplements were ordered by the RD and provided. Staff 13 (Dietary Manager) stated any recipe used in the kitchen was obtained through a generic search of the Internet since no recipes were provided by the facility. On 8/15/24 at 11:16 AM and 12:16 PM Staff 15 (RD) stated her audits of the facility kitchen did not include verification that diet spread sheets and system recipes were utilized. Staff 15 acknowledged system recipes with therapeutic diet spread sheets were to be utilized and foods were to be daily enhanced with extra calories to meet the expectations of a NEM diet order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to offer residents and representatives the opportunity to participate in the care planning process for 1 of 1 sampled resident (#2) reviewed for care planning. This placed residents at risk for unmet needs. Findings include: Resident 2 was admitted to the facility in 10/2022 with diagnoses including stroke and dementia. On 4/3/23 at 2:27 PM Witness 4 (Family Member) stated she had not been invited to a care conference recently. On 4/4/23 Resident 2's medical record was reviewed and revealed a care conference was completed on 10/20/22. There was no indication an additional care conference was held between 10/20/22 and 4/4/23. On 4/4/23 at 1:09 PM Staff 3 (Social Services Director) stated Resident 2 did not have a care conference since October of 2022. She stated the resident was discharged from therapy, currently received hospice services and did not trigger for a care conference. On 4/4/23 at 2:06 PM Staff 2 (DNS) acknowledged Resident 2's last care conference was 10/20/22, she stated the resident readmitted to the facility on [DATE] and her expectation was for an additional care conference to be completed two weeks after readmission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 131 admitted to the facility on [DATE] with diagnoses including femur fracture. The 4/5/22 FRI indicated on 3/31/22 an alleged violation of neglect was reported due to a medication error involving Resident 131 causing her/him to be hospitalized . The FRI was received by the State Agency on 4/5/22 at 2:30 PM (5 days after the incident occurred). On 4/7/23 at 9:50 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the 4/5/22 incident of alleged neglect for Resident 131 was not reported to the State Agency timely. Based on interview and record review it was determined the facility failed to report allegations of neglect to the State Agency within the required timeframe for 2 of 7 sampled residents (#s 82 and 131) reviewed for resident safety and medications. This placed residents at risk for abuse. Findings include: 1. Resident 82 admitted to the facility in 2021 with diagnoses including quadriplegia and critical illness myopathy (severe slowing of the muscles). A 7/8/22 facility investigation for alleged neglect indicated Resident 82 called Staff 9 (Resident Care Manager LPN) on her personal phone and was gagging. Staff 9 drove to the facility and found Staff 8 (Former LPN) sleeping at the nurses station. Resident 82 was found to be vomiting due to a side effect of an IV (intravenous) infusion. Staff 8 was alleged to have failed to administer Resident 82 with medication due to vomiting. The FRI was received by the State Survey Agency on 7/25/22 at 5:37 PM (17 days after the incident occurred). On 4/6/23 at 10:13 AM Staff 2 (DNS) acknowledged the 7/8/22 incident of alleged neglect for Resident 82 was not reported to the State Agency timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to complete a thorough investigation for 2 of 7 sampled residents (#s 82 and 131) reviewed for resident safety and medications. This placed residents at risk for abuse. Findings include: 1. Resident 131 admitted to the facility on [DATE] with diagnoses including femur fracture. A 4/13/22 facility investigation and FRI indicated on 3/30/22 an incorrect dosage of morphine concentrate liquid (opioid pain medication) was administered to Resident 131 which resulted in a higher than prescribed dose. The provider was contacted and the resident was transferred the emergency department via EMS. Emergency department records indicated the resident became drowsy in the ambulance and 2 mg of Narcan (opioid antidote) was administered. The root cause indicated two nurses removed the morphine from the emergency medication machine but the order was not updated in the record. The investigation indicated the following staff were involved or were witnesses to the incident: Staff 15 (CMA), Staff 6 (LPN), Staff 9 (LPN), Staff 18 (LPN) and Staff 11 (Resident Care Manager LPN). The investigation did not include witness statements from the staff involved in the incident. On 4/7/23 at 9:50 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility incident report did not include witness statements from Staff 15, Staff 6, Staff 9, Staff 18 or Staff 11. Staff 1 and Staff 2 acknowledged the 4/13/22 investigation was not thorough. 2. Resident 2 admitted to the facility in 2021 with diagnoses including including quadriplegia and critical illness myopathy (severe slowing of the muscles). A facility incident report indicated on 7/8/22 Resident 82 who was alert and oriented, called Staff 9 (Resident Care Manager LPN) at 2:45 AM on her personal phone stating she/he needed help and sounded like she/he was gagging. Staff 9 drove to the facility and arrived within 15 minutes. Staff 9 observed Staff 8 (Former LPN) sleeping at the nurses station. Staff 9 and Staff 4 (CNA) went into Resident 82's room and found the resident vomiting due to a side effect of an IV infusion. Staff 9 called out to Staff 8 several times before she woke up. The report concluded Staff 8 failed to provide medication to Resident 82 to address her/his vomiting and was terminated. The report included witness statements from Staff 4 and Staff 9. The report did not include statements from either Staff 8 or Resident 82. Resident 82 was unable to be contacted due to being at a hospital in another state. On 4/5/23 at 8:41 AM Staff 8 indicated she was not asked to submit a statement from the facility. On 4/6/23 at 10:12 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility incident report did not include statements from Staff 8 or Resident 82. Staff 1 and Staff 2 acknowledged the 7/8/22 investigation was not thorough.

Based on interview and record review it was determined the facility failed to provide bathing assistance for 1 of 4 sampled residents (#19) reviewed for ADLs. This placed residents at risk for lack of cleaniness. Findings include: Resident 19 admitted to the facility in 2022 with diagnoses including weakness and heart failure. The 11/1/22 care plan indicated Resident 19 required assistance with showers. Resident 19's shower records indicated showers were scheduled every Monday and Thursday evening. The shower records revealed the following: - From 11/11/22 through 11/19/22 not applicable was documented with no further documentation noted. The resident did not receive a shower until 11/22/22 (14 days since last documented shower on 11/7/22). - From 1/3/23 through 1/10/23 not applicable was documented with no further documentation noted. - From 1/18/23 through 1/25/23 not applicable was documented with no further documentation noted. - From 2/11/23 through 2/16/23 not applicable was documented with no further documentation noted. The next scheduled shower day on 2/20/23 was not indicated and the resident did not received a shower until 2/23/23 (13 days since last documented shower on 2/9/23). - From 2/25/23 through 3/2/23 not applicable was documented with no further documentation noted. The resident did not receive a shower until 3/9/23 (11 days since last documented shower on 2/23/23). - Resident 19's scheduled shower day on 4/3/23 was not documented on the shower record as being provided or offered. On 4/3/23 at 1:51 PM Resident 19 stated stated she/he was unaware of her/his shower schedule and believed she/he recieved a shower about every two weeks. On 4/4/23 at 2:27 PM Staff 10 (NA) stated she marked not applicable on Resident 19's shower record when it was something other than a refusal. Staff 10 stated she could not recall specifically why she marked not applicable for the resident because there was not a place to write any comments on the shower record. Staff 10 stated Resident 19 did not refuse showers very often. On 4/5/23 at 10:30 AM Staff 5 (CNA) stated she marked not applicable when the resident had a shower that was not on a scheduled day. Staff 5 stated there was no place on the shower record to write any comments or any other option than not applicable. Staff 5 stated it was a hit or miss if the resident refused a shower. On 4/5/23 at 3:30 PM Staff 9 (Resident Care Manager LPN) stated she noticed in January Resident 19 had a lot of documented refusals and not applicable on her/his shower record. Staff 9 stated she was aware there was a broken system related to showers and was aware of the holes in the resident's shower records. On 4/6/23 at 10:10 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 19 did not receive a shower for the identified dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 1 sampled resident (#82) reviewed for resident safety. This placed residents at risk for not receiving medications as ordered. Findings include: Resident 82 admitted to the facility in 2021 and discharged [DATE] with diagnoses including quadriplegia and critical illness myopathy (severe slowing of the muscles). A 7/7/22 physician progress note indicated Resident 82 was experiencing nausea and vomiting following a IVIG infusion (therapy treatment used for antibody deficiencies). A 7/7/22 physician order indicated the resident was to receive Zofran (anti-nausea medication) every four hours as needed for nausea/vomiting. The 7/2022 MAR indicated Resident 82 received Zofran on 7/7/22 at 8:28 PM. The next dose was not documented as administered until 7/8/22 at 7:49 AM. A facility incident report indicated on early morning of 7/8/22 Resident 82 who is alert and oriented, called Staff 9 (Resident Care Manager LPN) at 2:45 AM on her personal phone stating she/he needed help and sounded like she/he was gagging. Staff 9 drove to the facility. Staff 9 observed Staff 8 (Former LPN) sleeping at the nurses station. Staff 9 and Staff 4 (CNA) went into Resident 82's room and found the resident vomiting due to a side of effect of the IV infusion. Staff 9 called out to Staff 8 several times before she woke up. The report concluded Staff 8 failed to provide medication to Resident 82 to address her/his vomiting and was terminated. The report indicated Resident 82 was monitored and the infusion was continued. Resident 82 was unable to be contacted due to being at a hospital in another state. On 4/4/23 at 11:50 AM Staff 9 stated on 7/8/22 in the early morning, Resident 82 called her and she could hear her/him vomiting. Staff 9 stated she drove to the facility to assist the resident and found Staff 8 sleeping at the nurses station. Staff 9 stated she and Staff 4 cleaned the resident up and went to the nurses station to wake up Staff 8. Staff 9 stated she told Staff 8 Resident 82 needed medication for her/his nausea/vomiting. Staff 9 stated Staff 8 gave the resident Zofran. Staff 9 stated she administered Resident 82's Zofran at 8:28 PM on 7/7/22 and believed the resident did not receive the Zofran again until she arrived in the early morning of 7/8/22 around 4:00 AM. Staff 9 stated from her knowledge Staff 8 did not mark the Zofran as being adminsitered on the MAR. On 4/5/23 at 9:09 AM Staff 4 stated she started her shift at 6:00 PM on 7/7/22 and the off coming nurse informed her Resident 82 was not feeling well and told her what time the Zofran was last administered. Staff 4 stated around 12:00 AM Resident 82 was vomiting and she asked Staff 8 if the resident could have the nausea medication. Staff 4 stated around 4:00 AM Resident 82 started vomiting again. Staff 4 stated she went to ask Staff 8 for nausea medication for the resident and she found Staff 8 with her head down sleeping at the nurses station. Staff 4 stated Resident 82 had been vomiting for about half an hour before Staff 9 arrived to assist. Staff 4 stated Resident 82 did not receive nausea medication until after Staff 9 arrived and they woke up Staff 8. On 4/5/23 at 8:41 AM Staff 8 stated she vaguely recalled the incident on 7/8/22. Staff 8 stated Resident 82 was vomiting and she administered nausea medication on one occasion during the shift. Staff 8 stated she was not sleeping but was reading a book with headphones on and was not aware of what was happening until Staff 9 arrived at the facility. Staff 8 was not aware if she documented on the MAR the Zofran was given. On 4/6/23 at 10:12 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 82 did not receive the Zofran as ordered on the early morning of 7/8/22 by Staff 8.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to obtain treatment orders for a pressure ulcer for 1 of 1 sampled resident (#83) reviewed for pressure ulcers. This placed residents at risk for delayed wound treatment. Findings include: Resident 83 admitted to the facility on [DATE] with diagnoses including heart failure, respiratory failure and depression. Review of Resident 83's skin assessments revealed the following: -3/27/23 admission assessment indicated Resident admitted with a 2.5 cm x 1 cm stage 2 pressure ulcer on the lower back area. The wound was cleaned well and Optifoam was placed. - 3/29/23 stage 2 wound on lower back measured 2 cm x 1 cm x 2 cm. Wound was cleansed with wound cleanser, dried and Opifoam was placed. -4/3/23 wound measured 2 cm x 1 cm. Wound was cleaned well and placed Optifoam to cover. Review of Resident 83's progress notes revealed the following: - 3/27/23 pressure ulcer to lower back measured 2 cm x 1 cm, cleaned well and Optifoam was placed. - 3/28/23 pressure ulcer to lower back measured 2 cm x 1 cm, cleaned well and Optifoam was placed. - 3/30/23 physician note indicated resident with a pressure injury to lower back. Resident was encouraged to off load pressure by turning and lying on her/his side. - 3/31/23 wound on lower back was cleaned and a new dressing was applied. Review of 3/27/23 physician orders revealed no treatment orders were in place for Resident 83's stage 2 pressure ulcer to the lower back. On 4/6/23 survey staff attempted to observe Resident 83's pressure ulcer. Resident 83 refused to be observed. On 4/6/23 at 12:48 PM Staff 11 (Resident Care Manager LPN) stated treatment orders for Resident 83's pressure ulcer were not yet been signed by the physician. Staff 11 stated a nurse informed her the day before of no treatment orders in place. Staff 11 further stated she directed nursing staff to just copy what was already done and she would request an order for daily dressing changes and PRN. Staff 11 stated from her knowledge dressing changes were completed daily but she was not sure if it was documented. On 4/6/23 at 1:51 PM and 1:58 PM Staff 9 (Resident Care Manager LPN) stated she completed the initial skin assessment for Resident 83 and requested a treatment order after seeing the dressing. Staff 9 stated she believed nursing staff completed daily dressing changes to the resident's pressure ulcer but she was not sure. Staff 9 stated Resident 83's pressure injury had improved and measured 1 cm x 1 cm as of 4/6/23. Staff 9 acknowledged Resident 83 did not have a treatment order in place for her/his stage 2 pressure ulcer until 4/6/23. On 4/7/23 at 10:14 AM Staff 2 (DNS) acknowledged there were no treatment orders in place for Resident 83's stage 2 pressure ulcer until 4/6/23.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 2 of 3 sampled CNA staff (#s 13 and 14) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: On 4/6/23 at 10:18 AM Staff 1 (Administrator) was asked for the annual performance reviews for Staff 13 (CNA) and Staff 14 (CNA). Employee performance reviews indicated the following: -Staff 13 was hired 10/2006 and the last performance review was completed in 10/2020; -Staff 14 was hired 7/2013 and the last performance review was completed in 7/2020. On 4/6/23 at 2:41 PM Staff 2 (DNS) acknowledged the last performance review for Staff 13 was completed in 10/2020, the last performance review for Staff 14 was completed in 7/2020 and annual performance reviews were not completed.

Based on interview and record review it was determined the facility failed to respond to pharmacy recommendations timely for 1 of 6 sampled residents (#2) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 2 was admitted to the facility in 10/2022 with diagnoses including stroke and dementia. The 3/15/23 pharmacy recommendation indicated Resident 2 received haloperidol (antipsychotic medication) 0.5 mg QID (four times daily) and the IDT (Interdisciplinary Team) stated the resident currently had no behavior and to reduce her/his haloperidol to 0.5 mg TID. On 4/6/23 there was no indication in the clinical record to indicate the pharmacy recommendation was reviewed or signed by the physician. On 4/6/23 at 9:31 AM and 9:44 AM Staff 11 (LPN Resident Care Manager) stated the recommendation for Resident 2's haloperidol was faxed to the hospice physician and the facility did not receive a response. On 4/6/23 at 1:17 PM Staff 2 (DNS) acknowledged follow up for the 3/15/23 pharmacy recommendation was not received timely.

Based on interview and record review it was determined the facility failed to store food in accordance with professional standards for food service safety and maintain the ice machine for 1 of 1 kitchen reviewed for kitchen safety and cleanliness. This placed residents at risk for contamination. Findings include: 1. On 4/3/23 at 12:35 PM during the initial tour of the facility's kitchen, the refrigerator was observed to contain the following: - an undated bag of shredded lettuce - an undated bag of carrots - two packages of undated wrapped swiss cheese - a container four cooked chicken thighs, undated - a bag of undated raw broccoli - a container of strawberries, undated - a container of pineapple spears, undated - a large container of homemade red Jell-O, undated On 4/3/23 at 12:44 PM Staff 16 (Dietary Manager) confirmed the identified items were undated and/or opened to air. 2. On 4/3/23 at 12:30 PM and 4/7/23 at 8:55 AM the inside of the ice machine was observed to have a black mildew substance across the trim of the plastic ice dispenser. The ice was observed to be filled to the top with some of the ice touching the plastic trim. On 4/7/23 at 9:00 AM Staff 16 (Dietary Mananger) confirmed the indentified mildew substance in the ice machine and acknowledged the ice machine needed to be cleaned.

2. Based on interview and record review, it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens. This placed residents at risk for exposure to water-borne pathogens. Findings include: The facility's 10/2022 Legionella (a potentially harmful water borne pathogen) Policy and Procedure indicated the facility was to establish procedures to control the growth and spread of water-borne pathogens through a water management program. On 4/6/23 at 9:06 AM Staff 17 (Maintenance Director) stated he did not conduct routine risk analysis assessments for potential areas of growth and spread of water-borne pathogens such as Legionella. Staff 17 was unable to provide evidence of a monitoring system to mitigate the potential growth of water-borne pathogens within the facility's water system. On 4/7/23 at 10:10 AM Staff 1 (Administrator) confirmed the facility did not have a policy for routine risk analysis assessments in place to monitor for potential water-borne pathogens. 1. Based on observation, interview, and record review, it was determined the facility failed to ensure staff followed proper infection control guidelines when using common use glucometers (a device used to obtain blood glucose levels) for 1 of 1 observation during CBG tests. This placed residents at risk for infection. Findings include: The undated cleaning and disinfecting procedure for the glucometer indicated it should be cleaned and disinfected between each patient with EPA approved wipes. On 4/6/23 at 12:01 PM Staff 12 (LPN) was observed to complete a CBG on Resident 26. On 4/6/23 at 12:03 PM Staff 12 returned to the medication cart and cleaned the glucometer with an alcohol wipe. Staff 12 did not complete additional CBGs. Staff 12 stated she used alcohol wipes or bleach wipes on the glucometer, whichever was available at the time. Staff 12 was unaware she needed to use EPA approved wipes on the glucometer. On 4/6/23 at 12:54 PM Staff 2 (DNS) acknowledged alcohol wipes were not an approved EPA wipe to clean the glucometer and acknowledged Staff 12 did not use an EPA approved wipe on the glucometer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 5 admitted to the facility in 2018 with diagnoses including anxiety. The 5/31/18 comprehensive plan of care and the [NAME] (CNA care plan) did not include target behaviors related to the resident's diagnoses of anxiety and use of psychotropic medication. On 8/16/18 at 11:55 AM Staff 3 (LPN/Admissions Resident Care Manager) confirmed Resident 5's 5/31/18 comprehensive plan of care was not person centered to include target behaviors related to the resident's diagnoses of anxiety and use of psychotropic medication. Based on interview and record review it was determined the facility failed to implement a person centered care plan for 2 of 7 sampled residents (#s 5 and 176) reviewed for accidents and medications. This placed residents at risk for unmet care needs. Findings include: 1. Resident 176 was admitted to the facility in 2/2018 with diagnoses including Parkinson's disease, stroke and diabetes. The care plan and [NAME] (a tool used by CNAs to provide care) dated 2/22/18 indicated the resident ate independently. A 4/10/18 speech therapy evaluation note recommended Resident 176 was to receive a mechanical soft (foods that are soft, meats that are chopped into small pieces and easy to chew) diet, no liquid consistency restrictions, to be upright when eating meals and no straws were to be provided. The revised care plan and [NAME] dated 4/10/18 directed staff to assure Resident 176 ate upright in her/his wheelchair or bed, to take small bites and not supply straws to the resident during meals. On 8/15/18 at 9:10 AM Staff 14 (CNA) stated the resident ate all meals independently and she supplied adaptive silverware and straws to drink her/his beverages. On 8/15/18 at 9:57 AM Staff 15 (CNA) stated the resident ate all meals independently in her/his room and she supplied a straw for the resident to drink her/his beverage. Staff 15 further stated the resident always wanted a straw for her/his beverages. On 8/15/18 at 10:13 AM Staff 16 (Restorative Aide and CNA) stated the resident ate independently in her/his room and would ask if Resident 176 wanted a straw. On 8/15/18 at 10:57 AM Staff 4 (RNCM) stated the resident was independent with all meals, preferred to eat in her/his room, was on a mechanical soft diet and had no other restrictions to her knowledge. On 8/16/18 at 10:45 AM Staff 3 (LPN/admission Resident Care Manager) and at 1:07 PM Staff 2 (DNS) acknowledged staff were not following the care plan and should not have supplied Resident 176 with straws during meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to review and revise care planned interventions for 1 of 2 sampled residents (#176) reviewed for accidents. This placed residents at risk for unmet needs. Findings include: Resident 176 was admitted to the facility in 2/2018 with diagnoses including Parkinson's disease, stroke and diabetes. The care plan and [NAME] (a tool used by CNAs to provide care) dated 4/10/18 indicated the resident ate independently and directed staff to assure the resident was upright in her/his wheelchair or bed and check Resident 176's mouth for debris or pocketed food following meals. On 8/15/18 at 9:10 AM Staff 14 (CNA) and Staff 15 (CNA) at 9:57 AM stated the resident ate independently in her/his room and never had difficulty with chewing, coughing or swallowing her/his food. On 8/15/18 at 10:57 AM Staff 4 (RNCM) stated the resident was independent with all meals, preferred to eat in her/his room, was on a mechanical soft (foods that are soft, meats that are chopped into small pieces and easy to chew) diet and had no other restrictions to her knowledge. On 8/16/18 at 10:45 AM Staff 3 (LPN/Admissions Resident Care Manager) and at 1:07 PM Staff 2 (DNS) acknowledged Resident 176 was independent with her/his meals and never had issues with pocketing food and should not have been included on the care plan.

Based on observation, interview and record review it was determined the facility failed to ensure residents received the necessary services to maintain grooming for 1 of 1 sampled resident (#18) reviewed for ADLs. This placed residents at risk for unmet grooming needs. Findings include: Resident 18 admitted to the facility in 2013 with diagnoses including stroke. The 12/5/14 ADL Care Plan indicated the resident required extensive assistance from one staff for personal hygiene. On 8/15/18 at 8:33 AM Resident 18 was observed to have visible one-quarter inch length growth of hair over her/his upper lip and chin area. Review of the 7/17/18 through 8/14/18 point of care (tool used by CNAs to document resident cares provided) indicated the resident did not have any days in which she/he refused care. On 8/15/18 at 11:20 AM Staff 5 (CNA) confirmed the resident had visible hair growth on her/his upper lip and chin areas. Staff 5 stated the resident was provided care related to shaving during her/his shower days. Staff 5 stated the resident had a tendency to refuse to be shaved and the resident refused to be shaved on 8/14/18. Staff 5 confirmed she did not document the resident's refusal to be shaved. On 8/15/18 at 11:46 AM Staff 2 (DNS) acknowledged the resident had visible chin hair growth and confirmed the clinical record did not indicate the resident refused to be shaved.

Based on interview and record review it was determined the facility failed to follow physician orders related to blood pressure parameters and physician notification for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for adverse effects of medication. Findings include: Resident 5 admitted to the facility in 2018 with diagnoses including heart failure. The 7/25/18 signed physician orders indicated Resident 5 was to receive the following cardiovascular medications daily with parameters as follows: *carvedilol (high blood pressure medication) - Hold and notify physician if systolic (top number) blood pressure (SBP) was less than 100, if diastolic (bottom number) blood pressure (DBP) was less than 60 or if pulse was less than 55. *losartan (high blood pressure medication) - Hold and notify physician if SBP was less than 100 or if DBP was less than 60. Review of the 7/2018 and 8/2018 MARs revealed the blood pressure medications were administered on the following: *7/2/18 - with a pulse of 52 *7/3/18 - with a pulse of 54 *7/5/18 - with a pulse of 54 *7/7/18 - with a pulse of 51 *8/1/18 - with a BP of 90/56 *8/5/18 - with a pulse of 52 *8/15/18 - with a pulse of 51 Review of Resident 5's clinical record revealed no indication the physician was notified or the medications were withheld related to pulse and blood pressures that were outside of the parameters for the months of 7/2018 and 8/2018. On 8/16/18 at 12:02 PM Staff 3 (LPN/Admissions Resident Care Manager) acknowledged the seven dates in 7/2018 and 8/2018 when the resident had blood pressures or pulses outside of the parameters. Staff 3 acknowledged the medications were administered and the clinical record did not indicate the physician was notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 11 admitted to the facility in 3/2016 with diagnoses including heart failure and chronic obstructive pulmonary disease (COPD). a. A Skin investigation was completed on 7/14/18 and identified a small open area to Resident 11's buttocks region. Upon assessment the resident had a coccyx wound that was open and the area measured 2.0 cm x 0.5 cm. The wound was cleansed and calazime (a skin protectant) was applied. The investigation indicated Resident 11 had decreased mobility, was extensive assistance with all ADLs and was incontinent of bowel and bladder. She/he had a history of the area being opened and the skin was fragile. On 7/19/18 a Weekly Skin Ulcer Measurement Wound Evaluation indicated a Stage 2 facility acquired coccyx pressure ulcer, with elements of moisture related causes. The wound measured 2.0 cm x 0.3 cm and had no signs or symptoms of infection. On 7/21/18 Resident 11 was sent out to the hospital and readmitted on [DATE]. On 7/28/18 the readmission Profile had no information regarding the Stage 2 facility acquired coccyx pressure ulcer. On 8/2/18 a Weekly Skin Ulcer Measurement Wound Evaluation indicated a Stage 2 healing coccyx pressure ulcer. The wound measured 4.0 cm x 1.0 cm and had no signs or symptoms of infection. On 8/7/18 a Weekly Skin Ulcer Measurement Wound Evaluation indicated a Stage 2 healing coccyx pressure ulcer. The wound measured 2.0 cm x 0.5 cm and had no signs or symptoms of infection. A observation on 8/16/18 at 12:17 PM the coccyx wound in the crease appeared with minimal reddeness and had a small whitish line less than 1.0 cm in the base of the crease of the buttocks. The area appeared to be fragile, macerated (softening a breaking down of skin related to exposure to moisture) tissue. The area did not appear to be open. On 8/16/18 at 1:23 PM Staff 2 (DNS) stated Resident 11 had been sent out to the hospital on 7/21/18 and readmitted on [DATE]. She stated the 7/28/18 readmission Profile failed to identify the coccyx wound upon readmission. b. On 7/28/18 a readmission Profile indicated Resident 11 had a Stage 1 pressure ulcer in the gluteal crease that measured 4.0 cm x 0.1 cm with no signs or symptoms of infection. A 7/29/18 Initial Skin Ulcer Assessment indicated Resident 11 had a facility acquired Stage 2 pressure ulcer in the gluteal crease with no signs or symptoms of infection. On 8/2/18 a Weekly Skin Ulcer Measurement Wound Evaluation indicated Resident 11 had an unstageable pressure ulcer on the right buttock with 100% eschar (dead tissue). The wound measured 0.2 cm x 0.2 cm and no signs or symptoms of infection. On 8/7/18 a Weekly Skin Ulcer Measurement Wound Evaluation indicated Resident 11 had a unstageable pressure ulcer on the right buttock with 50% granulation (new connective tissue) 50% slough. The wound measured 0.2 cm x 2.5 cm with no signs or symptoms of infection. During an observation on 8/16/18 at 12:17 PM the right buttocks presented with a red round area approximately 2.5 cm with a small oval area 0.2 cm x 1.0 cm and appeared to be unstageable due to slough. The surrounding tissue was intact, the nurse applied barrier cream and there were no signs or symptoms of infection. On 8/16/18 at 1:23 PM Staff 2 (DNS) stated Resident 11 was sent out to the hospital on 7/21/18 and readmitted on [DATE]. The pressure ulcer noted on the 7/28/18 readmission Profile and the Initial Skin Ulcer Assessment on 7/29/18 were incorrectly identified as a gluteal crease pressure ulcer (Stage 1 and 2) and were not facility acquired. The pressure ulcer should have been identified as an unstageable pressure ulcer to the right buttocks and was present upon readmission. Based on observation, interview and record review it was determined the facility failed to accurately assess, measure pressure ulcers in a consistent manner and revise a treatment plan for 2 of 2 sampled residents (#s 7 and 11) reviewed for pressure ulcers. This placed residents at risk for ineffective pressure ulcer care. Findings include: 1. Resident 7 admitted to the facility in 2017 with diagnoses including end stage kidney disease requiring hemodialysis (a method of removing toxins from the blood) and diabetes. A care plan was developed 12/18/17 for potential skin problems related to current blisters on her/his chest, areas of yeast, itchiness due to kidney disease and preference for long nails and the use of briefs for occasional incontinence. Interventions included to provide nail care as resident would allow, avoid scratching, to educate on measures to prevent pressure ulcers, encourage good nutrition, eliminate causative factors and resolve when possible, float heels, keep skin clean, dry and protect from injury, use a draw sheet or lifting device to reduce friction with transfers and repositioning and to provide additional peri care and apply barrier cream to protect the skin. The MDS dated [DATE] identified Resident 7 was at risk for pressure ulcers, had no current pressure ulcers but did have moisture associated skin damage. A Pressure Ulcer CAA for the same assessment identified risk factors as diabetes, end stage kidney disease with fluid restriction, cardiac problems, respiratory problems, pain and decreased mobility. The goal was to minimize the risk for breakdown with careful monitoring and preventative measures. On 5/9/18 a new skin issue was identified. The nurse identified baseline darkened skin due to scarring from a previous pressure ulcer prior to admission. The skin was described as abraded and appeared to be related to moisture and friction due to identified risk factors. On 5/10/18 the care plan was revised to include a new order for liberally applied barrier cream TID. Wound documentation showed weekly monitoring and resolution on 7/9/18. On 7/16/18 a new skin issue was identified which appeared as an abrasion on the inner left buttock that measured 0.6 cm by 0.7 cm and right buttock measured 0.8 cm by 1.0 cm. The investigation noted all risk factors, previous interventions and concluded the wounds were pressure related and indicated the plan to continue barrier cream to both areas. A Weekly Skin Ulcer Measurement Wound Evaluation dated 7/24/18 noted no change in size or appearance of the wounds. The plan was to discuss at Nutrition at Risk (NAR) Committee weekly, administer vitamin C and multiple vitamin, apply barrier cream each shift by nurse, lay down after meals and before dialysis, communicate with the dialysis facility to encourage repositioning while in dialysis chair. On 7/28/18 the care plan was revised to include actual pressure ulcer related to end stage kidney disease, sedentary activity level, the resident was minimally able to reposition self, dialysis three times a week, history of breakdown due to noted scarring and thick elephant-like skin. Additional interventions included to administer treatments as ordered, encourage and assist to reposition if the resident was unable to do so by her/himself and avoid laying the resident on her/his back. On 7/30/18 the right side wound was described as 7 cm by 7 cm and the left as 1.0 cm by 1.0 cm. A Weekly Skin Ulcer Measurement Wound Evaluation dated 8/2/18 described the wounds as healing stage 3, purple skin surrounding the wound, elephant-like skin has resolved. The left buttock wound was measured as 3 cm by 2.8 cm and the right buttock as 3.8 cm by 2.5 cm. The surrounding skin was described as discolored but improved and to continue treatment. A Weekly Skin Ulcer Measurement Wound Evaluation dated 8/7/18 described the wounds as healing stage 3. The left buttock is measured as 3.2 cm by 3 cm and the right buttock as 4 cm by 2.4 cm and depth as less than 0.25 cm. Further description of purple colored skin and appeared to be old scarring from a previous pressure ulcer. A Weekly Skin Ulcer Measurement Wound Evaluation dated 8/14/18 described the wounds as healing stage 3 and measured the left buttock as 8.5 cm by 3.5 cm and the right buttock as 8 cm by 3 cm and both less than 0.25 cm in depth. On 8/16/18 at 11:53 AM Resident 7's wounds were observed. The inner aspect of both buttocks appeared thick, rough, dry and purplish in color. The left side had four open areas each less than 2 mm and the right side contained an open area approximately 1 cm by 0.5 cm. Both wounds were red in color. There were no signs of infection or discomfort. Staff applied a thick layer of barrier cream to the entire area, assisted with clothing adjustment and Resident 7 was assisted to her/his chair for dialysis transport. Resident 7 was observed to reposition herself/himself and sit back further in the wheelchair. On 8/17/18 at 9:42 AM Staff 2 (DNS) was asked about measurements and treatment selections. Staff 2 stated she and Staff 4 (RNCM) decided on the treatment and the use of barrier cream was the facility's standard and the facility did not consider alternate treatment options. Staff 2 further stated it appeared nursing staff were not measuring the wounds in a consistent manner and the nurses should describe the entire wound area and any open areas within that area. She described the wounds as having some scabbing, the surrounding tissue was thick, elephant-like and was dark in color.

Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were followed for 2 of 5 sampled residents (#s 4 and 14) reviewed for medications. This placed residents at risk for lack of monitoring and evaluation of medications. Findings include: 1. Resident 4 was admitted to the facility in 5/2017 with diagnoses including schizoaffective disorder (schizophrenia with mood disorder) and diabetes. Resident 4's medical record revealed the following pharmacist Consultation Reports with recommendations or requests: - 10/19/17: The resident receives Zyprexa (antipsychotic) and does not have a fasting lipid (cholesterol level) evaluation in her/his record. The physician declined the recommendation for the blood test. - 11/15/17: The resident receives Zyprexa, Depakote (anti-seizure) and clonazepam (anti-seizure) for treatment of schizo-affective disorder. The pharmacist requested an assessment of the risk versus benefits of the use of multiple psychotropic medication therapy, including resident-specific rationales describing why gradual dose reductions (GDRs) would be contraindicated. The physician declined and indicated the resident tolerated prior decreases poorly and was stable. - 4/17/18: The pharmacist repeated a request for a lipid panel due to the resident's 12/2017 level outside normal limits and she/he now received simvastatin (cholesterol lowering medication) daily. The physician declined the recommendation. - 6/4/18: The resident receives duplicate therapy of Benadryl (antihistamine) and loratadine (antihistamine). The pharmacist recommended discontinuing one of the medications, or if both were continued a risk versus benefit assessment was required per regulations. The physician declined the recommendation and indicated the resident was stable and she/he liked the regimen. - 6/6/18: A second request was made for documentation of a resident-specific rationale and risks versus benefits for the use of Zyprexa, Depakote and clonazepam including why GDRs would be contraindicated. The physician declined the recommendation and indicated do not change [her/his] psych meds. - 7/9/18: A third request was made for a fasting lipid level due to the resident's history of a previous high level and current use of simvastatin. The physician refused to accept or decline the recommendation and responded the resident was monitored at dialysis. Resident 4's medical record contained no documentation of lab results with lipid levels. During an interview on 8/17/18 at 10:20 AM Staff 3 (LPN/admission Resident Care Manager) and Staff 4 (RNCM) acknowledged the multiple pharmacy recommendations or requests and the physician's lack of response to them. Staff 4 stated Resident 4's status was fragile and changes could cause instability. Staff 3 stated she would attempt to locate documentation of the resident's lipid levels. No additional information was provided. 2. Resident 14 was admitted to the facility in 10/2017 with diagnoses including depression and insomnia. Resident 14's medical record contained the following pharmacy Consultant Reports with recommendations or requests: - 11/15/17: The resident was receiving Lunesta (hypnotic) every night for insomnia and a recommendation was made to change the medication to every other night. The physician accepted the recommendation and signed an order to give the Lunesta every other night for sleep. - 12/12/17: The pharmacist noted the resident received the following medications: atorvastatin (anti-cholesterol), insulin, aspirin and Lasix (diuretic to remove excess fluids) and requested lab work including a CBC (complete blood count) and a lipid panel (cholesterol level). The physician declined completion of the blood tests. - 3/20/18: The resident received Lexapro (antidepressant) and the pharmacist requested a gradual dose reduction (GDR) or documentation of risks versus benefits and a resident-specific rationale to support continued use. The physician declined and indicated the resident was stable on current dose. - 7/9/18: The resident received Lunesta and the recommendation was for the medication to be discontinued, or if continued the physician was asked for a resident-specific rationale describing the decision. The physician declined without providing the required documentation and noted the resident needs this medication to sleep. Resident 4's 11/2017 MAR indicated the Lunesta was not changed to every other night and staff continued to administer the medication every night. The resident's medical record contained no documentation of results of CBC or lipid level tests. On 8/17/18 at 9:43 AM Staff 3 (LPN/admission Resident Care Manager) and Staff 4 (RNCM) stated the CBC and lipid panel were completed on 12/21/17 but were not transferred into Resident 4's medical record from a portal where test results were sent when completed. Staff 3 and Staff 4 acknowledged the Lunesta was not changed as ordered due to an error by the nurse who received the order. Staff 3 and Staff 4 indicated it was an ongoing struggle regarding physicians and their refusal to respond appropriately to pharmacy recommendations.

Based on interview and record review it was determined the facility failed to ensure residents were provided information and informed of their right to formulate an advance directive for 4 of 4 sampled residents (#s 3, 5, 16 and 26) reviewed for advance directives. This placed residents at risk for being uninformed of their rights to execute an advance directive. Findings include: 1. Resident 5 admitted to the facility in 2018 with diagnoses including stroke and aphasia (language impairment). Review of Resident 5's clinical record revealed no indication the resident was provided information about or informed of her/his right to formulate an advanced directive. On 8/16/18 at 4:07 PM Witness 1 (Family) confirmed Resident 5 was not offered information or informed of her/his right to formulate an advanced directive. On 8/16/18 at 4:30 PM Staff 3 (LPN/Admissions Resident Care Manager) confirmed she did not provide information about or inform the resident or Witness 1 about the right to formulate an advance directive. 2. Resident 26 admitted to the facility in 2018 with diagnoses including diabetes. Review of the resident's clinical record on 8/13/18 revealed no indication the resident was provided education or informed of her/his right to execute an advanced directive. On 8/16/18 at 4:30 PM Staff 3 (LPN/Admissions Resident Care Manager) confirmed she did not provide information about or inform the resident about her/his right to execute an advance directive. 3. Resident 16 admitted to the facility in 2018 with diagnoses including infection. Review of Resident 16's clinical record on 8/13/18 revealed no indication the resident was provided education or informed of her/his right to execute an advance directive. On 8/13/18 at 3:35 PM Resident 16 was unable to recall if he/she had been offered information about her/his right to execute an advance directive. On 8/16/18 at 4:46 PM Staff 3 (LPN/Admissions Resident Care Manager) acknowledged she did not offer education or inform the resident of her/his right to execute an advance directive. 4. Resident 3 admitted to the facility in 2018 with diagnoses including a leg fracture. Review of Resident 3's clinical record on 8/13/18 revealed no indication the resident was provided education or informed of her/his right to execute an advance directive. On 8/16/18 at 4:44 PM Resident 3 stated she/he was not provided education or information of her/his right to formulate an advance directive. 08/16/18 4:45 PM Staff 3 (LPN/Admissions Resident Care Manager) confirmed she did not provide education or inform the resident of her/his right to execute an advance directive.

4. Resident 5 admitted to the facility in 2018 with diagnoses including stroke. According to the RAI 3.0 Manual the facility was to complete a BIMS (brief interview of mental status) assessment for residents upon admission and quarterly. Scores range from 00 through 15, with the higher number representing a higher level of cognitive functioning. The 3/27/18 admission MDS indicated the resident had a BIMS score of 5. The 6/27/18 Quarterly MDS indicated the resident had a BIMS score of 3. According to this score, the resident had declined in cognitive status since her/his last MDS Assessment. On the afternoon of 8/13/18 Resident 5 was observed to be alert and oriented and to shake her/his head for yes or no questions. On 8/16/18 at 11:33 AM Staff 6 (CNA) indicated Resident 4 had cognitively improved since her/his admission. On 8/17/18 at 10:00 AM Staff 24 (LPN) indicated the resident had an increase in cognitive functioning since her/his admission. On 8/16/18 at 12:14 PM Staff 3 (LPN/Admissions Resident Care Manager) acknowledged the 6/27/18 MDS was not accurate. Staff 3 further stated Resident 5 had an improvement, not a decline in cognitive functioning since her/his admission. 5. Resident 18 admitted to the facility in 2013 with diagnoses including stroke. The RAI 3.0 Manual directed staff to assess residents for cognitive abilities or to indicate if the resident was rarely/never understood. The 2/13/18 Annual MDS did not code the resident for cognitive function or indicate if the resident was rarely or never understood. On 8/15/18 at 12:10 PM Staff 2 (DNS) confirmed Resident 18's 2/13/18 Annual MDS was not accurately completed. Based on observation, interview and record review it was determined the facility failed to accurately code MDS assessments for 5 of 9 sampled residents (#s 4, 5, 18, 19 and 176) reviewed for accidents, ADLs, nutrition and medications. This placed residents at risk for inaccurately assessed needs. Findings include: 1. Resident 176 was admitted to the facility in 2/2018 with diagnoses including Parkinson's disease, stroke and diabetes. The resident's 6/1/18 Quarterly MDS indicated the resident required supervision and setup for all meals. The care plan dated 2/22/18 indicated Resident 176 was able to eat independently for all meals. On 8/15/18 at 11:15 AM Staff 4 (RNCM) stated Resident 176 was independent with her/his eating and the 6/1/18 Quarterly MDS was coded inaccurately. 2. Resident 4 was admitted to the facility in 5/2017 with diagnoses including schizoaffective disorder (schizophrenia with mood disorder) and diabetes. a. Resident 4's 3/3/18 Quarterly MDS indicated the resident received an antianxiety medication. The RAI 3.0 Manual included instructions to code for a medication's classification and not how it was used. The resident's medical record revealed she/he received clonazepam (anti-seizure medication) for an anxiety disorder since admission to the facility. There was no indication Resident 4 received a medication classified as an antianxiety. b. The 4/3/18 Quarterly MDS indicated Resident 4 received an antipsychotic and a GDR (gradual dose reduction) was last attempted on 11/15/17. A 11/15/17 pharmacist Consultation Report indicated Resident 4's physician declined to approve a GDR for the Zyprexa. c. Resident 4's 6/1/18 Annual MDS revealed the resident was not a current tobacco user and she/he continued to receive an antianxiety medication. - The resident's medical record revealed she/he continued to receive clonazepam (anti-seizure) for anxiety and contained no orders for an antianxiety medication. - On 8/16/18 at 8:02 AM Resident 4 stated she/he still smoked and always followed the smoking rules. During an interview on 8/17/18 at 9:53 AM Staff 3 (LPN/Admissions Resident Care Manager) and Staff 4 (RNCM) acknowledged Resident 4 was a current smoker. Staff 3 and Staff 4 further acknowledged the clonazepam was coded inaccurately as an antianxiety medication. Staff 4 stated she thought a request for a GDR was considered an attempt and confirmed there was no GDR attempt for Zyprexa, the antipsychotic medication Resident 4 received. 3. Resident 19 was admitted to the facility in 7/2018 with diagnoses including a post-surgical repair of a Stage 4 left buttock pressure ulcer and history of stroke. Resident 19's 6/1/18 Annual MDS indicated the resident had no impairment of her/his upper extremities. On 8/14/18 at 8:01 AM Resident 19 was observed in bed and her/his left arm was lying at her/his side and she/he stated she/he could move her/his left arm and hand but it was weak and not really usable. The resident further stated the stroke caused her/his left arm weakness. On 8/16/18 2:03 PM Staff 4 (RNCM) acknowledged the assessment of Resident 19's left upper extremity was not coded accurately.