**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 of 1 discharged residents reviewed with physician orders for Cymbalta (a medication prescribed to treat depression), Resident ID #4. Findings are as follows: Record review of Resident ID #4 revealed s/he was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, major depressive disorder. Record review of a pharmacy medication regimen review dated 8/1/2024 revealed a recommendation to decrease the resident's Cymbalta medication from 60 milligrams (MG) daily to 40 MG daily, after the current supply of medication is exhausted. Further review revealed that the provider approved the recommended dose reduction on 9/9/2024. Record review of a progress note dated 9/13/2024 revealed the new order of Cymbalta 40 MG daily should start on 11/5/2024, after the remaining supply is exhausted. Record review revealed a facility document titled Continuity of Care Discharge/Transfer of Patient Form was completed for the resident's discharge on [DATE]. Further review of post-discharge orders failed to reveal the order for Cymbalta 40 MG daily. During a surveyor interview with Director of Nursing Services, on 11/6/2024 at 3:58 PM, she revealed that she completed the discharge for the resident on 11/4/2024. She further acknowledged the Cymbalta 40 MG order was not included on the discharge transfer form. Additionally, the DNS called the receiving facility in the presence of the surveyor and it was revealed that the residents current physician's orders did not include Cymbalta 40 MG.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with recommendations from a gastrointestinal specialist (a medical practitioner that specializes in the diagnosis and treatment of disorders of the gastrointestinal tract also known as the passageway of the digestive system), Resident ID #5. Findings are as follows: Record review revealed the resident was re-admitted to the facility in October of 2024 after s/he was hospitalized and diagnosed with a gastrointestinal bleed (bleeding from the gastrointestinal tract). Record review of a Continuity of Care Consultation and Referral Form dated 11/1/2024 revealed the resident was seen by the Gastroenterologist for a follow up visit. Further review of the document states, Below are the orders from today's visit: -Benefiber (a fiber supplement) one tablespoon daily for 1 month -high fiber diet -GERD diet (a low acidic diet, gastroesophageal reflux disease a chronic condition that occurs when the stomach contents leak back into the esophagus) -Laboratory bloodwork including: -Complete Blood Count with differential (a blood test that is used to monitor and treat conditions in the body) -Iron, total iron binding capacity and % saturation (blood tests that measures the iron levels in your body) -Ferritin (a blood test that measures how much iron the body stores) -Vitamin B 12 and Folate (blood test that measures potential vitamin deficiencies) -Stool for Occult blood three times (a test that detects hidden blood in the stool) Record review of the physician's orders failed to reveal evidence of a high fiber diet and GERD diet. Additionally, the record failed to reveal evidence of an order for Benefiber. Review of the resident laboratory results, failed to reveal evidence that the above-mentioned bloodwork was completed. Additionally, the record failed to reveal evidence of occult blood testing. During a surveyor interview on 11/6/2024 at 1:32 PM with Registered Nurse, Staff B, she acknowledged that the resident did not have an order for Benefiber, a high fiber diet or a GERD diet. Staff B was unable to provide evidence of the above-mentioned laboratory results. She further revealed that testing for occult blood in the stool is tested at the lab and not in-house. During a surveyor interview on 11/7/2024 at 9:44 AM with the Director of Nursing Services, she was unable to provide evidence of the above-mentioned laboratory results or that the high fiber and GERD diets were implemented. Additionally, she acknowledged that there was not an order for Benefiber. During a surveyor interview on 11/7/2024 at 11:50 AM with the resident's provider, Registered Nurse Practitioner, Staff A, he revealed that the above mentioned recommendations were reviewed with the facility nurse, approved, and should have been implemented as physician's orders.

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for the resident that meets professional standards of quality care relative to a suprapubic catheter (S/P tube, a catheter inserted through the abdomen into the bladder to drain urine) and Methicillin resistant Staphylococcus aureus infection (MRSA, an infection that is caused by a type of staph bacteria that becomes resistant to several antibiotics) in a lower extremity wound, for 1 of 1 residents reviewed for baseline care plans, Resident ID #272. Findings are as follows: Record review revealed that the resident was admitted to the facility in November of 2023 with a diagnosis to include, but is not limited to, retention of urine. A. Review of a progress note dated 11/17/2023 states in part, .s/p tube located on right leg . Record review of the physician's orders revealed an order dated 11/17/2023 to document urine output from the resident's S/P tube, every shift. Additional record review failed to reveal any additional orders for a S/P tube. Review of the baseline care plan initiated on 11/17/2023 failed to reveal evidence of a care plan for a S/P tube. B. Surveyor observation on 11/20/2023 at 9:34 AM of the resident's room, revealed signage posted outside of his/her room indicating s/he was on contact precautions, with an isolation bin containing personal protective equipment (PPE) supplies. Further review of the progress note dated 11/17/2023 states in part, .on contact precautions [wear a gown and gloves for all interactions that may involve contact with the resident or the resident's environment] for MRSA in the wounds . Record review of the physician's orders failed to reveal an order for contact precautions. Record review of the baseline care plan initiated on 11/17/2023 failed to reveal evidence of a care plan relative to MRSA or contact precautions. During a surveyor interview on 11/22/2023 at 12:42 PM with Registered Nurse, Staff A, she acknowledged there was no care plan focus relative to the resident's S/P tube, contact precautions, or MRSA diagnosis. Additionally, she revealed there absolutely should be a care plan focus for the S/P tube, contact precautions, and MRSA diagnosis. During a surveyor interview on 11/22/2023 at 1:37 PM with the Director of Nursing Services, she revealed that the Minimum Data Set (MDS) Coordinator completes the baseline care plans upon a resident's admission and indicated it is populated via a preset template. During a surveyor interview on 11/24/2023 at 9:05 AM, with the MDS Coordinator, Registered Nurse, Staff B, she revealed that a baseline care plan is a pre-generated template which is completed within 48 hours of admission. She further revealed that items specifically tailored to residents do not show up on the baseline care plan until after the initial comprehensive assessment is completed. Additionally, she was unable to provide the surveyor with evidence that the facility implemented a baseline care plan within 48 hours of the resident's admission, that includes the instructions needed to provide effective and person-centered care for the resident relative to his/her MRSA infection, S/P tube or contact precautions.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 2 of 5 residents reviewed who use an air mattress, Resident ID #s 28 and 49, 1 of 1 resident with an order to not have straws with liquids, Resident ID #49, 1 of 1 resident reviewed with a hand contracture, Resident ID #33 and 1 of 2 residents observed during a treatment dressing, Resident ID #38. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . 1. Record review revealed Resident ID #28 was admitted to the facility in November of 2019 with diagnoses including, but not limited to, muscle weakness, hemiplegia and hemiparesis (weakness or paralysis to one side of the body) following a stroke. Record review revealed a physician's order dated 2/10/2023 which states in part, Air mattress to bed- check setting every shift (300 LBS [pounds] alternating every shift . During a surveyor observation of the resident and a simultaneous interview on 11/22/2023 at 9:50 AM with Registered Nurse Staff A, revealed his/her air mattress was set at 400 lbs. Staff A acknowledged the air mattress was set at 400 lbs, which was not the setting the physician ordered. During a surveyor observation of the resident and a simultaneous interview on 11/24/2023 at 12:18 PM with Registered Nurse Staff B, revealed the air mattress was set at 350 lbs. Staff B acknowledged the air mattress was set at 350 lbs, which was not the setting the physician ordered. 2a. Record review revealed Resident ID #49 was admitted to the facility in June of 2022 with diagnoses including, but not limited to, Parkinson's Disease, dysphagia (difficulty swallowing), muscle weakness and low back pain. Record review revealed a physician's order dated 6/6/2022 which states in part, Ensure air mattress is functioning and settings @ [at] 250/alternating every shift. Surveyor observations on the following dates and times revealed the air mattress setting was set to 325/static: -11/20/2023 at 12:28 PM -11/21/2023 at 12:05 PM -11/22/2023 at 9:05 AM -11/22/2023 at 3:02 PM Record review of the November 2023 Medication Administration Record revealed during the first shift, Registered Nurse Staff C, signed and documented that the air mattress setting was on 250/alternating on 11/21/2023 and 11/22/2023. During a surveyor interview immediately following the observation on 11/22/2023 at 3:02 PM with Staff C, she acknowledged that the air mattress setting was not set to the ordered setting. Additionally, Staff C was unable to explain why she had documented that the air mattress setting was at 250/alternating, when it was on 325/static. Staff C further revealed that when she checks to air mattress, she only checks that it is on. During surveyor interviews on 11/24/2023 at 11:29 AM and again at 12:27 PM with the Director of Nursing Services (DNS), she revealed that she would expect that the nurses would ensure the air mattress is functioning and that the air mattress settings are set according to the physician's order. 2b. Additional record review for Resident ID #49 revealed s/he has a diet order dated 12/10/2021 which states in part, Diet - Liquids: Thin liquids (no straws). Surveyor observations revealed the following: -11/20/2023 at 12:19 PM, 1 cup with a straw during the lunch meal -11/22/2023 at 9:05 AM, 2 cups with straws at the bedside -11/23/2023 at 9:08 AM, 1 cup with a straw at the bedside -11/23/2023 at 12:37 PM, 1 cup with a straw during the lunch meal During a surveyor interview immediately following the observation on 11/23/2023 at 12:37 PM with Nursing Assistant, Staff D, she acknowledged Resident ID #49 used a straw during his/her lunch meal and further revealed s/he often uses straws with his/her liquids. Additionally, she was unaware of the resident's order to not have straws with liquids. During a surveyor interview on 11/24/2023 at 12:53 PM with the DNS, she was unable to explain why the resident was provided with straws, when s/he has an order to not have them. 3. Record review revealed Resident ID #33 was admitted to the facility in February of 2023 with diagnosis including, but not limited to, contracture. Record review revealed a physician's order dated 9/28/2023, to ensure a hand roll is in the resident's left hand every shift. Surveyor observations revealed the following: -11/21/2023 at 8:12 AM, the hand roll was not in place to the resident's left hand while s/he was sitting in the dining room. -11/22/2023 at 9:06 AM, the hand roll was not in place to the resident's left hand, but was noted to be wearing a palm guard on each hand. Further record review failed to reveal evidence of an active order for palm guards. Additionally review revealed the resident had an order for palm guards that was discontinued on 9/28/2023 and replaced with the order for the hand roll to the left hand. During a surveyor interview on 11/22/2023 at 9:28 AM with Registered Nurse, Staff A, she acknowledged the resident did not have a hand roll to his/her left palm on 11/22/2023 and indicated that the resident should have one per the physician's order. Additionally, she revealed that the resident does not have an order for any device to his/her right hand and then removed both palm guards from his/her hands. During a surveyor interview on 11/22/2023 at 1:37 PM with the DNS, she revealed that it was due to the resident's left hand contracture that s/he has an order for a palm roll to prevent his/her nails from digging into his/her skin. 4. According to the facility policy titled, Clean Dressing Technique states in part, .PROCEDURE: .10. Establish a container for soiled dressings, supplies, etc .18. Discard soiled materials in plastic bag . Record review revealed Resident ID #38 was re-admitted to the facility in November of 2023 with diagnoses including, but not limited to, localized edema to bilateral lower extremities and disorder of the skin and subcutaneous (beneath the skin) tissue. Record review revealed a physician's order dated 11/17/2023 to wash both the left and right shins with Hibiclens (antiseptic product used to clean the skin), apply Aquaphor (ointment) diffusely to lower legs and cover with an ABD (type of dressing) pad and wrap with ACE wrap daily. During a surveyor observation of the wound treatment on 11/24/2023 at 9:48 AM, Registered Nurse Staff C, washed the resident's legs with gauze and placed them on a chux pad (disposable pad) which was under the resident's legs, and removed the chux pad with the soiled material used to wash the resident's legs, and discarded everything onto the floor. Staff C removed her gloves and then discarded them onto the soiled material on the floor. Staff C donned new gloves, applied Aquaphor to the resident's legs and then discarded the remaining soiled chux pad, which was under the resident's legs, the container with the remaining Aquaphor ointment, and her dirty gloves onto the floor. Staff C finished completing the dressing change and donned new gloves, removed the soiled material off the floor and discarded the material into the soiled utility room. During a surveyor interview on 11/24/2023 at 10:08 AM with Staff C, she acknowledged she discarded all of the soiled material during the treatment onto the floor and did not utilize a receptacle. During an interview on 11/24/2023 at 1:16 PM with the DNS, she revealed Staff C should have used a trash receptacle to discard the soiled material and not place the soiled material onto the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assess the resident for risk of entrapment from bed rails for 1 of 5 residents reviewed for use of bed rails with an air mattress, Resident ID #28. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised 2/3/2023 states in part, .Regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident's head or body. Gaps can be created by movement or compression of the mattress which may be caused by resident weight, resident movement or bed position, or by using a specialty mattress, such as an air mattress .Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time .The use of a specialty air-filled mattress or a therapeutic air-filled bed may also present an entrapment risk that is different from rail entrapment with a regular mattress. The high compressibility of an air-filled mattress compared to a regular conventional mattress requires appropriate precautions when used for a resident at risk for entrapment. An air-filled mattress compresses on the side to which a person moves, thus raising the center of the mattress and lowering the side. This may make it easier for a resident to slide off the mattress or against the rail. Mattress compression widens the space between the mattress and rail. When a resident is between the mattress and rail, the mattress can re-expand and press the chest, neck, or head against the rail. While using air therapy to prevent and treat pressure injuries, facilities should also take precautions to reduce the risk of entrapment. Precautions may include following manufacturer equipment alerts and increasing supervision .Facilities must also conduct routine preventive maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair . Review of a facility policy titled Bed Rail Policy last reviewed 6/10/2022, revealed in part, .The Maintenance Department will conduct inspections of all bed frames, mattresses, and bedrails, as part of a regular maintenance program to identify areas of possible entrapment upon admission, quarterly, yearly and as needed . Record review revealed the resident was admitted to the facility in November of 2019 with a diagnosis including, but is not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke). Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed the resident is dependent on two staff members to turn side to side in bed. Review of a physician's order dated 2/10/2023 revealed the resident has an air mattress to the bed set to 300 pounds with alternating pressure. Review of a physician's order dated 7/15/2021 revealed the resident utilizes Two half side rails daily for assist with bed mobility and transfers. Review of a care plan dated 5/27/2022, and last revised on 6/27/2023, by the Director of Nursing Services (DNS) revealed the resident utilizes bedrails related to maintaining and improving functional abilities. With interventions to include, but are not limited to, .will be assessed for continuation of the use of bed rails Quarterly, Annually, admission/readmission, and during a significant change in condition .Bed rail assists [the resident] and care giver with bed mobility secondary to bed controls are located on bed rails. Review of the observation history revealed that the resident's last side rail assessment and consent was completed on 3/16/2023. Further review failed to reveal evidence that the assessment was completed quarterly. Review of a maintenance document titled Bed System Measurement Device Test Results Worksheet revealed the last entrapment assessment was completed on 11/14/2022. During surveyor observations on the following dates and times revealed the resident had two side rails without bed controls on the rails. It further revealed a gap between the side rail and the resident air mattress, which was set to alternating pressure, leaving the bed frame visible and accessible to the resident: - 11/20/2023 at 8:40 AM - 11/21/2023 at 1:49 PM - 11/22/2023 at 8:38 AM - 11/22/2023 at 9:50 AM During a surveyor interview on 11/22/2023 at 9:51 AM with Registered Nurse, Staff A, she revealed that side rail assessments are completed quarterly. Additionally, she acknowledged there was a gap between the mattress and the siderail. On 11/22/2023 at 11:51 AM, the Maintenance Director completed an entrapment test of the resident's bed in the presence of the surveyor. He then acknowledged there was a gap between the air mattress and the siderails. He further acknowledged there was a concern for resident entrapment related to the alternating pressure of the air mattress. During a subsequent surveyor interview on 11/22/2023 at 1:20 PM with the Maintenance Director and the Director of Nursing Services, they acknowledged that the assessment was not completed quarterly or on a regular schedule. Additionally, they were unable to provide evidence that a quarterly side rail assessment per the care plan or an entrapment assessment had been completed for the resident per the facility's policy and as required by the regulation. Refer to F909

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 4 residents reviewed for parameters associated with blood pressure medication, Resident ID #2. Findings are as follows: Record review revealed the resident was admitted to the facility with a diagnosis of, but is not limited to, hypertension (high blood pressure, BP). Record review revealed a physician order dated 8/29/2023 for Losartan (a medication used to treat high blood pressure), 50 milligrams (mg) once daily, with parameters to hold for systolic blood pressure (SBP, the top number which refers to the amount of pressure experienced by the arteries while the heart is beating) less than 100. Record review of the October 2023 Medication Administration Record (MAR) revealed on the following dates Losartan was not administered when the resident's SBP was not less than 100: - 10/16/2023: BP was documented as 100/58, with a note that states, Not Administered: Due to condition Comment: held bp 100/58 p [pulse] 64. - 10/22/2023: BP was documented as 108/66, with a note that states, Not Administered: Due to condition Comment: HELD P 58. Record review of the November 2023 MAR revealed the following dates Losartan was not administered when the resident's SBP was not less than 100: - 11/5/2023: BP was documented as 113/65, with a note that states: Not Administered: Due to condition. - 11/10/2023: BP was documented as 102/67, with a note that states, Not Administered: Due to condition Comment: held P 57. - 11/12/2023: BP was documented as 106/61, with a note that states, Not Administered: Due to condition Comment: HELD P 58. - 11/14/2023: BP was documented as 101/59, with a note that states, Not Administered: Due to condition Comment: HELD P 58. - 11/16/2023: BP was documented as 102/58, with a note that states, Not Administered: Due to condition Comment: BP 102/58 P 57. During a surveyor interview on 11/22/2023 at 12:42 PM with Registered Nurse, Staff A, she revealed the resident's Losartan should only be held if his/her SBP is less than 100 and indicated it was not administered on the above-mentioned dates due to low pulse, which is incorrect. During a surveyor interview on 11/22/2023 at 1:37 PM with the Director of Nursing Services, she indicated that her expectation is that staff would follow the parameters associated with the resident's Losartan order and administer the medication as ordered. A surveyor interview was attempted on 11/24/2023 at 10:47 AM via telephone, with the resident's Registered Nurse Practitioner to inquire about the resident's held Losartan doses, however, he did not answer his phone, a voice mail was left for him, but the call was not returned to the surveyor.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities Last revised 2/3/2023 states in part, .Regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident's head or body .Facilities must also conduct routine preventive maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair . Review of a facility policy titled Bed Rail Policy last reviewed 6/10/2022, revealed in part, .The Maintenance Department will conduct inspections of all bed frames, mattresses, and bedrails, as part of a regular maintenance program to identify areas of possible entrapment upon admission, quarterly, yearly and as needed . Review of a document titled Bed System Measurement Device Test Results Worksheet revealed Resident ID #2's last inspection of his/her bed frame, mattress, and bed rails was completed on 11/14/2022. Review of a document titled Bed System Measurement Device Test Results Worksheet revealed Resident ID #28's last inspection of his/her bed frame, mattress, and bed rails was completed on 11/14/2022. Review of a document titled Bed System Measurement Device Test Results Worksheet revealed Resident ID #49's last inspection of his/her bed frame, mattress, and bed rails was completed on 11/14/2022. During a surveyor interview on 11/22/2023 at 1:20 PM with the Maintenance Director and the Director of Nursing Services, they acknowledged that the inspections of all bed frames, mattresses, and bed rails were not completed quarterly or on a regular schedule, but indicated they were completed upon admission. Additionally, they were unable to provide evidence that the maintenance department conducts regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program. Refer to F 700

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 4 residents reviewed for skin conditions, Resident ID #'s 14 and 45. Findings are as follows: Record review of a facility policy titled, Skin Care Program states in part, .With each dressing change or at least weekly .documentation must be present .location .wound bed: color and type of tissue/character including evidence of healing .The MD [Medical Director] and the resident's responsible party shall be made aware . 1. Review of Resident ID #14's record revealed s/he was admitted to the facility in March of 2021 with diagnoses including, but not limited to; unspecified dementia without behavioral disturbance and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 4, indicating severe cognitive impairment. Further review of the MDS revealed the resident has short and long-term memory problems. During the following surveyor observations, the resident was observed to have a bandage with white gauze to the back of his/her right ankle: - 9/7/2022 at 12:11 PM - 9/8/2022 at 12:00 PM Further observation on the above dates revealed there was no date indicated on the bandage. Record review of the physician's orders failed to reveal evidence of a treatment in place for the back of his/her right ankle. Further review of the resident's record failed to reveal evidence that there was documentation of the wound's location, origin, and/or treatment. During a surveyor interview on 9/8/2022 at 12:18 PM with Licensed Practical Nurse , Staff C, he revealed that when a skin tear or abrasion is identified, he will assess the area, document it in the resident's record and obtain a treatment order. He would also notify the resident representative and the doctor. He acknowledged that there was no treatment in place for the resident's right ankle and that the doctor and family were not notified. During a subsequent surveyor observation on 9/8/2022 at 1:35 PM of the resident in the presence of Staff C, the dressing to the back of his/her right ankle was removed. Underneath, there was an abrasion 8 centimeters (cm) in length, with slightly reddened edges and multiple scabbed areas. 2. Review of Resident ID #45's record revealed s/he was admitted to the facility in October of 2019 with diagnoses including, but not limited to, mild cognitive impairment and stroke. During the following surveyor observations, the resident was observed to have a dressing with a small amount of bloody drainage to his/her left forearm: - 9/7/2022 at approximately 10:30 AM - 9/8/2022 at 8:26 AM and 12:00 PM Observation on the above dates revealed there was no date indicated on the dressing. Record review of the physician's orders failed to reveal evidence of a treatment in place for the left forearm. Record review of the skin assessment dated [DATE] failed to reveal evidence that there was documentation of the wound's size, location, origin, and/or treatment. During a surveyor interview on 9/8/2022 at 12:18 PM with Staff C, he revealed that when a skin tear or abrasion is identified, he will assess the area, document it in the resident's record and obtain a treatment order. He would also notify the resident representative and the doctor. He acknowledged that there was no treatment in place for the resident's left forearm and the above skin assessment was inaccurate. During a subsequent surveyor observation on 9/8/2022 at 12:46 PM of the resident in the presence of Staff C, the dressing to the left forearm was removed. Beneath the dressing revealed a skin tear approximately 7 cm in length x 1 cm in width with bruising noted to the edges. During a surveyor interview with the resident at the time of the above observation, the resident stated it hurts. During a surveyor interview with the Director of Nursing (DON) on 9/8/2022 at 12:25 PM, she revealed if there is a skin tear or abrasion, she would expect it to be documented in the residents' record and that there would be treatment orders in place. She further revealed she would expect Resident ID #14's abrasion to be reported to the physician and resident representative.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 8 residents reviewed relative to weight monitoring, Resident ID #48. Findings are as follows: Review of the facility's policy and procedure titled, Weight Monitoring states in part: POLICY: it is the policy of this facility to monitor the weight of every resident on a regular basis and to carry out appropriate interventions when necessary to assure the optimum level of health possible for the individual resident . How to weigh the resident: 6. Weights that are + or minus 3 pounds from the last reading must be reported to the nurse who will then be required to supervise an immediate re-weight to double check the accuracy of the reading. The nurse is to enter the supervised reading to verify its accuracy. All re-weights are to be completed within twenty-four (24) hours . 7. Weights obtained that are + or - 3# [pounds] are to be reported to MD [medical doctor] and responsible party . Record review revealed the resident was admitted to the facility in November of 2020 with diagnoses to include, but not limited to, gastro-esophageal reflux disease (chronic digestive disease), diabetes mellitus, hypertension (high blood pressure), and adult failure to thrive. Record review revealed the resident has a physician's order dated 2/24/2021 for Monthly weights. Further record review revealed a care plan dated 12/8/2020 revised on 8/9/2022 for I have potential for alteration in nutrition r/t [related to] colitis [inflammation of the inner lining of the colon/large intestine].-pain-DM [diabetes mellitus]-weight gain-history of . An intervention for this care plan includes, but is not limited to, monitoring weight. Record review revealed the resident's weight was 167.8 pounds on 8/3/2022 and 160 pounds on 9/7/2022, which indicates a 7.8 pound weight loss. Further record review failed to reveal a re-weight was obtained within 24 hours, and/or that the resident's physician and/or the dietitian was notified as per the facility's policy. During a surveyor interview with Registered Nurse, Staff B, on 9/12/2022 at 9:29 AM, she revealed she was unaware that the resident's weight was 160 pounds on 9/7/2022, indicating a 7.8 pound weight loss. She revealed that a re-weight was not obtained and that the resident's physician and/or the dietitian were not notified of the significant weight loss. During an interview with the unit manager, Registered Nurse, Staff D, on 9/12/2022 at 9:49 AM, she revealed that per the facility's policy, if the resident has gained or lost 3 pounds or more from the previous reading, the re-weight should be obtained immediately. Staff D further revealed that weight changes within 3 or more pounds are to be reported to the resident's physician and dietitian. During a surveyor interview with the Director of Nursing on 9/12/2022 at 9:56 AM, she was unable to provide evidence that a re-weight was obtained and/or that the resident's physician and/or dietitian were notified as per the facility policy.

Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, for 2 of 3 sample residents reviewed for oxygen therapy, Resident ID #s 38 and 45. Findings are as follows: Record review of the facility policy titled Oxygen Administration revised 2/14/2008, states in part, .PROCEDURE: 1. Check physician's order for liter flow .7. Masks and nasal cannula's will be changed weekly. 1. Record review revealed Resident ID #38 was admitted to the facility in April of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease. Record review of the physician orders revealed an order dated 8/17/2022 which states, May provide Oxygen at 2 liters as needed via nasal cannula to maintain pulse ox [oxygen] above 91% or with reports of SOB [shortness of breath] As needed. During surveyor observations on the following dates and times, the resident was observed receiving oxygen therapy at 3 liters via nasal cannula, and the oxygen tubing was observed without a labeled date: - 9/7/2022 at 9:21 AM and 12:20 PM - 9/8/2022 at 9:22 AM and 12:17 PM During a surveyor observation and simultaneous interview on 9/8/2022 at 1:46 PM with Registered Nurse Staff B, she acknowledged the oxygen was set at 3 liters, and the tubing was not dated. Record review of the Medication Administration Record (MAR) and Treatment Administration Record(TAR) failed to reveal evidence of documentation that the oxygen was administered on the above-mentioned dates. Further record review of the resident's medical record failed to reveal evidence the nasal cannula is changed weekly. 2. Record review revealed Resident ID #45 was admitted to the facility in February of 2022 with diagnoses including, but not limited to, right heart failure (a condition where the heart is too weak to pump sufficient blood to the lungs), and pleural plaque (thickening of the lining in the lungs) with presence of asbestos. Record review of the physician orders revealed an order dated 6/9/2022, for O2 (oxygen) Therapy 1-4L/MIN (liters per minute) via nasal cannula as needed for SOB Every Shift - PRN [as needed]. Further record review revealed a physician's order dated 2/28/2022 for, Change oxygen tubing weekly. Sign/date. Once A Day on Sun 1st Shift. During surveyor observations of the resident on 9/7/2022 at 10:21 AM and on 9/8/2022 at 8:26 AM, s/he was observed receiving oxygen therapy at 3 liters via nasal cannula, and the oxygen tubing was observed without a labeled date. During a surveyor observation and simultaneous interview on 9/8/2022 at 12:46 PM with Licensed Practical Nurse, Staff C, he acknowledged the oxygen was set at 3 liters, and the tubing was not dated. Record review of the MAR and TAR failed to reveal evidence of documentation that the oxygen was administered on the above-mentioned dates and times. During a surveyor interview on 9/8/2022 at 2:00 PM with the Director of Nursing, she would expect the oxygen tubing to be labeled with the date and changed weekly. Additionally, she acknowledged the oxygen was not administered per the physician order or documented appropriately when administered for the above residents.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident's drug regimen is reviewed by a licensed pharmacist and includes a review of the resident's medical chart for 1 of 6 residents reviewed for unnecessary medications, Resident ID #11. Findings are as follows: Review of the resident's record revealed s/he was re-admitted to the facility in June of 2022 with diagnoses which include, but are not limited to, encounter for surgical aftercare following surgery on the genitourinary system (organs of the reproductive and urinary systems), Alzheimer's disease, and dysphagia (difficulty swallowing). Record review of the resident's monthly drug regimen review document dated 8/18/2022 revealed, This resident is receiving Remeron (mirtazapine) 7.5 mg [milligrams] at bedtime with the off label diagnosis of appetite stimulation. At low doses this agent carries higher sedative properties and could increase this resident's risk of drowsiness and falls. Although there is evidence to support that this medication, at low doses, can cause weight gain and improve appetite please comment on the risk benefit of continuing the use of this agent . Further review of this document revealed that the Nurse Practitioner indicated that the above medication should be continued as the benefits outweigh the risks. Record review of the physician's orders revealed an order for Remeron (mirtazapine) 7.5 mg to be taken at bedtime once daily which was discontinued on 6/8/2022. A subsequent order was put in place for Remeron 15 mg one time only on 6/8/2022. Further review of the record failed to reveal evidence that there were active orders in place for Remeron after 6/8/2022. During a surveyor interview with the Nurse Practitioner on 9/12/2022 at 12:26 PM, she revealed she was unaware that the resident was not actively taking Remeron when she signed the monthly pharmacy review. During a surveyor interview with Registered Nurse Staff D on 9/12/2022 at approximately 1:00 PM, she revealed that she was unaware that the resident's Remeron was discontinued and did not have an active order in place. During a surveyor interview with the Pharmacist on 9/12/2022 at 1:07 PM, she acknowledged that she did not review the resident's active orders in the medical record to verify that s/he was still taking the Remeron. During a surveyor interview with the Director of Nursing on 9/12/2022 at 1:20 PM, she revealed that she would expect the pharmacy to review and verify the physician's orders in the resident's medical record when making recommendations.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 8 residents, Resident ID #15. Findings are as follows: Record review revealed the resident was admitted to the facility in September of 2013 with diagnoses including, but not limited to, diabetes mellitus, dementia, and nutritional deficiencies. Record review of the physician's orders revealed a diet order dated 7/31/2022, which states in part, .Texture; ground, small bite size pieces (including breads) . During a surveyor observation of the lunch meal on 9/7/2022 at 12:13 PM revealed the resident's plate consisted of penne pasta, large chunks of zucchini, and non-bite sized pieces of chicken parmesan. During a surveyor observation on 9/8/2022 at 8:17 AM, Nursing Assistant, Staff E, was observed serving the resident breakfast which included two whole slices of toasted raisin bread. Further observation revealed a dietary slip on his/her tray which indicated a regular diet. During a surveyor interview on 9/8/2022 at 8:30 AM with Licensed Practical Nurse, Staff C, he acknowledged the resident had received two whole slices of bread, which did not follow his/her dietary order for meals ground, cut in small pieces, including bread. During a surveyor interview on 9/8/2022 at 2:45 PM with the Director of Nursing, she acknowledged that the resident received food that did not follow his/her dietary order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 1 of 5 residents reviewed relative to falls, Resident ID #19. Findings are as follows: Record review revealed the resident was admitted to the facility in March of 2017 with diagnoses to include, but not limited to, dementia with behavioral disturbance and history of falling. Additional record review revealed the resident has a physician's order dated 10/8/2020 which states, May have floor matt at bedside to avoid or reduce injury in the event of fall to floor. Review of the SH [Safe Handling] Fall Risk (Acuity) assessment dated [DATE], revealed the following: - Mental status: disoriented, Diminished Safety Awareness - Ambulation: Impaired Mobility - Medication Use: Antihypertensive (medication used to treat high blood pressure), Antipsychotics/Neuroleptics (medication used to treat mental illness) - Resident has the following conditions: impaired hearing, impaired vision, decline in functional status, decline in cognitive skills, dementia . Record review revealed a care plan initiated on 10/6/2020 and revised on 6/21/2022 for, Category: Falls I am at risk for falls R/T [related to] my HX [history] of falls, incontinence, poor safety awareness and dementia. This care plan has an intervention which includes but is not limited to, .matt on floor next to bed. Record review of Safety Events revealed the following: - On 6/17/2022 .had a large BM [bowel movement] and attempted to transfer [his/herself] to the bathroom. was on [his/her] buttocks directly adjacent to [his/her] bed . - On 12/26/2022 .was observed by staff sitting on [his/her] bottom, with [his/her] back leaning against the side of [his/her] bed .it appeared that .attempted to self transfer and [his/her] feet slid out .landed on [his/her] bottom . During surveyor observations on 9/8/2022 at 9:02 AM and 9:32 AM and on 9/9/2022 at 7:33 AM revealed the resident lying in his/her bed with no mat on the floor next to the bed. During a surveyor interview on 9/12/2022 at 8:14 AM, a first shift Nursing Assistant, Staff A, revealed she has been taking care of the resident approximately 5 times/week for at least 1 month. She revealed the resident does not have a mat on the floor next to his/her bed. During a subsequent interview on 9/12/2022 at 8:50 AM, with Registered Nurse, Staff B, she revealed the resident does not have a mat next to his/her bed when s/he is in bed. When informed of the care plan that was revised on 6/21/2022 which indicates matt on floor next to bed, Staff B stated, I thought it was discontinued. During a surveyor interview with the Director of Nursing on 9/12/2022 at 9:58 AM, she was unable to provide evidence that the resident has floor mats while in bed as per the plan of care.